Occupational therapy for accessory nerve palsy after radical neck dissection

Paralysis of the trapezius muscle: evaluation and surgical management

Background

Paralysis of the trapezius muscle most commonly results from iatrogenic injury to the spinal accessory nerve.

Methods

The clinical presentation and physical examination findings of trapezius palsy have been well characterized, but unfortunately the diagnosis of this condition is oftentimes missed or delayed, sometimes leading to unnecessary surgery on the rotator cuff or tendon of the long head of the biceps.

Results

The diagnosis can be confirmed using electromyography with nerve conduction studies. Although nonoperative treatment may help some patients with temporary neurapraxia of the spinal accessory nerve, nerve repair with or without nerve grafting should be performed soon for patients suspected of a nerve transection. Nerve transfers can be considered within the first year after the injury when nerve repair and grafting cannot be completed. For chronic trapezius palsy, transfer of the levator scapulae and rhomboids has been refined and represents a very successful surgical procedure. Rarely, scapulothoracic arthrodesis is considered for individuals with failed tendon transfers or multiple nerve involvement.

Conclusion

Trapezius palsy is oftentimes missed. An accurate diagnosis allows consideration of various treatment modalities that have been reported to provide good outcomes for properly selected patients.

Effects of patient-specific mobility therapy for TMJ, neck, and shoulder dysfunction after submandibular gland tumor surgery: a case report

Aims: This case report describes a patient-specific mobility therapy (PSMT) program to restore range of motion (ROM) and overcome functional limitations of the temporomandibular joint (TMJ), neck, and shoulder in a 48-year-old man who underwent submandibular gland tumor surgery.Methods: The patient also received transcutaneous electrical stimulation and ultrasound to relieve pain. Treatment was provided four sessions per week for four weeks. The measured outcomes included the Neck Disability Index (NDI), Patient-Specific Functional Scale (PSFS), and mobility of the TMJ, neck, and shoulder.Outcomes: The ROM of the TMJ, neck, and shoulder improved from 4.00 mm to 21.00 mm, 1.67 cm to 6.40 cm, and 9.75° to 56.00°, respectively, during the 1^st intervention phase when compared with the baseline phase, and these gains were also maintained in the later phases. Furthermore, the NDI and PSFS scores improved by 12.75 points (24.50 to 11.75) and 5.25 points (2.00 to 7.25), respectively.Conclusion: These findings demonstrate the success of PSMT in conjunction with transcutaneous electrical stimulation and ultrasound in alleviating pain and improving targeted impairments for this patient following submandibular gland tumor surgery.

Exercise interventions for shoulder dysfunction in patients treated for head and neck cancer

BACKGROUND

Shoulder dysfunction is a common problem in patients treated for head and neck cancer. Both neck dissections and radiotherapy can cause morbidity to the shoulder joint. Exercise interventions have been suggested as a treatment option for this population.

OBJECTIVES

To evaluate the effectiveness and safety of exercise interventions for the treatment of shoulder dysfunction caused by the treatment of head and neck cancer.

SEARCH METHODS

We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the search was 7 July 2011.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing any type of exercise therapy compared with any other intervention in patients with shoulder dysfunction due to treatment of head and neck cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias and extracted data from studies. We contacted study authors for information not provided in the published articles.

MAIN RESULTS

Three trials involving 104 people were included. We classified one study as having low risk of bias; the others had some limitations and we classified them as having high risk of bias.Two studies (one with low risk of bias and the other with high risk of bias) applied progressive resistance training (PRT) combined with range of motion exercises and stretching; the comparison group received standard care. Pooled data demonstrated that PRT can improve shoulder pain (mean difference (MD) -6.26; 95% confidence interval (CI) -12.20 to -0.31) and shoulder disability (MD -8.48; 95% CI -15.07 to -1.88), both measured using the Shoulder Pain and Disability Index (SPADI) (range 0 to 100). Similarly, secondary outcomes were also improved: active range of motion for external rotation (MD 14.51 degrees; 95% CI 7.87 to 21.14), passive range of motion for abduction (MD 7.65 degrees; 95% CI 0.64 to 14.66), forward flexion (MD 6.20 degrees; 95% CI 0.69 to 11.71), external rotation (MD 7.17 degrees; 95% CI 2.20 to 12.14) and horizontal abduction (MD 7.34 degrees; 95% CI 2.86 to 11.83). Strength and resistance of scapular muscles was assessed in one study and the results showed a statistically significant benefit of PRT. The studies did not demonstrate a statistically significant difference in quality of life. Only two non-serious adverse events were described in the PRT group compared with none in the standard care group.One study with high risk of bias used a broad spectrum of techniques including free active exercises, stretching and postural care for a period of three months following surgery. This study did not demonstrate a difference between the exercise group and routine postoperative physiotherapy care in shoulder function and quality of life, but serious methodological limitations could explain this. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

Limited evidence from two RCTs demonstrated that PRT is more effective than standard physiotherapy treatment for shoulder dysfunction in patients treated for head and neck cancer, improving pain, disability and range of motion of the shoulder joint, but it does not improve quality of life. However, although statistically significant the measured benefits of the intervention may be small. Other exercise regimes were not shown to be effective compared to routine postoperative physiotherapy. Further studies which apply other exercise interventions in head and neck cancer patients in the early postoperative and radiotherapy period are needed, with long-term follow-up.

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

BACKGROUND

Shoulder dysfunction remains a frequent complication after neck dissection procedures for head and neck cancer.

METHODS

We conducted a pilot study to evaluate the effects of progressive resistance exercise training (PRET) on shoulder dysfunction caused by spinal accessory neurapraxia/neurectomy in patients with head and neck cancer. Twenty patients (mean age, 61 +/- 7.7 years) were randomly assigned to PRET or standard care intervention. Subjects assigned to the PRET group exercised three times per week for 12 weeks. The goal of the exercise program was to enhance scapular stability and strength of the upper extremity. The resistance-training program was progressive in terms of number of sets and repetitions performed, as well as the amount of weight lifted, depending on performance status.

RESULTS

The completion rate for the trial was 85% (17 of 20). The exercise group completed 93% of scheduled exercise sessions. Significant improvements were found in favor of the PRET group in active shoulder external rotation (p =.001), shoulder pain (p =.038), and overall score for shoulder pain and disability (p =.045).

CONCLUSIONS

The study results demonstrate a high rate of completion and adherence with our PRET program among patients with head and neck cancer. The preliminary findings, although limited, also suggest a potential therapeutic role for resistance exercise as an adjunct to standard physical therapy treatment.