Over the past 15-20 our efforts in the treatment of dysphagia have moved from compensation and management to rehabilitation.
We know that through the principles of neuroplasticity that swallowing is the best way to have the patient rehabilitate the swallow. Having the patient swallow challenging bolus types or swallow without the use of compensation (chin tuck) can challenge the swallow. We can add resistance through a more challenging bolus for the patient or we can add weight to the bolus by having the patient swallow a thicker bolus (honey thick liquids as a therapy task only, even if the patient is on a thinner consistency).
Malandraki and Hutcheson 2018 stated that single intervention regimens may be inadequate to rehabilitate the complex swallowing deficits seen in patients with moderate-severe or persistent dysphagia. Protocols have the potential to standardize clinical methods and to maximize patient outcomes. Patients are anecdotally often less adherent when asked to complete too many therapies or long lists of exercises. Protocols help clinicians plan personalized therapies integrating both skill and strength.
In a survey of Speech Language Pathologists (SLPs) that are members of SIG 13, Carnaby et al found that of the 254 SLPs that responded, there were:
- 47 different interventions recommended
- 3.9% chose recommendations based on physiological deficits
- No single combination of therapies was repeated exactly
- 58% of recommendations did not match the specific dysphagia symptoms
Even a protocol will have to allow for individualization for the patient.
Intensive Dysphagia Rehabilitation
The Intensive Dysphagia Rehabilitation program (IDR) was developed in 2013 and published in 2016 by Malandraki, et al. IDR is a comprehensive and intensive rehabilitation approach based on the principles of neuroplasticity and exercise physiology with specific integration of adherence-inducing features.
- Maximizes patient outcomes
- Patients with moderate-severe neurogenic dysphagia
- Patient seen 2x/week in the clinic (Monday/Thursday or Tuesday/Friday) for 60 minutes with a home program daily (3x/day for 45-60 minutes/day)
- Usually 4, 8 or 12 weeks
First up in IDR is a comprehensive swallowing assessment to determine if the patient is a candidate. You first want to get a complete medical history including:
- Prior and current medical treatments and medication
- Current health, nutrition and respiratory status
- Existing social support system
- Patient preference for foods, liquids, sweets, flavors, mealtime routines
- Open interview-what are the patient and caregiver goals for therapy
A Clinical Swallowing Evaluation (CSE) is completed including assessment of oropharyngeal sensorimotor assessment, cranial nerve assessment, sensory perception and motor integrity (muscle tone, strength, ROM, speed, accuracy, reflexes) of muscles and structures in swallowing (using IOPI, Respiratory Pressure Meter).
The CSE is followed by an instrumental assessment, either VFSS or FEES, however VFSS is preferred.
Cognitive screening is completed using the Montreal Cognitive Assessment (MOCA) or the Cognitive Linguistic Quick Test (CLQT). Cognition is assessed as IDR requires a basic understanding of several steps and components. IDR has been successful with patients with normal or mildly impaired cognition.
There are 3 components to IDR.
Daily Evidence-Based Oropharyngeal Training– increasing gradually based on exercise physiology guidelines.
Two evidence-based exercises are selected and completed on alternating days. This allows for muscle rest and recovery and helps to sustain patient motivation. The intensity of the exercises increase biweekly based on exercise physiology principles. Each exercise should target different muscle groups (lingal , pharyngeal, suprahyoid) or different neuromuscular goals (strength vs. coordination). You can read more about exercise principles.
Evidence-based exercises include:
- Lingual strengthening
- Effortful Swallowing
- Mendelsohn Maneuver
Exercises are chosen based on:
- Underlying pathophysiology
- Ability to perform exercises
- General health
- Cognitive status
Daily Targeted Swallowing Practice (TSP)– which increases gradually in complexity following the principles of experience-dependent brain plasticity
This is where you challenge the swallow with a bolus. You can advance or downgrade what you are presenting the patient determined by the patient’s performance and health status.
Small sets of single swallows of materials identified during the instrumental assessment are used. Use textures/viscosities that are observed to be difficult but relatively manageable with the use of compensatory strategies. With TSP, you are continually having the patient use the swallowing mechanism and the central/peripheral neural circuits engaged in swallowing.
Adherence Inducing Features
We know that patients are more likely to complete 1 exercise per day, that they understand because you explain what the 2 chosen exercises do, rather completing a long list of seemingly meaningless exercises daily.
Why does IDR feature to increase adherence?
- Shown to improve exercise and treatment adherence.
- Salience, socal support, simple health literacy.
- Patient chooses flavors of the challenge swallows.
- Salience enhances experience-dependent neuroplasticity.
- Caregiver becomes the coach at home.
What does the research tell us?
Malandraki, et al 2016:
10 patients, 4 weeks
Penetration Aspiration Scores (PAS) improved
Maximal lingual isometric pressures increased.
EAT-10 (QOL measure) increased.
ASHA NOMS improved (level of oral intake) with less restrictive diet
4 patients remained on restricted diets indicating that 4 weeks may not have been enough for them.
If you want a little more information, the Malandraki & Hutcheson 2018 paper outlines the complete IDR program along with the MD Anderson BootCamp program (which I will outline here on the blog next).
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.
Malandraki, G. A., Rajappa, A., Kantarcigil, C., Wagner, E., Ivey, C., & Youse, K. (2016). The intensive dysphagia rehabilitation approach applied to patients with neurogenic dysphagia: a case series design study. Archives of Physical Medicine and Rehabilitation, 97(4), 567-574.