Page 13 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

low correlation between objective measures of swallowing function, and subjective/patient- reported swallowing outcomes, suggesting the need for an objective measure that better captures swallowing function in daily life (37, 38). The objective methods mainly measure the physical functions needed for swallowing, and thus for eating and drinking, such as the (safe) transportation of the food bolus to the esophagus. Patient-reported or subjective measures, on the other hand, measure the perceived swallowing (dis)ability and its impact on daily functioning. This perception is an expression of performance in daily life which relates not only to physical function, but also the level of adaptation to any dysfunction. In addition, patient- reported outcomes also reflect the perceived level of (dis)ability which may differ regardless of underlying function. Thus, to fully understand an individual’s swallowing problem, assessment of swallowing capacity - reflecting both function and the ability to adapt to possible dysfunction - in addition to function and perception is important. An objective measurement tool for swallowing capacity would be very helpful for identifying discrepancies and/or interactions between an individual’s physical functions, capacity, and perception and could help to guide the choice of rehabilitation interventions (40). Also, the assessment of swallowing capacity, in addition to function and perception, can help evaluate the effectiveness of swallowing rehabilitation over time. However, few tests are available for this purpose, and none of these tests includes the full range of consistencies used in daily life.
Minimizing functional loss
Considerable efforts have been put into reducing functional losses after HNC treatment. First, (organ-preserving) HNC treatment nowadays is more targeted and precise than in the early years of its conception. With the introduction of Intensity Modulated RT (IMRT) and Volumetric Modulated Arc Therapy (VMAT), it became technically possible to reduce the radiotherapy dose on functional structures adjacent to the tumor, including salivary glands and swallowing muscles (30, 31).
Second, efforts have been put into the development of rehabilitation programs to treat and, better yet, prevent the aforementioned functional losses. Numerous exercises and maneuvers are available targeting different aspects of the swallowing and mouth opening function (29). In the Netherlands Cancer Institute – Antoni van Leeuwenhoek (NKI-AVL) exercises such as jaw range of motion exercises (using tongue spatulas or the TheraBite® Jaw Motion rehabilitation SystemTM (Atos Medical AB, Hörby, Sweden)), the effortful swallow, Shaker (head raise) exercise, super-supraglottic swallow, Mendelsohn maneuver, and Masako (tongue hold) maneuver are traditionally used in daily practice. Depending on the etiology and degree/severity of the functional impairment, different exercises can be used to train and optimize function. The Shaker exercise, for example, targets the suprahyoid muscle to increase laryngeal elevation (29, 32). The super-supraglottic swallow helps to improve airway closure to prevent aspiration, but also seem to improve tongue strength (33, 34). In the MD Anderson Swallowing Boot Camp Program, an individualized choice of swallowing exercises is combined with taking foods with increasing difficulty with regard to texture and viscosity.
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Introduction
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