jeﬀery steinberg m.d. (neurology)neck pain. at the conclusion of her 10-week home rehabilitation...

Jeffery Steinberg M.D. (Neurology)

CERVIFIT NECK STRENGTHENING AND CONDITIONINGPROGRAM ON FORMER HEAD AND NECK SQUAMOUS CELL CARCINOMA PROTON THERAPY PATIENT. June 20, 2018

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CerviFit Neck Strength and Conditioning Program on former head and neck squamous cell carcinoma proton therapy Patient. | Jeffery Steinberg; MD

Introduction

Proton therapy is quickly becoming the preferred protocol when addressing invasive squamous cell carcinoma. According to MD Anderson, “proton therapy allows for the effective treatment of complicated head and neck tumors, while minimizing the radiation dose to vital structures such as the eyes, mouth and brain. Vital physical functions such as vision, smell, taste and swallowing remain virtually untouched when a patient is treated with proton therapy.” (1)

While mitigating some of the risk of side effects, proton therapy according to Penn State School of Medicine, “Damage to the muscles in the neck may also occur after radiation. Usually, damage to the muscles results in atrophy, or decrease in size of the muscles on one or both sides of the neck. The muscles and soft tissue may also develop a hard or “woody” texture. Some survivors will develop longer, thinner-appearing necks that are not as strong as they were before treatment due to muscle atrophy, resulting in difficulty holding their head up for long periods.” (2)

According to the article, A Comprehensive Review of Head and Neck Cancer Rehabilitation: Physical Therapy Perspectives, “isometric strengthening of the cervical extensors, and postural modifications with visual cuing, is beneficial. Manual fibrous release techniques are indicated when ROM is restricted by robust soft tissue fibrosis or tethering of the skin to subdermal tissues. Patients can be taught self-massage to augment the efficacy of ROM activities.” (3)

Currently, patients who undergo proton therapy are discharged with minimal home exercise instructions with no medical supervision. This can potentially increase the risk to the patient for mechanical injury to the cervical spine.

The CerviFit strengthening and conditioning program addresses the physician’s and patient’s concerns diagnostically and therapeutically. By establishing the subject’s baseline neck tensile strength and Range of Motion, the physician can objectively monitor an individual’s progress. The patient is seen by the physician or PA (Physician Assistant) bi-monthly insuring compliance, measuring tensile neck strength, ROM (Range of Motion) and modifying the program as needed. This approach has been shown to reduce pain, improve functionality, and return the subject’s quality of life. The CerviFit program utilizing the hand-held Dynamometer, an industry standard in diagnostic objectivity, removes any ambiguity in the objective diagnostic findings.

The Cervifit eight-week, Physician prescribed, and reviewed home rehabilitation and conditioning program results has been consistently reproduced in a multitude of patients with various underlining neuro-orthopedic conditions, which, were validated by the test results and clinical assessments. There is an emerging correlation between the strengthening of musculoskeletal system and the reduction of pain and headaches.

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Patient Summary

Patient is a 55-year-old female attorney diagnosed in March 2016 with squamous cell carcinoma and completed proton therapy in June 2016. Patient was formally treated at MD Anderson in Texas and at the time of initial appointment while in remission, suffered from cervical muscular atrophy and weakness caused by the prolonged effects of Targeted Proton Therapy. In addition, patient complained of recurring Migraines, and persistent referred neuropathy.

The Cervifit Strengthening and Conditioning Program was initiated under medical supervision consisting of a 10-week isotonic neck exercise regimen.

Conclusion

When initially evaluated, the subject was unable to lift her head off of the pillow and unable to work. The subject had substantial significant positive results within the first two weeks as documented by the Dynamometer (reference graphs below), which measures a subject’s tensile strength. The progressive, sustained patient anecdotal and objective improvement during the course of the CerviFit program included, increased physical activity, reduction in headaches and neck pain.

At the conclusion of her 10-week home rehabilitation program, there was marked improvement of the subject’s cervical tensile strength and mobility allowing a return to her occupation as an Attorney without any neck weakness or complaints.

CerviFit Program:

CerviFit Device:

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Planes of Movement

Method of Diagnostic Measurement, Handheld Dynamometer: The dynamometer is an instrument for measuring the force of muscular contraction. The subject(s) tested using this dynamometer were fitted with a custom nylon “halo”. The “halo” or means of attachment was designed to firmly fit around the crown of the subject complete with a “D” ring which was attached on the “pull” side of the device. The device was held by the attending physician and the seated subject was asked to exert as much pulling force as possible. The readings were recorded on the chart below and upon completion of the protocol was entered into an excel spreadsheet with the calculations demonstratively illustrated on the proceeding graphs.

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Patient Benchmark\Progress Record:

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Dynamometer Results:

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About Anatomical Architects

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Dr. Jeffery Steinberg is a board-certified Neurologist with over 25 years of clinical experience. Dr. Steinberg completed his residency at Kaiser Permanente, Los Angeles, an interventional pain fellowship at University of Louisville, (Veterans Administration) and neurophysiology/ sleep fellowship at Emory University. Professional accomplishments include: Created and former Medical Director of the Memory Center at Memorial Hospital Pembroke Pines, Fl; co-founded Leeza’s Place, a charitable organization supporting caregivers of those afflicted with Alzheimer’s, with TV Celebrity Leeza Gibbons.

Dr. Steinberg is the medical advisor for Anatomical Architects and oversees the rehabilitation protocol on the CerviFit program.

References (1) Proton Therapy for Head and Neck Cancers; https://www.mdanderson.org/patients-family/diagnosis-treatment/care-centers-clinics/proton-therapy-center/conditions-we-treat/head-and-neck-cancers.html

(2) Late Effects of Head & Neck Radiation; https://www.oncolink.org/frequently-asked-questions/cancers/head-and-neck/general-concerns/late-effects-of-head-neck-radiation

(3) A Comprehensive Review of Head and Neck Cancer Rehabilitation: Physical TherapyPerspectives; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477371/ © Indian Journal ofPalliative Care; Karthikeyan Guru, Udaya Kumar Manoor, and Sanjay Sudhakar Supe

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6/20/2018 Proton Therapy for Head & Neck Cancers | MD Anderson Cancer Center

https://www.mdanderson.org/patients-family/diagnosis-treatment/care-centers-clinics/proton-therapy-center/conditions-we-treat/head-and-neck-cancers.html 1/2

e power of protons

Proton therapy allows for the effective treatment ofcomplicated head and neck tumors, while minimizingthe radiation dose to vital structures such as the eyes,mouth and brain. Vital physical functions such asvision, smell, taste and swallowing remain virtuallyuntouched when a patient is treated with protontherapy.

Many head and neck cancer patients can benefit fromthe precision of intensity modulated proton therapy, orIMPT, a treatment offered exclusively at MD Anderson.IMPT delivers protons to the most complicated tumorsby focusing a narrow proton beam and essentially"painting" the radiation dose onto the tumor layer bylayer.

e need to implant a feeding tube during head andneck treatment, which can occur in up to 60% ofstandard radiation patients, may be avoided in IMPTpatients due to less collateral damage to the oral cavity.

Side effects such as nausea, damage to the salivaryglands, loss of taste and endocrine disorders are also

is image demonstrates how proton therapy can bemore beneficial in sparing important structures on thehead and neck area in comparison to traditionalradiation (IMRT). In this case proton therapy was ableto spare the oral cavity, brain stem, larynx and spinalcord.

Proton erapy for Head and Neck Cancers

Cancerous and non-cancerous tumors can occur in the skull base and neck, and even benign tumors in these areasmay cause symptoms or threaten the health and well-being of a patient.

MD Anderson provides comprehensive care for patients who have benign or malignant head and neck tumors.Treatment options include surgery, radiation, chemotherapy, or any combination of the three.

e MD Anderson Proton erapy Center treats cancers of the:

Nasal and sinus cavitiesOral cavity, including the salivary glands, tongue and tonsilsLarynxEyeSkull baseSpine

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https://www.mdanderson.org/

https://www.mdanderson.org/cancer-types/skull-base-tumors.html

https://www.mdanderson.org/treatment-options/surgery.html

https://www.mdanderson.org/treatment-options/radiation-therapy.html

https://www.mdanderson.org/treatment-options/chemotherapy.html

https://www.mdanderson.org/cancer-types/oral-cancer.html

https://www.mdanderson.org/cancer-types/throat-cancer.html

https://www.mdanderson.org/cancer-types/eye-cancer.html

https://www.mdanderson.org/cancer-types/skull-base-tumors.html

https://www.mdanderson.org/cancer-types/spinal-tumors.html

6/20/2018 Proton Therapy for Head & Neck Cancers | MD Anderson Cancer Center

https://www.mdanderson.org/patients-family/diagnosis-treatment/care-centers-clinics/proton-therapy-center/conditions-we-treat/head-and-neck-cancers.html 2/2

reduced with proton therapy. is enables patients tobetter maintain their weight and hydration, contributingto successful treatment outcomes and substantiallyimproving quality of life both during and aer cancertreatment.

Proton erapy Clinical Trials

Clinical trials underway at the Proton erapy Center are dedicated tounderstanding the advantages of protons for treatment of head and neck tumors.

is includes the first randomized Phase II/III trial comparing IMPT to standardconformal radiation therapy in patients with oropharyngeal carcinoma, whichoccurs at the back of the throat.

e trial aims to measure proton therapy’s ability to reduce a range of side effectscommon to head and neck cancers.

EXPECTATIONS

Proton therapy treatment for head and neck cancer typically takes about15-30 minutes each day and is delivered five days a week for 4-7 weeks.Most patients tolerate it extremely well and can continue to work and

exercise during and immediately aer treatment is complete.

© 2018 The University of Texas MD Anderson Cancer Center

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http://utm-ext01a.mdacc.tmc.edu/dept/prot/clinicaltrialswp.nsf/Index/2012-0825

6/20/2018 Late Effects of Head & Neck Radiation | OncoLink

https://www.oncolink.org/frequently-asked-questions/cancers/head-and-neck/general-concerns/late-effects-of-head-neck-radiation 1/2

Late Effects of Head & Neck RadiationLast Modified: June 23, 2009

Question:Dear OncoLink "Ask The Experts," I had radiation for 8 weeks for nasopharangeal cancer that had alsogone to a lymph node in my neck. Now over 4 years later, I have some problems with my voice andbreathing. My tongue has recently started cramping up on me for 5 or so minutes at a time, and I can'ttalk or swallow during this time. My right shoulder is weak, and I can't lift my arm as I used to and themuscle is gone on top of the shoulder. Is this normal, and is there any treatment that can be done or anymedication to stop the tongue from responding this way?

Answer:Christine Hill-Kayser, MD, Assistant Chief Resident in the Department of Radiation Oncology atthe Hospital of the University of Pennsylvania, responds:

Late effects from radiation to the head and neck may be complicated, and may involve several differentstructures in the regions that were irradiated. The most common late effect of radiotherapy for head andneck cancer is dry mouth. This can occur from damage to the glands that produce saliva. Dry mouthcan cause difficulty with swallowing or eating certain types of food. Additionally, chronic dry mouth cancause dental decay that may occur faster than usual. Survivors of head and neck cancer should befollowed closely by a dentist, and the dentist may recommend use of fluoride trays to promote dentalhealth. Artificial saliva products may be helpful in relieving dry mouth, as may taking small, frequent sipsof water. Radiation to the head and neck may alter the taste sensation, as well. In many cases, tastereturns to normal with time, but this is not always the case. Difficulties such as dry mouth and tastealteration may affect a survivor’s ability to take in adequate food. Use of nutritional supplements, suchas Ensure or Boost, may be helpful, and nutritional counseling is important for all survivors who mayhave difficulty eating.

Radiation to the neck may also cause damage to the vessels, nerves, and muscles. Damage to thevessels in the neck may cause increased risk of stroke from atherosclerosis (plaqueing) inside thevessels. Because of this risk, survivors of head and neck cancer should be particularly careful to avoidother risk factors for stroke – this includes eating a low-fat, healthy diet and avoiding smoking. Damageto the lymph vessels, which drain fluid from the head and neck, may cause lymphedema. Lymphedemamay cause swelling in the neck or face, which may be worse after lying down. Patients withlymphedema may be referred to a Lymphedema Therapist for therapy to address the problemsassociated with lymphedema.

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https://www.oncolink.org/

6/20/2018 Late Effects of Head & Neck Radiation | OncoLink

https://www.oncolink.org/frequently-asked-questions/cancers/head-and-neck/general-concerns/late-effects-of-head-neck-radiation 2/2

Damage to the nerves within the head and/ or neck is rare after radiation, but does occur in somecases. Damage to the nerves that control the throat may make swallowing difficult. If this occurs, aswallowing study may be performed (video swallow, barium swallow, or both). If a speech and swallowspecialist observes swallowing abnormality on a swallow study, s/he may recommend dietary changesto assist with swallowing and prevent choking. Damage to the nerves that control the voice may causehoarse voice, which may or may not be permanent. Damage to the nerves that control the arms canalso occur from radiation to the head and neck. This may occur from damage to a nerve structure calledthe brachial plexus, and may result in weakness of one arm or shoulder. Patients who develop armweakness should be referred to a Physical Therapist; they may also be referred to a Neurologist fortesting of nerve and muscle function. Very rarely, the nerves that control the tongue may be damagedby radiation. This may cause uncomfortable “spasms” of the tongue. Patients who develop painfulmotions or spasms of the tongue should be evaluated by a speech and swallow specialist, and mayalso be referred to a neurologist for testing of nerve and muscle function.

Damage to the muscles in the neck may also occur after radiation. Usually, damage to the musclesresults in atrophy, or decrease in size of the muscles on one or both sides of the neck. The muscles andsoft tissue may also develop a hard or “woody” texture. Some survivors will develop longer, thinner-appearing necks that are not as strong as they were before treatment due to muscle atrophy, resulting indifficulty holding their head up for long periods. Some practitioners will prescribe a brace or physicaltherapy to help with this condition.

Some practitioners may recommend a combination of medicines to address hardening, or fibrosis, oftissues of the head and neck, including pentoxifylline (Trental) and vitamin E. Survivors interested inmedical treatment for changes in the tissues of the neck may discuss these medicines with an oncologyspecialist with expertise in treating head and neck cancers.

You can learn more about late effects due to cancer treatment by creating your own OncoLife Care Plan(https://oncolife.oncolink.org).

Copyright © 2018 Trustees of the University of Pennsylvania

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https://oncolife.oncolink.org/

6/20/2018 A Comprehensive Review of Head and Neck Cancer Rehabilitation: Physical Therapy Perspectives

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477371/?report=printable 1/27

Go to:

Indian J Palliat Care. 2012 MayAug; 18(2): 87–97.doi: 10.4103/09731075.100820

PMCID: PMC3477371PMID: 23093823

A Comprehensive Review of Head and Neck CancerRehabilitation: Physical Therapy PerspectivesKarthikeyan Guru, Udaya Kumar Manoor, and Sanjay Sudhakar Supe

Srinivas College of Physiotherapy and Research Center, Mangalore, IndiaDepartment of Radiation Oncology, Bangalore Hospital, Bangalore, IndiaDepartment of Radiation Physics, Kidwai Memorial Institute of Oncology, Bangalore, IndiaAddress for Correspondence: Dr. Karthikeyan G; Email: [email protected]

Copyright : © Indian Journal of Palliative Care

This is an openaccess article distributed under the terms of the Creative Commons AttributionNoncommercialShare Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

Abstract

Rehabilitation in relation to cancer can be preventative, restorative, supportive,and palliative. It is recognized that patients may have rehabilitation needsthroughout their care pathway. The role of physiotherapy in the cancerrehabilitation is less understood and particularly in the head and neck cancer(HNC) patients. This results in various residual deformities and dysfunctions forthe patients with HNC. The objective of this review is to provide detailedinformation regarding the problems faced after the cancer treatments andrehabilitation of patients who suffered with HNC. The fact that cancer patients arefacing several months of chemotherapy and/or radiotherapy and usually majorsurgery, as well as the direct effect of immobility due to pain, means that musclewasting, joint stiffness, as well as deconditioning and fatigue are inevitable. Theabsence of physiotherapy intervention would be detrimental to patient care andthe ability of the patient/family to cope with the effects of the disease or itstreatment on their functional capacity and quality of life. Following any treatmentfor HNC, physical therapy may play an essential role in preventing variouscomplications and helping patients to mitigate impairments, and restoringfunction of the shoulder joint, neck, and face.

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https://dx.doi.org/10.4103%2F0973-1075.100820

https://www.ncbi.nlm.nih.gov/pubmed/23093823

https://www.ncbi.nlm.nih.gov/pubmed/?term=Guru%20K%5BAuthor%5D&cauthor=true&cauthor_uid=23093823

https://www.ncbi.nlm.nih.gov/pubmed/?term=Manoor%20UK%5BAuthor%5D&cauthor=true&cauthor_uid=23093823

https://www.ncbi.nlm.nih.gov/pubmed/?term=Supe%20SS%5BAuthor%5D&cauthor=true&cauthor_uid=23093823

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Keywords: Cancer rehabilitation, Head and neck cancer, Palliative care, Physicaltherapy

INTRODUCTION

Cancer is a leading health problem in India, with approximately 1 million casesoccurring each year. Over 200,000 cases of head and neck cancer (HNC) occureach year in India versus 30,000 for the USA. Cancer accounts for 8% of thedeaths in India.[1] Incidence of HNC primaries has shown to increase with age.Although the functional and cosmetic deficits are very apparent in HNCs, thisgroup of cancers accounts for only 5% of all malignancies.[2]

Worldwide, it is considered to be the fifth most common cancer with the seventhhighest cancer mortality.[3] The most commonly listed causes of HNCs aretobacco and alcohol abuse.[4] It is also suggested that use of alcohol in concertwith smoking is among the most common etiologic factors of HNCs. Otherreasons include exposure to different HNCinducing agents, such as bethelchewing, hot tea, smoking, alcohol consumption, and human papilloma viruses.[5–7]

Yeole[8] made an attempt to study the trends in the ageadjusted incidence ratesfor the sites of HNCs in Mumbai, Bangalore, Chennai, Delhi, Bhopal, and Barshiregistries’ populations. He found the clear trend of cancer of the tongue,oropharynx, and larynx where bidi smoking is the dominant risk factor could beexplained on the basis of available data.

Oncologists and scientists have made substantial progress in cancer treatment inthe last few decades. As both the number of cancer survivors and the length oftheir survival are increasing, longterm health issues related to cancer and itstreatment are becoming more important. To achieve such excellent outcomesmany patients receive aggressive treatment, including surgery, chemotherapy, andradiation therapy.[9]

CANCERRELATED PROBLEMS

The problems that occur in relation to the cancer disease and its treatment varywith the type of cancer, disease stage, and type of medical treatment[10] [Table 1].[11] Difficulties may develop in the period between diagnosis and primarytreatment, during primary treatment, and during followup.

The shoulder disability and chronic neck pain occurs following radical neckdissection.[12–16] In radical neck dissection the sternocleidomastoid and

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omohyiod muscles, the spinal accessory nerve, the anterior, external, and internaljugular veins, and the external maxillary artery are excised, along with thelymphatic groups in the anterior and posterior triangles. In comparison, amodified radical neck procedure removes the same muscles and lymphatics andthe internal jugular vein but spares the spinal accessory nerve. A functional neckdissection removes only the lymphatics and spares all muscles, nerves, andvessels.

Van Wilgen et al.[17] found that reduced shoulder abduction, shoulder pain, andneck pain are related to several domains of quality of life (QOL) at least 1 yearafter surgery. Acute complications are wound infections, chyle leakage, andpostoperative morbidity, such as cardiac problems and thrombosis.[18,19] Themost common late complications are shoulder disability, shoulder pain, reducedcervical mobility, and lymphedema.[17,20–22] Decreased cervical range ofmotion (ROM), lymphedema, swallowing, mouth opening, and shoulder disabilityare regarded as late complications. None of these parameters appear to be relatedto reduced survival, but most of them are considered to be associated withreduced QOL.[23–27]

Giulianno et al.[18] found the overall postsurgical complication rate of 50%. Thedeath rate was 3.6%. Fortyseven patients (42.7%) were electively referred to theintensive care unit (ICU). The occurrence of postoperative complications wasassociated with extended clinical severity stage (P = 0.02), type of surgery (P =0.03), ICU (P = 0.03), type of reconstruction (P = 0.02), Functional SeverityIndex (P = 0.03), neck dissection (P = 0.002), and Acute Physiology and ChronicHealth Evaluation II (APACHE II) (P = 0.008).

REHABILITATION

The term “rehabilitation” refers to a process aimed at enabling persons withdisabilities to achieve and maintain their optimal physical, sensory, intellectual,psychiatric, and/or social functional levels, thus providing them with the tools toadapt their lives toward a higher level of independence.[28] Rehabilitation doesnot focus on a prolongation of survival but rather on an improvement of thepatient's QOL. This is also the goal of palliation. The difference betweenrehabilitation and palliation can be found in the fact that rehabilitation attempts toreestablish impaired functions), while palliation focuses on the alleviation ofsymptoms. Traditionally, once diseasemodifying cancer treatment options havebeen exhausted, patients move to palliative care. Because of its initial ties to the

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modern day hospice movement, palliative medicine has been loosely defined ashospice care, terminal care, and endoflife care.[29,30]

Interdisciplinary team[18,31] involved in the Cancer Rehabilitation consists ofPhysician, Rehabilitation nurse, Physical therapist, Occupational therapist,Prosthetistorthotist, Nutritionist, Speech therapist, Psychologist, Vocationalcounsellor, Social worker, and Recreational therapist.

The rehabilitation takes place in various stages in different forms,[32] such asPreventive rehabilitation therapy is started early after the diagnosis of cancer ismade, where no significant physical impairment exists, but therapy is started toprevent functional loss. Restorative rehabilitation therapy is directed at thecomprehensive restoration of maximum function for patients who have a residualphysical impairment and disability. Supportive rehabilitation therapy attempts toincrease the selfcare skills and mobility of the cancer patient with physicalexercises to prevent the effects of immobilization, such as joint impairments,muscle atrophy, weakness, and pressure scores. Palliative rehabilitation therapyaims to increase or maintain the comfort and function of patients with terminalcancer by improving their wellbeing, giving pain relief, avoiding jointimpairments and pressure sores, and to provide at least partial selfsufficiency.

An important finding was that rehabilitation was underused in the populationstudied.[33] Reasons for underuse may include the failure of the acute care staffto identify functional impairments, lack of appropriate referral for rehabilitation,lack of awareness of rehabilitation services, and lack of knowledge among familymembers. These barriers can be overcome by providing education and byenlisting the cooperation of the clinical oncology staff, whose background inrehabilitation and functional issues may be limited or underemphasized.

Of importance, all practitioners must keep in mind that, after the patient'scondition is stabilized and after he or she is discharged from the hospital,rehabilitation services must be considered on an outpatient or homebased basis tomaintain gains and to prevent further deconditioning. At present, the vast majorityof patients are never referred for rehabilitation followup after discharge.

Role of physiotherapy

Role of physiotherapy in the cancer rehabilitation is less understood andparticularly in the HNC patients. This results in various residual deformities anddysfunctions for the patients with HNC. The role of the physiotherapist inpalliative care include that they work with respiratory, neurologic, lymphatic,

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orthopedic, musculoskeletal symptoms and complications, pain, and hemotalogicconditions.[34] Common interventions they utilise are positioning for preventionof pressure sores; Transcutaneous electrical nerve stimulation (TENS) for paincontrol; neurologic rehabilitation in peripheral neuropathies; mobility training toenhance the exercise tolerance, maintenance, and independence; passive/activerange of movement to prevention of contractures; and individual designedexercise programs for maintaining the general health of the patient.[35]

During the rehabilitation of these patients, it is of primary importance to unloadthe shoulder immediately postoperatively, reduce shoulder and neck pain, andprevent stretch fibrosis of the trapezius and contracture of the unopposedpectoralis muscles, as well as to provide strengthening exercises for the residualmuscles in the neck and shoulder girdle to compensate for lost muscles.[36]Postoperative physiotherapy includes prevention and management of therespiratory complications, such as respiratory distress and excess secretions;cardiovascular complications, such as deep vein thrombosis and dependentedema; and musculoskeletal complications, such as joint and muscle tissuestiffness and weakness in the face, neck, and shoulder.[37]

Sufficient wound healing should occur in 10–14 days to allow patient to begin theexercise program for the shoulder and neck. Prior to this it is imperative that thepatient be cognizant of proper positioning for the affected shoulder and neckareas. While the patient is seated, the shoulder and the upper arm should besupported on a pillow or the arm chair to prevent further stretching of thetrapezius. The start of the exercise program may be delayed in patients withdelayed wound healing or fistula formation and those in danger of carotid“blowout.” The risk of carotid blowout is critical approximately 2 weeks aftersurgery and is the result of arterial disease, radiation effects, or removal of thecarotid sheath. This is, unfortunately, the time at which most ROM/strengtheningexercises are scheduled to begin. The physical therapist must be ready to modifythe exercise program to protect the patient during this critical period, as a blowoutof the carotid is potentially fatal.

Thorsen et al.[38] observed the effect of physical activity shortly afterchemotherapy and found VO max increased by 6.4 mL/kg/min in patients in theintervention group who received physical activity and by 3.1 mL/kg/min inpatients in the control group (P < 0.01). The fatigue score decreased by 17.0points in the control group compared with only 5.8 points in the interventiongroup (P < 0.01).

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Spinal accessory nerve palsy

Therapeutic exercises are initially passive but gradually progress to activeassistive and eventually resistive exercises as tolerated by the patient. Strenuousphysical activities, such as lifting, carrying, pulling, and pushing, should beavoided initially but may be resumed in the course of time as the physicalcondition improves.[16]

Additionally, the physical therapist can help by training other muscles to assistwith shoulder function.[39–41] The levator scapulae, through their action asscapular elevators, can be trained to help maintain level shoulders. Patients areinstructed to work on these exercises in front of a mirror. The action of scapularretraction can be assumed by the rhomboids, which results in a balanced counterpull to the action of pectoralis major. The serratus anterior should be strengthenedto assist with scapular stabilization during shoulder flexion and abduction.

Training in Activities of daily living (ADL) is initiated approximately 1 weekpostoperatively. Prior to discharge, a decision is made as to whether the patientrequires a permanent orthosis or other assistive devices to compensate for lostfunction. After discharge, most patients are referred for continued therapy and aregiven specific instructions for exercise and other activities at home.[40]

Common complications and physiotherapy management

Disorders of pain, weakness, debility, deformity, and dysfunction in persons withcancer result from the direct and indirect effects of cancer or its treatment. Thecommon complications of HNC and its treatment which require physiotherapyassessment and rehabilitation are as follows:

Some degree of weakness can be elicited in mostpatients on the side of the neck dissection. The spinal accessory nerve may beentirely spared or subject to neurapraxic, axonotmetic, or neurotmetic insult, allwith different rates and degrees of recovery.[13,41] Additionally, electrocautery ofblood vessels can undermine blood supply to the vasanervorum, producingischemic injury.[42] Specific deficits may include a painful shoulder, trapeziusmuscle paralysis resulting in a rotated scapula, and loss of range in the shoulder.

Martin et al.[43] assessed the scapular flip sign 20 subjects (13 male, 7 female)presented with pain and decreased shoulder function following head and necksurgery or posttrauma and found the symptoms, including trapezius atrophy,shoulder girdle depression, limited active shoulder abduction to less than 90°,shoulder pain, and shoulder weakness.

20



Cervical contracture

The timing and intensity of rehabilitation should be guided by patient's prognosisfor recovery.[44] Spinal accessory nerve reinnervation can continue over 12months following surgery. Important ements of spinal accessory nerverehabilitation include the following[45]:

Prevention of frozen shoulder through active ROM and activeassistedROM;Prevention of anterior chest wall flexibility deficits through trunk mobilityexercises;Strengthening of alternate scapular elevators and retractors[13];Instruction of compensatory techniques for activities requiring sustainedshoulder abduction and forward flexion;Neuromuscular retraining of shoulder girdle muscles;Preservation of trapezius muscle tone through electrical stimulation[14] ifreinnervation is anticipated;Postural modification and reeducation; andProviding shoulder support[12] to allow recovery of the levator scapulae.

Susan et al.[46] proved that the patients undergoing neck resection with sparing ofthe nerve may experience a return of shoulder function and that physical therapymay play a role in recovery. They explained this with a 50yearold man with ahistory of Burkitt's lymphoma presenting with right upper extremity weakness,treated in physical therapy with ROM and strengthening exercises whodemonstrated an increase in shoulder strength, ROM, and function.

Patients with complete, persistent spinal accessory nerve palsy can be fitted withan orthosis. For patients plagued by levator scapulae fatigue and spasms, a “shelf”orthosis designed to encircle the waist, and to provide a ledge on which patientscan rest their affected arms when not in use, reduces symptoms.[47]

Progressive fibrosis of the anterior and lateral cervical softtissue may be highly problematic for HNC patients, particularly those who receiveexternal beam radiation.[41] Christine et al.[48] explained the complications ofthe radiation therapy, which results in imaging findings of tissue edema followedby fibrosis, scarring, and atrophy. Complications from radiation therapy can occurmonths to years after treatment.

Proactive ROM in all planes of neck motion should be initiated as soon as safelypossible and can be continued throughout radiation therapy in the absence ofsignificant skin breakdown. Irradiated patients should perform ROM twice dailyduring the first 2 years following cancer treatment and daily thereafter. After

21



Pain

surgery, the delicate balance between flexibility[25,49,50] and wound healingmust be respected. For optimal results, patients should be taught to provideadditional stretch during endrange lateral bending or rotation by exertingadditional pressure with the contralateral hand. Stretches should be held for 5deep breaths and repeated between 5 and 10 times per session.

Isometric strengthening of the cervical extensors, and postural modifications withvisual cuing, is beneficial. Manual fibrous release techniques are indicated whenROM is restricted by robust soft tissue fibrosis or tethering of the skin tosubdermal tissues. Patients can be taught selfmassage to augment the efficacy ofROM activities. Compression garments, either off the shelf or customized, are aconvenient means of applying compression. Customcut foam pieces strategicallyinserted can achieve greater focal pressure on stubborn areas. Constant vigilancemust be maintained to ensure that friable, irradiated skin is not compromised.

Up to 60% of patients at all stages of the disease process experiencesignificant pain.[11] Most of this pain can be adequately relieved by oralanalgesics. Unrelieved pain can be a risk factor for suicide in cancer patients.[49]Multiple pain disorders may be present simultaneously in a patient. Correctdetermination of the cause or causes of pain is essential to its successfultreatment.[41]

Breivik et al.[50] found that 56% of the 5084 adult patients they contacted,suffered moderatetosevere pain at least monthly. They found that out of 573patients, 320(55%) were receiving prescriptiononly analgesics, with 192/437(40%) taking strong opioids either alone or with other drugs for cancerrelatedpain. Of those prescribed analgesics, 281 (63%) experienced breakthrough pain.In all, 396 (69%) reported painrelated difficulties with everyday activities.

Treatment of pain disorders often involves a multimodality approach that mayinclude physical or occupational therapy, medications, and interventionalprocedures.[51] Physiotherapy can include therapeutic exercises, active or passivemobilization techniques, graded and purposeful activity, relaxation, distraction,postural reeducation, positioning, mobility, TENS, heat or cold, and massagetherapy.[31] Massage for pain relief can have an effect on complex behavioralpatterns as well as the simple perception of pain, although this is mainly derivedfrom empirical work.[52] Exercises commonly increase the subject's awareness ofposture, motion patterns and breathing and are designed to heighten the patient'sperception of the areas where pain originates and are a basis for active processingof pain by the patient.[53]

22



Shoulder disability

Trismus/temporomandibular joint dysfunction

Shoulder disability refers both to impaired mobility in theshoulder joint and to pain in the shoulder region after neck dissection. This is awellknown and common morbidity,[54] leading to denervation of the trapeziusmuscle and neuropathic pain with secondary effects in the shoulder, such asadhesive capsulitis and myofascial pain in muscles around the shoulder.[20,55]

Shoulder analysis following neck reconstruction with the pectoralis majorpedicled flap (PMPF) by Moukarbel et al.[56] showed a significantly reducedflexion angle (P = 0.043) and combined internal/external rotation angle on theoperated side (P = 0.027) and a significant strength reduction for the flexion,external rotation, and adduction domains (P < 0.05). SPADI score analysisshowed a significantly higher disability score (P = 0.017) and total score (P =0.009) on the PMPF side.

This leads to problems in daily activities and a reduced QOL.[24] Lauchlan et al.,[57] found while investigating the impact of preventative rehabilitation to preventshoulder disability in HNC population that out of 32 subjects, the patientsreceived a course of early physiotherapy for a period of 3 months followingsurgery rated their physical wellbeing higher than those subjects not undergoingrehabilitation.

The temporomandibular joint(TMJ) dysfunction includes fibrosis[58] due to radiotherapy, scarring, weaknessand atrophy of the muscles producing the movements after surgery, and intraarticular damage due to radiotherapy and surgery, which leads to the stiffness ofthe joint. So the patients may feel difficult in the mouth opening, mastication, andspeech.[58,59] Other problems include headaches, usually at the temples and sideof head, vague tooth soreness or toothaches, which often move around the mouth,pain and fatigue when eating hard or chewy foods, clicks, pops, or grinding soundin jaw joint, and cervical neck tension and pain.

Weber et al.[60] measured the maximal interincisal mouth opening (MIO) inpatients treated with surgery and radiation/chemoradiation for HNC and foundabout 50% of the patients had a limited mouth opening (<36 mm); and patientswith oropharyngeal cancer had a significant higher risk for trismus (P = 0.024)than patients with other HNCs.

The rehabilitation for preventing reduced mouth opening mainly concentrates onprograms using different jawstretchers or mouthopening exercises.[61–64]Different devices are available for jaw stretchers, such as Therabite, the TMJexerciser, and the Acute Medic jaw trainer and stretcher.[65,66] Physical therapy

23



Fatigue

can help relax the muscles, increase joint flexibility, and the other oromotorexercises[67] The occlusal splint will help to rest and should not chew gum, bitingnails, clenching teeth together while awake, or any other nonfunctional jaw habits(eg, pencil chewing).

Diet should be fairly soft, and chewy and crunchy foods should be avoided duringtreatment. Moist heat is very helpful for the sore muscles of TMD. Jaw and neckexercises, which will help the muscles stretch. Passive joint mobilization, reeducation of the jaw movement, scar mobilisation, and strengthening exercises tothe jaw muscles play vital part after the surgery or chemoradiotherapy.[68]

Van der Molen et al.[58] compared the effects of two rehabilitation programs onpre and posttreatment MIO, and found significant decrease over time (from 50to 47 mm, respectively; P < 0.01), but not in occurrence of trismus (MIO 35 mm;from 5 to 7 patients; P = 0.70). Even the pain scores (no, mild, moderate, andsevere pain) did not vary much (P = 0.42).

Some therapies may be preventative and may begin prior to and continuethroughout treatment. For example, the patient who receives radiotherapy andchemotherapy needs oral ROM exercises to maintain movement of the lips,tongue, and jaw. Initiate these exercises prior to radiation therapy and advise thepatient to continue doing the exercises 4–6 times daily, if possible, for 5–10 mineach time throughout the course of radiation and for at least 3 months thereafter.[68]

Fatigue is the most common symptom experienced by the cancerpatients.[41] The prevalence of fatigue ranges from 70% to 100% contingent onthe type and stage of cancer and is related to whether patients are receivingantineoplastic therapy.[69–73] Fatigue reduces the energy, mental capacity,functional status, and psychologic resilience of cancer patients. Anemia hasreceived the greatest attention as a source of fatigue.[74]

Janaki et al.[75] evaluated the magnitude of fatigue in cancer patients receivingradiotherapy and its relative impact on QOL. Fatigue was present in 87.8% ofpatients initially and increased gradually over the course of radiotherapy andpeaked in the last week. There was significant reduction in the functional scores(P < 0.001) of QOL, impairment of cognitive function (P = 0.059) along withsignificant reduction of social function (P < 0.001) and global health status (P <0.001).

Rehabilitation exercises including physical and occupational therapy may be ofhelp along with mild exercises or walking to overcome fatigue.[76,77] Mild to

24



moderate exercise to help promote energy are a boost for QOL even though theymay feel tired.[78]

Dimeo et al.[78] found that all the patients experienced a clear reduction offatigue and could carry out normal daily activities again without substantiallimitations with an improvement in maximal physical performance (from 6.4 ±0.4 km/h to 7.5 ± 0.9 km/h, P < 0.05) and maximal walked distance (from 1640 ±724 m to 3300 ± 953 m, P < 0.05). Heart rate and lactate concentration by anequivalent submaximal workload (5 km/h) were significantly reduced (from 138 ±21 beats/min to 113 ± 20 beats/min, P < 0.05, and from 2.6 ± 1.4 mmol/L to 1.3 ±0.6 mmol/L, P < 0.05).

An important thing is to avoid too much rest and overexercise, which may causefatigue by using important energy stores, lack of exercise can also cause fatiguethrough physical deconditioning and deterioration. In general, patients withanemias characterized by hemoglobin lower than 8 g/dL should not participate inphysical or occupational therapy unless cleared to do so by a physician.[79,80]

Knols et al.[81] reviewed the evidences systematically from 34 randomizedclinical trials and controlled clinical trials examining the effectiveness of physicalexercise in improving the level of physical functioning and psychologicalwellbeing of cancer patients during and after medical treatment and summarizedthat cancer patients may benefit from physical exercise both during and aftertreatment. However, the specific beneficial effects of physical exercise may varyas a function of the stage of disease, the nature of the medical treatment, and thecurrent lifestyle of the patient.

Lymphedema

Because surgery, radiation, and/or chemotherapy disrupt lymphatic structures,damage soft tissue leading to scar tissue formation and fibrosis, and further affectlymphatic function, patients with HNC may be at a high risk for developingsecondary lymphedema.[82]

Deng et al.[82] found 75.3% (61 of 81) of the patients with HNC who were 3months or more posttreatment had some form of lateeffect lymphedema. Ofthose, 9.8% (6 of 61) only had external, 39.4% (24 of 61) only had internal, and50.8% (31 of 61) had both types.

Edema in the head and neck region causes a dull pain and facial disfigurement,and in extreme cases lips and eyelids can be so swollen that vision and eating isimpaired.[83] Lymphedema therapy consists of sequential manual lymphatic

25



Chemotherapyinduced neuropathy

drainage of the edematous region according to Vodder's technique.[84,85] Thiscan be combined with compression garments.[86]

Conservative therapy of lymphedema involves a twostage treatment program.[87,88] The first phase consists of skin care, manual lymphedema treatment,remedial exercises, and compression applied with multilayered bandagewrapping. The bandaging achieves high tissue pressures during exercise but lowpressures at rest.[89] Simple elevation of a lymphedematous limb reduceswelling. Patients should be instructed to avoid heat, cold, local compression orexcessive exercise of the affected arm. A specific exercise program performedonce a day is aimed at augmenting muscular contraction, enhancing lymphaticflow and joint mobility, strengthening the limb and reducing the muscle atrophy.Phase 2 (initiated immediately after phase 1) consists of compression by lowstretch elastic stockings or sleeves, skin care, remedial exercises, and repeatedmanual lymphedema treatment as necessary.

Piso et al.[85] tested a series of 10 manual lymphatic drainage, which wereinitiated and completed early after surgery in 12 cancer patients for 6 weeks andsuggested that sequential therapy of manual lymphatic drainage and compressiongarments can significantly reduce early postoperative edema after curative surgeryfor orofacial tumors.

A prescription for lowstretch garments (custom made with specific measurementas needed) worn during the day to preserve the results of manual lymphedematreatment is essential. In principle, the highest compression level (usually 40–60mmHg) tolerated by the patient is likely to be the most beneficial.[90]Compliance is essential in maintaining subsequent lymphedema reductionfollowing conservative therapy.[91,92] Psychological support and QOLimprovement program is an integral component of any treatment of lymphedema.[93]

Patients receiving specific types ofneurotoxic chemotherapeutic agents may develop peripheral neuropathy that canresult in sensory, motor, and/or autonomic deficits. While some patients’ deficitswill resolve quickly after cessation of chemotherapy, others have a persistentperipheral polyneuropathy that may impact strength, balance, and function.[94,95]

Currently, numerous drug therapies are being tested to prevent and treatchemotherapyinduced peripheral neuropathy (CIPN),[96] but rehabilitationprofessionals lack a body of evidence to guide their intervention in individualswith CIPN. Exercise and occupational therapy can restore function in extremities,

26



Swallowing difficulty

but studies of their effectiveness have mostly been done in the early treatmentphase. Exercise can also enhance balance, strength, and safety, and braces can beused to support weak muscles.[97]

Dysphagia due to the trauma to the upper aerodigestivetract during treatment of HNC is associated with aspiration with an increased riskof pneumonia[98,99] and a reduced QOL.[100] The main reasons for swallowingproblems in HNC patients after radiotherapy are thought to be reduced tonguestrength, reduced laryngeal elevation, reduced tongue base retraction duringswallowing, and fibrosis of the muscles involved in swallowing.[101,102]

Weber et al.[60] measured the MIO in patients treated with surgery andradiation/chemoradiation for HNC and found about 50% of the patients had alimited mouth opening (<36 mm). Patients with oral cancer report about problemswith opening the mouth (73%), eating (65%), drinking (73%), xerostomia (92%),speech disorders (68%), and voice (62%).

Most rehabilitation programs concentrate on maintaining tongue strength, tonguemobility, and the mobility of the larynx.[103] In the rehabilitation program, theexercises consisted of tongue mobility and stretching and the Mendelson'smaneuver (holding the larynx in its most supine position during swallowing, for2–3 s during each swallow).[104,105]

Exercise and cancer

Physical activity seems to be useful in the rehabilitation process for cancerpatients. Impaired physical capacity can be explained by several factors, such astumor toxicity and the treatment of cancer, including surgery, chemotherapy, andradiotherapy, which may induce cardiorespiratory and musculoskeletaldeconditioning.[81]

Weert et al.[106] made a 15week rehabilitation program, including individualexercise, sports, psychoeducation, and information for cancer survivors (n = 63)and found significant improvements on healthrelated QOL with effect sizesvarying from 0.38 to 0.99 RAND36 (a 36 item survey tool to assess the HealthRelated Quality of Life, created by RAND Corporation) and from –0.34 to –0.57Rotterdam Symptom Check List (RSCL), most persistent at 3month followup.Furthermore, significant improvements in exercise capacity and muscle force ofupper and lower extremities and 80% of the patients prior to start and 58% of thepatients after completion of the program indicated that they preferred the entiremultidimensional program.

27



Go to:

The role of exercise in oncologic rehabilitation programs has far been mostlylimited to physical treatment addressing specific impairments caused, by diseaseor surgery. Moreover, recent studies have shown that physical activity mayimprove both the quality of life and mood and the physical performance of cancerpatients during and after treatment.[107]

Dimeo et al.[108] observed a significant increase of physical performance(workload at the anaerobic threshold pre 61.6 ± 26 W, post 78.6 ± 31 W, P <0.0001) and reduction of global fatigue (Functional Assessment of CancerTherapy: pre 45.7 ± 13.4, post 52.6 ± 12.4, P < 0.0001; Brief fatigue inventory(BFI): pre 37.9 ± 18.3, post 31.2 ± 17.1, P < 0.001) due to the effects of anendurance and resistance exercise program on persistent cancerrelated fatigue.

Physical exercise is perhaps the most important therapeutic modality in therehabilitation management of physical disabilities.[109] Musclestrengtheningexercises may be either isometric, isotonic, or isokinetic. Isometric exercise doesnot involve joint motion, and so is prescribed for painful or unstable body parts,whereas isotonic exercise involves joint motion against variable resistance.[15]Isokinetic exercise, a most effective strengthening exercise, involves the use ofspecific devices (e.g., the Cybex apparatus) to maintain constant speed of motionindependent of the force applied.[110] Taskoriented exercises, such asambulation or training in selfcare, may improve function and safety by repetitionand prolonged therapy. Aerobic exercise has been shown to increase theperformance status in breast cancer patients treated with conventionalchemotherapy.[111–117]

Dimeo et al.[118] found significantly higher maximal physical performance atdischarge in the trained cancer patients receiving highdose chemotherapy (P =0.04). Duration of neutropenia (P = 0.01) and thrombopenia (P = 0.06), severityof diarrhea (P = 0.04), severity of pain (P = 0.01), and duration of hospitalization(P = 0.03) were reduced in the training group. They suggested that aerobicexercise can be safely carried out immediately after highdose chemotherapy andcan partially prevent loss of physical performance.

Furthermore, a reduction of treatmentrelated complications has been observed incancer patients participating in exercise programs during cancer treatment.[118]Finally, preliminary evidence suggests that regular physical activity may improveimmune function. Therefore, exercise could play a potential role ascomplementary therapy for cancer patients during and after treatment.

CONCLUSION28



Go to:

Go to:

Management of cancer appropriately focuses on prevention, early diagnosis, andcure, but following effective treatment, most cancer patients experience somephysical impairment that results in a physical disability or a handicap. As theprognosis for most types of cancers improves, it becomes more important toensure that all cancer patients regain maximum function in the broadest sense toensure return to all former roles. Multidisciplinary rehabilitation, therefore, is anintegral part of the total management of the cancer patient. The exact functionaldeficits need to be identified for each patient and proper rehabilitationinterventions should started promptly or at the same time as other treatments.

FootnotesSource of Support: Nil.

Conflict of Interest: None declared.

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Figures and Tables

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Table 1

Side effects of the disease and therapies[11] for head and neck cancer

Articles from Indian Journal of Palliative Care are provided here courtesy of WoltersKluwer Medknow Publications

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jeﬀery steinberg m.d. (neurology)neck pain. at the conclusion of her 10-week home rehabilitation...

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