Swallowing interventions for the treatment of dysphagia after head and neck cancer: a systematic review of behavioural strategies used to promote patient adherence to swallowing exercises

Swallowing difficulties (dysphagia), which affect 60 –75% of patients treated for head and neck cancer (HNC) [1], arise both from the presence of a tumour, and as a consequence of its treatment [2]. Dysphagia is a major patient concern after cancer treatment due to the detrimental impact on patients’ quality of life (QOL) [3]. Improvement of swallowing function and earlier restoration of eating and drinking after surgery or chemo-radiation treatments may be achieved with swallowing rehabilitation exercises [4, 5]. Despite this, non-adherence to swallowing exercises in this population is reported to be high [6].

The World Health Organization report defines patient adherence as “the extent to which a person’s behaviour corresponds with agreed recommendations from a health care provider” [7]. This report highlights that adherence is influenced by multiple factors, and that increasing adherence to treatment could have a greater impact on health than trying to improve the efficacy of the treatment to which patients are encouraged to adhere. Adopting this perspective transforms the concept of patient adherence from a peripheral marker of study quality into a concept central to the intervention. The Medical Research Council’s “complex intervention” guidelines highlight that multiple components at different levels may interact to bring about desired health outcomes [8]. Effectiveness of swallowing exercise interventions are determined not just by the exercises but also the broader ‘behaviours of those delivering and receiving the intervention’ (p.979). Complex interventions that take place as pragmatic trials under real-world conditions [9] are influenced by context factors; how interventions are implemented (where, by whom) and how patients may respond to this (uptake/adherence) [10].

Newer paradigms in systematic reviewing such as realist reviews focus on understanding how and why interventions work in some situations and not others, rather than simply investigating whether they do or do not work [11]. Sutcliffe and colleagues [12] argue the importance of recognising and identifying the critical components of complex interventions highlighting that outcomes of complex interventions cannot be solely ascribed to the primary content, in this case swallowing exercises. Traditional systematic reviews that focus exclusively on pooling effect sizes may overlook other aspects that influence outcomes. This limits our ability to differentially examine the evidence and to gather important information that may improve future interventions.

The system in which the intervention takes place and the possible interactions that may occur can be represented as a logic model [13] (Fig. 1). Swallowing exercise interventions for patients with HNC are normally implemented by trained professionals such as speech therapists within a healthcare setting, and as part of a wider cancer care pathway. The content of the intervention tends to be focused on type, timing and intensity of different swallowing exercises. Accordingly, previous reviews have been largely concerned with these exercise parameters. Langmore and Pisegna [14] suggest that exercises such as the Shaker (head lift exercise) and Mendelsohn manoeuvre (larynx elevation exercise) have good efficacy in improving swallowing function. A general review of interventions to improve eating and drinking after HNC [15] concluded that some evidence exists to support exercises to improve swallowing function and jaw movement in patients treated for HNC but acknowledged that larger controlled studies are needed. A recent Cochrane review [16] concluded that the evidence for pre-treatment swallowing exercises in improving swallowing safety and efficiency is lacking due to insufficiently robust studies, heterogeneity of outcome measures across studies, and poor patient adherence. Whilst there is much to be learned from these reviews, the broader perspective proposed in our logic model may facilitate better understanding of the existing evidence that could improve the content and design of future studies (Fig. 1).

As highlighted in our model, behavioural strategies used to promote adherence to the exercises are an important part of the intervention content that may be frequently overlooked yet such strategies may have a potentially crucial influence on outcomes. This review employs established tools from Behavioural Science, in particular the Behaviour Change Technique Taxonomy (BCTTv1) [17] that defines 93 discrete behaviour change techniques (BCTs) thereby facilitating a standardised description of the techniques that can be used to change behaviour. BCTs represent the smallest observable and replicable components that may bring about a change in behaviour [17], and therefore may be potentially active ingredients in an intervention [18] The success of exercise interventions is dependent on good adherence. It is logical therefore that this aspect of the intervention be given appropriate consideration.

In this review, we aim to identify the specific behaviour change strategies reported in interventions to improve swallowing function after HNC. We also explored where possible, relationships between the presence of these components and intervention effectiveness. We propose that BCTs that occur at least twice as frequently in successful interventions may be useful to include in future interventions. We used a narrative synthesis approach [19] and as part of this we also explored the trial methods used more broadly (for example type of comparator group), providing discussion of possible associations with the study outcomes. To our knowledge this is the first attempt to apply this method of reviewing swallowing interventions within this field, and by its nature the work is exploratory.

We identified 15 controlled clinical trials (8 randomised) that currently represent the best available evidence of swallowing interventions for patients with HNC, and extracted three function categories and 20 different BCTs that characterize these interventions. By specifically isolating these BCTs, we may encourage more consistent descriptions of the non-exercise content of swallowing exercise interventions in the literature increasing our ability to replicate studies more accurately. Indeed, in time it may be possible to devise interventions that test the effectiveness of specific BCTs or groups of BCTs used in swallowing exercise interventions for this patient population, and to link these to underlying theory and mechanisms of change [50]. In so doing, we may be better placed to understand why interventions work, for whom and in which contexts [11].

We also examined the data for any relationships that may elucidate the interaction of different components of this complex intervention. For example, studies that employed active comparator groups using similar BCTs to the intervention group were more likely to demonstrate non-significant results. Furthermore in a trial that employed three groups [37], (an exercise group, a sham exercise group, and a non-active control group), the authors reported that the active sham exercise group that received similar BCTs to the pharyngocize (exercise treatment) group achieved much better outcomes compared to the non-active control group. It may therefore be the constituent BCTs that were responsible for intervention effectiveness, by stimulating greater adherence to the prescribed treatment. Whilst the authors themselves did not specifically make reference to BCTs, they did question whether the ‘benefits obtained from the sham group could be ascribed to the placebo effect of behavioral attention’ (p.219). Equally they speculated that the sham exercise (done diligently) might have had an intrinsic benefit from the increased movement of oral musculature. Regardless, these findings raise the possibility that BCTs may be functioning as active ingredients influencing intervention outcomes. For most studies where both the intervention and active comparison group used similar BCTs, no statistical significance in outcomes between groups was reported. This might be because the interventions given to both groups were too similar, or because of a lack of power due to small sample sizes. However it does raise other interesting questions: What contribution do BCTs add to intervention outcomes, and how does their presence in usual care/placebo interventions impact effectiveness? Reporting of swallowing exercise interventions tends to focus mainly on the treatment group and often provides only cursory reference to the usual care group. The findings of this review highlight that the same methodological care should be taken in devising the treatment manuals for the intervention and comparator groups ensuring that behaviour change components are also specified, given their potential to impact patient adherence and subsequent outcomes. This may prevent hasty conclusions that imply swallowing exercises have no benefit, rather than the conclusion that the “new intervention” was not shown to demonstrate any significant additional benefit over usual care.

The variability in the type and time-point of the primary outcome measures for clinical trials in this field restricts the ability to satisfactorily pool data or compute effect sizes to address the efficacy of swallowing interventions in patients with head and neck cancer. We generally observed that in studies that reported a positive outcome, this was mostly seen in the short term. One reason for this may be because patients do not continue with their exercises long term. Behavioural strategies such as habit formation, requires that an individual repeatedly perform the behaviour in the same context such that it becomes automatic. This automaticity may promote maintenance of exercises as it may over-ride conscious intentions [51] and could have a role to play in improving swallowing outcomes longer term. We also observed that outcomes collected after 6 months showed little difference between groups. This was especially relevant for patient-reported outcomes that arguably may also reflect patients’ changing expectations and adaptation over time, and not just functional swallowing status. Furthermore, this mirrors the usual trajectory of behaviour change where short-term goals are given priority. Rothman [52] highlighted that the psychological factors that underpin initiation of a new behaviour differ from those that predict maintenance of the behaviour. By implication, different BCTs may be required for these distinct phases. It was also noted that few studies actually collected objective measures of swallowing in the longer term, making it difficult to assess changes in swallow physiology at later time-points. Standardizing outcome measures and agreement on the key evaluation time-points will greatly progress efforts to understand if swallowing exercise interventions are indeed beneficial for this group of patients and over what time period. Consideration should also be given to the expected trajectory of swallowing recovery after head and neck cancer treatment including the possible onset of late effects of treatment such as post radiation fibrosis known to impair swallow function [53, 54].