Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2016 Aug 26;2016(8):CD011112.
doi: 10.1002/14651858.CD011112.pub2.

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

Alison Perry  1 , Siew Hwa Lee, Susan Cotton, Catriona Kennedy
Affiliations

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

Alison Perry et al. Cochrane Database Syst Rev. .

Abstract

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

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

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Web of Science; ClinicalTrials.gov; ICTRP; speechBITE; Google Scholar; Google and additional sources for published and unpublished trials.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

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

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

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

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

PubMed Disclaimer

Conflict of interest statement

  1. Alison Perry: none known.

  2. Sue Cotton: none known.

  3. Siew Hwa Lee: none known.

  4. Catriona Kennedy: none known.

Figures

1
1
Process for sifting search results and selecting studies for inclusion.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Tongue exercises + traditional therapy versus traditional therapy, Outcome 1 Swallowing function (OPSE).
2.1
2.1. Analysis
Comparison 2 Swallow therapy versus treatment as usual (TAU), Outcome 1 Swallowing velocity (ml/sec).
2.2
2.2. Analysis
Comparison 2 Swallow therapy versus treatment as usual (TAU), Outcome 2 Swallowing volume, ml.
2.3
2.3. Analysis
Comparison 2 Swallow therapy versus treatment as usual (TAU), Outcome 3 Weight change.
2.4
2.4. Analysis
Comparison 2 Swallow therapy versus treatment as usual (TAU), Outcome 4 Dysphagia severity.
3.1
3.1. Analysis
Comparison 3 Pharyngocise versus sham care, Outcome 1 Swallowing ability (VFE).
3.2
3.2. Analysis
Comparison 3 Pharyngocise versus sham care, Outcome 2 Weight loss (> 10%).
4.1
4.1. Analysis
Comparison 4 Pharyngocise versus treatment as usual (TAU), Outcome 1 Swallowing ability ‐ VFE.
4.2
4.2. Analysis
Comparison 4 Pharyngocise versus treatment as usual (TAU), Outcome 2 Weight loss (> 10%).
5.1
5.1. Analysis
Comparison 5 Sham exercises versus treatment as usual (TAU), Outcome 1 Swallowing ability (VFE).
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Carnaby‐Mann 2012 {published data only}
    1. Carnaby‐Mann G, Crary MA, Schmalfuss I, Amdur R. “Pharyngocise”: randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head‐and‐neck chemoradiotherapy. International Journal of Radiation Oncology, Biology, Physics 2012;83(1):210‐9. - PubMed
Kotz 2012 {published data only}
    1. Kotz T, Federman AD, Kao J, Milman, L, Packer S, Lopez‐Prieto C, et al. Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation: a randomized trial. Archives of Otolaryngology ‐‐ Head and Neck Surgery 2012;138(4):376‐82. - PubMed
Lazarus 2014 {published data only}
    1. Lazarus CL, Husainib H, Falcigliac D, DeLacurec M, Branskid RC, Krause D, et al. Effects of exercise on swallowing and tongue strength in patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy. International Journal of Oral & Maxillofacial Surgery 2014;43(5):523‐30. - PMC - PubMed
Mortensen 2015 {published data only}
    1. Mortensen HR, Jensen J, Aksglaede K, Lambertsen K, Eriksen E, Grau C. Prophylactic swallowing exercises in head and neck cancer radiotherapy. Dysphagia 2015;30:304‐14. [DOI 10.1007/s00455‐015‐9600‐y] - PubMed
van den Berg 2014 {published data only}
    1. Berg MGA, Kalf JG, Hendriks JCM, Takes RP, Herpen CML, Wanten GJA, et al. Normalcy of food intake in patients with head and neck cancer supported by combined dietary counselling and swallowing therapy: a randomized clinical trial. Head and Neck 2014 Dec 22 [Epub ahead of print]. [DOI: 10.1002/hed.23970] - DOI - PubMed
van der Molen 2011 {published data only}
    1. Molen L, Rossum MA, Burkhead LM, Smeele LE, Rasch CRN, Hilgers FJM. A randomized preventative rehabilitation trial in advanced HN cancer patients treated with chemoradiotherapy: feasibility, compliance and short‐tem effect. Dysphagia 2011; Vol. 26:155‐70. [DOI 10 1007/s00455‐010‐9288‐y] - PMC - PubMed
    1. Molen L, Rossum MA, Rasch CRN, Smeele LE, Hilgers FJM. Two‐year results of a prospective preventive swallowing rehabilitation trial in patients treated with chemoradiation for advanced head and neck cancer. European Archives of Oto‐Rhino‐Laryngology 2014;271(5):1257‐70. [DOI: 10.1007/s00405-013-2640-8] - DOI - PubMed

References to studies excluded from this review

Carroll 2008 {published data only}
    1. Carroll WR, Locher JL, Canon CL, Bohannon IA, McColloch NL, Magnuson JS. Pre‐treatment swallowing exercises improves swallowing function after chemotherapy. Laryngoscope 2008;118(1):39‐43. - PubMed
Tang 2011 {published data only}
    1. Tang Y, Shen Q, Wang Y, Lu K, Wang Y, Peng Y. A randomized prospective study of rehabilitation therapy in the treatment of radiation‐induced dysphagia and trismus. Strahlentherapie und Onkologie 2011;187(1):39‐44. [DOI: 10.1007/s00066-010-2151-0] - DOI - PubMed
Virani 2013 {published data only}
    1. Virani A, Kunduk M, McWhorter AJ. Effects of performing two different prophylactic swallowing exercise protocols on swallowing outcomes post‐chemoradiation therapies for head and neck cancers. Dysphagia 2013;28(4):605. [DOI: 10.1002/hed.23570] - DOI
Zhen 2012 {published data only}
    1. Zhen Y, Wang J, Tao D, Wang H‐J, Chen W‐L. Efficacy survey of swallowing function and quality of life in response to therapeutic intervention following rehabilitation treatment in dysphagic tongue cancer patients. European Journal of Oncology Nursing 2012;16:54‐8. - PubMed

References to ongoing studies

Barretos Cancer Hospital 2015 {published data only}
    1. NCT02075385. Randomized phase II trial: swallowing speech pathology intervention during radiochemotherapy on patients with head and neck cancer. https://clinicaltrials.gov/ct2/show/NCT02075385 (first received 23 January 2014).
Fredslund 2015 {published data only}
    1. NCT02385929. Pre‐habilitation of patients with head and neck cancer (SYNK). https://clinicaltrials.gov/ct2/show/NCT02385929 (first received 9 February 2015).
Govender 2014 {published data only}
    1. ISRCTN40215425. SIP SMART: swallowing intervention package ‐ self monitoring, assessment & rehabilitation training. http://www.isrctn.com/ISRCTN40215425 (first received 23 October 2014).
van Nuffelen 2014 {published data only}
    1. ISRCTN14447678. Tongue strengthening exercises in head and neck cancer patients: does level of resistance matter?. http://www.isrctn.com/ISRCTN14447678 (first received 12 February 2015).

Additional references

AJCC 2010
    1. Edge S, Byrd DR, Compton CC, Fritz, AG, Greene FL, et al. AJCC Cancer Staging Manual. 7th Edition. New York, NY: Springer, 2010.
Appleton 1994
    1. Appleton J, Machin J. Working with Oral Cancer. Oxon, UK: Winslow Press, 1994.
Argiris 2008
    1. Argiris A, Karamouzis MA, Raben D, Ferris RL. Head and neck cancer. Lancet 2008;1371(9625):1695‐709. - PMC - PubMed
Blot 1988
    1. Blot WJ, McLaughlin JK, Winn DM, Austin DF, Greenberg RS, Preston‐Martin S, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Research 1988;48(11):3282. - PubMed
Clark 2003
    1. Clark HM. Neuromuscular treatments for speech and swallowing: a tutorial. American Journal of Speech‐Language Pathology 2003;12:400‐15. - PubMed
CONSORT 2010
    1. Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. - PMC - PubMed
Decker 1982
    1. Decker J, Goldstein JC. Risk factors in head and neck cancer. New England Journal of Medicine 1982;306(19):1151‐5. - PubMed
Forastiere 2003
    1. Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. New England Journal of Medicine 2003;349:2091‐8. - PubMed
Frowen 2006
    1. Frowen J, Perry A. Swallowing outcomes after radiotherapy for head and neck cancer: a systematic review. Head and Neck 2006;28(10):932‐44. - PubMed
Fujiu 1996
    1. Fujiu M, Logemann JA. Effect of a tongue‐holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech‐Language Pathology 1996;5:23‐30.
Gillison 2000
    1. Gillison ML, Koch WM, Capone RB, Spafford M, Westra WH, Wu L, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers. Journal of the National Cancer Institute 2000;92:709‐20. - PubMed
Gregoire 2010
    1. Gregoire V, Lefebvre JL, Licitra L, Felip E. Squamous cell carcinoma of the head and neck: EHNS‐ESMO‐ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow‐up. Annals of Oncology 2010;21(Suppl 5):184‐6. - PubMed
Handbook 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Higgins 2009
    1. Higgins KM, Shah MD, Ogaick MJ, Enepekides D. Treatment of early‐stage glottic cancer: meta‐analysis comparison of laser excision versus radiotherapy. Journal of Otolaryngology ‐ Head & Neck Surgery 2009;38(6):603‐12. - PubMed
ICF 2001
    1. WHO. International Classification of Functioning, Disability and Health: ICF Short Version. Geneva: World Health Organization, 2001.
Jemal 2011
    1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA: A Cancer Journal for Clinicians 2011;61:69–90. [DOI: 10.3322/caac.20107] - DOI - PubMed
Langendijk 2007
    1. Langendijk JA. New developments in radiotherapy of head and neck cancer: higher precision with less patient discomfort?. Radiotherapy and Oncology 2007;85:1‐6. - PubMed
Logemann 1999
    1. Logemann JA. Behavioural management for oropharyngeal dysphagia. Folia Phoniatrica et Logopaedica 1999;51(4‐5):199‐212. - PubMed
Marur 2010
    1. Marur S, D'Souza G, Westra WH, Forestiere AA. HPV‐associated head and neck cancer: a virus‐related cancer epidemic. Lancet Oncology 2010;11(8):781–9. - PMC - PubMed
NCCN 2014
    1. National Comprehensive Cancer Network. Head and Neck Cancers (Version 2.2014). http://www.nccn.org/professionals/physician_gls/pdf/head‐and‐neck.pdf (accessed 16 June 2014).
NICE Guidelines 2016
    1. National Institute for Care and Health Excellence. Cancer of the upper aerodigestive tract: assessment and management in people aged 16 and over. https://www.nice.org.uk/guidance/ng36/chapter/recommendations#informatio... February 2016. [NICE guidelines [NG36]] - PubMed
Perry 2003
    1. Perry A, Shaw M. The evaluation of functional outcomes (speech and swallowing) after head and neck cancer treatment: results and analysis. Journal of Laryngology and Otology 2003;117(5):368‐81. - PubMed
Pignon 2009
    1. Pignon JP, Maître A, Maillard E, Bourhis J, MACH‐NC Collaborative Group. Meta‐analysis of chemotherapy in head and neck cancer (MACH‐NC): an update on 93 randomised trials and 17,346 patients. Radiotherapy and Oncology 2009;92:4–14. - PubMed
Ragin 2007
    1. Ragin CC, Modugno F, Gollin SM. The epidemiology and risk factors of head and neck cancer: a focus on human papilloma virus. Journal of Dental Research 2007;86(2):104‐14. - PubMed
Rappoport 2003
    1. Rappoport L. How We Eat. Ontario, Canada: ECW Press, 2003.
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Rosenbek 1996
    1. Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration‐aspiration scale. Dysphagia 1996;11(2):93‐8. - PubMed
Sankaranarayanan 1998
    1. Sankaranarayanan R, Masuyer E, Swaminathan R, Ferlay J, Whelan S. Head and neck cancer: a global perspective on epidemiology and prognosis. Anticancer Research 1998;18(6B):4779. - PubMed
www.ncri.ie
    1. The Irish Cancer Society. Cancer Trends No 10. National Cancer Registry, 2011. Cancers of the head and neck. www.ncri.ie (accessed March 2013).

References to other published versions of this review

Perry 2014
    1. Perry A, Cotton S, Kennedy C. Therapeutic exercises for affecting post‐treatment swallowing in people treated for advanced‐stage head and neck cancers. Cochrane Database of Systematic Reviews 2014, Issue 5. [DOI: 10.1002/14651858.CD011112] - DOI - PMC - PubMed

Publication types