Physical Therapy Challenges in Head and Neck Cancer

A Narrative Review on Pain Management in Head and Neck Cancer: Integrating Multimodal Analgesia and Interventional Procedures

Surgical interventions and radiotherapy for head and neck cancer frequently result in substantial instances of acute and chronic discomfort. Optimizing pain management techniques stands as a pivotal factor in enhancing the well-being and overall quality of life for patients. This comprehensive review discusses various pain conditions encountered after head and neck cancer and explores a multidimensional approach to pain management. The review highlights the significance of incorporating multimodal analgesia, physical therapy, psychological support, palliative care, and emerging techniques including nerve blocks to achieve efficacious pain control. Such an endeavor necessitates cooperation among head and neck surgeons, radiotherapists, and pain specialists.

Role of Prehabilitation and Rehabilitation on Functional Recovery and Quality of Life in Thyroid Cancer Patients: A Comprehensive Review

BACKGROUND

This narrative review aims to provide a comprehensive overview of the current prehabilitation and rehabilitation strategies for thyroid cancer survivors to optimize functional outcomes and enhance their quality of life.

METHODS

The review follows the SANRA quality criteria and includes an extensive literature search conducted in PubMed/Medline, Web of Science, and Scopus.

RESULTS

The review emphasizes the role of a comprehensive rehabilitation approach in targeting the different domains that generate disability in thyroid cancer patients. In this context, physical activity, range of motion exercises, myofascial release, joint mobilization, and postural exercises are crucial for improving functional outcomes and reducing treatment-related discomfort and disability. Moreover, tailored rehabilitative management addressing dysphonia and dysphagia might have a positive impact on the quality of life of these patients. Despite these considerations, several barriers still affect the implementation of a multimodal rehabilitative approach in common clinical practice. Thus, sustainable and effective strategies like digital innovation and patient-centered approaches are strongly needed in order to implement the rehabilitative treatment framework of these subjects.

CONCLUSIONS

This narrative review provides valuable insights into the current prehabilitation and rehabilitation strategies to treat thyroid cancer survivors, addressing physical, psychological, and vocational needs to optimize functional outcomes and enhance their quality of life.

Effect of Oral Exercise on Trismus after Oral Cancer Radiotherapy: A Quasi-Experimental Study

Trismus is a severe complication of oral cancer treatment. Oral exercise is a potentially helpful approach for preventing or improving trismus. The study aimed to test the efficacy of an oral exercise for enhancing the maximum inter-incisal opening (MIO) in patients undergoing surgery and radiotherapy for oral cancer. This is a quasi-experimental study. A sample of 69 oral cancer patients completed the study, with 35 in the control group and 34 in the intervention group. Intervention subjects were asked to perform three 20-min oral exercise sessions per day for six months. Data on oral exercise practicing time, MIO, and mandibular function impairment were collected at the last radiotherapy exposure (T1), three months (T2), and six months (T3) after the radiotherapy. At T3, the intervention group exercised 217.1 min (95%CI: 107.4~326.7) more than the control group. The generalized estimation equations showed a statistically significant group-by-time interaction in MIO. The change in MIO score from T1 to T3, as indicated by the regression slope, was 2.5 mm (95%CI: 0.4~4.6) greater in the intervention group than in the control group. The results support the efficacy of the study intervention for improving patient exercise adherence and MIO.

A Scoping Review of Physiotherapeutic Interventions for Trismus in Head and Neck Cancer: Where Is the Manual Therapy?

Purpose: Trismus, or restricted mouth opening, is a common side effect of treatment for head and neck cancer. This scoping review examined the characteristics, extent, and nature of existing research on manual therapy and jaw-mobilizing devices to prevent and manage trismus related to head and neck cancer. Method: Six electronic databases were searched using the terms trismus, head and neck cancer, and physical therapy and the associated MeSH terms. The review focused on the factors related to intervention delivery: timing, adherence, completion rates, and adverse events. Results: Nine studies were included. Eight examined the use of a jaw-mobilizing device, and one explored the benefit of remote telephone support. Two studies involved cancer survivors at risk of trismus, five involved survivors with trismus, and two included survivors both with and at risk of trismus. No studies were found examining physiotherapist provision of manual therapy. Within-group comparisons supported the benefit of using a jaw-mobilizing device to manage trismus, whereas significant between-groups differences were found only in non-randomized controlled trials. Survivor symptoms and intervention burden were reported reasons for poor adherence and completion rates. Conclusions: No benefit was found for the use of jaw-mobilizing devices for the prevention of trismus. Given the potential of manual therapy to enhance outcomes, physical therapist-led research is warranted.

Role of Manual Therapy for Neck Pain and Quality of Life in Head and Neck Cancer Survivors: A Systematic Review

Background:

Pain is the one the most dreadful side effects of head and neck cancers and cancer related treatments affecting patients during and after the treatment adding to the problems affecting their ability to speak, swallow, breath and feeding. Manual therapy is standard set of physiotherapy treatments used for alleviating neck pain. It has found to be effective in small subset of cancer patients for relieving pain.

Objectives:

To highlight the use of various manual therapy techniques focusing in decreasing neck pain and improving quality of life in Head and Neck Cancer survivors that may suggest its safe utilisation in oncology rehabilitation.

Materials and Methods:

Electronic search was conducted in PubMed, Google Scholar, CINAHL, Pedro, and COCHRANE databases. Reference lists of the included studies and relevant reviews were manually searched. Studies that met the inclusion criteria were evaluated using McMaster critical review form for quantitative studies. A descriptive synthesis was undertaken due to the heterogeneity of the included studies.

Results:

Seven studies were assessed for risk of bias that comprised of three clinical trials, one case series and three case reports that applied Maitland’s mobilisation, Myofascial release, Muscle Energy Techniques to head and neck cancer survivors in various clinical settings. The outcomes highlighted decrease in pain, improvement in cervical range of motion and quality of life.

Conclusion:

This review recommends application of manual therapy to head and neck cancer survivors. However, authors caution application of manual therapy in terms of choosing a particular technique. Further, well designed larger sample size with randomisation and double blinding would help to generate better evidence for head and neck cancer survivors.

Effect of Physical Therapy Modalities on Quality of Life of Head and Neck Cancer Survivors: A Systematic Review with Meta-Analysis

The objective was to describe the effectiveness of different physical therapy modalities to improve Quality of Life (QoL) in Head and Neck Cancer (HNC) survivors. PubMed, Scopus, Web of Science, CINAHL and Cochrane Library were searched for randomized clinical controlled trials published until 30 April 2020. Risk of bias assessment and meta-analysis were conducted using the Cochrane tools. A total of 251 records were retrieved, and 10 met the inclusion criteria. Interventions whose parameters focus on a 12-week exercise programs of aerobic activity (walking) or Progressive Resistance Training (PRT) for the whole body are effective and safe modalities improving QoL in HNC survivors. Electrophysical agents did not show significant results between groups. As for the assessment of methodological quality, 4 of the 10 articles included had a high risk of overall bias. Only five articles provided sufficient information to conduct a meta-analysis for exercise program intervention on QoL, showing a tendency in favor of intervention group, even when the global results did not show statistically significant improvements (pooled Cohen's d 0.15; 95% CI: -0.25 to 0.54; I² 45.87%; p heterogeneity = 0.10). The present review and meta-analysis identified meaningful benefits of exercise on QoL of HNC survivors; this has been confirmed in a meta-analysis. This review adds evidence supporting exercise interventions on Head and Neck Cancer population whose opportunities for successful recovery after medical treatment are more limited.

Autologous fat grafting in the face and neck: Multinational trends and knowledge of the safety, applications, and indications considering oncologic risk potential

BACKGROUND

Autologous fat grafting (AFG) is evolving in both aesthetic and reconstructive applications, since the body of evidence for its use has expanded. The earliest controversies were evident in lipofilling for oncological breast reconstruction, and to this day, some countries do not allow it for fear of inducing tumourigenesis in an oncologically ablated field.

METHODS

We sought to review contemporary harvesting and processing techniques for AFG in the craniofacial region, therefore distributed a survey to evaluate the clinical impact of oncological risk across four European countries.

RESULTS

We found no significant geographical differences between the German-speaking and the English groups concerning their harvesting and processing technique. Half of our respondents discuss the possibility of pro-oncologic behavior of AFG.

CONCLUSION

AFG harvesting and processing techniques do not considerably vary by geography. Further studies should evaluate oncologic risk potential of AFG in head and neck tumor sites, especially because there is no excellent article regarding this phenomenon.Level of Evidence: V.

Long-term neck and shoulder function among survivors of oropharyngeal squamous cell carcinoma treated with chemoradiation as assessed with the neck dissection impairment index

BACKGROUND

Of interest is the long-term neck and shoulder impairment of patients treated with primary chemoradiotherapy (CRT). This is important for counseling patients regarding treatment decisions when discussing primary CRT.

METHODS

A cross-sectional study to identify factors that contribute to neck and shoulder dysfunction in patients treated with primary CRT. We utilized the neck dissection impairment index (NDII). Eighty-seven patients treated between 2003 and 2010, who were free of disease, responded; 24 of these 87 underwent post-CRT neck dissection. Mean interval since completion of CRT was over 5 years (62.7 months). Mean age, 63.5 years, male:female 75:12.

RESULTS

Mean NDII score was 87.4 (SD 22.1, range 5-100). Multiple linear regression revealed worse NDII scores for patients with larger pre-CRT gross tumor nodal volume (GTVnodal), controlled for age, sex, body mass index (BMI), and the presence of neck dissection (p = 0.02). There were significant associations with increasing GTVnodal and "low" scores for components of the NDII that assessed neck pain (p = 0.02), neck stiffness (p = 0.01), lifting heavy objects (p = 0.02), reaching overhead (p = 0.02), and ability to do work (p = 0.02). Physical therapy (PT) was evaluated as an "anchor" but it was prescribed "as needed." Regression revealed participation in PT was associated with higher GTVnodal, lower BMI, presence of neck dissection, and female sex (p = 0.00007).

CONCLUSION

GTVnodal was an independent predictor of neck and shoulder impairment. High GTVnodal was associated with increased pain and stiffness, and increased difficulty lifting heavy objects, reaching overhead, overall ability to perform work-related tasks and was associated with participation in post-treatment PT.

Interventions for Trismus in Head and Neck Cancer Patients: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Current treatment for head and neck cancers (HNCs) have led to an improved survival. However, the sequelae of cancer treatment often result in trismus, or reduced mouth opening. The purpose of this report is to identify interventional studies for trismus management in HNC patients.

METHODS

A search of PubMed, Embase, Cumulated Index to Nursing and Allied Health Literature, and the Cochrane Library was conducted in March 2020 for randomized controlled trials (RCTs) involving interventions for trismus for head and neck cancer within 10 years. Intervention could involve the use of an exercise regime, jaw rehabilitation device, technological device, medication or massage therapy. The primary outcome was the measurement of mouth opening.

RESULTS

Eleven RCTs involving a total of 685 patients with HNC were included. Six RCTs evaluated the effectiveness of a jaw mobilization device with exercises; there was no significant benefit of an exercise regime with a jaw mobilization device either initiated before, during or after treatment compared to no exercise. Two RCTs compared 2 intervention groups that involved exercises only, with 1 study assessing the benefit of weekly supervised physical therapy with gum chewing and another evaluating the benefit of immediate (1-2 days) versus delayed (7-10 days) initiation of exercise post-surgery; there was no significant difference between groups in either study. One RCT that recruited only patients with trismus demonstrated that an exercise regime in combination with low-level laser therapy or low-intensity ultrasound had superior results in mouth opening measurements compared to exercise alone. Two RCTs compared intervention groups with and without follow-up reminders; both studies showed a significant improvement in mouth opening measurements in groups with follow-up reminders.

CONCLUSION

This systematic review did not convey a clear consensus as to optimal intervention for trismus in HNC patients. A variety of exercise regimens and jaw rehabilitation devices appear to have comparable effectiveness. However, efforts focused on increasing adherence to a particular intervention protocol may positively impact mouth opening measures in head and neck cancer patients. Also, low-level laser therapy and low-intensity ultrasound coupled with exercise may be beneficial for patients with trismus.