Effect tongue pressure feedback training with enabling education on swallowing and depression in head and neck tumor patients

Abstract

BACKGROUND

Patients with head and neck cancer often develop depressive symptoms during radiochemotherapy due to changes in saliva secretion, radiation-induced oral mucositis, and dysphagia. These symptoms significantly affect quality of life. Although existing nursing interventions provide some relief, they have limitations in improving swallowing function and developing coping strategies.

AIM

To evaluate the effectiveness of tongue pressure resistance feedback training combined with empowerment education in improving depressive symptoms and swallowing function in patients with head and neck cancer undergoing radiochemotherapy.

METHODS

This study included 110 patients with head and neck cancer who exhibited depressive symptoms and underwent radiochemotherapy at the Affiliated Hospital of Jiangnan University between January 2021 and December 2023. Patients were randomly assigned to either a reference group or an experimental group, each comprising 55 patients. The reference group received routine care, whereas the experimental group received tongue pressure resistance feedback training and empowerment education. After 6 weeks of continuous intervention, comparisons were made between the two groups regarding depressive symptom scores, swallowing function, coping strategies, and quality of life, both pre- and post-intervention.

RESULTS

Following the intervention, both groups demonstrated decreased scores for depressive symptoms and swallowing function, with the experimental group showing a significantly greater reduction than the reference group (P < 0.05). The experimental group also demonstrated higher confrontation scores and lower avoidance and submission scores for coping strategies than the reference group (P < 0.05). Quality of life scores improved in both groups after the intervention, with the experimental group showing markedly higher scores than the reference group (P < 0.05).

CONCLUSION

The combination of tongue pressure resistance feedback training and empowerment education is effective in alleviating depressive symptoms, enhancing swallowing function, optimizing coping strategies, and significantly improving the quality of life of patients with head and neck cancer undergoing radiochemotherapy. This approach shows promise for clinical applications and promotion.

Key Words: Tongue pressure resistance feedback training; Empowerment education; Depression; Swallowing function; Head and neck cancer

Core Tip: Tongue pressure resistance feedback training in conjunction with empowerment education can significantly improve swallowing dysfunction and alleviate depressive mood in patients with head and neck cancer undergoing radiotherapy. It also optimizes coping strategies and enhances quality of life.

INTRODUCTION

Radiochemotherapy is an important treatment modality for head and neck cancer, allowing patients to achieve treatment outcomes comparable to those of surgery while preserving the morphology and function of organs[1]. Patients with head and neck cancer undergoing radiochemotherapy experience changes in the salivary secretion volume, viscosity, and pH, making them highly susceptible to radiation-induced oral mucositis during radiotherapy, which can lead to dysphagia[2]. Additionally, reduced saliva secretion, dry mouth, difficulty in forming food boluses, and delayed swallowing initiation increase the risk of residual or silent aspiration during eating[3]. Tongue pressure resistance feedback training, a type of active resistance exercise, utilizes a tongue muscle rehabilitator to enhance swallowing. It aims to enhance the strength of the upward movement of the tongue through visual feedback, helping patients better understand swallowing actions and strengthening the suprahyoid muscle group[4]. Negative emotions in patients with head and neck cancer caused by disease and swallowing disorders can lead to anxiety and depression[5]. Empowerment education, an advanced educational concept, corrects and improves head and neck cancer patients' understanding of radiochemotherapy and functional exercises through psychological, cognitive, and behavioral dimensions. This study further analyzed the effects of tongue pressure resistance feedback training combined with empowerment education in patients with head and neck cancer undergoing radiochemotherapy. A total of 110 patients with head and neck cancer treated at the Jiangnan University Affiliated Hospital were divided into groups for comparison. The specific contents are as follows.

MATERIALS AND METHODS

General information

A total of 110 patients with head and neck cancer who underwent radiochemotherapy at Jiangnan University Affiliated Hospital between January 2021 and December 2023 were included. Diagnostic criteria: Meeting the diagnostic standards for head and neck cancer[6]. The inclusion criteria were as follows: (1) Patients with depressive symptoms upon admission; (2) Patients receiving radiochemotherapy at our hospital; (3) Patients aged 18-75 years; and (4) Patients and their families had provided informed consent. The exclusion criteria were as follows: (1) Poor compliance; (2) Severe organ dysfunction; (3) History of other psychiatric disorders; and (4) Communication or hearing impairments. We used a random number table to assign patients to groups, and the general characteristics of the two groups were balanced and comparable (P > 0.05) (Table 1).

Table 1 Comparison of general information, n (%)/mean ± SD.

General information	Experimental group (n = 55)	Control group (n = 55)	t/χ2	P value
Average age (years)	42.64 ± 4.55	43.29 ± 4.65	0.741	0.460
Tumor stage
Stage I	35 (63.64)	38 (69.09)	0.367	0.545
Stage II	20 (36.36)	17 (30.91)
Cancer type
Nasopharyngeal cancer	24 (43.64)	24 (43.64)	1.115	0.773
Oropharyngeal cancer	11 (20.00)	13 (23.64)
Laryngeal cancer	15 (27.27)	11 (20.00)
Others	5 (9.09)	7 (12.73)
SDS score (points)	57.81 ± 2.64	57.60 ± 3.32	0.367	0.714
Treatment method
Radiotherapy	19 (34.55)	21 (38.18)	0.705	0.703
Chemotherapy	18 (32.73)	14 (25.45)
Combined radiochemotherapy	18 (32.73)	20 (36.36)

SDS: Self-rating depression scale.

Reference group

Routine care: After admission, nursing staff must closely monitor changes in vital signs, such as heart rate and blood pressure, and promptly handle abnormalities. They should guide the patient's family in assisting with coughing and expectoration, and, if necessary, perform airway secretion clearance and suctioning. Depending on the patient's condition, medical advice was followed to provide liquid or semi-liquid food and gradually increase the intake while maintaining oral hygiene to prevent infection. Nursing staff should increase communication with patients to build closer relationships, assist with routine swallowing function disorder training, monitor the patient's psychological state, and provide encouragement and support.

Experimental group

Tongue pressure resistance feedback training combined with empowerment education: In addition to routine care, the experimental group received tongue pressure resistance feedback training combined with empowerment education.

Tongue pressure resistance feedback training: Preparation: Nursing staff needed to prepare items such as tongue pressure bars, tongue pressure measuring devices (JMS Co., Ltd., Japan), and stopwatches. Before the experiment, the tongue pressure bar was connected to a measuring device and turned on. Training steps: (1) Maximum tongue pressure resistance measurement; (2) The target value was set at 50% of the patient's maximum tongue pressure resistance[6]; and (3) The patient was instructed to lift and press the tongue against the airbag, maintaining a tongue pressure value greater than the target value for 10-20 seconds, with a 30-second interval between each set, repeating 10 sets. Each training session lasted 30 minutes and was conducted twice daily.

Empowerment education: Before the study commenced, the nursing team organized training sessions on empowerment. Individualized nursing intervention plans were developed for each patient, based on cognitive, psychological, and behavioral education.

Cognitive education

Nursing staff prepared multimedia educational materials on head and neck cancer, radiochemotherapy, and depressive symptoms. Using videos, PowerPoint slides, and illustrated brochures, they conducted one-on-one group educational sessions. These sessions were held twice a week, each lasting 30 minutes. The aim is to help patients understand their condition and treatment, correct misconceptions, and build confidence.

Psychological education

Nursing staff engaged patients in interest-based activities, such as calligraphy and painting. They also collaborated with professional psychologists to conduct music therapy, cognitive behavioral therapy, and outdoor activities. Group activities were held once a week, and one-on-one sessions were conducted weekly to assess the patients' psychological states and develop targeted interventions.

Behavioral education

In collaboration with the rehabilitation physicians, the nursing staff created personalized swallowing exercise plans. They demonstrated the exercises and provided video resources during one-on-one sessions. The patients were encouraged to receive rewards and praise to boost their compliance. Swallowing exercises were performed thrice daily with weekly monitoring. Additionally, considering the patients' conditions and dietary habits, the nursing staff collaborated with nutritionists and families to create personalized meal plans and provide guidance on healthy eating techniques.

Observation indicators

Comparison of depressive symptom scores between the two groups: The self-rating depression scale (SDS)[7] was used to assess depressive symptoms of patients before and after nursing care. The raw score, obtained by summing all items and multiplying by 1.25, was used to determine the actual score. A score of 53 was set as the threshold, with mild depression defined as scores between 53 and 62, moderate depression as scores between 63 and 72, and severe depression as scores above 72.

Comparison of swallowing function between the two groups: Swallowing function was assessed using videofluoroscopic swallowing studies (VFSS), before and after nursing care. Patients were administered 10 mL of meglumine diatrizoate, and if no aspiration occurred, an additional 60 mL was administered. Esophageal peristalsis, contraction, and activity were observed using X-ray fluoroscopy. The total score is 10 points, with lower scores indicating more severe swallowing dysfunction.

Comparison of coping strategy scores between the two groups: The medical coping modes questionnaire[8] was used to assess coping strategies before and after nursing care. This questionnaire consisted of 20 items, each scored on a scale of 1 to 4 points. It evaluates three dimensions: Confrontation (eight items, scored 8-32), avoidance (seven items, scored 7-28), and submission (five items, scored 5-20). Higher scores on each dimension indicate a greater tendency towards coping strategies.

Comparison of quality of life scores between the two groups: The Swallowing-Related Quality of Life Scale was used to assess the quality of life of patients before and after nursing care[9]. This scale employs a 5-point rating system and comprises 44 items that cover psychological stress, food selection, desire to eat, eating duration, and fear. The total score ranged from 44 to 220 points, with higher scores indicating a better quality of life.

Statistical analysis

All the data of this study were entered into SPSS25.0 analysis, including the expression form: n (%), χ² test, the measurement data conform to normal distribution, the expression form was mean ± SD, and t test, P < 0.05 represents the difference.

RESULTS

Comparison of depressive symptoms between the groups

No difference was observed in SDS scores (P > 0.05), but after nursing, the SDS score decreased in the two groups compared to the reference group, with a significant difference (P < 0.05), as shown in Table 2.

Table 2 Comparison of depressive symptoms before and after nursing care between the group, mean ± SD.

Group	Case	SDS
		Before	After
Experimental group	55	57.81 ± 2.64	31.30 ± 1.07a
Control group	55	57.60 ± 3.32	32.05 ± 1.85a
t		0.367	2.603
P value		0.714	0.011

^aP < 0.05 vs condition prior to care in this group.

SDS: Self-rating depression scale.

Comparison of swallowing function between the groups

Compared to pre-care, the swallowing function score decreased, and the VFSS score was lower than that in the control group (P < 0.05), as shown in Table 3.

Table 3 Comparison of swallowing function before and after nursing between the groups, mean ± SD.

Group	Case	VFSS
		Before	After
Experimental group	55	6.02 ± 0.55	2.44 ± 0.54a
Control group	55	6.01 ± 0.54	2.74 ± 0.59a
t		0.096	2.782
P value		0.924	0.006

^aP < 0.05 vs condition prior to care in this group.

VFSS: Videofluoroscopic swallowing studies.

Comparison of coping methods between groups

No difference was observed between the patients (P > 0.05). After nursing, the score was higher than that of the reference group, and avoidance and yield scores were lower than those of the reference group; the difference was statistically significant (P < 0.05), as shown in Table 4.

Table 4 Comparison of coping methods before and after nursing between groups, mean ± SD.

Group	Case	Face		Avoid		Surrender
		Before	After	Before	After	Before	After
Experimental group	55	15.88 ± 3.18	26.24 ± 3.07a	19.12 ± 2.34	12.08 ± 2.48a	12.14 ± 2.68	8.14 ± 1.05a
Control group	55	16.10 ± 3.14	22.73 ± 3.66a	18.78 ± 2.51	15.64 ± 2.64a	11.97 ± 2.66	9.95 ± 1.18a
t		0.365	5.449	0.735	7.289	0.334	8.498
P value		0.716	< 0.001	0.464	< 0.001	0.739	< 0.001

^aP < 0.05 vs condition prior to care in this group.

Comparison of quality of life scores between the groups

Compared to the current group, the patient's quality of life score increased after care, and the score in the test group was significantly higher than that in the reference group (P < 0.05), as shown in Table 5.

Table 5 Comparison of quality of life before and after care between groups, mean ± SD.

Group	Case	Quality of life
		Before	After
Experimental group	55	110.34 ± 23.54	168.79 ± 31.25a
Control group	55	111.28 ± 23.59	148.66 ± 28.46a
t		0.209	3.532
P value		0.835	0.001

^aP < 0.05 vs condition prior to care in this group.

DISCUSSION

Head and neck cancer is one of the most common cancers, and radiochemotherapy is the preferred treatment method. During radiochemotherapy, the damage caused by radiation and chemotherapeutic drugs in the body can lead to toxicity in normal tissue cells. Patients are more likely to experience adverse effects, such as radiation-induced pharyngitis and pain, during treatment. These factors not only affect patients' swallowing function but also significantly affect their quality of life[10]. Since patients with head and neck cancer rely on radiochemotherapy to inhibit the growth and proliferation of tumor cells, the adverse reactions such as vomiting and hair loss that occur during this process can increase the physical, emotional, and cognitive distress of patients, leading to negative emotions[11,12].

Research has shown[13,14] that dysphagia is relatively common in patients with head and neck cancer. Symptoms of depression caused by excessive mental stress affect not only patients' food intake but also their nutritional status. This clearly reduces patients' confidence in treatment and compliance with medical advice and exacerbates negative emotions. Therefore, the clinical focus is on optimizing the nursing intervention plan for patients with head and neck cancer undergoing radiochemotherapy to help them exercise their swallowing function and reduce the impact of negative emotions on their physical and mental well-being[15,16]. Tongue pressure resistance feedback training can clearly display a patient's tongue muscle strength on a screen using pressure values. As a positive feedback training method that guides patients to perform tongue pressure resistance autonomously, it aims to improve their tongue's fluid static pressure and enhance the activity and strength of the tongue muscles. However, patients are often affected by cancer, chemotherapy, and financial burdens, leading to negative emotions that affect their treatment behavior.

The results of this study showed that compared to before nursing care, the swallowing function scores of patients decreased after care, with the experimental group having lower VFSS scores than the control group (P < 0.05). The analysis suggests that tongue pressure resistance feedback training can improve the strength of the tongue muscles and the coordination of the pharyngeal muscles, allowing patients' swallowing abilities to recover to a certain extent. Repeated training helps patients gradually deepen their muscle memory. Empowerment education helps patients form a correct understanding of rehabilitation exercises and cancer, reduces their resistance to training difficulties, and plays a positive role in improving their swallowing function.

Depressive symptoms, a common adverse psychological state in patients with cancer, are related to patients' fear of cancer, negative attitudes influenced by drug side effects, and concerns about treatment costs. If a nursing plan for patients with head and neck cancer undergoing radiochemotherapy can be optimized to alleviate negative depressive symptoms, it will play a key role in disease treatment[17-19]. The results of this study showed that, after care, the SDS scores of both groups decreased, with the experimental group having lower scores than the reference group (P < 0.05). At the same time, compared with before care, the quality of life scores of patients increased after care, with the experimental group having higher scores than the reference group (P < 0.05). The analysis suggests that empowerment education, as a new type of clinical health education nursing model, aims to improve patients' incorrect understanding of cancer and treatment from the cognitive, psychological, and behavioral aspects. It helps patients understand the disease correctly and recognize the intervention effect of the treatment, enabling them to form positive treatment beliefs and effectively reduce depressive symptoms. In addition, while undergoing empowerment education, patients find through tongue pressure resistance feedback training that the negative impact of cancer and radiochemotherapy on themselves is reduced, which is key to helping them regain confidence in treatment and consequently improve their quality of life.

Coping strategies refer to the tactics individuals use when facing stressful situations. When confronted with a disease, patients with head and neck cancer, radiochemotherapy, and high treatment costs may experience avoidance and resistance owing to the adverse reactions to drugs and the negative impact of cancer on the body. After care, the experimental group had higher confrontation scores and lower avoidance and submission scores than the control group (P < 0.05). The analysis suggests that, through tongue pressure resistance feedback training combined with empowerment education, nursing staff can help patients form a correct understanding of head and neck cancer, radiochemotherapy, side effects, and swallowing disorders. By providing positive encouragement and affirmation to patients, they can correctly face adverse reactions caused by the above factors, thus significantly improving their confrontation scores in the later stages of care.

Innovative aspects and broader implications

This study highlights the synergistic effects of combining psychoeducation with tongue pressure training. Unlike previous studies that focused solely on physical training, this integrated approach not only strengthens tongue muscles but also addresses the psychological well-being of patients. This combination appears to be more effective in improving both swallowing function and mental health.

The mechanism by which tongue pressure training improves the swallowing function may be related to increased tongue muscle strength. Although this study did not use surface electromyography to measure muscle activity directly, future studies could incorporate this technology to verify the physiological changes underlying the observed improvements.

Limitations and future directions

This study had several limitations. First, the single-center design may have limited the generalizability of our findings. Second, the short follow-up period of only 6 weeks indicates that the long-term effects of the intervention remain unclear. Future research should adopt a multicenter design with longer follow-up periods to validate the effectiveness and sustainability of the intervention program.

CONCLUSION

The combination of tongue pressure resistance feedback training and empowerment education for patients with head and neck cancer undergoing radiochemotherapy with depressive symptoms effectively alleviated depressive symptoms and positively affected coping strategies. The integrated nursing approach significantly improved the patients' quality of life and swallowing function, making it a valuable and recommended practice.