This blog post gives an overview of tips and tools you can use to facilitate shoulder positioning for head and neck patients to improve patient comfort and decrease interfractional shoulder displacements.
We’ll be covering the following topics:
Shoulder Positioning Challenges
Shoulder positioning comes with a certain set of challenges, being:
- Anatomical characteristics
- Weight loss
It is important to stay aware of them, so you can take them into account each time you are positioning head and neck patients.
The shoulder is one of the most mobile joints in the human body. It can move freely in different directions, and that is why it can be so challenging to immobilize.
Head and neck patients tend to lose weight throughout treatment. As a consequence, the thermoplastic mask may not conform as well as it did at the start of the treatment. Especially around the shoulders and chest. This could cause the shoulder position to differ from the one determined in the treatment plan.
At the start of treatment, patients tend to be very tense because they are positioned for the first time and everything is very new to them. The mask molding process can be distressing and the hospital environment may feel unfamiliar. As a result, many patients pull their shoulders up.
This has two consequences:
- Firstly, the shoulders could cover the treatment area in the neck.
- Secondly, the shoulders may come down over the course of treatment. This often happens as the patient starts to feel more at ease. This could cause interfractional variations in shoulder positioning and affect the mask’s conformity.
Shoulder Positioning Tips
Fortunately, you can use several effective tools and techniques to work around these challenges to optimize shoulder positioning and improve your patient’s comfort.
Foremost, we want to stress the role of the radiation therapist. At the start of each fraction, perform visual checks to verify the shoulder position. In addition, the following tips could help you as well:
Manual shoulder positioning
Before you start molding your patient’s mask, pull the shoulders down as much as possible. Then, mold the mask as you normally would and let it set completely.
During the radiation therapy treatment, always make sure that the shoulders sit closely against the thermoplastic mask.
Take full advantage of MV, kV or CBCT imaging before each fraction. On these images, you can effectively compare the shoulder position with the CT planning images. Have there been any shoulder shifts? Then you can reposition the shoulders.
Draw positioning guides on the mask and the patient’s skin. These guides form an excellent reminder to pay extra attention to the shoulder positioning.
Draw a horizontal line at the exact point where the mask stops at the upper arm. Optionally, draw a vertical line that starts on the mask and extends onto the skin.
Before each fraction, use the guides on the mask and arms to find the correct shoulder positioning. The horizontal line on the patient’s skin should align with the edge of the mask. The vertical line should correspond with the line on the arm.
If you consistently verify this alignment, you can make sure that the shoulders are well-positioned inside the mask.
Shoulder Positioning Tools
Several tools exist that can help to maintain the shoulders in the right position over the course of the treatment. None of these will completely prevent shoulder motion, but they do make the treatment more comfortable for your patient. In turn, this will make it easier for them to remain in the correct position.
Again, the RTT should take extra care to check the shoulder positioning even if these tools are used.
5-points thermoplastic mask
The first tool that comes to mind is, of course, a 5-points head, neck and shoulders mask.
A well-molded 5-points mask that fits nicely around the shoulders will be very helpful when it comes to maintaining the correct shoulder position. As mentioned earlier, it is best to push the shoulders down before you start molding.
Vacuum bag or Moldcare
The vacuum bag or cushion offers added comfort and prevents the shoulders from sagging during treatment.
The shoulder retractor can help to pull the shoulders down when molding a 5-points mask.
Certain studies (e.g. Casey, 2015), however, do point out that the use of a shoulder retractor could make some patients feel tenser.
When using this tool, take extra care to see what works for your patient and for you as a therapist.
Special hand holds can be attached to the couch top or base plate. The patient can use these to rest their hands by gripping on to them. This can help them feel more relaxed during treatment which on its turn has a positive effect on tense shoulders.
Take these tips into account when immobilizing your head and necks patients and feel free to share them with your colleagues or department. You will improve patient comfort and will be more likely to maintain a correct shoulder position throughout the radiation therapy treatment of your patients.
Further reading on shoulder positioning
> Casey, K. E., Wong, P.-F., & Tung, S. S. (2015). Effect of interfractional shoulder motion on low neck nodal targets for patients treated using volumetric-modulated arc therapy (VMAT). Journal of Applied Clinical Medical Physics, 16(4), 40–51. https://doi.org/10.1120/jacmp.v16i4.5206
> Mesch, L., Hol, S., D’Olieslager, G., Buijs, C., & Washington, D. (2017). PO-0997: Improving shoulder positioning in a 5-points mask. Radiotherapy and Oncology, 123, S549–S550. https://doi.org/10.1016/s0167-8140(17)31433-0
> Neubauer, E., Dong, L., Followill, D. S., Garden, A. S., Court, L. E., White, R. A., & Kry, S. F. (2012). Assessment of shoulder position variation and its impact on IMRT and VMAT doses for head and neck cancer. Radiation Oncology, 7(1), 19. https://doi.org/10.1186/1748-717x-7-19
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