Swallowing Therapy With the Assistance of a Mobile Health Device in Head and Neck Cancer Patients: a Pan-Alberta Study

Background Dysphagia affects 22% of those over the age of 50 [1], which equates to 250 million people worldwide and 360,000 in Alberta [2]. At high risk are survivors of head and neck cancer (70%), stroke patients (78%), people with Parkinson's disease (82%) and those who've had a traumatic brain injury (65%) [3]. Left untreated, dysphagia has serious health consequences, such as malnutrition, aspiration pneumonia, and even death. The associated longer hospital stays and complications result in an estimated annual burden of care of $547 billion in USA [4]. In Alberta, managing just one consequence of dysphagia (aspiration pneumonia) in patients with head and neck cancer and stroke costs the healthcare system $2.53 million CAD a year [5]. Difficulties with swallowing are not only life threatening and resource-intense, but also socially limiting. Patients with dysphagia avoid social situations that involve eating, are disproportionately affected by depression, and miss more than 3 times the number of workdays than individuals without swallowing difficulties.

To regain swallowing function and avoid or reduce the aforementioned consequences of dysphagia, patients require regular, intensive therapy over many months to strengthen swallowing muscles and improve swallow coordination. This therapy is often coupled with visual biofeedback that uses surface electromyography (sEMG). sEMG biofeedback lets patients know how hard their muscles are contracting and for how long during a given exercise. sEMG biofeedback is used to teach patients how to perform exercises correctly, elicit maximum effort, and demonstrate incremental improvements in performance.

Despite evidence that swallowing exercises are effective when provided with an intensive regimen and when coupled with sEMG biofeedback, patients rarely receive it. This limited access stems from poor patient and clinician resources. For patients, getting to the clinic to access a clinician and the equipment is inconvenient and costly. In order to cope with limited patient engagement, clinicians are more likely to manage dysphagia by providing diet modifications, by prescribing feeding tubes, and by giving patients maneuvers and exercises on a printed sheet of paper. These approaches to the management of dysphagia are inadequate to meet the needs of patients. Furthermore, a recent systematic review found that average adherence to dysphagia management recommendations was between 22% and 52% [6]. With the advent of strict distancing restrictions during the COVID-19 pandemic, remote care via telerehabilitation or mobile health (mHealth) technologies has received increased attention.

AIMS: The primary aim of this work is to determine whether the use of a mobile system equipped with sEMG biofeedback affects adherence to home-based swallowing exercises.

The secondary aim of this work is to determine if the exercise program results in improved patient reported outcomes related to dysphagia and nutrition. Our tertiary aim is to determine if previous findings of adherence can be replicated.