27/8/23, 15:38 McNeill Dysphagia Therapy Program - 10 years of research experience with an exercise based dysphagia rehabilitation approa…

McNeill Dysphagia Therapy Program – 10 years of research experience with an exercise

based dysphagia rehabilitation approach
By Michael A. Crary, Ph.D., CCC-SLP, FASHA - November 19, 2015

Co-Author: Giselle Carnaby, Ph.D., CCC-SLP, MPH, FASHA

What is dysphagia rehabilitation?

Exercise based therapy for dysphagia seems to be a buzz word these days. Many purported
treatment activities are being termed ‘exercise based’. But a good question to ask is “what is
exercise based dysphagia rehabilitation?”. However, perhaps before we travel down that path we
should address a more basic question – what is dysphagia rehabilitation?

I like many ‘experienced’ clinicians (and you can fill in your own definition of experienced!)
remember walking the halls of the inpatient services with a cup of ice and several 00 laryngeal
mirrors. Faucial pillar stroking was all the rage in the late 70’s and early 80’s. And, nearly
everyone got a similar treatment approach. Later we learned of several limitations of this
treatment approach and as a result of important clinical research, this particular path is seldom
walked today. Around the same time we engaged in various head posture activities to facilitate
safe swallowing and a few maneuvers to facilitate the same outcome but also to improve impaired
swallowing physiology. This distinction reflects the difference between compensation and
rehabilitation. Both focus on improving safe oral intake, but they approach the goal from different
paths.

Compensation techniques are short-term adjustments to the patient, the food, or the swallow that
may contribute to a safe swallow permitting maintenance or improvement in oral intake. Safe
swallowing herein refers to no aspiration of swallowed materials. Thus, the chin tuck, head turn,
supraglottic swallow and more postural adjustments and maneuvers were employed to facilitate

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safe swallowing to maintain or enhance oral intake. Other compensations included diet and liquid
modifications usually with the same or highly similar goals to postural adjustments and
swallowing maneuvers. Compensation strategies play an important role for some patients. But, do
they have a ‘rehabilitation’ role? My answer is ‘no’, compensation techniques do not rehabilitate.

My criteria for rehabilitation are twofold:

1. a rehabilitation technique should provide evidence of physiologic improvement in an

impaired system (in this context an impaired swallowing system), and
2. demonstrate functional benefit to the patient (else why would we consider using such a
technique in a clinical environment?). Against that background, I would like to introduce the
McNeill Dysphagia Therapy Program (MDTP for short) as a dysphagia rehabilitation technique.

What is MDTP?
Before going into details, I think homage is due to McNeill. McNeill was actually Hannibal McNeill
who was the first patient to volunteer for a research program involving a novel to dysphagia
therapy in 2004. Hannibal (like many of our patients) presented with long standing dysphagia
following treatment for base of tongue cancer and also surviving a brainstem stroke. He was able
to eat a blended diet with difficulty and worked very hard to keep off a feeding tube. He shortly
returned to a regular diet and remained a healthy eater until he passed in his sleep a few years
later from a second cerebral bleed. His wife graciously allowed us to name this experimental
dysphagia therapy after him.

So, what is MDTP and what is the evidence to support my claim that it is a dysphagia
rehabilitation approach. MDTP is a systematic dysphagia rehabilitation program. It uses
swallowing as an exercise and it works to rehabilitate the synergistic swallowing mechanism. By
swallowing program I mean that MDTP is not a single activity or technique that is repeated over
and over again. Rather it integrates information directly from the patient assessment (one of the
few if the only approaches to do so in dysphagia rehabilitation) and focusing on patient
performance builds upon existing physiologic abilities to improve strength, speed, and
coordination of the impaired swallowing mechanism. The impaired swallow mechanism is
physiologically challenged in therapy during swallowing tasks. As patients progress, more difficult
physiologic challenges are introduced. This progression reflects ‘loading’ on the impaired
neuromuscular system for swallowing and represents a form of progressive resistance. MDTP is
also an intense therapy program. Each swallow is viewed as a unit of exercise and individual
sessions contain more swallow attempts than traditional therapies reflecting a higher intensity
level of swallowing exercise. Finally, MDTP is simple for the patient to participate reflecting good
adherence with the functional tasks including a home work component which extends the
therapeutic benefit outside of the therapy environment. The progression of swallowing tasks
begins based on the individual patient’s physiologic ability level and moves toward functional meal
completion.

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Evidence supporting MDTP

The evidence base supporting MDTP as a beneficial approach for dysphagia rehabilitation is
included among the references at the end of this monologue. Our applied research over the past
10 years has shown consistent functional benefit to most (but not all) patients with long standing,
severe swallowing problems; most of whom came to us on feeding tubes. In addition to functional
benefit we have demonstrated improvements in swallowing physiology including stronger lingual-
palatal contact during swallowing, greater base of tongue and pharyngeal contraction pressures
during swallowing, faster swallowing, and more swallowing effort as reflected in sEMG values
following therapy. We have also compared MDTP to other therapy techniques/approaches and
found superior results from MDTP. Our applied research designs started with case series to
observe clinical effects and physiologic change, move on to case-control studies for treatment
comparison, and progressed to a recent randomized clinical trial.

So, what have we learned over the past 10 years? Well, we initially selected the most difficult
dysphagia cases we could find. Most of our patients were on feeding tubes and many for several
years. We learned that we could help many of these difficult cases (but not all of them
unfortunately) and that improvement could be measured clinically, functionally, and
physiologically. The combination of functional and physiological improvements indicates that MDTP
does have an exercise/rehabilitation component. Finally, the results we observed in our patients
were maintained without complications. In our research we followed patients up to 6 months post
therapy, but in life we have maintained relationships with many of our patients for years. These
patients continue to eat without complication.

To be continued…
We are still studying MDTP and trying to learn how it can help different patients and how it might
be modified to help even more patients with severe swallowing difficulties. From those patients we
could not help we are learning something of the potential limits of MDTP and hope to be more
precise in the type of patient who will or will not be expected to benefit from this approach. Over
the past 10 years we have helped many patients and we have learned much…but we still have
more to learn.

Links of Interest
For more information regarding training in the MDTP approach visit www.fdi2.com
Dysphagia Cafe would like to acknowledge the recent release of the 2nd Edition
text by Crary and Groher- Dysphagia: Clinical Management in Adults and Children

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About the Authors

Michael A. Crary, PhD, FASHA is a professor of Speech-Language Pathology and Co-Director of the
Swallowing Research Laboratory at the University of Central Florida in Orlando. He joined the
faculty at UCF in August, 2015 as a Provost Scholar. Prior to that time, Professor Crary was
employed at the University of Florida (1984 – 2015) where he held the rank of Professor, and
Director of the Swallowing Research Laboratory. He served as both Speech-Language Pathology
Clinical Service Chief and Department Chair at UF. His research and clinical interests focus on
dysphagia in adults and he has published extensively on this topic. He has lectured internationally
on multiple topics related to dysphagia evaluation and rehabilitation in adults. Professor Crary is a
Fellow of ASHA, has served on the board of SIG13, and remains committed to high quality patient
care and clinical research.

Giselle Carnaby is a Professor in the Department of Communication Sciences and Disorders, and
Co- Director of the Swallowing Research Laboratory at the University of Central Florida. She is a
Speech Language Pathologist and ASHA fellow with over 25 years’ experience working clinically in
swallowing disorders. Dr. Carnaby also has a background as a Public Health Epidemiologist and
Biostatistician. She specializes and teaches in research methodology and biostatistics. Her
research focus lies in the rehabilitation of swallowing disorders following Stroke and Head / Neck
Cancer and she is currently funded on two NIH trials and is a life time Research Scholar for the
American Cancer Society.

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References
1. Carnaby G, Miller D, LaGorio L, Silliman S, Crary MA. Exercise-based intervention (MDTP)
with adjunctive NMES to treat dysphagia post stroke: a double blind placebo controlled trial.
Neurorehabilitation & Repair. October, 2015 (Accepted with Revision).
2. Sia I, Carvajal P, Lacy AA, Carnaby GD, Crary MA. Hyoid and laryngeal excursion kinematics-
magnitude, duration and velocity – changes following successful exercise-based dysphagia
rehabilitation: MDTP. J Oral Rehabil. 2015 May;42(5):331-9. doi: 10.1111/joor.12259. Epub
2014 Dec 8. PubMed PMID: 25488830.
3. Crary MA, Carnaby GD. Adoption into clinical practice of two therapies to manage swallowing
disorders: exercise-based swallowing rehabilitation and electrical stimulation. Curr Opin
Otolaryngol Head Neck Surg. 2014 Jun;22(3):172-80. doi: 10.1097/MOO.0000000000000055.
Review. PubMed PMID: 24675153; PubMed Central PMCID: PMC4104745.
4. Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and
nutritional considerations. Clin Interv Aging. 2012;7:287-98. doi: 10.2147/CIA.S23404. Epub
2012 Jul 30. Review. PubMed PMID: 22956864; PubMed Central PMCID: PMC3426263.
5. Lan Y, Ohkubo M, Berretin-Felix G, Sia I, Carnaby-Mann GD, Crary MA. Normalization of
temporal aspects of swallowing physiology after the McNeill dysphagia therapy program. Ann
Otol Rhinol Laryngol. 2012 Aug;121(8):525-32. PubMed PMID: 22953659.
6. Crary MA, Carnaby GD, LaGorio LA, Carvajal PJ. Functional and physiological outcomes from
an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy
Program. Arch Phys Med Rehabil. 2012 Jul;93(7):1173-8. doi: 10.1016/j.apmr.2011.11.008.
Epub 2012 Feb 25. PubMed PMID: 22365489.
7. Carnaby-Mann GD, Crary MA. McNeill dysphagia therapy program: a case-control study. Arch
Phys Med Rehabil. 2010 May;91(5):743-9. doi: 10.1016/j.apmr.2010.01.013. PubMed PMID:
20434612.

Michael A. Crary, Ph.D., CCC-SLP, FASHA

Michael A. Crary, PhD, FASHA is a professor of Speech-Language Pathology and Co-Director of the Swallowing
Research Laboratory at the University of Central Florida in Orlando. He joined the faculty at UCF in August, 2015
as a Provost Scholar.

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