Posted by Summer’s officially here and it’s time to heat things up! This 3-part series looks at recent works related to intensive dysphagia rehabilitation approaches. This post will give a general overview of not 1…not 2… but all 3 applications, with the additional parts to follow that dive deeper into the literature of each in order to push the intensity throttle to the max!🌡
Get ready to break a (mind) sweat😅 as we start the warm-up…
Before getting started, let it be said that there are likely other programs and/or protocols that have already been established, likely with or without specific company-related ties to them (e.g. McNeill Dysphagia Training Program, AmpCare, EMST, etc.) that also can have some great evidence behind them! So before reading and hopefully avoiding a “one-and-done” mindset with your rehab, make sure to always think critically and individualize all your treatments for each patient as appropriate (along with what is applicable to wherever your setting may be!).😉😉
First up:
Intensive Dysphagia Rehabilitation (IDR) Approach
I honestly am still in shock I never really heard as much as I would’ve thought or hoped about this specially created program! If you’ve ever read anything about Dr. Malandraki, you know “exercise physiology” and “principles of neuroplasticity” are often closely accompanied to anything with her name. That’s just what this approach focuses on, among other relevant concerns for patient adherence and functional outcomes.
Who’s it for:
- Adult patients with persistent neurogenic dysphagia that have attempted or completed single or multi-exercise programs for months/years but with no effect or minimal impact
- Medically stable status
- Patients with a basic level of understanding for its various steps/sequences (normal/mild impairments accepted per the evidence)
- Participants/Caregivers who are motivated and dedicated to completing the program and its components
These factors are the minimum for what to consider with IDR. This approach works closely in a team-designed model where the patient, caregiver, and clinician (along with other medical members) work together forming goals and assisting each other as needed. And like with anything that’s worth it, from doing Pelaton workouts to incorporating mindfullness into your day, some amount of commitment is required in order to get the most bang-for-your-buck!😉
What do you do:
Before starting the actual protocol, a thorough investigation and evaluation needs to be completed way before and is recommended to include (but not limited to) the following:
- Thorough and detailed medical history and interview
- Current neurological diagnosis and past/present/future medical treatments (dilation, chemo/radiation, surgery, etc.)
- Review of medications
- Nutrition
- Respiratory status
- Social support system
- Patient preferences for mealtime routines and foods, textures, tastes, sweets, flavors, etc.
- Patient personal goals
- Clinical Swallow Evaluation
- “Oropharyngeal sensorimotor assessment” (aka cranial nerve assessment)
- Additional measures can be included as needed:
- IOPI (Iowa Oral Performance Instrument) for maximum lingual strength
- Respiratory pressure meter (e.g. Peak Flow Meter) for Maximum Inspiratory/Expiratory pressures (MIP/MEP)
- Instrumental Swallow diagnostic assessment
- MBSS or FEES (MBSS is preferred)
- Cognitive Screen
- Montreal Cognitive Assessment (MOCA)
- Patient-reported Outcome Measures (PROMs) as secondary outcome measures
How it works:
After all the initial consultations, evaluations, and interviews patients follow a laid out schedule that typically lasts at least 4 weeks with varying durations even up to 8-12 weeks! Treatment rotations can also be repeated as needed:
- x2/week 60-minute sessions either in clinic, at home, or other rehabilitation setting with clinician
- Therapy sessions typically recommended for Monday/Thursday or Tuesday/Friday in order to allow adequate observation/re-assessment/modifications of both assigned exercises that alternate
- x3/day at-home independent carryover practice, 45-60 minutes/day
Just like graduating after each grade, there are always building blocks or a fundamental core that are the foundation to any well-received program.
IDR focuses on 3 primary components:
- Daily evidence-based oropharyngeal training
- ONLY 2 different exercises are selected and completed on alternating days in order to allow for rest/recovery for muscle function (and help with motivation😉)
- 2 exercises are based off evidence, individual physiological impairments, and overall health/cognition in order to perform the selected exercises independently or with minimal assistance
- When applicable, 2 exercises would target 2 different groups of muscles (e.g. lingual vs pharyngeal vs suprahyoid etc.) or focus on different swallowing aspects (e.g. strength vs coordination/timing etc.)
- “Exercises typically include protocols with some level of positive research evidence, for example, lingual strengthening, effortful swallows, Mendelsohn maneuver, or Shaker exericse”
- Intensity of each of the 2 exercises increases gradually each week (or bi-weekly depending)
- Daily targeted swallowing practice (TSP)
- aka “challenge swallows“
- Single swallows of various textures, viscosities, amounts verified by diagnostic swallow imaging to be “difficult, but relatively manageable” even with compensatory strategies
- Specific routine based off multiple factors:
- individualized swallow pathophysiology
- previous/current respiratory/health status
- ability to complete oral hygiene
- ability to safely consume the least restrictive TSP PO when using compensatory strategies per diagnostic swallow imaging
- caregiver training/support during home TSP routines
- Adherence-inducing features
- patient-preferred flavors and items they find rewarding for TSP
- caregiver/support mate participation currently required during clinician-present sessions and surrogates as patient’s “coach” for at-home practice
- daily log to document daily TSP at home, along with step-by-step instructions, photos, and details in take-home binder for carryover
Why it works:
This intense approach has got the evidence to back it up baby! Each of the above components is based off well-known principles, theories, and related research with references to match.
For the 2 specifically selected exercises, exercise physiology is the foundation for gradually intensifying each exercise and the importance of alternating for rest/recovery. Remember the critical TSP, aka “challenge swallows?” This specific type of training is based off the “use it or lose it” and specificity principles of experience-dependent plasticity.
“TSP is implemented to allow continued use of the swallowing mechanism and the central and peripheral neural circuits engaged in swallowing.” p.4
And as far as adherence goes, this component is based off 3 adherence-inducing features “shown to improve exercise and treatment adherence in related fields” :
- Salience
- Social Support
- Simple Health Literacy
“salience is considered an important principle of enhancing experience-dependent neuroplasticity (Kleim & Jones, 2008).” p.4
Additionally, the original study looking at a sample of 10 outpatient-participant used valid measures such as the PAS scale for airway invasion, IOPI for lingual isometric pressures, and patient-report for quality of life along with overall oral intake levels, showing the high bar that is set for this approach.
As far as the general results, PAS scores improved (maximally/average) as well as oral intake level as measured by ASHA NOMS. At follow-up, reported QOL was improved compared to post-treatment, though not statistically significant. No adverse affects were also noted following a 4-week follow-up.
What we need to consider:
- Unknown if mild severity levels can benefit versus moderate/severe
- No “back to normal” was reached in outcomes
- Adherence not tracked
For more questions or details, always be sure to reach out to Dr. Malandraki and her team!
Be sure to checkout the follow-up review for a deeper dive into the details!
Articles referenced:
Malandraki, G., Rajappa, A., Kantarcigil, C., Wagner, E., Ivey, C., & Youse, K. (2016). The Intensive Dysphagia Rehabilitation Approach Applied to Patients With Neurogenic Dysphagia: A Case Series Design Study. Archives Of Physical Medicine And Rehabilitation, 97(4), 567-574. doi: 10.1016/j.apmr.2015.11.019
Intensive Therapies for Dysphagia: Implementation of the Intensive Dysphagia Rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. (2018). Retrieved 22 April 2022, from https://pubs.asha.org/doi/abs/10.1044/persp3.SIG13.133
Next up:
MD Anderson “Boot Camp” Swallowing Therapy Program
Surprisingly enough, while the MD Anderson center is known world-wide for its proactive perspective when it comes to cancer-related treatment (and still emphasizes the “use-it-or-lose-it” framework for intervention), this specific “boot camp’s” purpose is geared towards reactive treatment, meaning after the primary treatment phase. Created in 2012 by none other than Dr. Hutcheson and Denise Barringer (also originators of DIGEST😉), this boot camp is meant to whip the swallow into shape!
Who’s it for:
“Boot camp is offered after cancer treatment to patients who, despite their best efforts at prevention or risk reduction of dysphagia, develop persistent or late onset of moderate to severe oropharyngeal dysphagia.” While many of the actual participants within the founding organization are seen due to radiation associated dysphagia, aka “RAD,” the boot camp can also be applicable to post-HNC surgery dysphagia as appropriate.
Additional factors for candidacy include:
- Completion of all planned cancer treatment
- Patient is cancer free
- All oropharyngeal wounds have healed
- Mucositis and odynophagia have resolved (acute stage)
- *preferred* Moderate-severe dysphagia (per DIGEST grade >2)
- Motivated and commited patient/support (time, effort, resources, etc.)
The consideration for candidacy can be an ongoing assessment, for example if there is recurrent cancer or a high-grade necrosis arises, likely leading to ceasing or revising an individualized program.
What do you do:
Similar to IDR, there are steps and phases to be completed sequentially in the boot camp (or at least how the authors’ institution goes about it😉):
- Multidisciplinary Evaluation
- Comprises of severity/pathophysiology of dysphagia, functional status, and patient’s perception of dysphagia overall QOL
- Interview for medical history
- Previous history of pneumonia with concurrent PO intake statuses or swallow therapy
- Patient primary/secondary goals
- VFSS and cranial nerve/oral mechanism exam
- Measure/grading of oral intake via Performance Status Scale of Head & Neck (PSS-HN)
- MD Anderson Dysphagia Inventory (MDADI)
- Additional assessments as available/appropriate: FEES, HRM, MEP, peak cough flow, videostroboscopy, maximal interincisal opening, maximum isometric lingual strength
- Interview for medical history
- Comprises of severity/pathophysiology of dysphagia, functional status, and patient’s perception of dysphagia overall QOL
- Consensus & Planning
- SLPs get together to discuss all boot camp candidates and gathered information to determine
- pre-boot camp interventions to maximize swallow changes
- optimal and individualized manner of functional therapy
- SLPs get together to discuss all boot camp candidates and gathered information to determine
- Optimization Phase
- “therapies that are expected to improve the strength or structure of the swallowing mechanism before intensive functional therapy begins“
- Based off MDTP approach😉
- May include medical/surgical options (e.g. esophageal dilation, vocal fold medialization), behavioral therapies (e.g. manual therapy, EMST, etc.), dental intervention (e.g. implants, dentures, etc.)
- Some overlap between optimization interventions and boot camp may occur (except for medical/surgical/dental treatments), although ideally would occur prior to the intensive phase
- Functional Therapy Phase (Boot Camp)
- Focuses on constantly “challenging the swallow“
- Short, intense program of daily therapy sessions over 2-3 weeks
How it works:
Better buckle up and get ready to pump that lingual iron during the actual intensive boot-camp phase of this approach! Mentioned before, true commitment on the patient/support system’s behalf will be required to ensure daily therapy sessions for the next few weeks. With a goal of 100+ swallows each session, each patient’s individualized program primarily focuses on a bolus-driven approach parallel to MDTP (the authors even mention using Carnaby & Crary’s model😉) and increasing the volume and viscosity of the bolus (“progressive loading”) forming the functional swallowing task. Device-driven options such as sEMG may also be utilized as appropriate in order to reinforce and further enhance the primary bolus-driven intervention.
Why it works
The authors are quick to mention their boot camp approach is NOT a quick fix or magic bullet to fully return to life without dysphagia for their cancer-surviving patients. Instead, it is really a way to facilitate the patient’s “new normal” for swallowing post-cancer treaments. The boot camp does utilize many of the same principles aligned with IDR and obviously MDTP, specifically (pun intended😉) the one mentioned earlier for exercise-training (i.e. specificity, overload/progression, recovery, variety, frequency, etc.) and neuroplasticity (i.e. saliency, intensity, repetition, use/lose it, etc.).
While initial outcomes showed more significant improvements in overall QOL and perceptual measures or variety in oral/texture consumption compared to specific swallowing physiological changes or degree of airway invasion, adding specific intervention modes such as manual therapy/myofascial release and EMST are starting to show even more improved and specific results.
For more questions or information, please reach out to Dr. Hutcheson and her team!!
What we need to consider:
- The population is pretty exclusive outside of post-HNC
- Future research is ongoing for efficacy and multiple intervention paths (bolus vs device driven etc.)
Articles Referenced:
Intensive Therapies for Dysphagia: Implementation of the Intensive Dysphagia Rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. (2018). Retrieved 22 April 2022, from https://pubs.asha.org/doi/abs/10.1044/persp3.SIG13.133
And last but not least:
Intensive Swallow Exercise Protocol
While there’s no established program using this protocol (yet!😉), after a thorough read it does seem to check a lot of boxes as far as its methods and somewhat parallels the previously mentioned approaches! While there hasn’t been any recent follow up studies yet, it’s definitely something to be on the look out for!
Who’s it for:
The specific article targeted a small sample of “otherwise healthy adults” that had already been recruited from a different, unrelated study and “had confirmed impairments in swallowing safety and/or efficiency on a modified barium swallow study.” This was confirmed on imaging using the Penetration-Aspiration Scale (PAS) for “swallow safety” criteria and MBSImP for “swallow efficiency” criteria (specifically regarding pharyngeal residue). While the actual protocol was changed up a bit from the proposed standard MBSImP version, it still had plenty of bolus varieties in amount and modes😉. To sum it all up, we’re lookin at a generally healthy, older adult population free of any specific neurogenic or progressive disorders or factors to consider, with some surprising swallow issues unbeknownst to them!
What do you do:
The article describes the approach with each participant completing:
- 8 weeks total duration (starting within 2 weeks from the initial MBSS)
- 1x/week in-clinic treatment session for 45 minutes
- 3 extra sets of the exercise regimen for daily at-home completion
- 20 reps per exercise ‘set’ (except Effortful pitch glide=10 reps)
- Goal of 110 swallow exercise reps per session
- Daily total of 330 swallow repetitions (in-clinic + at-home)
- Swallow exercises consisted of:
- Effortful swallows, tongue-hold swallows (Masako), supraglottic swallows, Shaker exercises, Mendelsohn manuevers, effortful pitch glides
How does it work:
While all the above exercises “were applied to all participants regardless of their underlying swallowing physiology,” the authors are quick to assert that it remains inclusive by providing both direct swallowing and non-swallowing tasks, working off the famous neuroplasticity principles for specificity and transference.
To sum up the results:
- 3 MBSImP components had significant changes from pre/post treatment:
- Initiation of pharyngeal swallow
- Laryngeal elevation
- Pharyngeal residue
- Both “Oral Total” and “Pharyngeal Total” scores were found to significantly improve post-treament
- PAS scores did not improve significantly pre/post treatment for swallowing safety
- Despite the clinical significance of the median score improving from a PAS 3 (unsafe/penetration) to a PAS1 (safe/normal) post-treatment (I’d say that’s significant enough for us clinicians!😉)
- No significant change even when comparing PAS in a binary way (scores 1-2 vs scores 3-8)
Why it works:
Well, since this was a verry preliminary study, there’s no doubt that a very small sample and lack of any control comparison certainly doesn’t lead us to any conclusive statement to give us the green light to go start implementing in clinics tomorrow😕.. However, the authors still use the foundational principles of neuroplasticity for specificity, transference, and intensity with the number and variety of daily repetitions as well as a bit longer than normal exercise regimens, making it one to watch with the other big dog approaches.🧐
What we need to consider:
- Inability to know which exercise might’ve resulted in what outcomes
- No adherence tracking
Article Referenced:
Balou, M., Herzberg, E., Kamelhar, D., & Molfenter, S. (2019). An intensive swallowing exercise protocol for improving swallowing physiology in older adults with radiographically confirmed dysphagia. Clinical Interventions In Aging, Volume 14, 283-288. doi: 10.2147/cia.s194723
And there you have it folks. Three options meant to “pump the swallow system up” as some SLP trainers might say😅. Be sure to keep following each month the rest of the summer to find out even more about the details, evidence, and outcomes behind each of these intense workouts!!🤓
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