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 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.

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

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.

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.

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