Monday 10th September 2012
Jodie Reynolds, Macmillan Advanced Practitioner Lymphodema Rehabilitation Physiotherapist, discusses the development of a lymphoedema rehabilitation scheme for people with head and neck cancer.
Early detection and multimodality therapy have improved survival rates for head and neck cancers. But this has meant many people with head and neck cancer are at risk of secondary complications, such as lymphoedema.
The effects of lymphoedema in the head and neck are not simply cosmetic - they can cause psychological distress and problems with communication, respiration, alimentation and movement.
Staff at the lymphoedema clinic at Singleton Hospital in Swansea found that people with head and neck cancer who had swelling also had poor skin care, decreased range of movement in cervical spine and impaired shoulder movement.
A winning formula
The clinic had already established award-winning lymphoedema rehabilitation schemes for people with breast and gynaecological cancer, so we decided to set up a similar scheme for head and neck cancers. The scheme is for patients undergoing partial or full lymph node removal via neck dissection.
Patients are referred by the head and neck multidisciplinary team, which I belong to. Patients are assessed pre-operatively and given advice on preventing lymphoedema, along with exercises and written information. We also record range of movement of cervical spine and upper limbs, along with pain, sensation and activity levels. The patients are then reviewed 4-6 weeks post-operatively to make sure the exercises are being performed correctly. At this assessment, we check range of movement, pain, sensation and status of the accessory nerve.
We also teach patients how to manage scars and any swelling, good skin care, and simple lymphatic drainage. If no problems are found during this assessment, patients are reviewed approximately six months later and at one year after their surgery. They are then discharged if they have no clinical signs of lymphoedema, but are advised to contact the clinic directly if problems arise.
We have seen 26 patients to date. At the post-operative follow-up assessment, 82% of patients had limited range of movement, 24% had pain and 71% had swelling. These symptoms were managed accordingly. Of course these measures may change at the patient’s second follow-up. It was interesting to see the high percentages of limited range of movement and swelling.
From these results, we contacted the lead outpatient physiotherapists and asked how many neck dissection patients they treated. The results were astonishing. The maximum treated were two, while the majority treated only one or none. This revealed a large unmet need that should be addressed through education and awareness.
Since coming into post, speech and language therapists have commented on the improvement in their patients’ swallowing and speech since my early intervention, and I have had positive feedback from the ear, nose and throat consultants.
Although lymphoedema is a significant complication of treatment for head and neck cancer, its presence in this population is generally under recognised and, in most cases, undertreated. The paucity of literature reflects this. Greater awareness through education is needed and we need to implement prevention schemes for this patient group.
We have more information about lymphoedema.