Swallowing Exercises Crucial After RT in Head and Neck Cancer

Lynn Acton, MS, CCC (SLP)

Patients with head and neck cancer who undergo intensity-modulated radiation therapy (IMRT) are likely to experience difficulties swallowing. However, the use of swallowing exercises can drastically improve the muscle movement for these patients both during and after radiation therapy (RT) for optimal long-term swallowing function, according to Lynn Acton, MS, CCC (SLP).

In a study conducted by researchers at Dana-Farber Cancer Institute and Brigham Women’s Hospital, patients with head and neck cancer who underwent RT in a 2-year period were evaluated for swallowing difficulty with a video swallow to score stricture and aspiration. Of the 96 patients evaluated who received IMRT once daily, 32% had some aspiration after therapy, while 37% had evidence of stricture following RT.

Studies are currently ongoing to explore the utility of swallowing modalities for these patients. For example, an interventional, randomized, multicenter phase III trial is comparing early-active swallowing therapy versus nonspecific swallowing management (NCT02892487). Researchers are conducting the study to determine that early-active swallowing therapy can improve the quality of life of patients undergoing RT for head and neck cancer.

Additionally, a behavioral questionnaire is evaluating adherence to preventative swallowing exercises and the reasons why patients choose not to follow them (NCT03010150). Patients will complete the questionnaire at baseline and again at 6 months following RT that will discuss adherence to swallowing exercises.

OncLive: What is the benefit of doing these swallowing exercises for this patient population?

Acton, a lecturer in surgery (otolaryngology) and speech pathologist at Yale School of Medicine, discussed the significance of swallowing modalities for patients with head and neck cancer during and after RT in an interview at the 2017 OncLive State of the Science Summit on Head and Neck Cancer.Acton: I spoke about prophylactic exercises for swallowing for patients with head and neck cancer who are undergoing RT. We have found that if we keep the muscles mobile during the treatment, there is less fibrosis of the muscles. If the patients don’t have fibrosis, they are able to move better and have better swallowing function. During the treatment, patients will have some pain. We try to manage that and do things like a mouthwash to numb the area before they do these exercises.

Have there been any advancements in this field that have increased the quality of life for these patients even further?

It is more important to keep the muscles mobile because, when a joint like your jaw becomes immobile, the cartilage becomes thinner and the joints becomes inflamed and painful. If we keep the muscles moving, then the function is much greater. We like to [continue] to do the exercises after treatment, because RT can continue to contract the muscles over time. Therefore, patients do the exercises several times during the day and after treatment, too. It is basically a lifelong thing at this point. For young patients, they say they feel relief after doing the exercises. Some of them [are simple] neck exercises, [such as] neck rolls. I do try to tag it in with something that they are already doing during the day. On their smartphone, I’ll put an [alarm] that reminds them to do their exercises on the way to work, or maybe [while] they are reading a newspaper. I [put the written exercises] in the memos section [of their phone] to explain the exercises. Doing those things makes it a positive result. For the patients who do the exercises, we notice that they’re able to maintain their oral opening. Normally, you should be able to put 3 fingers in your mouth.

What impact does prophylactic swallowing exercises have on patients?

When I started, I was seeing patients after RT because we didn’t know it was important to keep these muscles mobile [during treatment]. They would be at a 1-finger opening and then we would have to work to stretch the muscles. I’ve also talked to patients after completing their [swallowing exercises] and they no longer have food sticking in their throat. They do work. Well, not everybody is compliant, so we tell them what the negative effects are of not doing the exercises. Some patients have to get a feeding tube because they are not maintaining hydration.

How should specialists handle adherence to these exercises?

If you do the exercises, you can maintain good swallowing function and [function of the] muscles not only for swallowing. [They also help for] speech; some of the patients will have radiation and have very hoarse voices. I will have to counsel them on how to talk without straining. Their vocal chords become swollen during RT. We teach them how to talk gently so they don’t do further damage to the chords. It is most important for patients to do the exercises when they least feel like doing them. We want you to take the mouthwash, do the exercises, and if I see the patients I explain to them that this is a very intensive treatment. This [radiation] treatment works, but if you don’t do the things I am going to ask you to do, you are going to have disability after the treatment is done and we want to prevent that.

Are there any other types of exercises in addition to prophylactic swallowing that are worth mentioning?

You have to see the patient frequently. [Seeing] them during RT and after the treatment would be ideal, because patients get a lot of encouragement. I will explain to them that I have seen [other] patients and evaluated their swallowing, and [if it is] perfect and it is because they did the exercises. I also let them know that before we do the exercises, patients will have to increase the oral opening. We start with the mouth opening. Today, we are seeing a different population of people versus in the late 80s—it was a lot of type A-personality men and they sometimes found that [these exercises] were hard and [thought that] it was going to be better. It was the complete opposite.

We watch them do the exercises to move the muscles in the neck. Even just a simple, hard swallow can be done every time they eat or drink something, gargling, extreme-yawn positions, and moving the back of the tongue.

What are the main points you hope the community oncologists took away from your lecture and what does the future hold?

The head and neck area is a very narrow area, so I do tailor the exercises to the patient and [explain to them] what they might expect. What can you do if you feel the food sticking in your throat? You can swallow hard; you can swallow twice. I do explain to them the specific things they should do if these things happen. Generally, for anyone who is having RT [in this area] you want them to be able to move their neck and swallow—the RT the beams hit various points. In the future, I hope that patients will be able to see these professionals more frequently. It is just important that we see these patients and that they are treated. These exercises are very easy to do; [patients should] not be afraid of doing them.

Caglar HB, Tishler RB, Othus M, et al. Dose to larynx predicts for swallowing complications after intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2008;72(4):1110-1118. doi:10.1016/j.ijrobp.2008.02.048.