1. The Use of Therapeutic Modalities in Treating Post Radiation Fibrosis: A Case Review Dale R. Gregore, MS CCC SLP & Janet H. Sechrist MA CCC SLP Christiana Care Health System, Newark, DE DISCLOSURES: There are no financial conflicts for any of the authors. Dysphagia in the head and neck population is commonly attributed to radiation-induced muscle fibrosis and anatomical changes affecting key swallowing structures after surgery 1. The benefit of advanced training and clinical proficiency of combined therapeutic modalities is documented in the rehabilitation journals. Multimodality treatments in the H&N population is becoming the accepted practice model and includes thermal / neuromuscular stimulation, vibration, myofascial release and resistance exercises. This poster outlines the treatment of trismus, lingual atrophy and oropharyngeal dysphagia in a 50 year old male who was 7 years post comprehensive cancer treatment. 50 year old male s/p ® neck dissection and surgical resection of ® tonsillar region; s/p chemo/ XRT prior to surgery and chemo p/ surgery. HX of (+) upper esophageal stricture due to post radiation fibrosis; s/p UES dilation; oromandibular dystonia / trismus treated w/ Botox injections to masseter/ pterygoid bilaterally. s/p MVA 6 years later with reported sudden onset dysarthria/ cervical pain/ deterioration of swallow function METHODS / PLAN OF CARE Therapeutic modalities included moist heat to TMJ Myofascial release to cervical, laryngeal and intra oral/ buccal/ lingual musculature Mandibular massage and passive/ active ROM stretch of TMJ paired with TheraBite passive TMJ ROM program Neuromuscular electrical stimulation during strengthening exercises Therapeutic feeding w/ trained swallow techniques DISCUSSION Traditional approaches to dysphagia treatment do not fully meet the needs of the H&N population due to unique changes in tissue elasticity, muscular atrophy, reduced salivary function, predisposition to formation of strictures Skilled clinical paired with consistent completion of home modalities program effected improved swallow function LIMITATIONS There are limited training options in the use of modalities outside of Physical Therapy or Athletic Training Although we as a profession know more about the benefits of preventative treatment, there is a paucity of research aimed at identification and intervention using combined modalities in the H&N population. CONCLUSION Clinician knowledge and training in physical modalities greatly enhances treatment scope and effectiveness in the H&N population There should be increased availability of training in specialty treatments such as myofascial release, neuromuscular stimulation, and lymphedema management with corresponding outcomes research BACKGROUND COMPARATIVE MEASUREMENTS RESULTS Printed by Christiana Care Health System – 20131108 Patient presented with altered PO intake with documented weight loss due to severe oral pharyngeal dysphagia with history of upper esophageal dysfunction due to stricture. (+) moderate severe Dysarthria affected speech articulation precision due to lingual weakness; Hypernasal resonance/ voice dysfunction; trismus/ oromandibular dystonia affected speech intelligibility due to incomplete velopharyngeal seal/ nasal emission /assimilation and decreased oral ROM. Combined, speech/ communication and swallow dysfunction negatively affected patient’s quality of life, social interaction, communication effectiveness, and nutrition intake. Patient participated in 3x week outpatient rehabilitation at Christiana Care/ Wilmington Hospital. He was highly motivated and actively participative in his rehabilitation program. He completed 22 sessions total; 1 Video swallow Study over 2 month duration. ABSTRACT HOME/ DAILY MULTIMODALITY PROGRAM Complete twice daily 1.Start with moist heat to the neck and jaw 10 minutes as tolerated 2.Follow by PLATYSMA broad, surface neck massage/ stretch 2-5 minutes a.Move from ear to collar bone in towards jaw b.Hand crosses over to press/ massage/ stretch (i.e. (L) hand works ® side of neck and visa versa 3..SUPRAHYOID massage/ MFR to muscles above hyoid (chin to neck) a.Lean elbows on table or sit in chair/ rest elbow in other palm b.Thumbs together OR index digit press/ massage/ stroke and stretch from chin down to hyoid: minimum of 20 pressure MFR passes 4. INFRAHYOID muscles from hyoid ( below the Adam's apple to collar bone): a.Cross hand pressure massage/ stroke downward with gentle pressure massage, stretch b.Minimum of 20 pressure MFR passes 5. TMJ/ MASSETER (jaw / biting ) et al MFR a.Massage lateral above cheek bone from ear forward (PTERYGOID) b.Circular massage at TMJ: small circular pressure massage 20 rotations c.Stroke down/ pressure massage MASSETER from cheek bone down to lower jaw: 20 passes d.Follow by pressure point at TMJ with thumbs then index fingers on chin and stretch open mouth/ jaw 10 seconds, repeat x5 6. THERABITE 7/7 7. INTRA ORAL MFR: do both sides! a.“C” sweep OBICULARIS ORIS thumb inside/ index/ middle finger outside; starting mid lip and sweeping down, around to jaw/ mandible: sweep in gradually larger “c”s 5 times with pressure b.BUCCINATOR: thumb inside/ index/ middle finger outside: sweep from MASSETER edge diagonally to corner of lip ; repeat 5 times slow and with pressure c.MASSETER: thumb inside/ index/ middle finger outside; starting at cheekbone and massage inside/ outside masseter from cheek bone down to lower jaw: minimum of 5 passes. 8. Tongue range of motion (rom) and MFR a.Gently grasp tongue with gauze, stretch tongue out in middle/ central; hold 5 seconds to 10 seconds b.Gently tug then retract tongue and swallow tight c.Follow by 5 passive stretches of the tongue in the middle, right and left, swallowing after each stretch BASELINE STATUS 2010 RESOURCE: VitalStim Manual: Myofascial Release, John Kelly, MPT REFERENCES Buchbinder, D, Currivan, RB, Kaplan, AJ, Urken, ML. (1993) Mobilization Regimens for the Prevention of Jaw Hypomobility in the Radiated Patient: A Comparison of Three Techniques. Journal of Oral Maxillofacial Surgery, 51, 863-7. Dijkstra, PU, Sterken, MW, Pater, R et al. (2007) Exercise Therapy for Trismus in Head and Neck Cancer. Oral Oncology, 43, 389-94. Lazarus, CL, Logemann, JA, Pauloski, BR, Rademaker, AW, Larson, CR, Mittal, BB, Pierce, M. (2000 Aug) Swallowing and Tongue Function Following Treatment for Oral and Oropharyngeal Cancer. Journal of Speech Language and Hearing Research, 43, 1011-1023. Lewin, JS, Hutcheson, KA, Barringer, DA, Smith, BG, (2012) Preliminary Experience With Head and Neck Lymphedema and Swallowing Function in Patients Treated for Head and Neck Cancer, Perspectives on Swallowing and Swallowing Disorders, 19 (2) 45-52. Department of Speech Language Pathology