Rehabilitation following Partial Glossectomy and Neck Dissection for Tongue Cancer

Rehabilitation Oncology , 2004 by Courtney-Koro, Selena
• ABSTRACT Surgery for tongue cancer results in incision tightness that causes a loss of motion and a decrease in flexibility that ultimately impairs the functioning of the jaw, neck, and shoulder. This case report describes the physical therapy treatment provided to a patient who had surgery for tongue cancer. The subject of this study was a 49-year-old Caucasian woman who presented to physical therapy 6 weeks post partial glossectomy and neck dissection following cancer of the tongue. The patient reported loss of motion in the neck and shoulder. Physical therapy intervention focused on exercises, spasm reduction, Kinesio taping, manual therapy, and patient education. Following 18 visits in physical therapy, there was an increase in cervical and shoulder range of motion and strength, increased flexibility, increased scar tissue mobility, decreased muscle spasm, and improved function. Outcomes were measured using a goniometer, palpation by a therapist, and patient report of functional improvement. These findings indicate that therapy may be useful for patients postsurgery for tongue cancer.

INTRODUCTION The incidence of tongue cancer is on the rise.1 The treatment for tongue cancer is surgical removal of the cancer, radiation therapy, and chemotherapy.2,3 The results of those treatments are tightness in the shoulder and neck muscles.4,5 There also may be tightness around the incision. Physical therapy can be useful to address limitations in joint and muscle function from incision tightness.6 This is a case report of the use of physical therapy manual techniques and Kinesio taping status-postsurgical glossectomy (removal of part of the tongue) in a patient diagnosed with tongue cancer. A patient who had surgery for tongue cancer was left with loss of motion, spasms, weakness, and loss of function. The patient received physical therapy treatments of exercise, Kinesio tape to the incision, manual therapy, and education to improve movement and function. This case report will describe physical therapy methods to successfully treat correctable problems such as spasms, inflexibility, incision tightness, muscle weakness, and loss of motion. The literature supports using stretching and ischemic pressure to treat spasms.4,7,8 One case study has shown the successful use of Kinesio tape to treat incision tightness.9 This case report demonstrates the use of physical therapy to treat a patient's soft tissue limitations in the neck and shoulder. In this case report, physical therapy intervention focused on the following areas: shoulder and neck home exercises for range of motion, stretching and strengthening; spasm reduction techniques of ischemic pressure in the department and at home, incision treatment of Kinesio tape, friction massage; cervical muscle manual therapy of stretching using contract-relax and reciprocal inhibition; and postural correction using handouts and patient education. LITERATURE REVIEW Oral squamous cell cancer is estimated to be the sixth most common cancer worldwide.1 More than 90% of all upper aerodigestive (mouth and digestive tissues) cancers are squamous cell carcinomas.2

Incidence of oral cancer is on the rise.1 It is mainly a disease striking middle age men who smoke and drink alcohol. The first symptoms include a solitary ulceration anywhere in the oral cavity.3 The ulceration is usually a red or white nodule that has been present for longer that 3 weeks.3 Typically the carcinoma will present on the posterior lateral margin of the tongue and floor of the mouth.1 The patient will report symptoms of ulceration, lump, fissure, or enlarged cervical lymph nodes. The areas that are usually involved are the posterior and lateral margins of the tongue.3 Tongue cancer is most often caused by tobacco and alcohol use. The risk of multiple primary cancer is 3.9 times higher for those who are exposed to 40 or more cigarettes and 3 or more whiskey equivalents per day for at least 30 years compared to those who were exposed to the equivalent of 0 to 19 cigarettes and 0 to 2 whiskey equivalents per day.2 Other causes include a diet lacking in fresh fruit or vegetables, infective agents such as Candida or viruses, immune deficiency, and sun exposure (predisposes to lip carcinoma).1-3 It has been speculated that squamous cell carcinoma of the oral cavity becomes clinically significant when the patient's immunologic status is altered.2 There is no evidence that physical irritation from dentures, sharp teeth, or spicy foods plays a role in causing oral cancer.2 The anatomy of the tongue, jaw, and neck area include the oral cavity and the many structures inside the oral cavity. The more pertinent ones are the soft palate, hard palate, palatoglossal arch, tongue, lingual tonsil, palatopharyngeal arch, and gingivae (gums).6 The surgeon may excise some of these areas when they show signs of being cancerous. The muscles in this area are the sternocleidomastoid, platysma, upper trapezius and the facial muscles of masseter, digastric, orbicularis oris, zygomaticus major and minor. The muscles in the posterior cervical area may also be involved. These muscles include the splenius capitus, semispinalis capitus, obliquus capitis superior, and rectus capitus major. The muscles all together are called the posterior cervical muscles.7 A diagnosis of tongue cancer is made through a biopsy under local anesthesia, a jaw or chest x-ray, endoscopy, lab tests for blood count or liver function, or CAT scan or MRI tests.2 Screening for early stages of oral cancer is simple and can be done during a dental exam. Dental patients who are male, smokers, and over 40 years old should be examined carefully for oral cancer. Educating the public on being aware of oral cancer may help with early diagnosis. Education does make a difference since those adults who had an oral exam were also more likely to be more aware of the risks of oral cancer.1 Physical therapists may play an increasing role in wellness in the future and may be involved in educating the public on the prevention of tongue cancer.

Treatment for tongue cancer includes surgical removal of the tumor and 2 cm of the surrounding soft tissue. Two forms of neck dissection may be used including removal of the cervical lymph nodes and involved nerves (radical neck dissection) or removal of the cervical lymph nodes while preserving the jugular or sternocleidomastoid or accessory nerves (functional neck dissection).3 Partial glossectomy also may be required due to the spread of the cancer. In a partial glossectomy surgery, the tongue would be partially removed. The aim of surgical management is to excise the entire lesion to eliminate the spread of the cancer through the lymphatic system, nerves, and blood vessels.1 Radiation is standard care in cancer of the tongue. Radiation treatments may be given before surgery to shrink the tumor, or within 6 weeks after surgery to treat microscopic cancerous tissues remaining after the surgery.1,3 In one study, patients with early stages of tongue cancer had more than a 90% chance of 5-year recurrence-free survival when they had external beam irradiation.5 Surgical reconstruction may also be needed for soft tissue (lip flaps) or hard tissue (dental implants).3 Chemotherapy is used if there are metastases and may improve survival; however, there is an increase in morbidity from chemotherapy toxicity.1

Side effects from the surgery are morbidity, the need for reconstruction, and limitations due to scarring. Side effects from radiation include oral mucositis and osteoradionecrosis. Avoiding irritants like smoking, alcohol, and spicy foods can reduce mucositis. Mucositis may also be lessened by good oral hygiene, cooling the mouth with ice and medication such as topical aspirin.2 Patients may also complain of dry mouth, difficulty with speech, swallowing dry foods, a burning sensation in the mouth, dental caries, oral candidiasis (Candida fungus), and bacterial sialadenitis (salivary gland inflammation). Salivary tissue may be stimulated by sugar free gum or cholinergic medications such as Pilocarpine. Patients with dry mouth should avoid tobacco or alcohol since these impair salivation. They may also benefit from frequent sips of water, saliva substitutes, dietary control, and topical fluorides.2 The prognosis for the cancer is based on the stage at which the carcinoma is detected. Oral cancer is easiest to cure when it is less than 1 cm in diameter. It can be detected during routine dental exams. Unfortunately, most oral lesions are detected after they cause symptoms including a large lesion, ulceration, bleeding, and lymph node enlargement.2 The prognosis has remained poor and is in the range of 30% to 40 % for a 5-year survival rate.2 Early detection is critical to improving prognosis. Health care workers need to recognize the importance of referring a patient to an oral doctor if the patient reports an oral lesion that has been present for longer than 3 weeks. Educating the population about avoidance of tobacco and alcohol has been neglected. In one study, 47% of patients diagnosed with oral cancer still smoked and 36% still drank. Only one third of the patients in this study were aware that there is a synergistic effect of alcohol and tobacco in the development of oral cancer.2,3 PHYSICAL THERAPY Radical neck dissection will leave the patient with the postoperative problem of shoulder drop. "Physical Therapy to the affected shoulder can limit disability to a relativity small dysfunction. Much of the disability is due to disuse of the shoulder although taking the nerve does create weakness in the trapezius muscle. However, a patient may develop a frozen shoulder even when the nerve is spared unless adequate early postoperative physical therapy is initiated."4 Although the surgery occurs at the neck and anterior chest, a patient may develop a frozen shoulder due to pain with active movement of the scapula and humerus.

Although physical therapists rarely treat patients with tongue cancer, physical therapists are adept in scar management and in soft tissue treatment techniques. In the current Guide to Physical Therapist Practice, surgical wounds are classified under "impaired integumentary integrity secondary to full-thickness skin involvement and scar formation."8 Suggested treatments include modalities, manual therapy, exercise, functional ADL training, injury prevention education, and the use of adaptive equipment. Expected range of number of visits is 12 to 50.8 Physical therapists have been consulted and provided treatment for soft tissue tightness following burns, shoulder adhesive capsulitis, and torticollis. Types of treatment include modalities, taping, manual therapy, patient education, and exercise. Physical therapy has been helpful in treating scar tissue following burns using soft tissue mobilization to improve range of motion, scar pliability, and vascularity.9 The loss of motion in the neck and shoulder muscles following tongue cancer surgery can also be successfully treated in physical therapy using manual therapy techniques.7 Kinesio Tape In America, taping has been used as a modality for 50 years by physical therapists and athletic trainers.10 Kinesio tape, specifically, has been used in Japan for 30 years and has been introduced to America by its inventor Kenzo Kase, DC. The proponents of this method describe Kinesio taping as a technique that is based on the natural healing process of the body." The theory of Kinesio tape is that it activates the neurological and circulatory systems. Kinesio tape is made of cotton that will stretch

longitudinally more than 30% to 40% of its original length. It can be used to support weak muscles through use of its elastic properties. Edema can be reduced through improving the circulation of blood and lymphatic fluid. Pain may be suppressed through the neurological suppression of pain receptors. Kinesio tape has been used at Kinesio tape courses for treatment of scar tissue.11 One case study used Kinesio tape for treatment of the incision of a patient who had a soft tissue lesion excised on the dorsum of foot. The patient's scar was immobile and she complained of pain when walking. Kinesio tape was used over the patient's scar. "Within 24 hours, the patient reported she was pain free." The patient was able to return to active sports.12 One research study on Kinesio tape has found an increase in blood flow within 10 minutes of wearing the tape.13 Other research has shown increased knee extension range of motion when Kinesio tape is worn.14 Those subjects who wore the tape had increased active range of motion in knee extension compared to those who were not taped. Another study showed that the Kinesio tape controlled muscle damage and assisted in recovery following exercise.15 Trigger Point Theory

Soft tissue limitations from muscle spasms have been treated successfully in the past using the theory of trigger point. Janet Travell advanced the theory of trigger points in soft tissues in her book Myofascial Pain and Dysfunction: The Trigger Point Manual. The clinical characteristics of trigger points include a typical pattern of pain referred from the spasm and reveals local tenderness to palpation. The muscle may be shortened and weak. The palpation of the spasm may produce a local twitch; complaints of pain at the site of palpation, and possibly referred pain that follows a typical pattern.7 For example, the upper trapezius muscle will typically refer pain into the jaw and behind the eye. Electromyographic, clinical, and experimental evidence all suggest that a myofascial trigger point, which begins with muscular strain, becomes the site of sensitized nerves, increased metabolism, and reduced circulation. This initial neuromuscular dysfunction phase, if untreated, may progress to a dystrophic phase that causes demonstrable histological changes in the muscle."7 Travell's theory is that poor posture, weak muscles, poor nutrition, overuse, and tight muscles cause trigger points. The goal of treatment is to correct the problems that caused the trigger point or muscle spasm. Travell also instructed therapists to stretch the muscles using spray and stretch or ice. The muscles spasms were also to be treated with manual pressure to the spasm to make them decrease in size and intensity. The patient was taught to stretch the muscles at home and to apply tennis ball pressure to the spasms to decrease their intensity. These 'press-out' or ischemic pressure treatments should be applied for no longer than 5 minutes per day. The theory being that histamine release from the trigger point softening would flush into the tissue and cause soreness.7 CASE REPORT Ms DH was a 49-year-old Caucasian who presented to physical therapy 6 weeks postsurgery with a diagnosis of post partial glossectomy and neck dissection following surgery for tongue cancer. Although the patient did not have a history of using tobacco products, the patient did have a previous diagnosis of tongue cancer 3 years prior and had been treated with chemotherapy. The present episode of tongue cancer was revealed from a CT scan and the patient was subsequently treated with surgery and radiation therapy. Fortunately, the patient did not have lymph node involvement. Although she had a limited social support system, she was motivated to return to work because of monetary and social concerns. Following the surgical procedure, her physician requested physical therapy to help with soft tissue problems. The soft tissue problems included multiple muscle spasms and restricted incision mobility that contributed to decrements in flexibility, motion, and strength at the neck and shoulder, as well as poor posture. The patient had questions regarding her physical therapy program and was motivated to be compliant by her desire to return to work.

Range of motion of the shoulder and neck, as well as, pectoralis flexibility were measured at the beginning, middle, and end of the therapy program using a standard goniometer. Flexibility of the pectoralis muscle was measured using a goniometer across the chest and arm. The axis of the goniometer was placed on the humerus and the anterior chest. Other methods of measurement included the use of standard physical therapy examination of strength, palpation, function, and pain intensity. Strength was measured using manual muscle testing and the patient was graded on a 0-5 scale of strength. Palpation of the soft tissue checking for spasms, scar tissue restrictions, and tension beneath the muscles was done by a physical therapist experienced in manual palpation. Function was assessed by physical therapist questions and information volunteered by the patient in regard to performance of activities of daily living and instrumental activities of daily living. Pain intensity was assessed by patient's verbal self-rating on a scale of 0-10 with 10 being the worse pain she had ever experienced. Chief complaint was as follows: The patient denied pain at rest, but complained of muscle tightness and loss of motion in the neck and shoulder. The loss of mobility caused the patient to have functional losses with rotating the head while driving and lifting her arm overhead. The postural examination revealed a significant increase in thoracic kyphosis with protracted shoulder in both the seated and standing positions. Cervical spine AROM was as follows: * L side bending 20 ー * R side bending 10 ー with end range pain * L rotation 55 ー * R rotation 50 ー with end range pain Shoulder AROM was as follows: * L flexion 130 ー with end range pain * L abduction 125 ー with end range pain AROM and flexibility was as follows: * Pectoralis tightness measured 45 ー (axis of humerus to trunk with patient sitting) * The triceps had moderate tightness Cervical strength testing was as follows: * L side bending 4/5 * R side bending 4-/5 with complaints of pain in the left sternocleidomastoid muscle * L rotation 4/5 * R rotation 4-/5 with complaints of pain in the left sternocleidomastoid muscle Shoulder strength testing was as follows: * L shoulder abduction 3+/5 with shoulder pain * L shoulder flexion 4-/5 with shoulder pain Palpation was as follows: Integumentary examination revealed a well healed incision from the patient's chin to below the proximal sternum. The scar had limited mobility, limited pliability, and poor definition of muscle texture in the anterior neck at the site of the incision. Active palpable spasms measuring 2/3 in scalene, levator scapulae, rhomboids and upper trapezius muscles. Functional losses were reported as follows:

Subject complained of pain in the upper back with lifting shopping bags, pain with undressing, and loss of motion in the neck when turning the head while driving. The patient was on a leave of absence from work. The goals for physical therapy included: 1. improve flexibility in the triceps to minimal to allow reaching overhead, 2. increase AROM to 65 ー of cervical rotation to improve driving, 3. decrease spasm in the rhomboid to 1/3 to improve sitting tolerance, 4. independence and adherence to the home exercise program to prevent recurrence of loss of motion, 5. increase strength in shoulder abduction to 4+/5 to allow lifting, 6. increase flexibility in the pectoral muscles to 0 ー to improve posture, and 7. patient to be independent in use of scar massage. The patient's goals were to 're-gain range of motion in the neck and shoulder.' The patient's goals were discussed and with permission were revised to 'increase movement.' The discussion of the revision of the patient goals was used as an opportunity to educate the subject on realistic expectations for physical therapy intervention.

INTERVENTION Exercises were given to the patient in the department and as a home program (see figure 1 and 2 for the pulley mechanism and the exercises). The exercise handout was a compilation of exercised from Exercise Pro software program provided through BioEx Systems.17 Permission was granted to note the use of the exercise software in this paper. In the department, examples of exercises were pulleys for shoulder abduction and flexion. The patient was seated and facing away from the overhead pulleys and each position was used for 5 minutes. The patient was instructed on how to set up pulleys at home. The pulleys could be purchased through Dynatronics.18 Permission was granted to use the picture of the pulley system in this paper. Other departmental exercises included seated rows on the weight machine for strengthening the upper back. A minimum of 10 pounds was held by the patient for 5 seconds and repeated 10 to 15 times. Other exercises in the department used the rebounder for strengthening and coordination. The patient would throw a 2 pound ball at an angled minitramp for 5 minutes. The patient could be instructed to duplicate this at home by throwing a ball against a wall. Exercises at home were instructed and performed initially in the department by the subject. The subject was provided with a written handout of the home exercise program. One exercise that was taught was the sitting trapezius stretch. The patient was instructed to sit on one hand while the other hand passively stretched the head into a side bent position. The patient was instructed to hold this position for 5 seconds and to repeat 10 times. Another home stretch was the pectoral corner stretch. The patient was instructed to do shoulder range of motion exercises at home using the cane with overhead flexion of 3 sets of 10. The patient was taught to do 'climb the wall' exercises. The patient was told to face the wall and slide or walk the hand up the wall. This was done to increase shoulder range of motion. The patient was instructed on shoulder strengthening exercises of isometric abduction and extension. The strength of the neck muscles was addressed by teaching the patient to perform cervical isometric exercise at home. Another treatment given to this patient, included the use of Kinesio tape to soften the tight scar tissue across the neck and jaw area. The patient was instructed on the role of Kinesio tape in softening the restrictions. The patient was informed of the 2 causes of the side effects of blistering if the tape is pulled too tightly or if it is dried using a blow dryer. The patient was informed of the benefits of the tape in

helping to soften the areas of the incision that were movement impaired. The patient agreed with the treatment plan. The technique used was to cut a piece of brown, Kinesio tape to the length of the scar. The therapist cut the edges so they were rounded. Rounding the corners of the tape appears to prevent the clothing from adhering to the tape and pulling it off the patient's skin. The tape was placed on the incision without any pull. The therapist smoothed the tape to the skin to assist with improved adherence (Figure 3). The patient was told the tape could be left on for 4 to 5 days and the patient could take showers while wearing it. The patient was told to remove the tape if it irritated the skin (felt itchy). The patient was provided with a handout on the benefits, risks, theory of how Kinesio tape improves lymphatic fluid flow, and contact information for the tape. The Kinesio tape was useful in decreasing the restrictions. The patient experienced none of the possible side effects and she was taught how to apply the tape to her incision at home. Other treatments used included the use of manual therapy to stretch the sternocleidomastoid, upper trapezius, and scalenes. The physical therapist performed contract relax and reciprocal inhibition techniques to the upper trapezius, levator scapulae, sternocleidomastoid, and scalenes. For reciprocal inhibition, the patient was supine with her head supported on a pillow. The patient was asked to stabilize her arm by tucking her hand under her buttock. The therapist put her hand on the patient's temple while gently stabilizing the opposite shoulder. The command given to the patient was "push into my hand with your head." In this case, the patient was supine with the left hand under her buttock. The therapist had her right hand on the patient's right temple and the therapist's left hand was on the patients left shoulder. The therapist then instructs the patient to "push your right ear into my right hand." This was repeated 5 times on each side of the neck. The sternocleidomastoid, levator, and scalene were also stretched using either contract relax or reciprocal inhibition. The technique was to side bend the head to the left and rotate to the left. The left hand was anchored under the patients left buttock. The instructions were to "push your right ear into my hand." When the patient relaxed, the head was further side bent and rotated. Manually stretching the patient was always done to tolerance and was stopped if the patient complained of unusual pain. Also during manual therapy, the issue of tightness in the soft tissue at the site of the incision was addressed using gentle friction massage and myofascial release. The patient was instructed in friction massage by looking in the mirror while giving cross friction massage to the incision using the index and middle finger. It was stressed to the patient the importance of moving with the skin instead of sliding the fingers on the skin. The patient was told to gently massage across the scar as though she was making a cross on the incision.

Finally, the patient was instructed in a home program for trigger point reduction. The patient was told to use a tennis ball to press on the rhomboid spasm. The patient was told to put the ball into a sock and lean against a wall to press out on the spasm. Tenderness at the spasm site was the focus of the press out. The patient was told to press until she felt a tolerable pain that didn't radiate. The patient was told to do this every day for 5 minutes. The home program was first introduced in the department and performed under the supervision of this therapist. A handout was given to the patient with pictures of the exercises. All patient questions regarding frequency, reason for exercise, and technique were answered to the patient's satisfaction. Patient education focused on proper posture and body mechanics. The patient was instructed on selftrigger point press-out, Kinesio tape use at home, and home exercises. OUTCOMES In this case, physical therapy resulted in the patient returning to full cervical and shoulder range of motion. Cervical rotation AROM improved from 50 ー to 80 ー. Shoulder abduction AROM improved from 125 ー to 180 ー. Shoulder flexion AROM improved from 130 ー to 160 ー. The patient had improved flexibility, reduced spasms, and improved scar tissue extensibility. Pectoralis flexibility improved from

lacking 45 ー to lacking 5 ー. Rhomboid spasms improved from active, painful, and grading at 2/3 level of irritability to latent, not painful, and 1/3 level of irritability. The strength of shoulder abduction improved from 3+/5 to 4+/5. The patient received education on posture, home exercises, and self massage. The patient was able to return to work full time and had normal function in all her ADLs. The duration of treatment was 18 visits. Outcomes were measured using a goniometer, palpation by the therapist, and reports on pain and function from the patient. This was not a randomized clinical trial thus the treatment was not scientifically proven to be the reason for the improvement in this patient's condition. In summary, physical therapy treatment was provided for scar mobility and soft tissue limitations in a female with a diagnosis of tongue cancer who underwent surgery, chemotherapy, and radiation treatment. The etiology of this cancer was unknown since this patient was not a smoker. In this case, physical therapy intervention focused on the following areas: shoulder and neck home exercises for range of motion, stretching and strengthening; spasm reduction techniques of ischemic pressure in the department and at home; incision treatment with Kinesio tape and friction massage; cervical muscle manual therapy of stretching using contract-relax and reciprocal inhibition; postural correction using handouts and patient education.

The use of exercise to treat loss of motion has been documented in the literature.16 The literature supported the use of manual therapy to treat soft tissue restrictions.7,16 The manual therapy provided was stretching, spasm reduction, and cross friction massage. Dr Travell has documented the use of ischemic pressure for spasm reduction.7 The use of exercises to treat trigger points by stretching tight muscles is well documented in Dr Travell's textbook.7 The literature on the use of Kinesio tape to treat incision tightness is limited. The treatment provided to this patient was within the guidelines of the use of Kinesio tape. More research needs to be done on the use of manual therapy and Kinesio tape in physical therapy on patients following surgical treatment for cancer. For beginning users of Kinesio tape it is suggested that a course be attended to learn how to avoid overstretching the tape that could cause blistering of the patient's skin. It is also important to understand how the tape should be applied. One article that gives a good overview of the different way to tape for muscle weakness versus edema control is "Believe the Hype" by Burke and Bailey.10 Chiropractors, physical therapists, athletic trainers, orthopedic doctors, acupuncturists, and other health practitioners use Kinesio tape. More research needs to be done to document the science behind Kinesio tape. In conclusion, this case report described the method of treatment for a patient who had surgery for tongue cancer. Hypothetically, stretching will improve the movement of people who have had surgery for tongue cancer. The treatment used included Kinesio tape for incision restriction, manual therapy for spasm reduction, and stretching. This case report may be helpful to therapists who have never treated surgical restriction following tongue cancer. The use of Kinesio tape for treatment of scar tissue could also be a new treatment option for some therapists. Knowledge of these solutions may help other physical therapists that may be faced with treating patients with soft tissue restrictions following tongue surgery. This case report may guide others in aiding these patients regain lost movement, perform independent home treatments, improve function, and understand the importance of postural awareness. In the future, physical therapists may be called upon to educate patients on the importance of diet and wellness to improve their lifestyle.

Suggested future research includes the use of Kinesio tape in experimental studies, studies to determine which physical therapy interventions for tongue cancer have the greatest impact, and descriptive research on the impact of physical therapist in wellness in the prevention of tongue cancer. Limitations of future research may be a lack of a large enough number of patients to perform randomized studies of subjects receiving physical therapy following surgery for tongue cancer. ACKNOWLEDGEMENTS The author would like to thank the instructors Dr Beth Marcoux and Dr Chris Stiller at Oakland University for their assistance with this manuscript. This case report received an exempted IRB through the review board at Oakland University.

REFERENCES 1. Zakrzewska J. Oral cancer. Brit Med J. 1999; 318(7190):1051-1052. 2. Mashberg A, Samit A. Early detection, diagnosis, and management of oral and oropharyngeal cancer. CA Cancer J Clin. 1989;39(2):67-79. 3. Scully C, Porter S. Oral cancer. Brit Med J. 2000; 321(7253):97-100. 4. Cummings C, Flint P, Krause C. Neck cancer: what's optimal therapy? Patient Care. 1990;24(4):4454. 5. Cancer research weekly. Radiotherapy improves quality of life for tongue-cancer patients. 1993:1214. 6. Anatomy of the Oral Cavity. Available at: www.tarleton. edu/~anatorny/oralcavity.html. Accessed 11/15/2003. 7. Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol I. Baltimore, Md: Williams and Wilkins; 1983. 8. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001. 9. Silverberg R, Johnson J, Moffat M. The effects of soft tissue mobilization on the immature burn scar: results of a pilot study. J Burn Care Rehabil. 1996;17(3):252-259. 10. Burke W, Bailey C. Believe the hype. Phys Ther Products. 2002:30-33. 11. Kinesio Taping Association. Available at: Accessed October 9, 2003. 12. Stahl A. Clinician's Overview and case study: post operative neuroma and RSD. September 1999. Available at: Accessed October 9, 2003. 13. Kase K. Changes in the volume of the peripheral blood flow by using Kinesio taping. Available at: www.kinesiotaping. com. Accessed October 9, 2003. 14. Murray H. Effects of Kinesio taping on muscle strength after ACL repair. Available at: Accessed October 9, 2003. 15. Nosaka K. The effect of Kinesio taping on muscular microdamage following eccentric exercises. Available at: Accessed October 10, 2003. 16. Hou C, Tsai E, Cheng K, et al. Immediate effects of various physical therapy therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. 2002;83:1406-1414. 17. BioEx Systems. Exercise Pro exercise software. Available at: Accessed

October 10, 2003. 18. Dynatronics Rehabilitation Products. Rehab Pulley System. Available at: Accessed October 10, 2003. Selena Courtney-Koro, PT

BS in Physical Therapy in 1986 from the LSU Medical Center in New Orleans. Scope of practice has been primarily in outpatient hospital clinics. Currently Selena is enrolled in the DScPT program at Oakland University in Rochester Hills, Michigan. Copyright Rehabilitation in Oncology 2004 Provided by ProQuest Information and Learning Company. All rights Reserved

Bibliography for: "Rehabilitation following Partial Glossectomy and Neck Dissection for Tongue Cancer"
Courtney-Koro, Selena "Rehabilitation following Partial Glossectomy and Neck Dissection for Tongue Cancer". Rehabilitation Oncology. 30 Apr, 2009.