Clinician Article

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

  • Perry A
  • Lee SH
  • Cotton S
  • Kennedy C
Cochrane Database Syst Rev. 2016 Aug 26;2016(8):CD011112. doi: 10.1002/14651858.CD011112.pub2. (Review)
PMID: 27562477
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  • Surgery - Head and Neck
    Relevance - 6/7
    Newsworthiness - 5/7
  • Surgery - Ear Nose Throat
    Relevance - 6/7
    Newsworthiness - 4/7
  • Oncology - General
    Relevance - 5/7
    Newsworthiness - 6/7
  • Physical Medicine and Rehabilitation
    Relevance - 5/7
    Newsworthiness - 5/7
  • Oncology - Palliative and Supportive Care
    Relevance - 4/7
    Newsworthiness - 5/7
  • Oncology - Radiation
    Relevance - 4/7
    Newsworthiness - 4/7


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

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

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IndMed; PakMediNet; Web of Science;; ICTRP; speechBITE; Google Scholar; Google and additional sources for published and unpublished trials.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

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

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

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

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

Clinical Comments

Oncology - Palliative and Supportive Care

Very important Cochrane review of the value (or lack of evidence for) exercise interventions to alleviate the common difficulty with swallowing, arising after curative intent chemo-radiation in patients afflicted by head and neck cancer. The review demonstrated absence of prospective clinical trial data supporting any benefit of swallowing exercises. The authors appropriately call for more trials of rehabilitative measures designed with more rigor, and with better defined endpoints to further investigate how to help patients with head and neck cancer achieve better functional recovery.

Oncology - Radiation

Aspiration in patients afflicted with cancers of the oral tongue, oropharynx, hypopharynx and larynx is a real problem and cause of morbidity and mortality, which can assume alarming proportions if the treating team is not clued up or patients do not report in time. It is also attributed to pharyngeal muscle dysfunction, post radiotherapy. Dietary modifications and swallowing exercises are widely prescribed in the belief that they work. Therefore this article serves to place this specific intervention in perspective and cautions physicians not to be lulled into complacency in the assumption that it works.

Surgery - Ear Nose Throat

The article is not relevant in ENT clinical practice.

Surgery - Head and Neck

Good review as it is very important to assess and assist the patient having post treatment swallowing problem in oral cancer.

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