Bracing to treat dropped head syndrome in cancer patients: A retrospective review

IINTRODUCTION

Dropped head syndrome, further defined as neck extensor and cervical paraspinal weakness, results in reduced ability to maintain an upright cervical spine posture and ultimately a chin-on-chest head position.^1–3 Increased thoracic kyphosis may also be seen with dropped head syndrome with a forward flexed or anteriorly translated head.^1–4 Patients may only be able to achieve a neutral cervical spine position passively with the supportive use of a hand.² Dropped head syndrome is seen in neuromuscular conditions such as motor neuron disease, myasthenia gravis, isolated neck extensor myopathy, or Parkinson’s disease, and can be seen after cancer treatment including surgery and radiation. ^{1, 5–7}

Dropped head syndrome is a known late-stage complication in Hodgkin’s lymphoma, particularly after mantle field radiation.^{4, 8–10} Dropped head syndrome can also be seen as a treatment sequela in the head and neck cancer population after surgery, chemotherapy, or radiation. ^{3, 11–14} In the head and neck cancer and Hodgkin’s lymphoma populations, patients complain of progressive head drop with neck extensor and periscapular weakness and atrophy, reduced cervical range of motion, poor posture, in addition to neck and shoulder discomfort years after cancer treatment.^{1,4,8,9, 12–14} Typically the weakness is progressive and localized, and sensory changes and paresthesias do not occur.⁸ Electrodiagnostics historically have revealed myopathic and neurogenic changes, and muscle biopsy can demonstrate noninflammatory myopathic changes with muscle denervation. ^{4,8,9, 11–13}

Management of dropped head syndrome can be conservative or involve surgical fixation. ¹³ Conservative management includes physical therapy to stabilize the cervical spine and scapulae, strengthen the neck extensor and periscapular muscles, improve posture, and to develop a home exercise program. Historically, passive bracing to maintain a neutral head posture was accomplished with a variety of off-the-shelf cervical collars, such as the Philadelphia, Aspen Vista, Miami J, and Headmaster collars. Custom cervical collars such as a baseball cap orthosis, which utilizes two elastic straps attached to a baseball cap to promote cervical extension, have also been employed.^{3, 8, 10, 12, 15} Unfortunately, the use of passive bracing is not cosmetically appealing to individuals with dropped head syndrome, is not well-tolerated, and ultimately does not treat the underlying weakness that results in the head drop. ^{1, 5} Additionally, the use of such braces can result in skin breakdown, progressive weakness with deformity, and poor anatomy. ^1,3,5,13 Finally, these braces cause a sudden extension of the kyphotic neck without further correction, resulting in a potential myelopathic state in addition to poor biomechanics. ^{1,3,5, 13} Surgical management of dropped head syndrome involves multilevel cervical fusion which results in reduced cervical range of motion in addition to potential post-operative complications. ^{1, 5}

The ability to recruit and use available neck extensor and periscapular muscles in the setting of dropped head syndrome is the goal of active, rather than passive, bracing. In the current study, we review a program of active postural bracing to strengthen available cervical and thoracic spine extensors through conscious reminders in combination with a physical therapy program to address dropped head syndrome. This retrospective review describes the technique of active postural bracing to treat dropped head syndrome in the cancer population.

MATERIALS AND METHODS

Study Design

We performed a retrospective review of patients who presented to a brace clinic within an established cancer rehabilitation physiatry practice to identify individuals with dropped head syndrome over a three-year period. Generally, the brace clinic occurs weekly and has a physiatrist and an orthotist in attendance in addition to residents or fellows in training. Information collected as part of the review included the reason for referral, symptoms and signs, demographic data including age, gender, past medical, surgical and oncologic history, physical examination, type of brace selected, and follow-up data. All study subjects included in this study were age 18 or older.

The purpose of this project was to describe the population who presented to a brace clinic for treatment of dropped head syndrome. Each patient was assessed on an individual basis to determine the optimal bracing for dropped head syndrome. Typically, either a figure-of-8 brace possibly in conjunction with a lumbosacral orthosis or a SpinoMed IV thoraco-lumbo-sacral orthosis is used in this patient population at the brace clinic for dropped head syndrome. The figure-of-8 brace is used as an active, patient-driven, postural correction tool to promote conscious awareness to improve posture. Figure 1A demonstrates the figure-of-8 brace in a neutral posture and Figure 1B demonstrates the figure-of-8 used in a patient with dropped head syndrome with a chin-on-chest posture. The addition of a lumbosacral orthosis provides some support to the lumbar spine, but more importantly serves to provide cues on active core muscle engagement through a similar self-reminder technique. The figure-of-8 brace combined with a lumbosacral orthosis does not provide static, rigid support; rather, patients are educated about the need to consciously adjust their posture to fit the braces, thereby strengthening spine extensor and core muscles. Utilization of this brace technique encourages strengthening of scapular stabilizers and thoracic and cervical posterior paraspinal muscles through active postural correction. The thoracolumbosacral orthosis used most commonly in clinic is the SpinoMed IV. This brace is contoured to the individual patient’s best posture and also serves as an active, conscious postural reminder for core and paraspinal muscle engagement. Although this brace does provide some support to the trunk, it does not provide passive rigid support to the cervical spine. Figure 2A demonstrates the SpinoMedIV in a neutral posture and Figure 2B demonstrates the SpinoMedIV used in a patient with dropped head syndrome with a chin-on-chest posture. The decision between these two braces is dependent on patient acceptance, likely cooperation, and ease of wear. Additional considerations include extent of core weakness, flexibility of the head drop and kyphosis, and pelvic alignment when scapulae are retracted. Patients with neutral pelvic alignment and adequate core strength to maintain posture with cueing were provided with a figure-of-8. The LSO was added for those who were observed to have core weakness and abnormal pelvic tilt with correction. A SpinoMed IV TLSO was chosen for patients who maintained pelvic alignment but lacked core strength to maintain posture and had no abnormal pelvic tilt with correction, and for those who lacked the shoulder range of motion to don a figure-of-8.

Figure 1.

A demonstrates the figure-of-8 brace in a neutral posture and Figure 1B demonstrates the figure-of-8 used in a patient with dropped head syndrome with a chin-on-chest posture.

Figure 2.

A demonstrates the SpinoMedIV in a neutral posture and Figure 2B demonstrates the SpinoMedIV used in a patient with dropped head syndrome with a chin-on-chest posture.

After initial evaluation in brace clinic, patients returned for delivery of their braces. During this study, patients were educated about the wearing of the brace prescription and were encouraged to wear the brace up to 4–6 hours per day after an initial titration period. In conjunction with bracing, patients were encouraged to either start a physical therapy program or to continue their home exercise program from a prior physical therapy program. These exercise programs aimed to work on strengthening neck extensors and scapular stabilizers and postural correction.

Study Procedure

This project received approval from the Memorial Sloan Kettering Cancer Center Institutional Review Board. Each patient’s age, gender, cancer type, prior chemotherapy, radiation and surgical history in addition to presence of metastases or ongoing oncologic treatment was collected. Additional information including past medical history, presence of dropped head, neck extensor weakness, neck, shoulder or back pain, numbness or tingling, upper-limb weakness, and postural and back exam was collected. Participatory status in a physical therapy program was also included. Each individual was given a figure-of-8 brace ± lumbosacral orthosis or a SpinoMed IV thoracolumbosacral orthosis. The response to bracing, amount of improvement in subjective neck extensor strength and posture, and key exam findings at follow-up were collected.

Analytical Methods

Summary data were obtained to assess response and compliance with use.

RESULTS

A total of 41 patients were seen in brace clinic for dropped head syndrome over the study period. Twenty-nine (70%) of the patients followed up in brace clinic after the distribution of the recommended brace and out of the 12 who did not follow up in brace clinic, 4 patients (9.8%) followed up with their primary physiatrist. The average age of patients in this study was 66 years of age and 48.8% were female. In terms of cancer diagnoses, 34.1% had Hodgkin’s lymphoma and 51.2% had head and neck cancer. In this study, 48.8% of the population had other diagnoses of cancer besides Hodgkin’s lymphoma or head and neck cancer, as some patients had two or more primary cancer types. Within the study group, 73.2% had prior chemotherapy, 95.1% had prior radiation, and 75.6% had prior surgery for their cancer. Fifteen patients (36.6%) had known metastatic disease and 14.6% had ongoing oncologic treatment at time of physiatric evaluation. Postural or neck weakness was the primary chief complaint (85.4%) while neck pain was the second chief complaint (48.8%). The demographic details of this population can be seen in Table 1.

Table 1:

Patient Demographics

Characteristics
Age	66
Sex
Men	21 (51.2%)
Women	20 (48.8%)
Cancer Diagnosis
Hodgkin’s lymphoma	14 (34.1%)
Head and neck cancer	21 (51.2%)
Other	20 (48.8%)
Prior chemotherapy	30 (73.2%)
Prior radiation	39 (95.1%)
Prior surgery	31 (75.6%)
Ongoing oncologic treatment	6 (14.6%)
Metastases	15 (36.6%)
Chief complaint
Neck pain	20 (48.8%)
Postural/neck weakness	35 (85.4%)
Shoulder pain	8 (19.5%)
Back pain	3 (7.3%)
Past Medical History
Back surgery	4 (9.8%)
Vocal cord paralysis	4 (9.8%)
Osteoarthritis	8 (19.5%)
Osteoporosis/osteopenia	8 (19.5%)

At the time of initial evaluation, 34 patients (82.9%) had dropped head or forward neck posture and 24 patients (58.5%) reported neck pain. Additionally, 12 patients (29.3%) reported shoulder pain, 3 (7.3%) reported upper or mid-back pain, and 3 (7.3%) reported lower back pain. Less than half (22%) reported numbness or tingling in the upper limbs, head, or neck region. On exam, 63.4% had protracted shoulders, 56.1% had cervicothoracic kyphosis, and 78% had forward head and neck posture. Sixteen patients (39%) had atrophy of the neck, shoulder, or back, and 7 patients (17.1%) had upper-limb weakness on manual muscle testing. Seventeen patients (41.5%) had reduced cervical range of motion, 3 patients (7.3%) had reduced shoulder range of motion, and 7 patients (17.1%) had tenderness to palpation of the cervicothoracic spinous processes or paraspinals. Table 2 demonstrates the clinical findings in further detail.

Table 2:

Clinical Findings

Symptom/Sign Reported	Yes	No	Unknown
Dropped head/forward neck posture	34 (82.9%)	1 (2.4%)	6 (14.6%)
Neck pain	24 (58.5%)	6 (14.6%)	11 (26.8%)
Shoulder pain	12 (29.3%)	4 (9.8%)	25 (61%)
Upper/mid back pain	3 (7.3%)	4 (9.8%)	34 (82.9%)
Lower back pain	3 (7.3%)	4 (9.8%)	34 (82.9%)
Numbness/tingling in upper limbs or head/neck region	9 (22%)	18 (43.9%)	14 (34.1%)
Protracted shoulders	26 (63.4%)		15 (36.6%)
Cervicothoracic kyphosis	23 (56.1%)		18 (43.9%)
Forward head/neck posture	32 (78%)		9 (22%)
Atrophy of neck, shoulder and/or back musculature	16 (39%)		25 (61%)
Upper-limb weakness on exam	7 (17.1%)	10 (24.4%)	24 (58.5%)
Reduced cervical range of motion	17 (41.5%)		24 (58.5%)
Reduced shoulder range of motion	3 (7.3%)	1 (2.4%)	37 (90.2%)
Tenderness to palpation of cervicothoracic spinous processes or paraspinals	7 (17.1%)	9 (22%)	25 (61%)

As discussed, patients typically were recommended for a figure-of-8 brace ± LSO or a TLSO brace. Thirty patients (73.2%) were recommended for a figure-of-8 brace, 13 (31.7%) for addition of an LSO, and 5 patients (12.2%) were recommended for a TLSO. Six patients received alternative bracing based on their presenting symptoms. Patients were either enrolled in a prior physical therapy program (80.5%), had ongoing physical therapy (46.3%), or were given a referral for physical therapy at the initial brace appointment or delivery appointment (29.3%). Further details about treatment recommendations can be seen in Table 3.

Table 3:

Recommendations

Recommendation	Yes	No
Figure-of-8	30 (73.2%)	11 (26.8%)
LSO	13 (31.7%)	28 (68.3%)
SpinoMed	5 (12.2%)	36 (87.8%)
Other brace	6 (14.6%)	35 (85.4%)
Prior PT	33 (80.5%)	1 (2.4%)
PT ongoing	19 (46.3%)	19 (46.3%)
Pt script given at initial or delivery appointments	12 (29.3%)	29 (70.7%)

Table 4 details the response to bracing. Overall, 25 patients (61%) reported a positive response to the recommended brace. Seven patients (17.1%) reported subjective improvement in neck or back strength while 7 patients (17.1%) reported subjective improvement in pain using the brace as recommended. Sixteen patients (39%) reported improved posture and 27 patients (65.9%) had improved exam findings at time of follow-up. These objective exam findings included improved scapular retraction, kyphosis, and head positioning.

Table 4:

Response to bracing treatment

Responses
Response to bracing
Positive	25 (61%)
Mixed	1 (2.4%)
Negative	2 (4.9%)
No change	1 (2.4%)
Not wearing	4 (9.8%)
No follow up	8 (19.5%)
Subjective improvement in strength of neck or back at follow up
Improved	7 (17.1%)
No change	1 (2.4%)
Unknown	25 (61%)
No follow up	8 (19.5%)
Subjective improvement in pain at follow up
Improved	7 (17.1%)
No change	6 (14.6%)
Worsened	4 (9.8%)
Unknown	16 (39%)
No follow up	8 (19.5%)
Subjective improvement in posture at follow up
Improved	16 (39%)
No change	2 (4.9%)
Unknown	15 (36.6%)
No follow up	8 (19.5%)
Objective improvement on exam at follow up
Improved	27 (65.9%)
No change	3 (7.3%)
Worsened	1 (2.4%)
Unknown	2 (4.9%)
No follow up	8 (19.5%)

DISCUSSION

Dropped head syndrome is a well-reported adverse effect of treatments for head and neck cancers and Hodgkin’s lymphoma, and presents a unique challenge to medical providers. Prior conservative treatment of dropped head syndrome has involved a combination of physical therapy and passive bracing, and corrective surgery. Unfortunately passive bracing has been considered unappealing by patients due to discomfort, poor cosmetics, bulkiness of the braces available, and impact on skin. Surgical management has multiple associated complications. ^1,3,5,13

In this study, we present a successful alternative to treat dropped head syndrome through the use of active bracing. The technique of active bracing in this population theoretically strengthens the weak muscles in head drop and improves head position. Maintenance of these achievements, though not directly studied in this project, must be performed through a regular home exercise and bracing program as patients likely have a tendency to weaken again given prior oncologic treatments. Patients treated with this novel approach reported improved strength in the neck and back and reduced pain in addition to improved posture. By retraining the available muscle fibers within the neck extensors and periscapular groups, individuals were able to reduce their discomfort and improve their posture and head position.

We believe the findings are beneficial and add important information regarding treatment of dropped head syndrome. Through active postural bracing in combination with a regular physical therapy program, patients are able to strengthen associated weak muscles and improve head drop, posture, and associated symptoms. This approach to bracing can potentially be applied to other diagnoses as well outside of cancer.

Study Limitations

Limitations in this study include the retrospective design and unblinded analysis of patients. Despite having a three-year time span of analysis, our study was limited by the small sample size. Undoubtedly our sample size was also limited by referrals to physiatry for brace clinic, as there were likely patients with dropped head syndrome in the cancer center that were not referred to brace clinic. Another limitation of the study was the subjective data collection. We did not objectively measure the degree of improvement in posture or head position, but instead relied on repeat exams by the same providers and patient reports of improvement. Patient compliance with bracing and therapy exercises, though not evaluated in this study, also likely varied, contributing to varying outcomes in head drop, posture, and overall change. Almost a third (29.3%) of patients were lost to follow-up and did not return to brace clinic, thereby reducing available data.

CONCLUSIONS

Patients with dropped head syndrome after treatment for Hodgkin’s lymphoma or head and neck cancer experience poor posture, chin-on-chest head positioning, muscle atrophy, and discomfort. Through the use of active postural corrective bracing combined with physical therapy, we demonstrate that dropped head syndrome and its associated symptoms can be successfully managed.