Dysphagia with Head and Neck Cancer
As I have worked more and more with patients with head/neck cancer, I’ve discovered how much I like working with that population. One thing I have really learned with these patients, is they need to do SOMETHING, particularly during treatment. They need education well before treatment begins.
Many of these patients get a PEG tube prior to treatment and most just don’t feel like moving while undergoing treatment. If the patient doesn’t have a PEG tube prior to treatment it is likely they will get one during treatment.
Presenting the Research
In 2012 at the ASHA convention, Dr. Crary and Dr. Carnaby presented on a topic called pharyngocise. The results of this study were really not much of a surprise, but very interesting.
The full, free article can be found here.
The article title: “Pharyngocise”: Randomized Controlled Trial of Preventative Exercises to Maintain Muscle Structure and Swallowing Function During Head-and-Neck Chemoradiotherapy. by: Dr. Giselle Carnaby-Mann, Dr. Michael A. Crary, Dr. Ilona Schmalfuss and Dr. Robert Amdur. This article was published in the International Journal of Radiation Oncology at the above link.
This study looked at 58 patients with head and neck cancer of the oropharyngeal region. These patients were being treated with chemoradiotherapy (CRT). These patients also had no history of nonoral feeding for cancer-related illness.
The patients were split into 3 study groups including “usual care”, standardized sham treatment and pharyngocise groups.
Inclusion/Exclusion Criteria Included:
“Inclusion Criteria: – Head / neck cancer of the oropharyngeal or adjacent regions, confirmed by clinical history and exam, with positive cross sectional imaging studies and histopathological biopsy excluding other pathology. – Planned to undergo external beam radiation therapy, – No previous history of nonoral feeding for cancer related illness, – Able to undergo MRI procedures. – Physician / patient agreement to participate Exclusion Criteria: – Planned surgical intervention – Existence of a co-existing neurological or medical disorder known to cause dysphagia – Prior radiotherapy or surgery to the head / neck region that could contribute to dysphagia. – Previous swallowing therapy within four weeks of randomization”
The usual care group included treatment, if offered of supervision for feeding and precautions for safe swallowing including positioning, slow rate of feeding by the hospital SLP.
The sham group included a buccal extension maneuver that the research group calls “valchuff” (quick lip blowing, mouth opening and puffing tasks) 2 times daily with 10 reps over 4 cycles each 10 minutes and dietary modification. Therapy sessions lasted 45 minutes.
The pharyngocise group or the “standardized high-intensity swallowing therapy group” included a set of exercises: falsetto, tongue press, hard swallow and jaw resistance/strengthening using a Therabite Jaw Motion Rehabilitation System and dietary modifications. Therapy was 2 times daily with the SLP, for a max of 6 weeks (duration of CRT) including 10 reps over 4 cycles each lasting 10 minutes. Therapy sessions were 45 minutes.
All subjects received a clinical and instrumental exam of the swallow system prior to CRT.
Home Exercise Program
All patients also had a home practice program, with greater compliance with the sham group than the pharyngocise group.
Muscle loss was measured by MRI for the genioglossus, mylohyoid and hyoglossus. All groups had muscle deterioration. The genioglossus, mylohyoid and hyoglossus showed more deterioration in the usual care group with greater preservation of these 3 muscles with the pharyngocise group.
31% of patients had a reduction in MASA score (worsened) during CRT. Swallow ability deteriorated less in the pharyngocise group. All subjects consumed a normal oral diet at their baseline level. 23% (9) subjects maintained a normal diet throughout CRT. Subjects in the pharyngocise group (42%) maintained oral feeding at a greater rate than the usual care group (14%). Tube feedings received were 20% in the pharyngocise group and 30% in the usual care group.
FOIS scores declined in all subject groups, usual care group declined from a median of 7 to a median of 4, the sham group from median 7 to median 4 and pharyngocise group from a median of 7 to a median of 5.
Outcomes at 6 weeks for usual care vs. pharyngocise includes respectively:
Normal diet: 2/14 to 5/12
Nonoral feeding: 6/14 to 3/12
Functional swallowing: 2/14 to 6/12
Weight loss (>10%): 6/13 to 4/14
Salivation decline: 12/13 to 8/14
Taste decline: 10/12 to 9/14
Smell decline: 6/11 to 2/13
Any complication: 7/14 to 5/12
Results of this study: exercise helps to prevent muscle loss, decline in swallow function and decreased cost for patients with head and neck cancer. Diet modification alone results in increased nonoral feeding, increased weight loss, increased decline in taste and smell. While any exercise is good, pharyngocise demonstrated superior results as related to muscle maintenance and functional swallowing ability as there was a standardized protocol with these patients.
Remember, pharyngocise was studied and created for patients during CRT. More intense therapy will be required for patients following CRT.
Outcomes Measures for Patients with Head and Neck Cancer
Most tools for measuring outcomes for patients with head and neck cancer can be found online including:
Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). “Pharyngocise”: Randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology Biology Physics , 83, 210–219.
Research behind the MASA-C
Crary, M. A., Mann, G. D. C., & Groher, M. E. (2005). Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Archives of physical medicine and rehabilitation, 86(8), 1516-1520.
Schindler, A., Borghi, E., Tiddia, C., Ginocchio, D., Felisati, G., & Ottaviani, F. (2008). Adaptation and validation of the Italian MD Anderson dysphagia inventory (MDADI). Revue de laryngologie-otologie-rhinologie, 129(2), 97-100.
Armstrong, T. S., Mendoza, T., Gring, I., Coco, C., Cohen, M. Z., Eriksen, L., … & Cleeland, C. (2006). Validation of the MD Anderson symptom inventory brain tumor module (MDASI-BT). Journal of neuro-oncology, 80(1), 27-35.
Wang, X. S., Williams, L. A., Eng, C., Mendoza, T. R., Shah, N. A., Kirkendoll, K. J., … & Cleeland, C. S. (2010). Validation and application of a module of the MD Anderson Symptom Inventory for measuring multiple symptoms in patients with gastrointestinal cancer (the MDASI‐GI). Cancer, 116(8), 2053-2063.