1. Patient Synopsis: 65-year-old Caucasian married male with SCCA (squamous cell carcinoma) grade T2 N2b R0 M0 on the right anterior tonsillar pillar and posterior pharyngeal wall. Assessment was completed on 5/13/14 with a six-week post-treatment (surgery/radiation) follow up.
Medical Hx: History of alcohol abuse and smoking. Records report HTN, Hypertriglyceridemia, and T2 diabetes. Medications include Lipitor, Ambien, Oxycodone, and Claritin.
Swallowing Hx: Initial: adequate swallowing function with a full oral diet following surgical excision of the tumor. The MASA-C score was 196 and the FOIS score was level 7. Post-surgery Oral pain Scores reported as 23.04 for Intensity, and 23.53 for Unpleasantness. Xerostomia score was 11/80. Periotron oral dryness scores were 18, 23, and 24. The WHO scale for oral mucositis was Grade 2 indicating ulcers, soreness, and erythema. Mouth opening was 65mm (WDL). Taste sensation was reported as improving.
2. Current Swallow Function: 6-week post RAD assessment: weight loss (164.8 to 152.2 lbs.) with increasing difficulty and pain associated with swallowing and eating. MASA-C score was 176, FOIS score was 5, and oral pain measures for Intensity and Unpleasantness were each nearly doubled (78.43). Scores for Xerostomia (67/80) and oral dryness (59, 92,75) were significantly increased. Oral mucositis score was unchanged. Sore spots on the back of tongue and palate were noted. Leukoplakia patches were reported at the site of surgery. There was increased neck palpability indicating developing fibrosis. MBS revealed mild-moderate dysphagia, mild tongue weakness, reduced movement, and throat clearing. Client reports supplementing meals with nutrition shakes twice daily, and a food restriction for foods such as “tougher meats”. Mouth opening was 46mm (WDL) indicating trismus. Rehab potential is considered good but guarded. Good due to the client’s motivation, unimpaired cognition, no Hx of PNA and ability to tolerate bolus trials with minimal aspiration risk; guarded due to potential for post-rad fibrosis, Hx of smoking and ETOH abuse and psychosocial challenges.
3. Long-Term Goals
1. Will maintain a swallowing preservation program to promote ROM, efficiency, and function of the swallowing mechanism.
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Research rationale: To encourage psychosocial benefits related to empowerment and to maximize movement of the swallowing mechanism (Govender, et. al., 2017).
Setting: in clinic and at home
2. Will meet nutritional/hydration needs orally at the highest suitable diet level with no observable signs or symptoms of aspiration.
Research rationale: The swallow system is strengthened and coordinated by the action of swallowing against resistance (swallowing food). The psychosocial and health benefits of an oral diet are superior to non-oral diets (Carnaby-Mann, Crary, Schmalfuss,& Amdur, 2012; Govender, et al., 2017).
Setting: in clinic and at home
4. Short-Term Goals:
1a. Client will complete exercises with biofeedback in order to limit dysphagia-related deterioration of swallow function and muscles nutrition, and ROM with 85% compliance with (max, mod, min) modelling, verbal, visual and tactile cues.
Research rationale: Research supports the use of exercises to improve swallowing in HNC surgery-patients who receive therapy during the first 3 months post-treatment (Logemann et al., 1997) Preventative Pharyngocise swallowing programs provide cost-effective treatment to improve functional outcomes in HNC patients (Carnaby-Mann, Crary, Schmalfuss,& Amdur, 2012). Training, Education, & Enablement behavioral change techniques can improve adherence. (Govender, et al., 2017; Greco, 2018)
i. Clinician led 1. with sEMG 2. without sEMG
ii. Primary Caregiver (PCG) led 1. In clinic 2. At home
A. Clinician-led intervention with decreasing support (max, mod, min) verbal, and visual, tactile cues as mastery is gained.
B. Caregiver education and training to promote adherence outside of clinical setting.
C. Independently completing exercises at home.
Setting: formation training in clinic, then maintenance at home
Treatment tool: exercise program: falsetto, Mendelsohn, effortful swallow (no food), and jaw exercises using the Therabite with Active Band, and sEMG for all exercises but Therabite to measure effort and provide resistance.
• Falsetto: “eee” (Lateral pharyngeal wall contraction)
• Tongue-press (Suprahyoid muscles and lingual elevators, intrinsic tongue)
• Effortful Swallow (Lingual and pharyngeal muscles-suprahyoid/hyolaryngeal elevators)
• Jaw resistance/strengthening/opening; (Pterygoid and digastric)
Measurement metric/task: Chart data points for client reported adherence.
Data Collection: Chart Px-reported adherence data p/session to determine bi-monthly progress.
Treatment Context: 40 minutes Daily: 10 falsetto, 10 tongue press, 5 jaw resistance and 5 effortful swallows per 10 min cycle (4 cycles total). Complete in sequential order with a 1-minute break between cycles.
1b. Client will demonstrate a 10% decrease from baseline Xerostomia and Intensity and Unpleasantness scores by maintaining appropriate oral health techniques.
i. Will demonstrate knowledge of 6 compensatory techniques to promote adherence and psychosocial wellbeing by adequately listing and describing the benefits of 6/6 tasks in 8/10 opportunities.
ii. Will independently adhere to use of oral care techniques to reduce oral pain and xerostomia by 10% p/week.
Research rationale: Effects of radiation reduce QoL (Lazarus, 2009) and HNC patients do not commonly adhere to dysphagia exercise regimens. Strategies to increase adherence could be beneficial (Shinn et al., 2013). Training, Education, Enablement behavioral change techniques (BCTs) can improve adherence. (Govender, et al., 2017). Radiation mucositis and xerostomia can increase morbidity and reduce QoL. The above strategies can improve oral health (Radvansky, Pace, & Siddiqui, 2013). Exercises with sEMG seem to provide functional improvements for dysphagia related to HNC (Crary, Carnaby, Groher, & Helseth, 2004).
Increased/Decreased steps: Demonstrate knowledge and understanding with decreasing support (visual and tactile cues), then demonstrate the use of learned techniques independently.
Setting: i.clinic ii. home
Treatment tool: i. Education, oral review, and handouts; ii. The 6 listed oral care techniques.
Tasks: i. List and explain the benefits of: Chewing bicarbonate gum for xerostomia; Synthetic saliva to improve taste/sensation – place liquid under tongue in salivary glands; Rinsing with baking soda solution for balancing saliva PH, sucking on ice chips for mucositis; Soft toothbrush dipped in salt water to brush off oral mucosa and debris; Oral analgesic gels to ease pain. ii. Use strategies regularly outside the clinic.
Measurement metric/task: i. chart data points for listing and describing the 6 techniques over 10 sessions. ii. Track weekly Visual Analogue Scale (VAS) Oral Pain scores, and Periotron oral dryness scores.
Data Collection: After initial education and provision of take-home material, take data each session. After 10 sessions, administer VAS and Periotron to review progress toward 10% reduction.
Treatment Context: i. list techniques at the end of each clinic session. ii. perform each technique as appropriate every day at home and in the community.
2a. Will swallow foods of increasing size and consistency at the maximum appropriate diet level using Effortful Swallowing (ES) maneuvers with sEMG biofeedback with (max, mod, min) verbal, visual and tactile cues.
Research rationale: Research Supports exercises during the first 3 months post-treatment to improve swallowing in HNC patients (Logemann et al., 1997). ES increased duration of BOT-PPW contact with MM. Reduced pharyngeal residue in HNC Pts. (Lazarus et al., 2002). Training, Education, Enablement behavioral change techniques (BCTs) can improve adherence (Govender, et al., 2017).
Increased/Decreased steps: Advance through the diet hierarchy, first by size (5 then 10 ml), then by consistency (thinner to thicker), until all are tolerated with no outward signs of aspiration. A preliminary instrumental examination will determine the highest level bolus on the diet hierarchy that was safely swallowed, begin here. (Carnaby-Mann and Crary, 2008).
Treatment tool: Effortful Swallow with sEMG biofeedback
Tasks: The client will: 1) Hold the bolus in the mouth, breath quietly through the nose. 2) Swallow the bolus by pressing the tongue against the hard palate and squeezing the throat muscles. 3) Tongue pressure and throat squeeze must be maintained throughout the swallow while keeping closed mouth (Mendelsohn’s). Hold each swallow posture for 2 sec. using sEMG to track duration and effort.
Measurement metric/task: Observation of form to track number/type of corrections. Effort evidenced via sEMG.
Data Collection: Track data p/session for sEMG (duration and effort), and number and type of corrections.
Treatment Context: in clinic, goal of 40 swallows of the highest appropriate diet level bolus, held for 2 seconds.
5. Special Concerns/Considerations: Psychosocial: Fear of pain may prevent/reduce adherence. Consider caregiver burnout, provide support/training, and identify other family members/friends who can offer support. Hx of smoking and alcohol consumption present concerns over medication management (oxycodone). Consider Gabapentin as alternative pain relief (Mirabile et al., 2016). Offer Client/Caregiver education regarding poor oral health, post-radiation fibrosis, and disuse atrophy. Consider providing information on cancer management and support tools, such as the free LivingWith™ and smoking cessation Quitter’s Circle™ apps. Considerations for the potential prophylactic benefits of therapy in case the Cx returns due to the lower cure-rate for HPV negative cancers (Deschler, Moore, Smith 2014).
6. Frequency of therapy: 60 minute sessions 4 days a week based on the research indicating more frequent sessions lead to increased adherence and that the 3 months post-RAD are a window of opportunity for progress.
7. Total Duration: (tot # sessions): 6 weeks (24 sessions) with a reevaluation of progress toward goals and maintenance of home-program. Based on the exercise-based theory that physiologic change occurs between 4-6 weeks (Carnaby, 2018).
- Carnaby, G. (2018). Exercise and Dysphagia [Powerpoint slides]. Retrieved from https://webcourses.ucf.edu/courses/1297846/files/search?preview=69855142&search_term=Exercise+and+Dysphagia
- Carnaby-Mann, G., Crary, M. A. (2008). Adjunctive neuromuscular electrical stimulation for treatment-refractory dysphagia. Annals of Otology, Rhinology & Laryngology, 117, 279-287.
- 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(1), 210–219. Retrieved from https://login.ezproxy.net.ucf.edu/login?auth=shibb&url=https://search-ebscohostcom.ezproxy.net.ucf.edu/login.aspx?direct=true&db=lsdbip&AN=PREV201200382960&site=eds-live&scope=site
- Crary, M., (Mann), G. C., Groher, M., & Helseth, E. (2004). Functional Benefits of Dysphagia Therapy Using Adjunctive sEMG Biofeedback. Dysphagia, 19(3). doi:10.1007/s00455-004-0003-8
- Deschler DG, Moore MG, Smith RV, eds. (2014) Quick reference guide to TN staging of head and neck cancer and neck dissection classification, 4th ed. Alexandria, VA: American Academy of Otolaryngology–Head and Neck Surgery Foundation
- Greco, E., Simic, T., Ringash, J., Tomlinson, G., Inamoto, Y., & Martino, R. (2018). Clinical Investigation: Dysphagia Treatment for Patients With Head and Neck Cancer Undergoing Radiation Therapy: A Meta-analysis Review. International Journal of Radiation Oncology, Biology, Physics, 101, 421–444. https://doi.org/10.1016/j.ijrobp.2018.01.097
- Govender, R., Smith, C. H., Taylor, S. A., Barratt, H., & Gardner, B. (2017). Swallowing interventions for the treatment of dysphagia after head and neck cancer: A systematic review of behavioural strategies used to promote patient adherence to swallowing exercises. BMC Cancer, 17(1). doi:10.1186/s12885-016-2990-x
- Lazarus, C. L. (2009). Effects of chemoradiotherapy on voice and swallowing. Current Opinion in Otolaryngology & Head and Neck Surgery, 17(3), 172-178. doi:10.1097/moo.0b013e32832af12f
- Lazarus, C., Logemann, J. A., Song, C. W., Rademaker, A. W., & Kahrilas, P. J. (2002). Effects of Voluntary Maneuvers on Tongue Base Function for Swallowing. Folia Phoniatrica Et Logopaedica, 54(4), 171-176. doi:10.1159/000063192
- Logemann, J. A., Rademaker, A., Pauloski, B. R., Kelly, A., Stangl-Mcbreen, C., Antinoja, J., . . . Shaker, R. (2009). A Randomized Study Comparing the Shaker Exercise with Traditional Therapy: A Preliminary Study. Dysphagia, 24(4), 403-411. doi:10.1007/s00455-009-9217-0
- Mirabile, A., Airoldi, M., Ripamonti, C., Bolner, A., Murphy, B., & Russi, E. et al. (2016). Pain management in head and neck cancer patients undergoing chemo-radiotherapy: Clinical practical recommendations. Critical Reviews In Oncology/Hematology, 99, 100-106. doi: 10.1016/j.critrevonc.2015.11.010
- Radvansky, L. J., Pace, M. B., & Siddiqui, A. (2013). Prevention and management of radiation-induced dermatitis, mucositis, and xerostomia. American Journal of Health-System Pharmacy, 70(12), 1025-1032. doi:10.2146/ajhp120467
- Shinn, E. H., Basen-Engquist, K., Baum, G., Steen, S., Bauman, R. F., Morrison, W., . . . Lewin, J. S. (2013). Adherence to preventive exercises and self-reported swallowing outcomes in post-radiation head and neck cancer patients. Head & Neck, 35(12), 1707-1712. doi:10.1002/hed.23255