Development and Pilot Evaluation of Rehabilitation Consult for Survivors of Head and Neck Cancer
Phase: NA
Conditions: Head and Neck Neoplasms
Sponsor: Sunnybrook Health Sciences Centre

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STUDY PROTOCOL 
 
 
 
Title:   
Development and Pilot Evaluation of a Rehabilitation Consult for Survivors of 
Head and Neck Cancer 
 
 
Co- Principal Investigator:  
 
 
Sara McEwen, PhD  
 
 
Co- Principal Investigator:  
 
 
Jolie Ringash MD MSc 
 
 
Co- Investigator: 
 
 
 
 
Aileen Davis, PhD 
 
Co- Investigator: 
 
 
 
 
Jennifer Jones, PhD 
 
Co- Investigator: 
 
 
 
 
Rosemary Martino, MA MSc PhD 
 
Co-Investigator: 
 
 
 
 
Ian Poon, MD, FRCP(C)  
 
Co-Investigator:  
 
 
 
 
AnaMaria Rodriguez, PhD MSc BScPT 
 
Research Coordinator: 
 
 
 
Colleen Dunphy, BScPT 
 
Research Assistant:  
 
 
 
Jorge Rios, BSc 
 
 
 
 
 
Institutions:  Sunnybrook Health Sciences Center (Odette Cancer Center) and 
University Health Network (Princess Margaret Cancer Centre), 
University of Toronto 
 
 
 
 
 
 
 
 
 
 
 
Table of Contents 
 

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1.0 Background  
 
 
 
 
 
 
 
 
Page 3 
2.0 Methods/Design 
 
 
 
 
 
 
 
 
Page 4 
 
2.1 Step 1, Needs Assessment 
 
 
 
 
 
 
Page 4 
 
2.2 Step 2, Definition of Program Objectives 
 
 
 
 
Page 5 
 
2.3 Step 3, Selection of Theory-Based Intervention Methods  
     and Practical Applications 
 
 
 
 
 
Page 6 
2.4 Step 4: Production of Program Components and Pre Testing   
 
Page 6                                
2.4.1 Pre Testing 
 
 
 
 
 
 
Page 9 
  
 
2.4.1.1 Participants and Recruitment 
 
 
 
 
Page 9  
  
 
2.4.1.2 Procedures 
 
 
 
 
 
 
Page 10 
2.5 Step 5: Planning for adoption, implementation, and sustainability 
 
Page 11 
2.6 Step 6, Pilot Testing  
 
 
 
 
 
 
Page 12 
3.0 Discussion  
 
 
 
 
 
 
 
 
Page 14 
4.0 References  
 
 
 
 
 
 
 
 
Page 14 
Table 1: Intervention Mapping Step 1 - Needs Assessment Logic Model  
 
Page 19 
Table 2: Outcome Measures 
 
 
 
 
 
 
 
Page 21 
Table 3: Pilot (beta) version of Rehabilitation Consult process 
 
 
 
Page 22 
Figure 1: Project Timeline 
 
 
 
 
 
 
 
Page 25 
Appendix A: Orientation Script 
Appendix B: Pilot Testing Survey 
Appendix C: Goal Attainment Tool 
Appendix D: Self-Efficacy Tool 
 
 
 
 
 

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1.0 BACKGROUND 
In contrast with other major chronic conditions such as heart disease and stroke, cancer care does not 
routinely integrate evidence-based rehabilitation services within the standard continuum. This protocol 
describes a structured process for the development, implementation, and preliminary evaluation of a 
novel, integrated rehabilitation intervention for survivors of head and neck cancer (HNC) called the 
Rehabilitation Consultation (RC). The RC program goals are to increase knowledge about 
rehabilitation needs and resources to meet those needs; to establish individualized rehabilitation goals 
for HNC survivors and personalized action plans to meet those goals; and to provide support to HNC 
survivors for the implementation and evaluation of action plans. The goals will be personally important 
to the individual survivor, and the action plans will be achievable, using resources they can access close 
to home rather than at the cancer centre, when possible.  Additionally, the RC will be integrated into 
routine HNC follow-up procedures, and will be administered as soon as possible following active 
cancer treatment.  It will be led by a professional with a background in one of the traditional 
rehabilitation professions, and will include the following 3 components: 1. A brief, HNC-specific 
functional evaluation; 2. A resource compendium; 3. Collaborative goal-setting, action-planning, and 
follow-up processes.  
 
Reductions in function and quality of life are particularly high in HNC, as the disease and treatment 
cause more diverse and serious impairments than many other cancers. Issues include reductions in 
swallowing, speech, neck and upper extremity mobility, general deconditioning, fatigue, insomnia, 
lymphedema, neuropathies, visible facial deformity, and psychological distress [1-9]. In addition, a 
range of more global functional issues result, including body image dissatisfaction, cognitive and 
behavioural problems [10], decreased role functioning [11], decreased nutritional status [12], decreased 
communication [5], poor driving performance [13] and inability to return to work [14,15].  Among the 
9000 new cases of HNC in Canada each year [16], an increasing proportion is among young, working-

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aged patients, primarily related to the ongoing epidemic of oropharyngeal cancer associated with 
Human Papillomavirus [17]. Without rehabilitation services, the influx of younger survivors may 
increase the societal burden of the illness through loss of employment, increased absenteeism, and the 
financial, social, and potentially emotional effects on their families which may include young 
dependents [18,19]. 
 
Cancer rehabilitation has been defined as coordinated, professional care designed to enable people to 
maximize physical, social and psychological function within the limits imposed by the disease and 
treatment effects, and to engage in personally valued activities within their social contexts [20]. 
Rehabilitation interventions for HNC are demonstrably safe, feasible, cost-effective, and associated 
with improvements in quality of life, general conditioning, swallowing, muscle function, insomnia, 
pain, weakness, anorexia, shortness of breath, tube-feeding dependency, hospital readmissions, 
depression and distress [7,21-25]. Although evidence exists to support cancer rehabilitation, services 
are fragmented. Rehabilitation professionals are consulted infrequently and often long after treatment 
ends, when chronicity of problems limits the impact of intervention [unpublished observations]. 
Additional barriers to accessing rehabilitation services include cost, issues between and among patients, 
oncology professionals and rehabilitation experts related to communication and awareness of available 
resources [unpublished observations]. There are clear potential benefits to a comprehensive, integrated 
rehabilitation consultation process that targets all HNC patients soon after primary cancer treatment is 
completed, improves communication among stakeholders, and provides linkages to appropriate 
resources. Therefore, the overall objective of this project is to develop, implement, and conduct a pilot 
evaluation of the RC. This current protocol is concerned with pre-testing of an alpha version of the RC 
and subsequent pilot testing of a beta version.  
 
2.0 METHODS/DESIGN 

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This project employs Intervention Mapping as an ecologically valid, structured framework to develop, 
implement, and evaluate the RC [26]. Intervention Mapping consists of 6 steps: 1. Needs assessment 2. 
Definition of program objectives 3. Selection of theory-based intervention methods 4. Production and 
pretesting 5. Adoption, implementation, and sustainability planning 6. Process and effect evaluation.  
Research staff and the investigators will oversee the project with input from an eight-member Advisory 
Panel, including patient and family representatives, health care professionals working in oncology, 
health care professionals working in rehabilitation, and representatives of the provincial cancer care 
system. All Intervention Mapping steps are described below. Note that Steps 1 -4 have previously 
been completed or are in progress (REB # 13-6877-CE), with Steps 5-6 planned and the subject of 
this current proposal.    
2.1 Step 1, Needs Assessment 
In the previously-completed Step 1, Needs Assessment, we used information gleaned from focus 
groups with patients, family members, and front-line health care professionals (unpublished data, 
manuscript under preparation) and from a scoping literature review (unpublished data, 1 manuscript 
submitted, 1 manuscript under preparation) to establish the rehabilitation needs of HNC survivors. The 
rehabilitation needs appear as Phase 2 and Phase 1 in Table 1.  We next identified highly relevant and 
modifiable behavioural and environmental factors that contributed to the identified issues (Phase 3, 
Table 1), their determinants (Phase 4, Table 1), and the items targeted for change with the RC 
intervention (items in italics in Table 1). Finally, the following RC program goals were developed:  1. 
Increase knowledge of all stakeholders about rehabilitation needs and about resources to meet those 
needs; 2. Establish individualized rehabilitation goals and personalized action plans for HNC survivors; 
3. Provide support for the implementation and evaluation of action plans; 4. Facilitate HNC survivors’ 
access to rehabilitation professionals where it is most feasible for them. 
2.2 Step 2, Definition of Program Objectives 

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In the previously completed Step 2, Definition of Program Objectives, the resource requirements that 
will enable achievement of the program goals described above were specified. The specific resource 
requirements to be developed as components of the RC include a brief, HNC-specific functional 
evaluation, an online resource compendium that includes comprehensive information about 
rehabilitation services in Toronto and adjacent regions as well as educational modules for specific 
home-based exercises, a goal-setting and action planning process, and a follow-up process. The specific 
behavioural requirements are that the HNC survivors be confident in goal-setting and action planning, 
and that all stakeholders be knowledgeable about HNC rehabilitation needs and applicable resources. 
2.3 Step 3, Selection of Theory-Based Intervention Methods and Practical Applications 
In Step 3, Selection of Theory-Based Intervention Methods and Practical Applications, the research 
team reviewed the work completed in Intervention Mapping Steps 1 and 2 with the Advisory Panel. 
Then, the research team selected behavioural change methods from the Intervention Mapping tables 
[26, p 357-358] that are congruent with self-management and goal-setting theories and with the RC 
program parameters. Additional behavioural change methods derived from the Cognitive Orientation to 
daily Occupational Performance (CO-OP) approach were also incorporated, specifically cognitive 
strategy training and guided discovery. (Polatajko & Mandich, 2004) Behavioural change methods 
were linked to specific change objectives and determinants.  Two members of the research team (SM 
and CD) then identified practical applications (such as worksheets, pamphlets, websites, videos) to 
enact those methods. The Advisory Panel will conduct a final review of all methods and practical 
applications selected in Step 3 to ensure that they mesh with the program goals and resource 
requirements identified in Intervention Mapping Steps 1 and 2, and will make recommendations for 
modifications if necessary. 
2.4 Step 4: Production of Program Components and Pre Testing  
Figure 1 provides the expected timeline for completion of Steps 4 through 6. In Step 4, Production of 
Program Components and Pre Testing, all components of the RC will be developed and pre-tested for 

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acceptability and feasibility. The program components to be developed are as follows: a brief, HNC-
specific functional evaluation; a resource compendium; collaborative goal-setting, action-planning, and 
follow-up processes.  
 
The brief HNC-specific functional evaluation has the objectives of estimating both performance-
based issues, such as swallowing or joint mobility, but also patient-determined functional and life 
participation issues, such as return to work or family and social role functioning.  Items will be derived 
from the Needs Assessment completed in Step 1. The investigators and study staff will generate an 
initial list of items that will be reviewed for content, length, and intelligibility by the Advisory Panel, 
and modified as necessary.  
 
Development of the resource compendium is currently underway using interviews with key 
informants. This piece of the RC development was initiated as part of the previously approved project 
(REB # 13-6877-CE).  The resource compendium includes listings of rehabilitation services available 
in Toronto and adjoining regions that commonly refer to Toronto regional cancer centres, educational 
resources for patients and therapists, and materials to support the RC process, such as worksheets and 
pamphlets. All materials will be available online at www.hncrehab.ca and printed hard copies of 
materials will also be available for those survivors who have difficulty accessing the Internet. 
 
A preliminary version of the collaborative goal setting, action planning, and follow up processes 
has been developed. All survivor/professional processes are designed to establish a strong therapeutic 
alliance, to engage and motivate the survivor, and to foster independence and self-management. The 
alpha-RC face-to-face phase (collaborative goal setting and action planning process) includes the 
following steps: 

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A. A brief presentation (Appendix A) is given by the rehab consultant to orient the survivor to the 
reason for the consultation and the process.  
B.  The rehab consultant implements the brief HNC-specific functional evaluation, and then 
consults with the survivor regarding the results. The survivor identifies the issues that are 
currently most important to him or her.   
C. The survivor and the rehab consultant work collaboratively to set goals based on issues 
identified by the survivor as most important to him or her. The rehab consultant teaches the 
survivor a global problem solving strategy, Goal-Plan-Do-Check (Meichenbaum, 1971). 
D. Using the Goal-Plan phases of the problem solving strategy, the rehab consultant and the 
survivor develop an action plan to meet the identified goals. The rehab consultant uses 
motivational interviewing techniques (eliciting change talk, evoking motivation to make 
positive changes (Miller & Rollnick, 1991) and guided discovery techniques (ask don’t tell, 
coach don’t adjust, make it obvious, and one thing at a time (Polatajko & Mandich, 2004)).  
Also as part of the planning process, the rehab consultant and the survivor discuss potential 
barriers to implementing the action plan and develop coping responses, using planning coping 
responses techniques (Marlatt & Donovan, 2005. The rehab consultant introduces the survivor 
to the resource compendium for future use, and facilitates the assembly of resources necessary 
to implement the survivor’s plans.  
E. Telephone follow-up appointment is scheduled for between 2 and 10 weeks later, at a mutually 
convenient time.  The survivor also has the option of attending a follow up session in person. 
Preferred communication strategies are set in place, and the survivor is encouraged to execute 
(do) his or her plan.  
 The alpha-RC telephone follow-up process includes the following steps: 

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A. An email/text/or telephone reminder (as preferred by the survivor) regarding the follow-up 
appointment is sent 24 hours in advance. 
B. The rehab consultant phones at the designated date and time and confirms with the survivor that 
the appointment is still convenient.  
C. The rehab consultant re-orients the survivor to the RC process.  
D. The rehab consultant and the survivor begin the check phase of goal-plan-do-check. They 
review the goals and the actions plans, and proceed with a discussion about the do-check 
portion of the problem solving strategy. The rehab consultant guides the discussion using 
motivational interviewing and guided discovery techniques. If the plan was successfully 
implemented and the goals are achieved, next steps are discussed. If the plan was not 
implemented or the goals were not achieved, the rehab consultant will guide the survivor to 
modify the plan as necessary. The rehab consultant and the survivor discuss potential barriers to 
implementing the newly modified action plan and develop coping responses, using techniques 
for planning coping responses. 
E. The need for a second follow-up appointment is discussed and, if necessary, scheduled at a 
mutually convenient time. If the survivor seems to be struggling, a face-to-face follow-up might 
be scheduled. If a follow-up is deemed unnecessary at this time, the survivor is provided with 
information about how to access the rehab consultant in the future, should the need arise, and 
discharge occurs. The rehab consultant arranges a time for the research assistant to conduct a re-
assessment of the outcome measures (Research Assessment 2), as well as a semi-structured 
interview for participant feedback.  
2.4.1 Pre Testing 
2.4.1.1 Participants and Recruitment Pretesting of the alpha-RC process will be conducted using an 
iterative single case series of 5 to 10 survivors of HNC. Participants will be recruited from the HNC 
clinics at Sunnybrook Odette Cancer Centre and Princess Margaret Cancer Centre. Eligibility criterion 

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are adult survivors of HNC who have completed active treatment (surgery, radiation, chemotherapy or 
any combination thereof) within the last year. Exclusion criteria are lack of English fluency, cognitive 
impairment, or concurrent major degenerative conditions likely to cause functional deterioration.  Two 
members of the research team who are radiation oncologists (IP, Sunnybrook, and JR, Princess 
Margaret) will review patients scheduled for follow-up at their respective HNC clinics for eligibility, 
and will approach those who are eligible to ask if they are interested in learning more about a 
rehabilitation research project. Those who express interest will be connected with an on-site research 
assistant, who will provide the potential participant with additional information about the study and to 
answer any questions they may have. If the survivor is willing, the research assistant will obtain 
informed consent and schedule an assessment and alpha RC intervention time. The research assistant 
will provide the participant with the Brief Rehabilitation Assessment for Head and Neck Cancer 
Survivors (BRASH) for the patient to review and complete prior to meeting with the Rehabilitation 
Consultant. We anticipate that we will be able to recruit 1 participant per week. 
 
2.4.1.2 Procedures. Participants will be required to attend 3-4 sessions that are a combination of face-
to-face visits and telephone calls.  Session 1: Face-to-face, at the research site (either Sunnybrook or 
Princess Margaret) a research assistant will conduct a pre-intervention research assessment 
(approximately 60 minutes) and then on the same day, a rehabilitation consultant, licensed 
physiotherapist Colleen Dunphy, will administer the face-to-face phase of alpha-RC intervention 
(approximately 90 minutes). Session 2:  As a second phase of the alpha-RC intervention process, the 
rehabilitation consultant (CD) will conduct a telephone follow-up with the participant (45 to 60 
minutes).  Session 3: Within one week of Session 2, the participant will complete a post-intervention 
research assessment with the research assistant (approximately 60 minutes), either as a face-to-face 
visit at the research site, or as a telephone interview. For Session 3, it will be the participant’s choice to 
have either a face-to-face or telephone interview, based on what is most convenient for him or her. This 

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choice has been put in place because many patients travel to Sunnybrook and Princess Margaret from 
out-of-region to receive specialized treatment for head and neck cancer, making an additional face-to-
face visit very inconvenient for some. It is possible that, as part of the alpha-RC intervention, 
participants will require a second follow-up session that may occur as a second telephone call or a 
second face-to-face meeting.  This is expected to happen rarely.  The rehabilitation consultant will log 
any additional follow-up meetings, including type (phone or face-to-face), reason for meeting, outcome 
of meeting, next steps.   
 
Participants will be remunerated $25 for each research visit to the site to offset their transportation and 
parking costs, for a total of $50 per participant. Additional intervention-only visits will not have any 
remuneration.  
 
At both the pre and post intervention research assessments, the following constructs will be evaluated: 
function, quality of life, self-efficacy, community participation, goal attainment, and return to work 
status (if applicable). Additionally, the research assistant will collect data on the time to complete the 
assessment battery; perceived respondent burden; and ease of use of all tools. At the post-intervention 
assessment, the participant will be asked to complete a survey related to the content and process of the 
alpha-RC. Table 2 describes all tools to be used.  The rehabilitation consultant (CD) will video record 
the face-to-face phase and audio record the follow-up telephone call so that the processes can be 
reviewed and analysed in depth. The following information will be extracted from these recordings: 
time required for each segment in the process; adherence to planned methods and theory; challenges 
and successes with each participant.   
 
Descriptive analysis will be conducted; the research team will review results, and then make decisions 
about adaptations to the alpha-RC and finalization of the outcome measure battery.  The alpha-RC will 

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be modified iteratively based on the information gleaned from each survivor, outcome data, and 
feedback from research team members. Step 4 will be considered complete when the investigators are 
satisfied that a version of the RC suitable for formal pilot evaluation has been developed, the beta-RC. 
 
2.5 Step 5: Planning for adoption, implementation, and sustainability. 
This is a planning step, in which a logic model will be developed to guide the initial implementation 
and program evaluation. Specific objectives for adoption, implementation, and sustainability will be 
established, and determinants of those will be considered. We will seek input on the logic model from 
the Advisory Panel.  
As stated in sections 2.1 and 2.2, two of the objectives of the overall study are: 1. Increase knowledge 
of all stakeholders about rehabilitation needs and about resources to meet those needs; 2. Facilitate 
HNC survivors’ access to rehabilitation professionals where it is most feasible for them. To assist in 
this stage, head and neck cancer patients will be surveyed in clinic to determine their baseline level of 
awareness of rehabilitation services, where they receive any current information, and their preferences 
for receiving this information. Any consenting head and neck cancer patient will be eligible for the 
survey, but only those who meet inclusion criteria for the rest of the study will be approached for 
participation in the rehabilitation consult. We anticipate surveying 20-30 patients. This information will 
provide input into the design of adoption and implementation strategies to address the above objectives, 
and plan for long term sustainability. The same survey will be administered in clinic, to a separate 
sample of 20-30 patients, after these strategies have been implemented.   
2.6 Step 6, Pilot Testing 
In this step, we will implement the program evaluation plan established in Step 5, and will also include 
a pilot outcome evaluation to estimate the impact of the beta-RC on function and quality of life. We 
will implement and evaluate the beta-RC using a mixed method, single group study with a convenience 
sample of approximately 35 HNC survivors post primary cancer treatment, recruited from the Princess 

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Margaret Cancer Center HNC clinics*, with inclusion and exclusion criteria and recruitment as 
described above in section 2.4.1.  The procedures will be as described above in 2.4.1.2, with the 
following changes: 
a) An additional research assessment (Session 4) will be added. Session 4 will occur 1-2 months after 
Session 3; the participant will complete a follow-up assessment with the research assistant 
(approximately 60 minutes), either as a face-to-face visit or as a telephone interview. The assessment 
battery will be based on the tools described in Table 2. 
b)The intervention will include revisions based on feedback and observations from the pre-testing 
stage. The pilot testing version (beta RC) of the previously described intervention can be found in 
Table 3.  
c)The intervention will continue to be video recorded and reviewed by an investigator for fidelity. This 
will occur for the first 3 participants and then for every 5th participant who completes the intervention, 
starting with the 1st (1,2,3, then 8th, 13th, and so on). To explore survivor experiences with the RC, a 
survey will be administered during session 3, based on one-on-one semi-structured interviews carried 
out during the pre-testing phase. (approximately 30 minutes). The survey is included in Appendix B.   
 
Participants will be remunerated $25 for each research visit to the site to offset their transportation and 
parking costs. Additional intervention-only visits will not have any remuneration.  
 
Quantitative data analysis will be exploratory and descriptive, and effect sizes will be calculated for all 
outcomes to help plan for a future, controlled trial. We will calculate means, standard deviations, and 
Cohen’s d [39] effect size for normally distributed data. For non-normally distributed data, we will 
calculate medians, ranges, and a nonparametric effect size r using the formula r2=z2/N.[40] For 
qualitative analysis, all interviews will be audio recorded, transcribed verbatim, and analyzed using a 
                                                 
* Note that Sunnybrook-Odette will not be involved with data collection in Step 6 

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two-phased, hybrid approach that is both deductive and inductive, described by Fereday and Muir-
Cochrane [41]. Findings will be summarized and reported to the Advisory Panel, who will then make 
recommendations regarding any additional modifications to the RC. The research team will make final 
decisions about RC modifications and will finalize a version for future evaluation. 
 
In order to further evaluate individual program components, and address the objectives of adoption and 
knowledge translation to rehabilitation professionals, the research team will evaluate the brief, head 
and neck specific, functional evaluation that was developed as part of the project, and described in 
section 2.4. Content validity will be assessed by collecting feedback from professionals in the 
multidisciplinary head and neck cancer site group, regarding the degree to which items of the functional 
assessment adequately represents relevant rehabilitation issues in the head and neck cancer population. 
Concurrent (convergent and divergent) validity will be assessed through comparing the results of the 
functional assessment to the standardized and validated FACT-H&N and SF 36 assessments, which are 
already being administered to study participants. Data will be analysed using the content validity index, 
descriptive statics, and Spearman’s rho correlation coefficients. 
 
Assuming positive outcomes from this single group evaluation, a future, multi-site controlled trial will 
be designed and implemented in a future study. Results from this study will provide feasibility 
information, such as recruitment rates; help to define primary and secondary outcomes; and provide 
data to calculate sample size to ensure an adequately powered trial. 
 
3.0 DISCUSSION 
This project brings together the diverging views of rehabilitation specialists, focused on long-term real-
world function, with those of cancer specialists, focused on acute treatment and episodic symptom 
management.  We have set out to bring those views together to develop a clinically effective and cost-

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effective rehabilitation intervention that integrates seamlessly with an existing cancer care system.  
Survivors of HNC have among the most complex rehabilitation needs of all cancer patients because of 
the anatomical complexity of the head and neck region. The RC is expected to improve knowledge and 
uptake of rehabilitation resources and strategies in survivors of HNC, and thereby improve function 
and quality of life. The RC will be designed to ensure the components are readily modifiable for use 
beyond the regional cancer centres within which they were developed.  Further, we believe that HNC 
serves as an ideal incubator for development of the RC.  If it is effective in cancer patients with such 
high and diverse needs, it is expected that this project will produce a toolkit that will be adaptable for 
other types of cancer in other jurisdictions.  
FUNDING STATEMENT 
This work is supported by the Canadian Cancer Society Research Institute Innovation Grant (#702896). 
The background work was made possible by a University of Toronto Faculty Research Grant, the Grant 
Miller Cancer Grant.  
4.0 References 
 
1. Deng J, Ridner SH, Dietrich MS, Wells N, Wallston KA, Sinard RJ, Cmelak AJ, Murphy BA: 
Factors associated with external and internal lymphedema in patients with head-and-neck 
cancer. Int J Radiat Oncol Biol Phys. 2012, 84:e319-328. 
 
2. Bragante KC, Nascimento DM, Motta NW: Evaluation of acute radiation effects on mandibular 
movements of patients with head and neck cancer. Rev Bras Fisioter. 2012, 16:141-147. 
 
3. Neilson KA, Pollard AC, Boonzaier AM, Corry J, Castle DJ, Mead KR, Gray MC, Smith DI, Trauer 
T, Couper JW: Psychological distress (depression and anxiety) in people with head and neck 
cancers. Med J Aust. 2010, 193(Suppl 5):S48-51. 
 
4. Lima LP, Amar A, Lehn CN: Spinal accessory nerve neuropathy following neck dissection. Braz 
J Otorhinolaryngol. 2011, 77:259-262. 
 
5. Campos RJ, Maciel CT, Cesca MG, Leite IC: Voice analysis after cancer treatment with organ 
preservation. Head Neck Oncol. 2011, 3:19. 
 
6. Watkins JP, Williams GB, Mascioli AA, Wan JY, Samant S: Shoulder function in patients 
undergoing selective neck dissection with or without radiation and chemotherapy. Head Neck. 
2011, 33:615-619. 
 

Development and pilot evaluation of rehabilitation consult for survivors of head and neck cancer 
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7. Zhen Y, Wang JG, Tao D, Wang HJ, Chen WL: Efficacy survey of swallowing function and 
quality of life in response to therapeutic intervention following rehabilitation treatment in 
dysphagic tongue cancer patients. Eur J Oncol Nurs. 2012, 16:54-58. 
 
8. Killguss H, Gottwald F, Haderlein T, Maier A, Rosanowski F, Iro H, Psychogios G, Schuster M: 
Voice handicap and health-related quality of life after treatment for small laryngeal carcinoma. 
Folia Phoniatr Logop. 2011, 63:122-128. 
 
9. Martino R, Beaton D, Diamant NE: .Using different perspectives to generate items for a new 
scale measuring medical outcomes of dysphagia (MOD). J Clin Epidemiol. 2009, 62:518-526. 
 
10. Fingeret MC, Hutcheson KA, Jensen K, Yuan Y, Urbauer D, Lewin JS: Associations among 
speech, eating, and body image concerns for surgical patients with head and neck cancer. Head 
Neck. 2013, 35:354-360. 
 
11. Sawada NO, de Paula JM, Sonobe HM, Zago MM, Guerrero GP, Nicolussi AC: Depression, 
fatigue, and health-related quality of life in head and neck cancer patients: A prospective pilot 
study. Support Care Cancer. 2012, 20:2705-2711. 
 
12. Hutcheson KA, Alvarez CP, Barringer DA, Kupferman ME, Lapine PR, Lewin JS: Outcomes of 
elective total laryngectomy for laryngopharyngeal dysfunction in disease-free head and neck 
cancer survivors. Otolaryngol Head Neck Surg. 2012, 146:585-590. 
 
13. Yuen HK, Gillespie MB, Barkley RA, Day TA, Bandyopadhyay D, Sharma AK: Driving 
performance in patients with cancer in the head and neck region: A pilot study. Arch Otolaryngol 
Head Neck Surg. 2007, 133:904-909. 
 
14. Cooper AF, Hankins M, Rixon L, Eaton E, Grunfeld EA: Distinct work-related, clinical and 
psychological factors predict return to work following treatment in four different cancer types. 
Psychooncology. 2013, 22:659-667. 
 
15. Verdonck-de Leeuw IM, van Bleek WJ, Leemans CR, de Bree R: Employment and return to 
work in head and neck cancer survivors. Oral Oncol. 2010, 46:56-60. 
 
16. Canadian Cancer Society’s Steering Committee on Cancer Statistics: Canadian Cancer Statistics 
2012. Toronto; 2012. 
 
17. Nichols AC, Palma DA, Dhaliwal SS, Tan S, Theuer J, Chow W, Rajakumar C, Um S, Mundi N, 
Berk S, Zhou R, Basmaji J, Rizzo G, Franklin JH, Fung K, Kwan K, Wehrli B, Salvadori MI, Winquist 
E, Ernst S, Kuruvilla S, Read N, Venkatesan V, Todorovic B, Hammond JA, Koropatnick J, Mymryk 
JS, Yoo J, Barrett JW: The epidemic of human papillomavirus and oropharyngeal cancer in a 
Canadian population. Curr Oncol. 2013, 20:212-219. 
 
18. Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, Jiang B, Goodman MT, 
Sibug-Saber M, Cozen W, Liu L, Lynch CF, Wentzensen N, Jordan RC, Altekruse S, Anderson WF, 
Rosenberg PS, Gillison ML: Human papillomavirus and rising oropharyngeal cancer incidence in 
the United States. J Clin Oncol. 2011, 29:4294-4301. 
 

Development and pilot evaluation of rehabilitation consult for survivors of head and neck cancer 
January 11, 2016 
Version 1.8 
Page 17 of 26 
19. Ramqvist T, Dalianis T: Oropharyngeal cancer epidemic and human papillomavirus. Emerg 
Infect Dis. 2010, 16:1671-1677. 
 
20. Egan MY, McEwen S, Sikora L, Chasen M, Fitch M, Eldred S: Rehabilitation following cancer 
treatment. Disabil Rehabil. 2013, 35:2245-58. 
 
21. Nagy J, Braunitzer G, Antal M, Berkovits C, Novak P, Nagy K: Quality of life in head and neck 
cancer patients after tumor therapy and subsequent rehabilitation: An exploratory study. Qual 
Life Res. 2014, 23:135-143. 
 
22. Kotz T, Federman AD, Kao J, Milman L, Packer S, Lopez-Prieto C, Forsythe K, Genden EM: 
Prophylactic swallowing exercises in patients with head and neck cancer undergoing 
chemoradiation: A randomized trial. Arch Otolaryngol Head Neck Surg. 2012, 138:376-382. 
 
23. Retel VP, van der Molen L, Hilgers FJ, Rasch CR, L'Ortye AA, Steuten LM, van Harten WH: A 
cost-effectiveness analysis of a preventive exercise program for patients with advanced head and 
neck cancer treated with concomitant chemo-radiotherapy. BMC Cancer. 2011, 11:475. 
 
24. Carnaby-Mann G, Crary MA, Schmalfuss I, Amdur R: "Pharyngocise": Randomized controlled 
trial of preventative exercises to maintain muscle structure and swallowing function during head-
and-neck chemoradiotherapy. Int J Radiat Oncol Biol Phys. 2012, 83:210-219. 
 
25. Eades M, Murphy J, Carney S, Amdouni S, Lemoignan J, Jelowicki M, Nadler M, Chasen M, 
Gagnon B: Effect of an interdisciplinary rehabilitation program on quality of life in patients with 
head and neck cancer: Review of clinical experience. Head Neck. 2013, 35:343-349. 
 
26. Bartholomew, LK, Parcel, GS, Kok, G, Gottlieb, NH, Fernandez, ME: Planning Health Promotion 
Programs: An Intervention Mapping Approach. San Francisco: John Wiley & Sons; 2011. 
 
27. Lorig KR: Self-management of chronic illnesses: A model for the future. Generations. 1993, 
17:11-14. 
 
28. McGowan PT: Self-management education and support in chronic disease management. Prim 
Care. 2012, 39:307-325. 
 
29. Department of Health: The expert patient: a new approach to chronic disease management for the 
21st century. London; 2001. 
 
30. Wagner EH: Meeting the needs of chronically ill people. BMJ. 2001, 323:945-946. 
 
31. Canadian Health Services Research Foundation. Self-management education to optimize health and 
reduce hospital admissions for chronically ill patients. Ottawa; 2007. 
 
32. Rodgers H, Atkinson C, Bond S, Suddes M, Dobson R, Curless R: Randomized controlled trial of 
a comprehensive stroke education program for patients and caregivers. Stroke. 1999, 30:2585-
2591. 
 
33. Taal E, Riemsma RP, Brus HL, Seydel ER, Rasker JJ, Wiegman O: Group education for patients 
with rheumatoid arthritis. Patient Educ Couns. 1993, 20:177-187. 

Development and pilot evaluation of rehabilitation consult for survivors of head and neck cancer 
January 11, 2016 
Version 1.8 
Page 18 of 26 
 
34. Richardson A, Addington-Hall J, Amir Z, Foster C, Stark D, Armes J, Brearley SG, Hodges L, 
Hook J, Jarrett N, Stamataki Z, Scott I, Walker J, Ziegler L, Sharpe M: Knowledge, ignorance and 
priorities for research in key areas of cancer survivorship: Findings from a scoping review. Br J 
Cancer. 2011, 105(Suppl 1):S82-94. 
 
35. Law M, Polatajko H, Pollock N, Mccoll MA, Carswell A, Baptiste S: Pilot testing of the 
Canadian occupational performance measures: Clinical and measurement issues. Can J Occup 
Ther. 1994, 61:191-197. 
 
36. Randall KE, McEwen IR: Writing patient-centered functional goals. Phys Ther. 2000, 80:1197-
1203. 
 
37. Levack WM, Taylor K, Siegert RJ, Dean SG, McPherson KM, Weatherall M: Is goal planning in 
rehabilitation effective? A systematic review. Clin Rehabil. 2006, 20:739-755. 
 
38. Heckhausen H, Gollwitzer PM: Thought contents and cognitive functioning in motivational 
versus volitional states of mind. Motiv Emotion. 1987, 11:101-120. 
 
39. Cohen J,. Statistical power analysis for the behavioral sciences. Hillsdale, N.J.: Lawrence Erlbaum 
Associates, Incorporated; 1988.  
40. Fritz CO, Morris PE, Richler JJ: Effect size estimates: Current use, calculations, and 
interpretation. J Exp Psychol Gen. 2012, 141:2-18. 
41. Fereday J, Muir-Cochrane E: Demonstrating rigor using thematic analysis: A hybrid approach 
of inductive and deductive coding and theme development. Int J Qual Methods. 2006, 5:1-11. 
 
 
42. Ware JE,Jr, Sherbourne CD: The MOS 36-item short-form health survey (SF-36). I. conceptual 
framework and item selection. Med Care. 1992, 30:473-483. 
 
43. Medical Outcomes Study 36-Item Short Form Health Survey: Psychometric Properties 
[http://strokengine.ca/assess/module_sf36_psycho-en.html]  
 
44. List MA, D'Antonio LL, Cella DF, Siston A, Mumby P, Haraf D, Vokes E: The performance 
status scale for head and neck cancer patients and the functional assessment of cancer therapy-
head and neck scale. A study of utility and validity. Cancer. 1996, 77:2294-2301. 
 
45. Wood-Dauphinee SL, Opzoomer MA, Williams JI, Marchand B, Spitzer WO: Assessment of 
global function: The reintegration to normal living index. Arch Phys Med Rehabil. 1988, 69:583-
590. 
 
46. Gage M, noh S, Polatajko HJ, Kaspar V: Measuring perceived self-efficacy in occupational 
therapy. Am J Ocup Ther. 1994, 48:783-790. 
 

Development and pilot evaluation of rehabilitation consult for survivors of head and neck cancer 
January 11, 2016 
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47. Radiation Therapy Oncology Group: Compiled Computer-Assisted Self  Interview (CASI) 
system questionnaires 
[http://www.rtog.org/LinkClick.aspx?fileticket=JUjxRtTMVuE%3D&tabid=290].  
 
48. Kiresuk T, Sherman R: Goal attainment scaling: A general method for evaluating 
comprehensive community mental health programs. Community Ment Health J. 1968, 4:443-453. 
 
49. Stolee P, Stadnyk K, Myers AM, Rockwood K: An individualized approach to outcome 
measurement in geriatric rehabilitation. J Gerontol A Biol Sci Med Sci. 1999, 54:M641-647. 
 

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or absence 
 
 
 
 
 
 
 
 
 
 
 
Personality changes 
 
Respiratory issues 
 
Senses (ie. Smell, taste, 
touch, sight, hearing) 
 
Sexuality 
 
Speech 
 
Swallowing 
 
Voice 
 
Weight loss 
Difficult to 
Modify 
Age 
 
Disease site  
 
Education level  
  
Personality  
 
Sex 
 
Socioeconomic 
status/finances  
 
Treatment received  
Culture (of survivor) 
 
Familial/caregiver 
support  
 
Geographic location 
– rural vs urban 
 
Hospital type (eg 
cancer centre vs 
tertiary care centre) 
 
Language  
 
Living/workplace 
conditions 
(e.g. exposure to 
second-hand smoke, 
exposure to 
carcinogenic 
substances at work 
unknowing or 
without proper 
protection gear, etc.) 
 
 
 
Items in italics are targeted for change.  
 
Items in the “Determinants” column refer to both clinician and provider, where applicable, unless otherwise 
stated. 
 

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Table 2. Outcome Measures 
 
Construct 
Instrument(s) 
Description and Psychometric Properties 
Health-related 
Quality of Life 
Medical Outcomes Study 
36-item Short-Form Health 
Survey (SF-36) [42,43] 
SF-36 a widely used, generic, patient-report measure created 
to assess health-related quality of life (HRQOL). It consists of 8 
domains: Physical Functioning, Role limitations due to Physical 
problems, Bodily Pain, General Health Perceptions, Social 
Functioning, General Mental Health, Role limitations due to 
Emotional problems, and Vitality. SF-36 has been widely tested, 
and, with the exception of the Social Functioning subscale, has 
excellent internal consistency and interrater reliability; SF-36 has 
adequate to excellent convergent validity with a number of 
functional and HRQoL scales.  
 
 
The Functional Assessment 
of Cancer Therapy-Head 
and Neck Version 4 (FACT-
H&N) [44] 
Self-report reliable and valid quality of life questionnaire. The 
scale consists of a core FACT-G (General) questionnaire that 
covers four domains: physical, social/family, emotional, and 
functional. The scale is supplemented by a head and neck cancer 
specific subscale. Items are rated on a 0 (Not at all) to 4 (Very 
much) Likert scale and scores are calculated to produce subscale 
scores for each domain. It is reliable and valid in patients with 
HNC, scores correlating with treatment status and global 
performance status.  
 
Participation 
Reintegration to Normal 
Living Index (RNL) [45] 
The RNL consists of 11-items covering areas such as 
recreational and social participation, community mobility, family 
roles and other relationships.  It has high internal consistency, 
moderate interrater reliability, and is correlated with measures of 
quality of life and well being.  
 
Self-Efficacy 
HNC RC Self-Efficacy Tool 
There was no existing tool which adequately measured self-
efficacy as it relates to the goals of this study. Therefore, a self-
efficacy tool was created, using a 0-100 rating scale, based on 
Bandura (2006) “Guide to Constructing Self-Efficacy  Tools” to 
measure the confidence of participants to achieve outcomes 
specific to this study. This tool is included as Appendix D.  
 
Return to 
Work 
Radiation Therapy 
Oncology Group (RTOG)  
Work Status Questionnaire 
[47] 
The RTOG Work Status Questionnaire is a brief, patient-
report tool that takes less than 5 minutes to complete. It was 
designed for use in RTOG trials, and psychometric properties have 
not been tested, but meets content validity criteria and sensibility 
criteria. 
Goal 
Attainment 
Goal Attainment Tool 
Participants are asked about how well they currently perform a 
stated goal, which they develop in consultation with the 
rehabilitation consultant, how satisfied they are with this 
performance, and their confidence they can do the goal,  and rate 
these on a scale of 0-100. A score of 0 represents low 
performance/satisfaction, and 100 represents the highest level of 
performance/satisfaction. This tool is included as Appendix C.  
Patient 
Perspective 
Intervention 
Process 
Rehab Consult Process 
Survey 
Items for this survey were derived from questions posed in 
interview format during an earlier testing phase.  17 statements are 
scored using a 3-point Likert-type scale. Statements concerns 
intervention process issues such as timing, ease of use, and value  
of specific consult segments. This can be found in Appendix B.   
 
 
 
 

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Table 3: Pilot (beta) testing version of Rehabilitation Consult Process 
 
Name 
Process Steps 
Methods 
Orientation  
 
A. A brief orientation (Appendix A) is 
given by the rehab consultant to 
orient the survivor to the reason 
for the consultation and the 
process.  
Advance Organizer 
Consultation 
B. The rehab consultant reviews the 
brief HNC-specific functional 
evaluation (BRASH), and then 
consults with the survivor 
regarding the results. The survivor 
identifies the issues that are 
currently most important to him or 
her.  If the participant has no goals, 
the rehabilitation closes the 
session by reinforcing that the 
options available if he/she has 
issues arising at a later time, and 
providing information on accessing 
the resource compendium.   
Goal-setting  
Individualization  
Therapeutic alliance  
Facilitation 
Participatory problem solving 
 
Goal-setting  
C. The survivor and the rehab 
consultant work collaboratively to 
make goal statements based on 
issues identified by the survivor as 
most important to him or her. The 
rehab consultant administers a 
goal attainment tool (Appendix D) 
wherein the participant rates his or 
or her current performance, 
satisfaction, and confidence with 
the goals.  
Goal-setting  
Individualization  
Therapeutic alliance  
Facilitation 
Participatory problem solving 
Cognitive strategy training 
 
Teach 
cognitive 
strategy  
D. The rehab consultant teaches the 
global problem solving strategy, 
Goal-Plan-Do-Check 
(Meichenbaum, 1971).  
 
Action 
Planning, 
Planning 
Coping 
Responses, 
and 
Introduction 
to Resources  
 
E. Using the Goal-Plan phases of the 
problem solving strategy, the 
rehab consultant and the survivor 
develop an action plan to meet the 
identified goals. The rehab 
consultant uses motivational 
interviewing techniques (eliciting 
change talk, evoking motivation to 
make positive changes (Miller & 
Rollnick, 1991) and guided 
Individualization  
Therapeutic alliance  
Facilitation 
Participatory problem solving 
Motivational interviewing 
techniques 
Framing 
Guided discovery 
Implementation intentions 
Planning coping responses 

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discovery techniques (ask don’t 
tell, coach don’t adjust, make it 
obvious, and one thing at a time 
(Polatajko & Mandich, 2004)).  The 
rehab consultant reviews the 
rehabilitation resources of which 
the survivor may already be aware, 
or accessing. The rehab consultant 
reviews the study website 
(resource compendium) 
(www.hncrehab.ca), with the 
survivor, for future use, and 
facilitates the assembly of 
resources previously unknown to 
the survivor, which are necessary 
to implement the survivor’s plans. 
Also as part of the planning 
process, the survivor identifies 
potential barriers to implementing 
the action plan and develops 
coping responses, using planning 
coping responses techniques 
(Marlatt & Donovan, 2005), all 
facilitated by the rehabilitation 
consultant.   
Verbal persuasion 
 
Execution  
 
F. Facilitated by the rehab consultant, 
the survivor reviews his or her 
goals and action plan for clarity, 
and is encouraged to execute (do) 
his or her plan. Follow-up 
appointment is scheduled for 
between 2 and 10 weeks later, at a 
mutually convenient time.  This 
may be in person, or via telephone, 
as per survivor’s preference.  
Implementation intentions 
Planning coping responses 
Follow-Up Process 
Reminder  
 
A. A telephone reminder regarding 
the follow-up appointment is made 
24 hours in advance. 
Advance organizer 
Individualization 
Re-
Orientation 
 
B. The rehab consultant phones at 
the designated date and time and 
confirms with the survivor that the 
appointment is still convenient. 
The rehab consultant re-orients the 
survivor to the RC process. 
Facilitation 
Individualization 
Checking 
 
C. The rehab consultant and the 
survivor begin the check phase of 
goal-plan-do-check. They review 
the goals and the rehab consultant 
Self monitoring of behavior 
Individualization 
Goal setting 
Motivational interviewing 

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re-administers the goal attainment 
tool. Subsequently, the actions 
plans are reviewed and they 
proceed with a discussion about 
the do-check portion of the 
problem solving strategy. The 
rehab consultant guides the 
discussion using motivational 
interviewing and guided discovery 
techniques. If the plan was 
successfully implemented and the 
goals are achieved, next steps are 
discussed If the plan was not 
implemented or the goals were not 
achieved, the rehab consultant will 
guide the survivor to modify the 
plan as necessary. The rehab 
consultant and the survivor discuss 
potential barriers to implementing 
the newly modified action plan and 
develop coping responses, using 
techniques for planning coping 
responses.  
techniques 
Self monitoring of behaviours 
Self re-evaluation 
Goal setting 
Implementation intentions 
Planning coping responses 
Guided discovery 
Verbal persuasion 
Discharge or 
Further 
Follow-up 
 
D. The need for a second follow-up 
appointment is discussed and, if 
necessary, scheduled at a mutually 
convenient time. If the survivor 
seems to be struggling, a face-to-
face follow-up might be scheduled. 
If a follow-up is deemed 
unnecessary at this time, the 
survivor is provided with 
information about how to access 
the rehab consultant in the future, 
should the need arise, and 
discharge occurs.  
Individualization 
Facilitation 
Guided discovery 
Verbal persuasion 
Implementation intentions 
Planning coping responses 
 
 
 
 
 

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Figure 1: Timeline 
 
2015 
2016 
2017 
 
May-
Jun 
Jul-
Aug 
Sept-
Oct 
Nov-
Dec 
Jan-
Feb 
Mar-
Apr 
May-
Jun 
Jul-
Aug 
Sep-
Oct 
Nov-
Dec 
Jan-
Feb 
Mar-
Apr 
 Alpha-RC 
development 
 
 
 
 
 
 
 
 
 
 
 
 
REB 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-test 
recruitment 
 
 
 
 
 
 
 
 
 
 
 
 
 
Alpha-RC 
Intervention  
 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-testing 
assessments  
 
 
 
 
 
 
 
 
 
 
 
 
Beta-RC 
development 
 
 
 
 
 
 
 
 
 
 
 
 
Recruitment 
for pilot test 
 
 
 
 
 
 
 
 
 
 
 
 
Beta-RC 
Intervention 
 
 
 
 
 
 
 
 
 
 
 
 
Pilot test 
assess and f/u 
 
 
 
 
 
 
 
 
 
 
 
 
Analysis, 
reports, etc