Physiotherapy for patients with head and neck cancer

Research Doctorate - Doctor of Philosophy (PhD)The management of head and neck cancer is complex and challenging. Treatment frequently results in physical morbidity, such as shoulder pain and dysfunction, and facial lymphoedema. Neck dissection surgery, involving lymph node removal, is the most common treatment for head and neck cancer. Intra-operatively, the accessory nerve can become injured, even when it remains macroscopically intact, causing reduced trapezius muscle activity and weakness. Shoulder pain and dysfunction ensues, impacting on quality of life and function. Facial lymphoedema can result from the surgical removal of cervical lymph nodes and radiation therapy. The primary aim of this thesis was to investigate accessory nerve injury related to neck dissection surgery, and the effectiveness of a biomechanically specific physiotherapy intervention compared to a control group. The secondary aim was to explore the effects of facial lymphoedema on patients, and the understanding of and management of the condition by treating health professionals. The qualitative facial lymphoedema study consisted of interviews of both patients with secondary facial lymphoedema as a result of treatment of head and neck cancer, and treating health professionals. The main effect of the condition experienced by patients concerned appearance and body image. The understanding of interviewed health professionals regarding the condition was found to be similar to the patient experience, however patients experiencing facial lymphoedema were generally not referred to physiotherapy. Treating health professionals need to routinely screen for any potential negative psychological and physical effects of facial lymphoedema, and affected patients referred to physiotherapy if required. Our literature review found that little evidence exists pertaining to the effectiveness of physiotherapy on accessory nerve shoulder dysfunction after neck dissection surgery exists, with only one previous randomised controlled study published. We then undertook a case control electromyography study, to investigate any scapular muscle activity differences following neck dissection surgery in patients with clinical signs of accessory nerve injury. The upper trapezius and middle trapezius muscles of patients’ operated side were found to have significantly less muscle activity than both a healthy matched control group (p<=0.00), and their non-operated side (p =0.001). There was also significantly less electromyographic activity in the upper trapezius of the non-operated side compared with the healthy matched control group (p =0.031). A further comparative electromyography study, investigating scapular muscle activity during specific scapular strengthening exercises, found that overhead strengthening exercises were associated with higher levels of muscle activity. Scapular muscle activity findings from these innovative studies have provided crucial information to maximise the specificity of scapular muscle rehabilitation in this patient population, which then underpinned the development of a specific, graded physiotherapy intervention protocol. The major study described in this thesis was a blinded, multicentre randomised controlled trial (RCT) to investigate the short and long term effect of progressive scapular strengthening exercises on shoulder pain and dysfunction, compared to usual care in Australia. Per-protocol analysis on 52 participants /53 shoulders demonstrated that the intervention group had statistically significantly higher active shoulder abduction at 3 months compared to the control group (+26.6°; 95% confidence interval [CI] 7.28 to 45.95; p= 0.007). No significant differences were found between groups for the questionnaires assessing shoulder pain, function and region specific quality of life. At the 6 and 12-month follow-ups, there were no statistical differences between groups. This may reflect either a plateauing of the effect of the intervention in the long term, or the number of participants lost to follow-up. The RCT provided evidence that a progressive scapular strengthening program is more effective than usual care, for patients with accessory nerve injury after neck dissection surgery, that need to rapidly improve their active shoulder abduction. The second literature review involved the use of, and efficacy for, intra-operative accessory nerve monitoring. It found that there is minimal evidence for its effectiveness in either minimising accessory nerve injury, or as a predictor of shoulder morbidity. The studies contained in this thesis have provided novel insights which may improve both the multidisciplinary team management, and physiotherapy management, of patients affected with accessory nerve shoulder dysfunction and facial lymphoedema following head and neck cancer treatment. Further studies are required to investigate the effects of physiotherapy intervention in the long-term for accessory nerve shoulder dysfunction, the efficacy of intra-operative accessory nerve monitoring during neck dissection, and management of facial lymphoedema