1. Limitations for correction in future research include:
• Expand to a larger sample size with a rigorous study design.
• Have a greater focus on specific locations and types of head and neck
cancer
• Evaluate the efficacy of specific swallowing exercises on specific types
and locations of head and neck cancer.
• Determine the necessary dosage of each swallowing exercise for each
type and location of head and neck cancer.
• Use objective measures of swallowing function in order to reliably assess
swallowing function.
Implication of these findings are that prophylactic swallowing exercises
should be considered in treating patients undergoing chemoradiation
because there is a growing foundation of evidence to support their use.
Inclusion Criteria:
• Studies published in English
• Experimental studies, quasi-experimental studies, systematic reviews, and
meta-analyses.
• Studies whose participants were diagnosed with head and neck cancer
and receiving chemoradiation therapy
• Studies that employed a variety of swallowing exercises as a prophylactic
regimen.
Exclusion Criteria:
• Opinion articles
• Studies that did not have a control group
• Studies whose participants had surgical treatment for head and neck cancer
• No restrictions were placed based on the year of publication.
Relevant Research Based on Oxford Centre for Evidence-based
Medicine- Levels of Evidence
CAN PROPHYLACTIC EXERCISES PREVENT DYSPHAGIA IN HEAD AND NECK CANCER?
Sarah Blakeman, B.H.S.; Joseph Stemple, Ph.D., CCC-SLP; Robert Marshall, Ph.D., CCC-SLP
Division of Communication Sciences and Disorders
The first author has nothing to disclose. The 2nd and 3rd authors receive a salary from the University of Kentucky.
INTRODUCTION
PURPOSE
REFERENCES
BOTTOM LINE
Paleri, V., Roe, J. W., Strojan, P., Corry, J., Gregoire, V., Hamoir, Eisbruch, A., Mendenhall, W. M., Silver, C.
E., Rinaldo, A., Takes, R. P., Ferlito, A. (2014). Strategies to reduce long-term postchemoradiation
dysphagia in patients with head and neck cancer: an evidence-based review. Head Neck, 36(3), 431-
443. doi:10.1002/hed.23251
Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). "Pharyngocise": randomized
controlled trial of preventative exercises to maintain muscle structure and swallowing function during
head-and-neck chemoradiotherapy. Int J Radiat Oncol Biol Phys, 83(1), 210-219.
doi:10.1016/j.ijrobp.2011.06.1954
Kotz, T., Federman, A. D., Kao, J., Milman, L., Packer, S., Lopez-Prieto, C., Forsythe, K., Genden, E.M. (
2012). Prophylactic swallowing exercises in patients with head and neck cancer undergoing
chemoradiation: A randomized trial. Archives of Otolaryngology–Head & Neck Surgery, 138(4), 376-
382. doi:10.1001/archoto.2012.187
Ahlberg, A., Engstrom, T., Nikolaidis, P., Gunnarsson, K., Johansson, H., Sharp, L., & Laurell, G. (2011).
Early self-care rehabilitation of head and neck cancer patients. Acta Otolaryngol, 131(5), 552-561.
doi:10.3109/00016489.2010.532157
Kulbersh, B. D., Rosenthal, E. L., McGrew, B. M., Duncan, R. D., McColloch, N. L., Carroll, W. R., &
Magnuson, J. S. (2006). Pretreatment, preoperative swallowing exercises may improve dysphagia
quality of life. Laryngoscope, 116(6), 883-886. doi:10.1097/01.mlg.0000217278.96901.fc
Carroll, W. R., Locher, J. L., Canon, C. L., Bohannon, I. A., McColloch, N. L., & Magnuson, J. S. (2008).
Pretreatment swallowing exercises improve swallow function after chemoradiation. Laryngoscope,
118(1), 39-43. doi:10.1097/MLG.0b013e31815659b0
Shinn, E. H., Basen-Engquist, K., Baum, G., Steen, S., Bauman, R. F., Morrison, W., Garden, A. S., Sheil, C.,
Kilgore, K., Hutcheson, K. A., Barringer, D., Yuan, Y., Lewin, J. S. (2013). Adherence to preventive
exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
Head Neck, 35(12), 1707-1712. doi:10.1002/hed.23255
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4
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METHODOLOGY
RESULTS
There is a moderate level of evidence to suggest that the use of prophylactic
swallowing exercises can improve swallowing outcomes following
chemoradiation treatment; however, more research must be done in order to
accurately define what prophylactic therapies work best with each type of
head and neck cancer.
• When treating head and neck cancer, physicians often recommend
chemoradiation therapy instead of surgery as a means of preserving
swallowing and voice; however, chemoradiation has severe impacts as
well (Kotz, 2012, p. 376).
• Swallowing dysfunctions associated with chemoradiation are:
increased oropharyngeal transit time, decreased tongue-base
retraction, reduced hyolaryngeal excursion, increased pharyngeal
residue, abnormal esophageal sphincter function, and aspiration
(Carroll, 2008, p.39).
• Prophylactic swallowing exercises aim to prevent or diminish the
presence of swallowing dysfunction following chemoradiation
therapy.
• This critically appraised topic examines the use of prophylactic
swallowing exercises as a means of preventing swallowing
dysfunction from occurring post-chemoradiation therapy.
The purpose of this investigation is to determine whether there is evidence
to suggest that prophylactic swallowing exercises will improve swallowing
outcomes in adults with advanced head and neck cancer following
chemoradiation.
A clinically appraised topic (CAT)
is a method for facilitating
evidence-based practice. It begins
with a clinical question that inquires about
a specific population, intervention,
LIMITATIONS & IMPLICATIONS
comparison (optional), and outcome. Inclusion
and exclusion criteria are determined, a literature
search is performed, and articles meeting the preset
criteria are selected and critiqued. Best evidence is identified,
usually favoring the most recent and highest level evidence. The results of
the CAT are incorporated into evidence-based practice by providing the
research to be combined with clinical expertise and patient/family values.
METHODS
Clinical Question: In adults with advanced head and neck cancers, is there
evidence to suggest prophylactic swallowing therapy improves swallowing
outcomes following definitive chemoradiation therapy?
Search Databases:
• PubMed
• MEDLINE
• ASHA archives
• CINAHL
• Web of Science
The Paleri (2014) study was identified as best evidence and selected for critical
appraisal.
Purpose: To evaluate the efficacy of 3 strategies that may improve swallowing
function following cancer treatment.
Design & Population:
• Evidence-based systematic review including 3 controlled trials (2 of which
were randomized), a prospective cohort study, and a retrospective case
control study.
• The population of each study included in the systematic review consisted
of adults with advanced head and neck cancer undergoing chemoradiation.
One study contained subjects who had undergone surgery in addition
which disqualified it from being discussed in this CAT.
Findings:
• Results of the studies reviewed in this article suggest that prophylactic
swallowing exercises could improve swallowing outcomes; however, more
research must be done.
• Another consideration is dosage of chosen swallowing exercises. Some
exercise regimens may be considered too strenuous for certain patients
whose strength and health is significantly compromised due to
chemoradiation treatment. This factor influences the patient’s ability to
complete the exercises.
Study Design/ Methodology
of Articles Retrieved
Level Number
Located
Author (Year)
Evidence-based systematic
review
1a 1 Paleri (2014)
Prospective, randomized
controlled trial
1b 2 Carnaby-Mann
(2011)
Kotz (2012)
Prospective cohort study 2b 1 Kulbersh (2006)
Retrospective case control 3b 1 Carroll (2008)
Case series 4 1 Shinn (2013)
Search Terms:
• Prophylactic
• Prevent
• Exercises
• Swallowing therapy
• Pre-treatment
• Dysphagia
• Head and neck cancer
• Advanced
• Definitive
• Chemoradiation
• Neoplasm
INCLUSION AND EXCLUSION CRITERIA ADDITIONAL FINDINGS