"Baroreflex" Failure" A Rare Late Effect Of Radiation Treatment
I came across this article written by a Gentleman on another forum about late-term post-radiation effects which can give you a condition where your blood pressure swings wildly from high to low or low to high without notice. There is no cure but some control can be realized with meds. I just wanted to let the group know about this and make people aware. In fact, there may be someone on here that has this problem but I have never seen it brought up that I can remember. Below I will post his description and then some information below it. Radiation for head and neck cancers can cause debilitation problems years after treatment is completed. I felt this was important enough to share with our group. Be aware this can easily be a life-or-death issue.
Take Care, God Bless-Russ
The fellow that made the original posting goes by the name of Criswell and here is his post and then information on this post-radiation situation follows.
Mar 7, 2020 • 11:45 AM
I had radiation and chemo for tongue cancer in 2013-2014. While I am now cancer-free in 2020 I am suffering from Baroreflex Failure, a rare late effect of radiation treatment. Basically, it means that all control of my blood pressure is now gone forever. My systolic readings can range from 65 to 235 for no reason, all within an hour. There is no treatment, but some management can be achieved through medication. I can't find anyone else who has been through what I am experiencing. I am now a ticking time bomb, in fear of my life even while being cancer-free. I would love to hear from someone in my situation.
Information on this condition--
BARORECEPTOR DYSFUNCTION
Radiation for head and neck cancers can cause debilitation problems years after treatment is completed. When radiated areas include the neck or base of the skull, as is the case with tonsil and base of tongue primaries, the long-term damage may not surface for several years. Much of the damage is caused by radiation-induced fibrosis as the body continually attempts to heal the tissue damaged during treatment. We have pairs of nerves that extend from the brain through the neck and they are responsible for most functions of the body, as well as significant pain as fibrosis sets in. These nerves are called Cranial Nerves and the Lower Cranial Nerves are the nerves that are most affected from radiation-induced fibrosis. The particular Lower Cranial Nerves related to heart rate and blood pressure that are affected are the Glossopharyngeal Nerve (Cranial Nerve IX) and the Vagus Nerve (Cranial Nerve X). The Glossopharyngeal Nerve contains motor fibers, for activating muscles, and sensory nerve fibers to transmit information to the brain, via afferent nerve fibers, and receive instructions from the brain, via efferent nerve fibers. To regulate blood pressure, the glossopharyngeal nerve receives information from visceral fibers that sense oxygen levels in the trunk and the carotid bodies for measuring blood pressure. This information is sent to the brain to allow the autonomic nervous system (automatic body functions in simple terms) to control oxygen adjustment and blood pressure, for example. The Vagus Nerve is perhaps the most important nerve in the body and is also called the meandering or wandering nerve. To regulate blood pressure and heart rate, sensory nerve fibers of the vagus nerve receive information, via afferent nerve fibers from the carotid and aortic bodies. The vagus nerve, via efferent nerve fibers then innervates the heart and lungs. Baroreceptor Function, or baroreflex is a term that describes fluctuations in heart rate and blood pressure to maintain blood pressure as constant as possible. Baroreflex, the reflex mechanism by which baroreceptors regulate blood pressure, includes the transmission of nerve impulses from the baroreceptors to a specific portion of the brain called the Medulla Oblongata or Command Center of the body, specifically the medulla nucleus tractus solitaries (NTS) in response to a change in blood pressure that produces vasodilation (opening up of blood vessels) and a decrease in heart rate when blood pressure increases and vasoconstriction (closing of blood vessels) and an increase in heart rate when blood pressure decreases. Baroreflex can affect the heart and the brain by insufficient or excessive blood pressure, or changes in oxygen levels in the blood supplying the brain. Baroreceptor Failure is a condition that means the process is out of control while Baroreceptor Dysfunction more accurately describes what many people that have had radiation treatment and/or surgery to the neck as treatment for head and neck cancer can develop because baroreflex is sporadic and in control some of the time. Baroreceptor Dysfunction is a chronic disorder, occurring about 6 years after the completion of treatment in some cases. (1,2)
Baroreceptors are mechano-sensitive terminals of the glossopharyngeal (Cranial Nerve IX) and the vagus (Cranial Nerve X) nerves that project to the nucleus tractus solitarius (NTS) in the caudal medulla located in the medulla oblongata. The sinus nerve branches off of the glossopharyngeal nerve to the interior carotid artery to dilate or constrict the carotid artery flow to the brain. In response to postural changes, efferent projections from the NTS to sympathetic and parasympathetic preganglionic neurons in the brain and spinal cord govern acute fluctuations in heart rate and blood pressure. Baroreceptors are found in the blood vessels of all vertebrate animals, residing in the heart, vena cavae, arteries, carotid sinuses, and the aortic arch. The process is continuous and necessary to ensure blood pressure is maintained. The most sensitive baroreceptors are located in the carotid sinuses, usually in the field of radiation, and the aortic arch, the second major anatomical region of the aorta that sends blood from the left ventricle of the heart to the rest of the body. Impaired afferent signaling of this arterial baroreceptor reflex arc in humans causes a sustained increase in mean
BARORECEPTOR DYSFUNCTION
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arterial pressure lability (constant change), often leading to both paroxysms (sudden change) of hypercatecholaminergic tone (excitement of neurotransmitters) that resemble pheochromocytoma (attacks of raised blood pressure, heart palpitations, and headache) and contrasting episodes of profound orthostatic hypotension (decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position). What causes fluctuations in blood pressure? Cardiovascular adaptations are regulated by the autonomic nervous system. Standing activates afferent autonomic neural pathways to induce baroreceptor unloading, causing increases in efferent sympathetic outflow and vasoconstriction, to increase venous return and maintain resting blood pressure. When we change from sitting to standing, information is sent via baroreceptors to the brain because there is an automatic increase in systolic blood pressure. Orthostatic venous pooling (excess blood and fluid pooling from poor blood return to the heart) occurs in the legs when we stand and our body needs to modulate the blood pressure. Baroreflex failure occurs when afferent baroreceptor nerves or their central connections are impaired, causing a loss of buffering, and wide fluctuations of blood pressure and heart rate. Impairment of the baroreflex may present under a wide spectrum of symptoms with hypertensive crisis as the most common. Over a period of time, volatile hypertension (high blood pressure) with periods of hypotension (low blood pressure) occurs and may continue for months and years, usually with some attenuation of pressor surges and greater prominence of depressor valleys. Other scenarios include orthostatic tachycardia (rapid heartbeat) or orthostatic intolerance may appear, or vagotonia (excessive excitability of the vagus nerve resulting typically in vasomotor instability, constipation, and sweating) with severe bradycardia (low heartbeat) and hypotension and episodes of sinus arrest (loss of electrical signal to the heart that allows the heart to contract). In particular, after neck irradiation, long-term injury occurs commonly in the carotid arteries. Atherosclerotic (thickening or hardening of the walls of arteries) and thrombotic complications (blood clots or dislodged plaque in arteries that can result in heart attack or stroke) have drawn the most attention. Among 910 patients who survived at least 5 years after irradiation of head and neck tumors, stroke occurred in 6% and clinically significant carotid stenosis in 17%. Chronic inflammation and fibrosis of carotid arterial walls might lead to “splinting” of carotid sinus baroreceptors. Because these are stretch or distortion receptors, stiffening of the carotid sinus would be expected to lead to a decreased gain of the arterial baroreflex. Nevertheless, few reports have noted baroreflex failure after neck or brain stem surgery or irradiation. (4) At the American Neurological Association 133rd Annual Meeting, investigators presented a retrospective review highlighting the clinical features and typical findings on autonomic testing in patients with radiation-induced baroreflex failure. "The important thing is to recognize that patients who've had head and neck radiation may have late complications that may not manifest for years after treatment," second author Sara Schrader, MD, from the Mayo Clinic in Scottsdale, Arizona, told Medscape Neurology & Neurosurgery. "Radiation can cause multiple cranial neuropathy, which can manifest in many ways," Dr. Schrader noted. (5)
Neck Radiation Associated With Cranial Neuropathy
BARORECEPTOR DYSFUNCTION
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The researchers were led by Brent Goodman, MD, also from the Mayo Clinic. They identified 34 patients who had a history of neck radiation, labile hypertension, orthostatic hypotension, or syncope. The malignancy type was squamous-cell carcinoma in all but 2 patients. The mean age of participants at the time of diagnosis was 63 years. The average time from radiation exposure to the development of symptoms was 6.4 years. Radiation doses ranged from 55 Gy to 70 Gy. Formal autonomic testing was performed in 22 patients. Cardiovascular adrenergic function was the most frequent abnormality, showing impairment in late phase 2 and 4 during the Valsalva maneuver.
Neurological Complications Following Neck Radiation
Signs Symptoms Patients (%) Autonomic Postural lightheadedness 97 Labile hypertension 78 Syncope 73 Cardiac dysrhythmia 9 Bulbar Dysphagia 78 Dysarthria 33 Cerebrovascular Stroke 12 Carotid artery stenosis/occlusion 57 Vertebral artery stenosis 7
"This is a retrospective study, and some of the patients we've seen clinically, but the vast majority, we have not," Dr. Schrader pointed out during an interview. "The data we have for patients were not uniform, and testing may have differed," she noted. Shapiro and colleagues discovered lightheadedness and fluctuations in cardiovascular reflexes attributable to baroreceptor damage caused by radiation was elusive on routine cardiovascular testing. In a broader sense, cardiovascular dysautonomia has been linked to carotid sinus dysfunction occurring from radiation damage but also included bilateral carotid artery stenosis as a potential etiology. Further, response to traditional management when autonomic failure is caused by centrally mediated dysfunction is not effective, leading to severely diminished quality of life with greater risk for cardiovascular morbidity and mortality. (6) Table 1 presents an excerpt of head and neck cancer patients that received radiation or patients that had carotid stenosis.
BARORECEPTOR DYSFUNCTION
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Table 1. Excerpts of Characteristics of Head and Neck Radiation and Carotid Stenosis Patient Cases With Orthostatic Hypotension and Supine Hypertension Related to Baroreceptor Dysfunction
Case
Age, y Sex
FollowUp, mo
Cause of Baroreceptor Dysfunction
Pharmacologic Interventions
Nonpharmacologic ic Interventions
αAgonists
Fludrocortis one
Mean Home BPs/HR at Baseline (Supine/Standin g)
Mean Home BPs/HR at Last Visit (Supine/Standin g)
1. Abbreviations: BID, twice a day; BP, blood pressure; F, female; HR, heart rate; M, male.
2. Nonpharmacological interventions include: moderate sodium intake (2500-5000 mg/d), predominantly before noon on a given day, use of support stocking to thighs (25-30 mmHg), and when needed sleeping with head/neck elevated to 15-20 degree angle.
Case 1 84 M 1
Neck radiation therapy for laryngeal cancer and advanced bilateral carotid stenosis
Atenolol 25 mg BID and isradipine 5 mg at bedtime + – −
167/67/65 145/65/60
94/62/61 117/55/58
Case 3 63 M 14
Neck radiation therapy for tongue cancer
Atenolol 25 mg BID and isradipine 5 mg at bedtime + – −
146/91//57 136/86/58
97/63/60 104/84/62
Case 4 74 F 12
Advanced bilateral carotid stenosis
Atenolol 100 mg at night and nicardipine 40 mg at bedtime and 20 mg in the am + – −
162/90/77 155/85/70
110/76/75 147/70/70
Case 5 84 M 1
Advanced bilateral carotid stenosis
Atenolol 100 mg at night and nicardipine 40 mg at bedtime − – −
180/80/75 160/92/68
80/50/80 120/70/67
Case 6 82 M 12
Neck radiation therapy for head and neck cancer None +
Midodrine 5 mg in am as needed −
130/68/62 122/66/60
86/58/64 104/60/61
Case 7 63 M 12
Neck radiation therapy for tongue cancer
Atenolol 50 mg at bedtime + – +
185/105/62 152/82/58
155/76/68 146/80/60
Case 10 65 M 36
Neck radiation therapy for head and neck cancer
Atenolol 50 mg at bedtime and guanfacine 2 mg at bedtime + – −
156/80/84 145/77/56
128/60/82 123/67/60
Case 11 50 M 1
Neck radiation therapy for head and neck cancer
Nebivolol 10 mg qam and 5 mg qpm with ramipril 5 mg BID + – +
136/86/85 128/80/80
110/75/95 118/75/87
BARORECEPTOR DYSFUNCTION
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Autonomic dysfunction leads to impairment of compensatory mechanisms and clinically results in orthostatic hypotension, defined as a reduction in SBP ≥20 mm Hg or diastolic BP ≥10 mm Hg within 3 minutes of standing or head-up tilt to an angle of at least 60°. In hypertensive patients, a reduction of SBP >30 mm Hg is more appropriate. In addition to unpleasant and disabling symptoms, orthostatic hypotension is associated with an increased risk of falls, cognitive dysfunction, (7) coronary arterial disease, (8) chronic kidney disease, (9) stroke, (10) and cardiovascular and all-cause mortality. (11,12) The mechanisms behind them are unclear, and whether orthostatic hypotension is a cause or consequence of comorbidities is still uncertain. Orthostatic hypotension is associated with nondipping or reverse-dipping pattern of diurnal BP, while the cardiovascular risk remained even after adjustment for such diurnal BP patterns. (13) Once orthostatic hypotension is diagnosed, clinicians should take the patient's medical history and physical examination carefully. Certain medications such as antihypertensive drugs (eg, α-blockers, diuretics, and vasodilators) and antidepressants, and changes of daily life (eg, dehydration, weight loss, diet, infection, stress, sleep problems) are common causes of orthostatic hypotension. Assessments of other manifestations of autonomic neuropathy or neurodegenerative diseases can be helpful in the diagnosis of neurogenic orthostatic hypotension. Laboratory tests such as anemia, glucose, electrolyte, renal function, hormones (eg, thyroid and adrenal), and proteinuria might be helpful. Nonpharmacologic measures are important components of therapy of orthostatic hypotension. These include removal of offending medications, patient education to avoid precipitating factors, physical and dietary interventions, and patient education. Recognition and removal of drugs, which can cause orthostatic hypotension, is crucial. The most common offending medications are diuretics, α-adrenergic antagonists, and antidepressants.
Patients should also be instructed to 1. maintain appropriate hydration throughout the day by drinking at least 1.5 L/d to 2 L/d of water during meals and before exercise and also rapid intake of water in the morning before getting out of bed; 2. arise slowly, in stages, from supine to sitting to standing, particularly in the morning when orthostatic hypotension is more pronounced; 3. avoid activities that reduce venous return such as walking in hot weather, or straining; 4. elevate the head of the bed 10° to 20° to decrease nocturnal diuresis and maintain intravascular volume; 5. prevent episodes of postprandial hypotension by avoiding large meals, minimizing alcohol intake, and avoiding standing immediately after eating; and 6. perform leg-crossing maneuvers while actively standing to increase cardiac output and systemic BP. (14) The use of compression stockings that produce at least 20- to 25-mm Hg pressure or tight abdominal binders permits the application of graded pressure to the lower extremities and lower abdomen, thereby minimizing
BARORECEPTO DYSFUNCTION
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peripheral blood pooling in lower extremity and splanchnic circulation. It is essential that such stockings extend above the knees to the waist since most peripheral pooling occurs in the splanchnic circulation. Many patients, particularly those with peripheral neuropathies or those living in hot climates, poorly tolerate compression stockings. The efficacy of compression stockings and abdominal binders was validated in a small crossover study that showed reduced orthostatic BP decrease and symptoms compared with controls. (15) Increased salt and water intake are essential parts of treatment. Rapid ingestion of 500 cc of water in <5 minutes can serve as a therapeutic measure in symptomatic patients. The BP effect is observed in the first 5 to 10 minutes and peaks around 30 minutes after ingestion and is mediated by a sympathetic reflex rather than a volume effect. (16) Patients should be instructed to consume high-sodium–containing foods. Salt tablets may also be prescribed. While the optimal dose will vary among patients, a target dose of 6 g/d to 10 g/d of sodium taken with breakfast and lunch, or a target urinary sodium level of 150 mEq to 200 mEq should be maintained. Night dosing of salt intake should be minimized to avoid worsening of supine hypertension. (17)
Comments
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I have this, I wrote about it before.
I have to avoid heat, reaching over my head too long, standing too fast, standing too long. its fun, NOT!
You kinda notice its coming, seeing spots (dark patches) and total cold sweat, feeling like the world is a long way away.
But - there are easy things my awesome Dr gave me, he was amazing, but now retired :(
Midodrine - for low BP, I didnt/dont really use this as its hard to say "oh my bp will be low today" an almost instant kick is ice cold water, it can raise your BP 10 mm.
He was very sweet (No I'm not crushing on my DR, I think the whole hospital wanted to adopt him and take him home) - he explained that a lot of sleepiness after big meals is due to your blood supply having been rerouted to help digestion.
This is RARE. Believe me. They are now doing studies on it, as it is a rare, previously unknown side effect
1 -
Found your discussion while trying to help my husband! I knew he had late effects of radiation to the neck, especially with the tissue changes, but never heard of baroreflex failure!
My husband has been having so many symptoms affecting his heart and blood pressure and has been hospitalized numerous times over the last few years. Last year, I contacted several medical centers within 300 miles of our home, to try to get treatment for the late effects. He travelled to Moffitt and, although they advertised they had a clinic for post radiation effects, they didn't have a clue as to what my husband has been dealing with.
Two days ago he went to the hospital for what a doctor called "an almost heart attack" - they thought that maybe all of his heart meds were too strong because he has lost 40 lbs over the last year. Now they want to double the dose of Entresto because his heart ejection fraction has dropped to 30%. His ekg is normal but he has the fluctuations in blood pressure and dizziness, headaches, pain and stiffness - you name it. When he got out yesterday, I started researching treatment for heart failure and found a new device called a "Barostim". He spoke with a rep from the company today but does not know, yet, if any other patients treated with the Barostim are having their issues from radiation treatment.
We hope to soon find out if this is something a cancer survivor would be able to have done. I am happy he is cancer free since 2012, but sad to see all of the after effects he is suffering. We don't know any doctors that even know about this. Hoping to find someone to finally help with treatment!
0 -
Hello, KWPorter, and welcome to the CSN H&N discussion forum.
I am glad you found this posting discussion and hopefully, it will shed some light on your husband's issues. At least you can now put a name on what your husband possibly has and narrow down a solution.
As you stated about his trip to Moffitt " He traveled to Moffitt and, although they advertised they had a clinic
for post-radiation effects, they didn't have a clue as to what my
husband has been dealing with." As stated in the title "Baroreflex Failure" is a rare condition so it is a condition that very few cancer centers have seen and the doctors just don't recognize what they are dealing with.I hope this Barostim Device helps solve your husband's problems or greatly improves things quite a bit for him at the least if he chooses to get it.
Searching on the net there is no lack of information on the Barostim it is well represented and there is plenty of info. I watched a short video and was amazed by the way our body is created and the many tiny controls and regulatory systems God has put in place. In this case, there are tiny receptors on the carotid artery at work helping control our blood pressure. As stated in the video please check it out everybody at the 30-second mark and as stated in the video…
"This Barofelex is normally activated through sensory input through Carotid Baro Receptors, mechanical receptors. Mechanical receptors in the carotid sinus that respond to pressure changes. Activation of the Baroreceptors is processed in the brain stem and triggers the autonomic nervous system to regulate heart, kidney, and vascular function. Is this not truly amazing?"
Barostim™ Baroreflex Activation Therapy AnimationAlso here is a much longer video on the Barostim which may be helpful…
Introduction to BarostimI will thank God; for I am fearfully and wonderfully made: marvellous are his works; and that my soul knoweth right well.
KWPorter I hope you find the answers you need for your husband, it is very disheartening living with a life-and-death situation looming overhead all the time. I am going to put a couple more links to search results below here to help…
Baroreflex Failure, the subject itself shows up in a search with more coverage nowadays than when I last researched it…so here is a link to the results you can look at or just search yourself…
Baroreflex Failure…
https://duckduckgo.com/?q=Baroreflex+Failure&t=ffab&ia=web
And here are links to the Barostim…
https://duckduckgo.com/?t=ffab&q=barostim&ia=web
https://www.youtube.com/results?search_query=Barostim
Our motto here is NEGU (Never Ever Give Up)
Wishing You The Best
Take Care, God Bless
Russ
I would also recommend you check out the Superthread at the top of the page there is loads of information in there with links and you will find it helpful.
1 -
Russ,
He's back in the hospital - I knew the cath would not show anything. He and I both just know this is what is going on - and that everyone can have slightly different effects depending on the location targeted by radiation. Praying to find doctors that understand this late effect.
I read your reply with tears in my eyes. We were so touched by your reminder of His works through Psalms.
Kim
1 -
I seem to have most of the rare issues :)
Baroreceptor dysfunction is no fun. Basically, don't go out in high heat, don't raise your arms over your head (that's called coathanger syndrome) blood drops rapidly and you fall down. Learn your body, what makes you light headed, what makes you see dark spots.
He missed an important part of the "drink water" make sure it is ice cold, I keep half bottles of frozen water and just use those. The ice cold, freezing water can raise your BP 10 mmhg, negating the use of midodrine, which is more like a roller coaster. Another medication offered was Ritalin, and I seriously wondered if it would help my chemo brain. But, I'll stick with ice water. No more chemicals - please!
Another radiation rare side effect is a form of hives/Angioedema, leading to mastocytosis...yea, fun. Not!
Russ, I posted about baroreceptor dysfunction a while back, you forgot?
1 -
Oh, my, Suz, you sure have some issues to deal with.
Just when I think I got troubles someone like you comes on here with a list of issues they are dealing with and I am humbled and realize once again to be thankful to God that he got me through with my health the way it is and in perspective, I am not so bad off after all. And sometimes I sit down with a blank piece of paper and start writing out my Blessings, making a list and when I read them off I realize how Blessed I am. Count your blessings name them one by one.It seems you have learned quite a bit how to deal with your issues very well and it sure is great that you share them and are helping others.
Suz, please accept my sincere apologies for not acknowledging you and noting your previous posting on the subject.
I had no idea posted about baroreceptor dysfunction a while back. My Bad.I pray that you can continue to manage your post-treatment effects well and enjoy life.
Wishing You The Best
NEGU (Never Ever Give Up)
Take Care, God Bless
Russ
0 -
Hmpf. Reading all this about the effect of radiation on nerves in the neck, I wonder if the radiation I had back in 2018 (base of tongue cancer, surgery + rads, right side) could play a role in the shoulder paid I've been feeling at the gym in my right shoulder.
0 -
I would say there is definitely a possibility of it.
Check this out at Oncolink…
Survivorship: Late Effects After Radiation for Head and Neck CancerDamage to the Muscles, Bones, and Nerves
- Radiation can
cause small cracks (fractures) in the bones that are in the treatment
field. Try to avoid trauma including falls or accidents. If you do get
hurt, ask your provider if you need an x-ray to check for bone damage.
Take Care, God Bless
Russ
0 - Radiation can
-
In fact, kgasmart here is a posting I have from another forum addressing the same issue you mention. Read all the answers this seems to be a problem experienced by a number of people.
Henry_J Jun 20, 2024 • 1:00 PM
Hi friends,
Recently, I am experiencing pain on my shouldersHope this gives a little insight.
Take Care, God Bless
Russ
0 -
Thanks Russ! It just started a few months ago, whenever I'm doing shoulder presses or (to a lesser extent) bench presses - I can make the motion fine with no weights, but the moment I use actual weight it's like this shooting nerve pain from my right shoulder into the upper arm. I figured maybe it was a pinched nerve and maybe it is, but the fact it's on the same side as the radiation was makes me wonder.
0 -
Well kga, it might be or it might not, there are a lot of after-effects of cancer treatment that are directly related to and caused by it. There are also a lot of after-effects that happen because of injury or aging or just because they happened but sometimes we think they may be related to our treatment. Something like getting 35 radiation treatments for throat cancer and having difficulty swallowing is a direct effect of cancer treatment. This was me and I had 4 dilations later on to help me get back to better swallowing again. This was an obvious connection to the treatments.
Your situation may be connected to your treatment I think it may depend on how close they got to the area or how close they got to nerves affecting that area. Hopefully, it won't get any worse for you and may go away. Also, I don't know your age but are you old enough that some minor arthritis could be occurring? Unfortunately, we're all getting older.
Wishing You The Best
Take Care, God Bless
Russ
0 -
I have this as well. It surfaced 3 years after treatment. Treatment 2012 & Crazy blood pressure 2015. I’ve lived with it for 9 years. I don’t notice the highs but the lows! I had a 24hr monitor, I dropped 100mm in less than 20 minutes. I’ve learned to walk bent over. I take amlodipine as needed, 2.5 - 5 mg. I’m looking better control.
0 -
Well, Rer58, sorry you are troubled with this.
I guess you are getting used to it living with it for 9 years but that doesn't make it any easier.
It must be a bit odd at first adapting to walking bent over.
But as H&N patients we do what we gotta do to deal with the leftovers.
I sincerely hope you find your better control.
Take Care, God Bless
Russ
0
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