- Acid Reflux
- Being on Oxygen
- CPR and Anesthesia concerns
- Dry Mouth - Xerostomia
- Dental Issues
- Nebulizer Usage
- Neck and Shoulder Dysfunction
- Pain Management
- Peg Tube
- Recurrent Disease
- Second Primaries
- Stroke and Vascular Problems Related to Head Neck Radiation
Neck and Shoulder Dysfunction
When we have surgery - no matter how extreme or routine our particular surgery may be, there is cutting involved. In order to reach the site of our cancer, and remove it, our physicians must cut through tissue - skin tissue, muscle tissue, nerve fibers. In some cases, major nerves and muscles will need to be cut or removed. While our body has an amazing ability to mend itself and continue growth, it is reasonable to expect there to be scars - evidence of the trauma the body has been through - both internal and external.
This section discusses the neck and shoulder dysfunction that can be a common consequence of laryngectomy surgery. In many cases, the problems correct themselves with time as our bodies heal and adapt. Sometimes, the problems require additional medical treatment. Because each surgery is unique to the patient (no one person's cancer is in exactly the same area, the exact same size,shape or stage), each problem will be unique and will need to be addressed in a manner unique to you. Many times, trying several different things to see what works for you in your situation, is the only "attack plan" there is.
So does this mean you have to learn to "live with" the problem? Hello? We are Laryngectomees! We lose our vocal chords, yet we "Shout from rooftops," sing in the middle of crowded city streets, and otherwise find ways to make our voices be heard! Keep an open mind, work with your doctor, use resources, such as the WebWhispers email distribution list and this library!. Don't give up!
Shoulder dysfunction – loss of shoulder function is a potentially distressing consequence of neck dissection. This may cause a significant loss of shoulder flexion and abduction, and shoulder pain and drooping may also be a problem.
This restricted range of movement of the shoulder, and loss of function can impact on all activities of daily living related to shoulder function; for example, washing, dressing, combing hair, writing, reaching for objects above shoulder level, reaching into cupboards, hanging out washing, etc.
Severe pain in the neck and shoulder (s) may also occur as a consequence; and this pain often increases when moving the shoulder and lying on the affected shoulder. Neck tightness, stiffness, loss of sensation in the neck, or a feeling of constriction and restricted range of movement may also be a problem.
This can impact on everyday activities, such as turning the head to watch for traffic and other dangers. The appearance of the neck may also lead to psychological problems.
Insights from professionals
Pain and numbness after neck dissection
In doing this operation [neck dissection] it is necessary to indeed cut the nerves responsible for feeling in that side of your neck. The area of numbness likely extends from your ear down onto your neck then onto the upper chest and the top of your shoulder. Unfortunately, the numbness is permanent to a large degree. The actual area involved may over time decrease in size as sensory nerves grow into the numb area from surrounding normally sensate areas.
The weakness that you have noticed in your right shoulder is also from sacrificing another nerve in the neck, the spinal accessory nerve, which supplies the trapezius muscle on your back. The trapezius muscle helps you to raise your shoulder when you raise your arm. You have probably noticed that you have difficulty working above your head with your right arm. This is because you have difficulty raising your shoulder. The pain in your right shoulder is from stiffening in the capsule of your shoulder joint and also from some slight downward displacement of the shoulder from loss of the trapezius. The only real remedy for this is a vigorous program of exercise that is designed to strengthen the other muscles that help the trapezius to raise the shoulder.
The tightness and stiffness in your neck is indeed scarring in the soft tissues. Several factors have contributed to the development of this problem:
1. Radiation therapy causes fibrosis in the tissues under the skin, the amount of which can vary from patient to patient.
2. Surgery also can cause scarring.
3. A fistula and its repair can be a contributing factor.
Each of these things can lead to the problem, but when they occur together, the problem is made much worse. Use stretching exercises and massage to loosen the scarred tissue. This is going to be a slow process, like 6 months to a year, but it should loosen up some if you work on it. From: Dec 1997, HeadLines: The Doc on E-mail!!!
Glenn E. Peters, MD
The nerve that [we] are talking about is the "spinal accessory" nerve and it makes the trapezius muscle work. The trapezius muscle allows you to raise your shoulder, and thus your arm, over your head. Injury (or removal) of the spinal accessory nerve results in what we call the “shoulder syndrome” and it is characterized by pain and stiffness in the shoulder and the inability to easily raise your arm above your head. The spinal accessory nerve is not cut as a routine part of a standard laryngectomy. It is taken, however, as part of a radical neck dissection to remove lymph nodes that are involved with metastatic cancer. Most surgeons will do what is known as a modified neck dissection wherein they try to save the spinal accessory nerve to avoid the shoulder syndrome, but stretching the nerve to remove the lymph nodes around it can make it function poorly none the less. These days, more nerves are saved than sacrificed. http://webwhispers.org/Headlines/HLArticles00.htm
Glenn E. Peters, MD
Radical Neck Dissection
The radical neck dissection is the most comprehensive operation that can be done for cancer in the cervical nodes. It is a complete clean out of all node bearing groups and also involves the removal of the internal jugular vein, the sternocleidomastoid muscle, and the spinal accessory nerve that goes to the trapezius muscle. Obviously, this can result in a cosmetic deformity in the neck and more importantly weakness in raising the shoulder and arm from sacrifice of the spinal accessory nerve. From: http://www.webwhispers.org/headlines/headlines_mar01.asp
Glenn E. Peters, MD
"The best treatment for the shoulder syndrome is exercise. Without use, the shoulder will become stiff and ache. The longer you wait to begin exercising, the stiffer and more sore the shoulder will become. This starts a vicious cycle of ever increasing pain and stiffness. So exercise the shoulder and strengthen other muscles to compensate for the loss of the trapezius. A perfect example of the type of exercise would be to imagine you were using a paint roller to paint a wall. Other folks like to use a pulley or a towel thrown over a door. The goal is to get that arm up above your head. A consultation with a physical therapist may also be beneficial. " Dr. Glenn E. Peters
PubMed link on shoulder pain
"The most common complication of neck dissection is shoulder dysfunction due to manipulation of spinal accessory nerve, resulting in trapezius muscle atrophy mainly in procedures involving the posterior neck triangle."
Look to the right-hand column of the page for more articles on the subject.
TREATMENT: MASSAGE & STRETCHING
Can't move like you used to? Having a laryngectomy can cut into muscles and nerves that affect the way your shoulders move. Many of us have had the spinal accessory nerve cut, although some surgeries spare the accessory nerve. If you are having trouble with shoulders, you need to know what this can do.
Here is the definition from Medicinenet.com and you can find more information there:
'Accessory nerve: The eleventh cranial nerve, which emerges from the skull and receives an additional (accessory) root from the upper part of the spinal cord. It supplies the sternocleidomastoid and trapezius muscles. The sternocleidomastoid muscle is in the front of the neck and turns the head. The trapezius muscle moves the scapula (the wingbone), turns the face to the opposite side, and helps pull the head back.'
'Paralysis of the accessory nerve prevents rotation of the head away from that side and causes drooping of the shoulder.'
I have this problem. Massage helps, especially if done by an expert. Stretching helps even more because it is done daily, by you, and how much you improve is controlled by how much you do for yourself.
Do we have it in writing so you can try it? You bet we do. It has been tucked away in the HeadLines section, with all of you being reminded, every now and then, that there is a download there that can help you. But we have a lot of new members coming in and old members don't bother until they notice how bad their shoulder is getting. So here is another chance to help yourself. Download this file. Don't try to do everything at once. Pay particular attention to your posture and do the best you can.
To Download, http://webwhispers.org/library/headlines.asp
scroll to bottom of page and choose the PDF:
Self Massage and Stretching Booklet
STRETCH AND STRENGTHEN
By Shari Aizenman
"Welcome back! This is the first in a series for and about you. I am Shari Aizenman, a massage therapist in Atlanta, GA and Birmingham, AL. I have been in practice for twenty-two years now and have had the opportunity to work with thousands of people in a variety of situations. I specialize in recovery from injury and illness and incorporate the following exercises into my client's healing programs.
In my previous series, Massage and Stretching, I focused on relaxing and stretching as a part of an overall wellness program that anyone can integrate into their daily routine. In this series, Stretch and Strengthen, I will focus on a little more of an active and energetic role you can have in your wellness program. The first routine is more specific to the upper body. Subsequent routines will address other areas of the body.
Remember that each of us is different in many ways, and each of us can respond in a variety of ways to different stimuli. Let your body be your guide, and if you have any doubts or questions regarding beginning an exercise program of any sort, please consult your physician. These stretches and strengthening moves are designed get your blood moving, your muscles flexible, joints well-oiled, and your mind clear in a relaxing, comforting way that is also energizing.
Many of the stretches in this program can be done while sitting in a chair, while others require you to be standing near a wall or in a doorway. You may need a yardstick as a tool to assist in passive stretches.
Here we go! Begin by sitting in a chair, your feet firmly planted on the ground with your back supported. (Have these instructions nearby.) Gently allow your head to lead your spine into lengthening. You can imagine a string coming from the crown at the top of your head (that's an imaginary place where, if you draw a line from ear to ear across the top of your head, the center would be). Use this visualization of a string to gently lift your head, letting your chin drop and your jaw relax, while your head lifts up and up and each of your vertebrae separate. Get as tall as you can through your spine, your shoulders relaxing, and feel your ribs expand as you inhale. Then, allow your breath to relax and take a rest. Repeat this three times, feeding your body oxygen, preparing it for this routine.
As you sit with your back supported, relax your arms over the sides of the chair. Raise your right arm in front of you, palm up, as high as you can. When you reach your highest point, stretch your fingertips toward the sky, allowing your arm to separate away from your shoulder. Your palm will be pointing backward. From your shoulder, turn your arm in the shoulder socket until your palm is facing forward, and continuing to stretch your fingers out, lower your arm slowly to the side of the chair. Take a breath, and on the next inhale, raise your arm again, reaching and turning when you reach the top, a total of three times. Rest if you need to, and never work to the point of exhaustion. Repeat with your left arm.
Next, as you inhale, raise your arm out to the side, palm up, until your arm is next to your ear. Reach up with your fingers, turn your arm in the shoulder socket, and, palm facing down, slowly lower your arm to the side of the chair. Repeat for a total of three, rest, and repeat of the left side.
Here comes the strength part! Clasp your hands together on your lap. Stretch your arms straight out in front of you and on an inhale lift them together as high as you can. Hold for a count of ten as you relax into your breath and lower your arms slowly. Repeat for a total of five. Rest. if necessary, then place your palms on your knees. On an inhale, stretch your arms straight in front of you, lock your elbows and raise your arms at the same time as high toward the sky as possible. Hold for a count of ten and lower them slowly. Repeat for a total of five.
Last in this group is resting your arms out to the sides of the chair, and on an inhale, raise your arms, palms facing the floor, toward each other until your arms are touching your ears. Reach tall with your fingertips and slowly bring your arms back to your sides. Repeat for a total of three. Rest for a moment, then turn a few circles with your wrists, shake your hands out and shrug your shoulders ten times to let your body know that this portion of the exercise is over.
Time to use your yardstick! Stand with your feet a bit more than hip's width apart. Allow your knees to relax and hold the yardstick in front of you, hands side by side, palms facing down. On an inhale, lift the yardstick out in front of you until it is directly in front of your shoulders. Then gently twist at the waist toward the left, moving your upper body as a unit, as far as is comfortable. Breathe while there, lowering the yardstick and raising it again for the trip back to center. Now bring the yardstick back down, rest and repeat in the other direction. Go to each side a total of three times. Rest the yardstick against a wall and rotate your arms in windmills, making three big circles in one direction and then the reverse.
Pick up the yardstick and this time spread your arms out to the ends. As you inhale, raise the yardstick above your head and twist your body at the waist toward the left as far as is comfortable. With the yardstick still above your head, gently turn toward the right as far as you can. Once there, inhale and come back to center. Lower the yardstick, take a rest and repeat three times. Do a few windmills with your arms, rotating slowly through the shoulders to loosen and oil the joints. Then go in the opposite direction.
Are you sweating yet? Remember that you can design this program to fit your own needs. If a specific move causes discomfort, modify it or omit it. Are you resistant to trying something? My thought is this: What you resist persists! Let go of whatever is keeping you from at least trying and go for it! Also, it may help to make sure you do gently rotation movements through the shoulders after doing exercises where the arms are above your head. This keeps the joint well-oiled.
Rest for a moment. Walk around and give your legs a little exercise. Keeping the blood flowing throughout the entire organism (your body) is the best way to retain optimal health! Clap your hands together and then rub them together and then the backs of them to allow friction to get blood flowing down into your fingers.
For this next set of movements, you will need to stand next to the smallest doorway you can find. If you can reach the top of the door, hook the fingertips of your right hand over the end of the door. Then gently bend your knees to stretch the arm forward. Then lean forward to flatten your armpit against the edge of the door. Do not lean backward. Hold this stretch to the count of ten. Gently lower your arm, shake it out and repeat for a total of three stretches. Change arms and repeat on the other side.
Now stand in your doorway with one foot six inches ahead of the other. Bend your elbows 90 degrees and put your palms, forearms and elbows against the outer doorjamb. Gently lean onto your forward foot, allowing a little of your body weight to stretch your chest muscles outward, as you move forward. Remember to move from your center, belly button going straight forward and no arch in your back. Once you get to a comfortable stretch, hold to a count of ten and come back to the beginning point. Repeat the stretch for a total of three with your first foot forward, shake your arms out and repeat with the other foot forward.
Last in this series is to give yourself a variety of modified hugs. Reach your right arm across your chest toward your left elbow. Grasp your left elbow and pull it across your chest with your right hand, stretching out the upper shoulder. Assist the stretch by reaching around your waist with your left hand. Hold this to a count of ten and repeat five times, alternating sides with each stretch. Then reach across your chest as far as possible with your right hand toward the back of your neck, then grasp your right elbow with your left hand and hug your elbow further across the body and flat against your chest. If you want, you can give your left shoulder a squeeze with your right hand. Repeat this stretch a total of five times on each side, alternating sides with each stretch. Complete the stretch with a few windmills.
Finally, rub your hands, arms and shoulders briskly and give yourself a hand! Good job!
From Headlines, April 2008
Tips From Our Members
1. Please remember to discuss any treatment regimen with your physician before beginning any exercise program.
2. Standard advice on exercise is to avoid pain. The "no pain, no gain" saying is a myth. Move until you reach your current limit, hold it, and then move just a tiny bit past that point. Over time you will gain more and more range of motion.
David Blevins, 2006
3. Some neck exercises I regularly do are to turn my head to the left and right, tilt my head towards my shoulder (ear to shoulder, both sides...don't lift your shoulder), look down/look up, move my head to look at my shoulder (both sides), raise each hand over head and raise my head to look at my hand, look left and then in one continual motion look down and to the right and --- repeat. One NOT to do is the "Egyptian" or "turkey" head movement. Don't move your head in any unnatural direction or position.
David Blevins 2006
4. A well known physical therapist from Mayo Clinic spoke about this very subject at an IAL Annual Meeting. She helped several folks in the audience by demonstrating that by simply hooking your thumb into the belt, belt loop, or pocket, you can relieve the downward pull of a hanging arm and shoulder following neck dissection. The another simple exercise to help raise your arm with a 'frozen shoulder' is the finger walking up the wall that mastectomy patients use. I've seen significant improvement noted by other club members who have tried these easy suggestions.
Elizabeth Finchem, 2006
5. Some good shoulder exercises are found in the "Move it or Lose It" videotape/DVD available through the IAL.
David Blevins, 2006
Here my experience with what might have turned out to be chronic pain:
Before the operation the doctors had warned me about possible shoulder problems including chronic shoulder pain. Sure enough the nerve to my right shoulder was damaged in the operation. Seemed to me there was pain whenever I tried to lift the right arm.
I was also very aware of anxiety about this - would I be able to look after myself ... would it get worse ... etc etc. I went to physio and though she gave me exercises to do she said I had to expect restrictions to how well the shoulder would function now that some of the nerves had been severed.
Gradually the anxieties went away, and so did the pain. The movement and strength is still restricted but I've adapted pretty well.
I practice mindfulness and have often been struck by how difficult it is to separate mental and physical pain. The tension caused by anxiety can be physically painful. I wonder how much of my earlier shoulder 'pain' was caused by anxiety? And if I hadn't been practicing mindfulness, would those anxieties have persisted and resulted in chronic shoulder pain?
This is by way of encouraging anyone who suffers from chronic pain to think about doing a mindfulness course e.g. MBSR (Mindfulness Based Stress
Reduction) which was developed initially for people with chronic pain but now recommended in many areas of medicine and for general well-being.
Noirin, Dublin 2013.
Some members have reported some help with neck pain by the use of Theraworx topical spray. I found it at my local pharmacy.
Good information from our Newsletter
You can fiind a good article in our newletter on message by:
Holly Woodall M.C.D. CCC-SLP, LMP, CLT
Senior Speech Language Pathologist
University of Texas MD Anderson Cancer Center
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