Summary of findings for the main comparison. Therapeutic swallowing exercises compared with treatment as usual (TAU) for dysphagia in head and neck cancer patients.

Therapeutic swallowing exercises compared with treatment as usual (TAU) for dysphagia in head and neck cancer patients
Patient or population: adults with advanced head and neck cancer Settings: acute/hospital departments and clinics Intervention: therapeutic swallowing exercises Comparison: treatment as usual (TAU)
Outcomes	Illustrative comparative risks* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Treatment as usual (TAU)	Therapeutic swallowing exercises
Swallowing function/efficiency Measured using a rating of oropharyngeal swallowing efficiency (OPSE) quantifying the interaction of the speed of bolus movement and safety/efficiency in clearing material from the oropharynx Dysphagia is defined as an OPSE score of less than 39 10 weeks post‐treatment	N/A	N/A	10 weeks post‐treatment: MD ‐8.06 (95% CI ‐25.37 to 9.25)	16 (TAU group 8: intervention group: 8) (1 study) Lazarus 2014	⊕⊝⊝⊝ very low1,2	Swallowing function (OPSE) improved following treatment, However, the effect did not reach statistical significance.
Adverse event: Weight loss (> 10%) Change in nutritional status reflected by a patient's weight measured at 6 weeks post‐treatment	N/A	N/A	Weight loss at 6 weeks: RR 0.62 (95% CI 0.22 to 1.71)	27 (TAU group 13; Pharyngocise group 14) (1 study) Carnaby‐Mann 2012	⊕⊝⊝⊝ very low1,2	At 6 weeks post‐treatment, the risk of weight loss (> 10%) is around 40% lower in the Pharyngocise group compared to the TAU group. However, the estimate has a wide confidence interval and is not statistically significant.
Adverse event: Weight loss (> 10%) Change in nutritional status reflected by a patient's weight during the study period 10 weeks post‐treatment	N/A	N/A	Not estimable	55 (TAU 28; intervention group 27) (1 study) van der Molen 2011	⊕⊝⊝⊝ very low1,2	There was no comparison between the intervention and TAU group. Results were from the pre‐ and post‐treatment scores for 49 participants.
Adverse event: Weight change Patient's body weight 6 months before the start of treatment was retrieved from the patient's medical notes and "relative weight change" was calculated as the percentage weight change relative to the weight at week 0 6 months post‐treatment	N/A	N/A	6 months post‐treatment): MD 1.34 (95% CI ‐0.46 to 3.14)	120 (intervention group 60; TAU group 60) (1 study) van den Berg 2014	⊕⊝⊝⊝ very low1,2	The weight change estimate has a wide confidence interval, therefore the effect is uncertain.
Aspiration Scored as present, trace or absent, for any consistency 5 months post‐treatment	N/A	N/A	5 months post‐treatment: TAU group 18.18%; intervention group 7.69%	39 (TAU group 20; intervention group 19) (1 study) Mortensen 2015	⊕⊝⊝⊝ very low1,2,3	Results were reported as a percentage ‐ not estimable.
Penetration Scored as present, trace or absent, for any consistency 5 months post‐treatment	N/A	N/A	5 months post‐treatment: TAU group 45.45%; intervention group 23.08%	39 (TAU group 20; intervention group 19) (1 study) Mortensen 2015	⊕⊝⊝⊝ very low1,2,3	Results were reported as a percentage.
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; N/A: not applicable; OPSE: oropharyngeal swallowing efficiency; RR: risk ratio; TAU: treatment as usual
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

¹Few participants.

²Risk of performance bias is high (Carnaby‐Mann 2012; Lazarus 2014; Mortensen 2015; van den Berg 2014) or unclear (Kotz 2012; van der Molen 2011).

³Unclear if the assessor was blinded to the intervention (Mortensen 2015).