A randomized preventive rehabilitation trial in advanced head and neck cancer patients treated with chemoradiotherapy: feasibility, compliance, and short-term effects

Interactive website for head and neck cancer patients: Adherence and coping program to prevent dysphagia after radiation

INTRODUCTION

Pharyngeal and laryngeal cancers are highly curable; however survivors are at high risk for long-term dysphagia after radiation. To address lack of access to preventive care in community settings, we developed a responsive web-based application to help patients adhere to preventive swallowing exercises and cope with radiation side effects. We conducted an interim study analysis to determine website usage characteristics and to examine the effect size for future trials.

METHODS

Pharyngeal and laryngeal cancer patients were recruited for enrollment by speech language pathologists before primary radiation and introduced to the interactive website. The program (English and Spanish) features tracking logs for preventive exercises, instructional videos, patient stories and search features. Patients' self-reported swallowing function was assessed with the MD Anderson Dysphagia Inventory (MDADI) at baseline and at 6 months. Adherence to preventive exercises was assessed during the 10 week intervention. Number of unique website visits, total duration of website exposure, and rankings of the most popular webpages were calculated. Preliminary regression models were run using adherence and MDADI as outcomes.

RESULTS

Of the 160 enrolled, 96 had 10-week adherence data and 61 had 6-month MDADI data. The average age was 63 (SD = 12.26), 49.4% were from rural counties, 44% had a high school education or lower, and 42% reported annual income of $30,000 or less. The average number of visits was 5.49 (SD = 9.96) and the average total time spent with the website was 41.09 min (SD =88.48). Preliminary analyses indicated that number of unique visits to the website was independently associated with increased adherence to preventive exercises (p = .001-.008).

CONCLUSION

Our website showed significant effects in promoting adherence to swallowing exercises. However, our return visit rate showed that the platform needs improvement in navigability and usability for this older population undergoing challenging treatment in community settings with low resources.

The use of stretching devices for treatment of trismus in head and neck cancer patients: a randomized controlled trial

Purpose

To compare the effects of two stretching devices, the TheraBite® Jaw Motion Rehabilitation System™ and the Dynasplint Trismus System®, on maximal mouth opening in head and neck cancer patients.

Methods

Patients were randomly assigned to one of two exercise groups: the TheraBite® Jaw Motion Rehabilitation System™ group or the Dynasplint Trismus System® group. Patients performed stretching exercises for 3 months. During the three study visits, maximal mouth opening was measured and the patients completed questionnaires on mandibular function and quality of life.

Results

In our study population (n = 27), five patients did not start the exercise protocol, eight patients discontinued exercises, and two patients were lost to follow-up. No significant differences regarding the change in mouth opening between the two devices were found. Patients had an increase in MMO of 3.0 mm (IQR − 2.0; 4.0) using the TheraBite® Jaw Motion Rehabilitation System™ and 1.5 mm (IQR 1.0; 3.0) using the Dynasplint Trismus System®. Exercising with either stretching device was challenging for the patients due to the intensive exercise protocol, pain during the exercises, fitting problems with the stretching device, and overall deterioration of their medical condition.

Conclusions

The effects of the two stretching devices did not differ significantly in our study population. The factors described, influencing the progression of stretching exercises, need to be taken into account when prescribing a similar stretching regimen for trismus in head and neck cancer patients.

Trial registration

NTR - Dutch Trial Register number: 5589

Electronic supplementary material

The online version of this article (10.1007/s00520-019-05075-7) contains supplementary material, which is available to authorized users.

Efficacy of exercise therapy during radiotherapy to prevent reduction in mouth opening in patients with head and neck cancer: A randomized controlled trial

OBJECTIVE

The aim of this study was to compare the efficacy of 2 protocols of exercise therapy to avoid reduction in mouth opening (MO) in patients undergoing radiotherapy for head and neck cancer.

STUDY DESIGN

This was a randomized, controlled, double-blind, 3-arm, parallel-group, prevention clinical trial. Ninety patients were randomized into 3 groups to perform exercises during radiotherapy treatment: intervention group 1 (G1); intervention group 2 (G2); and control group (CG). Maximum MO was measured before (T0), immediately after (T1), and at 12 months (T2) after completion of radiotherapy treatment. Generalized estimating equations model complemented by the least significant difference test was applied to group comparisons.

RESULTS

There was no significant difference in MO measure between the groups at the 3 assessment time points (P = .264). The difference in MO measure from baseline to 12 months after having completed radiotherapy was -1 mm in CG (95% confidence interval [CI] -4.0 to 2.0); 1.3 mm in G1 (95% CI -1.7 to 4.3); and 0.5 mm in G2 (95% CI -3.4 to 4.4).

CONCLUSIONS

It was not possible to conclude that the exercise protocols performed in this study are more effective than the usual guidance to prevent reduction in MO in patients undergoing radiotherapy for head and neck cancer.

Use of the Penetration-Aspiration Scale in Dysphagia Research: A Systematic Review

The penetration-aspiration scale (PAS) is an 8-point scale used to characterize the depth and response to airway invasion during videofluoroscopy. Though widely used in the field of deglutition, there is a lack of consensus regarding the statistical properties of the scale. In order to better understand the state of the literature and the statistical use of the PAS, a systematic review was undertaken to descriptively examine trends in statistical and reporting practices of the PAS since its inception. Online databases were searched for studies citing the original PAS article, which yielded 754 unique articles. Of these, 183 studies were included in the review. Results showed inconsistencies in the statistical use of the scale; 79 studies treated the PAS as ordinal, 71 as categorical, and 49 as interval. Ten types of categorizations were identified. Reporting of power analyses (9%), as well as inter- (26%) and intra-rater (17%) reliability, was uncommon. Among studies that administered multiple bolus volumes or consistencies, 55% reported PAS analyses at the participant/group level only. This review confirms the existence of discrepancies in the statistical treatment of the PAS. A lack of consensus among researchers limits comparisons between studies. The approach to handling this scale dictates the statistical tests used, potentially affecting results and interpretations. Consistent application of statistically sound approaches to PAS analyses is vital for the future of deglutition research.

Association of a Proactive Swallowing Rehabilitation Program With Feeding Tube Placement in Patients Treated for Pharyngeal Cancer

Importance

A proactive speech and language pathology (SLP) program is an important component of the multidisciplinary care of patients with head and neck squamous cell carcinoma (HNSCC). Swallowing rehabilitation can reduce the rate of feeding tube placement, thereby significantly improving quality of life.

Objective

To evaluate the initiation of a proactive SLP rehabilitation program at a single institution and its association with rates of feeding tube placement and dietary intake in patients with HNSCC.

Design, Setting, and Participants

Cohort study at a tertiary care and referral center for patients with HNSCC serving the northern Chicago region. Patients were treated for squamous cell carcinomas of the hypopharynx, oropharynx, and nasopharynx from 2004 to 2015 with radiation or chemoradiation therapy in the definitive or adjuvant setting. Patients who received less than 5000 cGy radiation or underwent reirradiation were excluded.

Interventions

A proactive SLP program for patients with HNSCC was initiated in 2011. Study cohorts were divided into 2 groups: 2004 through 2010 and 2011 through 2015.

Main Outcomes and Measures

Primary outcome variables were SLP referral placement and timing of the referral. Secondary outcomes were feeding tube placement and ability to tolerate any oral intake.

Results

A total of 254 patients met inclusion criteria (135 before and 119 after implementation of SLP program; median age, 60 years [range, 14-94 years]; 77% male). With the initiation of a proactive SLP program, pretreatment evaluations increased from 29 (21.5%) to 70 (58.8%; risk ratio [RR], 2.74; 95% CI, 1.92-3.91), and rate of referral overall at any time increased from 60.0% to 79.8% (RR, 1.33; 95% CI, 1.13-1.57). Feeding tube placement rates decreased from 45.9% (n = 62) to 29.4% (n = 35; RR, 0.64; 95% CI, 0.46-0.89). Among patients receiving a swallow evaluation, feeding tube requirements were less frequent for those receiving a pretreatment evaluation (31 of 99 [31%]) than for those referred during (11 of 18 [61%]) or after (38 of 59 [64%]) treatment. The rate of tolerating any oral intake at the end of treatment improved from 71.1% (n = 96) in the preimplementation period to 82.4% (n = 98; RR, 1.16; 95% CI, 1.01-1.33).

Conclusions and Relevance

A proactive SLP program can be successfully established as part of the multidisciplinary care of patients with HNSCC and improve patient quality of life.

Effects of jaw exercise intervention timing on outcomes following oral and oropharyngeal cancer surgery: Pilot study

BACKGROUND

Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation.

METHODS

A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively.

RESULTS

Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points.

CONCLUSIONS

The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.

A scoping review of rehabilitation interventions for survivors of head and neck cancer

Purpose: The objectives of this scoping review were to summarize, understand, and disseminate findings from a broad body of literature on rehabilitation interventions used with survivors of head and neck cancer. Method: Searches were conducted in six databases. Inclusion criteria were studies of adult head and neck cancer survivors with a predefined primary rehabilitation outcome as a result of an intervention. Excluded were studies not written in English, opinion papers, or studies where the intervention was not carried out by a rehabilitation healthcare service. A second level, full-text review of the studies was conducted. A thematic analysis was used to examine and combine study findings. Results: A total of 3804 results were retrieved from all sources resulting in 39 papers that were analyzed. The thematic analysis of the included papers represented interventions focusing on swallowing and nutrition, speech, physical therapy, assistive devices, complementary and alternative modalities, comprehensive interdisciplinary programs, and preventive rehabilitation programs. Conclusion: This review has provided an overview of the scope of rehabilitation interventions available for survivors of head and neck cancer and preliminary information about their efficacy. This is foundational information for the development and refinement of rehabilitation interventions and programs for head and neck cancer survivors. Implications for Rehabilitation The existing evidence suggests that survivors of head and neck cancer can benefit from early screening of potential rehabilitation needs and being involved in preventive rehabilitation programs pre-surgery when possible. Rehabilitation programs should consider swallowing interventions for patients as evidence reports improved swallowing function, decreased pain and discomfort, and reduced duration of feeding tube use. Rehabilitation programs should consider nutritional interventions after radiotherapy: Patients benefited from stabilized weights, improved nutritional status, and an improved quality of life. Physical exercise interventions demonstrated improvements in physical function, muscular endurance, range of motion, overall quality of life, and showed reductions in pain, and fatigue.

Nutrition and swallowing therapy strategies for patients with head and neck cancer

Patients with head and neck cancer experience many problems with eating which make them at high risk of malnutrition. Pre-habilitation swallowing exercises as overseen by a speech pathologist can improve swallowing function. A multidisciplinary approach to care, including effective nutritional screening, assessment and intervention has demonstrated improved outcomes in terms of meet nutritional requirements, improved nutritional status and quality of life. Nutritional recommendations are 1.2-1.5 g protein per kilogram per day and 125kJ/kg body weight per day but as these are guides close monitoring of intake and weight is important. Multidisciplinary teams and telehealth have shown better outcomes for nutrition and swallowing status for head and neck cancer patients and ongoing support is required for best patient care.

Early Postoperative Oral Exercise Improves Swallowing Function Among Patients With Oral Cavity Cancer: A Randomized Controlled Trial

Dysphagia remains an unsolved problem for patients with oral cavity cancer who have undergone surgery. This randomized controlled trial was conducted to determine the effect of oral exercise in addition to standard general care and diet counseling on the physiology of swallowing. Fifty patients (25 in each group) with oral and oropharyngeal cancer who underwent tumor resection, neck dissection, and reconstruction were enrolled in this study. The Rosenbek penetration-aspiration scale and modified barium swallow study were administered at 1 and 4 month(s) postoperatively. We observed significant improvements in the intervention group regarding the penetration-aspiration scale (P = .037), and oral and pharyngeal residue with thickened boluses (Nectar P < .001, Honey P < .001, and Pudding P < .001). In conclusion, oral exercise significantly improves the postoperative swallowing function of patients with oral cavity cancers.

Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment

Background: In recent years, preventive swallowing exercises have been investigated as a means to limit dysphagia in head and neck cancer patients. However, adherence to exercise regimes has been poorly documented limiting the conclusions drawn on the effects of the interventions. We investigated adherence to a preventive swallowing exercise program and identified possible associations between adherence and four selected baseline factors: HPV status, partner status, concomitant chemotherapy and tumor site and between adherence to swallowing exercises and attendance to supervised training sessions. Material and methods: Forming part of an ongoing RCT (clinicaltrials.gov NCT02385929) adherence to intervention was based on participant provided training-logs. The exercise program consisted of 3 weekly supervised sessions of 30 min each and a home-based exercise program to be performed three times daily. Adherence was calculated as percentage of prescribed exercises completed and dichotomously as high (≥80%∼median) and low (<80%∼median) adherence. Associations between adherence and clinical/demographic factors (HPV, partner status, chemotherapy, tumor site or attendance level) were explored by logistic regression analyses. Results: Full adherence data were available from 45 (76%) participants. The total cohort median adherence to exercises was 78%. No association was found between any of the tested factors and adherence. Discussion: The study found a high adherence to preventive swallowing exercises in HNC patients undergoing (chemo)radiotherapy, both in home-based exercises and in supervised sessions, when compared to other studies, although median adherence to home-based exercises was below the defined 80% threshold. We acknowledge, that adherence in an RCT may be higher than in the everyday clinical situation due to surveillance bias. However, we find it reassuring that HNC patients comply with a preventive swallowing program, which requires some time investment from the patients.

Feasibility and outcomes of fibreoptic endoscopic evaluation of swallowing following prophylactic swallowing rehabilitation in head and neck cancer

OBJECTIVES

Investigate the feasibility and outcomes of fibreoptic endoscopic evaluation of swallowing (FEES) following a programme of prophylactic swallowing exercises in head and neck cancer (HNC) patients treated with radiotherapy.

DESIGN

Prospective, single cohort, feasibility study.

SETTING

Three head and neck cancer centres in Scotland.

PARTICIPANTS

Pre-radiotherapy HNC patients who consented to participate in a prophylactic swallowing intervention.

OUTCOME MEASURES

Fibreoptic endoscopic evaluation of swallowing recruitment and retention rates, assessment acceptability and compliance, qualitative process evaluation.

RESULTS

Higher rates of recruitment and retention were achieved in centres where FEES equipment was available on-site. Travel and anticipated discomfort were barriers to recruitment. Data completion was high for all rating scales, with good reliability. Following radiotherapy, swallowing safety significantly deteriorated for liquid boluses (P = 0.005-0.03); pharyngeal residue increased for liquid and semi-solid boluses. Pharyngo-laryngeal oedema was present pre-treatment and significantly increased post-radiotherapy (P = 0.001). Patients generally reported positive experience of FEES for their own learning and establishing a baseline.

CONCLUSIONS

Fibreoptic endoscopic evaluation of swallowing is an acceptable method of assessing patients for a prophylactic swallowing intervention and offers some additional information missing from VF. Barriers have been identified and should be taken into account in order to maximise recruitment for future trials.

Short- and Long-term Opioid Use in Patients with Oral and Oropharynx Cancer

OBJECTIVE

Opioid use and abuse is a national health care crisis, yet opioids remain the cornerstone of pain management in cancer. We sought to determine the risk of acute and chronic opioid use with head and neck squamous cell cancer (HNSCC) treatment.

STUDY DESIGN

Retrospective population-based study.

SETTING

Surveillance, Epidemiology and End Results (SEER)-Medicare database from 2008 to 2011.

SUBJECTS AND METHODS

In total, 976 nondistant metastatic oral cavity and oropharynx patients undergoing cancer-directed treatment enrolled in Medicare were included. Opiate use was the primary end point. Univariate and multivariable logistic analyses were completed to determine risk factors.

RESULTS

Of the patients, 811 (83.1%) received an opioid prescription during the treatment period, and 150 patients (15.4%) had continued opioid prescriptions at 3 months and 68 (7.0%) at 6 months. Opioid use during treatment was associated with prescriptions prior to treatment (odds ratio [OR], 3.28; 95% confidence interval [CI], 2.11-5.12) and was least likely to be associated with radiation treatment alone (OR, 0.35; 95% CI, 0.18-0.68). Risk factors for continued opioid use at both 3 and 6 months included tobacco use (OR, 2.23; 95% CI, 1.05-4.71 and OR, 3.84; 95% CI, 1.44-10.24) and opioids prescribed prior to treatment (OR, 3.84; 95% CI, 2.45-5.91 and OR, 3.56; 95% CI, 1.95-6.50). Oxycodone prescribed as the first opioid was the least likely to lead to ongoing use at 3 and 6 months (OR, 0.33; 95% CI, 0.17-0.62 and OR, 0.26; 95% CI, 0.10-0.67).

CONCLUSION

Patients with oral/oropharyngeal cancer are at a very high risk for receiving opioids as part of symptom management during treatment, and a significant portion continues use at 3 and 6 months after treatment completion.

Framework for Speech-Language Pathology Services in Patients with Oral Cavity and Oropharyngeal Cancers

This article provides a framework speech-language pathology services to optimize functional outcomes of patients with oral cavity and oropharyngeal cancers. Key principles include (1) a proactive rehabilitation model that minimizes intervals of disuse or inactivity of speech and swallowing systems, (2) standardized evaluation paradigms that combine objective instrumental assessments with patient-reported outcome measures, and (3) systematic methods for surveillance and intensive rehabilitation for late dysphagia.

Radiation dose to the masseter and medial pterygoid muscle in relation to trismus after chemoradiotherapy for advanced head and neck cancer

BACKGROUND

We studied the relationship between trismus (maximum interincisor opening [MIO] ≤35 mm) and the dose to the ipsilateral masseter muscle (iMM) and ipsilateral medial pterygoid muscle (iMPM).

METHODS

Pretreatment and post-treatment measurement of MIO at 13 weeks revealed 17% of trismus cases in 83 patients treated with chemoradiation and intensity-modulated radiation therapy. Logistic regression models were fitted with dose parameters of the iMM and iMPM and baseline MIO (bMIO). A risk classification tree was generated to obtain optimal cut-off values and risk groups.

RESULTS

Dose levels of iMM and iMPM were highly correlated due to proximity. Both iMPM and iMM dose parameters were predictive for trismus, especially mean dose and intermediate dose volume parameters. Adding bMIO, significantly improved Normal Tissue Complication Probability (NTCP) models. Optimal cutoffs were 58 Gy (mean dose iMPM), 22 Gy (mean dose iMM) and 46 mm (bMIO).

CONCLUSIONS

Both iMPM and iMM doses, as well as bMIO, are clinically relevant parameters for trismus prediction.

The impact of time after radiation treatment on dysphagia in patients with head and neck cancer enrolled in a swallowing therapy program

BACKGROUND

Swallowing dysfunction after radiotherapy (RT) for head and neck cancer can be devastating. A randomized control trial compared swallow exercises versus exercise plus neuromuscular electrical stimulation therapy and found no overall difference in outcomes.

METHODS

Quality of life (QOL), diet, and swallowing variables collected at discrete intervals on 117 patients were reanalyzed to test the hypothesis that shorter time between the completion of radiotherapy and beginning of the swallowing therapy program yielded improved outcomes.

RESULTS

At baseline, subjects < 1 year post radiation had significantly better function than subjects >2 years post RT in several measures. Over the therapy program, the early group showed significant improvement in diet and QOL. Swallowing physiologic variables showed no difference between groups.

CONCLUSION

Beginning a swallowing therapy program within 1 year of completion of radiotherapy demonstrates more consistent improvement in QOL and diet performance compared to later periods.

Electronic Swallowing Intervention Package to Support Swallowing Function in Patients With Head and Neck Cancer: Development and Feasibility Study

Background

Many patients undergoing treatment for head and neck cancer (HNC) experience significant swallowing difficulties, and there is some evidence that swallowing exercises may improve outcomes, including quality of life. This feasibility study developed an evidence-based, practical Swallowing Intervention Package (SiP) for patients undergoing chemoradiotherapy (CRT) for HNC. As part of the study, an electronic version of SiP (e-SiP) was concurrently developed to support patients to self-manage during treatment. This paper reports on the e-SiP component of this work.

Objective

The objective of our study was to develop and conduct a preliminary evaluation of an electronic support system (e-SiP) for patients undergoing CRT for HNC.

Methods

The study was conducted using a recognized mHealth development and evaluation framework and involved health professionals and patients who were undergoing CRT for HNC. The scoping stage of e-SiP development investigated the potential usefulness of the app, exploring how e-SiP would look and feel and what content would be appropriate to provide. Patient and carer focus groups and a health professionals’ consensus day were used as means of data gathering around potential e-SiP content. A repeat focus group looked at an outline version of e-SiP and informed the next stage of its development with regard to refining the requirements for the tool. This was followed by further development and a testing stage of e-SiP that involved the coding of a prototype, which was then evaluated using a series of steering group meetings, semistructured interviews with both patients and health care professionals, and analysis of e-SiP log data.

Results

Feedback from focus groups and health professional interviews was very positive, and it was felt e-SiP use would support and encourage patients in conducting their swallowing exercises. However, of the 10 patients who were offered e-SiP, only 2 opted to use it. For these patients, the aspects of the e-SiP app were considered useful, in particular, the ease of keeping a diary of exercises performed. Interviews with users and nonusers suggested significant barriers to its use. Most significantly, the lack of flexibility of the platform on which e-SiP could be accessed appeared a dominant factor in deterring e-SiP use.

Conclusions

The results suggest that further research needs to be conducted around the implementation of e-SiP. This involves evaluating how e-SiP can be better integrated into usual care and through patient training and staff engagement, can be perceived as a beneficial tool to help support patients in conducting swallowing exercises.

Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes

Head and neck cancer (HNC) guidelines recommend regular multidisciplinary team (MDT) monitoring and early intervention to optimize dysphagia outcomes; however, many factors affect the ability to achieve these goals. The aims of this study were to explore the barriers/facilitators to establishing and sustaining a MDT HNC care pathway and to examine the dysphagia-related speech-language pathology (SLP) and dietetic components of the pathway. Using the Consolidated Framework for Implementation Research (CFIR), a mixed methods study design was used to evaluate an established MDT HNC pathway. Ten MDT members provided perceptions of facilitators/barriers to implementing and sustaining the pathway. Patients attending the SLP and dietetic components of the pathway who commenced treatment between 2013 and 2014 (n = 63) were audited for attendance, outcome data collected per visit, and swallowing outcomes to 24-month post-treatment. Dysphagia outcomes were compared to a published cohort who had received intensive prophylactic dysphagia management. Multiple CFIR constructs were identified as critical to implementing and sustaining the pathway. Complexity was a barrier. Patient attendance was excellent during treatment, with low rates of non-compliance (< 15%) to 24 months. Collection of clinician/patient outcome tools was good during treatment, but lower post-treatment. Dysphagia outcomes were good and comparable to prior published data. The pathway provided patients with access to regular supportive care and provided staff opportunities to provide early and ongoing dysphagia monitoring and management. However, implementing and sustaining a HNC pathway is complex, requiring significant staff resources, financial investment, and perseverance. Regular audits are necessary to monitor the quality of the pathway.

Traumatic cervical spinal cord injury: recovery of penetration/aspiration and functional feeding outcome

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

This prospective cohort study aims to evaluate the recovery of penetration/aspiration and functional feeding outcome in patients with acute TCSCI.

SETTING

Tampere University Hospital, Tampere, Finland METHODS: Forty-six patients with TCSCI were enrolled. All the patients received speech therapeutic interventions based on their clinical needs and were examined with a videofluoroscopic swallowing study (VFSS) at enrollment. The incidence of VFSS-verified laryngeal penetration/aspiration according to Rosenbek's Penetration-Aspiration Scale (PAS) served as the primary outcome. The secondary outcome was the level of functional oral intake (as per the Functional Oral Intake Scale; FOIS). Based on the PAS results, the patients were divided into two groups: (i) penetrator/aspirators (PAS score ≥3) and (ii) non-penetrator/aspirators (PAS score ≤2). Follow-up VFS studies were primarily conducted on the patients with penetration/aspiration in prior VFS studies. The follow-up VFS studies were scheduled on the basis of clinical demand.

RESULTS

Of the 46 patients, 48% had penetration/aspiration in the first VFSS. The second VFSS was conducted on 20 patients, of whom 6 patients (30%) had penetration/aspiration. The third VFSS was conducted on 9 patients. Of these, only two (22%) patients were still penetrator/aspirators. The majority (n = 37, 88%) of the patients presented a total oral intake without restrictions at the time of the final follow-up. Only one patient (2%) was still tube-dependent with consistent oral intake.

CONCLUSION

Swallowing physiology in patients with TCSCI improved during the first months after injury, and the number of penetrator/aspirators decreased progressively.

Randomised feasibility study to compare the use of Therabite® with wooden spatulas to relieve and prevent trismus in patients with cancer of the head and neck

Our aim was to compare the efficacy of the Therabite^® jaw motion rehabilitation system (Atos Medical) with that of wooden spatulas to relieve and prevent trismus in patients who have had radiotherapy for stage three and four oral and oropharyngeal cancer. Secondary aims were to assess the feasibility and the impact of exercise on health-related quality of life (QoL), and the use of health services after treatment. We designed a randomised, open-label, controlled, three-centre feasibility study to compare the effectiveness and cost of the Therabite^® and wooden spatulas. We studied compliance with exercises and health-related QoL, assessed cost using three health economics measures, and conducted semistructured interviews with patients. Patients were randomised into two groups: the Therabite^® group (n = 37) and the wooden spatula group (n = 34). All patients had some sense of jaw tightening before the study started. Mean mouth opening after six months increased in both groups, but the difference between the groups was not significant (p = 0.39). Completion rates for the three economic measures were good. There was no significant difference between the two groups in frequency of contact with care services or in QoL. Exercises during and after radiotherapy can ameliorate trismus in patients with stage three and four oral and oropharygeal cancers, but differences between groups in efficacy, compliance, QoL, or use of hospital or community health services, were not significant.

Patient adherence to swallowing exercises in head and neck cancer

PURPOSE OF REVIEW

A younger population and improved treatments for head and neck cancer (HNC) mean that more people are now living longer with the consequences of treatment, including long-term swallowing problems (dysphagia). Exercises aim to improve swallowing function, however highly variable adherence rates are currently reported, with no standard measure of adherence.

RECENT FINDINGS

Measuring adherence to swallowing exercises depends on the definition of 'adherence', the tools used to measure adherence, and the acceptable threshold that is used to constitute adherence or nonadherence. Particular barriers to swallowing exercise adherence include the burden of treatment, the commitment required to undertake a home-based exercise programme and the difficulty in motivating patients to exercise before swallowing problems have become apparent. Findings from the wider literature on general exercise interventions highlight the importance of external and patient-related factors on adherence, including patient beliefs, social support, self-regulation and goal setting.

SUMMARY

Key barriers and motivators to adherence are presented, which will have implications for the design of future swallowing exercise interventions. The relevance of behaviour change theory in facilitating adherence is highlighted, with ongoing studies used to exemplify how behaviour change components and analysis of patient beliefs can be incorporated into intervention development.

Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors

BACKGROUND

The efficacy of rehabilitative exercises for chronic dysphagia treatment in head and neck cancer survivors has not been studied extensively and is ambiguous.

METHODS

A prospective clinical phase II study using an intensive strength training program was carried out in 17 head and neck cancer survivors with chronic dysphagia. Both swallow and nonswallow exercises were performed for 6-8 weeks with a newly developed tool allowing for progressive muscle overload, including chin tuck, jaw opening, and effortful swallow exercises. Outcome parameters were feasibility, compliance, and parameters for effect.

RESULTS

Feasibility in terms of the program completion rate was 88%. Compliance with the exercises was 97%. After the training period, chin tuck, jaw opening, and anterior tongue strength had substantially improved. All but 1 patient reported to benefit from the exercises.

CONCLUSION

Feasibility and compliance were high. Some objective and subjective effects of progressive load on muscle strength and swallowing function could be demonstrated.

Contemporary management of advanced laryngeal cancer

The treatment of advanced laryngeal cancer has undergone a paradigm shift in recent years, with an increase in chemoradiation for organ preservation and a decrease in primary surgery. This review will summarize the contemporary management of advanced laryngeal cancer and discuss treatment‐related toxicity and strategies to improve outcomes.

Level of Evidence

NA.

Exercise therapy for trismus secondary to head and neck cancer: A systematic review

BACKGROUND

Effects of exercise therapy for trismus secondary to head and neck cancer have not been reviewed systematically since 2004.

METHODS

Four databases were searched. The quality of observational studies and randomized controlled trials was assessed.

RESULTS

Two hundred eleven articles were found, 20 studies were included. A large variation in research methodology, stretching techniques, duration of stretch, and repetition of exercises was found. The overall quality was moderate. Five of the 8 preventive studies found that exercises during (chemo)radiotherapy could not prevent a reduction in mouth opening. In 4 therapeutic case studies, mouth opening increased between 17 and 24 mm. In 8 other therapeutic studies, mouth opening increased between -1.9 and 13.6 mm. No exercise therapy was clearly superior to the others.

CONCLUSION

Changes in mouth opening ranged considerably and no stretching technique was superior to others regarding either prevention or treatment of trismus. Clinical guidelines cannot be given based on this systematic review. © 2016 Wiley Periodicals, Inc. Head Neck 39: 160-169, 2017.

Trismus and reduced quality of life in patients with oral squamous cell carcinoma, who received post-operative radiotherapy alone or combined with chemotherapy

Background

Patients, who receive radiotherapy (RT) for head and neck cancer, develop chronic functional abnormalities and survive with reduced quality of life.

Purpose

We aimed to study patients with oral cancer, who received post-operative radiotherapy or chemoradiotherapy.

Patients

Ten patients (mean age 63.8 years) were included.

Methods

Oral mucositis, pain and xerostomia, maximum mouth opening (MMO) and functional abnormalities before and after RT were recorded. The 35 mm MMO or less was accepted as trismus. Patients completed the EORTC QLQ C-30 and Head/Neck35 questionnaires.

Results

Mean RT dose was 64.3 Gray. Six patients received chemoradiotherapy. Severe mucositis, pain and xerostomia were recorded in 6 and 5 patients respectively. MMO was reduced in all patients. The mean MMO (34 mm) reached the level of trismus. The total number of symptoms increased from 3.1 to 6.3 in C-30 and from 3.1 to 8.8 per patient in the H/N35. Severe fatigue, pain, limitations at work, weakness, sad feelings, family problems, sleeping problems, anorexia, financial difficulties, tense/irritable, constipation, nausea, vomiting and depression were most often reported with C-30. Most patients reported low to moderate quality of life. Severe oral, jaw and neck pain, swallowing problems, taste alterations, sticky saliva, dry mouth, coarseness, dental problems, feeling sick and reduced interest in life/sex were the most common symptoms reported with N/H35.

Conclusions

The observed trismus, 2- to 3-fold increase of symptoms and poorer quality of life highlighted the need for support of oral cancer patients, who receive postoperative radiotherapy or chemoradiotherapy.

Feasibility of tongue strength measurements during (chemo)radiotherapy in head and neck cancer patients

PURPOSE

The aim of this study was to investigate the feasibility of tongue strength measures (TSMs) and the influence of bulb location, sex, and self-perceived pain and mucositis in head and neck cancer (HNC) patients during chemoradiotherapy (CRT).

METHODS

Twenty-six newly diagnosed HNC patients treated with CRT performed anterior and posterior maximal isometric tongue pressures by means of the Iowa Oral Performance Instrument (IOPI). The Oral Mucositis Weekly Questionnaire (OMWQ) and a Visual Analogue Scale (VAS) for pain during swallowing were completed weekly from baseline to 1 week post CRT.

RESULTS

Feasibility of TSMs during CRT declines significantly from 96 to 100% at baseline to 46% after 6 weeks of CRT. But post-hoc analyses reveal only significant differences in feasibility between baseline and measurements after 4 weeks of treatment. No effect of gender or bulb location was established, but feasibility is influenced by pain and mucositis.

CONCLUSIONS

Feasibility of TSMs declines during CRT and is influenced by mucositis and pain. For the majority of subjects, TSMs were feasible within the first 4 weeks, which provides a window of scientific and clinical opportunities in this patient population.

Prophylactic Swallow Therapy for Patients with Head and Neck Cancer Undergoing Chemoradiotherapy: A Randomized Trial

Evidence supporting prophylactic swallow exercises for patients with head and neck cancer (HNC) has not been universally demonstrated. This RCT examined diet level, feeding tube use, swallow function, and quality of life (QOL) of patients undergoing chemoradiotherapy who performed prophylactic swallowing exercises. Sixty HNC patients were randomized into exercise versus control groups. Swallowing, oromotor, toxicity, and QOL data were recorded (baseline, 3, 6, 12, 24 months). Physiological swallow function was examined at baseline and 3 months. Swallow exercises were completed twice daily. Oral intake at 3 months was 10% better in the exercise group, which was not statistically significant (p = 0.49). Significant (p < 0.05) differences in secondary outcomes including oromotor function, pharyngeal impairment, oral pharyngeal swallow efficiency, and incisal opening were noted at early time points (3–6 months) in the exercise group. Possible positive early improvements in swallow function are associated with swallowing exercises, although these improvements are not significant longer term.

Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory

Poor patient adherence to swallowing exercises is commonly reported in the dysphagia literature on patients treated for head and neck cancer. Establishing the effectiveness of exercise interventions for this population may be undermined by patient non-adherence. The purpose of this study was to explore the barriers and facilitators to exercise adherence from a patient perspective, and to determine the best strategies to reduce the barriers and enhance the facilitators. In-depth interviews were conducted on thirteen patients. We used a behaviour change framework and model [Theoretical domains framework and COM-B (Capability–opportunity–motivation-behaviour) model] to inform our interview schedule and structure our results, using a content analysis approach. The most frequent barrier identified was psychological capability. This was highlighted by patient reports of not clearly understanding reasons for the exercises, forgetting to do the exercises and not having a system to keep track. Other barriers included feeling overwhelmed by information at a difficult time (lack of automatic motivation) and pain and fatigue (lack of physical capability). Main facilitators included having social support from family and friends, the desire to prevent negative consequences such as long-term tube feeding (reflective motivation), having the skills to do the exercises (physical capability), having a routine or trigger and receiving feedback on the outcome of doing exercises (automatic motivation). Linking these findings back to the theoretical model allows for a more systematic selection of theory-based strategies that may enhance the design of future swallowing exercise interventions for patients with head and neck cancer.

Comparing dysphagia therapy in head and neck cancer patients in Australia with international healthcare systems

PURPOSE

The Australian healthcare system has invested heavily in multidisciplinary cancer care teams. Despite such investments, guidelines that clearly delineate standard of care dysphagia treatment are lacking and services provided to Head and Neck Cancer (HNC) patients are not always consistent. There is little consensus regarding the frequency and intensity of dysphagia therapy. This is largely due to a lack of well-designed clinical trials that establish the efficacy of any dysphagia therapy in this patient population. The aim of this study was to evaluate HNC dysphagia therapy patterns among Australian speech-language pathologists (SLPs).

METHOD

A 22 question internet-based survey was administered to a web-based professional interest group. Results were analysed by institution type and individual clinical experience.

RESULT

A response rate of 46% was achieved (67 out of 144 surveyed). This survey identified several aspects of dysphagia management that were provided uniformly in addition to many aspects of care that showed a lack of consensus.

CONCLUSION

By comparing the results of this survey with existing international best-evidence treatment guidelines, the development of uniform Australian guidelines may be facilitated. However, more authoritative data on dysphagia treatment efficacy is needed to provide uniform evidence-based HNC dysphagia treatment guidelines.

Improving swallowing outcomes in patients with head and neck cancer using a theory-based pretreatment swallowing intervention package: protocol for a randomised feasibility study

INTRODUCTION

The incidence of head and neck cancer (HNC) in the UK is rising, with an average of 31 people diagnosed daily. Patients affected by HNC suffer significant short-term and long-term post-treatment morbidity as a result of dysphagia, which affects daily functioning and quality of life (QOL). Pretreatment swallowing exercises may provide additional benefit over standard rehabilitation in managing dysphagia after primary HNC treatments, but uncertainty about their effectiveness persists. This study was preceded by an intervention development phase to produce an optimised swallowing intervention package (SIP). The aim of the current study is to assess the feasibility of this new intervention and research processes within a National Health Service (NHS) setting.

METHOD AND ANALYSIS

A two-arm non-blinded randomised controlled feasibility study will be carried out at one tertiary referral NHS centre providing specialist services in HNC. Patients newly diagnosed with stage III and IV disease undergoing planned surgery and/or chemoradiation treatments will be eligible. The SIP will be delivered pre treatment, and a range of swallowing-related and QOL measures will be collected at baseline, 1, 3 and 6 months post-treatment. Outcomes will test the feasibility of a future randomised controlled trial (RCT), detailing rate of recruitment and patient acceptance to participation and randomisation. Salient information relating to protocol implementation will be collated and study material such as the case report form will be tested. A range of candidate outcome measures will be examined for suitability in a larger RCT.

ETHICS AND DISSEMINATION

Ethical approval was obtained from an NHS Research Ethics Committee. Findings will be published open access in a peer-reviewed journal, and presented at relevant conferences and research meetings.

TRIAL REGISTRATION NUMBER

ISRCTN40215425; Pre-results.

Trismus following different treatment modalities for head and neck cancer: a systematic review of subjective measures

The aim of this review was to compare systematically the subjective measure of trismus between different interventions to treat head and neck cancer, particularly those of the oropharynx. Using The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Guidelines, Six databases were searched for the text using various terms which include “oropharyngeal/head and neck cancer”, “trismus/mouth opening” and the various treatment modalities. Included in the review were clinical studies (> or =10 patients). Three observers independently assessed the papers identified. Among the six studies reviewed, five showed a significantly worst outcome with regard to the quality-of-life questionnaire scores for a radiotherapy or surgery and radiotherapy (RT) ± chemotherapy or chemoradiotherapy when compared to surgery alone. Only one study showed no significant difference between surgery alone and other treatment modalities. Subjective quality-of-life measures are a concurrent part of modern surgical practice. Although subjective measures were utilised to measure post operative trismus successfully, there was no consensus as to which treatment modality had overall better outcomes, with conflicting studies in keeping with the current debate in this field. Larger and higher quality studies are needed to compare all three treatment modalities.

Swallowing therapy and progressive resistance training in head and neck cancer patients undergoing radiotherapy treatment: randomized control trial protocol and preliminary data

BACKGROUND

Head and neck cancer (HNC) patients are often challenged by treatment induced dysphagia and trismus. Traditionally, rehabilitation is initiated when loss of function has already occurred. There is increasing evidence that it is of benefit to patients to initiate an early rehabilitation process before and during treatment. HNC patients have a unique set of functional challenges such as pre- and post-treatment dysphagia, pain and weight loss. The aim of the trial is to investigate the effects of swallowing and mouth-opening exercises combined with progressive resistance training (PRT) during radiotherapy. This report presents the protocol, interim inclusion and feasibility data.

MATERIAL AND METHODS

The trial (clinicaltrials.gov NCT02385929) is a multicenter randomized controlled trial (RCT) with a parallel-group randomization (1:1). The planned sample size of 240 HNC patients is randomly assigned to either (1) twice weekly PRT and three times weekly swallowing exercises by physio- and occupational therapists, respectively, as well as daily home exercises throughout radiotherapy or (2) standard care. Inclusion criteria are patients with cancer in the larynx, pharynx, oral cavity, or unknown primary tumor who are referred to radiotherapy with curative intent. Outcomes are measured at end-of-treatment and two, five, and 12 months post-treatment. Interim results: In 16 months, 321 HNC patients were screened for eligibility. Of these, 131 (41%) were eligible according to inclusion criteria. One-hundred-and-fifteen patients were invited to participate of which 69 (60%) were enrolled in the trial and randomized for either intervention or control group with 10 drop-outs (14%). The six pilot patients adhered more than 90% to the program.

CONCLUSION

Preliminary results show that exercise according to protocol is tolerable and feasible.

Swallowing interventions for the treatment of dysphagia after head and neck cancer: a systematic review of behavioural strategies used to promote patient adherence to swallowing exercises

BACKGROUND

Dysphagia is a significant side-effect following treatment for head and neck cancers, yet poor adherence to swallowing exercises is frequently reported in intervention studies. Behaviour change techniques (BCTs) can be used to improve adherence, but no review to date has described the techniques or indicated which may be more associated with improved swallowing outcomes.

METHODS

A systematic review was conducted to identify behavioural strategies in swallowing interventions, and to explore any relationships between these strategies and intervention effects. Randomised and quasi-randomised studies of head and neck cancer patients were included. Behavioural interventions to improve swallowing were eligible provided a valid measure of swallowing function was reported. A validated and comprehensive list of 93 discrete BCTs was used to code interventions. Analysis was conducted via a structured synthesis approach.

RESULTS

Fifteen studies (8 randomised) were included, and 20 different BCTs were each identified in at least one intervention. The BCTs identified in almost all interventions were: instruction on how to perform the behavior, setting behavioural goals and action planning. The BCTs that occurred more frequently in effective interventions, were: practical social support, behavioural practice, self-monitoring of behaviour and credible source for example a skilled clinician delivering the intervention. The presence of identical BCTs in comparator groups may diminish effects.

CONCLUSIONS

Swallowing interventions feature multiple components that may potentially impact outcomes. This review maps the behavioural components of reported interventions and provides a method to consistently describe these components going forward. Future work may seek to test the most effective BCTs, to inform optimisation of swallowing interventions.

Developing a Clinical Question Into a Research Question: The “Use It or Lose It” Example

Clinicians encounter countless questions every day. This paper provides an overview of the basic steps to translate a clinical question into a research question, then practical considerations for planning a research study. A published study of the author will be used to illustrate the process.

Impact of Compliance on Dysphagia Rehabilitation in Head and Neck Cancer Patients: Results from a Multi-center Clinical Trial

A 5-year, 16-site, randomized controlled trial enrolled 170 HNC survivors into active (estim + swallow exercise) or control (sham estim + swallowing exercise) arms. Primary analyses showed that estim did not enhance swallowing exercises. This secondary analysis determined if/how patient compliance impacted outcomes. A home program, performed 2 times/day, 6 days/week, for 12 weeks included stretches and 60 swallows paired with real or sham estim. Regular clinic visits ensured proper exercise execution, and detailed therapy checklists tracked patient compliance which was defined by mean number of sessions performed per week (0-12 times) over the 12-week intervention period. "Compliant" was defined as performing 10-12 sessions/week. Outcomes were changes in PAS, HNCI, PSS, OPSE, and hyoid excursion. ANCOVA analyses determined if outcomes differed between real/sham and compliant/noncompliant groups after 12 weeks of therapy. Of the 170 patients enrolled, 153 patients had compliance data. The mean number of sessions performed was 8.57/week (median = 10.25). Fifty-four percent of patients (n = 83) were considered "compliant." After 12 weeks of therapy, compliant patients in the sham estim group realized significantly better PAS scores than compliant patients in the active estim group (p = 0.0074). When pooling all patients together, there were no significant differences in outcomes between compliant and non-compliant patients. The addition of estim to swallowing exercises resulted in worse swallowing outcomes than exercises alone, which was more pronounced in compliant patients. Since neither compliant nor non-compliant patients benefitted from swallowing exercises, the proper dose and/or efficacy of swallowing exercises must also be questioned in this patient population.

Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program

The background and purpose of this paper is to investigate adherence, exercise performance levels and associated factors in head and neck cancer (HNC) patients participating in a guided home-based prophylactic exercise program during and after treatment [swallowing sparing intensity modulated radiation therapy (SW-IMRT)]. Fifty patients were included in the study. Adherence was defined as the percentage of patients who kept up exercising; exercise performance level was categorized as low: ≤1, moderate: 1–2, and high: ≥2 time(s) per day, on average. Associations between 6- and 12-week exercise performance levels and age, gender, tumour site and stage, treatment, intervention format (online or booklet), number of coaching sessions, and baseline HNC symptoms (EORTC-QLQ-H&N35) were investigated. Adherence rate at 6 weeks was 70% and decreased to 38% at 12 weeks. In addition, exercise performance levels decreased over time (during 6 weeks: 34% moderate and 26% high; during 12 weeks: 28% moderate and 18% high). The addition of chemotherapy to SW-IMRT [(C)SW-IMRT] significantly deteriorated exercise performance level. Adherence to a guided home-based prophylactic exercise program was high during (C)SW-IMRT, but dropped afterwards. Exercise performance level was negatively affected by chemotherapy in combination with SW-IMRT.

Therapeutic intervention in oropharyngeal dysphagia

Oropharyngeal dysphagia is a frequent consequence of several medical aetiologies, and even considered part of the normal ageing process. Early and accurate identification provides the opportunity for early implementation of dysphagia treatments. This Review describes the current state of the evidence related to dysphagia therapies - focusing on treatments most clinically utilized and of current interest to researchers. Despite successes in select studies, the level of evidence to support the efficacy of these treatments remains limited. Heterogeneity exists across studies in both how interventions are administered and how their therapeutic value is assessed, thereby making it difficult to establish external validation. Future work needs to address these caveats. Also, to be most efficacious, dysphagia therapies need to account for influences from pre-morbid patient characteristics as these factors have potential to increase the risk of dysphagia and the resulting complications of aspiration, malnutrition and psychological burden. Dysphagia therapies therefore need to incorporate the medical aetiology that is at its root, the resulting swallow physiology captured from comprehensive clinical and/or instrumental assessments, and the existing needs and supports of patients.

Dysphagia, Speech, Voice, and Trismus following Radiotherapy and/or Chemotherapy in Patients with Head and Neck Carcinoma: Review of the Literature

Introduction. Patients with head and neck cancer suffer from various impairments due to the primary illness, as well as secondary consequences of the oncological treatment. This systematic review describes the effects of radiotherapy and/or chemotherapy on the functions of the upper aerodigestive tract in patients with head and neck cancer. Methods. A systematic literature search was performed by two independent reviewers using the electronic databases PubMed and Embase. All dates up to May 2016 were included. Results. Of the 947 abstracts, sixty articles met the inclusion criteria and described one or more aspects of the sequelae of radiotherapy and/or chemotherapy. Forty studies described swallowing-related problems, 24 described voice-related problems, seven described trismus, and 25 studies described general quality of life. Only 14 articles reported that speech pathologists conducted the interventions, of which only six articles described in detail what the interventions involved. Conclusion. In general, voice quality improved following intervention, whereas quality of life, dysphagia, and oral intake deteriorated during and after treatment. However, as a consequence of the diversity in treatment protocols and patient characteristics, the conclusions of most studies cannot be easily generalised. Further research on the effects of oncological interventions on the upper aerodigestive tract is needed.

Therapeutic exercises for affecting post-treatment swallowing in people treated for advanced-stage head and neck cancers

BACKGROUND

Head and neck cancer treatment has developed over the last decade, with improved mortality and survival rates, but the treatments often result in dysphagia (a difficulty in swallowing) as a side effect. This may be acute, resolving after treatment, or remain as a long-term negative sequela of head and neck cancer (HNC) treatment. Interventions to counteract the problems associated with dysphagia include swallowing exercises or modification of diet (bolus texture, size), or both.

OBJECTIVES

To determine the effects of therapeutic exercises, undertaken before, during and/or immediately after HNC treatment, on swallowing, aspiration and adverse events such as chest infections, aspiration pneumonia and profound weight loss, in people treated curatively for advanced-stage (stage III, stage IV) squamous cell carcinoma of the head and neck.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 6); MEDLINE; PubMed; Embase; CINAHL; LILACS; KoreaMed; IndMed; PakMediNet; Web of Science; ClinicalTrials.gov; ICTRP; speechBITE; Google Scholar; Google and additional sources for published and unpublished trials. The date of the search was 1 July 2016.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of adults with head and neck cancer (stage III, stage IV) who underwent therapeutic exercises for swallowing before, during and/or immediately after HNC treatment to help produce safe and efficient swallowing. The main comparison was therapeutic exercises versus treatment as usual (TAU). Other possible comparison pairs included: therapeutic exercises versus sham exercises and therapeutic exercises plus TAU versus TAU. TAU consisted of reactive management of a patient's dysphagia, when this occurred. When severe, this included insertion of either a percutaneous endoscopic gastroscopy or nasogastric tube for non-oral feeding.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: safety and efficiency of oral swallowing, as measured by reduced/no aspiration; oropharyngeal swallowing efficiency (OPSE) measures, taken from videofluoroscopy swallowing studies; and adverse events, such as chest infections, aspiration pneumonia and profound weight loss. Secondary outcomes were time to return to function (swallowing); self-reported changes to quality of life; changes to psychological well-being - depression, anxiety and stress; patient satisfaction with the intervention; patient compliance with the intervention; and cost-effectiveness of the intervention.

MAIN RESULTS

We included six studies (reported as seven papers) involving 326 participants whose ages ranged from 39 to 83 years, with a gender bias towards men (73% to 95% across studies), reflecting the characteristics of patients with HNC. The risk of bias in the studies was generally high.We did not pool data from studies because of significant differences in the interventions and outcomes evaluated. We found a lack of standardisation and consistency in the outcomes measured and the endpoints at which they were evaluated.We found no evidence that therapeutic exercises were better than TAU, or any other treatment, in improving the safety and efficiency of oral swallowing (our primary outcome) or in improving any of the secondary outcomes.Using the GRADE system, we classified the overall quality of the evidence for each outcome as very low, due to the limited number of trials and their low quality. There were no adverse events reported that were directly attributable to the intervention (swallowing exercises).

AUTHORS' CONCLUSIONS

We found no evidence that undertaking therapeutic exercises before, during and/or immediately after HNC treatment leads to improvement in oral swallowing. This absence of evidence may be due to the small participant numbers in trials, resulting in insufficient power to detect any difference. Data from the identified trials could not be combined due to differences in the choice of primary outcomes and in the measurement tools used to assess them, and the differing baseline and endpoints across studies.Designing and implementing studies with stronger methodological rigour is essential. There needs to be agreement about the key primary outcomes, the choice of validated assessment tools to measure them and the time points at which those measurements are made.

Development and feasibility of a Swallowing intervention Package (SiP) for patients receiving radiotherapy treatment for head and neck cancer-the SiP study protocol

Background

Head and neck cancer (HNC) is the sixth most common cancer worldwide, and the functional, psychological and social consequences of HNC cancer and its treatment can be severe and chronic. Dysphagia (swallowing problems) affects up to two thirds of patients undergoing combined chemoradiotherapy. Recent reviews suggest that prophylactic swallowing exercises may improve a range of short- and long-term outcomes; however, the importance of psychological and behavioural factors on adherence to swallowing exercises has not been adequately studied. This study aims to develop and test the feasibility of a Swallowing intervention Package (SiP) designed in partnership with patients, speech and language therapists (SLTs) and other members of the head and neck multi-disciplinary team (MDT), for patients undergoing chemoradiotherapy (CRT) or radiotherapy (RT) for head and neck cancer.

Methods/design

This feasibility study uses quantitative and qualitative research methods, within a quasi-experimental design, to assess whether patients will tolerate and adhere to the SiP intervention, which aspects of the intervention can be implemented and which cannot, whether treatment fidelity can be achieved across different contexts, whether study processes and outcome measures will be feasible and acceptable and to what extent the intervention is likely to have an impact on swallowing dysfunction and quality of life. Patients are being recruited from five sites in Scotland and England (three interventions and two usual care). The SLT based in the relevant intervention centre teaches the exercise programme and provides supporting materials. A combination of patient-reported outcome measures (PROMs), adherence measures and clinical swallowing assessments are used prior to intervention (baseline), at the end of treatment, 3 and 6 months post-treatment.

Discussion

This collaborative study has taken a unique approach to the development of a patient-centred and evidence-based swallowing intervention. The introduction of an e-SiP app provides an exploration of the use of technology in delivering this intervention. The study provides an opportunity to examine the feasibility of delivering and participating in a supported swallowing intervention across several different NHS sites and will provide the evidence needed to refine intervention and study processes for a future trial.

Trial registration

NCRI portfolio, 18192 & 20259