Head and Neck Cancer and Exercise

Report
Approaches to Ax and Tx for the
SLP for Patients with Head and
Neck Cancer
MEGAN HYERS, MS, CCC-SLP
REBECCA SCHOB, MS, CCC-SLP
PPMC Ampitheater
March 29, 2014
Dysphagia and XRT

3 phases of Treatment
 Before
 During
 After
“Few other cancers demonstrate the need for anticipatory
Tx and rehab to the magnitude required in the
management of head and neck cancer”
(Myers, Barofsky, and Yates. 1986)
Phase 1: Evaluation before XRT

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Clinical eval of speech, voice, swallowing
establish baselines
optimize performance status
implement strategies as needed
determine need for further evaluation
Phase 1: Treatment before XRT

Patient counseling
 compare
normal aerodigestive A&P
 discuss swallow, voice production, airway management,
trach
 review short- and long-term XRT sequelae
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Swallowing
Breathing
Trismus
Mucositis
Xerostomia
Intervention for Dysphagia
Order based on muscle effort, ease of application,
ease of learning:
 postures
 sensory stimulation
 swallow maneuvers
 diet modification
Pretreatment Dysphagia Protocol

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Tongue exercises include passive range of motion and
active assistive range of motion.
Tongue Hold
Effortful Swallow
Laryngeal elevation exercises: pitch glides and
vocalizing /i/ at a high pitch.
Mendelsohn Maneuver and Shaker Exercises
Jaw range of motion exercises: maintain rotary
movements of mastication and decrease the chance of
trismus
Myofascial Release

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Start pt working on their scar tissue – ASAP once
staples removed, scabs have fallen off
Mobilizing the scar tissue may help prevent
adhesions, reduced ROM, persistent pain, more
significant effects of lymphedema
Promotes blood flow and blood vessel growth
Most benefit comes just below pain threshold
Use firm pressure, start gently and increase to
deeper massage (see handout)
Desensitization
Trismus
http://oralcancerfoundation.org/dental/trismus.htm



Persistent contraction of
the masticatory muscles
due to hypovascularity
or neural damage.
Prevalence:10%-40%
“Elevator Muscles”
 Temporalis
 Masseter
 Medial Pterygoid
 Lateral pterygoid
Trismus
http://oralcancerfoundation.org/dental/trismus.htm
Results in:
 Pain:
muscle guarding
 Limited oral opening:
 Difficulty wearing dentures
 Difficulty having dental work performed
 Difficulty with intubation for later (elective) surgeries
 Dysarthria: decreased speech intelligibility
 Dysphagia: difficulty swallowing/eating/drinking
 Reduced rotary mastication
 Can’t use spoon/fork, take bite of sandwich etc.
Trismus Therapy
Stretching Systems :
 Tongue blades (short stretch)
 Therabite or Orastretch system (7x/day, 7reps, 7
seconds or 3x/day, 5 reps, 30 seconds)
Trismus stretching systems (cont)

Dynasplint Trismus System (DTS) prolonged stretch

Current study : randomized trials using stretching system for 3-6 months
 Start
5-10 minutes, increase to 30-45 mins, 3x/day or
maximum 90 mins/day
 Once achieved, then increase tension
Trismus Therapy
Manual Treatments:
 Myofascial release
 Intra-/extra-oral palpation, stretching, massage
 Oral aperture measurements

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Female normal bite range is 35-38 mm
Normal for an adult male is 45 to 50 mm
Exercises should be continued for min: 1 year
Contraindications for Trismus
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Pain
Poor dentition
Oral aperture of <10mm
Phase 2: during XRT

short-term: get pt through XRT (tolerate and
maintain oral intake)
 compensatory
strategies, swallow maneuvers
 exercises regimen
 pain management
 desensitization therapy
 saliva substitutes
 diet changes

monitor w/subjective and objective evaluators.
Anticipate Acute Effects of XRT
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edema
dermatitis and mucositis
mild changes to loss of
taste
xerostomia
odynophagia
erythema
dysgeusia
hypersensitivity
decreased appetite
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acute changes in
swallowing occur
vocal deterioration
(hoarseness pitch
changes, vocal fatigue)
later:
stiffness and sensory loss
pain and edema
depression
Mucositis


Inflammation and ulceration of mucosal membranes
From XRT or Chemo
 If
Chemo: Usually in 4-10 days
 If XRT: 2 weeks, may last 6-8 weeks

Results in
 Pain
 Dysphagia
 Bleeding
 Infection
 Change
in taste
 Decreased appetite and PO intake
How
Development of Oral mucositis
WHO Grading of Oral mucositis
Mucositis
Stage 1 (above) Stage 3 (below)
http://www.caphosol.ca/health-care-professionals
Stage 2 (above) Stage 4 (below)
Px & Tx of Oral Mucositis
http://www.uspharmacist.com/content/s/172/c/29044

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pretreatment dental examination
improved dental hygiene
 clean
the mouth every 4 hours and at bedtime
 more often if the mucositis worsens
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use a non-detergent toothpaste
floss between the teeth
use an alcohol-free mouthwash. Use saline or
baking soda mouthwash to soothe & clean the
mouth
Tx of Oral Mucositis
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Use artificial saliva, lozenges, gum to lubricate the
mouth.
Suck ice chips
Drink at least 3L/day
Avoid citrus fruits, tomatoes, acidic foods, alcohol,
and hot foods that can aggravate mucositis lesions
Avoid hard, crunchy foods
No smoking
No alcohol
Treatments available
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Saliva substitutes
topical and oral medications
Med Oral
Oral Balance (gel)
Mouthkote (lemon based)
Salivart (oil based)
Alcohol-free toothpaste/mouthwash (biotene)
Treatment for Xerostomia
 Sip
water, ice chips
 Artificial saliva (rinse, spray)
 Suck on lozenges/candies (sugar free)
 Chew to stimulate saliva production (gum, wax, etc)
 Moisten foods
 Avoid salty, dry foods, high sugar content foods/drinks
 Avoid alcohol or caffeine, also acidic juices
 Aloe water, papya
 Netti bowl/pot, nasal saline lavage
Overall intervention techniques

Mucositis/Xerostomia:
 Oral

hydration : mist bottles, humidifier, etc
Dysgeusa/hypersensitivity
 Desensitization
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therapy: utensils, taste, texture
Diet modifications
Dysphonia
 Vocal
hygiene strategies
 Personal amplification (e.g., Chattervox)
Pureed… again?
Need variety!
Protein
powders
Nut butters
Frozen
veggies
Anything!
What can
your blender
handle?
Stress Management
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Laughter!!
Pacing and Rest (related to daily tasks and eating)
Guided meditation or relaxation
Breaking down tasks, taking breaks
Mindfulness practices
What’s energy giving (music, pets, walks, bath…)
Basic stretches and mobility
Discuss self-care, talking to someone who can just
listen
The Rule of 10
Logeman, Sisson & Wheeler, 1980
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To eat or not to eat?
oral transit time and pharyngeal transit time > 10
seconds, maintain PO but will need non-oral
supplementation
aspiration > 10% , pts eliminate consistency
coughing, choking ? at10% pts stop eating but silent
aspirators continue to eat
aspiration > 10% = non-oral feeding
When to TF?
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If PO is good, wait for the problem
if nutrition is poor before XRT, then immediate
weight loss greater than or equal to 5% in less than
or equal to 1 month or greater then or equal to
10% during XRT
Enteral Means of Nutrition
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J-tube (jejunostomy) placed between the jejunum and
surface of abdominal wall
G-tube (gastrostomy) placed in the stomach
PEG (percutaneous endoscopic gastrostomy) placed
endoscopically
PFG (percutaneous flurosopic gastostomy) placed
fluoroscopically
Dobhoff/N-G (naso-gastric) tube – place in nose and
passed to esophageus
TPN (total parenteral nutrition) nutrients administered
intravenously-bypass GI system
Why TF?
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Optimize tx tolerance
reduce complications related to poor nutrition
improve healing and recovery
increase strength and energy
enhance overall QOL
Temporary!!
Made it!!
Phase 3: After XRT
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re-eval speech and swallow when acute Sx have
resolved
one month pt follow-up
re-review effects of fibrosis
swallowing exercises protocol begins and may be
continued for at least one year (5 mins
sessions/10x/day)
evaluate and treat prn
MBSS/VFSS or FEES if needed
Up the Ante for
Dysphagia/Dysarthria Tx

When able, use Biofeedback as much as possible!
 FEES
 EMG

monitoring for swallow strengthening
 Mirror
 Tactile feedback
 Record and self-evaluate for voice
Vital Stim (Neuromuscular Electrical Stimulation)
 If okay’d by physician
 No active neoplasm
Know your resources

Prostheodontists or denturist
 Palatal

lifts, prosthesis for partial glossectomy…
Behavioral health, MSW
 Smoking
cessation
 Depression
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Nutritionist
Financial assistance
 Return
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to work
Support Groups
Clergy
Weaning from TFs
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Swallow must be safe and efficient
Consider nutritional status pre-XRT
Consider wt loss before/during XRT
Reducing TFs – MUST maintain adequate
nutrition/caloric intake and hydration
Make a plan
Pt’s frequent complaint: lack of appetite
 small frequent meals 5-7 meals /day
 carry snacks
 Goal of eating every hour
 consider what else effects appetite:
 taste
loss
 dysphagia
 Constipation, diarrhea
 reduced enjoyment
Barriers
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Mental
Anxiety about swallowing d/t past pain/difficulty
Effort (cooking time, eating time, swallowing
strategies, calorie counting, etc)
Feelings of isolation, everyone finished before me
at meals, food gets cold, not enjoyable anymore
Most difficult to rehab: one who eats only 1
meal/day, lives alone, etc
In Practice:

The Soft Skills are the most important
 Motivational
Interviewing
 Listen for the individual’s needs: emotional will likely
come before physical
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goals/motivation to eat a type of food, go out to
eat with friends, upcoming holiday meal
ID the support system and get them involved
eat first thing in the morning BEFORE TF so one has
an appetite, normal routine…
Try the scariest foods together in sessions
Lymphedema
Assessment and Treatment for the SLP
Lymphedema


Accumulation of fluid that is relatively high in
protein content
Often found in H&N Cancer following surgery or
XRT

Dx made by physician, not SLP

Why are we looking? Why is it important?
 Edema
may exacerbate dysphagia
 Negatively impacts QOL
Prevention of lymphedema
Trach tie
 should be 1 finger loose as long not moving
 can create turniquet effect lump/bump
 can induce swelling above trach tie if too tight
 if too loose, may cause coughing and pt may be
resistant
Medical Hx
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reveals clues re: lymphedema vs other edema
fluctuations in edema
onset of edema vs Tx/trauma
physical characteristics of edema
medical contraindications to Tx?
Physical limitations for implementations?
Post-XRT fibrosis of neck
Timing
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how long since surgery, xrt, chemo, or trauma?
Acute post-op edema first 30 days after surgery
CAN INTERVENE DURING this time if SEVERE
typically wait 4-6 wks after surgery or XRT (can
start 2 weeks after surgery)
common onset of lymphedema is 6-8 wks after XRT
completed
lymphedema
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Swelling usually starts most distal: lower neck, then
progresses upwards into neck, jowls, etc from scar
up. Over time.
Usually NOT painful
if it is, seek other causes
other causes of edema
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hot tub
exercise
allergy
insect bite
drug reactions
thyroid function
etc
Edema characteristics
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Soft or Firm?
Persistent or fluctuating? AM to PM, day to day
periods of resolution or exacerbation?
 Garden,
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car, airplane, heat?
Pitting vs Non-pitting?
If pitting, stage it
Edema characteristics continued
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Visual, color?
Should be approximately same as surrounding
tissue
If Dark red tissue
 may

be angiosarcoma => lymphatic mets
Physical: feverish, hot, tender
 may
be infection or metastasis
Pitting edema
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eval based on limbs
Push in gently for 5 seconds,
judge how long it takes for pit to refill
Lymphedema Classifications
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International Society of lymphology Lymph rating
scale according to Foldi
NIH lymphedema scale
lymphedema measures
Foldi Stage (0, 1, 2, 3)
MDACC stage (O, 1a, 1b, 2, 3)
Foldi Stages
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Stage 0
reported tightness or fullness but no pitting or
significant edema
may fluctuate during the day
Stage I
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Pitting edema that is
quickly reversible
No fibrosis or tissue
changes
Improves during the
day and worsens at
night
Swelling may be
temporarily reduced
with elevation
Stage 1
MD Anderson further differentiates:
 1a: visible edema you can't pit
 1b: visible edema you can pit
Stage II
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Not spontaneously reversible
Longer lasting pitting
Fibrosis – scar-like structures within tissues that cause
them to harden
Pressure may result in only slight indentation or none
No severe tissue changes, breakdown etc
Stage III: lymphostatic elephantiasis


Not typically seen in H&N
Severe tissue Changes
 Hyperkeratosis
– increased thickness of outer layer of
skin
 Papillomatosis – small solid benign tumors
 wounds
 elephantiasis

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Severe fibrosis
Cannot pit with pressure
Facial measurements
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facial circumference
submental circumference
horizontal neck circumference
Site of H&N Edema
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Face (include eyelids, upper lip, jowl etc)
Submental
Neck
Intra-oral
Suraclavicular Fossa
Unchanged from initial evalutation? PMHx?
 left,
right, bilateral, none now
Tactile evaluation: what do you
feel?
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Tissue Changes?
Thickness, heaviness
pitting
fibrosis
Lumps & Bumps?
 Recurrent
tumor
 dermal mets
 Cyst
 Soft lump, lipoma (fat deposit, soft, always ask)

If ??? Notify MD
Contraindications to Lymphedema
Tx
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Infection
Cellulitis
CHF
Cardiac Edema
Renal Failure
Acute DVT
Uncontrolled HTN
Carotid sensitivity
None
Other__________
Physical appearance
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Scarring
trap door effect
firm/rigid scar
hypertrophic scar
no effect
Determine
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General Functional status (swallow, speech, voice,
cosmesis, respiration, ROM)
Impairments related to edema vs treatment
Support system
Caregivers available to assist?
Home vs outpatient
Cognitive status, new learning ability, commitment?
Treatment
To justify Tx:
 Pt requires lymphedema Tx to soften tissues and
prevent fibrosis which may/could/can lead to
dysphagia...
If pt returns
 Pt received Tx 'x'# months ago with 'x' diet, now
following 'x' for edema..
 pt
feels with edema his/her dysphagia has increased
or
 in
AM it’s harder to swallow
Treatment options

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Manual Lymphatic Drainage (MLD)
self-MLD
Compression: applies external pressure to promote
improved mobilization of lymph
 softens
firm edema and softens skin before MLD
 prevents refilling of tissues and promotes continued
drainage via open pathways after MLD



Kinesiotape
Deep breathing for respiratory function/circulation
swallowing routine 4x/day
Who provides the treatment?


In our region: PT’s mostly
YOU can be certified:
 Next,
closet training for Eval and Management of H&N
Lymphedema is
 July
11-13, 2014
 San Francisco
 for
Complete Decongestive Therapy(CDT) Certification
 July
5-13, 2014
 Eugene, OR
Norton School may offer H &N only, IF you contact them and
express interest: www.nortonschool.com
THANK YOU!
“Far and away the best prize that life
offers is the chance to work hard at
work worth doing.”
~Thomas Jefferson (1743-1826)

http://www.lymphnotes.com/article.php/id/208/

http://www.uspharmacist.com/content/s/172/c/29044/

http://www2.mdanderson.org/depts/oncolog/articles/13/8-aug/8-13-1.html

http://www.lymphedemablog.com/2012/05/11/secondary-lymphedema-of-the-head-andneck/

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