Perspectives of the ASHA Special Interest Groups

SIG 13, Vol. 3(Part 4), 2018, Copyright © 2018 American Speech-Language-Hearing Association

Intensive Therapies for Dysphagia: Implementation of the

Intensive Dysphagia Rehabilitation and the MD Anderson
Swallowing Boot Camp Approaches
Georgia A. Malandraki
Department of Speech, Language, and Hearing Sciences, Purdue University
West Lafayette, IN

Kate A. Hutcheson
Department of Head and Neck Surgery, Section of Speech Pathology and Audiology,
The University of Texas MD Anderson Cancer Center
Houston, TX
Disclosures
Financial: Part of the research cited in this work was supported by Teachers College, Columbia
University, and the University of Texas MD Anderson Cancer Center.
Nonfinancial: Georgia A. Malandraki developed the Intensive Dysphagia Rehabilitation approach.
Kate A. Hutcheson has no relevant nonfinancial interests to disclose.

Purpose: In the past 15–20 years, many promising rehabilitative regimens (strength or skill
based) were introduced for the management of oropharyngeal dysphagia. Despite their
positive outcomes, single intervention regimens, even when performed frequently, may
be inadequate to rehabilitate the complex swallowing deficits often seen in patients with
moderate to severe or persistent dysphagia. Developing protocols to help clinicians select
and implement personalized, intensive exercise training protocols has the potential to
standardize clinical methods and maximize patient outcomes. To begin addressing
this clinical need, the authors each developed personalized, intensive approaches that
combine oropharyngeal exercise and skill-based training approaches in a systematic and
evidence-based way for their particular clinical settings. The 1st approach is known as the
Intensive Dysphagia Rehabilitation approach and is designed for patients with neurogenic
dysphagia. The 2nd protocol is the MD Anderson Swallowing Boot Camp protocol designed
for patients with persistent moderate to severe dysphagia after treatment for head and
neck cancer.
Conclusion: Standardization of intensive models of swallowing therapy is feasible to offer
reproducible but personalized therapy options for diverse populations. This article discusses
the evolution and implementation of 2 such personalized approaches, their main components,
and preliminary outcomes.

In the past four decades, the field of speech-language pathology made remarkable strides
to improve behavioral oropharyngeal dysphagia management. Perhaps, the most remarkable
advancement in this area is the leap from focus on compensation to rehabilitation that started
approximately 15–20 years ago. Since then, many rehabilitative advancements were introduced to
clinical practice. Most of these regimens focus on various methods to strengthen the oropharyngeal
muscles as a way to ultimately improve the safety and efficiency of swallowing. Examples of such
regimens include hyolaryngeal muscle strengthening (Logemann et al., 2009; McCullough et al.,
2012; Shaker et al., 2016), lingual strengthening exercises (Lazarus, Logemann, Huang, & Rademaker,
2003; Rogus-Pulia et al., 2016; Yeates, Molfenter, & Steele, 2008), bolus-driven strengthening
regimens (i.e., McNeil Dysphagia Treatment Program; Carnaby-Mann & Crary, 2010; Crary,
Carnaby Mann, Groher, & Helseth, 2004), and expiratory muscle strength training (EMST;
Troche et al., 2010), all with reports of highly positive outcomes.

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 More recently, structured skill-based training programs also emerged as rehabilitative
options for dysphagia. In these programs, instead of strength, the focus is on improving the skill
of using the oropharyngeal muscles with controlled force and/or timing (Athukorala, Jones,
Sella, & Huckabee, 2014; Steele et al., 2013) or on improving the coordination of swallowing and
airway protection (Martin-Harris et al., 2015). This work uses motor learning approaches and,
albeit preliminary, already provides increased rehabilitation opportunities for our patients.
However, single intervention regimens (strength or skill based), even when performed
intensively, may be inadequate to rehabilitate the complex swallowing abnormalities often seen in
patients with moderate to severe or chronic dysphagia (Rogus-Pulia & Robbins, 2013). Indeed,
reportedly, clinicians frequently use more than four swallowing interventions per session in an
attempt to maximize patient outcomes (Carnaby & Harenberg, 2013). Combined implementation
of these interventions, however, varies greatly with respect to treatment combinations, frequency,
and intensity and, despite common use, has little to no supporting efficacy data (Carnaby &
Harenberg, 2013). In addition, patients are anecdotally often less adherent when asked to complete
too many therapies or long lists of exercises.
Developing protocols and algorithms to help clinicians plan personalized therapies that
integrate both skill and strength training protocols in an optimal manner is recognized as a key
objective for our field (Ciucci, Jones, Malandraki, & Hutcheson, 2016). Standardization of treatment
leads to increased reliability in treatment decisions and is critical in order to enable measureable
and reproducible quality of care. To this end, the authors each developed personalized, intensive
approaches that combine some of the aforementioned evidence-based exercises in a systematic
and evidence-based way for their respective clinical populations (Hutcheson et al., 2015; Malandraki
et al., 2016). The first protocol, that is, the Intensive Dysphagia Rehabilitation (IDR) approach, was
primarily designed for and has been implemented in patients with moderate–severe neurogenic
dysphagia (Malandraki et al., 2016). The second protocol, that is, the MD Anderson Swallowing
Boot Camp protocol, was designed for and implemented in patients with persistent moderate
to severe dysphagia after treatment for head and neck cancer (HNC; Hutcheson et al., 2015). It is
important to note that these approaches are not new therapies. Rather, both represent standardized
protocols to organize existing therapy options to meet the needs of specific patient populations. As
such, these protocols have evolved substantially since their inception and are likely to continually
evolve as therapies mature and new options emerge. This article discusses the development and
implementation of these approaches, their main components, and preliminary outcomes.

The IDR Approach for Neurogenic Dysphagia

The IDR approach is a comprehensive, intensive rehabilitative approach/philosophy based
on principles of neuroplasticity and exercise physiology with specific integration of adherence-
inducing features. IDR was first developed in 2013 by the first author. It was specifically targeted
for patients with persistent neurogenic dysphagia, who had often participated in multiple single-
exercise or multiexercise programs for months or years at a time with limited to no improvements.
Many of these patients had been completing several evidence-based exercises per day during these
periods; however, these exercises were typically implemented without a formal structure and
were often completed at home without guidance or supervision. IDR was conceptualized to help
clinicians systematize selected interventions in an evidence-based way that could maximize patient
outcomes and increase patient adherence (Malandraki et al., 2016).
Evaluation for IDR Candidacy
A comprehensive swallowing assessment is the first step before the IDR planning and
implementation and is of utmost importance, as it will determine if the patient is a candidate
for the approach and also determine the likelihood of the implementation being successful.

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 Our assessment includes the following procedures:
a. A detailed medical history of the patient with emphasis on the primary neurological
condition; any prior and current medical treatments and medications; current health,
nutritional, and respiratory status; and the existence of a social support system:
An important section of the case history includes questions on patients’ preferences
for foods, liquids, sweets, or flavors as well as on their preferences for mealtime
rituals. These components are taken into consideration as the IDR approach is planned
to enhance salience and adherence (see a detailed description of these components
in the following section). Additionally, following an open interview approach, patients
are asked to discuss their own goals for participation in the IDR program. The patient,
their caregiver, and the clinician as a team determine the final IDR goals. Clearance
from the primary care physician or neurologist for IDR is also requested (but not
necessarily required) prior to IDR initiation.
b. A clinical swallowing evaluation, including an oropharyngeal sensorimotor assessment
of swallowing (i.e., cranial nerve assessment) assessing sensory perception and motor
integrity (muscle tone, strength, range of motion, speed, accuracy, reflexes) of muscles
and structures involved in swallowing: This assessment helps us identify underlying
neurophysiological components that may be targeted in treatment. At times, it is
supplemented by instrumental assessments including the use of Iowa Oral Performance
Instrument for measuring maximum lingual strength and the use of a respiratory
pressure meter for evaluating maximum respiratory pressures.
c. An instrumental imaging swallowing assessment (fiberoptic endoscopic evaluation of
swallowing or videofluroscopic swallowing study [VFSS]) that will ultimately help
determine the primary swallowing pathophysiology that needs to be targeted: For this
reason, VFSS is preferred.
d. A cognitive screening using the Montréal Cognitive Assessment (Nasreddine et al.,
2005) or the Cognitive Linguistic Quick Test (Helm-Estabrooks, 2001): This screen
helps determine cognitive function. Given its intensive nature, IDR requires a basic
understanding of several steps and components. At this time, it has been applied in
patients with normal or mildly impaired cognition with success (Malandraki et al., 2016).
e. Quality of life (QOL) and depression scale assessments (using the Swallowing
Quality of Life survey (SWAL-QOL); McHorney et al., 2000, and the Beck Depression
Inventory; Beck, Steer, & Brown, 1996, respectively) are also completed and used as
covariates or secondary outcome variables.
IDR Components: Planning and Implementation
IDR incorporates three components: (a) daily evidence-based oropharyngeal training
increasing gradually in intensity based on exercise physiology guidelines, (b) daily targeted
swallowing practice (TSP) increasing gradually in complexity following principles of experience-
dependent brain plasticity, and (c) adherence-inducing features.
a. Daily evidence-based oropharyngeal training increasing gradually in intensity: For
this component, two evidence-based exercises are selected and are completed on
alternating days to enable muscle rest and recovery (Garber et al., 2011; Kisner &
Colby, 2012) and sustain patient motivation. It is important that only two regimens
are selected to help increase patient adherence and ensure accurate completion of
the exercises. Intensity for each exercise is increased gradually weekly or biweekly
based on exercise physiology principles (Burkhead, Sapienza, & Rosenbek, 2007;
Garber et al., 2011; Robbins et al., 2007). Further, when feasible, each exercise
targets different muscle groups (e.g., lingual, pharyngeal, suprahyoid) or has
different neuromuscular goals (e.g., strength vs. coordination), for maximum

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 possible benefit. Exercises typically include protocols with some level of positive
research evidence, for example, lingual strengthening, effortful swallows, Mendelsohn
maneuver, or head lift (Shaker exercise). The specific exercises chosen for each
patient are determined by three criteria: the patient’s (a) underlying swallowing
pathophysiology, (b) ability to perform the selected exercises accurately independently
or with minimal supervision, and (c) general health and cognitive status.
b. Daily TSP increasing gradually in complexity: For the second component, known as
TSP or challenge swallows, patients complete a daily TSP routine, including a small
set of single swallows of materials identified during an instrumental assessment as
materials that allow for targeted/challenging practice. These include textures/viscosities
observed to be difficult but relatively manageable especially with the supplemented
use of compensatory strategies. TSP is implemented to allow continued use of the
swallowing mechanism and the central and peripheral neural circuits engaged in
swallowing (per the “use it or lose it” principle of experience-dependent plasticity; Kleim
& Jones, 2008) and training specificity (per the specificity principle of experience-
dependent plasticity; Kleim & Jones, 2008). The specific TSP routine for each patient
is determined by the following five criteria: the patient’s (a) underlying swallowing
pathophysiology, (b) current and prior respiratory and health status, (c) potential to
consume the least restrictive TSP relatively safely when using compensatory techniques
(as determined during the instrumental assessment), (d) demonstrated ability to
perform independent oral care, and (e) caregiver training and support during all TSP
routines practiced at home. Advancement or downgrading of materials during TSP
is determined by patient performance and health status.
c. Adherence-inducing features: The third component is the inclusion of three adherence-
inducing features shown to improve exercise and treatment adherence in related fields
(DiMatteo, 1994). These features are salience, social support, and simple health literacy.
In terms of salience, for their TSP routine, patients choose the flavors of their challenge
swallows; that is, they practice swallowing flavors they find rewarding. In addition
to improving adherence, salience is considered an important principle of enhancing
experience-dependent neuroplasticity (Kleim & Jones, 2008). For social support, a
caregiver or aid participates in the in-clinic sessions and becomes the patient’s “coach”
for home practice. At this time, this is a requirement for participation in the IDR
approach, although research is being conducted to determine if this subcomponent is
as critical as we deem it to be clinically. In addition, caregivers and patients are provided
with a binder including detailed daily logs with step-by-step and photo instructions and
exercise log sheets and are asked to complete the logs together daily.
IDR Schedule
In the traditional IDR application, patients are seen in the clinic/home or other rehabilitation
settings twice a week but are asked to practice their IDR program daily (three times per day for
approximately 45–60 min per day). The two in-clinic sessions are typically held on a Monday and
Thursday or Tuesday and Friday schedule to ensure that the clinician will observe and reexamine
performance with each of the two assigned exercises (because they alternate days). IDR can have
varying durations, although the most commonly examined durations include 4 weeks (Malandraki
et al., 2016), 8 weeks, and 12 weeks (Bauer Malandraki & Malandraki, 2017). IDR cycles can also
be repeated, if needed.
IDR Candidacy
IDR is a time- and effort-intensive intervention approach for both the patient and the
clinician. As such, the patient has to be highly motivated and able to complete this program. At
this time, minimum criteria for eligibility and specific criteria for best possible candidacy are
included in Table 1. As IDR evolves and is being more thoroughly investigated, these criteria are
expected to evolve as well.

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Table 1. Intensive Dysphagia Rehabilitation criteria for eligibility and best candidacy.

Minimum criteria for eligibility Clinical criteria for best candidacy

Stable neurological and medical health status High patient and caregiver motivation
Cognitive ability to participate Normal cognition
Patient commitment Acute-onset dysphagia (not required)
Caregiver commitment Nonprogressive dysphagia (not required)

Outcomes and Evolution of the IDR Approach for Neurogenic Dysphagia

In a recent before–after trial, the safety and preliminary effectiveness of IDR was examined
in a consecutive sample of 10 patients with adult-onset neurologic disease and dysphagia
(Malandraki et al., 2016). Participants completed personalized 4-week IDR protocols including
two oropharyngeal exercise regimens, a targeted swallowing routine using salient stimuli, and
adherence features as described above. Treatment included hourly sessions twice per week
and home practice for approximately 45 min per day. Outcome measures assessed pretreatment
and posttreatment included airway safety using the 8-point Penetration–Aspiration Scale (PAS;
Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996), maximum lingual isometric pressures,
self-reported swallowing-related QOL using the 10-item Eating Assessment Tool (Belafsky et al.,
2008), and level of oral intake using the American Speech-Language-Hearing Association’s
National Outcomes Measurement System (NOMS). Also, patients were monitored for adverse
dysphagia-related effects. Results revealed that, despite its short duration (4 weeks), the IDR
approach was safe and effective in improving maximum and mean PAS scores ( p < .05) for most
participants (7/10), as well as level of oral intake (as measured using the American Speech-Language-
Hearing Association’s National Outcomes Measurement System.; p < .005) in all 10 patients. QOL
was also improved; however, it remained above the functional/normal level for all patients at
follow-up. Additionally, some patients (n = 4) remained on restricted diets post-IDR. These findings
likely indicate that the duration of treatment was not adequate.
Since this small-scale case series study, we have been clinically implementing the IDR
approach in three rehabilitation settings (outpatient university clinic, subacute care hospital, and
home health) and have collectively applied it to 35 patients with neurogenic dysphagia, with
overall positive results and no adverse effects reported or observed. At this time, a clinical trial
is being designed that will enable us to examine the differential effect of the IDR components
and cycle durations and gain more insights on its efficacy.

Swallowing Boot Camp in Oncology: The MD Anderson Protocol

The Swallowing Boot Camp therapy program at MD Anderson was launched in 2012 to
address the unmet need to standardize the institutional approach to intensive therapy for patients
who develop moderate to severe persisting oropharyngeal dysphagia after HNC therapy.
Boot camp refers to reactive therapy. That is, boot camp is not used to describe MD
Anderson’s proactive model (i.e., “use it or lose it”) for swallowing therapy during cancer treatment
(Hutcheson et al., 2013). For more than 15 years, proactive swallowing therapy has been offered
to patients at the author’s institution before and during wide-field radiotherapy or chemoradiation
for most HNCs. Proactive therapy intends to maintain function or reduce the severity of functional
decline by avoiding prolonged disuse of the swallowing musculature during cancer treatment
(Carnaby-Mann, Crary, Schmalfuss, & Amdur, 2012).
In contrast to the standard proactive swallowing therapy program, boot camp is offered
after cancer treatment to patients who, despite best efforts at prevention or risk reduction of
dysphagia, develop persistent or late onset of moderate to severe oropharyngeal dysphagia. In the

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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 (Hutcheson
et al., 2015).
In general, the boot camp program is carried out in four stages: (a) evaluation, (b) consensus
and planning, (c) optimization phase, and (d) functional therapy phase (boot camp). The following
sections are intended to detail the MD Anderson’s model (i.e., “how we do it”) currently used to
implement boot camp therapy.
Evaluation for Boot Camp
Comprehensive evaluation is the first step to therapy. All patients interested in boot camp
complete standard multidisciplinary evaluations prior to planning the therapy program. The
speech pathology evaluation for boot camp always includes
• a VFSS;
• oral intake or diet grading using the Performance Status Scale of Head and Neck
(PSS-HN) Cancer Normalcy of Diet Subscale (List, Ritter-Sterr, & Lansky, 1990);
• the MD Anderson Dysphagia Inventory (MDADI; Chen et al., 2001); and
• a cranial nerve and oral mechanism examination.
Jointly, these evaluation methods serve to understand the severity and pathophysiology
of the dysphagia (per VFSS), the functional status of the patient (per PSS-HN), and the patient’s
perception of his or her dysphagia and impact to QOL (per MDADI). It is likely that additional
quantitative physiologic studies, such as pharyngeal high-resolution manometry, would be
valuable to further detail pathophysiology and refine therapy plans (Knigge, Thibeault, & McCulloch,
2014), but this method is not currently available at the author’s institution.
Adjunctive functional measures taken by the speech pathologist while evaluating for boot
camp may also include: maximum interincisal opening, maximum isometric lingual strength,
maximum expiratory pressures, peak cough flow, nasopharyngoscopy, and/or laryngeal
videostrobocopy.
Endoscopic examination is extremely useful for cranial nerve examination to assess the
degree and symmetry of velopharyngeal closure, tongue base retraction, glottic closure, and
pharyngeal constriction (on pharyngeal squeeze maneuver), particularly in patients with late
radiation-associated dysphagia for whom the provider should have high suspicion of lower
cranial neuropathies contributing to dysphagia (Awan et al., 2014; Hutcheson, 2013; Hutcheson
et al., 2012; Hutcheson, Yuk, Hubbard, Gunn, & Fuller, 2017). Endoscopy is also invaluable to
observe anatomic impact of prior treatment such as fibrosis, scar bands, edema, and/or surgical
defects in the laryngopharynx. The physician’s evaluation prior to boot camp includes physical
examination with endoscopy and/or imaging, as indicated, to verify cancer-free disease status
and provide medical clearance for intensive therapy.
History
Detailed history obtained from the medical record and patient interview includes, at
a minimum, the clinical and demographic variables of interest, as summarized in Table 2.

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Table 2. Relevant history for boot camp planning.

Age
Comorbidities
HNC treatment details
Time post treatment
Disease status
Pneumonia history, including PO status at the time of prior pneumonia(s)
Prior swallowing therapy, including response to therapy(ies)

Note. HNC = head and neck cancer; PO = per os (by mouth).

Many patients who enter boot camp have a history of aspiration pneumonia. Not all
pneumonias are the same. That is, a critical element of history taking is to understand not only
the severity of the pneumonia (e.g., Was hospitalization required? Mechanical ventilation?) but
also the per os status of the individual at the time of prior pneumonia events. Ascertaining details
of prior pneumonia episodes is helpful to give a sense of susceptibility and pulmonary risk because
boot camp often centers around bolus trials as the therapeutic task.
In addition to these variables, it is critical to ascertain the patient’s primary (and secondary)
goal(s) of boot camp during the patient interview. Although the program seeks to standardize
options for intensive therapy, there is a balance. Therapy is personalized with the patient goal at
the center.
Candidacy
Similar to the IDR approach, boot camp is a huge commitment for both the patient and the
clinical team. Patients typically commit, at a minimum, to daily therapy sessions for 2–3 consecutive
weeks (often preceded by weeks of pre-boot camp exercise and possible medical procedures). This is
a notable commitment not only by the patient but also by the clinic to allocate staffing and resources
to dozens of outpatient therapy slots in a 2- to 3-week window to a single patient. For this reason,
candidacy for boot camp is a particularly critical consideration.
The history and evaluation serve to determine candidacy. Table 3 outlines the general
guidelines followed to identify appropriate candidates for swallowing boot camp after HNC
therapy. The author’s institution considers three factors that are almost absolute prerequisites
to boot camp:
1. The patient has completed all planned cancer treatment.
2. The patient is cancer free.
3. The oral and pharyngeal tissue has healed sufficiently or is wound free for intensive,
typically bolus-driven, swallowing therapy.

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Table 3. Clinical eligibility for boot camp swallowing therapy.

Moderate to severe dysphagia (per DIGEST grade ≥ 2)

HNC treatment completed
Cancer free
Acute mucositis and odynophagia resolved
Radionecrosis (if present) managed
No active oral or pharyngeal wounds/ulcers

Note. HNC = head and neck cancer; DIGEST = Dynamic Imaging Grade of Swallowing Toxicity.

The clinician evaluates candidacy before boot camp and iteratively throughout the program.
For instance, candidacy may evolve if a patient develops recurrent cancer or high-grade necrosis
during the therapy program requiring the clinician to stop or revise the program.
Sufficient healing indicates that visible mucositis (oral or pharyngeal) or soft tissue ulcers
(e.g., pharyngeal) and functionally limiting odynophagia or mucosal sensitivity have resolved.
In the author’s experience, this window is typically a minimum of 3 months after completing
chemoradiation (this window also allows time for the patient’s initial response assessment to
ensure he or she is cancer free and requires no additional cancer treatment before starting boot
camp). Patients with dysphagia in the early months after chemoradiation treatment are followed
routinely and provided structured home programs including exercise and strategy training but
are not enrolled in boot camp until their mucosal healing and pain allow them to successfully
follow through with intensive therapy. The optimal window postsurgery is more variable. After
surgery, the same principle applies. That is, oropharyngeal pain should be minimal, and the
surgical site must be sufficiently healed for oral intake. For late dysphagia referrals, tissue
integrity indicates that the speech pathologist has verified with the referring oncologist that the
physical examination is free of unmanaged osteoradionecrosis (mandibular), chondroradionecrosis
(laryngeal), or oral or pharyngeal wounds (e.g., ulcers).
It is not an absolute requirement but is also customary to limit boot camp to those
patients with at least moderate severity of dysphagia (graded at the author’s institution using
the Dynamic Imaging Grade of Swallowing Toxicity criteria on VFSS, grade ≥ 2; Hutcheson
et al., 2016). This criterion, again, relates to the amount of resource commitment by the
patients and the provider.
Consensus and Planning
The MD Anderson approach relies on clinical consensus to plan the boot camp program
for each patient. Much like the multidisciplinary tumor board model familiar to oncology
providers, speech pathologists convene to present all cases considered for boot camp prior
to beginning therapy. The team reviews clinical videos and the details outlined in the sections
above to decide on recommendations for (a) pre-boot camp therapies recommended to optimize
the swallowing system and (b) the mode of functional therapy that will be used during boot
camp. Figure 1 summarizes the checklist of items discussed in the boot camp planning
meeting.

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Figure 1. Checklist of boot camp planning considerations.

Note. HNC = head and neck cancer; ORN = osteoradionecrosis; VFSS = videofluroscopic swallowing
study; DIGEST = Dynamic Imaging Grade of Swallowing Toxicity; PSS-HN = Performance Status Scale
of Head and Neck Cancer; MIO = maximum interincisal opening; VC = vocal cord; ROM = range of
motion; IOPI = Iowa Oral Performance Instrument; EMST = expiratory muscle strength training;
sEMG = surface electromyography; FEES = fiberoptic endoscopic evaluation of swallowing.

Optimization Phase (Pre-Boot Camp)

Optimization refers to therapies that are expected to improve the strength or structure
of the swallowing mechanism before intensive functional therapy begins. This concept was
introduced with the McNeil Dysphagia Therapy Program (Carnaby-Mann & Crary, 2010). A
number of complementary options can be considered for patients with HNC in the optimization
phase. These include medical/surgical therapies such as esophageal dilation or vocal fold
medialization and behavioral therapies targeting mobilization (e.g., manual therapy) or strengthening
of the swallowing musculature (e.g., EMST or Iowa Oral Performance Instrument; Hutcheson,
Barrow, et al., 2017; Krisciunas et al., 2016; Lewin, Hutcheson, Barringer, & Smith, 2010;
Rogus-Pulia et al., 2016). Dental rehabilitation (e.g., dentures, implants) is also considered in the
optimization phase. Although ideal to complete all optimization prior to beginning intensive
functional therapy, some patients (particularly those who do not live locally) need to coordinate
visits as much as possible due to transportation or scheduling constraints. In these scenarios,
patients may begin behavioral therapies in the optimization phase several weeks before boot
camp begins and overlap the therapies in later weeks. Overlap may occur at times for behavioral
therapies, but any medical, surgical, or dental therapy needed for optimization should generally
occur before boot camp function therapy phase begins.
Functional Phase (Boot Camp)
The hallmark of the boot camp program is a period of clinician-directed, intensive functional
therapy that continually challenges the swallowing task. The functional therapy delivered during
boot camp includes a short, intense series of daily therapy sessions over a 2- to 3-week period.
Device- and bolus-driven options are both available to challenge the swallowing task in the daily
sessions. The therapy sessions center on mass practice (typically 100+ swallows per session) of
the functional task (i.e., swallows) under progressive conditions. The device-driven model uses
surface electromyography to intensify the work of swallowing in manners previously described
(Crary et al., 2004). The bolus-driven model of boot camp increases the volume and viscosity of

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the bolus to progressively load (“challenge”) the swallowing task as described in the McNeil Dysphagia
Therapy Program (MDTP; Crary, Carnaby, LaGorio, & Carvajal, 2012). In a case–control comparison
among patients with dysphagia of mixed etiology, including HNC, bolus-driven therapy (MDTP)
outperformed device-driven (surface electromyography) therapy with regard to reduced aspiration,
less gastrostomy dependence, and better diet levels (Carnaby-Mann & Crary, 2010). On the basis
of these results and the salience of diet advancement, the author’s institution prefers bolus-
driven functional therapy using MDTP whenever possible.
Outcomes and Evolution of Boot Camp Swallowing Therapy for HNC
The boot camp model is not a silver bullet or a “fix” to restore a normal swallow. Rather,
boot camp seeks to optimize the functional status of the patient to help adapt to the new normal
swallowing mechanism after cancer treatment. The author and colleagues previously presented
initial results of the boot camp experience among 34 patients consecutively enrolled in the first
2 years of the program (Hutcheson et al., 2015). All had a history of head and neck radiotherapy,
and approximately one quarter also had surgery to the primary site or radical neck dissection.
Median time posttreatment when starting boot camp approximated 5 years. Prior to boot camp,
more than 90% of the patients were aspirating (median PAS of 8, “silent aspiration”), half were
gastrostomy dependent, and almost half had a history of pneumonia. After boot camp, global
MDADI scores significantly improved (> 10 points on average, p < .05) as did PSS-HN diet scores
(on average from nonchewable diet before to solid foods with restrictions after). Considering all
domains (functional status, aspiration, and perceived dysphagia), approximately 80% improved
at least one aspect of swallowing, whereas approximately 60% improved functional status (either
diet level on PSS-HN, degree of liquid restrictions, or tube use). PAS scores did not significantly
change (p > .05) after boot camp (Hutcheson et al., 2015).
In response to the observation that aspiration persisted (although sometimes improved)
after boot camp in the early years of implementation, the program expanded to include exercise
targeting airway protection in the optimization phase preceding functional therapy in boot camp.
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 (Hutcheson,
Burrow, et al., 2017). A prospective trial is ongoing to validate these observations. Other recent
extensions of boot camp at the author’s institution include the addition of adjunctive manual
therapy, including myofascial release, currently under study at the author’s institution for patients
with late dysphagia and palpable high-grade fibrosis.

Conclusions
The need to personalize dysphagia management in a systematic and evidence-based
manner is essential in our efforts to maximize clinicians and patients’ time and energy and, most
importantly, treatment outcomes. The IDR approach and the MD Anderson Swallowing Boot
Camp protocol are two such approaches. Acknowledging early data available, we believe that both
hold promise. Both programs are based on systematic exercise physiology and neuroplasticity
principles and offer evidence-based guidance to implement personalized protocols of dysphagia
management for two different populations. Further research on efficacy and differential impact
of their components is warranted and already planned or conducted.

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History:
Received May 15, 2018
Accepted September 10, 2018
https://doi.org/10.1044/persp3.SIG13.133

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