Page 224 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

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Chapter 10
In Chapter 4, the swallowing, trismus and speech function ten years after chemoradiotherapy (CRT) combined with preventive swallowing rehabilitation for advanced stage HNC are described. These outcomes were also compared to previously published six-year results of the same cohort. Fourteen of the 22 patients who participated in the six-year follow-up study still were evaluable, after ten years. Although objective swallowing-related outcomes showed no deterioration (e.g., no feeding tube dependency and no pneumonia), swallowing-related quality of life slightly deteriorated over time. None of the patients had or perceived trismus. Voice and speech questionnaires showed little problems in daily life. Overall quality of life was good. We concluded that after CRT with preventive rehabilitation exercises for advanced HNC, swallowing-, trismus- and speech-related outcomes moderately deteriorated from six- to ten- years, with all patients maintaining full oral intake and an on average good overall quality of life.
Chapter 5 describes the functional limitations, including dysphagia, trismus, and speech problems, within the first year after radiation-based treatment for advanced stage oropharyngeal carcinoma. This cohort includes patients from the implementation of a dedicated rehabilitation program (2013) until 2019, and therefore the study also facilitates the evaluation of implementation of such a program in clinical practice. Accrual increased from 19% in 2013 to 85% in 2018, with a slight decrease to 79% in 2019. Objective and patient-perceived function deteriorated until six months and improved until twelve months after treatment, but did not return to baseline levels with 25%, 20% and 58% of the patients with respect to objective dysphagia, trismus and speech problems, respectively. Feeding tube dependency and pneumonia prevalence were low. From these results, we concluded that a substantial proportion of patients still experience functional limitations at one-year post radiation-based treatment for OPC, suggesting room for improvement of the current rehabilitation program. Results also showed that pretreatment sarcopenia seems to be associated with worse functional outcomes and that this issue might therefore be a relevant target for rehabilitation strategies.
Swallowing-muscle strength exercises with or without progressive load, are effective in restoring swallowing function. For performing the most likely effective exercises with progressive load, earlier, a tool called the Swallow Exercise Aid (SEA) was developed in our institute. For these exercises, including those with the SEA, precise knowledge on which muscles are activated is lacking. This knowledge could aid in optimizing the training program to target the relevant swallowing muscles, if necessary. In Chapter 6, the MRI assessment of swallowing muscle activation with the SEA exercises (i.e., chin tuck against resistance, jaw opening against resistance and effortful swallow) and with conventional exercises (i.e., conventional effortful swallow, Shaker (head lift in supine position) and Masako (effortful swallow with tongue protrusion)) is described. Three healthy volunteers performed the exercises in supine position inside an MRI scanner. Fast muscle-functional MRI scans (generating quantitative T2-maps) were made immediately before and after the exercises. Median T2-values at rest and after exercise were compared to identify activated muscles. We conclude that the conventional exercises activate the suprahyoid, infrahyoid, and sternocleidomastoid muscles. During the SEA exercises, these muscles are also activated as well as the lateral pterygoid muscles, the