Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors

Systematic review of adherence to swallow and trismus exercises during radiation therapy for head and neck cancer

Understanding the barriers and facilitators for prophylactic swallowing and trismus exercises for patients undergoing radiation to the head and neck may help exercise adherence. The analysis reviews all published reports of exercise adherence with a critical appraisal following PRISMA guidelines. A total of 137 potential papers were identified; 20 studies met the inclusion criteria. The most commonly reported facilitators for swallowing and trismus exercises were regular clinician contact and online resources to reinforce instructions, set goals, and manage radiation toxicities. Social support and perceived benefit from exercises were also reported to be of help. The most common barriers to exercise were radiation toxicities, anxiety, feeling overwhelmed with information, and not understanding the reason for the exercises. Understanding facilitators and barriers to adherence is critical when designing exercise interventions for patients undergoing radiation for head and neck cancer.

Exercise-Based Dysphagia Treatment: A Proposed Checklist

PURPOSE

Oropharyngeal swallowing exercise-based interventions are frequently utilized to target physiologic mechanisms with the goal of improving swallowing function. However, study replicability and evidence synthesis regarding effects of interventions are limited due to inconsistent reporting on factors known to influence treatment delivery. In order to promote consistency of reporting factors associated with replicability, the authors constructed a set of preferred parameters focused on dysphagia as part of the initial version of the larger tool (Framework for RigOr aNd Transparency In REseaRch on Swallowing or FRONTIERS).

METHOD

Thirty-eight initial questions were assembled by the authors as part of the treatment subsection. Questions were then reviewed by individuals in the FRONTIERS collaborative who have expertise in research, clinical practice, or both.

RESULT

Twenty-four questions were removed following review, reducing the final set of treatment-focused questions to 14 questions.

CONCLUSIONS

The revised set of questions provides users of the exercise-based treatment section of the FRONTIERS checklist with an initial checklist to promote transparency and rigor to improve study replicability and evidence synthesis. We intend for this treatment section of FRONTIERS to undergo further refinement following commentary and feedback.

Socioeconomic Impact on Swallow Therapy Attendance

Dysphagia negatively impacts quality of life and increases health care costs. Swallow therapy is the primary and effective treatment for dysphagia of various etiologies, and attendance is critical to success. This study seeks to identify barriers to swallow therapy attendance at a tertiary care, safety-net hospital. A total of 309 patients were referred for swallow therapy from January 1, 2018, to April 30, 2019. Patients were divided into those who "Attended" at least one swallow therapy appointment and those who "Did not Attend" any swallow therapy appointment. Demographics, socioeconomic factors, and diagnosis prompting therapy referral were compared between the two groups. Socioeconomic status (SES) was based on insurance status and income. 177 patients (57%) attended at least one swallow therapy appointment and 132 (43%) did not attend any appointments. Overall, 240 (78%) patients had public insurance and 69 (22%) had private insurance. Analysis of SES status identified 106 (34%) patients as double-low SES, 157 (51%) as low SES, and 43 (14%) as high SES. Referral diagnoses were "Dysphagia-unspecified type" (n = 119, 38%), "Cancer" (n = 66, 21%), "Neurologic" (n = 46, 15%), "Globus" (n = 29, 9%), "Aspiration" (n = 17, 6%), "Reflux" (n = 17, 6%), and "Throat Pain" (n = 15, 5%). No patient demographic factors, SES factors, or referral diagnosis correlated significantly with swallow therapy attendance. Overall, swallow therapy attendance was poor. In this group, socioeconomic and demographic factors did not significantly impact swallow therapy attendance. Future research should focus on identifying barriers to swallow care and strategies to improve attendance.

Exploring the Acceptability of Behavioral Swallowing Interventions for Head and Neck Cancer Patients During Radiotherapy: A Qualitative Study of Patients' Experience

The PRO-ACTIVE randomized clinical trial offers 3 swallowing therapies to Head and Neck Cancer (HNC) patients during radiotherapy namely: reactive, proactive low- ("EAT-RT" only), and high-intensity ("EAT-RT + exercises"). Understanding the perceived acceptability of these interventions is important to inform eventual implementation into clinical practice. This study explored patients' perspectives using qualitative methodology. At 2 Canadian PRO-ACTIVE trial sites, 24 trial participants were recruited for individual semi-structured interviews, representing each of the 3 trial arms. Data collection and thematic analysis were guided by the Theoretical Framework of Acceptability (TFA). Member checking was conducted through follow-up focus groups. Seven themes were derived reflecting the TFA constructs. Overall, regardless of trial arm, patients reported a positive experience with therapy. Patients identified benefits of EAT-RT therapy, reporting that it provided meaningful feedback on diet progress and supported goal setting for oral intake. Patients who received proactive therapies valued the opportunity to set expectations early, build mealtime routine iteratively over time, and have an extended engagement with the SLP. Regardless of trial arm, patients agreed proactive therapy aligned with what they think is best and that therapy intensity should accommodate individual needs. This study identified the value to HNC patients of receiving swallowing interventions during RT and setting realistic expectations around swallowing. Compared to reactive care, proactive therapies were perceived helpful in consolidating habits early, establishing realistic expectations around swallowing and building an extended rapport with the SLP. These findings will inform the implementation of proactive versus reactive swallowing therapies in clinical practice.

Preventing radiation-induced dysphagia and trismus in head and neck cancer-A randomized controlled trial

BACKGROUND

Radiation-induced dysphagia and restricted mouth opening are common problems among patients with head and neck cancer. The aim of the present randomized controlled trial was to determine if an exercise protocol could prevent swallowing and mouth opening impairment.

METHODS

Eighty-nine participants were randomly assigned to either an active group performing preventive swallowing and mouth opening exercises (n = 45) or to a control group (n = 44). Outcome measures were collected at baseline before radiotherapy and approximately 1-month post-treatment. Primary endpoints were changes in swallowing function according to the Penetration Aspiration Scale and mouth opening ability measured in millimeters. Intention-to-treat analysis was used.

RESULTS

Swallowing function and mouth opening deteriorated in both groups, with no statistically significant positive effect of the protocol detected at follow-up. Among patients who completed >75% of exercises, there was a trend toward better outcomes.

CONCLUSIONS

Preventive exercises did not improve short-term swallowing function and mouth opening after radiotherapy.

The Acceptability of Behavioural Swallowing Interventions for Head and Neck Cancer Patients During Radiotherapy: A Qualitative Study Exploring Experiences of Clinical Trial Speech-Language Pathologists

The PRO-ACTIVE randomized clinical trial offers 3 swallowing therapies to Head and Neck Cancer (HNC) patients during radiotherapy (RT) namely: reactive, proactive low- ("EAT-RT" only) and high-intensity ("EAT-RT + exercises"). Understanding the experiences of the trial Speech-Language Pathologists (SLPs) will be useful to inform clinical implementation. This study assessed SLP opinions of acceptability and clinical feasibility of the 3 trial therapies. 8 SLPs from 3 Canadian PRO-ACTIVE trial sites participated in individual interviews. Using a qualitative approach, data collection and thematic analysis were guided by the Theoretical Framework of Acceptability. Member checking was conducted through a follow-up focus group with willing participants. Seven themes were derived: intervention coherence, burden, barriers/facilitators, self-efficacy, attitude, ethicality, and perceived effectiveness. SLPs felt all 3 therapies had potential benefit yet perceived more advantages of proactive therapies compared to reactive. Compared to exercises, SLPs particularly endorsed the EAT-RT component. A major barrier was keeping patients motivated, which was impacted by acute toxicity and sometimes conflicting instructions from the healthcare team. Strategies utilized by to overcome barriers included: scaling exercises and/or diet up/down according to the changing patient needs and communicating therapy goals with healthcare team. A model was derived describing the perceived acceptability of the swallowing therapies according to SLPs, based on the interconnection of main themes. Proactive therapies were perceived as more acceptable to trial SLPs, for facilitating patient engagement. The perceived acceptability of the swallowing therapies was related to seven interconnected aspects of providers' experience. These findings will inform the implementation and potential uptake of the PRO-ACTIVE swallowing therapies in clinical practice.

Prophylactic Swallowing Therapy During Head-and-Neck Cancer Radiotherapy: Effect of Service-Delivery Mode and Overall Adherence Level on Swallowing Function and Muscle Strength-the PRESTO Trial

Prophylactic swallowing exercises (PSE) during head-and-neck cancer (HNC) (chemo)radiotherapy (CRT) have a positive effect on swallowing function and muscle strength. Adherence rates to PSE are, however, moderate to low, undermining these effects. PRESTO already showed that the service-delivery mode (SDM), the way the exercises are offered, can influence adherence. The aim of this study was to investigate the effect of SDM on swallowing function and muscle strength during and post-CRT. In addition, the effect of overall adherence (OA), independent of SDM, was also investigated. A total of 148 HNC patients, treated with CRT, were randomly assigned to one of the three SDM's (paper-supported, app-supported, or therapist-supported PSE) and performed a 4-week PSE program. OA was calculated based on the percentage of completed exercises. Patients were divided into OA levels: the OA75+ and OA75- group performed respectively ≥ 75 and < 75% of the exercises. Swallowing function based on Mann Assessment of Swallowing Ability-Cancer (MASA-C), tongue and suprahyoid muscle strength during and up to 3 months after CRT were compared between the SDM's and OA levels. Linear Mixed-effects Models with post hoc pairwise testing and Bonferroni-Holm correction was used. No significant differences were found between the three SDMs. Significant time effects were found: MASA-C scores decreased and muscle strength increased significantly during CRT. By the end of CRT, the OA75+ showed significantly better swallowing function compared to OA75-. Muscle strength gain was significantly higher in the OA75+ group. SDM had no impact on swallowing function and muscle strength; however, significant effects were shown for OA level. Performing a high level of exercise repetitions is essential to benefit from PSE.Trial registration ISRCTN, ISRCTN98243550. Registered December 21, 2018-retrospectively registered, https://www.isrctn.com/ISRCTN98243550?q=gwen%20van%20nuffelen&filters=&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search.

Improvement in Swallowing Function in Patients with Previous Irradiation for Nasopharyngeal Carcinoma by Expiratory Muscle Strength Training

Dysphagia and chronic aspiration are common post-irradiation complications in nasopharyngeal carcinoma (NPC) survivors. Expiratory Muscle Strength Training (EMST) is a simple device-driven exercise therapy for swallowing training. This study investigates the effectiveness of EMST in a group of post-irradiated NPC patients. This prospective cohort, including twelve patients with previous irradiation for NPC and with swallowing disturbance, was performed between 2019 and 2021 in a single institution. Patients were trained with EMST for 8 weeks. Non-parametric analyses examined effects of EMST on primary outcome, maximum expiratory pressure. Secondary outcomes were measured with Penetration-aspiration scale, Yale pharyngeal residue severity rating scale (YPRSRS) by flexible endoscopic evaluation of swallowing, and Eating Assessment Tool (EAT-10) and M.D. Anderson Dysphagia Inventory questionnaire. Twelve patients, with a mean (SD) age of 64.3 (8.2) were recruited. There was no patient dropout with 88.9% overall compliance of training. Maximum expiratory pressure improved by 41% (median 94.5 to 133.5 cmH2O, p = 0.003). There was reduction in Penetration-aspiration scale with thin liquid (median 4 to 3, p = 0.026), and in YPRSRS at pyriform fossa with mildly thick liquid (p = 0.021) and at vallecula with thin liquid (p = 0.034), mildly thick liquid (p = 0.014) and pureed meat congee (p = 0.016). Questionnaire scores did not significantly change statistically. EMST is an easy-to-use and effective exercise therapy to improve airway safety and swallowing function in post-irradiated NPC survivors.

Prehabilitation in radiation therapy: a scoping review

PURPOSE/OBJECTIVES

Radiation therapy (RT) is a central component of cancer treatment with survival and long-term quality-of-life benefits across a spectrum of oncologic diagnoses. However, RT has been associated with varying levels of fatigue, pain, weight loss, and changes in mental health both during and post-treatment. Prehabilitation aims to optimize health prior to anti-neoplastic therapy in order to reduce side effects, increase adherence to treatment, expedite post-treatment recovery, and improve long-term outcomes. Though prehabilitation has been studied in those undergoing cancer-related surgery, literature on prehabilitation in individuals undergoing RT has not been comprehensively explored. Thus, this scoping review aims to summarize the existing literature focused on prehabilitation interventions for patients receiving RT.

MATERIALS/METHODS

The PRISMA-ScR checklist for conducting scoping reviews was adopted to identify and evaluate studies investigating the efficacy of prehabilitation before and during RT for cancer over the past 21 years (10/2002-10/2022). A search of prehabilitation and RT was performed to identify studies investigating prehabilitation interventions in adult cancer patients undergoing RT.

RESULTS

A total of 30 articles met inclusion criteria, yielding 3657 total participants. Eighteen (60%) studies were randomized controlled trials (RCTs) with sample sizes ranging from 21 to 221. The most commonly studied populations were patients with head and neck cancer, followed by rectal, breast, and lung cancer. A majority (80%) of studies evaluated one prehabilitation intervention (i.e., unimodal). Targeted physical exercises were the most common intervention, followed by general physical exercises and technology/apps. Adherence/feasibility was the most common primary outcome, representing 30% of studies. All studies reported data on sex, and 5 (17%) reported data on race and/or ethnicity.

CONCLUSIONS

Prehabilitation interventions have been successfully implemented in patients with cancer undergoing surgical treatment. Based on limited current literature, prehabilitation appears to have a promising effect in reducing morbidity in adult cancer patients requiring RT. Though our review identified many RCTs, they were frequently small sample trials with primary outcomes focused on feasibility, rather than functional status or quality of life. Thus, there is a need for adequately powered, randomized controlled intervention trials to investigate the efficacy of prehabilitation and maximize the treatment outcomes for patients undergoing RT.

Swallowing muscle training for oropharyngeal dysphagia: A non-inferiority study of online versus face-to-face therapy

INTRODUCTION

The purpose of this study is to show the non-inferiority of the telemedicine therapy versus face-to-face using the exercise therapy of oropharyngeal muscles in 183 patients treated consecutively from 2010 to 2020.

METHOD

We conducted a retrospective study comparing two dysphagia treatment groups: online versus face-to-face. Patients were distributed in a non-random way but according to patient's preferences. All patients followed the same pathway and were evaluated at the beginning and at the end of the study using the dysphagia outcome and severity scale and the functional oral intake scale. A non-inferiority analysis approximation was done with delta = 1 in both variables.

RESULTS

Within a total of 183 patients, 114 (62.3%) used the online treatment and 69 (37.7%) the face-to-face one. The main cause of dysphagia was neurological in the total sample (60.7%) and within both groups. When we evaluate the clinical response, we find that both groups improved regardless of the type of therapy. The confidence interval of the difference between the beginning and the end of treatment did not reach the inferior limit of the delta defined, therefore supporting the no inferiority of online versus presential.

DISCUSSION

This study shows the no inferiority of the online therapy versus the face-to-face one for the oropharyngeal training of the swallow muscles.

Prehabilitation of dysphagia in the therapy of head and neck cancer- a systematic review of the literature and evidence evaluation

Background

Prehabilitation is becoming increasingly important in oncology because of the significant survival benefits that the reduction of malnutrition provide. Specifically, tumor- and therapy-related dysphagia leads to malnutrition in more than half of head and neck tumor patients. Studies describe the positive effects of an early onset of swallow-specific prehabilitation on the protection of the swallowing function. This paper intents to evaluate the existing evidence on the efficacy of preventive forms of swallowing therapy.

Methods

A systematic literature search was performed in February 2022 in the Cochrane Library, MEDLINE via PubMed, and ClinicalTrials.gov databases for randomized controlled trials investigating preventive swallowing therapy in head and neck tumor patients. This Procedure complies with the PRISMA statement. The RCTs were evaluated by using the PEDro Scale and the Cochrane Risk of Bias tool RoB2.

Results

Five randomized-controlled trials with 423 participants were identified. Four Studies showed moderate to high quality in the PEDro analysis, one showed less. The risk of bias was high in all studies because there was no possibility for blinding and there were high dropout rates. Heterogeneity in interventions, measurement instruments, measurement time points, and outcomes limits a general statement about which swallowing exercises are suitable for the prevention of dysphagia in head and neck tumor patients. Evidence is provided for short-term effects (≤24 months) on functional aspects of swallowing and quality of life. Overall, a decreasing adherence over time was observed in the intervention groups.

Discussion

Initial studies describe swallowing-specific prehabilitation programs in head and neck tumor patients as effective, at least in the short term, whereas long-term effects need to be further investigated. At the current time the evidence base for clear recommendations does not appear to be sufficiently high and studies share a high risk of bias. Further well-designed research, especially considering the conditions in the national health care system, is needed.

Other

There was no funding and no registration.

Quality of life and swallowing outcomes after early proactive swallowing rehabilitation by either transcutaneous neuromuscular electrical stimulation or exercise-based swallowing training in patients with nasopharyngeal carcinoma after radiotherapy

Background

Exercise-based swallowing training (EBST) and transcutaneous neuromuscular electrical stimulation (TNMES) are common modalities used to treat late dysphagia after radiotherapy for nasopharyngeal carcinoma (NPC). We aimed to investigate and compare the efficacies of EBST and TNMES as proactive treatments administered early after radiotherapy.

Methods

Patients with early post-radiotherapy NPC (n = 120) underwent either TNMES or EBST. Flexible endoscopic evaluation of swallowing (FEES), quality of life (QOL), and swallowing function questionnaires were completed before the intervention as well as immediately, 6, and 12 months after the intervention. Outcome measures included the scores for the swallowing function score (SFS), penetration and aspiration scale (PAS), dynamic imaging grade of swallowing toxicity (DIGEST), functional oral intake scale (FOIS), swallowing performance status scale (SPSS), pharyngeal motor impairment (PMI), pharyngeal function impairment (PFI), and functional assessment after cancer therapy-nasopharyngeal (FACT-NP) questionnaire.

Results

Three months after radiotherapy, 31 and 34 patients underwent TNMES and EBST, respectively, and completed swallowing assessments at all four assessment timepoints. All patients showed post-radiotherapy impairments in the SFS, PAS, DIGEST, PMI, and PFI. Compared with the EBST group, the TNMES group showed significant improvements in the PFI and PMI scores, with small-to-medium effect sizes. Additionally, compared with the EBST group, the TNMES group demonstrated a trend toward slightly better improvements in the PAS, DIGEST, FOIS, and SPSS scores immediately and 6 months after the intervention. The SFS scores improved from baseline in both groups; however, the TNMES group showed an earlier improvement. Finally, the TNMES group showed better QOL according to the FACT-NP than the EBST group.

Conclusion

Proactive TMNES and EBST are safe and feasible modalities for improving swallowing in patients with NPC when administered early after radiotherapy. Although TNMES showed better results than EBST, these results should be interpreted with caution given the study limitations.

Level of evidence

1B.

Stratifying Risk of Nonadherence in Lingual Strengthening Dysphagia Rehabilitation

PURPOSE

Exercise-based treatments may improve swallowing safety and efficiency; yet, it is not clearly understood which factors predict nonadherence to recommended treatment protocols. The aim of this study was to construct an algorithm for stratifying risk of nonadherence to a lingual strengthening dysphagia treatment program.

METHOD

Using recursive partitioning, we created a classification tree built from a pool of sociodemographic, clinical, and functional status indicators to identify risk groups for nonadherence to an intensive lingual strengthening treatment program. Nonadherence, or noncompletion, was defined as not completing two or more follow-up sessions or a final session within 84 days.

RESULTS

The study cohort consisted of 243 Veterans enrolled in the Intensive Dysphagia Treatment program across six sites from January 2012 to August 2019. The overall rate of nonadherence in this cohort was 38%. The classification tree demonstrated good discriminate validity (C-statistic = 0.74) and contained eight groups from five variables: primary diagnosis, marital status, Penetration-Aspiration Scale (PAS) severity score, race/ethnicity, and age. Nonadherence risk was categorized as high (range: 69%-77%), intermediate (27%-33%), and low risk (≤ 13%-22%).

CONCLUSIONS

This study identified distinct risk groups for nonadherence to lingual strengthening dysphagia rehabilitation. Additional research is necessary to understand how these factors may drive nonadherence. With external validation and refinement through prospective studies, a clinically relevant risk stratification tool can be developed to identify patients who may be at high risk for nonadherence and provide targeted patient support to mitigate risk and provide for unmet needs.

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.

Telehealth Interventions in Head and Neck Cancer Patients: A Systematic Review

BACKGROUND

Head and neck cancer (HNC) and its treatments often result in adverse effects that impair a patient's quality of life. Although intensive rehabilitative strategies can be used, their applicability can be limited due to patient-specific and socioeconomic barriers. Telehealth interventions represent a possible novel approach to increase access to these services and improve posttreatment quality of life in the HNC population.

OBJECTIVE

The objective of this systematic review was to identify studies investigating telemedicine-based interventions for HNC patients to determine whether there is a consensus concerning the cost-effectiveness, clinical utility, and accessibility of this model for rehabilitation.

METHODS

PubMed, EMBASE, Web of Science, and CINAHL were used to identify literature without time limit for publication. A critical appraisal of individual sources was conducted by 2 reviewers. Sixteen studies met inclusion criteria.

RESULTS

Studies related to telehealth interventions in the HNC population are limited. Salient themes included feasibility of telehealth as an intervention, effects on self-management and knowledge, impact on quality of life, physical and psychiatric symptoms, and cost.

CONCLUSION

Although the current literature presents promising data, indicating that telehealth interventions may be both effective and cost-efficient in the management of HNC patients, more research is needed to definitively elucidate their role in management.

IMPLICATIONS FOR PRACTICE

Telehealth interventions are valuable for clinicians as an alternative to expand access to care across the cancer continuum, to strengthen patients' knowledge and consequently their self-management, and to provide continuity of services as well as for remote monitoring of symptoms and response to treatment.

Adherence to swallowing recommendations during (chemo)radiotherapy in head and neck cancer survivors: a scoping review

PURPOSE OF REVIEW

There is a paucity of knowledge regarding patient adherence to dysphagia recommendations. It is recognized that unique barriers and facilitators contribute to poor treatment adherence in head and neck cancer (HNC) survivors. This review aims to identify the key themes and knowledge gaps regarding adherence to swallowing recommendations in HNC survivors during (chemo)radiotherapy (C)RT.

RECENT FINDINGS

Seven studies were identified. Six facilitators to adherence were extracted, namely pain relief, behavioural intervention, attendance at multidisciplinary clinic, individualised swallowing therapy, absence of prophylactic percutaneous endoscopic gastronomy (PEG) and positive social control from a spouse. Barriers to adherence included pain, depression and presence of prophylactic PEG. Adherence to swallowing recommendations positively impacted swallowing outcomes in one study.

SUMMARY

Little is known about adherence to swallowing recommendations during (C)RT in HNC survivors. Capturing adherence is challenging. Several knowledge gaps were identified. Further research is needed to better understand the barriers and facilitators from the survivors' perspective. This will inform development of best practice regarding how swallowing recommendations are provided to promote adherence and improve outcomes.

Dysphagia Advances in Head and Neck Cancer

Purpose of Review

This review summarises the current literature regarding head and neck cancer-associated dysphagia. Up-to-date evidence for dysphagia outcome measurement for this population is provided, in addition to recent innovations that aim to prevent, reduce or remediate the common and debilitating side effects of treatment.

Recent Findings

Both patient-reported outcomes and clinical measures are necessary to capture the multi-dimensional nature of swallowing. A minimally important difference in scores has been calculated for some of these measures, to aid interpretation and powering of clinical trials. The number of dysphagia-related trials has increased, predominantly investigating optimal treatment for oropharyngeal HPV-positive disease, and speech and language pathology interventions using an impairment-based approach.

Summary

Although substantial progress has been made, further work is necessary to establish a consensus over outcome measures. Modifying treatments may improve outcomes. Several trials are underway to establish the effectiveness of speech and language pathology dysphagia interventions.

Usefulness of Telemedicine for Disabled Children Receiving Feeding Therapy

We performed a retrospective cohort study using medical records of 374 pediatric patients who visited a university dental clinic specializing in dysphagia rehabilitation in Japan between 2019 and 2020 to clarify the usefulness of telemedicine among disabled children receiving feeding therapy. The primary outcome was the feeding developmental stage confirmed at the final evaluation. Propensity score matching was performed between individuals in two treatment groups (in-person and telemedicine) before the final analysis using patients' age, sex, primary disease, gross motor function, and feeding developmental stage as covariates. A total of 36 patients were enrolled in each of the in-person and telemedicine groups. The initial evaluation for the propensity score matched population using the χ² test showed no significant difference between the two groups in any parameter. The feeding developmental stage evaluated at the final evaluation using the Wilcoxon signed-rank test significantly improved compared with the stage at the initial evaluation in both groups (in-parson group, p = 0.007; telemedicine group, p = 0.013). The difference in level achieved at the final evaluation revealed that the most common level was "unchanged," followed by "improvement by one level" in both groups, indicating that there was no significant difference in the efficacy of feeding therapy between the two groups (p = 0.314). Our results show that telemedicine can achieve the same therapeutic outcomes as in-person therapy to improve feeding function in children with disabilities when receiving feeding therapy.

Feasibility and Cost of Telehealth Head and Neck Cancer Survivorship Care: A Systematic Review

OBJECTIVE

Evaluate the feasibility and cost-effectiveness of telehealth head and neck cancer (HNC) survivorship care.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, CINAHL.

REVIEW METHODS

A systematic search for peer-reviewed feasibility studies on telehealth models for HNC survivorship care published between 2005 and 2021 was conducted using the terms "head and neck cancer" and "telehealth" and their synonyms. Inclusion criteria were studies on telehealth survivorship program interventions for HNC patients with quantitative feasibility outcome measures (eg, enrollment, retention, attrition/dropout rate, adherence/task completion rate, patient satisfaction, cost).

RESULTS

Thirty-eight studies out of 1557 identified met inclusion criteria and were included for analysis. Feasibility outcomes evaluated were enrollment and attrition rates, adherence/task completion rates, patient satisfaction, and user feedback surveys in different survivorship domains. Patient enrollment ranged from 20.8% to 85.7%, while attrition ranged from 7% to 47.7%. Overall, adherence was 30.2% higher in the intervention group than in the control group (46.8% vs 16.6%). Studies with cost analysis found telehealth models of care to be statistically significantly less expensive and more cost-efficient than the standard model of care, with a $642.30 saving per patient (n = 3). Telehealth models also substantially reduced work time saving per visit (on average, 7 days per visit).

CONCLUSION

While telehealth survivorship programs are feasible and cost-effective and are associated with improved patient outcomes, they might not be ideal for every patient. Further investigations are needed to understand the role of telehealth in survivorship care, given the variability in study design, reporting, measures, and methodological quality.

Improving compliance with swallowing exercise to decrease radiotherapy-related dysphagia in patients with head and neck cancer

Objective

Dysphagia, one of the most common complications in head and neck cancer (HNC) treated with radiotherapy, can severely affect patients' quality of life. Currently, because no "gold standard" treatment exists, swallowing exercise remains the main rehabilitation strategy for dysphagia. However, patients' compliance with long-term swallowing exercise is only 40%, thus, greatly compromising outcomes. This article aims to analyze thefactors influencing swallowing exercise compliance in patients with HNC and explains strategies developed to date for improved rehabilitation outcomes.

Methods

Research studies published between 2005 and 2022 were retrieved from seven databases: PubMed, Cochrane Library, Embase, CINAHL, CNKI, Wan Fang Database, and VIP Database, and 21 articles were shortlisted and systematically reviewed.

Results

The swallowing exercise compliance in patients with HNC undergoing radiotherapy was affected by multiple factors, including socio-demographic factors, illness-associated factors, treatment-associated factors, and psychosocial factors. Regarding the interventions, current strategies mainly address psychosocial issues via developing various education programs.

Conclusions

Different factors influencing swallowing exercise compliance are important and should be observed. Measures including developing multidisciplinary teams, applying innovative equipment, refining the intervention procedure, and applying systematic theory frameworks should be performed to achieve better outcomes of compliance interventions.

Effect of Intensive Oropharyngeal Training on Radiotherapy-Related Dysphagia in Nasopharyngeal Carcinoma Patients

OBJECTIVE

To evaluate the effect of intensive oropharyngeal functional training on swallowing in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma.

METHODS

Fourteen patients with nasopharyngeal carcinomas and dysphagia after radiotherapy received intensive oropharyngeal training for two weeks. The Functional Oral Intake Scale (FOIS) and videofluoroscopic swallowing studies (VFSS) were used to evaluate swallowing function before and after intensive oropharyngeal training. Spatiotemporal parameters of the VFSS were analyzed using a digital image analysis system.

RESULTS

After training, the FOIS, Rosenbek penetration-aspiration score, DIGEST, normalized residue ratio scale, and spatiotemporal parameters of VFSS were significantly improved (P < 0.05).

CONCLUSIONS

This study indicated that intensive oropharyngeal training improves swallowing function after radiotherapy in patients with nasopharyngeal carcinoma.

The Feasibility of Home-Based Treatment Using Vibratory Stimulation in Chronic Severe Dysphagia

PURPOSE

Previously, externally placed vibratory laryngeal stimulation increased rates of swallowing in persons with and without dysphagia. This study examined the feasibility of using a vibratory device on the skin over the thyroid cartilage for home-based swallowing rehabilitation in long-standing dysphagia.

METHOD

Only participants with long-standing dysphagia (> 6 months) following cerebrovascular accident or head/neck cancer who had not previously benefited from dysphagia therapy participated. The device had two modes used daily for 90 days. In automatic mode, participants wore the device when awake, which vibrated for 4-8 s every 5 min to trigger a volitional swallow. In manual mode, participants practiced by activating vibration while swallowing rapidly. Study-related adverse events, such as pneumonia, and device-recorded adherence were tracked. Swallowing function on a modified barium swallow study was assessed at baseline and after 3 months of device use. Outcome measures included the Dysphagia Outcome and Severity Scale (DOSS), Penetration-Aspiration Scale (PAS), and swallowing timing measures. Participants' perceptions of the vibratory device and training were obtained.

RESULTS

The intent to treat analysis showed seven of 11 participants completed the study, all with severe chronic dysphagia. Of those seven participants completing the study, two developed respiratory complications (possibly due to pneumonia) that cleared after antibiotic intervention. For prescribed practice trials, adherence was 80% or greater in four of seven participants (57%) whereas prescribed automatic stimulations were met in only two of seven participants (29%). Three participants (43%) had a modest benefit on DOSS. The time to vestibule closure after the bolus passed the ramus was reduced in five participants (71%) on the modified barium swallow study.

CONCLUSION

Overall, the results have indicated that intensive home-based practice with stimulation may provide limited functional benefits in severe chronic dysphagia.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21498591.

Home-based intensive treatment of chronic radiation-associated dysphagia in head and neck cancer survivors (HIT-CRAD trial)

Background

Chronic radiation-associated dysphagia (C-RAD) is considered to be one of the most severe functional impairments in head and neck cancer survivors treated with radiation (RT) or chemoradiation (CRT). Given the major impact of these late toxicities on patients’ health and quality of life, there is a strong need for evidence-based dysphagia management. Although studies report the benefit of strengthening exercises, transference of changes in muscle strength to changes in swallowing function often remains limited. Therefore, combining isolated strengthening exercises with functional training in patients with C-RAD may lead to greater functional gains.

Methods

This 3-arm multicenter randomized trial aims to compare the efficacy and possible detraining effects of mere strengthening exercises (group 1) with a combination of strengthening exercises and functional swallowing therapy (group 2) and non-invasive brain stimulation added to that combination (group 3) in 105 patients with C-RAD. Patients will be evaluated before and during therapy and 4 weeks after the last therapy session by means of swallowing-related and strength measures and quality of life questionnaires.

Discussion

Overall, this innovative RCT is expected to provide new insights into the rehabilitation of C-RAD to optimize post-treatment swallowing function.

Trial registration

International Standard Randomized Controlled Trials Number (ISRCTN) registry ID ISRCTN57028065. Registration was accepted on 15 July 2021.

Exploring patient experiences with a telehealth approach for the PRO-ACTIVE trial intervention in head and neck cancer patients

INTRODUCTION

Following the COVID-19 directive to cease non-essential services, a rapid shift was made in the delivery of Speech Language Pathology (SLP) dysphagia management in the 3-arm, randomized PRO-ACTIVE trial. To inform future programs, this study explored patients' experiences with telehealth when the planned in-person SLP intervention was moved to a telehealth modality.

METHODS

A theory-guided qualitative descriptive approach was used. Willing participants who had received at least one telehealth swallowing therapy session participated in a one-time semi-structured interview. Interview transcripts were subjected to a standard qualitative content/theme analysis. Researchers reviewed all transcripts and used a multi-step analysis process to build a coding framework through consensus discussion. Summaries and key messages were generated for each code.

RESULTS

Eleven participants recounted their telehealth experiences and reported feeling satisfied, comfortable and confident with the session(s). They identified that previous experience with teleconferencing, access to optimal technical equipment, clinician skill, and caregiver assistance facilitated their telehealth participation. Participants highlighted that telehealth was beneficial as it reduced commuting time, COVID-19 exposure and fatigue from travel; and also allowed caregiver participation particularly during COVID. In comparing their in-person SLP sessions to telehealth sessions, limitations were also identified, including: lack of previous experience with and/or poor access to technology, and less opportunity for personalization. Participants indicated that use of phone alone was less preferred than an audio/video platform.

DISCUSSION

Patients reported that overall, telehealth sessions did not compromise their learning experience when compared to in-person sessions. Patients benefited from use of telehealth in several ways despite some limitations of the use of technology. Patient feedback about telehealth provides an important perspective that may be critical to inform best practices for care delivery.

Increasing Adherence to Prophylactic Swallowing Exercises During Head and Neck Radiotherapy: The Multicenter, Randomized Controlled PRESTO-Trial

Background

Prophylactic swallowing exercises (PSE) during radiotherapy can significantly reduce dysphagia after radiotherapy in head and neck cancer (HNC). However, its positive effects are hampered by low adherence rates during the burdensome therapy period. Hence, the main goal of this multicenter randomized controlled trial (RCT) was to investigate the effect of 3 different service-delivery modes on actual patients’ adherence.

Methods

A total of 148 oropharyngeal cancer patients treated with primary (chemo)radiotherapy were randomly assigned to a 4 weeks PSE program, either diary-supported (paper group; n = 49), app-supported (app group; n = 49) or therapist-supported (therapist group; n = 50). Participants practiced 5 days/week, daily alternating tongue strengthening exercises with chin tuck against resistance exercises. Adherence was measured as the percentage of completed exercise repetitions per week (%reps). Statistical analysis was performed by means of SPSSv27, using Linear Mixed-effects Models with post hoc pairwise testing and Bonferroni-Holm correction.

Results

Adherence and evolution of adherence over time was significantly different between the three groups (p < .001). Adherence rates decreased in all three groups during the 4 training weeks (p < .001). During all 4 weeks, the therapist group achieved the highest adherence rates, whilst the app group showed the lowest adherence rates.

Conclusions

PSE adherence decreased during the first 4 radiotherapy weeks regardless of group, but with a significant difference between groups. The therapist group achieved the highest adherence rates with a rather limited decline, therefore, increasing the face-to-face contact with a speech-language therapist can overcome the well-known problem of low adherence to PSE in this population.

Trial Registration

Trial registration: ISRCTN, ISRCTN98243550. Registered December 21, 2018 – retrospectively registered, https://www.isrctn.com/ISRCTN98243550?q=gwen%20van%20nuffelen&filters=&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search.

Systematic Review of Functional Outcomes in Cancer Rehabilitation

OBJECTIVE

To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019.

STUDY SELECTION

Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion.

DATA EXTRACTION

Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV).

DATA SYNTHESIS

Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome.

CONCLUSIONS

These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

A Systematic Review of Adherence Strategies for Adult Populations in Speech-Language Pathology Treatment

PURPOSE

Speech-language pathologists (SLPs) often advise adult patients to complete at-home programs in order to improve outcomes. Despite this widespread practice, relatively little is known about treatment adherence. The purposes of this systematic review were to identify adherence strategies and adherence tracking methods used by adult populations that are commonly treated by SLPs (i.e., dysphagia, aphasia, traumatic brain injury, dysphonia, dysarthria), and to identify the efficacy of these strategies.

METHOD

The systematic review was conducted in accordance with A Measurement Tool to Assess Systematic Reviews guidelines. A comprehensive literature search was performed in three databases (CINAHL, PubMed, and Web of Science).

RESULTS

Of the 679 articles found, 18 were selected for analysis. Two thirds of the included articles received the second highest rating on the 5-point JAMA Quality Rating Scheme. Interventions designed to alter treatment adherence included (most to least frequent) computer programs, portable devices/phone apps, alarm reminders, instructional DVDs, check-ins from a clinician/volunteer, and wearable device. Adherence reporting methods included (most to least frequent) self-report diaries, computer program/app-aided collection, wearable device, and clinician/volunteer observation. Of the articles that reported practice frequency, 58% found that adherence strategies improved practice frequency as compared to control. Of the articles that reported treatment outcomes, 66% found that adherence strategies were associated with improved treatment outcomes as compared to control.

CONCLUSIONS

The paucity of publications reviewed suggests that treatment adherence is considerably understudied in speech-language pathology. A clearer understanding of how to improve the design of adherence strategies could yield highly valuable clinical outcomes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19393793.

Telemedicine and Telementoring in Rhinology, Otology, and Laryngology: A Scoping Review

Objective

Telemedicine and telementoring have had a significant boost across all medical and surgical specialties over the last decade and especially during the COVID-19 pandemic. The aim of this scoping review is to synthesize the current use of telemedicine and telementoring in otorhinolaryngology and head and neck surgery.

Data Sources

PubMed and Cochrane Library.

Review Methods

A scoping review search was conducted, which identified 469 articles. Following full-text screening by 2 researchers, 173 articles were eligible for inclusion and further categorized via relevant subdomains.

Conclusions

Virtual encounters and telementoring are the 2 main applications of telemedicine in otolaryngology. These applications can be classified into 7 subdomains. Different ear, nose, and throat subspecialties utilized certain telemedicine applications more than others; for example, almost all articles on patient engagement tools are rhinology based. Overall, telemedicine is feasible, showing similar concordance when compared with traditional methods; it is also cost-effective, with high patient and provider satisfaction.

Implications for Practice

Telemedicine in otorhinolaryngology has been widely employed during the COVID-19 pandemic and has a huge potential, especially with regard to its distributing quality care to rural areas. However, it is important to note that with current exponential use, it is equally crucial to ensure security and privacy and integrate HIPAA-compliant systems (Health Insurance Portability and Accountability Act) in the big data era. It is expected that many more applications developed during the pandemic are here to stay and will be refined in years to come.

Telepractice and Dysphagia Management: The Era of COVID-19 and Beyond

The COVID-19 pandemic drove rapid and widespread uptake of telepractice across all aspects of healthcare. The delivery of dysphagia care was no exception, with telepractice recognized as a service modality that could support social distancing/infection control, overcome service delivery challenges created by lockdowns/service closures, and address consumer concerns about attending in-person appointments. Now, almost two years since most services first rapidly deployed telepractice, it is time to reflect on the big picture, and consider how telepractice will continue as a service option that is sustained and integrated into mainstream dysphagia care. It is also timely to consider the research agenda needed to support this goal. To this end, in this paper we present 4 discussion topics, which raise key considerations for the current and future use of telepractice within adult and pediatric dysphagia services. These are (1) Dysphagia services must meet consumer and service needs; (2) Aspects of dysphagia services can be safely and reliably provided via telepractice; (3) Telepractice can be used in flexible ways to support the delivery of dysphagia services; and (4) Providing quality dysphagia services via telepractice requires planned implementation and evaluation. Then directions for future research are discussed. These considerations are presented to help shift perspectives away from viewing telepractice as simply a COVID-19 "interim-care solution". Rather, we encourage clinicians, services, and researchers to embrace a future of "integrated care", where traditional dysphagia services are combined with telepractice models, to enhance the quality of care provided to our clients.

The PRO-ACTIVE trial protocol: a randomized study comparing the effectiveness of PROphylACTic swallow InterVEntion for patients receiving radiotherapy for head and neck cancer

BACKGROUND

Swallowing therapy is commonly provided as a treatment to lessen the risk or severity of dysphagia secondary to radiotherapy (RT) for head and neck cancer (HNC); however, best practice is not yet established. This trial will compare the effectiveness of prophylactic (high and low intensity) versus reactive interventions for swallowing in patients with HNC undergoing RT.

METHODS

This multi-site, international randomized clinical trial (RCT) will include 952 adult patients receiving radiotherapy for HNC and who are at high risk for post-RT dysphagia. Participants will be randomized to receive one of three interventions for swallowing during RT: RE-ACTIVE, started promptly if/when dysphagia is identified; PRO-ACTIVE EAT, low intensity prophylactic intervention started before RT commences; or, PRO-ACTIVE EAT+EXERCISE, high intensity prophylactic intervention also started before RT commences. We hypothesize that the PRO-ACTIVE therapies are more effective than late RE-ACTIVE therapy; and, that the more intensive PRO-ACTIVE (EAT + EXERCISE) is superior to the low intensive PRO-ACTIVE (EAT). The primary endpoint of effectiveness is duration of feeding tube dependency one year post radiation therapy, selected as a pragmatic outcome valued equally by diverse stakeholders (e.g., patients, caregivers and clinicians). Secondary outcomes will include objective measures of swallow physiology and function, pneumonia and weight loss, along with various patient-reported swallowing-related outcomes, such as quality of life, symptom burden, and self-efficacy.

DISCUSSION

Dysphagia is a common and potentially life-threatening chronic toxicity of radiotherapy, and a priority issue for HNC survivors. Yet, the optimal timing and intensity of swallowing therapy provided by a speech-language pathologist is not known. With no clearly preferred strategy, current practice is fraught with substantial variation. The pragmatic PRO-ACTIVE trial aims to specifically address the decisional dilemma of when swallowing therapy should begin (i.e., before or after a swallowing problem develops). The critical impact of this dilemma is heightened by the growing number of young HNC patients in healthcare systems that need to allocate resources most effectively. The results of the PRO-ACTIVE trial will address the global uncertainty regarding best practice for dysphagia management in HNC patients receiving radiotherapy.

TRIAL REGISTRATION

The protocol is registered with the US Patient Centered Outcomes Research Institute, and the PRO-ACTIVE trial was prospectively registered at ClinicalTrials.gov , under the identifier NCT03455608 ; First posted: Mar 6, 2018; Last verified: Jun 17, 2021. Protocol Version: 1.3 (January 27, 2020).

Association Between Objective Ratings of Swallowing and Dysphagia-Specific Quality of Life in Patients Receiving (Chemo)radiotherapy for Oropharyngeal Cancer

The pervasive nature of dysphagia in the head/neck cancer (HNC) population necessitates a comprehensive evaluation approach, including both objective assessment of dysphagia, and subjective patient-reported functional measures. However, the congruence between clinician-rated and patient-perceived function is still not well understood. The current study investigated the association between objective clinician-rated swallow physiology (using the MBSImP) and patient-reported measures of swallowing-related quality of life (using the MDADI) in a secondary analysis of patients with oropharyngeal HNC treated with (chemo)radiotherapy. Seventy-nine patients with oropharyngeal HNC receiving (chemo)radiotherapy completed a standardised videofluoroscopic swallow study (VFSS) rated using the MBSImP, and the MDADI, at pre-treatment (baseline), 6 weeks and 3 months post-treatment as per a previous prospective RCT. Data on n = 67 participants were analysed as part of the secondary analysis. Association between MBSImP oral and pharyngeal composite scores versus MDADI Global and subscale scores was examined using ordinary least squares regression and mixed-effects general linear modelling (GLM). Univariable analyses demonstrated significant associations between MBSImP oral composite scores and each of the MDADI subscales, as well as the MBSImP pharyngeal composite scores and all MDADI subscales. GLM analysis revealed significant associations were maintained between MBSImP pharyngeal scores and the MDADI global and emotional subscale scores at the multivariable level, with the physical subscale trending towards significance. No significant association was observed between the MBSImP oral composite scores and any of the MDADI subscales at the multivariable level. This study found significant associations between objective measures of pharyngeal swallow physiology and patient-perceived swallowing-related quality of life. These findings suggest a higher degree of concordance between clinician-rated and patient-reported measures up to 3 months post-(C)RT than previously reported.

Clinical Manifestation, Evaluation, and Rehabilitative Strategy of Dysphagia Associated With COVID-19

ABSTRACT

Dysphagia is the difficulty in swallowing because of the presence of certain diseases; it particularly compromises the oral and/or pharyngeal stages. In severe acute respiratory syndrome coronavirus 2 infection, neuromuscular complications, prolonged bed rest, and endotracheal intubation target different levels of the swallowing network. Thus, critically ill patients are prone to dysphagia and aspiration pneumonia. In this review, we first discuss the possible cause and pathophysiology underlying dysphagia associated with coronavirus disease 2019, including cerebrovascular events, such as stroke, encephalomyelitis, encephalopathy, peripheral neuropathy, and myositis, that may lead to the dysphagia reported as a complication associated with the coronavirus disease 2019. Next, we present some recommendations for dysphagia evaluation with modifications that would allow a safe and comprehensive assessment based on available evidence to date, including critical considerations of the appropriate use of personal protective equipment and optimization individual's noninstrumental swallowing tasks evaluation, while preserving instrumental assessments for urgent cases only. Finally, we discuss a practical managing strategy for dysphagia rehabilitation to ensure safe and efficient practice in the risks of severe acute respiratory syndrome coronavirus 2 exposure, in which swallowing therapy using newer technology, such as telerehabilitation system or wearable device, would be considered as a useful option.

Preliminary development and validation of a measure of fear of swallowing and swallowing-related movement injury in head and neck cancer: Swallowing Kinesiophobia Scale

BACKGROUND

Fear is an under-recognized issue in intervention adherence in head and neck cancer (HNC). We developed and validated a patient reported outcome for swallowing fear in HNC patients.

METHODS

Items were adapted from the Tampa Scale for Kinesiophobia to swallowing function. A beta version was completed by 51 HNC patients undergoing chemo +/- radiotherapy at baseline and post-treatment. Psychometric and factor structure analyses were applied.

RESULTS

Swallowing Kinesiophobia Scale (SWKS) demonstrated strong face and content validity, internal consistency, and test-retest reliability. Factor analysis revealed three-factors: somatic factor, swallow avoidance, and fear of harm. Factors correlated positively with depression score, worry scale, and anxiety and pain scales. Score differences between patient subgroups (dysphagic vs nondysphagic) confirmed discriminative validity.

CONCLUSION

The SWKS is a psychometrically valid tool to identify patients with fear of swallowing and swallowing-related movement. It can help identify patients early in treatment who may need additional support.

Management of dysphagia in the patient with head and neck cancer during COVID-19 pandemic: Practical strategy

The global pandemic of 2019 novel coronavirus disease (COVID-19) has tremendously altered routine medical service provision and imposed unprecedented challenges to the health care system. This impacts patients with dysphagia complications caused by head and neck cancers. As this pandemic of COVID-19 may last longer than severe acute respiratory syndrome (SARS) in 2003, a practical workflow for managing dysphagia is crucial to ensure a safe and efficient practice to patients and health care personnel. This document provides clinical practice guidelines based on available evidence to date to balance the risks of SARS-CoV-2 exposure with the risks associated with dysphagia. Critical considerations include reserving instrumental assessments for urgent cases only, optimizing the noninstrumental swallowing evaluation, appropriate use of personal protective equipment (PPE), and use of telehealth when appropriate. Despite significant limitations in clinical service provision during the pandemic of COVID-19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies.

Adherence to Dysphagia Treatment Recommendations: A Conceptual Model

Purpose Conceptual models of complex health problems are useful when designing targeted clinical interventions and focused research studies. Understanding and studying patient adherence often involves interplay among many factors that influence whether a patient successfully follows recommendations or completes a therapy program. Functional frameworks serve to arrange these factors visually, increasing interpretability and allowing for empirical testing of relationships among concepts. The purpose of this article is to integrate relevant factors from the literature into a comprehensive framework that describes adherence to dysphagia treatment. Method Using peer-reviewed, published guidelines regarding conceptual model construction, the authors created a list of potential factors that influence patient adherence to dysphagia-related treatment recommendations. During model construction, following extensive review of the literature and existing theories that have been applied in other areas of health care, factors were identified and grouped into conceptually similar domains (clusters). Clusters were arranged into larger categories that emerged during model optimization. Ultimately, two models were created: one that illustrates the interrelated factors of patient adherence and another that illustrates a subset of modifiable risk factors that a clinical speech-language pathologist may influence when developing a dysphagia treatment plan. Results Three general categories from 14 factors emerged based on relationships between factors and aspects of patient care: health factors, individual patient factors, and contextual factors. A second model consisting of modifiable risk factors included access, treatment type, patient perceptions, self-efficacy, health literacy, support factors, and provider bias. Conclusions This conceptual model allows clinicians and researchers to identify and explore the mechanisms driving adherence. Continual refinements of this model should be made as future studies uncover how the interconnectedness of factors affects adherence in dysphagia management. The models we have presented here are ready for clinical application and should also serve researchers as they generate hypotheses and design targeted research questions.

Virtual Dysphagia Evaluation: Practical Guidelines for Dysphagia Management in the Context of the COVID-19 Pandemic

With encouraging signs of pandemic containment nationwide, the promise of return to a full range of clinical practice is on the horizon. Clinicians are starting to prepare for a transition from limited evaluation of emergent and urgent complaints to resumption of elective surgical procedures and routine office visits within the next few weeks to months. Otolaryngology as a specialty faces unique challenges when it comes to the COVID-19 pandemic due to the fact that a comprehensive head and neck examination requires aerosol-generating endoscopic procedures. Since the COVID-19 pandemic is far from being over and the future may hold other highly communicable infectious threats that may require similar precautions, standard approaches to the clinical evaluation of common otolaryngology complaints will have to be modified. In this communication, we present practical recommendations for dysphagia evaluation with modifications to allow a safe and comprehensive assessment.

Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial)

Background

Dysphagia is a common and serious complication after (chemo)radiotherapy (CRT) for head-and-neck cancer (HNC) patients. Prophylactic swallowing exercises (PSE) can have a significantly positive effect on post-treatment swallowing function. However, low adherence rates are a key issue in undermining this positive effect. This current randomized trial will investigate the effect of adherence-improving measures on patients’ swallowing function, adherence and quality of life (QOL).

Methods

This ongoing trial will explore the difference in adherence and swallowing-related outcome variables during and after PSE in HNC patients performing the same therapy schedule, receiving different delivery methods. One hundred and fifty patients treated in various hospitals will be divided into three groups. Group 1 performs PSE at home, group 2 practices at home with continuous counseling through an app and group 3 receives face-to-face therapy by a speech and language pathologist. The exercises consist of tongue-strengthening exercises and chin-tuck against resistance with effortful swallow. The Iowa Oral Performance Instrument and the Swallowing Exercise Aid are used for practicing. Patients are evaluated before, during and after treatment by means of strength measurements, swallowing and QOL questionnaires.

Discussion

Since low adherence rates undermine the positive impact of PSE on post-treatment swallowing function, there is need to develop an efficient PSE protocol maximizing adherence rates.

Trial registration

ISRCTN, ID: ISRCTN98243550. Registered retrospectively on 21 December 2018.

Telepractice for Adult Speech-Language Pathology Services: A Systematic Review

Purpose

We conducted a systematic review of the literature regarding adult telepractice services (screening, assessment, and treatment) from approximately 2014 to 2019.

Method

Thirty-one relevant studies were identified from a literature search, assessed for quality, and reported.

Results

Included studies illustrated feasibility, efficacy, diagnostic accuracy, and noninferiority of various speech-language pathology services across adult populations, including chronic aphasia, Parkinson's disease, dysphagia, and primary progressive aphasia. Technical aspects of the equipment and software used to deliver services were discussed. Some general themes were noted as areas for future research.

Conclusion

Overall, results of the review continue to support the use of telepractice as an appropriate service delivery model in speech-language pathology for adults. Strong research designs, including experimental control, across multiple well-described settings are still needed to definitively determine effectiveness of telepractice services.

Prophylactic swallowing therapy for patients with head and neck cancer: A three-arm randomized parallel-group trial

BACKGROUND

Intensive prophylactic swallowing therapy can mitigate dysphagia in patients with oropharyngeal (OP) SCC, however, presents service challenges. This trial investigated the clinical efficacy of three service models delivering prophylactic swallowing therapy during (chemo)radiotherapy ([C]RT).

METHODS

Patients (n = 79) with OPSCC receiving (C)RT were were randomized to: (a) clinician-directed face-to-face therapy (n = 26); (b) telepractice therapy via "SwallowIT" (n = 26); or (c) patient self-directed therapy (n = 27). Swallowing, nutritional, and functional status were compared at baseline, 6-weeks, and 3-months post-(C)RT. Patients' perceptions/preferences for service-delivery were collated posttreatment.

RESULTS

Service-delivery mode did not affect clinical outcomes, with no significant (P > .05) between-group differences or group-by-time interactions observed for swallowing, nutrition, or functional measures. Therapy adherence declined during (C)RT in all groups. SwallowIT and clinician-directed models were preferred by significantly (P = .002) more patients than patient-directed.

CONCLUSIONS

SwallowIT provided clinically equivalent outcomes to traditional service models. SwallowIT and clinician-directed therapy were preferred by patients, likely due to higher levels of therapy support.

Effects of prophylactic swallowing exercises on dysphagia and quality of life in patients with head and neck cancer receiving (chemo) radiotherapy: the Redyor study, a protocol for a randomized clinical trial

BACKGROUND

Radiation-induced dysphagia is common in patients with head and neck cancer (HNC). Available evidence suggests that exercise therapy prior to oncological treatment could potentially improve deglutition and quality of life; however, a randomized clinical trial is needed to confirm this observation.

METHODS/DESIGN

The Redyor study is a single-blind randomized clinical trial designed to compare the effect of prophylactic oropharyngeal exercises on quality of life and dysphagia of 52 patients with HNC referred to the Radiotherapy Department. The intervention will consist of respiratory muscle training (3 times/day, 5 days/week, 21 weeks) added to the standard swallow therapy. All patients will perform the same exercise intervention, but at different times: before chemoradiotherapy (CRT; early intervention group) or immediately after completing CRT (late intervention group). The main outcome will be change in dysphagia severity assessed with the Penetration-Aspiration Scale in videofluoroscopy study; quality of life will be assessed with the EORTC-QLQ-C30 and its Head and Neck Cancer Module (QLQ-H&N35) at 3, 6, and 12 months after completing CRT.

DISCUSSION

This ongoing clinical trial, registered in 2016, is based on the hypothesis that undergoing a pre-radiotherapy rehabilitation (pre-habilitation) program will have greater benefits (less decrease in quality of life, less delay in swallowing parameters, and less severe dysphagia) compared to post-CRT rehabilitation. The main objective is to assess dysphagia severity in HNC patients; and secondly, to evaluate changes in dysphagia-related quality of life, and to determine the correlation between a clinical variable and instrumental parameters during this period.

TRIAL REGISTRATION

NCT0209009911 .

Effects of prophylactic swallowing exercises on dysphagia and quality of life in patients with head and neck cancer receiving (chemo) radiotherapy: the Redyor study, a protocol for a randomized clinical trial

BACKGROUND

Radiation-induced dysphagia is common in patients with head and neck cancer (HNC). Available evidence suggests that exercise therapy prior to oncological treatment could potentially improve deglutition and quality of life; however, a randomized clinical trial is needed to confirm this observation.

METHODS/DESIGN

The Redyor study is a single-blind randomized clinical trial designed to compare the effect of prophylactic oropharyngeal exercises on quality of life and dysphagia of 52 patients with HNC referred to the Radiotherapy Department. The intervention will consist of respiratory muscle training (3 times/day, 5 days/week, 21 weeks) added to the standard swallow therapy. All patients will perform the same exercise intervention, but at different times: before chemoradiotherapy (CRT; early intervention group) or immediately after completing CRT (late intervention group). The main outcome will be change in dysphagia severity assessed with the Penetration-Aspiration Scale in videofluoroscopy study; quality of life will be assessed with the EORTC-QLQ-C30 and its Head and Neck Cancer Module (QLQ-H&N35) at 3, 6, and 12 months after completing CRT.

DISCUSSION

This ongoing clinical trial, registered in 2016, is based on the hypothesis that undergoing a pre-radiotherapy rehabilitation (pre-habilitation) program will have greater benefits (less decrease in quality of life, less delay in swallowing parameters, and less severe dysphagia) compared to post-CRT rehabilitation. The main objective is to assess dysphagia severity in HNC patients; and secondly, to evaluate changes in dysphagia-related quality of life, and to determine the correlation between a clinical variable and instrumental parameters during this period.

TRIAL REGISTRATION

NCT0209009911 .

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.

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.

The efficacy of telerehabilitation in dysphagic patients: a systematic review

SUMMARY

Telerehabilitation is the use of telecommunications technology for rehabilitation. Recently, some studies have shown positive effects of telerehabilitation of swallowing disorders, yet there are no systematic reviews verifying the evidence. The aim of this review is to assess the effects of telerehabilitation in the field of dysphagia as an alternative to face-to-face patient care, considering swallowing recovery and/or quality of life in different patient populations. We searched the Cochrane Library, MEDLINE, EMBASE, Google Scholar, Google Search and the grey literature from inception until December 2016 for publications written in English (keywords: telerehabilitation, telemedicine, dysphagia, swallowing disorders), which resulted in 330 records. Abstract screening and data extraction was carried out independently by two reviewers. Four papers were selected to read in full, and the methodological quality of the studies included was evaluated using Cochrane Collaboration's tool for assessing risk of bias. One study met our inclusion criteria (Wall et al. 2016), which showed that telerehabilitation improves adherence to treatment compared to patient-directed intervention. Although adherence is an important factor that influences the treatment outcome, clinical outcomes have to be examined in randomised controlled trials in order to reach evidence in this field. Lastly, this systematic review did not demonstrate the efficacy of telerehabilitation compared with face-to face therapy.

Analysis of dysphagia in advanced-stage head-and-neck cancer patients: impact on quality of life and development of a preventive swallowing treatment

OBJECTIVES

Swallowing and voice dysfunctions are common side effects following head-and-neck squamous-cell carcinoma (HNSCC) treatment. Our aim was to analyze the relationships between quality of life, swallowing, and phonatory problems in patients with an advanced-stage HNSCC and to prospectively evaluate the effects of a prophylactic swallowing program.

METHODS

First, we retrospectively studied 60 advanced HNSCC patients treated with exclusive or adjuvant radiotherapy/chemoradiotherapy (RT/CRT). Subjects were classified according to general and clinical-therapeutic features. Outcome measures included EORTC QLQ-C30, EORTC QLQ-H&N35, Dysphagia Handicap Index (DHI), M.D.Anderson Dysphagia Inventory (MDADI), and Voice Handicap Index (VHI). Then, we conducted a prospective evaluation of a prophylactic swallowing counselling in 12 consecutive advanced-stage HNSCC patients by a two-arm case-control analysis. These patients were treated with exclusive or adjuvant RT/CRT.

RESULTS

71% of the retrospective population studied reported swallowing dysfunction as a major side effect. No differences were detected in the severity of dysphagia or dysphonia according to type of treatment or staging of the primary tumour, while hypopharyngeal and laryngeal cancer patients showed significantly better swallowing ability and better QoL compared to oral cavity and oropharyngeal localisation (p < 0.05). In addition, a relevant correlation between swallowing and voice problems emerged (p < 0.05). In the prospective part, while no statistical correlation was evident before the start of RT/CRT in the experimental group compared to the control one, the former showed better performances at MDADI (p = 0.006) and DHI (p = 0.002) test 3 months after its end.

CONCLUSION

Dysphagia is both an acute-and-long-term side effect which greatly affects QoL of HNSCC patients undergoing multimodality treatment. Our data show that a prophylactic swallowing program could actually produce a beneficial effect on patients' outcomes.

LEVEL OF EVIDENCE

1b and 2b.

Patient Adherence to Dysphagia Recommendations: A Systematic Review

Patient adherence to treatment recommendations is an important issue for healthcare providers, in a multitude of specialties, and is critical when assessing the efficacy and effectiveness of a particular treatment approach. Patients who have swallowing impairment often require complex and specific interventions requiring altered daily patterns of behavior. Patients with dysphagia who do not follow recommendations or prescribed exercises may not receive maximum benefit of an intervention. Poor adherence also makes it more difficult to evaluate efficacy of a treatment both clinically and in experimental settings. Further, swallow safety can be compromised if certain recommendations are not followed. Our purpose was to systematically review the literature to understand what is known about adherence within the field of dysphagia treatment. We systematically identified 12 studies that tracked and reported patient-specific adherence. In this review, we found that the average adherence rate from these studies ranges between 21.9 and 51.9%. Adherence to prophylactic treatment recommendations for patients with head and neck cancer was the focus in 9/12 studies. The findings of this review identify a large gap in knowledge regarding adherence to dysphagia treatment. Few studies account for adherence within their study designs. When planning dysphagia treatment studies, it is imperative that investigators include information regarding patient adherence to accurately interpret findings. Given the variable adherence rates found in this review, factors influencing patient adherence with dysphagia treatments should be identified to increase adherence in future trials.

Survivorship: Morbidity, Mortality, Malignancy

Survivorship encompasses the entire therapeutic, psychosocial, functional, and financial experience of living with and through a cancer diagnosis. The period of survivorship starts on the day of the cancer diagnosis and lasts until the end of the survivor's life, regardless of the cause of death. The National Cancer Institute's Office of Cancer Survivorship expands the term "survivor" to include, importantly, caregivers, family, and friends close to the survivor who also live through this period.

The health professionals' perspectives of support needs of adult head and neck cancer survivors and their families: a Delphi study

PURPOSE

The aim was to identify the views of Australian and New Zealand health professionals regarding the support needs of people with head and neck cancer (HNC) and their families and current gaps in service delivery.

METHODS

A modified Delphi process assessed support needs of people with HNC following acute medical management. A systematic review of the literature was used to develop items relevant to seven key concepts underpinning the psychological experience of living with HNC. A panel of 105 health professionals was invited to participate in two questionnaire rounds.

RESULTS

Of the potential panellists, 50 (48%) completed round 1, and of these, 39 (78%) completed round 2. Following two rounds, there was consensus agreement on the concepts uncertainty and waiting, disruption to daily life and fear of recurrence. The concepts the diminished self, making sense of and managing the experience, sharing the burden and finding a path did not achieve consensus. There were no differences in responses according to gender, organization type or location. Medical professionals had significantly higher agreement for the concept uncertainty and waiting compared to allied health professionals, and professionals with five years' or more experience had significantly higher agreement than those with less experience.

CONCLUSIONS

Health professionals agreed that many psychosocial support needs of HNC survivors and families are not being met and that they experience difficulties in meeting these needs. Findings may inform evidence-based treatment programs for HNC survivors and their families to promote psychological resilience and quality of life in this vulnerable population.