A pilot study of a randomized controlled trial to evaluate the effects of progressive resistance exercise training on shoulder dysfunction caused by spinal accessory neurapraxia/neurectomy in head and neck cancer survivors

A case report of ansa cervicalis to spinal accessory transposition graft: a new surgical technique to prevent shoulder dysfunction

Introduction and importance

The spinal accessory nerve is at risk when performing neck dissections for head and neck cancers. Injury to this nerve can result in shoulder syndrome, which can be challenging to manage. Various nerve repair or grafting methods are available to prevent this condition. A safe, simple, and cost-effective option is the ansa cervicalis to spinal accessory transposition graft.

Case presentation

A 60-year-old Afro-Trinidadian female presented to the Outpatient clinic for evaluation of a scalp lesion and a large neck mass for a duration of one year. Preoperative tissue biopsies confirmed she had squamous cell cancer with metastatic spread to the cervical nodes. The patient underwent surgical excision of the scalp lesion and left neck dissection with the sacrifice of the sternocleidomastoid and the left spinal accessory nerve due to tumour involvement. During the procedure, the ansa cervicalis was successfully joined to the distal remainder of the spinal accessory nerve. After the surgery, the patient fully recovered and achieved a good quality of life during the 24-month follow-up.

Clinical discussion

This is the first reported case of using the ansa cervicalis to reinnervate the trapezius muscle through the spinal accessory nerve. This procedure aims to prevent pain, muscle wasting, and adhesive capsulitis. A quality-of-life questionnaire and adequate range of motion proved the success of this procedure, demonstrating that this option provides practical, functional, and aesthetic benefits for patients.

Conclusion

The ansa cervicalis to spinal accessory transposition nerve graft is a valuable option for reinnervation. This case report highlights the effectiveness of this single-stage procedure in preventing shoulder syndrome.

Efficacy of aerobic and resistance exercises on cancer pain: A meta-analysis of randomised controlled trials

Purpose

To evaluate effects of aerobic and resistance exercises for cancer-related pain in adults with and surviving cancer. Secondary objectives were to a) evaluate the effect of exercise on fatigue, psychological function, physical function, b) assess fidelity to exercise.

Design

A systematic search of MEDLINE, EMBASE, AMED, CINAHL and Cochrane Central Register of Controlled Trials was conducted to identify randomised controlled trials (RCTs) comparing aerobic and/or resistance exercise to control groups. The primary endpoint were changes in cancer-related pain intensity from baseline to post intervention. Meta-regression analysis evaluated predictors for heterogeneity between study findings. Tolerability was defined as reporting of exercise-induced adverse events while fidelity evaluated by reported intervention dropout.

Results

Twenty-three RCTs including 1954 patients (age 58 ± 8.5 years; 78 % women); 1087 (56 %) and 867 (44 %) allocated to aerobic/resistance exercise therapy and control group, respectively. Exercise therapy was associated with small to moderate decreases in cancer-related pain compared to controls (SMD = 0.38, 95 % CI: 0.17, 0.58). Although there was significant heterogeneity between individual and pooled study effects (Q = 205.25, p < 0.0001), there was no publication bias. Meta-regression including supervision, age, duration and exercise type as moderators showed no significant differences in reported outcomes. Analysis of secondary outcomes revealed a moderate effect for improvements in physical function, fatigue and psychological symptoms.

Conclusions

Aerobic and resistance exercises are tolerable and effective adjunct therapies to reduce cancer-related pain while also improving physical function, fatigue and mood. Future RCTs of dose, frequency, compliance and exercise type in specific cancer settings are required.

Rehabilitation Interventions in Head and Neck Cancer: A Scoping Review

OBJECTIVE

The aim of the study is to identify and appraise current evidence for rehabilitation interventions in head and neck cancer.

DESIGN

A previously published scoping review spanning 1990 through April 2017 was updated through January 11, 2023 and narrowed to include only interventional studies (Arch Phys Med Rehabil. 2019;100(12):2381-2388). Included studies had a majority head and neck cancer population and rehabilitation-specific interventions. Pairs of authors extracted data and evaluated study quality using the PEDro tool. Results were organized by intervention type.

RESULTS

Of 1338 unique citations, 83 studies with 87 citations met inclusion criteria. The median study sample size was 49 (range = 9-399). The most common interventions focused on swallow (16 studies), jaw (11), or both (6), followed by whole-body exercise (14) and voice (10). Most interventions took place in the outpatient setting (77) and were restorative in intent (65 articles). The overall study quality was fair (median PEDro score 5, range 0-8); none were of excellent quality (PEDro >9).

CONCLUSIONS

Most head and neck cancer rehabilitation interventions have focused on restorative swallow and jaw exercises and whole-body exercise to address dysphagia, trismus, and deconditioning. More high-quality evidence for head and neck cancer rehabilitation interventions that address a wider range of impairments and activity and social participation limitations during various cancer care phases is urgently needed to reduce head and neck cancer-associated morbidity.

Comparative effects of different types of exercise on health-related quality of life during and after active cancer treatment: A systematic review and network meta-analysis

BACKGROUND

The positive influence of most types of exercise has been reported repeatedly, but what the most effective exercise approaches are for improving health-related quality of life (HRQoL) in people with cancer remains unknown. The aim of this systematic review and network meta-analysis was to synthesize the evidence from intervention studies to assess the effects of different types of exercise on HRQoL during and after cancer treatment.

METHODS

MEDLINE, SPORTDiscus, the Cochrane Library, Web of Science, and Scopus were searched for randomized controlled trials aimed at testing the effects of exercise interventions meant to improve HRQoL in people with cancer. Separate analyses were conducted for HRQoL as measured by general and cancer-specific questionnaires. We also evaluated whether the effects of exercise were different during and after cancer treatment in both the physical and mental HRQoL domains.

RESULTS

In total, 93 studies involving 7435 people with cancer were included. Network effect size estimates comparing exercise intervention vs. usual care were significant for combined exercise (0.35, 95% confidence interval (95%CI): 0.14-0.56) for HRQoL as measured by general questionnaires, and for combined (0.31, 95%CI: 0.13-0.48), mind-body exercise (0.54, 95%CI: 0.18-0.89), and walking (0.39, 95%CI: 0.04-0.74) for HRQoL as measured by cancer-specific questionnaires.

CONCLUSION

Exercise programs combining aerobic and resistance training can be recommended to improve HRQoL during and after cancer treatment. The scarcity and heterogeneity of these studies prevents us from making recommendations about other exercise modalities due to insufficient evidence.

Feasibility and safety of Heavy Lifting Strength Training in Head and Neck Cancer survivors post-surgical neck dissection (the LIFTING trial)

BACKGROUND

Light-to-moderate intensity strength training (LMST) improves muscular strength, physical functioning, and some side effects in head and neck cancer survivors (HNCS). Heavy lifting strength training (HLST) may further improve these outcomes; however, it has not been studied in HNCS. The primary aim of the LIFTING trial was to examine the feasibility and safety of a HLST program in HNCS ≥1-year post-surgical neck dissection.

METHODS

In this single-arm feasibility study, HNCS were asked to complete a twice weekly, 12-week, supervised HLST program, gradually progressing to lifting heavy loads of 80-90% of 1 repetition maximum (1RM) for barbell squat, bench press, and deadlift. The feasibility outcomes included recruitment rate, 1RM completion rate, program adherence, barriers, and motivation. The preliminary efficacy outcomes included changes in upper and lower body strength.

RESULTS

Nine HNCS were recruited over an 8-month period during the COVID-19 pandemic. All 9 (100%) completed the 1RM tests and successfully progressed to heavy loads at approximately 5 weeks. The median attendance was 95.8% (range 71-100%), and few barriers were reported. Weight lifted increased for squat/leg press (median change: +34kg; 95% CI +25 to +47), bench press (median change: +6kg; 95% CI +2 to +10), and deadlift (median change: +12kg; 95% CI +7 to +24). No adverse events were reported and participants were motivated to continue HLST after the study.

CONCLUSIONS

HLST appears feasible and safe for HNCS and may result in meaningful improvements in muscular strength. Future research should consider additional recruitment strategies and compare HLST to LMST in this understudied survivor population.

TRIAL REGISTRATION

NCT04554667.

The role of exercise for pain management in adults living with and beyond cancer: a systematic review and meta-analysis

BACKGROUND

Pain is a common side effect of cancer or cancer treatment that negatively impacts biopsychosocial wellbeing and quality of life. Exercise is a potential intervention to manage pain that is safe and has multiple benefits. The objective was to determine the role of exercise in cancer pain management.

METHODS

We completed a systematic review and meta-analysis of exercise interventions in adults with any type or stage of cancer by searching Ovid MEDLINE®, Embase, APA PsycInfo, the Cochrane Central Register of Controlled Trials, CINAHL, and SPORTDiscus. We included experimental and quasi-experimental designs where pain was measured as an outcome. Data synthesis included narrative and tabular summary. A meta-analysis was performed on studies powered to detect the effect of exercise on pain. Study quality was evaluated using the Cochrane risk of bias tool and certainty of evidence was evaluated using the GRADE tool.

RESULTS

Seventy-six studies were included. Studies were predominantly conducted in breast cancer and exercise usually included a combination of aerobic and strength training. Ten studies were included in the meta-analysis demonstrating a significant effect for exercise in decreasing pain (estimated average standard mean difference (SMD) was g =  - 0.73 (95% CI: - 1.16 to - 0.30)); however, the overall effect prediction interval was large. Overall risk of bias for most studies was rated as some concerns and the grading of evidence certainty was low.

CONCLUSION

There are limitations in the evidence for exercise to manage cancer-related pain. Further research is needed to understand the role of exercise in a multimodal pain management strategy.

Impact of physical activity on postural stability and coordination in children with posterior fossa tumor: randomized control phase III trial

Background

Posterior fossa tumor is a type of brain tumor that is located at the borders of both the brain stem and cerebellum. The cerebellum is the brain region in charge of balance and coordination. Pediatric patients diagnosed with posterior fossa tumor have been reported to fall frequently.

Objectives

The aim of this study is to investigate the effectiveness of balance and coordination training in these children.

Methods

This randomized control clinical trial (ClinicalTrials.gov Identifier: NCT04528316) was carried out between September 2020 and April 2021 at Children’s Cancer Hospital-57357. The inclusion criteria were patients with posterior fossa tumor in maintenance phase and, age between 5 and 12 years. The exclusion criteria were patients who had a genetic disorder or suffer from mental retardation, a chronic lung disease, severe cardiomyopathy, or a neuromuscular disease that does not relate to tumor. The study participants were randomly assigned into three groups: Group I/Control group: they received Pilates core stability exercises program, Group II/Postural stability group: they received the same program plus HUMAC balance program, and Group III/Coordination group: they received the same program plus coordination exercises of BOT-2. The semi-parametric proportional odds model was used to compare follow-up scores of the Postural stability group vs Control, and Coordination group vs Control, while adjusting for baseline values. All tests were two sided, with alpha set to 0.05.

Results

Sixty children including 38 boys and 22 girls were enrolled in this study. In all three groups, postural stability and coordination improved significantly in terms of modified clinical test of sensory integration of balance, center of pressure, limits of stability, bilateral coordination, and upper-limb coordination.

Conclusion

The current study supports the value of adding postural stability and coordination training to the physiotherapy plan for children with posterior fossa tumor.

Trial registration number and date of registration

ClinicalTrials.gov Identifier: NCT04528316 on August 27, 2020.

An Overview on the Evidence of Physical Activity Interventions in the Health of Individuals with Head and Neck Cancer: Literature Systematic Review

Introduction: Head and neck cancer is considered a global public health problem, which arises in aesthetically and functionally critical areas. The practice of physical exercise has been considered one of the significant and effective non-pharmacological strategies to minimize the physical and psychological consequences. Objective: To analyze the evidence of physical activity interventions in the physical and psychological health of individuals with head and neck cancer. Method: A systematic review was conducted blindly and independently, from March to May 2021, according to the PRISMA guidelines. The search was performed in the following databases: PubMed Central®; Cochrane Library; Web of Science, Scopus, ScienceDirect. Results: Of the 515 selected studies, 15 were included in this systematic review with a total of 670 participants aged between 18 and 76 years old. The studies included aerobic exercises, endurance, mobility, stretching, strengthening, and yoga. Conclusion: Evidence proves that physical activity interventions performed with individuals with head and neck cancer may be beneficial in the treatment and physical/psychological health of this population. This study may help new researches considering the detailed information described previously regarding the interventions applied, in addition to discussing the most used instruments with this public and indicating the modalities that are being safely performed. It is suggested that more randomized trials be conducted to obtain more concise results.

Nurse-Led Counseling Intervention of Postoperative Home-Based Exercise Training Improves Shoulder Pain, Shoulder Disability, and Quality of Life in Newly Diagnosed Head and Neck Cancer Patients

This randomized controlled trial investigated the effectiveness of the nurse-led counseling intervention (NLCI) of postoperative home-based exercise training (HBET) on functional outcomes in patients with newly diagnosed head and neck cancer (NDHNC). Forty NDHNC patients were randomly and equally divided into the control and intervention groups. Both groups received routine care, and were instructed to undergo a HBET program with 40 min moderate-intensity exercise 3–4 times per day for 12 weeks after their surgery. Only the intervention group received the NLCI with a bedside demonstration, coaching, consultation, and a weekly telephone follow-up. Shoulder pain (SP), shoulder disability (SD), and quality of life (QOL) scores were assessed using questionnaires at 2 weeks presurgery and at several timepoints postsurgery. Over the 12-week study period, all three scores remained relatively stable in the control group. By contrast, the SP, SD, and QOL scores significantly improved in the intervention group. The generalized estimating equation analysis revealed a significant time effect, group effect, and group–time interaction. The analysis of covariance revealed that all three scores significantly improved in the intervention group compared with those in the control group at 12 weeks postsurgery. We concluded that the NLCI of postoperative HBET improved the SP, SD, and QOL of NDHNC patients.

Impacts of nutritive and bioactive compounds on cancer development and therapy

For persons who survive with progressive cancer, nutritional therapy and exercise may be significant factors to improve the health condition and life quality of cancer patients. Nutritional therapy and medications are essential to managing progressive cancer. Cancer survivors, as well as cancer patients, are mostly extremely encouraged to search for knowledge about the selection of diet, exercise, and dietary supplements to recover as well as maintain their treatment consequences, living quality, and survival of patients. A healthy diet plays an important role in cancer treatment. Different articles are studied to collect information and knowledge about the use of nutrients in cancer treatment as well as cancer prevention. The report deliberates nutrition and exercise strategies during the range of cancer care, emphasizing significant concerns during treatment of cancer and for patients of advanced cancer, but concentrating mostly on the requirements of the population of persons who are healthy or who have constant disease following their repossession from management. It also deliberates choice nutrition and exercise problems such as dietary supplements, food care, food selections, and weight; problems interrelated to designated cancer sites, and common questions about diet, and cancer survival. Decrease the side effects of medicines both during and after treatment.

State of Rehabilitation Research in the Head and Neck Cancer Population: Functional Impact vs. Impairment-Focused Outcomes

PURPOSE OF REVIEW

Management of head and neck cancer (HNC) typically involves a morbid combination of surgery, radiation, and systemic therapy. As the number of HNC survivors grows, there is growing interest in rehabilitation strategies to manage HNC-related comorbidity. In this review, we summarize the current state of HNC rehabilitation research.

RECENT FINDINGS

We have organized our review using the World Health Organization's International Classification of Function (ICF) model of impairment, activity, and participation. Specifically, we describe the current research on rehabilitation strategies to prevent and treat impairments including dysphagia, xerostomia, dysgeusia, dysosmia, odynophagia, trismus, first bite syndrome, dysarthria, dysphonia, lymphedema, shoulder syndrome, cervicalgia, cervical dystonia and dropped head syndrome, deconditioning, and fatigue. We also discuss the broader impact of HNC-related impairment by exploring the state of rehabilitation literature on activity, participation, psychosocial distress, and suicidality in HNC survivors. We demonstrate that research in HNC rehabilitation continues to focus primarily on impairment-driven interventions. There remains a dearth of HNC rehabilitation studies directly examining the impact of rehabilitation interventions on outcomes related to activity and participation. More high-quality interventional studies and reviews are needed to guide prevention and treatment of functional loss in HNC survivors.

Role of Manual Therapy for Neck Pain and Quality of Life in Head and Neck Cancer Survivors: A Systematic Review

Background:

Pain is the one the most dreadful side effects of head and neck cancers and cancer related treatments affecting patients during and after the treatment adding to the problems affecting their ability to speak, swallow, breath and feeding. Manual therapy is standard set of physiotherapy treatments used for alleviating neck pain. It has found to be effective in small subset of cancer patients for relieving pain.

Objectives:

To highlight the use of various manual therapy techniques focusing in decreasing neck pain and improving quality of life in Head and Neck Cancer survivors that may suggest its safe utilisation in oncology rehabilitation.

Materials and Methods:

Electronic search was conducted in PubMed, Google Scholar, CINAHL, Pedro, and COCHRANE databases. Reference lists of the included studies and relevant reviews were manually searched. Studies that met the inclusion criteria were evaluated using McMaster critical review form for quantitative studies. A descriptive synthesis was undertaken due to the heterogeneity of the included studies.

Results:

Seven studies were assessed for risk of bias that comprised of three clinical trials, one case series and three case reports that applied Maitland’s mobilisation, Myofascial release, Muscle Energy Techniques to head and neck cancer survivors in various clinical settings. The outcomes highlighted decrease in pain, improvement in cervical range of motion and quality of life.

Conclusion:

This review recommends application of manual therapy to head and neck cancer survivors. However, authors caution application of manual therapy in terms of choosing a particular technique. Further, well designed larger sample size with randomisation and double blinding would help to generate better evidence for head and neck cancer survivors.

Attention to principles of exercise training: an updated systematic review of randomized controlled trials in cancers other than breast and prostate

BACKGROUND

The primary objective of this systematic review was to update our previous review on randomized controlled trials (RCTs) of exercise in cancers other than breast or prostate, evaluating: 1) the application of principles of exercise training within the exercise prescription; 2) reporting of the exercise prescription components (i.e., frequency, intensity, time, and type (FITT)); and 3) reporting of participant adherence to FITT. A secondary objective was to examine whether reporting of these interventions had improved over time.

METHODS

MEDLINE, EMBASE, CINAHL and SPORTDiscus databases were searched from 2012 to 2020. Eligible studies were RCTs of at least 4 weeks of aerobic and/or resistance exercise that reported on physiological outcomes relating to exercise (e.g., aerobic capacity, muscular strength) in people with cancer other than breast or prostate.

RESULTS

Eighty-six new studies were identified in the updated search, for a total of 107 studies included in this review. The principle of specificity was applied by 91%, progression by 32%, overload by 46%, initial values by 72%, reversibility by 7% and diminishing returns by 5%. A significant increase in the percentage of studies that appropriately reported initial values (46 to 80%, p < 0.001) and progression (15 to 37%, p = 0.039) was found for studies published after 2011 compared to older studies. All four FITT prescription components were fully reported in the methods in 58% of all studies, which was higher than the proportion that fully reported adherence to the FITT prescription components in the results (7% of studies). Reporting of the FITT exercise prescription components and FITT adherence did not improve in studies published after 2011 compared to older studies.

CONCLUSION

Full reporting of exercise prescription and adherence still needs improvement within exercise oncology RCTs. Some aspects of exercise intervention reporting have improved since 2011, including the reporting of the principles of progression and initial values. Enhancing the reporting of exercise prescriptions, particularly FITT adherence, may provide better context for interpreting study results and improve research to practice translation.

Effect of Physical Therapy Modalities on Quality of Life of Head and Neck Cancer Survivors: A Systematic Review with Meta-Analysis

The objective was to describe the effectiveness of different physical therapy modalities to improve Quality of Life (QoL) in Head and Neck Cancer (HNC) survivors. PubMed, Scopus, Web of Science, CINAHL and Cochrane Library were searched for randomized clinical controlled trials published until 30 April 2020. Risk of bias assessment and meta-analysis were conducted using the Cochrane tools. A total of 251 records were retrieved, and 10 met the inclusion criteria. Interventions whose parameters focus on a 12-week exercise programs of aerobic activity (walking) or Progressive Resistance Training (PRT) for the whole body are effective and safe modalities improving QoL in HNC survivors. Electrophysical agents did not show significant results between groups. As for the assessment of methodological quality, 4 of the 10 articles included had a high risk of overall bias. Only five articles provided sufficient information to conduct a meta-analysis for exercise program intervention on QoL, showing a tendency in favor of intervention group, even when the global results did not show statistically significant improvements (pooled Cohen's d 0.15; 95% CI: -0.25 to 0.54; I² 45.87%; p heterogeneity = 0.10). The present review and meta-analysis identified meaningful benefits of exercise on QoL of HNC survivors; this has been confirmed in a meta-analysis. This review adds evidence supporting exercise interventions on Head and Neck Cancer population whose opportunities for successful recovery after medical treatment are more limited.

Cost-utility and cost-effectiveness of a guided self-help head and neck exercise program for patients treated with total laryngectomy: Results of a multi-center randomized controlled trial

OBJECTIVES

The guided self-help exercise program called In Tune without Cords (ITwC) is effective in improving swallowing problems and communication among patients treated with a total laryngectomy (TL). This study investigated the cost-utility and cost-effectiveness of ITwC.

MATERIALS AND METHODS

Patients within 5 years after TL were included in this randomized controlled trial. Patients in the intervention group (n = 46) received access to the self-help exercise program with flexibility, range-of-motion and lymphedema exercises, and a self-care education program. Patients in the control group (n = 46) received access to the self-care education program only. Healthcare utilization (iMCQ), productivity losses (iPCQ), health status (EQ-5D-3L, EORTC QLU-C10D) and swallowing problems (SwalQol) were measured at baseline, 3- and 6-months follow-up. Hospital costs were extracted from medical files. Mean total costs and effects (quality-adjusted life-years (QALYs) or SwalQol score) were compared with regression analyses using bias-corrected accelerated bootstrapping.

RESULTS

Mean total costs were non-significantly lower (-€685) and QALYs were significantly higher (+0.06) in the intervention compared to the control group. The probability that the intervention is less costly and more effective was 73%. Sensitivity analyses with adjustment for baseline costs and EQ-5D scores showed non-significantly higher costs (+€119 to +€364) and QALYs (+0.02 to +0.03). A sensitivity analysis using the QLU-C10D to calculate QALYs showed higher costs (+€741) and lower QALYs (-0.01) and an analysis that used the SwalQol showed higher costs (+€232) and higher effects (improvement of 6 points on a 0-100 scale).

CONCLUSION

ITwC is likely to be effective, but possibly at higher expenses.

TRIAL REGISTRATION

NTR5255.

Rehabilitation Interventions for Shoulder Dysfunction in Patients With Head and Neck Cancer: Systematic Review and Meta-Analysis

OBJECTIVE

Shoulder pain and dysfunction are highly prevalent after neck dissection in the treatment of head and neck cancer (HNC). They can lead to muscle weakness, limited range of motion, and shoulder tilt and pain, which can reduce patient functioning. The purpose of this study was to evaluate the effectiveness of rehabilitation interventions for shoulder dysfunction in patients with surgically treated HNC.

METHODS

A search of principal databases (MEDLINE, Embase, CENTRAL, LILACS, IBECS, PEDro, and SciELO) was conducted, in addition to hand searches and a search of gray literature, for all randomized clinical trials (RCTs) published before February 2020. Two authors independently selected all relevant studies. The 7 RCTs fulfilling all inclusion and exclusion criteria were assessed for risk of bias and certainty of evidence using the Cochrane Collaboration risk-of-bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool, respectively.

RESULTS

Moderate-certainty evidence suggests that progressive resistance training is better than conventional treatment for improving pain and dysfunction in patients with HNC (pooled data from 214 participants; mean difference = -5.92; 95% CI = -11.38 to -0.45). Low-certainty evidence (data from 2 RCTs with 106 participants that could not be combined) suggests that acupuncture seems to be more effective than conventional treatment.

CONCLUSIONS

Progressive resistance training is effective for improving shoulder pain and dysfunction in patients with HNC. Further high-quality RCTs are needed to examine the effectiveness of acupuncture for improving shoulder pain and dysfunction in these patients. Future studies with longer follow-up times are needed to clarify the effects of early postoperative intervention.

IMPACT

Clinicians can have confidence that progressive resistance training in patients with surgically treated HNC is effective.

LAY SUMMARY

These study results show that people with head and neck cancer can benefit from gradually increased resistance training to reduce shoulder pain and improve function. This study will help researchers design clinical trials to determine whether treatments such as acupuncture and early physical therapy also could be effective in treating this population.

Motor control integrated into muscle strengthening exercises has more effects on scapular muscle activities and joint range of motion before initiation of radiotherapy in oral cancer survivors with neck dissection: A randomized controlled trial

Background

Accessory nerve shoulder dysfunction is common after neck dissection in oral cancer survivors. This study aimed to investigate the short-term effects of scapular muscle strengthening exercises with motor-control techniques on neck dissection-related shoulder dysfunction in oral cancer survivors before the initiation of radiotherapy.

Methods

Thirty-eight participants were randomly allocated into the motor-control and regular-exercise groups. Each group received conventional physical therapy and specific scapular muscle strengthening exercises for 1 month immediately after neck dissection. Motor control techniques were integrated with scapular strengthening exercises for the motor-control group. Shoulder pain, active range of motion (AROM) of shoulder abduction, and scapular muscle activities including upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) when performing maximal voluntary isometric contraction (MVIC) and scapular muscle exercises were evaluated at baseline and after 1 month of training.

Results

Both groups reduced shoulder pain and increased muscle activity of maximum voluntary isometric contraction (MVIC) of each muscle after the intervention. Increased AROM of shoulder abduction was only observed in the motor-control group (95% CI 3.80 to 20.51, p = 0.004). Relative to baseline evaluation, muscle activities of UT decreased in the motor-control group when performing shoulder shrug with 1-kg weight (95% CI -33.06 to -1.29, p = 0.034). Moreover, the SA activity decreased in the motor-control group (95% CI -29.73 to -27.68, p<0.001) but increased in the regular-exercise group (95% CI 28.16 to 30.05, p<0.001) when performing shoulder horizontal adduction and flexion.

Conclusion

Early strengthening exercise with motor control techniques has greater benefits for improving AROM of shoulder abduction, muscle economy, and reducing compensatory scapular muscle activities in patients with neck dissection-related shoulder dysfunction before the initiation of radiotherapy.

Upper body motor function and swallowing impairments and its association in survivors of head and neck cancer: A cross-sectional study

Background

Upper body motor function and swallowing may be affected after curative treatment for head and neck cancer. The aims of this study are to compare maximum mouth opening (MMO), temporomandibular dysfunction (TMD), cervical and shoulder active range of motion (AROM) and strength, and swallowing difficulty between survivors of head and neck cancer (sHNC) and healthy matched controls (HMC) and to examine the correlations between these outcomes in sHNC.

Methods

Thirty-two sHNC and 32 HMC participated on the study. MMO, TMD, cervical and shoulder AROM, cervical and shoulder strength, the SPADI shoulder pain and disability indices, the Eating Assessment Tool (EAT-10) score, swallowing difficulty as determined using a visual analogue scale (VAS), and the location of disturbances in swallowing, were recorded.

Results

MMO and cervical and shoulder AROM and strength were significantly lower in sHNC, whereas FAI, SPADI score, EAT-10 and VAS were higher. The MMO, TMD, cervical and shoulder AROM, and cervical shoulder strength values showed significant correlations (some direct, others inverse) with one another. Swallowing difficulty was inversely associated with the MMO, cervical AROM and shoulder strength.

Conclusion

Compared with controls, sHNC present smaller MMO, lower cervical and shoulder AROM, lower cervical and shoulder strength and higher perception of TMD, shoulder pain and disability and swallowing difficulty. sHNC suffer impaired swallowing related to lower MMO, presence of TMD, cervical AROM and shoulder strength values. Improving these variables via physiotherapy may reduce the difficulty in swallowing experienced by some sHNC.

Feasibility and Effects of a Supervised Exercise Program Suitable for Independent Training at Home on Physical Function and Quality of Life in Head and Neck Cancer Patients: A Pilot Study

Introduction: Head and neck cancer patients often suffer from physical and cognitive impairments after cancer treatment. During rehabilitation, exercise therapy can improve physical function and quality of life (QoL). Surveys demonstrated patients' preference for home training with low- to moderate-intensity. This study was conducted in order to develope a suitable home-based training program. Therefore, the feasibility and effects of a low- to moderate-intensity exercise intervention on physical functions and QoL were evaluated. Methods: Training was conducted as supervised group training and consisted of mobilization, coordination, resistance, stretching, and relaxation exercises. The intervention lasted 12 weeks with 2 training sessions per week. Feasibility, attendance rate, physical function (eg, range of motion, 6-minute walk test [6MWT]), and QoL (eg, EORTC QLQ-30) were analyzed. Results: Ten out of 12 participants completed the intervention (83%) with an average attendance rate of 83%. Participants showed significant improvements in selected physical functions. For example, head rotation increased by 11.2° (P = .042), walking distance in the 6MWT increased by an average of 43.3 m (P = .010), and the global QoL scale improved by 8.2 points (P = .059). Additionally, there were positive changes in the physical function scale (P = .008), cognitive function scale (P = .015), and social function scale (P = .031) of the EORTC QLQ-30. Conclusion: Data indicate that the exercise program was feasible and had positive effects on physical function and QoL. Future research will analyze the effects of a home-based exercise program on physical function and QoL in a large-scale study.

Feasibility of eccentric overloading and neuromuscular electrical stimulation to improve muscle strength and muscle mass after treatment for head and neck cancer

PURPOSE

Treatment of head and neck cancer (HNC) results in severe weight loss, mainly due to the loss of lean body mass. Consequently, decreases in muscular strength and health-related quality of life (HRQL) occur. This study investigated the feasibility of a 12-week novel strength training (NST) and conventional strength training (CST) intervention delivered after HNC treatment.

METHODS

Participants were randomized to a NST group (n = 11) involving eccentric overloaded strength training and neuromuscular electrical stimulation (NMES), or a CST group (n = 11) involving dynamic resistance exercises matched for training volume. Feasibility outcomes included recruitment, completion, adherence, and evidence of progression. A neuromuscular assessment involving maximal isometric voluntary contractions (MIVCs) in the knee extensors was evaluated prior to and during incremental cycling to volitional exhaustion at baseline and after the interventions. Anthropometrics and patient-reported outcomes (PROs) were also assessed.

RESULTS

Although recruitment was challenging, completion was 100% in NST and 82% in CST. Adherence was 92% in NST and 81% in CST. Overall, MIVC increased by 19 ± 23%, muscle cross-sectional area improved 18 ± 22%, cycling exercise time improved by 18 ± 13%, and improvements in HRQL and fatigue were clinically relevant.

CONCLUSIONS

Both interventions were found to be feasible for HNC patients after treatment. Strength training significantly improved maximal muscle strength, muscle cross-sectional area, and PROs after HNC treatment. Future research should include fully powered trials and consider the use of eccentric overloading and NMES during HNC treatment.

IMPLICATIONS FOR CANCER SURVIVORS

Eccentric- and NMES-emphasized strength training may be useful alternatives to conventional strength training after HNC treatment.

Cancer Rehabilitation:: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 2

Cancer affects millions of individuals, and approximately half will develop functional impairments. Cancers that commonly, either from direct effects or from its treatments, result in functional impairments include breast, head and neck, brain, and spinal cord tumors. There is a plethora of potential impairments including pain, spasticity, dystonia, weakness, and neurogenic bowel or bladder. This article reviews the functional impairments frequently encountered in breast, head and neck, brain, and spinal cord tumors. The authors also discuss management and treatment options incorporated in comprehensive cancer rehabilitation to address these impairments to maximize and maintain function and quality of life.

Cancer Rehabilitation: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 1

Individuals with cancer commonly experience functional impairments. Symptoms may present immediately or years to decades following their treatment. These impairments may include fatigue, pain, neuropathy, lymphedema, or radiation fibrosis syndrome and have the potential to deleteriously impact their function and quality of life. Cancer rehabilitation is a comprehensive resource that facilitates maximizing and maintaining cancer survivors' physical, social, psychological, and vocational functioning. This article covers the common functional impairments experienced by cancer survivors and the treatment strategies used in cancer rehabilitation. Application of these services can enhance the ongoing care for cancer survivors.

Effectiveness of a guided self-help exercise program tailored to patients treated with total laryngectomy: Results of a multi-center randomized controlled trial

OBJECTIVE

To investigate the effectiveness of a guided self-help exercise program on swallowing, speech, and shoulder problems in patients treated with total laryngectomy (TL).

MATERIALS AND METHODS

This randomized controlled trial included patients treated with TL in the last 5 years. Patients were randomized into the intervention group (self-help exercise program with flexibility, range-of-motion and lymphedema exercises and self-care education program) or control group (self-care education program). Both groups completed measurements before and 3 and 6-months after randomization. The primary outcome was swallowing problems (SWAL-QOL). Secondary outcomes were speech problems (SHI), shoulder problems (SDQ), self-management (patient activation: PAM) and health-related quality of life (HRQOL: EORTC QLQ-C30/H&N35). Adherence was defined as moderate-high in case a patient exercised >1 per day. Linear mixed model analyses were conducted to investigate the effectiveness of the intervention and to investigate whether neck dissection, treatment indication (primary/salvage TL), time since treatment, severity of problems, and preferred format (online/booklet) moderated the effectiveness.

RESULTS

Moderate-high adherence to the exercise program was 59%. The intervention group (n = 46) reported less swallowing and communication problems over time compared to the control group (n = 46) (p-value = 0.013 and 0.004). No difference was found on speech, shoulder problems, patient activation and HRQOL. Time since treatment moderated the effectiveness on speech problems (p-value = 0.025): patients within 6 months after surgery benefitted most from the intervention. Being treated with a neck dissection, treatment indication, severity of problems and format did not moderate the effectiveness.

CONCLUSION

The guided self-help exercise program improves swallowing and communication.

TRIAL REGISTRATION

NTR5255.

Clinical Evaluation and Management of Cancer Survivors with Radiation Fibrosis Syndrome

OBJECTIVES

To define radiation fibrosis and radiation fibrosis syndrome; review the basics of radiotherapy, the pathophysiology of radiation injury, and the principles of clinical evaluation and management of the common late effects resulting from radiation therapy for cancer treatment.

DATA SOURCES

Peer-reviewed journal articles, book chapters, Internet.

CONCLUSION

There is no cure for radiation fibrosis syndrome, but supportive treatment of its clinical sequelae can potentially result in improved function and quality of life.

IMPLICATIONS FOR NURSING PRACTICE

The sequelae of radiation fibrosis syndrome can often be improved with early detection and supportive care by a multidisciplinary team including cancer rehabilitation physiatrists, oncologists, oncology nurses, nurse practitioners, physical therapists, occupational therapists, and speech and language pathologists.

Do patients benefit from physiotherapy for shoulder dysfunction following neck dissection? A systematic review

OBJECTIVE

Accessory nerve palsy affects a proportion of patients following neck dissection, and results in shoulder dysfunction and regional pain. This project aimed to establish the evidence supporting post-operative physiotherapy for the shoulder following neck dissection.

METHOD

A systematic review was conducted of prospective trials investigating the efficacy of rehabilitation for shoulder or upper limb dysfunction and pain following any type of neck dissection.

RESULTS

A total of 820 papers were identified; through a staged review process, 7 trials were found that fulfilled the inclusion criteria. These included three randomised, controlled trials and four non-randomised studies. Five out of the seven trials demonstrated a statistically significant benefit of physiotherapy.

CONCLUSION

Current evidence shows a benefit from physiotherapy in patients with shoulder dysfunction following neck dissection. Some evidence suggests progressive resistance is superior to other types of physiotherapy. Long-term benefit and cost efficacy have not been studied.

Postural balance in pediatric posterior fossa tumor survivors: Through impairments to rehabilitation possibilities

BACKGROUND

The rehabilitation after pediatric brain tumors is a pressing issue in current neuro-oncology. The purpose of this study was to reveal the peculiarities of postural stability in pediatric posterior fossa tumor survivors as compared to the healthy controls. Additionally, we aimed to determine the feasibility of the balance biofeedback training for these patients.

METHODS

We measured 6 postural stability parameters with the eyes opened and closed in 35 patients and 25 healthy controls aged 7-17. Further, the patients were divided into two groups: the intervention and waitlist. The intervention group was the first to undergo a 2-week biofeedback training designed to enhance balance control, while the waitlist group performed only the usual exercises. Then the groups were interchanged. Pre- and post-stability scores were measured in each condition.

FINDINGS

The current results suggest the pronounced deficiency of stability in the patients. Their results in both opened and closed eyes conditions were similar. The post-training measurements revealed that some stability parameters were improved: ellipse square and mean root square oscillations in the frontal and sagittal planes.

INTERPRETATION

The patients predictably demonstrated the significantly worse stability measurements as compared to the healthy controls. Moreover, they were shown not to use visual information to correct postural balance thus prompting us to assume severe deficits of the eye movements control due to the cerebellar pathology. This specificity, as well as the post-training significant improvement, emphasizes the clinical necessity to consider them when designing the rehabilitation protocols for posterior fossa tumor survivors.

2b or not 2b? Shoulder function after level 2b neck dissection: A double-blind randomized controlled clinical trial

BACKGROUND

Selective neck dissection (SND) is a mainstay of head and neck cancer treatment. A common sequela is shoulder syndrome from spinal accessory nerve (SAN) trauma. Extensive dissection in neck levels 2 and 5 leads to SAN dysfunction. However, it is not known whether limited level 2 dissection reduces SAN injury. The purpose of this double-blind randomized controlled trial was to determine whether omitting level 2b dissection would improve shoulder-related quality of life and function.

METHODS

Patients with head and neck cancers undergoing surgery were randomized 1:1 to SND without level 2b dissection (group 1) or with it (group 2) on their dominant-hand side. Patients, caregivers, and assessors were blinded. The primary outcome was the change in the Neck Dissection Impairment Index (NDII) score after 6 months. An a priori calculation of the minimally important clinical difference in the NDII score was determined to establish a sample size of 15 patients per group (power = 0.8). Secondary outcomes included shoulder strength and range of motion (ROM) and SAN nerve conduction. The trial was registered at ClinicalTrials.gov (NCT00765791).

RESULTS

Forty patients were enrolled, and 30 were included (15 per group). Six months after the surgery, group 2 demonstrated a significant median decrease in the NDII from the baseline (30 points) and in comparison with group 1, whose NDII dropped 17.5 points (P = .02). Shoulder ROM and SAN conduction demonstrated significant declines in group 2 (P ≤ .05). No adverse events occurred.

CONCLUSIONS

Level 2b should be omitted in SND when this is oncologically safe and feasible. This allows for an optimal balance between function and cancer cure.

Strategies of complementary and integrative therapies in cancer-related pain-attaining exhaustive cancer pain management

PURPOSE

Complementary integrative therapies (CITs) correspond to growing demand in patients with cancer-related pain. This demand needs to be considered alongside pharmaceutical and/or interventional therapies. CITs can be used to cover certain specific pain-related characteristics. The objective of this review is to present the options for CITs that could be used within dynamic, multidisciplinary, and personalized management, leading to an integrative oncology approach.

METHODS

Critical reflection based on literature analysis and clinical practice.

RESULTS

Most CITs only showed trends in efficacy as cancer pain was mainly a secondary endpoint, or populations were restricted. Physical therapy has demonstrated efficacy in motion and pain, in some specific cancers (head and neck or breast cancers) or in treatments sequelae (lymphedema). In cancer survivors, higher levels of physical activity decrease pain intensity. Due to the multimorphism of cancer pain, certain mind-body therapies acting on anxiety, stress, depression, or mood disturbances (such as massage, acupuncture, healing touch, hypnosis, and music therapy) are efficient on cancer pain. Other mind-body therapies have shown trends in reducing the severity of cancer pain and improving other parameters, and they include education (with coping skills training), yoga, tai chi/qigong, guided imagery, virtual reality, and cognitive-behavioral therapy alone or combined. The outcome sustainability of most CITs is still questioned.

CONCLUSIONS

High-quality clinical trials should be conducted with CITs, as their efficacy on pain is mainly based on efficacy trends in pain severity, professional judgment, and patient preferences. Finally, the implementation of CITs requires an interdisciplinary team approach to offer optimal, personalized, cancer pain management.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Comparison of hospital based and home based exercise on quality of life, and neck and shoulder function in patients with spinal accessary nerve injury after head and neck cancer surgery

OBJECTIVES

The purpose of this study was to compare the effects of hospital-based and home-based exercise programs on quality of life (QOL) and neck and shoulder function of patients who underwent head and neck cancer (HNC) surgery.

METHODS

This clinical trial included 40 patients with neck and shoulder dysfunction after HNC. The exercise program included range of motion (ROM) exercises, massage, stretching, and strengthening exercises. Twenty patients who were assigned to the hospital-based exercise group performed physical therapy for 40 min three times a week for four weeks, and the remaining 20 patients were assigned to the home-based group. The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), the EORTC Head and Neck Questionnaire (EORTC QLQ-H&N), the Neck and Shoulder Disability Index (NDI), ROM, and numeric rating scale (NRS) were assessed before and after the exercise program. The program consisted of a 10-minute ROM to the neck and shoulder, a 10-minute massage, and 15 min of progressive resistance exercises, followed by a five-minute stretching exercise.

RESULTS

There were statistically significant differences in the changes of neck and shoulder disability index (p < .05). Additionally, there were significant differences in neck extension and rotation ROM and NRS in the hospital-based group compared with the home-based group (p < .05). QOL was not significantly different between the two groups.

CONCLUSIONS

Home-based exercise was effective for improving QOL, shoulder function, and pain relief. Hospital-based exercise had better effects on physical function of the neck and shoulder and reduced pain.

Interventions for promoting habitual exercise in people living with and beyond cancer

BACKGROUND

This is an updated version of the original Cochrane Review published in the Cochrane Library 2013, Issue 9. Despite good evidence for the health benefits of regular exercise for people living with or beyond cancer, understanding how to promote sustainable exercise behaviour change in sedentary cancer survivors, particularly over the long term, is not as well understood. A large majority of people living with or recovering from cancer do not meet current exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important for understanding the most effective strategies to ensure benefit in the patient population and identify research gaps.

OBJECTIVES

To assess the effects of interventions designed to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following secondary questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals and/or healthcare professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with better behavioural outcomes? What behaviour change techniques (BCTs) are most often associated with increased exercise behaviour? What adverse effects are attributed to different exercise interventions?

SEARCH METHODS

We used standard methodological procedures expected by Cochrane. We updated our 2013 Cochrane systematic review by updating the searches of the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, Embase, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro up to May 2018. We also searched the grey literature, trial registries, wrote to leading experts in the field and searched reference lists of included studies and other related recent systematic reviews.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared an exercise intervention with usual care or 'waiting list' control in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

DATA COLLECTION AND ANALYSIS

In the update, review authors independently screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that could not be safely excluded without assessment of the full text (e.g. when no abstract is available). We extracted data from all eligible papers with at least two members of the author team working independently (RT, LS and RG). We coded BCTs according to the CALO-RE taxonomy. Risk of bias was assessed using the Cochrane's tool for assessing risk of bias. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. If statistical heterogeneity was noted, a meta-analysis was performed using a random-effects model. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation (SD) of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate the standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we narratively synthesised studies. The quality of the evidence was assessed using the GRADE approach with the GRADE profiler.

MAIN RESULTS

We included 23 studies in this review, involving a total of 1372 participants (an addition of 10 studies, 724 participants from the original review); 227 full texts were screened in the update and 377 full texts were screened in the original review leaving 35 publications from a total of 23 unique studies included in the review. We planned to include all cancers, but only studies involving breast, prostate, colorectal and lung cancer met the inclusion criteria. Thirteen studies incorporated a target level of exercise that could meet current recommendations for moderate-intensity aerobic exercise (i.e.150 minutes per week); or resistance exercise (i.e. strength training exercises at least two days per week).Adherence to exercise interventions, which is crucial for understanding treatment dose, is still reported inconsistently. Eight studies reported intervention adherence of 75% or greater to an exercise prescription that met current guidelines. These studies all included a component of supervision: in our analysis of BCTs we designated these studies as 'Tier 1 trials'. Six studies reported intervention adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendations: in our analysis of BCTs we designated these studies as 'Tier 2 trials.' A hierarchy of BCTs was developed for Tier 1 and Tier 2 trials, with programme goal setting, setting of graded tasks and instruction of how to perform behaviour being amongst the most frequent BCTs. Despite the uncertainty surrounding adherence in some of the included studies, interventions resulted in improvements in aerobic exercise tolerance at eight to 12 weeks (SMD 0.54, 95% CI 0.37 to 0.70; 604 participants, 10 studies; low-quality evidence) versus usual care. At six months, aerobic exercise tolerance was also improved (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants; 7 studies; low-quality evidence).

AUTHORS' CONCLUSIONS

Since the last version of this review, none of the new relevant studies have provided additional information to change the conclusions. We have found some improved understanding of how to encourage previously inactive cancer survivors to achieve international physical activity guidelines. Goal setting, setting of graded tasks and instruction of how to perform behaviour, feature in interventions that meet recommendations targets and report adherence of 75% or more. However, long-term follow-up data are still limited, and the majority of studies are in white women with breast cancer. There are still a considerable number of published studies with numerous and varied issues related to high risk of bias and poor reporting standards. Additionally, the meta-analyses were often graded as consisting of low- to very low-certainty evidence. A very small number of serious adverse effects were reported amongst the studies, providing reassurance exercise is safe for this population.

Functional outcomes and quality of life after a 6-month early intervention program for oral cancer survivors: a single-arm clinical trial

Background

Advanced treatment of oral cancer increases survival rates; however, it also increases the risk of developing shoulder dysfunction, dysphagia, oral dysfunction, donor site morbidity and psychological issues. This single-arm preliminary pilot study aims to explore the effects of a six-month early intervention program following reconstructive surgery in oral cancer survivors.

Methods

A total of 65 participants were analyzed following reconstructive surgery. Outcome measurements were taken during the first visit, and at one, three and six months after reconstructive surgery.

Results

Scapular muscle strength and shoulder range of motion progressively improved during the 6-month follow-up. The mean Disability of the Arms, Shoulder and Hand (DASH) score showed significant improvement at 1 month (p < .001). Health related QoL showed significant differences between baseline and 6-months post-surgery scores on global health and on most of the function and symptom scales. The predicted return-to-work rate was 80% at one year after the operation. Return-to-work rate differs in different vocational types, with a higher rate of return in the skilled or semi-skilled (87.5%) and self-employed (86.7%).

Conclusions

We suggest that early integrated intervention program with a follow-up of at least six months following reconstructive surgery may help develop and identify intervention guidelines and goals in the initial six months of treatment following neck dissection in oral cancer survivors.

Uncertain effect of preventative shoulder rehabilitation for patients who underwent total laryngectomy with neck dissection

INTRODUCTION

Total laryngectomy (TL) with neck dissection (ND) is considered as crucial management for advanced-stage of laryngeal cancer. Shoulder dysfunction has long been recognized as a potential complication resulting from neck dissection. The aim of this study was to evaluate the effect of early prophylactic rehabilitation program in patients who underwent TL with ND.

METHODS

A prospective, nonrandomized design was used. Seventy-six participants who underwent TL with ND were assigned into either an intervention or a control group. The control group received current standard care with no formal shoulder exercise provided, while the intervention group attended early preventive rehabilitation lasting 12 weeks. Participants were assessed at baseline, and at 3 and 6 months after surgery. Measured outcomes included shoulder function and patient-reported quality of life. General linear models with repeated measures were used to examine outcome changes in both groups over the designated assessment intervals.

RESULTS

Improvement in shoulder function and patient-reported quality of life were both statistically significant over time, with no significant difference between control or intervention groups, indicating little or no benefit of preventative intervention on shoulder function outcomes. Analysis involving five subscales and the summary score of the quality of life questionnaire had only statistically significant improvement over time for both the control or intervention groups, except for physical well-being domain which had statistical significance both over time and between the control and intervention groups.

CONCLUSION

In this study, preventative exercise program initiated immediately after surgery had a limited impact on both shoulder function and perceived quality of life.

Which exercise prescriptions improve quality of life and physical function in patients with cancer during and following treatment? A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

Certain exercise prescriptions for patients with cancer may improve self-reported quality of life (QoL) and self-reported physical function (PF). We investigated the effects of exercise on QoL and PF in patients with cancer and studied differences in effects between different intervention-related and exercise-related characteristics.

DESIGN

We searched four electronic databases to identify randomised controlled trials investigating exercise effects on QoL and PF in patients with cancer. Pooled effects (Hedges' g) were calculated using Comprehensive Meta-Analysis software. Subgroup analyses were conducted based on intervention dimensions, including timing, duration and delivery mode, and exercise dimensions, including frequency, intensity, type and time (FITT factors).

RESULTS

We included 74 exercise arms. Patients who were randomised to exercise interventions had significantly improved QoL (g=0.15, 95% CI (0.10 to 0.20), n=67 exercise arms) and PF (g=0.21, 95% CI (0.15 to 0.27), n=59 exercise arms) compared with patients in control groups. We found a significant between-group difference for exercise delivery mode, with significant beneficial effects for supervised exercise interventions (g=0.20, 95% CI (0.14 to 0.26) for QoL and g=0.27, 95% CI (0.20 to 0.33) for PF), but not for unsupervised interventions (g=0.04, 95% CI (-0.06 to 0.13) for QoL and g=0.09, 95% CI (-0.01 to 0.19) for PF). No statistically significant differences in intervention effects were found for variations in intervention timing, duration or exercise FITT factors. Unsupervised exercise with higher weekly energy expenditure was more effective than unsupervised exercise with lower energy expenditure (z=2.34, p=0.02).

CONCLUSIONS

Exercise interventions, especially when supervised, have statistically significant and small clinical benefit on self-reported QoL and PF in patients with cancer. Unsupervised exercise intervention effects on PF were larger when prescribed at a higher weekly energy expenditure.

Development and pre-testing of a rehabilitation planning consultation for head-and-neck cancer

BACKGROUND

In contrast with other major chronic conditions such as heart disease and stroke, cancer care does not routinely integrate evidence-based rehabilitation services within the standard continuum. The objectives of the present project were to develop a rehabilitation planning consultation (rpc) for survivors of head-and-neck (hn) cancer, to test its feasibility, and to make refinements.

METHODS

Using intervention mapping, the rpc-alpha was developed by examining potential theoretical methods and practical applications relative to the program objectives. During feasibility testing, a single case series was conducted with survivors of hn cancer who had completed their cancer treatment within the preceding 11 months; iterative refinements were made after each case.

RESULTS

The rpc-alpha was led by a rehabilitation professional and was based on self-management principles. The initial consultation included instruction in a global cognitive strategy, goal-setting, introduction to available resources, action planning, and coping planning. A follow-up consultation was conducted a few weeks later. Of 9 participants recruited, 5 completed post-intervention assessments. Participants reported that the rpc helped them to make rehabilitation plans.

CONCLUSIONS

The rpc was feasible to use and satisfactory to a small group of hn cancer survivors. A pilot test of the refined version is in process.

Effectiveness and cost-utility of a guided self-help exercise program for patients treated with total laryngectomy: protocol of a multi-center randomized controlled trial

BACKGROUND

Total laryngectomy with or without adjuvant (chemo)radiation often induces speech, swallowing and neck and shoulder problems. Speech, swallowing and shoulder exercises may prevent or diminish these problems. The aim of the present paper is to describe the study, which is designed to investigate the effectiveness and cost-utility of a guided self-help exercise program built into the application "In Tune without Cords" among patients treated with total laryngectomy.

METHODS/DESIGN

Patients, up to 5 years earlier treated with total laryngectomy with or without (chemo)radiation will be recruited for participation in this study. Patients willing to participate will be randomized to the intervention or control group (1:1). Patients in the intervention group will be provided access to a guided self-help exercise program and a self-care education program built into the application "In Tune without Cords". Patients in the control group will only be provided access to the self-care education program. The primary outcome is the difference in swallowing quality (SWAL-QOL) between the intervention and control group. Secondary outcome measures address speech problems (SHI), shoulder disability (SDQ), quality of life (EORTC QLQ-C30, QLQ-H&N35 and EQ-5D), direct and indirect costs (adjusted iMCQ and iPCQ measures) and self-management (PAM). Patients will be asked to complete these outcome measures at baseline, immediately after the intervention or control period (i.e. at 3 months follow-up) and at 6 months follow-up.

DISCUSSION

This randomized controlled trial will provide knowledge on the effectiveness of a guided self-help exercise program for patients treated with total laryngectomy. In addition, information on the value for money of such an exercise program will be provided. If this guided self-help program is (cost)effective for patients treated with total laryngectomy, the next step will be to implement this exercise program in current clinical practice.

TRIAL REGISTRATION

NTR5255 Protocol version 4 date September 2015.

Muscle Strength, Body Composition, and Physical Activity in Women Receiving Chemotherapy for Breast Cancer

There is evidence to suggest that treatment of breast cancer with chemotherapy can induce metabolic changes in skeletal muscle. Women undergoing treatment for breast cancer with certain chemotherapeutic agents can experience declines in lean body mass and muscle strength and a subsequent increase in body weight. These alterations not only can lead to declines in physical function but also predispose women to weight-related chronic illness. Excess body weight may also play a role in the development or recurrence of breast cancer. There is evidence that physical exercise may improve body composition and enhance muscular endurance, flexibility, and quality of life (QOL) in women with breast cancer. While studies of aerobic, resistance, and combinations of aerobic and resistance exercise for women with breast cancer have been conducted, most studies employed supervised aerobic exercise sessions. Few studies have examined the role of resistance exercise or the combination of resistance and aerobic exercise in maintaining or increasing muscle strength while preserving lean body mass in this population. The relatively small sample sizes and short duration of physical activity interventions in previous studies make it difficult to detect dose responses to exercise training. Physical activity interventions with larger sample sizes and of longer duration are necessary to achieve long-term health outcomes. Physical activity interventions that include the older or more obese women with breast cancer are also needed, as this population may be most at risk of functional decline and the development of chronic illness. Interventions appropriate for women treated for breast cancer who have comorbid disease are also needed. Newer, more intense chemotherapy regimens may induce a differential effect on muscle strength and body composition. However, the role of physical activity during dose-dense chemotherapy protocols has not been established.

American Cancer Society Head and Neck Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

Patient-reported outcomes, body composition, and nutrition status in patients with head and neck cancer: Results from an exploratory randomized controlled exercise trial

BACKGROUND

Patients with head and neck cancer experience loss of weight and muscle mass, decreased functioning, malnutrition, depression, and declines in quality of life during and after treatment. The purpose of this exploratory randomized study was to determine the optimal timing for the initiation of a lifestyle and progressive resistance exercise training intervention (during or after radiation therapy), as determined by intervention adherence and by comparing between-group outcomes across 24 weeks.

METHODS

Sixty patients with head and neck cancer were randomized to engage in a 12-week lifestyle intervention and progressive resistance-training program either during radiation treatment or immediately after completion. The primary outcome of body composition--specifically, lean body mass, body mass index, and body fat--as well as secondary outcomes of fitness, quality of life, depression, and nutrition status were evaluated.

RESULTS

The progressive resistance-training intervention carried out during treatment did not significantly influence the primary outcome of body composition, despite a significant increase in weekly physical activity reported by the intervention group. A small-to-medium intervention effect was noted for some secondary outcomes, including fitness, quality of life, and nutrition status. Regardless of whether patients received the immediate or delayed progressive resistance-training intervention, the analysis revealed a main effect of time on body composition, fitness, quality of life, depression, and nutritional scores.

CONCLUSIONS

Although the intervention during treatment did not reduce the loss of lean body mass, delaying the exercise program until after treatment completion was associated with improved intervention adherence, a finding with important clinical implications.

Refining Measurement of Social Cognitive Theory Factors Associated with Exercise Adherence in Head and Neck Cancer Patients

Social cognitive theory (SCT) measures related to exercise adherence in head and neck cancer (HNCa) patients were developed. Enrolling 101 HNCa patients, psychometric properties and associations with exercise behavior were examined for barriers self-efficacy, perceived barriers interference, outcome expectations, enjoyment, and goal setting. Cronbach's alpha ranged from.84 to.95; only enjoyment demonstrated limited test-retest reliability. Subscales for barriers self-efficacy (motivational, physical health) and barriers interference (motivational, physical health, time, environment) were identified. Multiple SCT constructs were cross-sectional correlates and prospective predictors of exercise behavior. These measures can improve the application of the SCT to exercise adherence in HNCa patients.

Intraoperative brief electrical stimulation (BES) for prevention of shoulder dysfunction after oncologic neck dissection: study protocol for a randomized controlled trial

Background

Shoulder pain and dysfunction are common after oncologic neck dissection for head and neck cancer (HNC), due to traction, compression, and devascularization injuries to the spinal accessory nerve (SAN). Shoulder pain and dysfunction can hinder postoperative rehabilitation and hygiene, activities of daily living (ADLs), and return to work after treatment for HNC. Due to the rising incidence of human papillomavirus (HPV)-associated oropharyngeal cancer, patients are often diagnosed in the third or fourth decade of life, leaving many potential working years lost if shoulder dysfunction occurs. Brief electrical stimulation (BES) is a novel technique that has been shown to enhance and accelerate neuronal regeneration after injury through a brain-derived neurotrophic growth factor (BDNF)-driven molecular pathway in multiple peripheral nerves in both humans and animals.

Methods/Design

This is a randomized controlled trial testing the effect of intraoperative BES on postoperative shoulder pain and dysfunction. All adult participants with a new diagnosis of HNC undergoing surgery with neck dissection, including Level IIb and postoperative radiotherapy, will be enrolled. Participants will undergo intraoperative BES after completion of neck dissection for 60 min continuously at 20 Hz, 3 to 5 V, in 100-msec pulses. Postoperatively, participants will be evaluated using the Constant-Murley Shoulder Score, a scale that assesses shoulder pain, ADLs, strength, and range of motion. Secondary outcomes measured will include nerve conduction studies (NCS) and electromyographic (EMG) studies, as well as scores on the Oxford Shoulder Score (OSS), the Neck Dissection Impairment Index (NDII), and the University of Washington Quality of Life (UW-QOL) score. Primary and secondary outcomes will be assessed at 6 weeks, 3 months, 6 months, and 12 months.

Discussion

The objective of this study is to evaluate the effect of BES on postoperative clinical and objective shoulder functional outcomes and pain after oncologic neck dissection. BES has been shown to be successful in accelerating peripheral nerve regeneration in both animal and human participants in multiple different peripheral nerves. If successful, this technique may provide an adjunctive prevention option for shoulder pain and dysfunction in HNC patients.

Trial registration

NCT02268344: 17 October 2014.

Cost-effectiveness of selective neck dissection versus modified radical neck dissection for treating metastases in patients with oral cavity cancer: A modelling study

BACKGROUND

Choosing between a more or less extensive neck dissection implies a tradeoff between survival, quality of life, and costs. The purpose of this study was to determine if selective neck dissection (level I-III or I-IV) is cost-effective compared with modified radical neck dissection (level I-V) in patients with cT1-2 oral squamous cell carcinoma (OSCC) with singular nodal disease confined to level I or II.

METHODS

A decision-analytic model was developed to model quality-adjusted life years (QALYs) and costs over a lifetime horizon, based on literature.

RESULTS

The selective neck dissection strategy resulted in an expected health loss of 0.06 QALY and savings of €1351 per patient compared to modified radical neck dissection. The results were sensitive to differences in regional failure probabilities between the strategies.

CONCLUSION

With the evidence used in this model, selective neck dissection was not cost-effective compared to modified radical neck dissection. Prospective research on regional failure is needed to provide optimal treatment for patients with OSCC.

A clinic-supported group exercise program for head and neck cancer survivors: managing cancer and treatment side effects to improve quality of life

PURPOSE

The purpose of the evaluation of this clinic-supported 12-week progressive strength-training program was to assess the feasibility and impact of an exercise intervention for head and neck cancer (HNC) survivors.

METHODS

Recruitment and adherence feasibility, as well as health-related fitness measures and patient-reported symptom management were assessed on the 21 HNC survivors in the exercise program.

RESULTS

Overall, this program was feasible, as indicated by recruitment, adherence, and safety outcomes. Survivors experienced improved acute symptom management over the period of one exercise class for tiredness, depression, anxiety, drowsiness, and overall wellbeing. Over the course of the program, survivors experienced significant improvements in physical functioning outcomes and improved management of tiredness and fatigue.

CONCLUSIONS

A progressive strength-training program is feasible for HNC survivors on and following treatment and is associated with improved acute and chronic fitness outcomes and symptom management.

Impact of resistance training in cancer survivors: a meta-analysis

PURPOSE

Current evidence suggests many health benefits from physical activity during and after cancer treatment. However, the optimal exercise program for cancer survivors has not yet been established. The purpose of this meta-analysis was to summarize evidence for the efficacy of resistance training (RT) interventions to improve muscle strength and body composition among adult cancer survivors. We also investigate potential dose-response relationships between intensity, duration, and frequency of RT and assessed outcomes.

METHODS

A systematic literature review of the Clinical Trial Register, Cochrane Trial Register, MEDLINE, and EMBASE literature databases was undertaken. Studies were included if they were randomized controlled trials (RCT) comparing RT with an exercise or nonexercise control group in cancer survivors during and after treatment. Thirteen articles from 11 RCT met our inclusion criteria. We performed a random-effects meta-analysis to determine weighted mean differences (WMD) with 95% confidence intervals using the Cochrane Review Manager 5.0.25. A random-effects metaregression model was performed to examine dose-response relationships between RT variables and assessed outcomes.

RESULTS

Quantitative evidence shows a large effect of RT on lower-limb and upper-limb muscle strength (WMD: +14.57 kg, P = 0.0005 and +6.90 kg, P < 0.00001, respectively) and moderate effects on lean body mass and percentage of body fat (WMD: +1.07 kg, P < 0.0001 and -2.08%, P = 0.003, respectively). A small positive effect of RT was noted on Functional Assessment of Cancer Therapy-Fatigue (P = 0.05). Upper-limb muscle strength and percentage of body fat improved to a greater extent when RT interventions were of low to moderate intensity (≤ 75% one-repetition maximum, P = 0.042).

CONCLUSIONS

RT was shown to be associated with clinically important positive effects on muscular function and body composition in patients during treatment or in long-term follow-up.

Quality of life, shoulder range of motion, and spinal accessory nerve status in 5-year survivors of head and neck cancer

OBJECTIVE

To determine the association of neck dissection and radiation treatment for head and neck cancer (HNC) with subsequent shoulder range of motion (ROM) and quality of life (QOL) in 5-year survivors.

DESIGN

A cross-sectional convenience sample.

SETTING

Otolaryngology clinics at tertiary care hospital and Veterans Affairs medical center.

PATIENTS

Five-year, disease-free survivors of HNC.

METHODS

Demographic and cancer treatment information was collected, including type of neck dissection (none, spinal accessory "nerve sparing," and "nerve sacrificing") and radiation. QOL questionnaires were administered, and shoulder ROM was measured.

MAIN OUTCOME MEASUREMENTS

University of Washington Quality of Life (UWQOL), Functional Assessment of Cancer Therapy (FACT) Head and Neck, and Performance Status Scale for Head and Neck. Shoulder ROM measurements included abduction, adduction, flexion, extension, internal and external rotation.

RESULTS

One hundred and five survivors completed QOL surveys; 85 survivors underwent additional shoulder ROM evaluations. The nerve sacrifice group exhibited significantly poorer scores for UWQOL measures of disfigurement, level of activity, recreation and/or entertainment, speech and shoulder disability, and willingness to eat in public, FACT functional well-being, and FACT Head and Neck (P < .05). Shoulder ROM for flexion and abduction was poorest in the nerve sacrifice group (P < .05). Radiation was associated with significantly worse UWQOL swallowing (P < .05), but no other differences were found for QOL or ROM measurements. Decreased QOL scores were associated with decreased shoulder flexion and abduction (P < .05). Survivors with decreased shoulder abduction had significantly (P < .05) worse scores in disfigurement, recreation and/or entertainment, employment, shoulder disability, and FACT emotional well-being.

CONCLUSIONS

Sparing the spinal accessory nerve during neck dissection is associated with significantly less long-term shoulder disability in 5-year survivors of HNC. QOL measures demonstrated the highest level of function in the no dissection group, an intermediate level of functioning with nerve sparing, and poorest function when the nerve is sacrificed. Decreased shoulder flexion and abduction is associated with reduced QOL in long-term survivors of HNC.