Page 95 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

Long-term function after CRT and preventive rehabilitation
pharyngeal residue over all bolus trials (either < 10%, 10-49%, 50-90%, or > 90%). The DIGEST grade combines both safety and efficiency in a 5-point ordinal scale ranging from grade 0 (no pharyngeal dysphagia) to grade 1 (mild), grade 2 (moderate), grade 3 (severe) and grade 4 (life threatening). All videofluoroscopy studies were assessed by two of the researchers who came to a consensus afterwards. Oral diet was assessed by means of the Functional Oral Intake Scale (FOIS), which reflects the oral intake on a seven-point ordinal scale with scores below 7 indicating a modified diet (27). A visual analog scale (VAS) of 0–100 mm was used to assess pain with scores greater than 4 mm indicating pain (28).
Also, subjective swallowing related outcomes were assessed by means of a study specific questionnaire as described earlier (29). The questionnaire included questions on whether the patient perceived xerostomia, difficulty swallowing and masticating, and problems with oral transport or swallowing of solids, thick liquids and/or thin liquids (outcome was dichotomized into no meaning not at all, and yes meaning a little, quite a bit or very much). Also, patients were asked whether they have been continuing performing the rehabilitation exercises after the one-year training period post CRT.
Trismus related outcomes
To assess trismus, we measured the maximal inter-incisal opening (MIO) by means of the TheraBite Jaw Range of Motion Scale (Atos Medical AB, Malmo, Sweden), and used a mouth opening of 35 mm or smaller as a criterion for trismus (30). The MIO was measured by two different raters at timepoints which might cause inter-rater variability. However, the inter-rater reliability of mouth opening measurement is very high (intraclass correlation coefficient of 0.98) (31). To increase reliability of the measurements in our study, two measurements were taken at each timepoint with the highest value as maximal MIO. Also, subjects were asked if they perceived their mouth opening as deteriorated.
Voice and speech related outcomes
Speech recordings consisted of an excerpt from a standard, balanced 189 word long Dutch text called ‘De vijvervrouw’ and a sustained /a/. The recordings were automatically analyzed by the program Automatic Speech analysis In Speech Therapy for Oncology (ASISTO) (32, 33). This program determined the intelligibility based on Alignment-free phonological and phonemic features (ALF-PPFs) with scores ranging from 0 to 100%. Voice quality was determined with the Acoustic Voice Quality Index (AVQI, version 2.03) (1 (normal)–8 (least normal); a value <2.92 reflects normal voice quality) using 4 seconds of the running speech and 3 seconds of the sustained /a/ (34, 35). Speech recordings from the six-year follow-up were unavailable for re- evaluation. Therefore, results from the analyses performed for the earlier published paper by Kraaijenga et al. on voice quality at six-year follow-up were reported, which were analysed using an earlier version of the ASISTO software.
As subjective outcome, patients were asked whether they perceived their voice as different.
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