Dharamshila Narayana Superspeciality Hospital

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Rehabilitation Clinic

Rehabilitation in relation to cancer is preventative, restorative, supportive, and palliative Patients may have rehabilitation needs throughout their care pathway. The role of physiotherapy in the cancer rehabilitation is less understood and particularly in the head and neck cancer patients. This results in various residual deformities and dysfunctions for the patients with Head and Neck Carcinomas. The fact that cancer patients are facing several months of chemotherapy and/or radiotherapy and usually major surgery, as well as the direct effect of immobility due to pain, means that muscle wasting, joint stiffness, as well as de-conditioning and fatigue are inevitable. The absence of physiotherapy intervention would be detrimental to patient care and the ability of the patient/family to cope with the effects of the disease or its treatment on their functional capacity and quality of life. Following any treatment for Head and Neck Carcinomas, physical therapy plays an essential role in preventing various complications and helping patients to correct impairments, and restoring function of the shoulder joint, neck, and face. To treat head and neck cancer cases, many patients receive aggressive treatment, including surgery, chemotherapy, and radiation therapy.

The most common complications are shoulder disability, shoulder pain, reduced cervical mobility or Decreased cervical range of motion (ROM), difficulty in swallowing, limited mouth opening .None of these parameters appear to be related to reduced survival, but most of them are considered to be associated with reduced Quality of life. The term “rehabilitation” refers to a process aimed at enabling persons with disabilities to achieve and maintain their optimal physical, sensory, intellectual, psychiatric, and/or social functional levels, thus providing them with the tools to adapt their lives toward a higher level of independence. Rehabilitation does not focus on a prolongation of survival but rather on an improvement of the patient′s quality o life.

The rehabilitation takes place in various stages in different forms, such as Preventive rehabilitation therapy is started early after the diagnosis of cancer is made, where no significant physical impairment exists, but therapy is started to prevent functional loss. Restorative rehabilitation therapy is directed at the comprehensive restoration of maximum function for patients who have a residual physical impairment and disability. Supportive rehabilitation therapy attempts to increase the self-care skills and mobility of the cancer patient with physical exercises to prevent the effects of immobilization, such as joint impairments, muscle atrophy, weakness, and pressure scores. Palliative rehabilitation therapy aims to increase or maintain the comfort and function of patients with terminal cancer by improving their wellbeing, giving pain relief, avoiding joint impairments and pressure sores, and to provide at least partial self-sufficiency.

Role of physiotherapist

The role of the physiotherapist in palliative care involve that they work with respiratory, neurologic, lymphatic, orthopaedic, musculoskeletal symptoms and complications and pain conditions. Common interventions utilised are positioning for prevention of pressure sores; Trans-cutaneous electrical nerve stimulation (TENS) for pain control; neurologic rehabilitation in peripheral neuropathies; mobility training to enhance the exercise tolerance, maintenance, and independence; passive/active range of movement to prevention of contractures; and individual designed exercise programs for maintaining the general health of the patient

During the rehabilitation of these patients, it is of primary importance to unload the shoulder immediately postoperatively, reduce shoulder and neck pain, and prevent stretch fibrosis of the trapezius and contracture of the unopposed pectoralis muscles, as well as to provide strengthening exercises for the residual muscles in the neck and shoulder girdle to compensate for lost muscles. Postoperative physiotherapy includes prevention and management of the respiratory complications, such as respiratory distress and excess secretions; cardiovascular complications, such as deep vein thrombosis and dependent edema; and musculoskeletal complications, such as joint and muscle tissue stiffness and weakness in the face, neck, and shoulder.

Sufficient wound healing should occur in 10–14 days to allow patient to begin the exercise program for the shoulder and neck. The physiotherapist modifies the exercise program gradually.

Physiotherapy during and shortly after chemotherapy includes Therapeutic exercises which are initially passive but gradually progress to active-assistive and eventually resistive exercises as tolerated by the patient. Strenuous physical activities, such as lifting, carrying, pulling, and pushing, should be avoided initially but may be resumed in the course of time as the physical condition improves

Additionally, the physiotherapist can help by training other muscles to assist with shoulder function.Thelevator scapulae, through their action as scapular elevators, can be trained to help maintain level shoulders. Patients are instructed to work on these exercises in front of a mirror. The action of scapular retraction can be assumed by the rhomboids, which results in a balanced counter pull to the action of pectoralis major. The serratus anterior should be strengthened to assist with scapular stabilization during shoulder flexion and abduction.

Common complications and physiotherapy management

Disorders of pain, weakness, debility, deformity, and dysfunction in persons with cancer result from the direct and indirect effects of cancer or its treatment. The common complications of Head and Neck Carcinomas and its treatment which require physiotherapy assessment and rehabilitation are as follows:

Spinal accessory nerve palsy

Some degree of weakness can be elicited in most patients on the side of the neck dissection. The spinal accessory nerve may be entirely spared or subject to neurapraxic, axonotmetic, or neurotmetic insult, all with different rates and degrees of recovery. Specific deficits may include a painful shoulder, trapezius muscle paralysis resulting in a rotated scapula, and loss of range in the shoulder.

The timing and intensity of rehabilitation should be guided by patient′s prognosis for recovery.Spinal accessory nerve re-innervation can continue over 12 months following surgery. Important elements of spinal accessory nerve rehabilitation include the following

  • Prevention of frozen shoulder through active ROM and active-assisted ROM;
  • Prevention of anterior chest wall flexibility deficits through trunk mobility exercises;
  • Strengthening of alternate scapular elevators and retractors
  • Instruction of compensatory techniques for activities requiring sustained shoulder abduction and forward flexion;
  • Neuromuscular retraining of shoulder girdle muscles;
  • Postural modification and re-education; and
  • Providing shoulder support to allow recovery of the levator scapulae.

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