Interventions for Trismus in Head and Neck Cancer Patients: A Systematic Review of Randomized Controlled Trials

Abstract

Background: Current treatment for head and neck cancers (HNCs) have led to an improved survival. However, the sequelae of cancer treatment often result in trismus, or reduced mouth opening. The purpose of this report is to identify interventional studies for trismus management in HNC patients. Methods: A search of PubMed, Embase, Cumulated Index to Nursing and Allied Health Literature, and the Cochrane Library was conducted in March 2020 for randomized controlled trials (RCTs) involving interventions for trismus for head and neck cancer within 10 years. Intervention could involve the use of an exercise regime, jaw rehabilitation device, technological device, medication or massage therapy. The primary outcome was the measurement of mouth opening. Results: Eleven RCTs involving a total of 685 patients with HNC were included. Six RCTs evaluated the effectiveness of a jaw mobilization device with exercises; there was no significant benefit of an exercise regime with a jaw mobilization device either initiated before, during or after treatment compared to no exercise. Two RCTs compared 2 intervention groups that involved exercises only, with 1 study assessing the benefit of weekly supervised physical therapy with gum chewing and another evaluating the benefit of immediate (1-2 days) versus delayed (7-10 days) initiation of exercise post-surgery; there was no significant difference between groups in either study. One RCT that recruited only patients with trismus demonstrated that an exercise regime in combination with low-level laser therapy or low-intensity ultrasound had superior results in mouth opening measurements compared to exercise alone. Two RCTs compared intervention groups with and without follow-up reminders; both studies showed a significant improvement in mouth opening measurements in groups with follow-up reminders. Conclusion: This systematic review did not convey a clear consensus as to optimal intervention for trismus in HNC patients. A variety of exercise regimens and jaw rehabilitation devices appear to have comparable effectiveness. However, efforts focused on increasing adherence to a particular intervention protocol may positively impact mouth opening measures in head and neck cancer patients. Also, low-level laser therapy and low-intensity ultrasound coupled with exercise may be beneficial for patients with trismus.

Orofacial Myofunctional Therapy with and without Photobiomodulation in the Rehabilitation of Radiation-Induced Trismus: Case Series

“…One study compared therapy through exercises associated with ultrasound and low-intensity PBM and isolated OMT, a configuration similar to the proposal of this series of cases where three patients performed the exercise program exclusively and three the exercises associated with the application of PBM. In synergy with the results of Elgohary et al, it was possible to observe a significant benefit of LASER associated with mouth opening exercises compared to exercise therapy alone [17]. These results deserve an in-depth look as it can be an interesting strategy for the rehabilitation process of these patients and in a shorter period of time.…”

“…Our study observed a reduction in pain levels in all cases, but more markedly in those submitted to the association of exercises with low-frequency LASER. Other studies carried out in similar populations obtained very similar numerical results, with an average reduction of 8 points on the Visual Analogue Scale after the LASER protocol [17,31].…”

“…Our study analysed adherence through a form that the patient filled in every time he performed the scheduled exercise. This remote control allows us to evaluate with greater precision the efficiency of the strategies and the viability of the disposition of the number of exercises and daily series [17].…”

Effect of Oral Exercise on Trismus after Oral Cancer Radiotherapy: A Quasi-Experimental Study

“…Oral exercise involving actively or passively stretching the jaw using jaw motion rehabilitation systems (e.g., TheraBite, Dynasplin, or tongue depressors) is a potentially helpful approach for preventing or improving trismus. Findings from previous studies [ 13 , 17 , 18 ] provide preliminary support for the efficacy of oral exercise in improving MIO in patients with trismus caused by HNC treatment. However, the sample sizes of the previous studies were small, and there was a high degree of heterogeneity in the oral exercises employed in these studies [ 18 ].…”

Impacto da dor orofacial na qualidade de vida de portadores de câncer de boca e orofaringe

“…O Questionário MPQ-McGill (11) (The McGill Pain Questionnaire) tem como objetivo estudar a aplicação de indicadores padronizados para a avaliação do impacto da dor na vida de pacientes. Outros autores, como Chee et al (12) , também realizaram estudos objetivando a avaliação da dor na vida de pacientes, utilizando ferramentas, dentre elas, o MPQ-McGill. No Brasil, a versão em português do questionário foi proposta por Pimenta e Teixeira e é denominado Questionário de Dor McGill (Br-MPQ) (13) , que tem sido utilizado em estudos que visam avaliar o impacto da dor orofacial na qualidade de vida de pacientes (14) .…”