What in the Heck is IDR? | Intensive Dysphagia Rehabilitation Explained for SLPs
Have you ever wondered how to create a protocol for your patient without throwing the entire kitchen sink at them?
How do you choose the right exercises—based on actual need—and not just habit?
Now you can streamline treatment and focus your intervention with Intensive Dysphagia Rehabilitation (IDR).
Moving from Compensation to Rehabilitation
Over the past 15–20 years, our approach to treating dysphagia has shifted from compensation and management to active rehabilitation.
Thanks to the principles of neuroplasticity, we know that swallowing itself is one of the best ways to rehabilitate the swallow. Challenging the swallow—whether through bolus consistency or removing compensatory strategies like the chin tuck—can make therapy more effective.
💡 Try increasing the challenge by:
- Presenting a more difficult bolus
- Using a thicker consistency (e.g., mildly or moderately thick liquids) as a therapy tool only
Grab your free Neuroplasticity & Exercise Principles Cheat Sheet to apply this evidence-based approach in your therapy.
📥 Download your own IDR Cheat Sheet here.
Why Protocols Matter in Dysphagia Therapy
“Single intervention regimens may be inadequate to rehabilitate the complex swallowing deficits seen in patients with moderate-severe or persistent dysphagia.”
— Malandraki & Hutcheson, 2018
Protocols help us standardize treatment, maximize outcomes, and simplify planning. Plus, patients are less likely to complete 10 random exercises than with a clearly explained, meaningful routine.
What the Research Shows
A SIG 13 survey (Carnaby et al.) of 254 SLPs revealed:
- 47 different interventions recommended
- Only 3.9% based recommendations on physiological deficits 🤯
- No repeated combinations of exercises
- 58% of recommendations didn’t match the patient’s specific symptoms
We can do better. Enter: IDR.
Why IDR?
Traditional swallowing therapy often involves single exercises loosely based on neuroplasticity or exercise physiology—but these isolated tasks are frequently inadequate.
Clinicians have reported using more than four swallowing exercises or interventions per session, often without clear progression or intensity targets. Combine that with reimbursement cuts, shorter treatment times, and therapy caps, and the need for a structured, evidence-based, intensive program becomes clear.
Emerging research supports intensive protocols for swallowing rehabilitation, and IDR was designed to bring these principles together in one cohesive, clinically applicable framework.
What Is Intensive Dysphagia Rehabilitation (IDR)?
Developed by Malandraki et al. (2013, published 2016), IDR is a comprehensive, intensive therapy program based on:
- Neuroplasticity
- Exercise physiology
- Patient adherence and salience
Who It’s For:
Patients with moderate to severe neurogenic dysphagia, who have the cognitive ability and support to participate in structured therapy and home practice.
What It Looks Like:
- In-person therapy: 2x/week (e.g., Mon/Thurs or Tues/Fri)
- Session duration: 60 minutes
- Daily home program: 3x/day, 45–60 minutes/day
- Program length: 4 weeks
Step 1: Comprehensive Swallowing Assessment
Before starting IDR, complete a full evaluation to determine candidacy.
What to Include:
- Medical history, nutrition, respiratory status
- Social support system and patient preferences
- Clinical Swallowing Evaluation (CSE) including oropharyngeal sensorimotor, cranial nerve, sensory, and motor assessments
Tools often used:
- IOPI
- Respiratory Pressure Meter
Instrumental assessment:
- VFSS or FEES
Cognitive and QoL assessments:
- MOCA or CLQT
- SWAL-QOL
- Beck Depression Inventory
The 3 Core Components of IDR
1. Daily Evidence-Based Oropharyngeal Training
Exercises are alternated to allow rest and progressively increased every two weeks.
Common exercises include:
- Lingual strengthening (using the IOPI)
- Effortful Swallow
- Mendelsohn Maneuver
- Shaker or Head Lift
These are chosen based on:
- Underlying pathophysiology
- Cognitive status
- Physical ability
Training intensity is gradually increased by re-evaluating maximum strength/capacity weekly or biweekly and adjusting load targets.
2. Daily Targeted Swallowing Practice (TSP)
TSP uses bolus textures identified as “difficult but manageable” from the instrumental assessment.
- Approximately 60 swallows per day (20 swallows, 3x/day)
- May be reduced to 30 swallows per session if safety is a concern
- Bolus difficulty is upgraded or downgraded based on performance
This component applies experience-dependent plasticity and motor learning principles:
- Use it or lose it
- Use it and improve it
- Specificity and salience matter
Salient tasks (favorite foods, realistic settings) increase patient engagement and generalization.
3. Adherence-Inducing Features
IDR is intentionally designed to promote follow-through:
✔️ Explain exercises and their purpose
✔️ Use patient-preferred foods and flavors
✔️ Provide caregiver coaching and inclusion
✔️ Offer visual aids and homework sheets
✔️ Encourage daily logs and oral care routines
✔️ Short, structured program duration (often 4 weeks)
Adherence was tracked through daily logs, showing 89.5% compliance—a remarkable rate for home exercise completion!
Sample IDR Weekly Schedule
Here’s a simplified version of the original protocol schedule used by Malandraki et al.:
Monday, Wednesday, Friday:
- Morning, afternoon, and evening: 20 Targeted Swallows + Exercise 1
- Oral care at the end of each day
Tuesday, Thursday, Saturday:
- Morning, afternoon, and evening: 20 Targeted Swallows + Exercise 2
- Oral care completed daily
- Two SLP sessions per week (e.g., Tuesday and Friday)
Sunday:
- 3 sessions of Targeted Swallowing Practice (TSP) only
- Oral care
This alternating structure provides muscle rest, intensity, and repetition while maintaining salience and safety.
Does IDR Work?
In the Malandraki et al. (2016) study of 10 patients with adult-onset neurogenic dysphagia, participants met the following criteria:
- PAS >3 and ASHA NOMS ≤4
- Cognitive and physical ability to participate
- Caregiver support for home program
Outcomes measured:
- PAS via FEES (4 bolus types: 5ml thin, 10ml thin, straw, pudding)
- IOPI (anterior/posterior lingual strength)
- EAT-10
- ASHA NOMS
Therapy: 2x/week + daily 45-minute home program
Results:
- PAS: All 7 participants who had pre/post FEES improved
- Lingual strength: Marked improvement on IOPI
- EAT-10: Improved quality of life scores at 4 weeks, even greater at 8 weeks (4 weeks after treatment!)
- ASHA NOMS: 8/10 patients improved (2 remained unchanged—one with low adherence, one with a new peripheral nerve diagnosis)
- Diet:
- 5 patients NPO at baseline → 2 ended fully PO, 2 partial PO, 1 remained NPO (pleasure only)
- 3 patients partial PO at baseline → 1 fully PO, 2 with expanded diet options
Key Takeaway:
IDR was found to be safe, effective, and associated with improved airway safety, swallowing function, and quality of life. No dysphagia-related complications were reported during treatment or follow-up. IDR also had better adherence with the HEP.
Clinical Takeaway: My Thoughts
What I love about IDR is how it bridges the gap between evidence and real-world practice.
Instead of throwing random exercises at a patient, you’re guided by principles that make sense: progressive overload, repetition, specificity, and salience.
I’ve found that incorporating pieces of the IDR framework—even if not in its full structure—helps me create more meaningful, personalized therapy plans. Patients understand why they’re doing what they’re doing, and that increases buy-in and results. Patients are also more likely to complete 2 exercises that make sense to their deficits than to complete 25 pages of exercises.
So whether you fully adopt the IDR program or simply apply its principles, you’re already taking a more intentional step toward rehabilitation rather than compensation.
What’s Next?
Want to dive deeper into IDR and other therapy protocols?
👉 Read the full Malandraki & Hutcheson (2018) paper for a detailed comparison of IDR and the MD Anderson Bootcamp.
You can also read more about MD Anderson Bootcamp protocol, right here on Dysphagia Ramblings.
📥 Download the IDR Quick Reference Guide and start simplifying your therapy planning today!
Ready to take your dysphagia practice even further?
Join the Dysphagia Skills Accelerator for more tools, cheat sheets, and in-depth discussions to level up your clinical reasoning.
✨ Click here to join now!
References:
Colodny N. Dysphagic independent feeders’ justifications for noncompliance with recommendations by a speech-language pathologist. Am J Speech Lang Pathol 2005;14:61-70.
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Clark H, Shelton N. Training effects of the effortful swallow under three exercise conditions. Dysphagia 2014;29:553-63.
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. ArchPhys Med Rehabil 2012;93:1173-8.
Lazarus CL, Logemann JA, Huang CF, Rademaker AW. Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatr Logop 2003;55:199-205.
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Robbins J, Kays SA, Gangnon RE, et al. The effects of lingual exercise in stroke patients with dysphagia. Arch Phys Med Rehabil 2007; 88:150-8.
Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res 2008;51:S225-39.
Robbins J, Butler SG, Daniels SK, et al. Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence. J Speech Lang Hear Res 2008;51:S276-300.
Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia 1996;11:93-8.
American Speech-Language-Hearing Association. National Outcomes Measurement System (NOMS): adult speech-language pathology user’s guide. Rockville: American Speech-Language-Hearing Association; 2003.
Belafsky PC, Mouadeb DA, Rees CJ, et al. Validity and reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol 2008;117:919-24.
Butler S, Markley L, Sanders B, Stuart A. Reliability of the penetration aspiration scale with flexible endoscopic evaluation of swallowing. Ann Otol Rhinol Laryngol 2015;124:480-3.
Burkhead LM, Sapienza CM, Rosenbek JC. Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research. Dysphagia 2007;22:251-65.
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