Oncologists, ear, nose & throat specialists and speech-language pathologists have struggled to better understand and address a disturbing side effect of chemotherapy and/or external-beam radiotherapy when they are administered to treat head and neck cancer; namely, a decline in the ability of the patient to swallow for the purposes of nutrition and hydration.
One reason for this decline is the development of deep-tissue fibrosis as a result of chemo-radiation. Increases in tissue fibrocity combined with acute radiation effects such as edema (swelling), mucositis and xerostomia (decrease in saliva production) may ultimately result in muscular disuse or atrophy, and thus a decline in the patient’s ability to swallow. This functional decline may often take up to a year to manifest itself. Unfortunately, by the time symptoms begin to emerge, the patient may well have reached a crisis point in his/her ability to obtain sufficient oral nutrition for healthy functioning. Research in response to this issue has recently focused on how best to prevent and/or minimize the effects of chemo-radiation in these patients, while continuing to explore more effective ways to maximize a return of function in patients who are already experiencing a decline in their ability to tolerate oral nutritional intake.
McNeill Dysphagia Therapy Program
Carnaby-Mann and McCrary (2008) at the Swallowing Research Laboratory of the University of Florida Health Science Center initially developed the McNeill Dysphagia Therapy Program (MDTP) as a swallowing rehabilitation program based on exercise physiology principles. MDTP is different from more traditional swallow therapy approaches in its emphasis on utilizing oral-motor and swallowing exercises primarily in the context of trial feedings. This difference in approach is based on research evidence which suggests that exercises in the absence of an actual food or liquid bolus generally fail to take into account the physiological principles of muscle training. These include progressive overloading of muscles, specificity (e.g., the most effective training should reflect the desired activity outcome), training of muscles across all planes of desired movements, and use of proper technique associated with the desired muscle action. The MDTP provides SLP’s with a well-designed, research-based method of assessing all aspects of swallow function (including cognitive readiness to participate in therapy), and tailoring the therapy program so that patients and therapists can maximize the effectiveness of the therapeutic process.
Pharyngocise as a Preventative Therapy
What, then, can medical professionals do to address the effects of chemo-radiation therapy head on, so that the deleterious effects on swallow function can be minimized or prevented before they ever occur? Based on the results of more recent randomized controlled exercise trials, the answer may well be the implementation of an exercise program dubbed “Pharyngocise” (Carnaby-Mann, G., Crary, M.A., Schmalfuss , I., & Amdur, R., 2012). Pharyngocise is a high-intensity swallowing therapy which incorporates a battery of exercises during the time when the patient is actually undergoing chemo-radiation therapy, NOT following the conclusion of therapy when symptoms have begun to appear. The patient undergoing Pharyngocise therapy ideally completes a cycle of four specific swallowing exercises in ten repetitions over four cycles, each of 10 minutes duration for a total of 40-45 minutes twice a day. Since current third-party payor restrictions may limit skilled therapy services to no more than once a day, use of the Pharyngocise protocol may be modified so that patients can complete one exercise cycle with the SLP while completing the second cycle at home, once training has been satisfactorily completed. The exercise program may be implemented throughout the cycle of chemo-radiation treatment.
Results from a randomized controlled study (Carnaby-Mann, G., et. al, 2012) provide evidence to support the use of Pharyngocise as a preventative therapeutic modality. When patients were assessed at six weeks following the conclusion of radiation or chemo-radiation therapy, subjects in the Pharyngocise trial had a 36% absolute risk difference of achieving functional swallowing compared to subjects receiving traditional care. Pharyngocise subjects were 35% less likely to suffer from salivation decline; 19% less likely to suffer from taste decline; and 39% less likely to have experienced a decline in olfactory (smell) sensation. Finally, 20% of Pharyngocise subjects were receiving gastronomy tube feedings compared to 30% of the traditional care group subjects.
Initial study results provide evidence to suggest that incorporating Pharyngocise into head and neck cancer patients’ treatment plan as a preventative measure may well increase the chances that they will maintain the ability to consume adequate nutrition and hydration without the use of alternative sources of feeding like g-tubes once radiation or chemo-radiation therapy has ended. Patients undergoing such treatments are encouraged to talk with their oncologists to discuss whether such a preventative treatment program might be in their best long-term health interests.
Carnaby-Mann, G.D. & Crary, M.A. (2008). McNeill Dysphagia Therapy Program Manual. Published by the authors.
Carnaby-Mann, G., Crary, M.A., Schmalfuss , I., and 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.