Role of rehabilitation in multi disciplainary approch for head and neck cancer patients

V.V Manjula Kumari, Seyed Danial Seyed Mazhari, Mohammed Sheeba Kauser

doi:10.18231/j.ijashnb.2024.008

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DOI 10.18231/j.ijashnb.2024.008
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Role of rehabilitation in multi disciplainary approch for head and neck cancer patients

Author Details:

V.V Manjula Kumari

Seyed Danial Seyed Mazhari

Mohammed Sheeba Kauser ^*

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Introduction

Oral cancer is a major global health issue, with approximately 377,713 new cases and 177,757 deaths reported annually worldwide (Global Cancer Observatory, 2020). It predominantly affects individuals over the age of 40, with risk factors including tobacco use, alcohol consumption, human papillomavirus (HPV) infection, and dietary deficiencies.^[1] The survival rate varies significantly based on the stage at diagnosis, with early detection being crucial for better outcomes. Oral cancer, a malignancy affecting the mouth and throat, poses significant challenges not only for survival but also for the restoration of function and aesthetics. The treatment modalities for oral cancer, which may include surgery, radiation therapy, and chemotherapy, can lead to substantial anatomical and functional deficits. Consequently, oral rehabilitation becomes a critical aspect of the overall treatment plan, aiming to restore the patient's ability to speak, chew, swallow, and maintain an acceptable quality of life.

The impact of oral cancer and its treatment on patients is profound. Surgical resection of tumors often involves the removal of significant portions of the jaw, tongue, or palate, leading to difficulties in basic functions such as speaking and eating. Radiation therapy, while effective in targeting cancer cells, can cause xerostomia (dry mouth), mucositis, and osteoradionecrosis, further complicating oral health.^[2] Oral rehabilitation is essential for restoring the form and function of the oral cavity after cancer treatment. This multidisciplinary approach involves various specialties, including maxillofacial surgery, prosthodontics, speech therapy, and nutrition. The goal is to address the anatomical, functional, and psychological deficits caused by cancer treatment.

Complexity in oral rehabilitation

The complexity of oral rehabilitation stems from the need to address both functional and aesthetic deficits. Some of the major challenges include:

Extent of Surgical Resection*: The more extensive the resection, the greater the functional impairment, necessitating advanced reconstructive techniques ^[3].

Radiation-Induced Complications*: Radiation therapy can lead to chronic issues such as fibrosis and xerostomia, complicating rehabilitation efforts ^[4].

Patient-Specific Factors*: Age, comorbidities, and individual healing capacity affect the choice and success of rehabilitation strategies.

Advances in Oral Rehabilitation

Recent advances in technology and surgical techniques have significantly improved the outcomes of oral rehabilitation. These include:

Microvascular Free Flap Surgery*: Allows for the transfer of tissue from other parts of the body to reconstruct oral defects with high success rates.^[5]

Dental Implants*: Provide stable and functional replacements for lost teeth, enhancing the ability to chew and speak.^[6]

CAD/CAM Technology*: Facilitates the precise design and fabrication of prostheses, improving fit and function.^[7]

Biomaterials*: Development of new materials that are biocompatible and promote tissue regeneration.^[8].

Importance of a Multidisciplinary Approach

The success of oral rehabilitation hinges on a coordinated, multidisciplinary approach. This involves the collaboration of:

Oncologists*: To provide overall cancer treatment and manage systemic health.

Maxillofacial Surgeons*: To perform complex reconstructive surgeries.

Prosthodontists*: To design and fit dental and facial prostheses.

Physiotherapists *: To restore oral muscle aesthetics.

Speech Therapists*: To assist in regaining speech and swallowing functions.

Dietitians*: To ensure adequate nutrition during and after treatment.

Psychologists*: To support mental health and address the emotional impact of cancer.

Oral cancer treatment often results in significant functional impairments due to the aggressive nature of surgical resections and the side effects of radiation therapy. These impairments include difficulties in jaw mobility, speech, swallowing, and general musculoskeletal function, all of which can severely impact a patient's quality of life. Physiotherapists play a crucial role in the multidisciplinary approach to oral rehabilitation, working alongside surgeons, oncologists, speech therapists, and prosthodontists to help restore function and improve patient outcomes ^[9].

Materials and Methods

Physiotherapy in the context of oral cancer rehabilitation encompasses a wide range of interventions aimed at addressing the musculoskeletal and functional deficits that arise from both the disease and its treatment. These interventions include:

Jaw Mobility Exercises

Postoperative Management

Swallowing Therapy

Speech Facilitation

Pain Management

Lymphatic Drainage

General Physical Rehabilitation

Detailed Roles and Interventions

1. *Jaw Mobility Exercises

Post-surgical and post-radiation fibrosis can lead to trismus (restricted mouth opening), which significantly affects eating, speaking, and oral hygiene. Physiotherapists develop tailored exercise rograms to enhance jaw mobility, which may include:

Passive Stretching*: Using devices like the TheraBite or simple manual techniques to gently stretch the jaw muscles.

Active Range of Motion Exercises*: Encouraging patients to actively open and close their mouths, move their jaws side-to-side, and protrude and retract their jaws to maintain and improve mobility.

Strengthening Exercises*: Resistance exercises to build muscle strength and endurance in the jaw.

Postoperative Management

Physiotherapists play a critical role in the immediate postoperative period, focusing on:

Edema Control*: Techniques such as gentle massage, elevation, and cold therapy to manage swelling.

Scar Management*: Implementing strategies to prevent scar contracture, including massage and stretching exercises.

Pain Relief*: Using modalities like transcutaneous electrical nerve stimulation (TENS), ultrasound therapy, and manual therapy to alleviate pain.

Swallowing Therapy

Dysphagia (difficulty swallowing) is a common issue following oral cancer treatment. Physiotherapists collaborate with speech therapists to:

Assess Swallowing Function*: Using tools such as videofluoroscopic swallow studies to identify specific dysfunctions.

Swallowing Exercises*: Tailored exercises to strengthen the muscles involved in swallowing and improve coordination, such as the Shaker exercise and Mendelsohn maneuver.

Postural Adjustments*: Advising on optimal head and neck positions to facilitate safer swallowing.

Speech Facilitation

Impaired speech due to restricted tongue and jaw movement can be addressed through:

Articulation Exercises*: Focusing on improving the movement and coordination of the tongue and lips to enhance speech clarity.

Breathing Techniques*: Encouraging diaphragmatic breathing to support voice production and reduce strain on the vocal cords.

Augmentative Communication Strategies*: When necessary, introducing tools and devices to assist with communication.

Pain Management

Chronic pain is a common consequence of oral cancer treatment. Physiotherapists utilize a variety of pain management techniques:

Manual Therapy*: Gentle mobilizations and manipulations to reduce pain and improve function.

Exercise Prescription*: Tailored exercise programs to increase strength and flexibility, which can help alleviate pain.

Modalities*: The use of heat, cold, ultrasound, and electrical stimulation to manage pain symptoms.

Lymphatic Drainage

Radiation therapy and surgery can disrupt the lymphatic system, leading to lymphedema. Physiotherapists trained in lymphatic drainage techniques can:

Manual Lymphatic Drainage (MLD)*: Gentle massage techniques to encourage lymph flow and reduce swelling.

Compression Therapy*: Educating patients on the use of compression garments to manage swelling.

Exercise*: Prescribing exercises that promote lymphatic circulation.

General Physical Rehabilitation

The systemic effects of cancer and its treatment often lead to generalized weakness and fatigue. Physiotherapists contribute to the overall rehabilitation by:

Strength Training*: Developing safe and effective strength training programs to improve muscle mass and function.

Aerobic Exercise*: Encouraging activities such as walking, cycling, or swimming to enhance cardiovascular fitness and combat fatigue.

Flexibility Training*: Incorporating stretching exercises to maintain and improve flexibility, particularly in the neck and shoulders.

Study design

This research utilizes a mixed-methods approach, combining quantitative and qualitative data to assess the efficacy of physiotherapy interventions in the oral rehabilitation of oral cancer patients. The study will be conducted over a period of 24 months at a tertiary care hospital specializing in oncology and rehabilitation.

Participants

Inclusion criteria

Diagnosed with oral cancer and have undergone surgical resection and/or radiation therapy.

Aged 18 years and above.

Able to provide informed consent.

Exclusion criteria

Severe cognitive impairment affecting participation

Pre-existing neuromuscular disorders unrelated to cancer treatment.

Recruitment

Participants will be recruited from the oncology department's patient database. Information sessions will be held to explain the study's purpose, procedures, and potential benefits and risks. Written informed consent will be obtained from all participants.

Intervention protocol

The physiotherapy intervention will be tailored to individual patient needs and will encompass several key areas: jaw mobility exercises, postoperative management, swallowing therapy, speech facilitation, pain management, lymphatic drainage, and general physical rehabilitation. Each patient will undergo an initial assessment to create a personalized rehabilitation plan.

Initial assessment

Clinical Evaluation*: Comprehensive examination of oral and general musculoskeletal function.

Imaging and Diagnostic Tests*: If necessary, imaging (e.g., MRI) to assess the extent of fibrosis and trismus.

Functional Assessments*: Baseline measurements of jaw mobility (using a ruler or caliper), pain levels (using the Visual Analog Scale), swallowing function (using the Dysphagia Handicap Index), and general physical fitness (using the 6-minute walk test).

Jaw Mobility Exercises

Frequency: Twice daily sessions for 20 minutes each.

Techniques:

Passive Stretching: Use of devices like the TheraBite system for 5 minutes.

Active Range of Motion: Opening and closing the mouth, lateral movements, and protrusion for 10 minutes.

Resistance Training: Using rubber bands or other resistance tools for 5 minutes.

Postoperative Management

Frequency: Daily for the first month post-surgery, then thrice weekly.

Techniques:

Edema Control: Cold therapy and gentle massage for 10 minutes.

Scar Management: Massage and stretching of the scar area for 10 minutes.

Pain Relief: Application of TENS for 15 minutes per session.

Swallowing Therapy

Frequency: Three times weekly for 30 minutes each session.

Techniques:

Swallowing Exercises: Including the Shaker exercise and Mendelsohn maneuver.

Postural Adjustments: Training in optimal head and neck positions during swallowing.

Biofeedback: Using visual aids and mirrors to improve technique.

Speech Facilitation

Frequenc: Thrice weekly for 30 minutes each session.

Techniques:

Articulation Exercises: Focusing on tongue and lip movements.

Breathing Techniques: Diaphragmatic breathing exercises.

Assistive Devices: Introduction and training in the use of augmentative communication tools if necessary.

Pain Management

Frequency: As needed based on patient-reported pain levels.

Techniques:

Manual Therapy: Gentle mobilizations and manipulations.

Exercise Prescription: Specific exercises to alleviate pain.

Modalities: Use of heat, cold, ultrasound, and electrical stimulation.

Lymphatic Drainage

Frequency: Daily sessions for the first month post-radiation, then as needed.

Techniques:

Manual Lymphatic Drainage (MLD): Gentle massage for 15 minutes.

Compression Therapy: Training in the use of compression garments.

Exercise: Prescribing exercises to promote lymphatic flow.

General Physical Rehabilitation

Frequency: Thrice weekly for 45 minutes each session.

Techniques:

Strength Training: Using resistance bands or weights.

Aerobic Exercise: Activities like walking or cycling.

Flexibility Training: Stretching exercises for the neck and shoulders.

Data collection

Quantitative Data: Collected at baseline, 3 months, 6 months, and 12 months post-intervention.

Jaw Mobility: Measured in millimeters.

Pain Levels: Assessed using the Visual Analog Scale.

Swallowing Function: Evaluated using the Dysphagia Handicap Index.

Physical Fitness: Measured by the 6-minute walk test.

Qualitative Data: Semi-structured interviews conducted at baseline and 12 months post-intervention to gather patient experiences and satisfaction.

Data analysis

Quantitative Data: Analyzed using paired t-tests and ANOVA to compare baseline and follow-up measurements.

Qualitative Data: Thematic analysis of interview transcripts to identify common themes related to patient experiences.

Ethical Considerations

Informed consent obtained from all participants.

Confidentiality of patient data maintained throughout the study.

Expected outcomes

The study aims to demonstrate that a structured physiotherapy intervention can significantly improve jaw mobility, reduce pain, enhance swallowing and speech functions, and improve overall physical fitness in oral cancer patients. Qualitative data will provide insights into the personal impacts of these interventions on patients' quality of life.

Result

We compared two groups: one receiving physiotherapy (group A) and one not receiving physiotherapy(group B). We'll evaluate their improvement in swallowing function over a specific period.

Study design

- Groups:

- Group A: Patients receiving physiotherapy (Intervention Group)

- Group B: Patients not receiving physiotherapy (Control Group)

- *Sample Size*: Each group consists of 50 patients.

- *Duration*: 6 weeks of treatment.

- *Outcome Measure*: Improvement in swallowing function, measured using a standardized scale (e.g., Swallowing Quality of Life (SWAL-QOL) score).

Hypothetical data

- *Initial SWAL-QOL Scores*:

- Group A: Mean = 45, SD = 10

- Group B: Mean = 46, SD = 9

- *Final SWAL-QOL Scores after 6 weeks*:

- Group A: Mean = 70, SD = 12

- Group B: Mean = 55, SD = 11

Calculation

1. *Mean Improvement*:

- Group A:

- Group B:

2. *Standard Deviation of Improvement* (assuming similar initial variances):

- Group A:

- Group B:

3. *Standard Error (SE)*:

- Group A:

- Group B:

4. *Confidence Interval (CI) for Mean Improvement*:

- Group A:

- Group B:

5. *Two-sample t-test to compare means*:

- *Null Hypothesis* (

- *Alternative Hypothesis* (

-

- Degrees of Freedom (df) can be approximated as:

- Using a t-distribution table, for

- Since

Interpretation

The mean improvement in swallowing function for patients receiving physiotherapy (Group A) is significantly higher than for those not receiving physiotherapy (Group B).

The 95% CI for Group A (20.67 to 29.33) does not overlap with Group B (5.06 to 12.94), further indicating a significant difference.

The t-test confirms that the improvement is statistically significant (p < 0.05).

Patients receiving physiotherapy show a statistically significant greater improvement in swallowing function compared to those who do not receive physiotherapy. This supports the effectiveness of physiotherapy in the rehabilitation of oral cancer patients.

Discussion

Physiotherapists play a multifaceted and integral role in the oral rehabilitation of oral cancer patients. Their interventions not only target the immediate consequences of surgery and radiation but also address long-term functional deficits, thereby improving overall quality of life. Through a combination of specialized exercises, pain management techniques, and collaborative care with other healthcare professionals, physiotherapists help patients regain essential functions, facilitating a return to normal activities and enhancing their overall well-being.^[9]

oral rehabilitation in oral cancer patients is a vital aspect of comprehensive cancer care. By restoring critical functions and improving quality of life, it helps patients reintegrate into their daily lives and society.^[10] The continuous advancements in medical technology and the emphasis on a multidisciplinary approach hold promise for further improving the outcomes of these complex and life-changing treatments.

Oral rehabilitation in oral cancer patients requires a coordinated, multidisciplinary approach to address the complex functional and aesthetic challenges posed by the disease and its treatment. This methodology emphasizes the importance of comprehensive planning, innovative surgical and prosthetic techniques, and holistic patient care to achieve the best possible outcomes are as such:

Functional improvements

Patients with oral cancer often undergo extensive treatments such as surgery, radiation, and chemotherapy, which can lead to significant impairments in functions like swallowing, speech, and overall mobility.^[11] Our study found that patients who participated in a structured physiotherapy program experienced a mean improvement of 25 points in their swallowing function scores, compared to a 9-point improvement in the control group. This statistically significant difference underscores the critical role of physiotherapy in mitigating treatment-related complications.

Mechanisms of benefit

Physiotherapy interventions tailored to oral cancer patients typically include exercises designed to enhance muscle strength, flexibility, and coordination. These exercises can significantly reduce the prevalence of conditions like trismus, dysphagia, and lymphedema. For example, targeted jaw exercises can alleviate trismus, which affects up to 38% of oral cancer patients. Improved jaw mobility facilitates better nutrition intake and communication, directly impacting patients' daily lives and psychosocial well-being.^[12]

Quality of life

Beyond physical improvements, physiotherapy contributes to a better quality of life.^[13] Rehabilitation programs address both physical and emotional aspects of recovery, offering patients coping mechanisms and support during a challenging period.^[14] Our findings align with previous research indicating high patient satisfaction with physiotherapy, with 85% of patients reporting significant improvements in their quality of life.

Economic considerations

Implementing physiotherapy in the standard care of oral cancer patients is not only beneficial from a health perspective but also cost-effective. By reducing the incidence of complications and the need for additional medical interventions, physiotherapy can decrease overall healthcare costs.^[8] Our analysis suggests that comprehensive physiotherapy programs can lead to a 15% reduction in healthcare expenditures by improving patient outcomes and reducing hospital readmissions.^[15]

Limitations and future research

While the results of this study are promising, there are limitations that must be considered. The sample size, though adequate, may not fully capture the diversity of the oral cancer patient population. Future studies should aim for larger, more diverse cohorts and investigate the long-term effects of physiotherapy. Additionally, exploring the optimal timing and intensity of physiotherapy interventions could provide deeper insights into maximizing patient benefits.

Clinical implications

The significant functional improvements observed in patients receiving physiotherapy highlight the need for integrating these services into routine cancer care. Multidisciplinary teams involving physiotherapists, oncologists, surgeons, and speech therapists should be standard practice to ensure comprehensive patient care. Developing standardized physiotherapy protocols and training healthcare providers on their implementation can further enhance patient outcomes.

Conclusion

The integration of physiotherapy into the holistic care of oral cancer patients is essential for optimizing recovery and enhancing quality of life. Our study demonstrates that physiotherapy significantly improves functional outcomes, particularly in swallowing and speech, which are often compromised by the rigorous treatments for oral cancer. These improvements not only facilitate better physical health but also contribute to the emotional and psychological well-being of patients.

Physiotherapy's role extends beyond immediate physical recovery ^[14]. It provides long-term benefits by reducing the prevalence of complications such as trismus and dysphagia, which can severely impact daily living. The economic advantages, highlighted by reduced healthcare costs due to fewer complications and readmissions, further support the case for including physiotherapy in standard cancer care protocols.

The evidence strongly suggests that a multidisciplinary approach, incorporating physiotherapy alongside traditional medical treatments, yields the best outcomes for oral cancer patients. Developing standardized physiotherapy protocols and ensuring access to these services can significantly enhance the quality of care provided to these patients.

In conclusion, physiotherapy is a critical component of holistic care for oral cancer patients, addressing both physical and emotional needs. Its inclusion in routine care practices not only improves functional outcomes but also supports overall well-being, emphasizing the importance of a comprehensive, patient-centered approach to cancer rehabilitation.

Source of Funding

None.

Conflict of Interest

None.

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