Head and Neck Cancer

In 2019, approximately 4500 Australians were diagnosed with a form of head and neck cancer (excluding thyroid cancer). It is the fifth most common cancer in Australian men.

Exercise and Head and Neck Cancer

Exercise improves in upper limb strength and function in people with head and neck cancer. It may also aid other issues such as fatigue, function and quality of life.

Head and neck cancer is associated with lifestyle risk factors such as tobacco smoking and alcohol consumption. People with head and neck cancer may have other medical conditions associated with these risk factors that impact exercise tolerance (e.g. chronic obstructive pulmonary disease)

Cancers of the oropharynx are associated with the human papillomavirus rather than smoking and alcohol, and occur in patients aged 30-50 years. Patients with HPV-associated oropharyngeal cancer may have no or few other comorbidities to restrict exercise tolerance.

Treatment for head and neck cancer may include:

  • Surgery e.g. neck dissection
  • Radiation therapy
  • Chemotherapy

Due to the position of the tumours, patients are likely to have reduced nutritional intake, which impacts upon energy levels available for exercise.

Patients who receive radiation therapy lose on average 10% of their body weight during the 6-week course of treatment. Most of this body weight is lost from lean muscle mass. As a result, resistance exercise training to maintain or improve muscle mass is important.

There are a number of musculoskeletal changes following treatment for head and neck cancer that occur in the upper quadrant – exercise prescription should be modified where appropriate to accommodate this.

Risk factors for post-operative upper quadrant dysfunction include:

    • Pre-operative shoulder stiffness, specifically internal rotation
    • Younger age at surgery
    • Greater BMI at surgery
    • Multimodality treatment – having post-operative radiation therapy or chemoradiation therapy in addition to surgery
  • Perform a thorough assessment upper body biomechanics to identify impairments and understand if these impairments can be rehabilitated or whether a compensation strategy needs to be adopted, for example, in the setting of accessory nerve resection. You may need to consider a referral to a physiotherapist to address specific issues.
  • The upper and middle trapezius muscles demonstrate reduced muscle activity after neck dissection on the surgical side, therefore choose upper body resistance exercises that facilitate trapezius activity and promote optimal scapulohumeral rhythm – overhead movements of the shoulder such as the overhead press
  • The non-operated trapezius muscle can also have reduced muscle activity  so bilateral exercises are required for full rehabilitation
  • Don’t forget the neck! If patients have significant pain and weakness, exercises that involve the neck flexing (e.g. sit ups) or extending (e.g. in four point kneel) against gravity may need modification. Patients may need isolated rehabilitation of the neck muscles, for example with isometric flexion and extension in sitting, before moving to these more challenging positions.
  • Patients who undergo radiation therapy can experience acute side effects during and for ~2 weeks after that can be barriers to engaging in exercise – increases in fatigue, pain, swelling, skin changes, and reduced oral intake of food and fluids.
  • Dry mouth is a common barrier to exercise. Up to 40% of people report dry mouth as a barrier, 37% report fatigue and 30% report shortness of breath as barriers to exercise. Patients combat dry mouth with frequent drinking of water – make sure to have extra water available to patients in exercise classes.
  • Neck dissection is a common surgical procedure that comprises part of the management of head and neck cancer. It involves removing lymph nodes from the neck, and potentially non-lymphatic structures such as the sternocleidomastoid muscle, accessory nerve, and internal jugular vein
  • Removal of the accessory nerve interrupts the innervation of the trapezius and sternocleidomastoid muscles, with associated disruption to the movement patterns of the neck and shoulder
  • Having a neck dissection (irrespective of accessory nerve status) increases the risk of having shoulder dysfunction post-operatively – possible explanations include the surgical manipulation of the soft tissues of the neck, subsequent scarring, additional radiation fibrosis (muscle stiffening), changes to proprioceptive input, and kinesiophobia.
  • Communicating with the treating surgeon and/or reviewing the operation notes can indicate whether any muscles were used within a muscular flap to reconstruct the surgical site. Pectoralis major, lateral scapular border (involving teres major, latissimus dorsi, and serratus anterior), and rectus femoris are popular muscles for free flap reconstruction. These ‘donor sites’ will need rehabilitation too.