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Improving Compliance with Swallowing Exercise to Decrease Radiotherapy-related Dysphagia in Head and Neck Cancer Patients

  • Author Footnotes
    a This authors contributed equally.
    Jizhe Zhu
    Footnotes
    a This authors contributed equally.
    Affiliations
    The College of Nursing and Health of Zhengzhou University, Zhengzhou, 450001, China
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  • Author Footnotes
    a This authors contributed equally.
    Xin Wang
    Footnotes
    a This authors contributed equally.
    Affiliations
    The College of Nursing and Health of Zhengzhou University, Zhengzhou, 450001, China
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  • SuXiang Chen
    Affiliations
    Centre for Molecular Medicine & Innovative Therapeutics. Building 390, West Entrance, Discovery Way, Murdoch,WA 6150, Australia
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  • Ruofei Du
    Affiliations
    The College of Nursing and Health of Zhengzhou University, Zhengzhou, 450001, China

    Academy of Medical Sciences of Zhengzhou University, Zhengzhou, 450001, China
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  • Haoning Zhang
    Affiliations
    The College of Nursing and Health of Zhengzhou University, Zhengzhou, 450001, China
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  • Menghan Zhang
    Affiliations
    The College of Nursing and Health of Zhengzhou University, Zhengzhou, 450001, China
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  • Mengwei Shao
    Affiliations
    The College of Nursing and Health of Zhengzhou University, Zhengzhou, 450001, China
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  • Changying Chen
    Correspondence
    Co-Corresponding author: , Department of Quality control. The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
    Affiliations
    Department of Quality Control. the First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
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  • Tao Wang
    Correspondence
    Corresponding author. The College of Nursing and Health of Zhengzhou University, Zhengzhou, 450001, China; Telethon Kids Institute, Perth, WA, 6872, Australia; Telethon Kids Institute, Perth, WA, 6872, Australia; People’ s hospital of Hebi, Hebi, 458010, China.
    Affiliations
    The College of Nursing and Health of Zhengzhou University, Zhengzhou, 450001, China

    Telethon Kids Institute, Perth, WA, 6872, Australia

    Medical School, University of Western Australia, Perth, WA, 6872, Australia

    People’ S Hospital of Hebi, Hebi, 458010, China
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  • Author Footnotes
    a This authors contributed equally.
Open AccessPublished:November 19, 2022DOI:https://doi.org/10.1016/j.apjon.2022.100169

      Abstract

      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 analyzes the factors influencing swallowing exercise compliance in patients with HNC and explains strategies developed to date for improved rehabilitation outcomes. 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. The evaluation methods could be performed either subjectively or objectively, and 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, although current strategies mainly address psychosocial issues via developing various education programs, other factors influencing swallowing exercise compliance are also important and should be observed. Notably, different delivery methods can lead to significant differences in compliance outcomes even with the same intervention mode.

      Keywords

      1. Introduction

      Head and neck cancer (HNC), the sixth most common cancer worldwide, refers to malignant tumors located from the skull base and supraclavicle to the anterior cervical spine. HNCs include neck cancer, otorhinolaryngological cancer, and oral and maxillofacial cancer.
      • Sup A.A.S.C.
      Epidemiology of Head and Neck Cancers: An Update.
      ,
      • CorresAuth C.R.L.S.
      • Sup P.J.F.S.
      • CorresAuth R.H.B.S.
      The molecular landscape of head and neck cancer.
      The Global Burden of Disease (GBD) study has estimated that 890,000 new head and neck cancers (HNCs) occurred worldwide in 2017 and has indicated an increased incidence rate in recent years.[
      • Sup A.A.S.C.
      Epidemiology of Head and Neck Cancers: An Update.
      ] Currently, radiotherapy is the most important treatment option for patients with HNC, approximately 80% of whom receive radiotherapy at least once.[
      • Borras J.M.
      • Barton M.
      • Grau C.
      • et al.
      The impact of cancer incidence and stage on optimal utilization of radiotherapy: Methodology of a population based analysis by the ESTRO-HERO project.
      ] However, whereas tumor cells are irradiated during radiotherapy, normal cells adjacent to the tumor are also exposed, thereby resulting in a series of adverse effects, ranging from relatively mild tissue fibrosis, reduced saliva secretion, or local tissue swelling to life-threatening dysphagia.[
      • Borras J.M.
      • Barton M.
      • Grau C.
      • et al.
      The impact of cancer incidence and stage on optimal utilization of radiotherapy: Methodology of a population based analysis by the ESTRO-HERO project.
      ] Indeed, dysphagia is considered a major concern for patients with HNC undergoing radiotherapy,[

      Zhang M, Li C, Zhang F, et al. Prevalence of Dysphagia in China: An Epidemiological Survey of 5943 Participants. Dysphagia. 2021.

      ] owing to the local pressure caused by the tumor mass effect or the invasion of tumors into swallowing-associated tissues.[

      Eytan DF, Blackford AL, Eisele DW, Fakhry C. Prevalence of comorbidities and effect on survival in survivors of human papillomavirus-related and human papillomavirus-unrelated head and neck cancer in the United States. Cancer-Am Cancer Soc. 2019:249-260.

      ] After radiotherapy, 72.4% of patients with HNC have been reported to develop solid food dysphagia, and 17.2% develop liquid dysphagia.[

      Zhang M, Li C, Zhang F, et al. Prevalence of Dysphagia in China: An Epidemiological Survey of 5943 Participants. Dysphagia. 2021.

      ]
      Dysphagia can cause sensory changes (such as taste changes or mucosal pain), which results in appetite loss or eating difficulty, malnutrition, and dehydration.

      Zhang M, Li C, Zhang F, et al. Prevalence of Dysphagia in China: An Epidemiological Survey of 5943 Participants. Dysphagia. 2021.

      ,
      • Cohen E.E.
      • LaMonte S.J.
      • Erb N.L.
      • et al.
      American Cancer Society Head and Neck Cancer Survivorship Care Guideline.
      Moreover, patients with dysphagia tend to avoid attending social activities and to have psychological disorders (such as depression and cognitive impairment).[
      • Yifru T.A.
      • Kisa S.
      • Dinegde N.G.
      • Atnafu N.T.
      Dysphagia and its impact on the quality of life of head and neck cancer patients: institution-based cross-sectional study.
      ] Moreover, the patients’ lives can be threatened if dysphagia-associated aspiration pneumonia develops.[
      • Wu C.H.
      • Hsiao T.Y.
      • Ko J.Y.
      • Hsu M.M.
      Dysphagia after radiotherapy: endoscopic examination of swallowing in patients with nasopharyngeal carcinoma.
      ]
      Currently, because no “gold standard” treatment can alleviate the damage caused by radiotherapy-associated dysphagia, different types of swallowing exercises have been introduced and confirmed to be beneficial for patients with HNC.[
      • Roe J.W.
      • Carding P.N.
      • Rhys-Evans P.H.
      • Newbold K.L.
      • Harrington K.J.
      • Nutting C.M.
      Assessment and management of dysphagia in patients with head and neck cancer who receive radiotherapy in the United Kingdom - a web-based survey.
      ] Swallowing exercises include active exercise and passive exercise. Active exercises include bulging the cheek or mouth, knocking the teeth, performing swallowing actions, stretching the tongue, and rolling the tongue. Passive exercises mainly include actions around the throat, tongue, and jaw, such as Masako maneuvers and Mendelsohn swallowing.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Loewen I.
      • Jeffery C.C.
      • Rieger J.
      • Constantinescu G.
      Prehabilitation in head and neck cancer patients: a literature review.
      Generally, a typical swallowing exercise includes four to five actions, depending on patients’ individual needs. The importance of adhering to swallowing exercises has been well documented. As shown in a study led by Starmer, compared with non-compliant patients, patients with better compliance with an exercise program show better tolerance to regular diet(54.4% vs. 21.4%), a lower G-tube dependence(22.8% vs. 53.6%), and a higher rate of adhering to a self-managed diet(54.4% vs. 25.0%).[
      • Duarte V.M.
      • Chhetri D.K.
      • Liu Y.F.
      • Erman A.A.
      • Wang M.B.
      Swallow preservation exercises during chemoradiation therapy maintains swallow function.
      ] Another study has found that patients with >50% swallowing exercise compliance, compared with <50% compliance, score much higher in swallowing-associated quality of life.[
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ]
      However, despite the effectiveness of swallowing exercises, a lack of compliance is common. The long-term exercise compliance of patients with HNC is only 40%,[
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ] thus inevitably affecting rehabilitation outcomes. Here, through an integrative review, we explored the factors influencing swallowing exercise compliance in patients with HNC, then analyzed the advantages and disadvantages of existing intervention strategies to address this issue. The ultimate goal was to help healthcare providers develop effective interventions to improve the outcomes of patients with HNC with radiotherapy-associated dysphagia.

      2. Methods

      This is an integrative review study on the challenges of improving compliance with swallowing exercises in patients with HNC. This integrated review of literature summarized previous studies by extracting the study results according to the Russell model, which comprises five steps: (1) problem identification; (2) literature search; (3) evaluation of data; (4) data analysis; and (5) interpretation and presentation of the results.[
      • Russell C.L.
      An overview of the integrative research review.
      ]

      2.1 Problem identification

      This study was planned to explore the factors influencing swallowing exercise compliance in patients with HNC, and to determine the advantages/disadvantages of existing intervention strategies and corresponding solutions. Three key questions were used to guide the review process: (1) What factors influence swallowing exercise compliance in patients with HNC? (2) How should the compliance of swallowing exercise be evaluated? (3) How can compliance of swallowing exercise in patients with HNC be improved? Answering these key questions will help healthcare providers develop effective interventions to improve the outcomes of patients with HNC with radiotherapy-associated dysphagia.

      2.2 Literature search

      The following databases were searched from inception to August 2022: PubMed, Cochrane Library, Embase, CINAHL, CNKI, Wan Fang Database, and VIP Database. The reference lists of relevant articles were also searched. The following Medical Subject Headings were used in the search: “head and neck neoplasms”, “cancer of head and neck”, “exercise therapy”, “rehabilitation", “self-management”, “swallow training”, “swallowing exercise”, “deglutition training”, “rehabilitation program”, “rehabilitation plan”, “rehabilitation intervention”, “rehabilitative intervention”, “rehabilitative interventions”, “patient compliance”, “adherence”, “compliance”, “patient adherence”, “patient non-compliance”, “implementation rates”, and “execution rate”. For detailed search strategies, please see the “Appendix”.

      2.3 Data evaluation

      The inclusion criteria in this study were developed on the basis of analysis of participants, treatments, and outcomes. The detailed inclusion criteria were as follows: (1) patients with HNC with tumors in the oral cavity, oropharynx, nasopharynx, larynx, hypopharynx, parotic gland, and parotic gland; (2) patients ≥18 years of age; (3) patients planning radiotherapy or who underwent radiotherapy; (4) outcomes including compliance with preventive swallowing exercises or swallowing exercises after radiotherapy; and (5) articles written in either Chinese or English. The exclusion criteria were (1) articles for which the original article and detailed methods could not be accessed and (2) articles irrelevant to the research questions.

      2.4 Data analysis

      Two reviewers independently screened the title and abstract of each article to assess its relevance before reviewing the full texts of potential studies. As shown in Figure 1, a total of 1108 articles were identified from databases. After removal of duplicates, 676 remaining articles were screened for relevance. Eventually, 40 articles were selected for full-text checking, and 21 articles met the inclusion criteria and were included in this integrative review.
      Figure 1
      Figure 1A schematic of the sampling process.
      Next, data including the first author, year of publication, study design, participants, setting, intervention, comparison, and outcome variables were extracted and imported into Note Express. The extracted data were cross-checked for accuracy.

      3. Results

      3.1 Study design and patient characteristics

      In terms of study design, the 21 selected studies (Table1)
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      • Brady G.C.
      • Goodrich J.
      • Roe J.W.G.
      Using experience-based co-design to improve the pre-treatment care pathway for people diagnosed with head and neck cancer.
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      • Govender R.
      • Wood C.E.
      • Taylor S.A.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory.
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      • You G.
      • Dai Q.
      • Liu L.
      Analysis of compliance of nasopharyn-geal carcinoma patients accepting functional exercise during radiotherapy and nursing care of them (in Chinese with abstract).
      comprised six randomized controlled studies,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      ,
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      eight quasi-experimental studies,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ,
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      ,
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      and seven observational studies.
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Govender R.
      • Wood C.E.
      • Taylor S.A.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory.
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      ,
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ,
      • You G.
      • Dai Q.
      • Liu L.
      Analysis of compliance of nasopharyn-geal carcinoma patients accepting functional exercise during radiotherapy and nursing care of them (in Chinese with abstract).
      Regarding the radiotherapy stage, seven studies focused on patients planning radiotherapy,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      ,
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      12 studies focused on the patients completed radiotherapy,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      • Govender R.
      • Wood C.E.
      • Taylor S.A.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory.
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      and only one study focused on patients in pre-radiotherapy, mid-radiotherapy, or post-radiotherapy.[
      • You G.
      • Dai Q.
      • Liu L.
      Analysis of compliance of nasopharyn-geal carcinoma patients accepting functional exercise during radiotherapy and nursing care of them (in Chinese with abstract).
      ] The typical swallowing exercise included: effortful swallow,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      the Mendelsohn maneuver, the Masako maneuver,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      , and mouth-opening exercise.
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      • You G.
      • Dai Q.
      • Liu L.
      Analysis of compliance of nasopharyn-geal carcinoma patients accepting functional exercise during radiotherapy and nursing care of them (in Chinese with abstract).
      Furthermore, Jaw stretches,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      tongues stretching and strengthening,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      tapping teeth, chewing, and blowing
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      ,
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      were also reported.
      Table1Study and patient characteristics (n = 21).
      First

      Author, Year, Language
      Study designSample size (I/C)Participant characteristicsSwallow training regimen
      Starmer, H, 2022,

      English
      Quasi-experimental study44/47Cancer type: HNC (oral cavity, oropharynx, nasopharynx, larynx, and hypopharynx)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      During radiation.
      Age(years): 59.3 ± 9.9/61.0 ± 9.6
      Gender: male (85.7%/87.2%)
      Treatment: radiation.
      Timepoint: planning radiation.
      Dysphagia stage: NR
      Constantinescu, G., 2021, EnglishQuasi-experimental study20Cancer type: HNC(oral, oropharyngeal, or other cancers)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      A target of 72 swallows per day split between three different exercise types: three regular swallows, three effortful swallows, and three Mendelsohn maneuver swallows.
      Age(years): 61± 8
      Gender: male (75%)
      Treatment:surgery ± (chemo)radiation
      Time point:3 months post-HNC treatment.
      Dysphagia stage: may benefit from the
      Mendelsohn maneuver swallow(depend on SLP)
      Hajdú, SF, 2019, EnglishQuasi-experimental study45Cancer type: HNC(oral cavity, larynx, oropharynx, hypopharynx, or unknown primary tumor)

      Age(years): 62 (41-78)

      Gender: male (78%)

      Treatment: (chemo)radiotherapy

      Timepoint: planning radiation

      Dysphagia stage: NR

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      During radiation.
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Three times daily.
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      14 exercises (tongue stretching and strengthening, jaw mobility and mouth opening, Mendelsohn maneuver, Shaker exercise, Masako maneuver, Effortful swallow, and Valsalva).
      Starmer, HM, 2018, EnglishQuasi-experimental study36Cancer type: HNC (oropharyngeal tumors 83%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      During radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      3 sets of 10 reps of each exercise twice daily

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Specific exercises included effortful swallow, Masako, Mendelsohn, effortful pitch glides, and jaw stretches.
      Age(years): 61± 8
      Gender: male (80%)
      Treatment: Chemoradiation (75%)
      Surgery + radiation (17%)
      Radiation(8%)
      Timepoint: planning radiation
      Dysphagia stage: NR
      Cnossen, IC, 2017, EnglishQuasi-experimental study50Cancer type: HNC (oral cavity, oropharynx, hypopharynx, or larynx)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      At least once a day for 15 min and preferably three times a day.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Swallowing with strength: effortful swallow, taking sips of water regularly.
      Age(years): 66  (40-77)
      Gender: male (78%)
      Treatment: (chemo)radiotherapy
      Time point: terminate radiotherapy
      Dysphagia stage: RTOG scores:2-4
      Wall, LR, 2017, EnglishRandomized controlled study20/25/26Cancer type: HNC (100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      During radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Usual swallowing rehabilitation based on a literature review.
      Age(years): 58± 8
      Gender: male (89%)
      Treatment: (chemo)radiotherapy
      Time point: planning radiation
      Dysphagia stage: FOIS:7 /≤6
      Shinn, EH, 2013, EnglishCohort109Cancer type: oropharyngeal cancer (100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Pre-radiotherapy / Mid-radiotherapy / Post-radiotherapy

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Speech Pathology-led swallowing exercises
      Age(years): 57± 9
      Gender: male (87%)
      Treatment: (chemo)radiotherapy
      Time point:planning radiation
      Dysphagia stage:NR
      Govender, R, 2020, EnglishRandomized controlled study16/16Cancer type: HNC(oral cavity, nasopharynx, Oropharynx, hypopharynx, larynx)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Usual post-treatment swallowing rehabilitation
      Age(years):58.56±12.41/55.19±9.45
      Gender: male (95%)
      Treatment: radiotherapy ± Surgery(2%) ± chemotherapy
      Time point:planning radiation (radiotherapy group)
      Dysphagia stage:NR
      Govender, R, 2017, EnglishQualitative13Cancer type: HNC(oral cavity, nasopharynx, oropharynx, hypopharynx/larynx)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Depend on swallowing exercise consulting with a SLT.
      Age(years): 56.5± 6.5
      Gender: male (69%)
      Treatment: radiotherapy±Surgery±chemotherapy
      Time point: terminate radiotherapy
      Dysphagia stage:PSS: <50: 4 PSS: ≥50: 9
      Kraaijenga, S A, 2017, EnglishQuasi-experimental study18Cancer type: HNC(parotic gland, parotic glan, hypopharynx, oral cavity,neck metastasis,oropharynx,larynx)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Perform the SEA exercises 3 times daily for at least 6 weeks and for a maximum of 8 Week.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Progressive muscle overload, including chin tuck, jaw opening, and effortful swallow exercises.
      Age(years): 65(42-74)
      Gender: male (76%)
      Treatment: (chemo)radiotherapy
      Time point: The dysphagia had to be persistent for at least 1 year.
      Dysphagia stage: PAS ≤4
      Baudelet, M, 2020, EnglishRandomized controlled

      Study (protocol)
      50/50/50Cancer type: HNC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Before and during radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      5times/week (30–40 min)

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Tongue-strengthening exercises and chin-tuck against resistance combined with an effortful swallow
      Treatment: (chemo)radiotherapy
      Time point:4 weeks before (chemo)radiotherapy
      Wen, K, 2021, ChineseCross-sectional study124Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Mouth opening exercise
      Age(years): <60:78 ≥60:46
      Gender: male (66%)
      Treatment: radiotherapy
      Time point: terminate radiotherapy
      Dysphagia stage:NR
      Zhang, YF, 2020, ChineseCross-sectional study88Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      (1) Mouth opening exercise lasting 5 seconds, more than 60 times a day;

      (2) Tapping teeth,100 times / time, 3 times /d;

      (3) Drum gills, chewing gum, blowing balloons and other exercises;

      (4) Neck exercise 3 ∼ 5 min / time, 5 times /d
      Age(years): 35-60
      Gender: male (49%)
      Treatment: radiotherapy
      Time point: terminate radiotherapy
      Dysphagia stage:NR
      Xu, X, 2018, ChineseQuasi-experimental study118/121Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Mouth opening exercise
      Age(years): 25-65
      Gender: male (76.03%)
      Treatment: radiotherapy
      Time point:terminate radiotherapy
      Dysphagia stage:NR
      He,PY, 2015, ChineseRandomized controlled study143/144Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      (1)Mouth opening exercise, 10-15 min/ time, 3 times/ d;

      (2)Tapping teeth, 100 times / time, 3 times /d;

      (3)Tongue exercise, 10 times / d, each interval of 10min;

      (4)Drum cheeks, chewing, whistling, deep breathing exercise, 10-15 min / time, 3 times / d;

      (5)Temporomandibular joint massaging, 10 ∼ 15 min/ time, 3 times / d;
      Age(years): 47±11
      Gender: male (76.1%)
      Treatment: radiotherapy
      Time point: terminate radiotherapy
      Dysphagia stage:NR
      Yu, JF, 2021, ChineseRandomized controlled study40/40Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Mouth opening exercise.
      Age(years):40±6
      Gender: male (68.8%)
      Treatment: radiotherapy
      Time point:terminate radiotherapy
      Dysphagia stage:NR
      Fan, SQ, 2021, ChineseCross-sectional study150Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      During radiation and after radiation

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Mouth opening exercise.
      Age(years):40±6
      Gender: male (68.8%)
      Treatment: radiotherapy
      Time point: undergoing radiotherapy for more than 4 weeks
      Dysphagia stage:NR
      Wang, XM, 2017,

      Chinese
      Quasi-experimental study84Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      During radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Mouth opening exercise.
      Age(years):17-72
      Gender: male (70.2%)
      Treatment: radiotherapy
      Time point: Planning radiotherapy
      Dysphagia stage:NR
      Lu, XN, 2017, ChineseRandomized Controlled study60/60Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Mouth opening exercise, drum gill, shrink gill exercise, tongue exercise, knock teeth exercise, temporomandibular joint exercise, neck muscle exercise.
      Age(years):24-69
      Gender: male (78%)
      Treatment: radiotherapy
      Time point:terminate radiotherapy
      Dysphagia stage:NR
      Chen, PJ, 2016, ChineseCross-sectional study124Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      After radiation.

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Mouth opening exercise
      Age(years):<60:78 ≥60:46
      Gender: male (66.1%)
      Treatment: (chemo)radiotherapy
      Time point: terminate radiotherapy
      Dysphagia stage: NR
      You, GM, 2005, ChineseCross-sectional study50Cancer type: NPC(100%)
      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Pre-radiotherapy / Mid-radiotherapy / Post-radiotherapy

      HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.
      Mouth opening exercise: mouth opening to the maximum and then slowly closed, repeated 10 rounds, 3 times a day; bite cork 10min ∼ 15min, 1 times a day.
      Age(years):<60:78 ≥60:46
      Gender: male (68%)
      Treatment: radiotherapy
      Time point:planning radiotherapy
      Dysphagia stage:NR
      a HNC: Head and neck cancer, NPC: Nasopharyngeal carcinoma cancer, I/C: Intervention / Control, NR: Not report, SLTs: Speech and language therapists, SLPs: Speech and language pathologist, PSS: Performance status scale, IOPI: Iowa Oral Performance Instrument, FOIS: The Functional Oral Intake Scale, PSS: Performance status scale, PAS: Penetration-Aspiration Scale, SEA: Swallow Exercise Aid RTOG: Radiation Therapy Oncology Group.

      3.2 Compliance Evaluation

      3.2.1 Evaluation methods

      The evaluation methods were performed either subjectively or objectively, and the implementation included compliance quantification
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      ,
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      ,
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      and patient self-report
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ,
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      ,
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ,
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      ,
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      . As shown in Table 2, subjective evaluation was used in most (17/22) studies including observation,
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      ,
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ,
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      ,
      • You G.
      • Dai Q.
      • Liu L.
      Analysis of compliance of nasopharyn-geal carcinoma patients accepting functional exercise during radiotherapy and nursing care of them (in Chinese with abstract).
      inquiry,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      questionnaire surveys,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      face-to-face interviews.[
      • Govender R.
      • Wood C.E.
      • Taylor S.A.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory.
      ] In contrast, only two studies used novel equipment for evaluating compliance objectively.
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      For example, a mobile health (m-Health) system, Mobili-T, was used to collect the number of swallowing exercises on the basis of surface electromyography data for swallowing muscles.[
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ] In another case, a device called the Iowa Oral Performance Instrument, which was equipped with a digital display function and was connected to an air-filled bulb, was used. After the bulb was placed into the patient’s mouth, the patient was instructed to push the bulb as forcefully as possible against the palate to perform tongue-strengthening exercises, and the number of exercises performed was recorded automatically. Furthermore, the degree of compliance was assessed on the basis of the time spent using these exercise training devices/apps.[
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ] One study was a mixed subjective and objective evaluation.[
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ]
      Table 2Evaluation methods of compliance (n = 20).
      First Author and YearThe tool used to measure complianceDefinition of complianceCompliance measuring timeDuration
      Starmer, H, 2022,Logs of an m-Health App: HNC Virtual Coach and paper logsPercent trials completed of trials prescribed.

      Input
      Once a week during radiotherapy.7weeks
      Constantinescu, G, 2021An m-Health system: Mobili-TPercent trials completed of trials prescribed.Once a week during the intervention.6 weeks
      Hajdú, SF, 2019Participants’ training-logsPercentage of prescribed exercises completed.Once a week during radiotherapy.7 weeks
      Starmer, H.M., 2018Logs of the Vibrent™ mobile applicationPercentage of prescribed logs completed.Per exercise7 weeks
      Cnossen, IC, 2017,Patients’ diaries on paper or onlinePercentage of patients who kept up exercising and exercise performance level.T1:6th weeks during the intervention12 weeks
      T2:12th weeks during the intervention
      Wall, LR, 2017,Exercise log books and an m-Health system: Swallow-ITPercentage of prescribed exercise completed.Once a day6 weeks
      Shinn, E. H., 2013,Speech pathologists’ documentationDemonstrated adequate competency in all assigned swallowing exercises to a speech pathologist or not.T1: weeks 3 to 6 during radiation,2 years
      T2:Six months after completion of radiation
      T3:1–2 years after completing radiation
      Govender, R, 2020,A study questionnaire.Percentage of patients with satisfactory to good adherence based on the responses to the adherence form.T1:one month during the intervention6 months
      T2:3rd months during the intervention
      T3:6th months during the intervention
      Kraaijenga, SA, 2017,A study-specific questionnaire.NR6∼8 weeks after intervention.\
      Baudelet, M, 2020,Paper registration of patients and therapists and an equipment: IOPIThe total number of exercises performed per week and the time spent on the app.During the first 4 weeks of radiotherapy.4 weeks
      Wen, K, 2021,A self-designed questionnaireDepend on the 3 factors: compliance with mouth opening exercise, compliance with precautions, and compliance with advice-seeking.3 months after completion of radiotherapy.\
      Zhang, YF

      , 2020
      A self-designed compliance questionnaireDepending on patients’ scores in different exercise actions:1 point means no exercise, and 2 points mean sometimes exercise.NR\
      Xu, X, 2018A compliance questionnaireDepending on the 3 factors: faith, will, and confidence for mouth-opening exercise,Six months after radiotherapy.\
      He,PY,2015A compliance questionnaireComplete compliance: fully completed the prescribed actions;After radiotherapy and 3 months after discharge.3 months
      Partial compliance: partially completed prescribed actions;
      Non-compliance: occasionally exercised or never exercise.
      Yu, JF, 2021Nurse(s)Complete compliance: fully completed the prescribed actions;After 6 months of intervention\
      Partial compliance: partially completed prescribed actions;
      Non-compliance: occasionally exercised or never exercise
      Fan, SQ, 2021Mouth opening exercise compliance questionnaireDepend on the 3 factors: compliance with mouth opening exercise, compliance with precautions, and compliance with advice-seeking.The first review at the end of radiotherapy\
      Wang, XM, 2017Nurse(s)Complete compliance: fully completed the prescribed actions;Terminate radiotherapy\
      Partial compliance: partially completed prescribed actions;
      Non-compliance: occasionally exercised or never exercise.
      Lu, XN, 2017,Nurse(s)Full compliance: fully completed the prescribed actions;12 months after discharge\
      Partial compliance: partially completed prescribed actions; including the action is not in place, the number of training is not enough;
      Non-compliance: never exercise or mouth-opening exercise less than 10 times a day.
      Chen, PJ, 2016,A self-designed compliance questionnaireDepend on the compliance of seeking advice and the compliance of precautions.3 months after radiotherapy\
      You, GM, 2005Nurse(s)The degree of consistency between patient ' exercise actions and prescribed action.T1: Pre-radiotherapyDuring radiotherapy
      T2: Mid-radiotherapy
      T3: Post-radiotherapy
      HNC: Head and neck cancer, NR: Not report, SLPs: Speech and language pathologist, IOPI: Iowa Oral Performance Instrument.

      3.2.2 Compliance level

      Compliance levels were classified with two methods: (1) a continuous method, in which compliance was divided into three or more levels (full compliance/partial compliance/non-compliance)
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      (2) a dichotomous method, in which compliance was divided into two levels (high compliance or low compliance)[
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ] or was represented as a percentage determined by the researchers.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      Three studies evaluated patient compliance on the basis of compliance-associated factors, including taking precautions, help-seeking, faith, willingness, self-efficacy, and the ability to complete the assigned swallowing exercises.
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).

      3.2.3 Time points

      The range of measurement baseline spanned the first day of radiotherapy
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      to 12 months after radiotherapy.[
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ] The duration of evaluation ranged from 6 weeks
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      to 2 years,[
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ] and the most common evaluation frequency was once per week.
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.

      3.3 Factors influencing compliance

      Fourteen studies reported factors influencing swallowing exercise compliance,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      ,
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      ,
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      ,
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ,
      • You G.
      • Dai Q.
      • Liu L.
      Analysis of compliance of nasopharyn-geal carcinoma patients accepting functional exercise during radiotherapy and nursing care of them (in Chinese with abstract).
      as detailed below.

      3.3.1 Socio-demographic factors

      Five studies showed that male sex, older age, smoking, low education level, and residence in rural areas were negative factors influencing patients’ compliance with swallowing exercises.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      ,
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ,
      • You G.
      • Dai Q.
      • Liu L.
      Analysis of compliance of nasopharyn-geal carcinoma patients accepting functional exercise during radiotherapy and nursing care of them (in Chinese with abstract).
      Interestingly, two studies indicated that sex and age had no significant effects on compliance with swallowing exercises.
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      Moreover, economic factors, such as income and the method of paying for the treatment, affected compliance with swallowing exercises.
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ,
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      For example, as shown in a study led by Chen, patients with nasopharyngeal cancer whose per capita monthly household income exceeded 3000 Chinese yuan showed better compliance with mouth-opening exercises than patients with lower incomes, and the compliance rate increased gradually with increasing income.[
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ] In addition, according to Wen’s study, the method of paying for the treatment, such as the self-paid medical care model, medical insurance model, or government-paid medical care model, was also a significant factor influencing patient compliance with swallowing exercises.[
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ]

      3.3.2 Illness-associated factors

      Although patients with oropharyngeal tumors have been reported to be less likely to complete exercises than patients with tumor sites in the oral cavity, oropharynx, nasopharynx, larynx, or hypopharynx,[
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ] as shown in a study led by Hajdú, no significant relationship between swallowing exercise compliance and tumor site (oral cavity, oropharynx, larynx, or hypopharynx) was found.[
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ] According to the selected studies, the tumor differentiation grade,[
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ] HNC duration,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      , and complications[
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ] affected swallowing exercise compliance. For example, a higher tumor differentiation grade was associated with lower compliance scores,[
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ] and patients with an HNC duration >1 year had poor compliance with exercise during radiotherapy.[
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      ] In another study, after 6 weeks of exercise, patients 2–5 years post-radiation demonstrated higher adherence than patients <2 years post-treatment.[
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ]

      3.3.3 Treatment-related factors

      The treatment-associated factors of radiotherapy course,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • You G.
      • Dai Q.
      • Liu L.
      Analysis of compliance of nasopharyn-geal carcinoma patients accepting functional exercise during radiotherapy and nursing care of them (in Chinese with abstract).
      radiation-associated adverse effects (such as pain, fatigue, and nausea),
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      and involvement of concomitant therapy (chemotherapy) significantly affected compliance with swallowing exercises.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      Two studies reported that compliance with swallowing exercises gradually decreased after radiotherapy.
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • You G.
      • Dai Q.
      • Liu L.
      Analysis of compliance of nasopharyn-geal carcinoma patients accepting functional exercise during radiotherapy and nursing care of them (in Chinese with abstract).
      Moreover, the pain of radiation stomatitis, fatigue, or nausea sometimes even resulted in suspension of functional exercises.[
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      ] Additionally, compared with patients treated with radiotherapy only, patients receiving concomitant chemotherapy had lower exercise frequency.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.

      3.3.4 Psychosocial factors

      Social support Most (13) of the assessed studies reported that better social support increased swallowing exercise compliance.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      • Govender R.
      • Wood C.E.
      • Taylor S.A.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory.
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      For example, in a study led by Wall, patients with HNC who underwent self-exercise, compared with clinician-directed face-to-face therapy and m-Health application-assisted therapy, showed the lowest adherence to swallowing exercises.[
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ] Generally, the forms of social support included notification reminders, educational videos, remote monitoring based on m-Health systems,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      face-to-face instruction sessions,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ,
      • Govender R.
      • Wood C.E.
      • Taylor S.A.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory.
      , and peer education.[
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      ]
      Cognition and belief According to our analysis, in most cases, the lack of compliance with swallowing exercises was due to a lack of understanding regarding their importance or to insufficient motivation.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Govender R.
      • Wood C.E.
      • Taylor S.A.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory.
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      ,
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      Three studies reported that self-management efficacy, which was associated with attitudes toward treatment and self-decision-making, was positively correlated with compliance with swallowing exercises.
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ,
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      ,
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).

      3.4 Characteristics of the interventions

      3.4.1 Deliverer

      Among all included studies, the interventions were delivered by different personnel, including speech and language pathologists (SLPs),
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      speech and language therapists (SLTs),[
      • Brady G.C.
      • Goodrich J.
      • Roe J.W.G.
      Using experience-based co-design to improve the pre-treatment care pathway for people diagnosed with head and neck cancer.
      ] speech therapists,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      oncology specialist nurses,
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      oncologists,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      radiation therapists,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      and clinician researchers,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      as shown in Table 3. Five studies used multidisciplinary team-led interventions.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      In addition to healthcare providers, one study developed a peer education program by inviting patients with nasopharyngeal cancer post-radiotherapy to perform a swallowing training program and then participate in an experience-sharing session.[
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      ]
      Table 3. Characteristics of the interventions in studies included in the review. (n=14).
      First

      Author and Year
      Delivered byMediumInterventionControlResults that are relevant for the review
      Starmer, H, 2022SLP(s)HNC Virtual Coach appA notification reminder and a link to a training video through the “HNC Virtual Coach” app twice a day.Did not have access to educational videos but were provided handoutsThe adherence of patients in the app arm is higher than in the paper arm.
      before the start of RT.
      Constantinescu, G., 2021SLP(s) and clinician researchersAn m-Health system:(1) Remotely monitored exercise data and answer questions;NRAdherence to the exercise regimen remained high from 84% in Week 1 to 72% in Week 6.
      Mobili—T(2) Check-in appointment with this SLP.
      Hajdú, SF, 2019OTOT-led swallowing exercises(1) Designed targeted exercise programsNRThe total cohort median adherence to exercises was 78%.
      based on the clinical examination of patients’;
      (2) Supervised individual training and provided sessions.
      Starmer, HM, 2018SLP(s)Vibrent™ Mobile App(1) The application provided training videos, reminders, exercise logging, and an educational program.NROn average, there was a 29% adherence rate. 25% of participants logged at least two exercise sessions per day over the 7-week treatment period and 53% recorded at least one session per day.
      (2) Communication between patients and providers was possible through a messaging system.
      Cnossen, IC, 2017SLP(s) and swallowing therapist(s)

      and speech therapist(s)

      A guided home-based prophylactic(1) Online training including photo and video examples of the exercises, and educational booklet;NRThe adherence rate at 6 weeks was 70% and decreased to 38% at 12 weeks.
      (2) Face-to-face instruction session;
      (3) Each patient is contacted by phone in a weekly 10-min coaching session by an experienced speech therapist.
      Wall, LR, 2017Clinician and speech pathologist(1)Clinician-directed therapy(1) Face-to-face education session by clinician;

      (2) The Swallow-IT application: tracks the number of repetitions and cycles completed and records patient perceptions of perceived effort when completing each exercise.

      Joint speech pathology/dietetic sessions weeklyThe lowest adherence was observed in the patient-directed therapy group.

      There was a trend for higher adherence in the Swallow-IT group.
      (2) Technology-assisted therapy
      (3) Independent patient-directed therapy
      Govender, R, 2020SLP(s)Pre-treatment swallowing intervention package: SIP SMART(1) Patients underwent an x-ray swallow assessment that enabled a physiological analysis of swallowing and the selection of specific and targeted exercises.(1) One 45-min session;Patient-reported adherence in The intervention group  is higher than the control group.
      (2) Showed a video animation of swallowing.(2) Clinical baseline screening of swallowing and communication;
      (3) Goal setting, self-monitoring, and behavioral practice were actively employed.(3) Information provision.
      Kraaijenga, SA, 2017Clinical investigatorSEA-based exercise regimenExercise by an innovative tool.NRThe median compliance in terms of adherence to the 3 daily exercise sessions was 97% (range 86%–100%).
      Baudelet, M, 2020Radiation therapists and SLPs(1) Technology-assisted exercise(1)App group: practices at home but receives continuous counseling and gets instructions by videos via an application on a tablet,

      (2)Therapist group: was given face-to-face therapy and be counseled by an SLP five times per week.

      Perform the exercises at home, without the supervision of an SLP but with a counseling session of 10 min every week.NR
      (2)Therapist-led exercise
      (3)Patients self-exercise
      Xu, X, 2018Oncologist, oncology specialist nurse, radiotherapy technician, psychological consultant, and nutritionist, statisticianPeer education program(1)Peer educators use text, pictures, videos to carry out education, and emphasize the importance of mouth exercise through online and offline communication, case sharing, and other forms.(1)Symptom prevention, control, and management;

      (2)Recorded the mouth-opening exercise by video;

      (3)Encouraged and reminded patients to exercise;
      The intervention group has higher training compliance than the control group.
      (2)Organized patients to do exercise, and provided supervision.
      He,PY, 2015NursesPDCA cycle education model(1)Nurses checked patient's completion every day;Mouth opening exercise training, the content of functional exercise is the same as the intervention group.The intervention group has higher training compliance than the control group.
      (2)Solve problems of patients;
      (3)A seminar was held every 2 weeks;
      (4)Patients with poor compliance were guided by the nursing team leader to strengthen the patient's health knowledge and behavior.
      Yu, JF, 2021NursesPender health promotion modelIntervention based on past behavioral factors,Provided disease-related knowledge, diet and life guidance, and help patients complete functional trainingThe intervention group has higher training compliance than the control group.
      personal factors, cognitive factors, and behavioral emotional factors.
      Wang, XM, 2017NursesComprehensive nursing intervention model
      • (1)
        Improve nurses' awareness of scientific research;
      NRPatients could complete their exercises under the guidance of nurses while the willingness to complete them independently was poor.
      • (2)Implement health education for patient and their family members;
      (3)Pain intervention;
      (4)Communication by network platform.
      Lu, XN, 2017NursesOrem self-care model(1)Provided information about the disease, and guidance to help them in self-care;(1)Health education and exercise guidance during hospitalization;

      (2)Routine follow-up by a dedicated disease manager.
      The intervention group has higher exercise compliance than the control group.
      (2)Theoretical knowledge, case introduction, graphic examples;
      (3) Strengthen communication with patients and their families and help mobilize patient's exercise initiative;
      (4)Encourage family members to give patients more support;
      (5)Encourage patients to exercise based on their abilities.
      HNC: Head and neck cancer, SLPs: Speech and language pathologist, NR: Not report, SEA:Swallow Exercise Aid, OT:occupational therapist.

      3.4.2 Procedure of intervention

      Most studies included the following procedures: (1) screening patients with HNC treated with radiotherapy (pre-radiation, during radiation, or post-radiation); (2) evaluating patients’ demographic information, cancer status, and treatment information; (3) training patients and providing a swallowing exercise plan; and (4) supervising patients and encouraging them to implement their individualized exercise plans.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      • Brady G.C.
      • Goodrich J.
      • Roe J.W.G.
      Using experience-based co-design to improve the pre-treatment care pathway for people diagnosed with head and neck cancer.
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ,
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      ,
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      In a study led by He, the PDCA cycle model was proposed to standardize education procedures. This model included the following steps: (1) plan: formulate the overall plan on the basis of literature review, questionnaires, and expert interview; (2) deliver: perform training in the following order: (a) emphasize the adverse effects of radiotherapy, (b) emphasize the importance of swallowing exercise, and (c) formulate an individual exercise plan; and (3) check and apply: verify patient compliance and analyze existing problems to determine their causes and revise exercise plans. The PDCA training was repeated after each round until patients were discharged.[
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      ]

      3.4.3 Interventions designed to address various psychosocial factors

      Before exercise, the following interventions had been used in the assessed studies: face-to-face instruction sessions,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ,
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      peer experience sharing,[
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      ] and providing training materials such as photographic examples of the exercise,[
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ] training videos,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ,
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ,
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      and educational booklets including information on the importance of exercise, adverse reactions to radiotherapy, and exercise plans.[
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ] During exercise, beyond refreshing patients memory regarding previously performed training, a series of follow-up activities were implemented by healthcare providers.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      For example, professional appointments were implemented in person, by phone, or through e-mail to determine whether participants required additional supplies.[
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ] Additionally, in one study, an educational program focused on improving understanding among nurses and family members of patients was used to better manage patients’ swallowing exercises.[
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      ]

      3.4.4 Innovative equipment-based intervention

      The recent developments of novel m-Health systems, such as the HNC Virtual Coach,[
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ] Mobili-T,[
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ] Vibrent™ Mobile,[
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      ] Swallow-IT apps[
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ] have brought new hope for improving compliance with swallowing exercises, through providing educational videos, enabling interactive feedback, automatically recording exercise data, and providing notification reminders. Additionally, Kraaijenga developed a physical tool called “The Swallow Exercise Aid” based on an existing swallowing exercise tool, which featured a feedback device to prompt patients to progressively add exercise load by increasing exercise resistance.[
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      ]

      3.4.5 Theoretical framework underlying the intervention

      According to our analysis, 14 of the 21 studies
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      ,
      • Kraaijenga S.
      • Molen L.V.
      • Stuiver M.M.
      • et al.
      Efficacy of a novel swallowing exercise program for chronic dysphagia in long-term head and neck cancer survivors.
      ,
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      • Xu X.
      • Chen P.
      • Zhou J.
      Effects of peer education on mouth-opening training compliance among patients with nasopharyngeal carcinoma after radiotherapy(in Chinese with abstract).
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Wang X.
      • Yang D.
      • Chen Y.
      Role of comprehensive nursing intervention in improving compliance of patients with nasopharyngeal carcinoma in functional exercise (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      took measures to improve swallowing exercise compliance in patients with HNC on the basis of behavior change strategies (BCTs), such as goal setting, self-monitoring, and prompting.[
      • Wood C.E.
      • Eccles M.P.
      • Francis J.
      • et al.
      The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions.
      ] Pender’s Health Promotion Model helped healthcare providers provide targeted swallowing interventions based on patients’ behavioral factors, demographic factors, cognitive factors, and emotional factors.[

      N JP. Health Promotion in Nursing Practice. 3rd Ed ed. New Jersey: Prentice-Hall. 1996.

      ] For inpatients, Orem self-care theory was used to formulate mouth-opening exercise plans, on the basis of patients’ self-care agency relating to consciousness, vital signs, and exercise tolerance, whereas for outpatients, the supportive-educative system was formally used.[
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ]

      4. Discussion

      4.1 Combined subjective and objective evaluation enables more reliable compliance assessment

      Currently, widely accepted methods or tools for evaluating swallowing exercise compliance in patients with HNC are lacking.[
      • Yang W.
      • Nie W.
      • Zhou X.
      • et al.
      Review of prophylactic swallowing interventions for head and neck cancer.
      ] As a result, the evaluation is highly dependent on how researchers define the concept of compliance. To evaluate the swallowing exercise compliance of patients with HNC, different researchers may have different standards. For example, Starmer has used the percentage of completed trials as an indicator of patients’ compliance with swallowing exercise and used an m-Health application to record the times of exercise automatically.[
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ] However, in another study, although an m-Health system was also used to record the times of exercise, the total number of exercises performed per week and the time spent on the app were used to indicate patients’ compliance with swallowing exercises.[
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      ] Additionally, as shown in a study led by Shinn, compliance with long term exercise (from the initial radiation to 1–2 years after radiotherapy) depended on whether patients were able to fully complete swallowing exercises at the following specific time points: (1) 3–6 weeks during radiation, (2) 6 months after completion of radiation, and (3) 1–2 years after completion of radiation.[
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ]
      Although the concept of compliance differed, all evaluations could be performed either subjectively or objectively. The subjective evaluation method was widely used because of its advantages such as being equipment free and low cost. However, this method is limited by inevitable subjectivity. On the patient side, beyond the Hawthorne effect, the outcomes of patients’ self-reported compliance may be affected by forgetting to record exercise, lacking time to record, fatigue, or app/internet issues (if patients must log exercise dates online).[
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      ] On the researcher side, a lack of quantitative criteria for performance levels also inevitably results in subjectivity in judgment.
      In contrast, the objective evaluation method avoids the shortcomings of subjectivity to some extent. Nevertheless, the extensive application of objective methods is restricted by issues such as the need for specific equipment, higher costs, and technological difficulties.[
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      ] Moreover, the causes of non-compliance cannot be easily revealed by recording only the percentage of the prescribed exercises that were performed. Experts have recommended that combined methods including subjective and objective evaluations should be used to multi-dimensionally assess relevant information and obtain the most accurate compliance data.[
      • Sin N.L.
      • DiMatteo M.R.
      Depression treatment enhances adherence to antiretroviral therapy: a meta-analysis.
      ] From the analyses, introducing factors regarding performance levels and the reason for non-compliance into the equipment design appears promising.

      4.2 Socio-demographic, illness-associated, and treatment-associated factors should be emphasized

      According to previous studies, whether the sex and age of patients with HNC affects exercise compliance was unclear,
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Zhang Y.
      Influencing factors of the compliance of nasopharyngeal carcinoma patients with mouth opening exercise (in Chinese with abstract).
      • Wen K.
      • Chen P.
      • He Y.
      Influencing factors of mouth?opening exercise compliance and its relationship with self?management efficacy in adult patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      • Fan S.
      • Zou Y.
      • Chen C.
      Study on the correlation between self-management efficacy and mouth opening function exercise compliance of nasopharyngeal carcinoma patients during radiotherapy (in Chinese with abstract).
      ,
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ,
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      possibly because of differences in target populations, as well as sample selection bias. Therefore, whether and how sex and age affect exercise compliance must be further investigated. Notably, approximately 60% of patients with HNC were ≥60 years of age at the time of diagnosis.[
      • Guo K.
      • Xiao W.
      • Chen X.
      • Zhao Z.
      • Lin Y.
      • Chen G.
      Epidemiological Trends of Head and Neck Cancer: A Population-Based Study.
      ] Compared with younger patients, older patients may have more difficulties in learning exercise skills, owing to diminished cognitive ability.[
      • Gronstedt H.
      • Vikstrom S.
      • Cederholm T.
      • et al.
      Effect of Sit-to-Stand Exercises Combined With Protein-Rich Oral Supplementation in Older Persons: The Older Person's Exercise and Nutrition Study.
      ] Furthermore, older patients may be more likely to feel exhausted, fatigued, or uncomfortable during exercise, owing to diminished physical function, thus decreasing their compliance with the required exercises.[
      • Gronstedt H.
      • Vikstrom S.
      • Cederholm T.
      • et al.
      Effect of Sit-to-Stand Exercises Combined With Protein-Rich Oral Supplementation in Older Persons: The Older Person's Exercise and Nutrition Study.
      ] Therefore, targeted training and more flexible exercise plans are necessary, particularly for older people with poor endurance. Another factor associated with poor outcomes of swallowing exercise is smoking, which can cause poorer response to radiotherapy and increase radiotherapy-associated toxicity.[
      • McCarter K.
      • Baker A.L.
      • Britton B.
      • et al.
      Smoking, drinking, and depression: comorbidity in head and neck cancer patients undergoing radiotherapy.
      ] Consequently, this factor should also be assessed.
      After discharge, most economically disadvantaged patients living in rural areas in developing countries may not pay attention to their symptoms because of cost implications and/or living far from rehabilitation centers.[
      • Varughese J.
      • Richman S.
      Cancer care inequity for women in resource-poor countries.
      ] As shown in a study led by Chen, the compliance rate decreased gradually with decreasing income.[
      • Chen P.
      • Lu Z.
      • Zhang C.
      Effects of self-care self-efficacy on mouth open training compliance among patients with nasopharyngeal carcinoma after radiotherapy (in Chinese with abstract).
      ] This finding is understandable, given that the economic burden of patients with low incomes may make them worry more about their family’s economic status than their own quality of life, thus, decreasing their motivation to comply with rehabilitation exercises. However, different countries may have different social security and medical care systems,[

      Clements B, Cody D, Gupta S. Economics of public health care reform in advanced and emerging economies. 2017.

      ] and differences in whether/how the cost of rehabilitation is covered might directly affect compliance with swallowing exercises among patients with HNC, and therefore, rehabilitation outcomes.
      Increased and uncontrolled pain and radiotherapy-associated toxicity may also impair patients' ability to complete swallowing exercises, particularly their exercise tolerance.
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Shinn E.H.
      • Basen-Engquist K.
      • Baum G.
      • et al.
      Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      Similar results have also been shown in another study.[
      • Carnaby-Mann G.
      • Crary M.A.
      • Schmalfuss I.
      • Amdur R.
      Pharyngocise": Randomized Controlled Trial of Preventative Exercises to Maintain Muscle Structure and Swallowing Function During Head-and-Neck Chemoradiotherapy.
      ] A study led by Starmer has reported that patients who received gabapentin (a painkiller) in the first week of radiotherapy, compared with patients who did not treat pain with gabapentin, showed better outcomes in pain relief and maintaining swallowing function.[
      • Starmer M.
      • Yang W.
      • Raval R.
      • et al.
      Effect of gabapentin on swallowing during and after chemoradiation for oropharyngeal squamous cell cancer.
      ] Hence, the management of pain and toxicity should be further investigated.

      4.3 Intervention strategies and perspectives

      4.3.1 Multidisciplinary intervention is becoming a standard model for the management of swallowing exercises in patients with HNC

      In previous studies, the interventions were delivered mainly by SLPs, SLTs, and speech therapists.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Starmer H.M.
      • Klein D.
      • Montgomery A.
      • et al.
      Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      • Govender R.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      • Taylor S.A.
      SIP SMART: A parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer.
      • Brady G.C.
      • Goodrich J.
      • Roe J.W.G.
      Using experience-based co-design to improve the pre-treatment care pathway for people diagnosed with head and neck cancer.
      • Baudelet M.
      • Van den Steen L.
      • Duprez F.
      • et al.
      Study protocol for a randomized controlled trial: prophylactic swallowing exercises in head-and-neck cancer patients treated with (chemo)radiotherapy (PRESTO trial).
      • Hajdú S.F.
      • Christensen M.B.
      • Kristensen M.Ø.
      • Wessel I.
      • Johansen C.
      • Dalton S.
      Adherence to preventive swallowing exercises for head and neck cancer patients undergoing (chemo)radiotherapy treatment.
      ,
      • Cnossen I.C.
      • van Uden-Kraan C.F.
      • Witte B.I.
      • et al.
      Prophylactic exercises among head and neck cancer patients during and after swallowing sparing intensity modulated radiation: adherence and exercise performance levels of a 12-week guided home-based program.
      enerally, both SLPs and SLTs are trained in anatomy, physiology, neurology, linguistics, phonetics, normal and pathological speech, language, voice, and swallowing.
      Jackie McRae Sup Class Affiliation-links Sup EMSC
      The role of speech and language therapists in the intensive care unit.
      ,
      • Abdel-Aty Y.
      • Charney S.
      • Lott D.G.
      The Role of Speech-Language Pathologists in Otolaryngology Resident Education.
      In contrast, SLPs focus on providing rehabilitation services to patients with varying neurological, oncological, or other disease processes that affect communication, cognition, and/or swallowing abilities.[
      • Chahda L.
      • Mathisen B.A.
      • Carey L.B.
      The role of speech-language pathologists in adult palliative care.
      ] The roles of SLTs are aimed at the correction of speech problems for both elocution and medical disorders, including aphasia, motor speech disorders, head and neck cancer, voice disorders, and dysphagia.[
      Jackie McRae Sup Class Affiliation-links Sup EMSC
      The role of speech and language therapists in the intensive care unit.
      ] In contrast, speech therapists are trained to provide behavioral interventions for dysphonia to optimize patients' interaction with their environment.
      • Olivares C.A.
      • Tapia S.E.
      Role of speech therapist in palliative care.
      ,
      • Oates J.M.
      Treatment of dysphonia in older people: the role of the speech therapist.
      However, in practice, because SLPs, SLTs, and speech therapists have similar expertise, they all may be involved in the treatment of swallowing disorders.
      Most published swallowing exercise protocols in patients with HNC have required intensive therapeutic services, thus placing a high demand on rehabilitation resources.
      • Roe J.W.
      • Carding P.N.
      • Rhys-Evans P.H.
      • Newbold K.L.
      • Harrington K.J.
      • Nutting C.M.
      Assessment and management of dysphagia in patients with head and neck cancer who receive radiotherapy in the United Kingdom - a web-based survey.
      ,
      • Lawson N.
      • Krisciunas G.P.
      • Langmore S.E.
      • Castellano K.
      • Sokoloff W.
      • Hayatbakhsh R.
      Comparing dysphagia therapy in head and neck cancer patients in Australia with international healthcare systems.
      However, owing to limited resources, the overall utilization rate was only 20.7% for SLPs and 26.2% for occupational/physical therapy services.[
      • Wang J.R.
      • Nurgalieva Z.
      • Fu S.
      • et al.
      Utilization of rehabilitation services in patients with head and neck cancer in the United States: A SEER-Medicare Analysis.
      ] Moreover, although unmet rehabilitation needs have been identified in 60–70% of patients with HNC, professional rehabilitation therapists were reported to be reluctant to refer patients with HNC to general community-based services, owing to the uncertain quality of service.
      • Hodgkinson K.W.C.F.
      • Butow P.M.P.R.
      • Hobbs K.M.W.C.
      • Hunt G.E.D.O.
      • Lo S.K.F.O.
      • Wain G.W.C.F.
      Assessing unmet supportive care needs in partners of cancer survivors: The development and evaluation of the Cancer Survivors' Partners Unmet Needs measure (CaSPUN).
      ,
      • McEwen S.
      • Rodriguez A.M.
      • Martino R.
      • et al.
      I didn’t actually know there was such a thing as rehab”: survivor, family, and clinician perceptions of rehabilitation following treatment for head and neck cancer.
      In developing countries, most swallowing rehabilitation treatments are provided by rehabilitation therapists. However, most of these rehabilitation therapists are transferred from other medical specialties after short-term training;[
      • Xie L.
      • Xu T.
      • Liu Y.
      Research on Current Situation of Rehabilitation Therapy Education in China (in Chinese with abstract).
      ] therefore, they often have insufficient professional knowledge and skills. Simultaneously, the work to improve compliance with swallowing exercises in patients with HNC is typically undertaken by nurses, whose professional qualifications should also be considered.
      The issues of rehabilitation resources have highly limited the management of swallowing rehabilitation of patients with HNC. In recent years, multidisciplinary team led interventions have been established in many groups and have been considered a standard model for the management of patients with HNC.[
      • Taberna M.
      • Gil M.F.
      • Jané-Salas E.
      • et al.
      The Multidisciplinary Team (MDT) Approach and Quality of Care.
      ] Indeed, this multidisciplinary practice allows for rational distribution of the duties of healthcare providers and provides an effective means of optimizing healthcare resources for improved swallowing exercise results.

      4.3.2 Refining the intervention procedure

      As shown in the selected studies, although demographic screening and disease evaluation–exercise training–supervision and encouragement was the most common intervention procedure for increasing compliance with swallowing exercises, detailed investigations of the validity of the individual steps were not performed. For example, the time points of swallowing screening and evaluations, the exercise training content, and the order of provision of different training content were ambiguous, in agreement with the results reported by Ashley.[
      • Logan A.M.S.S.
      • Landera M.A.S.S.
      Clinical Practices in Head and Neck Cancer: A Speech-Language Pathologist Practice Pattern Survey.
      ] In a study led by He, the PDCA cycle model was proposed to standardize education procedures, and the compliance with mouth-opening exercise among patients with nasopharyngeal cancer has been effectively improved through this procedure.[
      • He P.
      • Wei J.
      • Du P.
      The influence of healthe education based on PDCA cycle comliance with mouth opening exercise inpatients with nasopharyngealcer cinoma after radiotherapy (in Chinese with abstract).
      ] Given the clear advantages of this detailed procedure, we suggest that more evidence-based individual steps of intervention procedures should be developed.

      4.3.3 Patients’ exercise tolerance and social support are important for completing swallowing exercises

      The motivation of patients with HNC to comply with swallowing exercises is affected by their capacity and available social support.[
      • Steltenpohl C.N.
      • Shuster M.
      • Peist E.
      • Pham A.
      • Mikels J.A.
      Me Time, or We Time? Age Differences in Motivation for Exercise.
      ] Long-term exercises often change patients’ lifestyles; therefore, individuals’ beliefs are important in facilitating their adherence to these time-consuming rehabilitation exercises.[
      • Essery R.
      • Geraghty A.W.
      • Kirby S.
      • Yardley L.
      Predictors of adherence to home-based physical therapies: a systematic review.
      ] Correspondingly, to promote cognition and beliefs regarding swallowing exercises among patients with HNC, different types of interventions were implemented in different forms at different stages of exercise, such as notification reminders, educational programs, and remote monitoring. However, the extent to which these social supports promote patient compliance, particularly among patients with poor individual capacity, such as poor exercise tolerance or passive attitude, should be further investigated.[
      • Govender R.
      • Wood C.E.
      • Taylor S.A.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory.
      ]

      4.3.4 Further exploration of the availability of innovative equipment

      Owing to limited clinical resources, most rehabilitation exercises were offered as home programs rather than in clinical settings.[
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ] In these circumstances, m-Health systems have made enabled healthcare providers to conveniently remotely monitor exercise data, answer questions, and adjust training schedules for individuals.
      • Wall L.R.
      • Ward E.C.
      • Cartmill B.
      • Hill A.J.
      • Porceddu S.V.
      Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors.
      ,
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ,
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      Moreover, the use of the m-Health systems has been reported to be cost-effective, thus providing patients with HNC with greater support in home-swallowing exercise, while minimizing the burden of health service costs (e.g., service time, consumables, and therapy resources) and patient-attributable costs (e.g., travel).[
      • Wall L.R.
      • Kularatna S.
      • Ward E.C.
      • et al.
      Economic Analysis of a Three-Arm RCT Exploring the Delivery of Intensive, Prophylactic Swallowing Therapy to Patients with Head and Neck Cancer During (Chemo)Radiotherapy.
      ] Importantly, biofeedback in apps provides a substantial advantage in making patients feel rewarded after even small improvements during swallowing training.[
      • Govender R.
      • Wood C.E.
      • Taylor S.A.
      • Smith C.H.
      • Barratt H.
      • Gardner B.
      Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory.
      ] This aspect is crucial to motivate patients to perform the required exercises.
      Although a high overall satisfaction with m-Health Apps had been reported, this result might be affected by selection bias, because patients with higher motivation typically volunteer to participate in telepractice, and the exercise motivation of patients might also be influenced by the use of a novel m-Health solution.[
      • Constantinescu G.
      • Rieger J.
      • Seikaly H.
      • Eurich D.
      Adherence to Home-Based Swallowing Therapy Using a Mobile System in Head and Neck Cancer Survivors.
      ] In using m-Health Apps, the notifications function of the app, which were used for reminding patients to exercise, were sometimes too frequent for patients with HNC, and internet issues have also become factors in participant dropout.[
      • Starmer H.M.
      • Abrams R.
      • Webster K.
      • et al.
      Feasibility of a Mobile Application to Enhance Swallowing Therapy for Patients Undergoing Radiation-Based Treatment for Head and Neck Cancer.
      ] Solutions designed to solve these problems by addressing these factors will improve the acceptance and motivation of patients to comply with swallowing exercise.

      4.3.5 Applying systematic theory frameworks to improve intervention efficiency

      According to our analysis, although behavioral change strategies had been used to unconsciously improve swallowing exercise compliance among patients with HNC, the poor descriptions of the strategies in most previous studies have greatly limited their generalization in clinical settings.
      • Craig P.
      • Dieppe P.
      • Macintyre S.
      • Michie S.
      • Nazareth I.
      • Petticrew M.
      Developing and evaluating complex interventions: the new Medical Research Council guidance.
      ,
      • Michie S.
      • Fixsen D.
      • Grimshaw J.M.
      • Eccles M.P.
      Specifying and reporting complex behaviour change interventions: the need for a scientific method.
      Behavior Change Technology theory includes detailed strategies for goal setting, problem-solving, action plans, and feedback on behavior, and thus might provide a potential solution. The interventions can be implemented effectively according to the content of BCTs.[
      • Govender R.
      • Smith C.H.
      • Taylor S.A.
      • Barratt H.
      • Gardner B.
      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.
      ] Pender’s Health Promotion Model theory also had an advantage in identifying effective factors or barriers to swallowing exercise and allowed healthcare providers to provide targeted interventions for exercise compliance improvement.[
      • Yu J.
      • Li H.
      • Liu Y.
      Application of Pender health promotion model in mouth opening training of nasopharyngeal carcinoma patients after radiotherapy Pender (in Chinese with abstract).
      ] Furthermore, Orem self-care theory, which typically focuses on the self-care deficit of patients with HNC, may help clinicians design specific exercise plans according to patients’ self-care abilities in different stages of HNC. This theory was particularly important for discharged patients.[
      • Lu X.
      • Tang Z.
      • Chen Y.
      Evaluation on effect of Orem self-care mode in mouth opening exercise for discharged patients with nasopharyngeal carcinoma undergoing radiotherapy (in Chinese with abstract).
      ]

      5. Limitations

      In this review, we aimed to identify specific factors and effective strategies for improving compliance with swallowing exercises in patients with HNC. Although different types of HNC have been examined in previous studies, such as the oral cavity, oropharynx, nasopharynx, larynx, hypopharynx, parotic gland, and parotic gland cancers, owing to the limited number of references, the effects of different tumor sites in exercise compliance could not be deduced. Additionally, direct comparison of different findings was constrained by the differences in the definitions of compliance and exercise regime.

      6. Conclusions

      To our knowledge, this is the first attempt to systematically analyze compliance with swallowing exercises among patients with HNC. According to the analysis, multiple factors affect compliance with swallowing exercises in patients with HNC, including socio-demographic factors, illness-associated factors, treatment-associated factors, and psychosocial factors. However, current interventions have focused mainly on psychosocial issues, such as developing various education programs; therefore, the other factors affecting swallowing exercise compliance should be further emphasized. Although the development of multidisciplinary teams and the application of innovative equipment have relieved the pressures on healthcare resources and economic status of patients to some extent, the professional qualifications of health providers and the availability of innovative equipment should be considered. Additionally, measures including refining the intervention procedure and applying systematic theory frameworks should be performed to achieve better outcomes of compliance interventions.

      Author contributions

      Wang Tao and Du Ruofei: Conceptualization, Methodology. Wang Tao and Chen Changying: Data curation. Zhu Jizhe: Writing- Original draft preparation. Zhang Haoning, Zhang Menghan, Shao Mengwei: Literature search and Data analysis. Zhu Jizhe, Wang Xin, Wang Tao, Chen Suxiang, and Du Ruofei: Writing- Reviewing and Editing.

      Declaration of competing interest

      None declared.

      Role of the funding source

      This work was supported by the National Natural Science Foundation of China (No.82101505) and China Postdoctoral Science Foundation in 2018: (2018M630839).

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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