THE USE OF CORE STABILIZATION EXERCISES IN … · After oral cavity, throat or any other head and...

90 Dysfunctions of the Locomotor System ▪ 2011

THE USE OF CORE STABILIZATION EXERCISES IN POSTOPERATIVE PATIENTS WITH HEAD

AND NECK CANCER

Marian Majchrzycki¹, Sławomir Marszałek2,3, Joanna Lipiec¹, Aleksandra Kulczyk4

¹ Department and Clinic for Rehabilitation, Poznan University of Medical Sciences, Poland2 Track and Field Athletics Department, University School of Physical Education in Poznan, Poland

3 Department of Head and Neck Cancer, Greater Poland Cancer Centre in Poznan4 Department of Pathophysiology of Locomotor Organs, Poznan University of Medical Sciences,

Poland

Abstract

Patients after head and neck cancer surgery require rehabilitation. Procedures like this cause serious functional dysfunctions and they are often associated with skeletomuscular complications. Core stabilization exercises are one of the main factors in rehabilitation.The aim of this paper is to characterize and present basic head and neck core stabliza-tion exercises.The exercises are performed in the postoperative period, and that is why it is important to teach them before the procedure. Patient’s correct posture is emphasized. In the later stage of aftercare, cervical spine and shoulder core stabilization exercises are an impor-tant element of rehabilitation. These exercises can inlcude scapular patterns exercises (PNF-proprioceptive neuromuscular facilitation), cervical stability exercises and respira-tory therapy.

Key words: core stabilization exercise, head and neck cancer, physiotherapy

IntroductionHead and neck squamous cell carcinoma accounts for 5% of all malicious

cancers in developed countries and up to 50% in developing countries, ranking sixth most common cancer type. It is estimated that 500,000 people develop this type of cancer each year [1, 2].

Methods used in the treatment of head and neck squamous cell carcinoma are strictly dependent on the factors related to the tumor: its localization, its stage and the state of patient’s health and non-medical factors, e.g. the experi-ence of medical facility the patiente is referred to. Head and neck cancers are

The use of core stabilization exercises in postoperative patients with head and neck cancer

2011 ▪ Dysfunctions of the Locomotor System 91

often associated with severe physical ailments. They usually impair basic life functions (breathing, eating, speaking), and they can sometimes damage sight, hearing, smell, taste and other nervous system’s functions. Disfiguration and functional defects caused by the disease and its treatment have serious psycho-logical and social consequences [3, 4, 5, 6].

During tumor removal surgery many patients undergo reconstructive proce-dures in a single operation. These procedures include grafting and/or muscle transplants from the shoulder girdle region, and, occasionally, additional trans-plants, e.g. bones, from arm or leg for the purpose of face or neck reconstruc-tion. Restitution of movement ability is almost always necessary after this type of surgery. Proper rehabilitation can improve patient’s functioning by stretching and strengthening of the neck and head muscles. This also apllies to the neck’s range of motion. Scar massage techniques used in the prevention of motion restrictions are also very valuable.

After oral cavity, throat or any other head and neck surgery, a complex reha-bilitation is needed. It includes speech therapy, swallowing reformation, maxil-lofacial and dental rehabilitation. Patients in order to achieve their full health potential should be a full-scale health care, and this includes physiotherapeu-tic care which aims to restore full functional ability. Functional impairment can severly restrict the ability of the patient to participate in daily activities like work and hobbies. Physiotherapist has to be aware of patient’s dysfunctions that were present before the cancer. This will allow to design strategies to deal with pain, restore the impaired functions and prevent future complications which can oc-cure in the muscle tissue or in the scar area if there is one [7].

Functional dysfunctionsDuring a common surgical procedure in the neck area – total laryngectomy

– larynx is removed along with the hyoid bone and with the muscles surrounding the area (infrahyoid muscles and suprahyoid muscles, parts of platysma muscle, sternocleidomastoid muscle). The absence of those muscles and their important functions causes muscle imbalance in the front of the neck and functional com-plications related with it.

Surgical complication can manifest itself in the form of damage to the cervi-cal plexus and to the superficial branch of accessory nerve (CN XI). C4 and C3 nerve roots irritation and their role in the shoulder area’s innervation are a case in point. Complications are motor and sensory in nature – numbness, formica-tion, hyperesthesia, parasthesias and dysfunction in the mobility of shoulder and scapula articulations on the side of the operated limb. Mobility deficits in the sternocleidomastoid muscle and the trapezius muscle affecting shoulder’s function can occur as a result of the damage of the accessory nerve [8, 9, 10, 11, 12, 13].

Muscles in the front part of the cervical spine are most commonly damaged during the surgical procedure. Infrahyoid muscles, suprahyoid muscles and deep neck flexors which function as a support of the hyoid bone and bend the head to the front. The damage of those muscle groups results in muscle imbal-

Marian Majchrzycki, Sławomir Marszałek, Joanna Lipiec, Aleksandra Kulczyk


ance. In a reflex, their anatagonists are weakened and shortened – the muscles of the back of the neck [14].

So called upper crossed syndrome can occur. It is characterized by in-

creased muscle tension in the back part of the cervical spine (descending part

of trapezius muscle, erector spinae muscles, levator muscle of scapula, sub-

occipital muscle group and scalene muscles) and the contracture of pectoral

muscles and the weakening and extension of deep neck flexors, scapular stabi-lizer muscles. This results in an increased tension in the neck-shoulder area and

in dysfunctions and pain of cervical spine, shoulder and arm pain, and also in

restriced chest mobility and breathing difficulties [16]. Increased postural muscle tension weakens and impedes, through spinal

reflex, the activity of deep neck flexors phasic muscles. When phasic muscles get weaker, they cannot balance the muscle system which results in further in-

creased activity of the tonic muscles. This perpetual cycle worsens the state of

the muscle static imbalance which is a form of muscle cooperation dysfunction

affecting their tension, activity and strength. Stress and a tense feeling of fear

after the operation can result in psychogenic increase of resting tension in tonic

muscles, consequently, increasing the imbalance in question [14, 15, 16].

In healthy people as well as in patients after cancer surgery in the head and

the neck area, disturbed neuromuscular coordination in the cervical spine leads

to difficulties in performing movements. Repeated incorrect movement are be-

ing encoded in the central nervous system. When the system’s adaptive capa-

bilities are exhausted, pain occurs in venter and in head’s and neck’s muscle

attachments. As a result, compression on spine articulations increases. This can

result in spinal pains, neck, shoulder and upper extremity numbness. This state

can be worsened by the shifting of the head forwards due to muscle imbalance.

Others symptoms might include cervical headaches, eye pain, balance issues

and hearing impairment [14, 17, 18].

Confirmation of those theories can be found in research conducted by Marszałek et al [2004] where an increase in the muscle strength was observed in patients who underwent laryngectomy and a subsequent rehabilitation. This

was achieved without the use of typical strength exercises. Only techniques

restoring disturbed coordination and muscle balance were used. It follows that

the main aim of movement rahbilitation of laryngectomy patients should be to

restore proper neuromuscular coordination and normal active motion in the cer-

vical spine. Decreased resting tonus will allow better blood supply and faster

tissue regeneration. Rehabilitation will minimize the risk of lymphostasis in neck

muscles after the removal of lymph nodes and radiotherapy. Consequently, this

will allow to increase the strength of muscles in the cervical spine. One can

suppose that decreased muscle tension in head and neck area in patients after

laryngectomy will have a positive impact on the stabilizing effect of the chest

and respiratory efficiency, as well as on the acceleration of oesophageal speech acquisition [19, 20, 21].

In the process of rehabilitation it is important to use directed kinesiotherapy

and specific autotherapy with regard to myofascial release, relaxation and mo-

bilization. This allows the patient to be involved in the therapeutic process, and



also, or most of all, allows psychoemotional activation of the patient. Conse-quently, the patient is not left alone and the natural regeneration and autoregula-tion are given a boost.

This is why during therapy the techniques used should be applied on in-dividual basis, and the time spent with the patient should depend on the par-ticular patient’s state. Use of general schemes of therapy from other areas of physiotherapy can result in structural damage or, at best, overstimulation of the nervous and immune systems.

After the restoration or improvement of tissue motion and the range of motion in the areas of body under oncological treatment, the patient should be taught new proper movement patterns and solidify new ranges of motion. Postural re-education and instructions of proper body movements are essential parts of physiotherapeutic proceeding after or even during the therapy of soft tissues in cancer patients [21].

Core stabilization training in postoperative periodIn the postoperative period prevents postoperative complications. These in-

clude early risks and complications:– delayed healing of postoperative wounds– wound dehiscence– swelling and lymphostasis– suggillations, haematomas– bleeding– fistulas– dyspnoea– general complications.

Learning how to properly stand up, lie down and sit should be a part of the training.

Adopting proper positions during the day is essential for proper and safe swallowing. They allow full upside movement of the hyoid bone and the larynx, and consequently the closing of epiglottis and prevent the airways from choking [22].

Proper, upright position also allows proper functioning of the diaphragm which prevents postoperative complications related with cardiopulmonary sys-tem. Another important element of early rehabilitation is the acquisition of safe rotation movements in retraction. The patient is asked to perform retraction (chin retraction) and only then the patient is asked to perform rotation that is looking sideways (Fig. 1). We make sure that the patients does not do any rapid side-way movements without chin retraction. Proper execution of these movements prevents wound dehiscence, suggillations and delayed wound healing. Faster healing results in lower amount of fibrosis in the operative area [21].



Aftercare core stabilization trainingIn addition to achieving normal range of motion and myofascial elasticity, it

is important to perform core stabilizing training. It aims at: proper body alignment with special emphasis on the positioning

of the head, the shoulder girdle and the upper trunk.

Suggested postoperative rehabilitation exercises for patients with head and neck cancers

Figure 1. Position with retraction of the cer-vical spine.

Figure 2. Reflexive stabilization technique.



Exercises should be adjusted to the postoperative stage, the time that passed since the procedure, patient’s abilities and contraindications. PNF (pro-prioceptive neuromuscular facilitation) techniques should be used from neck and head muscles. Reflexive stabilization technique is particularly useful and important. It aims at practicing isotonic contractions with a force which prevents the movement from happening. Therapist tries to unsettle the patient from his/her position, and the patient tries to maintain the position or the therapist ap-plies physical resistance and asks the patients to push therapist’s hand. These exercises improve stability and balance, muscle strength and coordination of agonistic and antagonistic muscles (Fig. 2) [23, 24, 25].

Face musclesFace muscles reflect feelings, move the lower jaw bone, protect the eyes

and help to produce speech. The basic function in the exercises are functional tasks, e.g. pretending to be surprised, grimace, „bad smell”. It is important to maintain symmetry in both sides of the face. Use of mirror can be helpful.

Tongue movementsTo simulate or resist movements of the tongue one may use wooden medical

spatula soaked with water or therapist’s fingers in a disposable glove. Examples of exercises (Fig.3 A, B):– forcing the tongue out in a straight line/on the left/on the right– touching the nose and the chin with a tongue– rolling the tongue into a „pipe” (not everyone can do this)– bending the tongue– moving the tongue sideways inside the mouth– touching the palate by the front line of the teeth with the tip of one’s tongue.

A B

Figure 3. Exercises of the tongue with use wooden medical spatula.



Scapular patterns exercises (PNF Patterns)Scapular patterns exercises are very important in the rehabilitation of cervi-

cal spine, upper extremity, shoulder complex, scapula and trunk. Movements in two diagonal directions are used: front elevation – back lowering (Fig. 4) or back elevation – front lowering (Fig. 5).

It was observed that the muscle imbalance occurs when the shoulder is lifted upwards and forward. That is why movements which will be used most commonly in the therapy will be lowering movements, directing the scapula to-wards the spine.

In the case of dysfunction of the accesory nerve caused by the postopera-tive complications in cervical lymph nodes, there is the tendency for the shoul-der to lower and move forward in the affected side. Back elevation exercises are used.

The goal of the exercises is to improve the motion and stabilize the shoulder complex, as well as to facilitate motion in the cervical spine and to stabilize it – that is because scapula and cervical spine stabilize each other [23, 24, 25].

Neck stability exercises with the use of a ballThe goal of the exercises with the use of a ball is to stabilize the cervical

spine and to strengthen the muscles upholding the head. The exercises, when done regularly, improve the range of motion in the cervical spine, coordination, functioning, and they also help to develop better stability. If any discomfort ap-pears during the exercises, they should be stopped and one should assess

Figure 5. The PNF pattern of back eleva-tion of scapula.

Figure 4. The PNF pattern of back lowering of scapula.



one’s position and strength. It is very important that the exercises do not cause

any pain in the patient.

During the exercises the patient is asked to continually control the tension of

the muscles through chin retraction.

Exercise 1. Exercise influences muscles in the front part of the neck (Fig. 6).

Patient stands facing the wall. He bears a ball on his forehead, gently push-

ing forward – neutral position. Patients can be instructed in the following way:

1. Point your forehead to your chest (ball rolls down the forehead).

2. Now lift you head, so the ball rolls through forehead to your nose. When you

are at eye level move your head down as if you wanted to look at your right

shoulder. Follow the line back do neutral position.

3. Now look down at the left arm. Follow the line back to the neutral position.

The exercises should be done in a way so they stimulate the muscles and

joints without overburdening them.

Exercise 2. Exercise influences both sides of the neck (Fig. 7).Patient stands with his side to the wall and head straight up. The ball is

places between the well and the head, right above the ear. The patient can be

instructed in the following way:

1. The head is a roll, bend the head to touch the shoulders, and then go back the

the neutral position.

2. Motion is carried out only in the cervical spine.

3. Turn around and do the exercise from the other side.

Patient stands facing the wall. He bears a ball on his forehead, gently pushing forward �–

neutral position. Patients can be instructed in the following way:

1. Point your forehead to your chest (ball rolls down the forehead).

2. Now lift you head, so the ball rolls through forehead to your nose. When you are at

eye level move your head down as if you wanted to look at your right shoulder.

Follow the line back do neutral position.

3. Now look down at the left arm. Follow the line back to the neutral position.

The exercises should be done in a way so they stimulate the muscles and joints without

overburdening them.

Figure 6. Exercise influences muscles in the front part of the neck.

Exercise 2. Exercise influences both sides of the neck (Fig. 7).

Patient stands with his side to the wall and head straight up. The ball is places between the

well and the head, right above the ear. The patient can be instructed in the following way:

1. The head is a roll, bend the head to touch the shoulders, and then go back the the

neutral position.

2. Motion is carried out only in the cervical spine.

3. Turn around and do the exercise from the other side.

Figure 6. Exercise influences muscles in the front part of the neck.



Exercise 3. Exercise of the neck since it works on the back with the neck muscles. This can be the most important exercise (Fig. 8).

The position is back to the wall, feet at the arms level, around 6-12 cm from the wall. Place the ball above the base of the skull. The patient is asked to draw „W” with the head, starting with the middle of „W”. Next, the patient is asked to gently press the ball again. the patient can be instructed in the following way:

1. Look straight at the ceiling while lifting your head, if it is necessary you can move.

Figure 7. Exercise influences sides of the neck.

Figure 8. Exercise of the neck and back muscles.



2. Next roll the head down, almost touching your chest with your chin.3. Now bring the head looking right in 45 degrees (bringing right ear to right

shoulder during adjusting the head to the back).4. Bring the head back to the neutral position (chin to the chest).5. Rolling 45 degrees to the left.6. Go back to the neutral position. This is one repetition. Initially three repeti-

tions, until we reach ten repetitions [26].

Respiratory therapy According to many researchers the goal of the physiotherapy supporting the

acquisition of esophageal speech is to activate diaphragmatic breathing and to relax the accessory muscles mentioned above. This is why in the process of rehabilitation it is important to relax the muscles of the back of the neck and to teach diaphragmatic breathing [13, 27].

Respiratory dysfunctions affect adversly body strcutures and functions leading to muscle contraction imbalance, position motor control dysfunctions and body homeostasis dysfunction. In respiratory dysfunctions we observe in-creased contraction and shortening of accessory respiratory muscles, as well as breathing throught mouth with improper tongue restiing position. Improper respiratory pattern can result in tension and pain in the back of the neck or chest area, headaches, dizziness, fatigue, anxiety, digestion problems and worsened blood circulation. Respiratory dysfunctions are a direct indication for therapy, whereas indirect indications include activization of the rib cage, trunk and shoul-der girdle, pain reduction and relaxation [28].

Exercises in proper breathing should be done before the pre-operation pe-riod and they should continue in the first days after the operation. The goal of the exercises is to relax and activate the diaphragm and other respiratory muscles.

An example of a therapy:1. The patient lies on the back with bent knees. The therapist is by the patient’s

side. The therapist holds with the closer hand patient’s front parts of lower ribs below the xiphoid process. The other hand goes under the ribs, synchroniz-ing with breathing phases. During exhalation the closer hand stretches the tissues towards stomach area, and the farther hand goes under the costal margin. During inhalation the grip is gently released (Fig. 9A).

2. The patient is on his back with bent knees. The therapist is behind the pa-tient’s head. The therapist holds both sides of the costal margin with fingers. During inhalation the therapist holds (“opens”) the costal margin (Fig. 9B).

3. The therapist is behind the patient’s head and the patient is on his back with bent kness. The therapist puts hands symmetrically on the costal margins below the processus xiphoideus. The patient is asked to take deep breaths. During exhalation the therapist moves his hands along with the patient’s chest movement in coccygeal direction (applying slight pressure), then the patient is asked to take a deep breath leaving his hands pressuring. When the inhala-tion phase is ending, the therapist gets his hands off patient’s chest dynami-cally which makes the inhale even deeper causing a distinctive air ingestion (Fig. 10A).



4. The patient is on his back with lower extremities bent in knees. During the re-spiratory phases the therapist mobilizes the chest by facilitating or hindering respiratory phases (pressing the ribs – deepens the exhalation, hinders the inhalation). The therapist puts his hands depending on the area of the chest which he wants to mobilize (Fig. 10 B).

Figure 9. Respiratory therapy.

Figure 10. Respiratory therapy.

A

A

B

B



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DISCLOSURE: This study was supported by the Polish Scientific Fund in years 2009-2012 as the research project No. N N404 191136.

WYKORZYSTANIE ĆWICZEŃ GŁĘBOKIEJ STABILIZACJI U PACJENTÓW PO ZABIEGACH OPERACYJNYCH

W WYNIKU NOWOTWORU W OBRĘBIE GŁOWY I SZYI

Marian Majchrzycki1, Sławomir Marszałek2,3, Joanna Lipiec1, Aleksandra Kulczyk4

1Katedra i Klinika Rehabilitacji, Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu2Wydział Wychowania Fizycznego, Sportu i Rehabilitacji, Akademia Wychowania Fizycznego

w Poznaniu3Oddział Chirurgii Głowy i Szyi i Onkologii Laryngologicznej, Wielkopolskie Centrum Onkologii

w Poznaniu4Zakład Patofizjologii Narządu Ruchu, Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu

Streszczenie

Pacjenci po zabiegach operacyjnych w obrębie głowy i szyi wykonywanych w wyniku leczenia nowotworu wymagają usprawniania leczniczego. Zabiegi te powodują poważne zaburzenia funkcjonalne i często związane są z powikłaniami ze strony układu mięśnio-wo-szkieletowego. Jeden z ważnych czynników rehabilitacji stanowią ćwiczenia głębo-kiej stabilizacji.



Celem pracy jest scharakteryzowanie i przedstawienie podstawowych ćwiczeń stabilizu-jących górną połowę ciała po zabiegach w obrębie głowy i szyi.Ćwiczenia te wykonujemy już w okresie pooperacyjnym, dlatego ważne jest wyuczenie ich przed zabiegiem. Zwraca się szczególną uwagę na właściwą postawę ciała pacjenta. W późniejszym okresie poszpitalnym ćwiczenia głębokiej stabilizacji odcinka szyjnego kręgosłupa i obręczy kończyny górnej stanowią również ważny element usprawniania. Przykładowymi mogą być ćwiczenia wzorców łopatki, ćwiczenia stabilności odcinka szyj-nego oraz terapia oddechowa.

Słowa kluczowe: głęboka stabilizacja, fizjoterapia, onkologia głowy i szyi.

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