OPENING UP: INNOVATIVE PHYSICAL THERAPY HELPS A CANCER SURVIVOR
By Kristi L. Nelson
Monday, February 4, 2008
Physical therapist Susan Daugherty performs ASTYM treatment on
patient Esther Cahal at Farragut's BenchMark Physical Therapy.
Treatment for a rare type of tongue cancer left Esther Cahal's
neck and jaw scarred to such an extent that she wasn't able to
open her mouth. After several months of ASTYM, she can
partially open her mouth. Physical therapist Susan Daugherty
performs ASTYM treatment on patient Esther Cahal at Farragut's
BenchMark Physical Therapy. Treatment for a rare type of tongue
cancer left Esther Cahal's neck and jaw scarred to such an
extent that she wasn't able to open her mouth. After several
months of ASTYM, she can partially open her mouth.
A long, deep yawn.
A bite of a chocolate bar or crab meat.
A vigorous brushing and thorough flossing.
For 2 1/2 years, Esther Cahal has forgone these and other
small pleasures most people take for granted.
An unusual complication from a rare form of particularly
aggressive tongue cancer left Cahal's mouth locked shut, able
to open barely wide enough to insert her little finger. She
stays alive by hooking herself up to a feeding tube unit each
night and sleeping in an upright position while she "eats" a
liquid nutritional supplement for eight hours through a port in
her stomach. A little more than a year ago, Cahal, facing a
recurrence of her cancer, "decided that before I die, I'm going
to eat again," Cahal said. "If this cancer's going to kill me,
at least I'm going to have something good down my throat."
But Cahal has had two "clear" scans for cancer - and now an
innovative physical therapy treatment is helping open her up to
experiencing food again. It started in February 2004, when
Cahal's dentist found an ulcer on the right side of her tongue.
She thought the skin was irritated by a tooth, but when the
tooth was fixed, the ulcer still didn't heal.
So she had a biopsy. "It came back as extremely aggressive
cancer," Cahal said. "It was a surprise for everybody, because
I didn't have any risk factors."
The type of cancer Cahal had most commonly affects men older
than 60 who drink alcohol, smoke or use oral tobacco products
("dip"). Not only did Cahal not have any of those habits, she
had no family history of any type of cancer. In fact, she'd
been out sick from work only two days in her then 22 year
career as a physician's assistant. Cahal had surgery to remove
the cancer, followed by six weeks of weekly chemotherapy and
seven weeks of daily radiation, a course designed to minimize
the chance the rare cancer would come back. The radiation
burned her skin badly, and by the second week she couldn't
swallow. That's not a common complication of radiation, and
Cahal's doctors weren't sure why it happened.
But by the fall of 2004, not only could Cahal still not
swallow, she couldn't open her jaw because of scarring from the
radiation, which badly burned her skin. Then, almost a year to
the day, her cancer came back. This time, surgeons removed a
third of Cahal's tongue. She had eight more weeks of
chemotherapy. A few months later, a test showed the cancer in
her lymph nodes. She had all the nodes removed from her
Seven months of weekly chemotherapy followed, then Cahal
finished up five more weeks of radiation to just her neck area
in December 2006. During the radiation treatments, Cahal was
burned so badly that when she turned her head, the skin would
crack and bleed all the way down her neck. Her daughter, now
11, was so distressed by her mother's appearance that Cahal
sent her to stay with a friend for three weeks. She asked the
really hard questions: 'Are you going to be there when I
graduate from high school? Are you going to be there when I
have my baby? Are you going to be there when I get married?'
remembered Cahal, who said she was always honest with her
children." I said: 'I don't know. I'm trying.' That's all I
could tell her." Cahal had PET scans in July and December 2007,
and neither showed any cancer. It was the first time since
diagnosis that she'd had two "clear" scans in a row.
But she couldn't open her mouth to shout for joy; her jaw was
still locked tight. Since moving to Knoxville from Johnson
City, Cahal has been under the care of otolaryngologist Dr.
Mark Overholt. Overholt recommended physical therapy to try to
solve Cahal's problem; he even tried to manually force her jaw
open when he was operating on her cancer. He had to stop for
fear of breaking the jaw.
"We tried a lot of different things to treat Esther," Overholt
said. "None of the things seemed to work very well."
Then last September a colleague in the neurosurgeon's office
where Cahal works as a P.A. heard about a local seminar being
given by Indiana physician Dr. Thomas Sevier, on a
rehabilitation system, ASTYM, that he developed to treat
chronic tendon disorders, scar tissue and fibrosis. Because
Cahal couldn't attend, her co-worker brought her some
She contacted Sevier to ask him if he thought his system could
help her. He'd not used it for her particular problem, he said,
and told her, "I don't know if you can swallow again, but I can
probably get your jaw open," she said. "I said, 'Well, if you
can get my jaw open, I'll be happy.'" Cahal agreed to try 10
sessions of ASTYM, formerly called ASTM for "Augmented Soft
Tissue Mobilization" (the "Y" was added later to aid with
She made an appointment with physical therapist Susan
Daugherty of Benchmark Physical Therapy in Farragut. Daugherty
was the first of about 25 PTs in Benchmark's 55 clinic networks
to become ASTYM certified. She'd enjoyed success using the
method to treat patients with chronic tendinopathy,
postoperative scarring, Achilles tendinitis, carpal tunnel
syndrome and plantar fasciopathy, which is notoriously
frustrating for both patients and PTs because of its difficulty
During the manual ASTYM treatment, a PT uses acrylic tools to
locate and put pressure on scar tissue, increasing blood flow
to the scar and ultimately helping the tissue heal, Daugherty
said. The tools allow a PT to feel "bumpy" scar tissue more
easily and to work on a larger area without tiring out, as
happens when doing deep tissue massage with the hands alone. It
works on patients who have immobility problems caused by
scarring; patients whose problems are caused by inflammation
won't benefit, she said. Daugherty hadn't used the method on a
patient's face, however, and Cahal had little confidence it
would work for her. Still, she thought, "It can't hurt." She
was wrong. The therapy did hurt - a lot. Though Daugherty isn't
pressing especially hard, Cahal's facial tissue is very
"She's not gentle," Cahal said, laughing. After a session, "I
look like I've been slapped around," because the increased
blood flow to the scar tissue makes her skin red. But it also
worked. Within two weeks, Cahal was already seeing improvement.
A visit to Overholt confirmed it: she could open her mouth wide
enough that he could get his finger in the back of her
By November, Cahal was able to eat her first food in more than
two years. She had a bowl of vanilla pudding. Cahal is now
regularly eating soft foods, such as soups and mashed potatoes.
She still has some trouble; enough of her tongue is missing
that she can't move food around in her mouth, and she lacks
sensation at the back of her throat. Daugherty also takes her
through exercises to strengthen muscles she hasn't used in
years. But she's not complaining.
"You don't realize until you lose the ability to eat, how
social that is," said Cahal, who said waiters have asked her
why she didn't like their restaurant's food, and people have
accused her of being anorexic: "I was always having to explain
why I wasn't eating." She still has to supplement with her
"liquid supper" at night, since she can't yet take in enough
calories by mouth. But it's "a big breakthrough when you can't
eat anything at all," said Overholt, adding, "Six to eight
months ago, I thought she probably would be dependent on a
feeding tube for the rest of her life. Now I'm optimistic that
she won't." Cahal's next goal is to be able to open wide enough
to go to the dentist. A tooth that's been bothering her will
now probably have to be removed, because her mouth has been
closed too tightly even for pediatric dental instruments. She
also hopes to be able to yawn, and to swallow a pill. Right now
when she gets a headache, Cahal must either dissolve a pill,
which takes about an hour, or have on hand specially ordered
ibuprofen that has been compounded into liquid form at about
$50 for 10 800-mg doses.
And maybe someday she'll be able to eat more of the foods she
misses, like chocolate. "I miss being able to bite a chocolate
bar," Cahal said. "But if I can never eat regular food, that's
fine. I never really thought I'd eat again." Since the
radiation also left Cahal's tongue scarred, her sense of taste
is diminished. Daugherty has begun using the smallest ASTYM
instrument to massage Cahal's tongue, on the off chance it
might help bring some of that back.
"Her story is so inspiring," Daugherty said. "It makes you
really glad for the profession you're in. Really changing
someone's life in big ways is just so awesome." Cahal hopes
others with similar problems will learn from her experience and
start ASTYM treatment earlier; her scar tissue was already
quite calcified when Daugherty began treating her. Had she
known it would be so effective, she said, she would have
started during radiation. "I'm just glad she was willing to go
off the road" of tried therapy to help, Cahal said.