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While many patients develop dysphagia during or immediately following a medical condition, patients with head and neck cancer (HNC) often develop dysphagia due to late-effect complications months or years after radiation treatment (XRT).   Patients post-radiation may swallow adequately immediately following their cancer treatment but then slowly start to complain that they can’t eat their usual diet.  This change is often due to increasing scar-like tissue called fibrosis in the radiated area.

It is helpful to understand how and why fibrosis develops.  Normal wound healing is governed by a system of cell-signaling mediators that instruct cells to fix damage by making new tissue, which often results in a scar.  When the wound is repaired, scar tissue formation stops.  For some patients the system that regulates wound healing is damaged during radiation treatment.  Since the checks and balances of this system no longer function properly, the cells continue to make scar tissue long-term resulting in increasing stiffness and loss of range of motion (ROM) over time. (Langmore 2010)  

Post-radiation fibrosis is likely why dysphagia following XRT is generally characterized by reduced movement throughout the swallowing mechanism (Kotz 2004).   

There are 2 primary factors that cause dysfunction with this population: 

  1.  The fibrosis results in tethering of swallowing structures such as the hyolaryngeal complex which must elevate, protract and approximate to protect the airway 
  2.  The fibrosis restricts movement of muscles which results in disuse atrophy.  Muscles must move to stay strong and to get strong, and the slow accumulation of fibrotic tissue causes increasing weakness as there is less movement and subsequently less use of the muscles.

Traditional therapy is ineffective

A recent study published in Head & Neck evaluated the efficacy of swallowing therapy with head and neck cancer patients with and without neuromuscular electrical stimulation (NMES).  Therapy consisted of the effortful swallow, the Mendelsohn maneuver, and the super supraglottic swallow which are well-supported in the literature as effective swallowing treatments.  The authors concluded that swallowing exercise, regardless of the application of NMES, did not make a statistically significant improvement in functioning with HNC patients.  

The authors write “For patients with head and neck cancer with moderate to severe dysphagia caused by radiation therapy, current behavioral therapies are of limited help in reversing long-term dysphagia”, and “…once post irradiation dysphagia is well established, current interventions are limited in reversing the decline in swallow function” (Langmore 2016).   

To be effective, swallowing maneuvers such as the effortful swallow, the Mendelsohn, and the super supraglottic swallow are dependent upon a patient’s ability to move their swallowing structures and muscles during the exercise.  Since decreased range of motion of the swallowing mechanism is often the primary impairment with HNC patients, it is logical to conclude that the stiffness is what prevents swallowing intervention with this population from being effective.

How can we treat this condition?

The key to successful dysphagia rehabilitation is to address the underlying impairments that are causing the dysfunctions.   In an effort to target the impairment of stiffness with HNC patients, myofascial release and manual therapy have become increasingly used components of swallowing treatment.

Myofascial release (MFR) involves a low load, long duration stretch to the myofascial complex to mobilize adhesive tissue to restore optimal length, decrease pain, break up adhesions, and improve function.  Fascia is the connective tissue that surrounds muscles, nerves, and organs, and it tightens and hardens over time in response to trauma (such as radiation treatment) (Kelly 2008). Manual therapy (MT) involves skilled passive movement of joints and soft tissue to restore range of motion.

As shown in the chart linked below, MFR/MT can be used to treat multiple aspects of the swallow.  Several muscles that cannot be reached directly can be targeted indirectly by stretching the attachment points of those muscles.

MFR/MT Target Area

What evidence do we have for MFR/MT in dysphagia treatment?

Thus far, there has been limited research about the use of MFR/MT in dysphagia treatment.  Evidence has primarily consisted of anecdotal reports of positive outcomes from clinicians and patients, but evidence in the form of research trials is emerging.    

In 2016, Krisciunas et al investigated the impact of a manual therapy program for HNC patients during radiation treatment.  The outcome measures were pain before, during, and after manual therapy and subjective range of motion (ROM) measurements.   All the patient felt that MT lessened their pain, and none experienced an increase in pain.   ROM improvements were positive but inconsistent.   The authors noted that “No change or slight increases in mobility are promising as it is commonly thought that tissue and joint movement decreases in most patients undergoing radiation”.   The authors further concluded that “[manual therapy] …. has the potential to reduce localized pain and to mitigate contractile tensions, inflammation, and hypoxia, all of which are implicated in aberrant wound healing, long-term fibrosis, and dysphagia” “…as there are no proven practices or rehabilitative behavioral or pharmacologic interventions capable of mitigating these long-term fibrosis sequel, the potential effect of manual therapy is of great interest”.

In 2017, Lewin et al at MD Anderson Cancer Center researched the potential benefit of an adjunct manual therapy program for patients with a history of HNC an average of 8 years post XRT.   All patients improved their cervical ROM and reported functional gains in swallowing, airway, voice, and patient perception.

Where do we go from here?

Myofascial release and manual therapy are promising modalities to help restore range of motion in the swallowing mechanism after HNC treatment to allow for more effective dysphagia treatment.   While more details are still needed about the most effective protocol and techniques, expected outcomes, and the potential long-term benefits, there is optimism in the dysphagia field that MFR/MT may be the key element that increases the effectiveness of swallowing therapy with this population.

References

  1. Kelly J. Myofascial Release and Other Manual Techniques in Dysphagia Management. CIAO Seminars. Continuing education course. January 2008. www.ciaoseminars.com 
  2. Krisciunas GP, Golan H, Marinko LN, Pearson W, Jalisi S, Langmore SE. (2016).  A novel manual therapy programme during radiation therapy for head and neck cancer – our clinical experience with five patients. Clin Otolaryngol. Aug; 41(4):425-31
  3. Kotz T, Costello R, Li Y, Posner M. (2004) Swallowing Dysfunction After Chemoradiation for Advanced Squamous Cell Carcinoma of the Head and Neck.  Head and Neck; 26:365-372.
  4. Langmore SE, Krisciunas GP. (2010) Dysphagia After Radiotherapy for Head and Neck Cancer: Etiology, Clinical Presentation, and Efficacy of Current Treatments.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia). June; 19:32-38.
  5. Langmore, Susan E., et al. (2016) Efficacy of electrical stimulation and exercise for dysphagia in patients with head and neck cancer: A randomized clinical trial.” Head & Neck Apr; 38 Suppl 1:E1221-31
  6. Lewin J, Woodall H, Porsche C, Barrow M, Hutcheson K. (2017) Integration of Manual Therapy Into a Speech and Swallowing Rehabilitation Program for Head and Neck Cancer.   MD Anderson Cancer Center, unpublished.

5 COMMENTS

  1. Jen. Have you done research on your own patients re Myofascial Release Therapy. For your successful outcomes anecdotally speaking, what were they able to do post treatment? How was success measured in your own clinic? Were there patients you treated who did not have ‘success.’ Because the method ‘shows promise’ should we be implementing this now?? I’m really curious about this treatment. Have those who teach the courses done research as well? Thanks Nannette Crawford SLP.

    • Great questions Nannette. I have not yet had an opportunity to be a part of any research studies on this modality, and as we all know, conducting pure “research” in treatment clinics can challenging for practicing clinicians. But that doesn’t mean that we can’t use critical thinking to determine if what we are doing in therapy is effective. Many of the H&N CA patients I work with are treatment refractory for swallowing exercise alone during previous therapy attempts. I find that after swallowing therapy with the addition of MFR, patients have improvements in swallowing function defined by improved ease in swallowing and a greater variety of food consistencies that they can swallow. I’m starting to collect data on pre/post EAT-10 scores. I also see changes in post-therapy MBSs characterized more by improvement in symptoms (less residue, less aspiration) than improvements in actual function (impaired epiglottic inversion both pre and post-treatment).
      There are certainly patients who do not have success with MFR. Lack of progress seems to be due mostly to the severity of the fibrosis or the dysphagia. Poor patient compliance also appears to impact outcomes. I think it’s fair to say that those are the same factors that limit progress with other therapies too.
      As for if we should adopt a treatment that ‘shows promise’, I think that’s up to your clinical judgement based on your patients and what sort of outcomes you’re getting with this population. Personally, I believe that if what we’re currently doing with H&N CA patients is ineffective (Langmore 2016), then a treatment that is theoretically sound (poor ROM with these patients, MFR improves ROM) is worth examining. I think that “theory base medicine” is a valid approach when “evidence” is not yet available.
      As for your last question, I am not aware of any published research from the course instructors.
      Let me know if you have any other questions. -Jen

  2. Hi Jen,
    Thanks for a great article. MFR has been my primary modality for decades, both in my PT practice as well as in my workshops. I’ve not yet met John Kelly, but have heard really good things about the workshop he teaches. My approach to MFR has taken on some different directions than the traditional one that you speak of and, like nearly anything in science and life; there are competing/conflicting theories on how things work. Without sidetracking your great post, suffice it to say that there are many who feel that it is an impossibility to singularly and selectively impact fascia (or any other tissue under the skin, for that matter) and that the effects of our engagement, MFR or otherwise, comes via neurodynamic/neurological effects and potential autonomic/contextual changes. But the work is effective.

    In my workshop I supply a few more references you may find interesting. The first two pertain to MFR/manual therapy and its impact on dysphagia. These and many other relevant papers/summaries listed at: http://www.waltfritzseminars.com/myofascialresource/wp-content/uploads/2018/04/References-Foundations-in-Myofascial-Release-Seminar-for-NVS-April-2018.pdf

    1. Burks, M., Bailey, S., and Jefferson, Manual Therapy May Improve Swallowing Outcomes in Post-Treatment Head and Neck Cancer Patients. Poster presentation at 2014 Triological Society. http://www.triomeetingposters.org/wpcontent/uploads/2014/05/C100.pdf
    “The primary objective of this small case series was to demonstrate the potential application of myofascial release in the treatment of dysphagia in HNC survivors following definitive therapy.” “Conclusion: Dysphagia is a common post-treatment sequela in HNC patients. Our descriptive observational data preliminarily suggests that the novel approach of manual therapy may have role for the treatment of HNC patient dysphagia. Future study will further investigate the effects, the long-term benefits, and ideal regimen of myofascial release in this patient population.”

    2. Gugliotti, M. (2011) The Use of Mobilization, Muscle Energy Technique, and Soft Tissue Mobilization Following a Modified Radical Neck Dissection of a Patient with Head and Neck Cancer. “Rehabilitation Oncology 29(1); . 2011. Retrieved April 01, 2016 from HighBeam Research: https://www.highbeam.com/doc/1P3-2342376511.html
    “Manual therapy techniques such as joint mobilization, muscle energy technique, and soft tissue mobilization were safely and effectively applied to this patient with head and neck cancer.” “Soft tissue mobilization was chosen due to its reported ability to reduce pain and increase tissue extensibility.”

    Looking at the effects of manual therapy from a neurological perspective in the SLP field is in its infance, though better established in the PT literature. A new paper that speaks to the potential impact of neurodynamic technique, which is said to be the first paper of its kind in the SLP literature, is as follows. Though it applies to dysarthria and not dysphagia, I think you will be seeing more of this approach mentioned in the literature:

    69. Ateras, B., von Piekartz, H. (2017). Integration of a neurodynamic approach into the treatment of dysarthria for patients with idiopathic Parkinson’s disease: A pilot study. Journal of Bodywork & Movement Therapies xxx (2017) 1e9. https://doi.org/10.1016/j.jbmt.2017.12.004.
    (This study is the first to introduce concepts of neurodynamic testing/treatment into the speech language pathology world. Its methods and manner of presentation is to be applauded, as unlike many papers that mention a style/type/brand of manual therapy, much is left to the imagination as to just what was done to constitute the study. This particular paper shows in great detail much of the hands-on work, as well as speak to specific nerves in terms of distribution/innervation as well as how best to access/treat it, from a neurodynamic technique perspective. This paper fits my bias, hence the enthusiasm, in that addressing dysfunction from models that are explained from narratives more acceptable to the wider scientific community may be less fitting the older rabbit hole narratives of tissue-specific change and effects.)

    Thanks for a few new links for my interests.

    Walt Fritz, PT

    • Hi Walt-
      Thanks for your comments and for the additional references I appreciate you adding a PT perspective about the potential neurodynamic/neurological effects of MFR. Very interesting!
      -Jen

  3. My daughte is suffering with celebral palsy since birth. One of the symptoms is the dysfagia. Untill 14 she was feeded through the mouth with the same food as we ate blended. Due to aspirations we have suggested and instalked a gastrostomy and since then we feed them vie tube. However due to long not use of larengeal muscles the swalloing became very difficult and the number of aspirations grow resulting to severe pneumonia. We recently spent two months in the hospital due to breathing and aspirTions problems. Iliana is now 23,5 yeRs old. We have mde unsuccesfully in 2000 transplant of stem cells sourced from abortions.
    Can we apply your method in this kind of patients.

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