For the last 5 years, I have focused my practice on oncology. In school, we had always been told to avoid manual therapy with the cancer population. However, I have found due to the gentle, pain-free nature of the Mulligan concept, it has become a great asset in improving mobility in this population.
When treating any patient with cancer, the physiotherapist always wants to complete a thorough history, including medication, types of treatments the patient has undergone, tumor type and classification, radiation treatments’ duration and locations, and especially the location of any metastatic lesions. All are critical in establishing treatment protocols. The physiotherapist becomes part of the oncology team, including the surgeon, oncologist, radiation oncologist, speech therapist, social worker, and nutritionist. Each has its specific job through the recovery process. Good, open communication between team members is key.
Once the joint /bone or surrounding tissues have been cleared of metastatic or cancer lesions, it is safe to apply gentle, pain-free techniques! I have been working closely with the head and neck population. Especially following radiation, patients develop fibrosis of the musculature which tends to draw the head and neck forward and can progress to “dropped head syndrome". If the posture is not addressed in a timely fashion, this condition can become dysfunctional very quickly. I have found that gently performing NAGs to the lower cervical spine followed by gentle active ROM can dramatically improve patients’ ability to move.
Ideally, the NAGs are performed with the patient sitting, but I have modified the technique to be done supine. With this clinical variation, I can utilize gravity to allow the neck to come back to a neutral position. By gently supporting the head on my forearms while the middle phalanx of my index finger hooks under the spine’s process, I can still apply the glide up toward the eyes.
For the lower cervical and upper thoracic spine, I find RNAGs too aggressive. Accordingly, I modified to supine where I stabilize the upper segment with the middle phalanx of my index finger, but have the patient perform bilateral shoulder elevation. As the patient lifts their arms the therapist feels the vertebra dropping under his fingers, allowing the neck to move into gentle axial extension. These techniques are often coupled with myofascial work to the fibrotic musculature on the anterior aspect of the neck and active ROM. Post-session I often see improved head control, with improved mobility.
The other area of dysfunction seen in our head and neck population is truisms. This condition can begin quickly after direct surgery on the jaw or as a result of post-radiation changes. In some individuals truism tightness comes on gradually, due to teeth removal before surgery, eating a soft to liquid diet, or requiring a feeding tube for nutrition. Some patients have lost the ability to speak. All of these these patients are challenging. Again, if the therapist can start treatment and education early, teaching patients jaw exercises, some of the loss may be prevented. But once a restriction is noted I use some of Mark Oliver’s techniques, along with trigger point work around the face and neck and hyoid region. I have found these to be invaluable with these patients.
So, don’t be afraid of oncology patients, be smart. Work with your team, to know what you're working with. Gentle, pain-free treatments can be extremely beneficial to allow pain-free mobility.
Patricia Black PT, MS, MCTA, CLT