Page 17 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

Introduction
Figure 4 Exercises performed with the swallow exercise aid. Left: start position; middle left: chin tuck against resistance (CTAR) exercise; middle right: jaw opening against resistance (JOAR) exercise; right: effortful swallow (ES) exercise.
(long-term) functional problems. RFT policies stimulate the patient to maintain oral intake as long as possible, which prevents non-use atrophy of the swallowing muscles (36, 40, 51, 55). On the other hand, prophylactic feeding tube placement strategies have been advocated and used to prevent treatment interruption due to dehydration (56). However, with this strategy, all patients are given tube feeding. As this would likely be unnecessary in a substantial proportion of these patients, this unnecessarily increases their risk for non-use atrophy of the swallowing muscles (57-59). Both protocols thus have advantages and disadvantages and it would be beneficial if one could predict whether a reactive or prophylactic approach would be most appropriate for a given patient (i.e., personalized medicine) (60). Predictive factors for tube placement and (prolonged) dependency have been identified before (59, 61-70). These factors include radiotherapy variables, tumor, and nodal stage, and weight loss prior to treatment. However, a clinically applicable prediction model to select patients for proactive tube feeding in high-risk patients is still lacking.
Sarcopenia
Besides the currently available (predominantly clinical) parameters, new biomarkers are making their way into daily practice, and these might be of value in the risk assessment for functional loss and tube dependency specifically. Sarcopenia, loss of skeletal muscle mass and function, might be one of those relevant biomarkers related to functional loss. Recently, it was shown that sarcopenia is associated with inferior cancer treatment outcomes, also for HNC patients (71-77). Sarcopenia could also be a factor associated with functional impairment by co-causing (long-term) swallowing dysfunction, as patients suffering from sarcopenia have limited reserves with regard to muscle mass and function. Consequently, in these patients, non-use atrophy of the swallowing muscles may even sooner lead to prolonged functional impairment (78, 79). Therefore, sarcopenia might be a relevant predictive factor which can be used to select high-risk patients for (early) rehabilitation or proactive feeding tube placement.
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