It’s getting intense! Part 2-MD Anderson’s “Swallow Boot Camp” Approach

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Title: Intensive Therapies for Dysphagia: Implementation of the Intensive Dysphagia Rehabilitation and the MD Anderson Swallowing Boot Camp Approaches/ Offering more for persistent dysphagia after head and neck cancer: The evolution ofboot camp swallowing therapy
Authors: Malandraki & Hutcheson; Hutcheson et. al
Journal: Perspectives of the ASHA Special Interest Groups Sig 13; Paper presentation
Year of Publication: 2018; 2015
Design Type: Narrative Summary/Consecutive Case Series
Purpose: Assess outcomes of β€œboot camp” swallowing therapy program 2 years after implementation
Population: adults with persistent dysphagia from post-HNC
Inclusion criteria: adult with persistent dysphagia >3 months post-HNC treatment
Exclusion criteria: Non-head and neck cancer diagnoses; no radiotherapy completed; recurrent/active head & neck cancer; abbreviated boot camp

While locating an individual article for this specialized head and neck cancer program proved difficult, getting the overall framework and some details still makes me wanna roll of my sleeves, push up my hyoid, andwork work work on this Boot Camp Approach!πŸ’ͺ

To make sure we’re all on the same page, this approach coming from MD Anderson is specifically looking at improving swallow function in head & neck cancer after-the-fact versus its well-known pro-active approach, which has more research that you’d think. Because the expert investigators know all too well that being proactive doesn’t always guarantee a change and that there will always be patients who aren’t able or willing to put in the work before/during cancer interventions, something needed to be done to ensure these groups aren’t left in dusty despair.

“In the author’s institution, the vast majority of patients who enroll in boot camp have radiation-associated dysphagia, but boot camp can also address postsurgical dysphagia in HNC survivorship.” p.5

We’re talking about those with RAD, persistent and refractory dysphagia post head & neck cancer treatments who despite all their best efforts need more work, those that may not have stuck to the plan beforehand, or maybe had their own plan in mind but are now ready and accepting of a recommended intervention for change.

More specifically for this program’s origin, from Dr. Hutcheson and colleagues’ 2015 presentation they enrolled a total of 34 adults participants with history of head & neck radiotherapy over a 2-year timespan. Eight of the particiants had additional surgery or radical neck dissection, and most had late effects of treatment over 3 years post-radiotherapy.

To get even more specific:

  • 91% of participants had PAS >6 (silent aspiration being common)
  • 44% had history of pneumonia
  • 50% were dependent on alternative tube-feeding
  • 97% had baseline FOIS <7

Additionally, the majority of participants ended up being male and averaging 65 years of age (ranging 49-75 years), having concurrent therapy with radiotherapy for oropharyngeal tumor sites being the most common, and averaging about 5-years post treatment.

If those demographics sound eerily similar to where you’re at and who you work with, keep reading!

For the initial study, the authors looked at the following measures to compare pre and post-intervention:

  • Airway Invasion
    • Penetration-Aspiraton Scale (PAS)
  • Swallow-related QOL
    • MD Anderson Dysphagia Inventory (MDADI)
  • Functional Status Measurements
    • Functional Oral Intake Scale (FOIS)
    • Performance Status Scale for Head & Neck Cancer Patients (PSSHN)
    • Liquids restrictions/tube dependence
    • Number of cans/day of nutritional supplement (PO or tube feeding)

For a more detailed overview of the intensive Swallow Boot Camp, check out Phew!πŸ˜“ Intensifying Approaches for Dysphagia Management. But here’s the gist of how the program looks across the 4 stages:

*original image from article*

From this original consecutive case series study, the investigators utilized a device-driven only boot camp for the first year which 20 of the participants completed (1 participant also has additional biofeedback), while adding and allocating a bolus-driven approach the second year to 14 participants (3 participants had a food hierarchy).

As far how things went for the original study:

  • Across 2 weeks:
    • 24 out of 34 subjects completed daily sessions
    • 10 out of 34 completed bi-daily sessions
  • # of participants who completed>10 sessions
    • Device driven: 16/20 participants
    • Bolus-driven: 8/14 participants

Before moving on, it’s important to note out of the original 34 participants, 3 were not able to complete follow up post-boot camp.

Let’s get to it!

“81% (25/31) improved at least 1 domain of swallowing after boot camp (functional status, perception, or penetration/aspiration). None improved in all 3 domains.” 2015 paper presentation

If we look a bit more closely, when it came to a change in:

PAS scores (via MBSS)

While PAS scores did not significantly change, clinically 16% of participants improved (lowered) their scores by 1-2 points, and only 1 patient stopped aspirating altogether.

Swallow-related QOL measures

  • A total of 35% of participants improved
  • “At a median follow-up of 2 months, global MDADI scores and PSS diet scores significantly improved after boot camp”
  • 10 patients changed >20 points on MDADI statement “my swallow affects my day to day actvities
  • Average MDADI increased across all domains
  • Average MDADI global score increased 11 points

Functional Status

  • “61% improved functional status” in some form
  • 6% had tube removal
  • 12% went from NPO to partial PO
  • 24% improved (decreased) their liquid restrictions and # of supplemental cans used
  • Median FOIS changed 1.5 points
  • Median PSSHN diet changed+20 points
    • “on average from nonchewable diet before to solid foods with restrictions after”

“Nonetheless, we observed statistically significant improvement in global swallowing-specific QOL suggesting that intensive swallow therapy helps patients adapt to severe levels of swallowing dysfunction, essentially helping them to cope and compensate–to live better with the problem. These findings represent early outcomes of an evolving therapy program.” 2015 paper presentation

In order to further maximize the continued (but improved) aspiration from this study,

“Since 2015, EMST has been offered as a resistive expiratory strengthening paradigm for optimization of patients with safety impairment evident on VFSS prior to the functional phase of boot camp.”

“In a recent publication examining 26 patients consecutively enrolled into an 8-week EMST exercise program for chronic radiation-associated aspiration, the author and colleagues observed significant improvement in maximum expiratory pressures (subglottic expiratory force-generating capacity) and swallowing safety on VFSS (p<.05). Dynamic Imaging Grade of Swallowing Toxicity safety grade dropped (improved) in 30% of the patients after EMST, reflecting either less frequent episodes of high-grade penetration/aspiration or better clearance among those patients.” p.10

After all these revelations and new results, we really we need to keep looking to the future and watch out for more to come from these talented experts leading the change! Seriously though, they’re currently working on a prospective trial along with also studying the impact of a combined approach with manual therapy (e.g. myofascial release) for persistent dysphagia and fibrotic patients.πŸ€“

Needless to say, this boot camp approach just gives us more options to choose from as clinicians to best help our patients!

Make sure to watch out for the last installment of the Series to get even more options: It’s getting intense! Part 3 – A novel approach for intensive swallow therapy in healthy, dysphagic adults

Need to rewind? Check out the previous part of the Series:

Articles Referenced:

Intensive Therapies for Dysphagia: Implementation of the Intensive Dysphagia Rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. (2018). Retrieved from

Hutcheson, K. A., Kelly, S., Barrow, M. P., Barringer, M. S., Perez, D. G., Little, L. G., .. . Lewin, J. S. (2015). Offering more for persistent dysphagia after head and neck cancer: The evolution ofboot camp swallowing therapy. Paper presented at the Combined Otolaryngology Spring Meeting, Boston, MA. Retrieved from