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Head Neck Peer Supervision Group: So should we be doing prophylactic exercises with Head Neck Patients who

Background of group:. H

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Head Neck Peer Supervision Group: So should we be doing prophylactic exercises with Head Neck Patients who

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    1. Head & Neck Peer Supervision Group: “So should we be doing prophylactic exercises with Head & Neck Patients who are about to have Radiation Therapy?” NSW Speech Pathology EBP Network ‘Extravaganza 2009’

    2. Background of group: H&N peer supervision formed 2008: Initiative from Sydney Managers Meeting Small group that focuses on: Clinical support / supervision Resource sharing and development EBP (CAP’s CAT’s) Competencies Clinical indicators (PICI) Across-site continuum of care

    3. Background of group (cont’d) We’re not a traditional EBP group (However, individually we’re all active EBP members of the network) Therefore primary goal of peer supervision group is not to regularly conduct EBP & complete CAPS / CAT We used our EBP training to: Answer a clinical question pertinent to our specialty Conduct the EBP process including completing CAPs/CAT within a small group Direct S/Path H&N radiation oncology service delivery

    4. H&N patient population: H&N Cancers typically seen by S/Path: Oral – lips, tongue, buccal, hard palate Nasopharyngeal Oropharyngeal – tonsil, soft palate, base of tongue Pharyngeal & Neck Larynx Occasionally parotid/salivary glands/brain/skin The stereotypical H&N patient: Single 60 - 70yr old male Heavy smoker and drinker Socially isolated Compliance with therapy and recommendations vary However, due to the change in womens’ social habits, and the increase of SCC caused by HumanPapillomaVirus (HPV), this is changing.

    5. Major Side effects of H&N radiotherapy impacting on swallowing & communication Odynophagia (pain on swallowing ) Mucositis (inflammation of mucosa) Xerostomia (dry mouth) Trismus (restricted jaw opening) Dysphagia & Dysarthria Due to site of cancer, and all of the above Dysphonia Impaired taste and motivation for E&D Prophylactic PEG insertion is becoming common practice with these patients

    6. Speech Pathology service delivery for H&N radiotherapy population Current: Typically seen in H&N centres Reactive Rehabilitative Therapeutic “monitor and fix problems as they arise” ? Future & already seen in some OS H&N centres Preventative Prophylactic ? Problems with compliance Pt suitability Demands on resources

    7. Background to our question: “Hot” topic…..prophylactic swallow rehab with H&N radiation oncology pts Shift in treatment towards organ preservation ? normal function Rachelle’s sabbatical 2008 Virginia’s experience in UK & Netherlands H&N conference 2008 (Cathy Lazarus) Changes in service delivery internationally – should we change ours??? Photo of Professor Frans Hilgers, NKI, Amsterdam

    8. Clinical Question:

    9. 1st CAP: SWALLOWING FUNCTION Carroll et al (2008). Pretreatment swallowing exercises improve swallow function after chemoradiation. The Laryngoscope 118: 39-43 18 pts with advanced SCC of the oropharynx, hypopharynx and larynx treated at the University of Alabama at Birmingham (UAB) Treated with combined Chemotherapy/Radiation therapy (CRT) with a minimum dose of 70Gy. All patients had a prophylactic PEG placed, prior to RT.

    10. Experimental Group: 9 pts received pre treatment swallowing exercises, 2 weeks prior to commencing CRT.     These exercises included tongue-hold (ie: Masako), tongue resistance, effortful swallow, Mendelsohn Manouevre, and Shaker exercise. Provided with verbal & written instructions for daily practise at home. Instructed to perform ex/s for 10 reps, 5 times a day: Encouraged to integrate these into other daily activities

    11. Control Group: 9 pts received post treatment swallowing exercises as swallowing problems arose (therapeutic or rehabilitative model of care). These pts saw the speech pathologist after completing CRT. They also had a MBS conducted approx 3 months post CRT

    12. Results: Tongue base was positioned more closely to the Posterior Pharyngeal wall during the swallow in experimental grp (P=0.025). Pts in experimental grp maintained more normal epiglottic inversion during swallowing than the control group: statistically significant (P=0.02) No other differences were observed between the groups on other relevant outcome measures, including timing of PEG tube removal

    13. Limitations: No baseline swallow Ax pre CRT– measure change with exercises? Small numbers of pts with different tumour & treatment sites: Pts not randomised No comment on oral intake prior to & during treatment, nor on pt’s compliance to Rx. 1 Radiologist interpreted results Although statistically significant difference in tongue base position and epiglottic inversion when swallowing for experimental group:- What impact does this have on swallowing status and QOL? Are these the best outcome measures to collect?

    14. Clinical bottom line: Due to the limitations of the study design, it is uncertain whether pre treatment exercises improve long term swallowing outcomes in Head and Neck patients having Radiation therapy. However the findings of improved epiglottic inversion and base of tongue retraction when swallowing, justify further investigation of the role of prophylactic exercises in the proactive management (vs traditional ‘therapeutic model’) of patients with H&N cancer undergoing Radiation Therapy” in the proactive management (vs traditional ‘therapeutic model’) of patients with H&N cancer undergoing Radiation Therapy”

    15. 2nd CAP: SWALLOW QOL Kulbersh et al (2006) Pretreatment, preoperative swallowing exercises may improve dysphagia quality of life. Laryngoscope 116. Clinical bottom line: “Commencing swallow exercises prior to starting head & neck radiotherapy (+/- chemotherapy) may improve patient quality of life relating to oral intake post treatment. However due to study limitations application is limited”

    16. Clinical applications: Limited evidence available – only 1 article on function & 1 on QOL Limitations of current evidence Further research is in progress (UK & NL) At present, we may still encourage prophylactic exercises if resources/service delivery allows and you have a motivated patient as no contraindications to conducting prophylactic ex/s. However, not enough robust evidence at present to apply for funding to key stakeholders to radically change current service delivery BUT….. WATCH THIS SPACE

    17. THANK YOU H&N Peer Supervision Group Virginia Simms Katrina Blyth Armalie Muller Danielle Stone Candice Baxter Rachelle Robinson

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