MD Anderson Bootcamp for Swallowing

Dysphagia after head and neck cancer treatment is one of the most challenging complications we face as clinicians. Despite best efforts at prevention, many patients continue to develop moderate to severe swallowing difficulties following radiation or surgery.

At MD Anderson Cancer Center, the Dysphagia Boot Camp was launched in 2012 to standardize an intensive, multidisciplinary approach to treating these patients.

Reactive vs. Proactive Therapy

Boot Camp is a reactive therapy program, designed for patients who develop persisting dysphagia after cancer treatment has ended. This is different from the proactive “use it or lose it” model (Carnaby-Mann, Crary, Schmelfuss, & Amdur, 2012), which aims to prevent or minimize functional decline by keeping the swallowing musculature active during cancer therapy.

Boot Camp is offered to those who, despite prevention efforts, continue to struggle with significant swallowing impairment.

Who Attends Boot Camp?

Most participants have radiation-associated dysphagia or swallowing impairment after surgery (Hutcheson et al., 2015). Many have a history of aspiration pneumonia, tube dependence, or severe limitations in diet texture.

To qualify, patients must:

Have completed all cancer therapy and be cancer-free
Be at least 3 months post-chemoradiation with mucositis and odynophagia resolved
Be free of active oral or pharyngeal wounds (e.g., ulcers, untreated osteoradionecrosis)
Demonstrate moderate to severe dysphagia (DIGEST ≥ 2)
Experience minimal or no oropharyngeal pain

Comprehensive Evaluation

Each Boot Camp candidate undergoes a standardized multidisciplinary evaluation including:

Speech-Language Pathology Assessment
- MBSS to assess severity and pathophysiology
- Cranial nerve and oral mech exam
- Oral intake/diet grading using the Performance Status Scale of Head and Neck Cancer (PSS-HN)
- MD Anderson Dysphagia Inventory (MDADI) for quality of life
- Functional measures: maximum interincisal opening, isometric lingual strength, expiratory pressures, peak cough flow
- Endoscopic exam and videostroboscopy, when appropriate
Medical and Patient History
- Age and comorbidities
- Cancer treatment details and time since therapy
- Pneumonia history and PO status at the time
- Prior swallowing therapy and response
- Patient’s primary and secondary goals

This ensures that therapy can be tailored to both clinical needs and patient-driven outcomes.

What Happens in Boot Camp?

Boot Camp consists of a short, intense course of therapy—typically daily sessions over 2–3 weeks. Therapy is structured into two phases:

Optimization Phase

Dilatation
Botox
Vocal cord medialization
Therabite/jaw ROM
Manual therapy
Lingual strengthening (IOPI)
Expiratory muscle strength training (EMST)
Dental rehabilitation (e.g., dentures, implants)

Functional Therapy Phase

This is the heart of Boot Camp:

100+ swallows per session under progressive conditions
Bolus-driven therapy (MDTP) using graduated volumes/viscosities to load and challenge swallowing
Device-driven options such as sEMG biofeedback and BioFEESback

Research suggests bolus-driven therapy outperforms device-only therapy, leading to decreased aspiration, reduced tube dependency, and improved diet levels.

Importantly, the goal is not to restore a “normal” swallow, but to optimize functional status—making swallowing as safe and efficient as possible for each patient.

Outcomes

In the first two years of Boot Camp, 34 patients participated:

Median start: 5 years post-treatment
90% aspirated (PAS 8, often silent)
~50% were tube-dependent
~50% had a history of aspiration pneumonia

After Boot Camp:

MDADI and PSS-HN diet scores significantly improved
Many progressed from non-chewable diets to solids with restrictions
80% improved at least one aspect of swallowing
60% improved functional status (diet level, liquid restrictions, or tube use)
PAS scores, however, did not significantly change

The program later expanded to include EMST targeting airway protection. In one group of 26 patients, 8 weeks of EMST led to significant improvements in maximum expiratory pressure, swallow safety, and DIGEST grades in 30% of participants.

Final Thoughts

The MD Anderson Dysphagia Boot Camp provides a systematic, evidence-based, and personalized approach to swallowing rehabilitation in head and neck cancer survivors. Much like Intensive Dysphagia Rehabilitation (IDR), it combines high-intensity, functional therapy with individualized optimization strategies.

For many patients, Boot Camp doesn’t promise a “normal” swallow—but it offers a path toward improved safety, efficiency, diet variety, and quality of life.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

References

Carnaby-Mann, G., Crary, M., Schmalfuss, I., & Amdur, R. (2012). “Pharyngocise”: Randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology, Biology, Physics, 83(1), 210–219. https://doi.org/10.1016/j.ijrobp.2011.06.1954
Chen, A. Y., Frankowski, R., Bishop-Leone, J., Hebert, T., Leyk, S., Lewin, J., & Goepfert, H. (2001). The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: The M. D. Anderson Dysphagia Inventory. Archives of Otolaryngology–Head & Neck Surgery, 127(7), 870–876. https://doi.org/10.1001/archotol.127.7.870
Hutcheson, K. A., Bhayani, M. K., Beadle, B. M., Gold, K. A., Shinn, E. H., Lai, S. Y., … Lewin, J. S. (2015). Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: Use it or lose it. JAMA Otolaryngology–Head & Neck Surgery, 141(10), 981–989. https://doi.org/10.1001/jamaoto.2015.1185
List, M. A., Ritter-Sterr, C., & Lansky, S. B. (1990). A performance status scale for head and neck cancer patients. Cancer, 66(3), 564–569. https://doi.org/10.1002/1097-0142(19900801)66:3<564::AID-CNCR2820660324>3.0.CO;2-U
Malandraki, G. A., & Hutcheson, K. A. (2018). Intensive therapies for dysphagia: implementation of the intensive dysphagia rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. Perspectives of the ASHA Special Interest Groups, 3(13), 133-145.
Ouyoung, L. M., Nurimba, M., Swanson, M., Wu, F., Zilter, R., & Nam, S. (2020). Timing of Using Exercise-Based Dysphagia Boot Camp (DBC) Impacts Functional Swallowing Outcomes after Surgical Management of Oropharyngeal Cancer. Am J Otolaryngol Head Neck Surg. 2020; 3 (6), 1108.

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