The impact of developing a speech and swallow rehab program: Improving patient satisfaction and multidisciplinary care

Profiling of swallowing function in head and neck cancer patients prior to radiation therapy-Findings from a tertiary hospital in South India

Purpose

Head and neck cancer (HNC) patients often face difficulties with swallowing, which can be due to the cancer itself or the treatment modalities like radiation therapy. The presentation of HNC can vary between developing and developed countries due to socioeconomic factors. The current study aimed to profile the swallowing function of HNC patients before starting radiation therapy in a tertiary hospital in India.

Method

This cross-sectional observational study examined patients with HNC who were scheduled for radiation therapy. The Functional Oral Intake Scale (FOIS) and Karnofsky Performance Status Scale were used to assess the patients' swallowing status and functional abilities, respectively. The study also evaluated the relationship between swallowing function and clinical-demographic factors.

Results

Our assessment of 162 HNC patients found that the cancer site significantly affects swallowing. Although 92% of patients had an oral diet, 64% made dietary modifications. Patients with non-oral intake had either oral or pharyngeal cancer, and over 80% of oral cancer patients and 60% of those with pharyngeal cancer had already made changes to their diet. Patients with laryngeal cancer had a better oral intake, with 58% reporting no swallowing issues.

Conclusion

Patients with HNC scheduled for radiation therapy may experience varying degrees of swallowing difficulty. Early intervention and teaching of safe swallowing strategies are crucial to prepare for the potential worsening of swallowing difficulties resulting from the treatment. Advanced tumor stages and oral/pharyngeal cancers increase the risk of significant swallowing issues.

Effectiveness of Home-Based Telerehabilitation Interventions for Dysphagia in Patients With Head and Neck Cancer: Systematic Review

BACKGROUND

Multimodal treatment-induced dysphagia has serious negative effects on survivors of head and neck cancer. Owing to advances in communication technologies, several studies have applied telecommunication-based interventions that incorporate swallowing exercises, education, monitoring, feedback, self-management, and communication. It is especially urgent to implement home-based remote rehabilitation in the context of the COVID-19 pandemic. However, the optimal strategy and effectiveness of remote interventions are unclear.

OBJECTIVE

This systematic review aimed to examine the evidence regarding the efficacy of telerehabilitation for reducing physiological and functional impairments related to swallowing and for improving adherence and related influencing factors among head and neck cancer survivors.

METHODS

The PubMed, MEDLINE, CINAHL, Embase, and Cochrane Library databases were systematically searched up to July 2023 to identify relevant articles. In total, 2 investigators independently extracted the data and assessed the methodological quality of the included studies using the quality assessment tool of the Joanna Briggs Institute.

RESULTS

A total of 1465 articles were initially identified; ultimately, 13 (0.89%) were included in the systematic review. The quality assessment indicated that the included studies were of moderate to good quality. The results showed that home-based telerehabilitation improved the safety of swallowing and oral feeding, nutritional status, and swallowing-related quality of life; reduced negative emotions; improved swallowing rehabilitation adherence; was rated by participants as highly satisfactory and supportive; and was cost-effective. In addition, this review investigated factors that influenced the efficacy of telerehabilitation, which included striking a balance among swallowing training strategy, intensity, frequency, duration, and individual motor ability; treating side effects of radiotherapy; providing access to medical, motivational, and educational information; providing feedback on training; providing communication and support from speech pathologists, families, and other survivors; and addressing technical problems.

CONCLUSIONS

Home-based telerehabilitation has shown great potential in reducing the safety risks of swallowing and oral feeding, improving quality of life and adherence, and meeting information needs for dysphagia among survivors of head and neck cancer. However, this review highlights limitations in the current literature, and the current research is in its infancy. In addition, owing to the diversity of patient sociodemographic, medical, physiological and functional swallowing, and behavioral factors, we recommend the development of tailored telemedicine interventions to achieve the best rehabilitation effects with the fewest and most precise interventions.

Clinical Practice Guidelines for Oropharyngeal Dysphagia

OBJECTIVE

Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one's physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia.

METHODS

Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology.

RESULTS

Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended.

CONCLUSION

This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients

OBJECTIVE

To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx.

METHODS

Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible.

RESULTS

The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus.

CONCLUSION

Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Phoniatricians and otorhinolaryngologists approaching oropharyngeal dysphagia: an update on FEES

PURPOSE

Oropharyngeal dysphagia (OD) is a common phenomenon in otorhinolaryngology and phoniatrics. As both sub-disciplines have a strong tradition and clinical experience in endoscopic assessment of the upper aerodigestive tract, the implementation of fiberoptic endoscopic evaluation of swallowing (FEES) was an almost self-evident evolution. This review aims to provide an update on FEES and the role of phoniatricians and otorhinolaryngologists using FEES in Europe.

METHODS

A narrative review of the literature was performed by experts in the field of FEES both in the clinical context and in the field of scientific research.

RESULTS

FEES is the first-choice OD assessment technique for both phoniatricians and otorhinolaryngologists. FEES is becoming increasingly popular because of its usefulness, safety, low costs, wide applicability, and feasibility in different clinical settings. FEES can be performed by health professionals of varying disciplines, once adequate knowledge and skills are acquired. FEES aims to determine OD nature and severity and can provide diagnostic information regarding the underlying etiology. The direct effect of therapeutic interventions can be evaluated using FEES, contributing to design the OD management plan. Standardization of FEES protocols and metrics is still lacking. Technological innovation regarding image resolution, frame rate frequency, endoscopic light source specifications, and endoscopic rotation range has contributed to an increased diagnostic accuracy.

CONCLUSION

The rising number of phoniatricians and otorhinolaryngologists performing FEES contributes to the early detection and treatment of OD in an aging European population. Nevertheless, a multidisciplinary approach together with other disciplines is crucial for the success of OD management.

An integrated care systems model approach for speech and language therapy head and neck cancer services in England: service development and re-design in Cheshire and Merseyside

PURPOSE OF REVIEW

The incidence of head and neck cancer (HNC) is increasing globally and changes in treatment mean that patients are living longer with the condition. It is recognised that while there have been improvements at the diagnostic phase of the pathway, follow-up and on-going care can be fragmented and inequitable. Integrated care models (ICMs) are acknowledged as beneficial. The National Health Service in England is moving to a model whereby services are being re-organised to integrated care systems. This paper reviews the literature and discusses potential models of care to enhance speech and language therapy (SLT) provision for patients with HNC in line with the emerging ICS.

RECENT FINDINGS

The COVID-19 pandemic has provided an opportunity to review service provision and SLT teams quickly adapted to offering remote support. Discussions are currently on-going to explore the potential for patient initiated follow-up via the PETNECK 2 trial and the Buurtzorg 'neighbourhood model' holds promise.

SUMMARY

ICMs put the patient at the centre of care and have reported benefits for experience of care and clinical outcomes. Navigating organisational structures is complex. The Buurtzorg model provides a practical and theoretical framework to support organisational change.

Ibero-American Expert Consensus on Squamous Cell Carcinoma of the Head and Neck Treatment in Patients Unable to Receive Cisplatin: Recommendations for Clinical Practice

Cisplatin is the standard of treatment for squamous cell carcinoma of the head and neck (SCCHN) that has demonstrated efficacy, either in locally advanced disease when combined with radiotherapy at high doses, or in metastatic/recurrent disease when combined with other agents. However, the usual toxicities related to cisplatin, such as neurotoxicity, nephrotoxicity, ototoxicity, and hematologic toxicities, especially when high doses have been administered, have important implications in the patients' quality of life. The decision to administer cisplatin depends on several patient factors, such as age, performance status, weight loss, comorbidities, previous toxicities, chronic viral infection, or even the current SARS-CoV-2 pandemic. In order to establish recommendations for the management of patients with SCCHN, a group of experts in medical and radiation oncology from Spain and Latin-American discussed how to identify patients who are not candidates for cisplatin to offer them the most suitable therapeutic alternative.

Traumatic Spinal Injury: Preliminary Results of Respiratory Function, Voice and Quality of Life

OBJECTIVES

Assess respiratory muscle strength, voice and the quality of life of patients with traumatic cervical and thoracic spinal cord injury.

METHODS

Preliminary analytical case control study of 28 adult men, aged between 18 and 65 years, divided into two groups: a research group consisting of 14 patients with cervical and thoracic spinal cord injury, and control group (CG) with 14 noninjured individuals. The subjects had their maximum inspiratory and expiratory pressures measured, underwent voice handicap index-10 assessment, had their voices recorded for auditory perception analysis, using the voice deviation and GRBASI scales, and for acoustic analysis, based on extraction of the parameters selected and completed a quality-of-life questionnaire (WHOQOL-bref protocol).

RESULTS

Intergroup comparison indicated that the research group exhibited lower respiratory muscle strength in relation to the CG, MIP and MEP P-values < 0.001 and < 0.001, respectively; and in relation to the device's reference value, MIP and MEP P-values < 0.001 and < 0.001, respectively; the patients reported no voice handicaps according to the voice handicap index; overall vocal deviation severity on the voice deviation was higher in the CG, P = 0.040; there was greater occurrence of roughness and instability on the GRBASI scale, P= 0.040; there was greater difficulty in modulating vocal frequency (P= 0.002) and resonance, with a laryngopharyngeal focus; the acoustic parameters were normal; and lower scores were obtained in the physical domain of quality of life (P< 0.001).

CONCLUSION

The individuals with traumatic spinal cord and thoracic injury exhibited changes in respiratory measures, vocal deviation and dissatisfaction in the physical domain of the WHOQOL-bref protocol.

Building an integrated multidisciplinary swallowing disorder clinic: considerations, challenges, and opportunities

Dysphagia is a complex condition with numerous causes, symptoms, and treatments. As such, patients with dysphagia commonly require a multidisciplinary approach to their evaluation and treatment. Integrated multidisciplinary clinics provide an optimal format for a collaborative approach to patient care. In this manuscript, we will discuss considerations for teams looking to build a multidisciplinary dysphagia clinic, including what professionals are typically involved, what patients benefit most from this approach, what tests are most appropriate for which symptoms, financial issues, and traversing interpersonal challenges.

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.

Utilization of rehabilitation services in patients with head and neck cancer in the United States: A SEER-Medicare analysis

BACKGROUND

Head and neck cancer (HNC) and its treatment lead to functional impairments. Rehabilitation by speech-language pathology (SLP) and occupational/physical therapy (OT/PT) can decrease morbidity.

METHODS

The Surveillance, Epidemiology and End Results-Medicare data for patients with HNC diagnosed between 2002 and 2011 was utilized to evaluate posttreatment rehabilitation.

RESULTS

In 16 194 patients, the overall utilization rate was 20.7% for SLP and 26.2% for OT/PT services. Treatment modality was significantly associated rehabilitation utilization. Compared to patients treated with primary surgery, those treated with primary radiotherapy had significantly lower odds of OT/PT utilization. Patients treated with surgery plus adjuvant treatment and primary concurrent chemoradiation had higher odds of SLP utilization compared to patients treated with surgery alone.

CONCLUSIONS

Rehabilitation services appeared to be underutilized by patients with HNC in the United States and vary with treatment modality. There is a need to improve integration of rehabilitation services into the HNC care continuum.

SUMMARY

Rehabilitation services are underutilized by patients with HNC during posttreatment surveillance in the United States. Treatment modality significantly impacts rehabilitation utilization patterns.