Be Proactive! A Best Practice Guide for Treating Radiation-Associated Dysphagia

“Give it time.” “Let’s see how they recover.” “Patients feel lousy from radiation, they aren’t up for therapy yet.”

These are common sentiments that patients and their providers might share when considering swallowing therapy in the acute and subacute (i.e., first 3 to 6 months after radiotherapy) period of care after head and neck radiotherapy (RT). However, a growing amount of evidence tells us that keeping the swallowing system active during radiotherapy makes a difference! Given the opportunity, most patients will buy into some form of proactive swallowing therapy during radiotherapy and adhere to swallowing exercise or oral intake regimens.

Best Practice – Before Radiotherapy 

Implementing a proactive model in your facility starts with identifying high-risk patient groups and developing a pathway for standard early referral and therapy.

The fundamental tenet of proactive swallowing therapy is “use it or lose it.” Patients are encouraged to keep the pharynx active and mobile during radiotherapy. Eating and exercise can encourage this activity.

Eating

Maintaining oral intake daily throughout RT is recommended to prevent disuse atrophy (even if a feeding tube is needed for nutritional support). Our primary goal is to keep the pharynx active while ensuring that oral intake is safe – and, therefore, train compensatory strategies or diet modification when necessary to minimize aspiration risk.

Exactly how much and what type of oral intake is best to maintain swallow function during RT has not been studied. We do not know whether it helps to keep eating solids or if just drinking liquids is enough to keep the swallowing mechanism active.

Empirically, speech pathologists often motivate patients to maintain intake of textures that are as challenging as possible (i.e., keep swallowing the heaviest food that is not painful). This practice largely derives from data on normal populations finding that muscle recruitment and movement trajectories increase as the load of the bolus increases (i.e. larger volume or thicker consistency). In any case, at least three studies support that maintaining oral intake of anything during the six to seven weeks of radiotherapy (even just water) – and avoiding even brief NPO intervals – is associated with better oral intake or quality of life scores years later in cancer survivorship.^7,8,14

Exercise

Preventive swallowing exercise has been studied extensively in this population^3,8,11. Several small trials suggest that patients who adhere to swallowing exercises during RT see the following benefits:

• Better post-RT muscle mass on MRI
• Better epiglottic and base of tongue movement on post-RT videofluoroscopy
• Earlier diet recovery
• Faster tube removal
• Less hospitalization than those who do not

Exercise regimens studied vary in the precise routine, but it is most common to include 5 to 8 exercises that target hyolaryngeal excursion, base of tongue and pharyngeal constriction, and jaw opening at around 30 repetitions daily.

Other complementary systems, including smartphone apps, can also enhance adherence and help patients overcome barriers to exercise and eating. Empowering and encouraging your patients, as well as properly managing their pain can have a profound impact on adherence and activity.

Empowerment

Clinicians are more effective when they focus on empowering patients about “what they can do” rather than focusing on negative messages that induce fear. Unpublished data suggest fear is counter-productive to adherence.

Pain Management

Mucositis (mouth sores) occurs in almost all patients who get full field RT. Mucositis makes swallowing very painful. Less pain allows patients to eat more during RT and may result in better post-RT swallowing function based on preliminary single institution data.²⁰ As an SLP, communicate with the medical providers about uncontrolled pain your patient reports.

How do I get started?

Below are a few steps to get started in pre-RT speech pathology evaluation and swallow therapy:

• Get to know your HNC team.
• Attend the multidisciplinary tumor board at your facility.
• Develop a pathway through which higher risk patients (e.g. bilateral neck RT with or without chemo) are referred for pre-RT speech pathology evaluation and swallow therapy.
• Document and provide feedback.

Do you know your facility’s feeding tube rate? As a start, consider auditing the feeding tube dependence rates before and after implementing a pro-active swallow therapy model. Feeding tube rates at 1 year should be well under 10%.¹⁷

After Radiotherapy Best Practices

Despite our best efforts at prevention, still at least 20-30% of survivors develop moderate to severe chronic radiation-associated dysphagia (RAD). Chronic RAD is an exceedingly challenging clinical problem. In-field fibrosis and subcutaneous edema are commonly implicated as the primary sources of RAD. Denervation also contributes, particularly in progressive and late-onset RAD.

There is no proven best therapy for patients with persistent post-RT dysphagia. However, a comprehensive review of the literature supports the following fundamentals:

• Intervene Early – The “use it or lose it” philosophy remains in the post-RT setting. Earlier intervention for persistent dysphagia is more effective than late intervention. A comprehensive evaluation to consider intensive swallowing therapy should be considered for patients experiencing one of the following:
  • Persistent tube feeding past 3 months
  • Delayed return to solid foods
  • On-going symptoms of aspiration
  • Pneumonia during or after RT
• Standardize the Evaluation – Good therapy starts with a comprehensive evaluation. Instrumental evaluation (videofluoroscopy or endoscopy) should be coupled with standardized ratings of functional status (e.g., PSSHN or FOIS) and patient-reported outcomes (e.g., MDADI or EAT-10).^1,4,5,18
• Avoid “Immobilization” (i.e., avoid NPO) – As in the “on-treatment” period, we strive to avoid any prolonged NPO period. Patients are encouraged to maintain frequent intake of consistencies they swallow safely.
• Go Beyond a Home Program – Data suggest that simply giving recommendations in the clinic for the patient to carry out at home, be it exercise, diet, or compensations, is likely insufficient to make meaningful gains in this challenging population. Providers should also be aware of a recent negative multi-site federally funded trial that found no added benefit of surface neuromuscular electrical stimulation to a home program of exercise in this population.¹⁵
• Optimize the “System” – If your instrumental examination finds actionable, physical problems like cervical esophageal stricture or vocal fold paresis, it is ideal to address these before starting intensive therapy sessions for functional training.
• Use the Progressive-Resistive Model of Functional Strength Training – Intensive models of daily therapy that rely on the varying the bolus type (i.e., McNeil Dysphagia Therapy) or biofeedback (i.e., surface electromyography) to intensify the exercise “load” while swallowing show promise to help patients make functional gains after RT. Our clinic refers to this model as “boot camp” methods that seek to progressively load a functional swallowing task in systematic, daily sessions.^2,6
• Consider Skill Training – Recent data suggest that skill training (e.g., Respiratory Swallow Training) using biofeedback to improve motor sequence of swallowing may lessen aspiration events in the chronic post-RT setting.

RAD is a complex condition. It is common to feel overwhelmed by all the options for management of this population. To provide the best care possible, we should know RT effects, patterns of post-RT dysphagia, and evidence-based considerations for proactive and reactive swallowing therapy for RAD.