Swallowing rehabilitation in Head and Neck cancer

Marika Muttilainen, SLP

Tampere University Hospital

ELS Workshop Helsinki 10.6.2019

The importance of swallowing

● Dysphagia is strongly associated with psychological distress, poorer quality of life, social isolation, and is a top priority concern for HNC survivors●Dysphagia can lead to malnutrition, dehydration and pulmonary issues

Wilson et al., 2011, Rhoten et al., 2018

11.6.2019

Two year prevalence of dysphagia and related outcomes in head and neck cancer survivors: An updated SEER Medicare analysis. Hutcheson et al ‐ ‐2019

11.6.2019

Two year prevalence of dysphagia and related outcomes in head and neck cancer survivors: An updated SEER Medicare analysis. Hutcheson et al ‐ ‐2019

Guidelines for swallowing rehabilitation●SLPs are core members of MDT

●Head and neck cancer (HNC) guidelines recommend regular multidisciplinary team (MDT) monitoring and early intervention to optimize dysphagia outcomes.

●The pathway provided patients with access to regular supportive care and provided staff opportunities to provide early and ongoing dysphagia monitoring and management.

● However, implementing and sustaining a HNC pathway is complex, requiring significant staff resources, financial investment, and perseverance.

Messing et al., 2018

Guidelines for swallowing rehabilitation in H&N Cancer

”Guidelines that clearly delineate standard of care dysphagia treatment are lacking and services provided to Head and Neck Cancer (HNC) patients

are not always consistent.”

Lawson et al 2017

Guidelines for swallowing rehabilitation in H&N Cancer

● Speech and swallow rehabilitation in head and neck cancer: United Kingdom National Multidisciplinary Guidelines

Clarke et al., 2016

● Framework for Speech-Language Pathology Services in Patients with Oral Cavity and Oropharyngeal Cancers.

Arrese & Hutcheson, 2018.

Dysphagia evaluation

● Patient reported outcome

SSQ, MDADI, EORT QLQ-C30+H&N35, EAT-10

● Objective measures

VFS, FEES, PAS, 100ml water swallowing test, maximal jaw opening

● Feeding status

FOIS, PSS-HN

Arrese et al., 2019

Dysphagia treatment●Rehabilitation

●Compensatory techniques

●Food texture modification

●Alternative feeding devices

●Swallowing-respiratory system training

Dysphagia treatment

Rehabilitation:

“Rehabilitative exercises are those meant to change and improve the swallowing physiology in force, speed or timing, with the goal being to produce a long-term effect /…/

Rehabilitative exercises also involve retraining the neuromuscular systems to bring about neuroplasticity, since pushing any muscular system in an intense and persistent way will bring about changes in neural innervationand patterns of movement. ”

Langmore & Pisegna 2015

Dysphagia treatment

●Rehabilitation:

Swallowing, challenging the system

Swallowing manouvers

Non-swallowing task

- lingual strength

- Shakers exercise

Dysphagia treatment

Compensatory techniques:

●Liquid washes

●Swallowing manouvers

● Chin tuck, head tilt

Dysphagia treatment

Food texture modification:

● Choosing foods that are easy to swallow

● Adding sauce, oil etc to foods

● Modified food consistencies, soft or pureed foods

● Thickening liquids

Dysphagia treatment

Alternative feeding devices:

● Glossectomy spoon

+

● Intraoral prosthetics

Dysphagia treatment

Swallowing-respiratory system training:

● Swallow- breathing cordination

● Expiratory muscle training (EMST)

Head and Neck cancer survivorshipThere are 3 phases of survivorship:

Acute survivorship starts at diagnosis and goes through to the end of initial treatment. Cancer treatment is the focus.

●Extended survivorship starts at the end of initial treatment and goes through the months after. The effects of cancer and treatment are the focus.

●Permanent survivorship is when years have passed since cancer treatment ended. There is less of a chance that the cancer may come back. Long-term effects of cancer and treatment are the focus.

●American Society of Clinical Oncology, 2019

Acute phase

Cancer treatment is the focus.

The goal for SLP: to keep the patient eating.

After surgery returning to oral diet

Eating/swallowing through (chemo)radiation

Proactive or reactive excesizes

Acute phase

After surgery returning to oral diet

Hiararchy:

-saliva management

- introducing oral feeding (safety)

- increase volume-increase complexcicity

Early training can lead to better swallowing function in tongue cancer.

Hsiang et al., 2019

Proactive swallowing excercises●Excercises are introduced before swallowing detoriation, usually first weeks in C/RT

●Goal to minimize disuse of muscles and to help maintain oral nutrition during treatment●Evidence supporting prophylactic swallow exercises for patients with head and neck cancer (HNC) has not been universally demonstrated

Proactive swallowing excercises●lingual strengthening,

● Masako maneuver,

●effortful or supraglottic swallow,

●Mendelson maneuver

● Shaker exercise.

●A TheraBite® Jaw Motion Rehabilitation System™ (www.atosmedical.com) is dispensed and instruction provided when a patient is identified as having reduced incisal opening as measured by the TheraBite® measuring device to be less than 40 mm.

●Expiratory muscle strength training (EMST) devices are utilized as part of the treatment program to improve airway clearance and airway protection in patients who are at risk for penetration and aspiration .

●Patients were encouraged to complete their prescribed exercises twice daily, 6 days a week

John Hopkins Medical Cente Greater Baltimore, Messing et al 2019

Proactive swallowing excercises

● Use it lose it- study ● MDACC retrospective review:

(n=497, pharyngeal cancers 2002-2008)

Hutcheson et al., 2013

Proactive swallowing excercises

●Mendelsohn

●Jaw/FOM stretch

●Supraglottic

●Masako

●Effortful

3 sets, 10 reps

Eat All Through (EAT) RT

● EAT diet staircase (food

hierarchy)

● Mealtime routine

M.D.Anderson Cancer Center, Texas, Hutcheson 2019

Proactive excercises● Ongoing research:

● Swallowing therapy and progressive resistance training in head and neck cancer patients undergoing radiotherapy treatment: randomized control trial protocol and preliminary data. Hajdu et al.2017

● https://clinicaltrials.gov/ct2/show/results/NCT03455608?view=results

Subacute phase

The effects of cancer and treatment are the focus.

The goal for SLP: evaluate the swallowing and rehabilitate when needed

Intensive rehabilitation

Returning to as normal as possible oral diet

Minimizing aspiration

Intensive rehabilitationMDACC Swallowing BOOT CAMP

Progressive resistive functional exercise program:

sEMG Biofeedback “device-driven”

or

MDTP

“bolus- driven”

• Home carry-over

(min 6-8 wks)

• “Mass practice”– Intensive, daily– QD or BID– 2-3 weeks• FUNCTIONAL task= swallowing• Intensifies over time = progressive,Resistive swallowing (exercise)paradigm

Intensive rehabilitationMDACC Swallowing BOOT CAMP

Late phase

Long-term effects of cancer and treatment are the focus.

The goal for SLP: help the patient to adjust to ”new normal”, evaluate when needed.

The swallowing is not likely to get better.

Few patients experience lower cranial neuropathy (median latency 8 years)

Aspiration prevention

Late dysphagia rehabilitation

Late dysphagia rehabilitation

The results showed no improvement measured in PAS.

Late dysphagia rehabilitation

Beginning a swallowing therapy program within 1 year of completion of radiotherapy demonstrates more consistent improvement in QOL and diet performance compared to later periods

Van Daele et al., 2019

11.6.2019

Two year prevalence of dysphagia and related outcomes in head and neck cancer survivors: An updated SEER Medicare analysis. Hutcheson et al ‐ ‐2019

Aspiration pneumonia after concurrent chemoradiotherapy for head and neck cancer,

Xu et al, 2014

Prevention of aspiration pneumonia

Swallow breathing cordination

Expiratory muscle training (EMST)

Oral hygiene

Swallow breathing cordination

HNC patients were trained to initiate swallows during the midexpiratory phase of quiet breathing and continue to expire after swallowing, by using visual biofeedback.

Improvements in 3 MBSImP component scores: laryngeal vestibular closure , tongue base retraction , and pharyngeal residue.

Significant improvements were also seen in PAS scores (P<.0001).

Martin-Harris et al., 2015

EMST / other resipiratory training

●Expiratory muscle strength training (Sapienza)

●Expiratory Muscle Strength Training can increase swallowing safety in HNC patients.

Hutcheson et al., 2018

Oral hygiene

A meta-analysis could only be done on 4 trials; analysis showed a significant risk reduction in pneumonia through oral care interventions

Kaneoka et al., 2017

Novel ideas

●

● Efficacy of a novel swallowing exercise program for chronic dysphagia in long term head ‐and neck cancer survivors.

Kraaijenga et al, 2017

Thank you!

References

Aggarwal, P., Zaveri, J. S., Goepfert, R. P., Shi, Q., Du, X. L., Swartz, M., . . . Hutcheson, K. A. (2018). Symptom burden associated with late lower cranial neuropathy in long-term oropharyngeal cancer SurvivorsSymptom burden associated with late lower cranial neuropathy in long-term oropharyngeal cancer SurvivorsSymptom burden associated with late lower

cranial neuropathy in long-term oropharyngeal cancer survivors. JAMA Otolaryngology–Head & Neck Surgery, 144(11), 1066-1076. doi:10.1001/jamaoto.2018.1791

Arrese, L. C., Schieve, H. J., Graham, J. M., Stephens, J. A., Carrau, R. L., & Plowman, E. K. (2019). Relationship between oral intake, patient perceived swallowing impairment, and objective videofluoroscopic measures of swallowing in patients with head and neck cancer. Head & Neck, 41(4), 1016-1023. doi:10.1002/hed.25542

Clarke, P., Radford, K., Coffey, M., & Stewart, M. (2016). Speech and swallow rehabilitation in head and neck cancer: United kingdom national multidisciplinary guidelines. The Journal of Laryngology & Otology, 130(S2), S180. doi:10.1017/S0022215116000608

Hsiang, C., Chen, A. W., Chen, C., & Chen, M. (2019). Early postoperative oral exercise improves swallowing function among patients with oral cavity cancer: A randomized controlled trial. Ear, Nose & Throat Journal, , 0145561319839822. doi:10.1177/0145561319839822

Hutcheson, K. A., Barrow, M. P., Plowman, E. K., Lai, S. Y., Fuller, C. D., Barringer, D. A., . . . Lewin, J. S. (2018). Expiratory muscle strength training for radiation-associated aspiration after head and neck cancer: A case series. The Laryngoscope, 128(5), 1044-1051. doi:10.1002/lary.26845

Hutcheson, K. A., Nurgalieva, Z., Zhao, H., Gunn, G. B., Giordano, S. H., Bhayani, M. K., . . . Lewis, C. M. (2019). Two-year prevalence of dysphagia and related outcomes in head and neck cancer survivors: An updated SEER-medicare analysis. Head & Neck, 41(2), 479-487. doi:10.1002/hed.25412

Kaneoka, A., Pisegna, J., Miloro, Lo, Saito, H., Riquelme, L., . . . Langmore, S. (2015). Prevention of healthcare-associated pneumonia with oral care in individuals without mechanical ventilation: A systematic review and meta-analysis of randomized controlled trials doi:10.1017/ice.2015.77

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Langmore, S., Pisegna, J., Krisciunas, G., Meyer, T., & Pauloski, B. (2016). A closer look at residue in the post-radiated HNC population

Lawson, N., Krisciunas, G. P., Langmore, S. E., Castellano, K., Sokoloff, W., & Hayatbakhsh, R. (2017). Comparing dysphagia therapy in head and neck cancer patients in australia with international healthcare systems.International Journal of Speech-Language Pathology, 19(2), 128-138. doi:10.3109/17549507.2016.1159334

Malandraki, G., & Hutcheson, K.,A. (2018). Intensive therapies for dysphagia: Implementation of the intensive dysphagia rehabilitation and the MD anderson swallowing boot camp approachesdoi:10.1044/persp3.SIG13.133

Martin-Harris, B., McFarland, D., Hill, E. G., Strange, C. B., Focht, K. L., Wan, Z., . . . McGrattan, K. (2015). Respiratory-swallow training in patients with head and neck cancer doi://doi-org.libproxy.tuni.fi/10.1016/j.apmr.2014.11.022

Messing, B. P., Ward, E. C., Lazarus, C., Ryniak, K., Kim, M., Silinonte, J., . . . Lee, G. (2019). Establishing a multidisciplinary head and neck clinical pathway: An implementation evaluation and audit of dysphagia-related services and outcomes. Dysphagia, 34(1), 89-104. doi:10.1007/s00455-018-9917-4

Pisegna, J., & Langmore, S. (2015). Efficacy of exercises to rehabilitate dysphagia: A critique of the literaturedoi:10.3109/17549507.2015.1024171