Getting Ahead of Dysphagia: Prehab in Head & Neck Cancer

Speaker1:
[0:18] Oh, Emily! I'll do it for us. Hi, everyone. I'm Emily, and this is Eva, and you're listening to Speech Talk. We're your research-based book club, so you can do evidence-based practice in practice. Now let's get talking.

Speaker0:
[0:36] Oh, it was cute.

Speaker1:
[0:37] I did the whole thing.

Speaker0:
[0:38] I was listening from the floor.

Speaker1:
[0:41] Fall risk. Cognitively intact, but fall risk.

Speaker0:
[0:47] I need that PT email.

Speaker1:
[0:48] Any fun stories from this week, Emily?

Speaker0:
[0:50] This week I'm trying to start a dementia program. And my very first victim is the hardest person I could have chosen. And one of my goals is that this person will participate in a, you know, a leisure tasks, leisure task with me for five minutes. And in that five minutes, he told me he hated me. He threatened my life. The aide saw me taking him to Pocino. She asked me the next day, she goes, how did that go? Not good. Oh no so that's my fun story it it's fun to talk about yeah.

Speaker1:
[1:40] I uh i hear you and i'm so

Speaker0:
[1:43] Sorry that you were doing.

Speaker1:
[1:45] Leisure activities under duress

Speaker0:
[1:47] I know who would have thought like a a bingo ish type thing would cause so much anger don't.

Speaker1:
[1:57] Make me go there

Speaker0:
[1:58] What about you even But what are your fun stories this week?

Speaker1:
[2:02] I had a guy who he got sent out. He came back. He and I had worked together a long time ago for feeding and swallowing. And during that time, we had like rehabbed his eating. He came in on puree. We got him up to McSoft.

Speaker1:
[2:21] And I was like, all right, so moving forward, it's like, you're completely okay to go ahead and have advanced textures. And he was like, but I don't want to because I need my food pureed so that my body can process it. So with that context in mind, this time he was a cock pickup. And I was like all right we're doing attention and memory aids because he wants to go home and I want to be able to show that he can like use a calendar and make appointments and you know manage stuff and we were going like 10 rounds on how to use his phone he was like well I want my I'm going to figure my phone out my own time and I was like you haven't so far so like why are you going to start? Can I help you with this? And he was like, no, no, no. I need a friend to do it. And I was like, okay, but I haven't seen you have any friends in the building, so, like, it's my job. I can help you. I didn't put it like that, but that was the gist. And he was like, well, I'm just not going to use my phone. And I was like, okay, why didn't we start there? Why would you just, like, I don't use my phone?

Speaker1:
[3:37] So that was, like, 30 minutes of just back and forth, only to find out he doesn't want to use it. Ta-da!

Speaker0:
[3:47] I don't know, Eva. I think that you and I need a lesson in fun because our stories this week are trash. We are not having fun this week. This week was not fun.

Speaker1:
[4:00] Have more fun. No, no. The week is young and I'm already smacking my head against a wall. Anyways, what are we talking about this week, Emily?

Speaker0:
[4:09] So this week we are talking about prehab for head and neck cancer patients.

Speaker1:
[4:17] Prehab, baby. It's not rehab. It's prehab. It's like rehab's newer, fancier friend. And I really want to do this because I've had a few head and neck cancer patients. I've only had a handful in my tenure, and some of them were post-operative. But this year, for the first time, I had people who came into our facility before they either went surgery or chemo. And I was like, I'm sure we could do some stuff. Let's do some exercises. And so the more I started to look into prehab, the more I was like, oh, this is a really good idea. This is something that should be standardized and I should know more about and be routine for folks who we have come in who are going to be undergoing HNC treatment.

Speaker0:
[5:09] Yeah I think I think that kind of speaks to our sites we are not getting a lot of prehab people because most of the people that we have are either you know they're short term for other reasons not you know like planned cancer treatment people who happen to come to a skilled nursing facility I've also had just a couple people and it's like they had developed cancer whilst living in the facility so then we're like okay so this is kind of where we're going with this and then like you said Eva too same like people are in in the midst of treatment and they're like what is a speech, pathologist and I'm like you poor poor unfortunate soul so sad where have you been where you been And I think that kind of speaks to maybe like, you know, general people's understanding of speech therapists and what they do in that kind of setting. And I'd assume most doctors are pushing for speech therapists, but you never know.

Speaker1:
[6:19] There's, you never know. And man, I've had the range. I haven't had many, but of the prehab patients I have had, I had woman who was like, I'm going to get in there. Let me do all the exercises. Like I'm really motivated. I want to maintain as much function as possible. She was totally on board. I had another guy who told me to get the F out of his room and flip this tray. And I was like, Hey man, it's your glossectomy. Like I'm just here to help you preserve lingual function. They're going to take a big old chunk out of your tongue.

Speaker0:
[6:50] I want to help you prepare for that. It's so funny. Cause I, that's, I always think whenever I have a head and neck, head and neck cancer patient, they're always so spicy. They are like the spiciest chilies of the bunch. They always come in like hot and fired up about something. Like, I don't know what we're getting into, but I'm getting yelled at and we're yelling together.

Speaker1:
[7:12] We're yelling together. Let's turn that yelling at me into a yelling together and harness it for like a really good buddy treatment where we're both really invested.

Speaker1:
[7:26] Okay, so this episode we're going to explore a literature review by Lowen et al titled Prehabilitation for Head and Neck Cancer Patients. Pretty straightforward. So Emily, tell us some fun facts from the article.

Speaker0:
[7:43] Fun facts. So up to 80% of the patients treated for oropharyngeal cancer will have swallow dysfunction in daily life.

Speaker1:
[7:53] So this is a large percentage.

Speaker0:
[7:55] It's a large percentage.

Speaker1:
[7:56] 80 out of 100. That's a lot of them. Yeah. So as both the incidence of oral pharyngeal head and neck cancer increases and there are improved survival rates, it means that there are going to be more patients with needs for dysphagia intervention.

Speaker0:
[8:11] So this research was really looking at the need for increased focus on maximizing long-term function with prevention being a key approach. And prevention leads us to prehab. da-da-da.

Speaker1:
[8:24] It's pre. It's fun. So what is prehab? Well, like so many things in this young, young field of ours, it's got variable definitions. For the purposes of their research, the article selected two key definitions. One, pretreatment prehabilitation, which describes exercises prior to the start of acute cancer treatment, and treatment concurrent prehab, which describes exercises prior to impairment, but it already happens with the onset of cancer treatment. So it's occurring concurrently.

Speaker0:
[9:00] Right. And exercises prior to impairment. Like, dysphagia impairment. So we are treating the dysphagia before it's even a thing. All right.

Speaker1:
[9:12] Methods section. Uh-huh. I'm like really in a cheerleader mood today.

Speaker0:
[9:16] Yeah, you are. I was going to say that. You were a cheerleader today. I just feel so like...

Speaker1:
[9:20] It was a long day.

Speaker0:
[9:22] Pumped up.

Speaker1:
[9:23] I'm really cheering myself on right now.

Speaker0:
[9:25] We have to make it.

Speaker1:
[9:27] All right. So the methods.

Speaker0:
[9:29] The authors reviewed some 29 existing studies on prehabilitation for head and neck cancer. They looked at different types of prehab interventions like exercise programs, nutritional plans, and psychosocial support. They just wanted to see how these things kind of impacted the patient outcomes.

Speaker1:
[9:49] Yeah, and they looked at patient outcomes both immediately after, say, radiation therapy and 12 months after and a little longer after that. So they did try to get some understanding of immediate versus longitudinal impact. And what were their results? Well, they found that prehab can help preserve swallow function, improve nutritional status, and enhance overall quality of life. We love that QOL.

Speaker0:
[10:16] Patients who did prehab were better able to handle treatment and had fewer complications like aspiration or severe weight loss.

Speaker1:
[10:24] They also noted that psychosocial support and patient education played a role in reducing anxiety and improving the patient experience. So they ended up measuring success in a variety of methods. They did some questionnaires, and that's how they were able to understand the improvements in quality of life or reducing anxiety. They also did some really tangible ones, such as measuring patient oral opening. They're doing their FOIS scales. Instrumental studies were not as prevalent because they're not as accessible for a variety of sites, so they tried to focus more on things that clinicians could take a look at, like presence of a pipe tube. On a more serious note, one of the things that they looked at for indicators of success was just survival rate. And in as much as we have been making jokes and trying to put the fun in cancer treatment, That was kind of a sad part of reading the story is just recognizing that cancer's a bitch. Not all of these patients are going to make it. Yeah. So, you know, quick moment of appreciation for the gravity there.

Speaker0:
[11:36] I want to talk about the results a little bit because, like, it makes sense, right, that these, like, doing these exercises or talking to people about their diet, having conversations earlier, giving that psychosocial support. Would help these patients' outcomes because they're able to understand better what's going on with them. And who are the experts in the room but us? If anybody is supposed to talk to people about the changing in their taste because they had a laryngectomy or trying to keep eating, just through it being exercised or, you know, putting together support groups with other people who have dysphagia so that they can have some camaraderie with other people who are doing the same things. And those are all things that speech therapists do.

Speaker1:
[12:27] Yeah. I find often and unfortunately that I'm the one leading those discussions. Patients are aware maybe of diagnoses that they have, whether, you know, it's cancer or something else, progressive degenerative. And no one's told them what it's going to do to them. They just have been told you have this. And it's not easy necessarily to take the plunge on leading that discussion. And I certainly feel underqualified for it a lot of the time. But every time I do start that conversation, people always say thank Thank you. So if you're out there trying to have those conversations for the first time, you're doing the right thing. I know it's hard.

Speaker0:
[13:12] I remember like in our stuttering class, ironically, we talked a lot about counseling and just leaving that room for silence or space and letting people talk about their feelings. And I feel like this is a very poignant place to talk about those things. Like we will not have cancer. We can give them all the exercises or we can talk to them about different diets or what it might feel like at different stages based on maybe other people that we've seen. But, you know, we we can't we can't walk in those shoes. So just giving them space to talk about that and be that person to listen to them in those times like that. That's an important, important part. You're listening to their concerns as it pertains to their swallow and complications with their food and how they're feeling about that. All of that's a very important part of that psychosocial support element.

Speaker1:
[14:11] Yeah. And. Sort of full circle, that professor we had actually passed due to a rapidly progressive form of cancer. So another moment out there for, you know, the gravity of this topic. She was a really wonderful teacher.

Speaker0:
[14:30] She obviously made a big impact on us. Shout out to our professor Caggiano because she really was just the best.

Speaker1:
[14:38] So let's move on to clinical takeaways. Let's start off with clinical takeaways for swallowing exercises and baseline assessment. I'm going to lead with a quote from the article. Early implementation of swallowing exercises can help preserve swallow function and reduce risk of aspiration. So the exercises they implemented or observed to be implemented across the articles they reviewed ranged from general stretching and range of motion to trismus, like block jaw, and swallowing specific exercises. Emily, why don't you tell us which of those were most commonly used and or impactful?

Speaker0:
[15:16] The most common swallowing specific exercise was the Mendelssohn. They used that for both swallow, Shakir, and Maseco maneuver. Then in dosage, they did 10 repetitions of an exercise three times a day for the duration of their radiation therapy.

Speaker1:
[15:33] Yeah, and Emily and I ended up having a really good conversation on what the heck is a dose? And we were so glad that they defined it in this article. They have a little helpful formula, which is that exercises times reps times sessions a day equals dosage. So, for example, if you are assigning somebody five exercises times five reps, three times a day, that's five times five times three. And my very quick mental math will make that 5 times 5 is 25 times 3 is 75 so the dose would be 75 in that example. Most of the programs recommended about 160 daily repetitions Typically spread throughout the day, not just sitting down and busting out 160 oral motor pharyngeal exercises.

Speaker0:
[16:22] Unless you're my client and then we sit there and do 160 repetitions in our 30-minute treatment, like, let's go.

Speaker1:
[16:32] By the end, your tongue is just like lolling out like a cartoon.

Speaker0:
[16:35] Yeah, they get mad. It's okay. It's for their good.

Speaker1:
[16:38] Yeah, it's for your own good that you hurt. I actually do tell my patients that even though when we're doing this together, it's going to be a little awkward, it's not going to be uncomfortable. However, throughout the course of the day, it's going to get more uncomfortable. Your mouth does not do these movements. Your throat does not do these movements regularly. And if you do it 160 times, you're going to feel a little sore. So let's get some buy-in. Start early with the simpler ones like the effortful swallow, which apparently Emily hates. No, I hate it.

Speaker0:
[17:10] I'm not doing that. It doesn't make any sense. They say, pretend you're swallowing peanut butter. What does that mean? No, I say a grape. A grape?

Speaker1:
[17:19] Yeah, like imagine you're swallowing a whole grape.

Speaker0:
[17:23] Well, then you have to make a bowl with your tongue. Do you hold the bowl? That's extra mental load for me. No, if I want someone to do an effortful swallow, I'm giving that person 10 saltines no water that is effort what they are just drying out their mouth and i'm swallow and i'll like you know i have a cup of water i was like if you really need it you could take a sip but if you don't need it let's go we're going do it work.

Speaker1:
[17:52] Hard dang you are a strict boss emily my goodness

Speaker0:
[17:57] Back to the article i like this article because they looked at the importance of the details in the exercise regimen. So unlike my programs where we're just drilling these out, they really looked at, utilizing their program to either improve strength and endurance of a muscle and, or they looked at improving the strength and the power of a muscle. So strength and endurance requires more repetitions per set. So like think eight to 12 instead of five. And then the program looking to improve strength and power really does fewer repetitions per set. So six or eight.

Speaker1:
[18:39] Yeah. And that being said, the optimal number of sets and reps has yet to be figured out. As per usual, we're always trying to flag potential research opportunities. You CCC, SLP, PhDs, get out there, find that golden number of sets and reps.

Speaker0:
[18:56] I mean, that will be a podcast episode one of these days, but that is like a hot topic in our field. Do swallowing exercises actually work? So the more research, the better.

Speaker1:
[19:11] Outcome measures range from patient and clinician reports to objective tools like weight, mouth opening, G-tube use, etc., etc. Next clinical takeaway.

Speaker1:
[19:22] Let's collaborate, particularly with our nutritionists or our dieticians.

Speaker0:
[19:27] And I quote, nutritional optimization before treatment has been associated with improved treatment tolerance and overall outcomes. So we're looking at avoiding excessive weight loss here.

Speaker1:
[19:41] Yeah, your body's going to go through a lot in cancer treatment and making sure that we're also not dealing with malnutrition, making sure your body has energy. It's quite important.

Speaker0:
[19:54] Yeah, definitely balancing that tricky teeter of... I don't want to eat because I'm going through cancer treatments and or I'm anxious about cancer treatment and I can't swallow now because of my cancer treatment. So what can I eat?

Speaker1:
[20:09] Next is breathing and voice exercises. So respiratory and voice training were found to be beneficial in maintaining respiratory muscle strength and vocal quality. Why is that important? Not just for talking, but we also know that maintaining vocal quality is a good indicator for airway protection.

Speaker0:
[20:27] We were talking about psychosocial support and communication support. So psychosocial support as a part of rehabilitation can reduce patient anxiety and improve quality of life. People genuinely felt more prepared when they were able to talk about, you know, things that they were going to be doing. Maybe, you know, we need to do some voice banking or really talk to people about what's going to be happening with their ability to communicate as time's moving forward. So leading those conversations, being an ear to people about their perceived ideas about those different communication systems and how those things are going to change is super, super important.

Speaker1:
[21:15] Yeah. Again, a lot is people feeling better equipped to deal with what is about to come to them just through talking. Never underestimate the power of talking. Next, let's do patient and family education. So this kind of ties into the psychosocial support, but the researchers found patient and family education regarding the benefits

Speaker1:
[21:39] of prehab can empower them to participate more actively. So again, we all know that patients have better outcomes if they have good community support and making sure that family is educated on what's about to happen and gets them more on board and improves their ability to be there for or help reinforce whatever rehab or treatment the patient is going to undergo. Not really in any category, but some other fun takeaways.

Speaker0:
[22:10] Prehabilitation can provide head and neck cancer patients and they're treating clinicians with baseline measures. So we want to see what they were like before everything started happening. That means that we are collecting early data points that may assist with cancer treatment planning.

Speaker1:
[22:29] Yeah. Well, how we're always talking about prior level of function, now is your chance to know what prior level of function is. It's like, get that data, go, collect it.

Speaker0:
[22:38] And then prehabilitation before surgery and radiation therapy can provide the opportunity for habit formation. So the earlier that we can get to people to, you know, start developing that buy-in, make our patients like us so they want to come back to us and do the exercises with us, guilt them into coming to see us.

Speaker1:
[23:00] Guilt, best weapon.

Speaker0:
[23:02] I know, my mother knows best.

Speaker1:
[23:07] And within that, the routine is important. The habit formation is important. Having patients come back from radiation or dialysis or... Any number of chronic treatments that can just zap the life out of you, you know, patients get back to the facility. They're super tired. It's really helpful if their exercises are routine. They're not learning it. They're not trying to begin it for the first time.

Speaker0:
[23:37] Yeah.

Speaker1:
[23:38] And on that kind of get to folks early, Emily's friend did some fun stuff. Tell us about it, Em.

Speaker0:
[23:43] My friend, my friend Lauren Sweet and her colleague Sarah Netro did some research which found that patients who started dysphagia therapy before or within three months of radiation had 100% returned to a regular diet without feeding tubes. In contrast, if therapy began after three months, only 24% returned to a regular diet. Another 24% managed on a modified diet. Over half remained feeding tube dependent.

Speaker1:
[24:14] There were 41 referrals of the 41 patients. 20 were seen before or within the three months, and 21 were seen greater than three months to seven years post-radiation.

Speaker0:
[24:26] But that's incredible. Just having a speech therapist in your lane before or within three months of your radiation, 100% return to a regular diet without feeding tubes, that's perfect. You can't get better than 100%.

Speaker1:
[24:43] It's quite hard. It is quite hard. And of the rehab treatments they note, some of these things may sound familiar. They did prophylactic or, you know, preventative exercises, stretching during radiation treatments. They did use fees as an assessment measure. They did myofascial release or manual therapy. They did counseling and training to navigate changes. They did ongoing communication with patients' medical team. And expiratory muscle strength training. So some of those we did not go over, but certainly exercise, measuring,

Speaker1:
[25:25] counseling, communication, and respiratory work are all things that the research had touched on. Okay, moving on. Emily and I love to bring in cognition. With every dysphagia story, there's a cognitive story.

Speaker0:
[25:39] I know, they just go hand in hand, don't they? The authors acknowledge that the cognitive changes can occur and there's growing interest in including cognitive exercises and prehabilitation.

Speaker1:
[25:50] I once heard it called chemo brain.

Speaker0:
[25:52] Yeah. Oh, I was going to say cancer brain. You're right. It's chemo brain. But yeah, all of the medicines are impacting their cognition and you see that decline with people.

Speaker1:
[26:03] Yeah. So knowing that that is going to be or will likely be a part of your plan of care and navigating that with your patients is an important factor for you as a clinician and kind of lends itself back to that idea of starting earlier means there's less of a cognitive lift later once they're undergoing treatment, which will be difficult, especially if they're seeing cognitive change.

Speaker0:
[26:26] Yeah.

Speaker1:
[26:27] Let's really quickly dip into limitations of this study before we begin to wrap up. So one, there was kind of some small and heterogeneous studies.

Speaker0:
[26:39] So the authors pointed out that many of the existing studies on prehabilitation are relatively small and they use varied methodologies. That means that while the results are promising, they're just not yet consistent across large populations or standardized protocols. Story of our life.

Speaker1:
[26:58] A story of our lives, also a story of our lives, limited standardization. They noted there is a huge lack of standardized prehab programs. Prehab programs, say that 10 times fast. This makes it really hard to compare results and to create universal guidelines. So get out there. Let's do more research. Hear it for the research wave. But yes, if you are now looking for what can

Speaker1:
[27:23] I do for prehab, what guidelines are out there? Guess what? They're going to be pretty varied.

Speaker0:
[27:28] The other limitation that they talked about was the short window between diagnosis and the start of treatment. And that can make it challenging to implement a full prehabilitation program. Right you find the cancer you hurry up and get it treated so timeline is wicked fast and this time constraint can limit the extent of the interventions like if you don't have time to talk about what's

Speaker0:
[27:54] going on you don't have time you just kind of pumping through what needs to get done yeah.

Speaker1:
[28:00] So that was sort of our short dive deep dive into prehab for head and neck cancer patients. We hope you guys found this helpful.

Speaker0:
[28:12] Okay. Meeting adjourned. Now go sneak some evidence-based practice into your team meetings.

Speaker1:
[28:20] I love it when we're cheesy. Bye.

Speaker0:
[28:25] You've been listening to Speech Talk.

Speaker1:
[28:28] Thank you everyone for coming to listen to our research book club. Until next time, keep learning and leading with research.

Speaker0:
[28:34] If you liked this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world, because as podcasters, our love language is in positive affirmations.

Speaker1:
[28:45] If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speechtalkpod.com.

Speaker0:
[28:59] If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more.

Speaker1:
[29:11] We're your hosts, Eva Johnson and Emily Brady.

Speaker0:
[29:14] Our editor and engineer is Andrew Sims.

Speaker1:
[29:17] Our music is by Omar Benzvi.

Speaker0:
[29:19] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

Speaker1:
[29:24] To learn about Speech Talk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers.

Speaker0:
[29:36] Speech Talk is a proud member of the Human Content Podcast Network.