Manual Therapy for Patients With Radiation-Associated Trismus After Head and Neck Cancer

Abstract

IMPORTANCETrismus is highly prevalent in head and neck cancer (HNC) survivorship. Current standards for trismus treatment include various stretch-based exercise protocols as a primary and single treatment modality with limited evidence regarding the role of manual therapy (MT) for this indication.OBJECTIVE To assess the effect size and associations of response to MT to increase oral opening in the setting of radiation-associated trismus. DESIGN, SETTING, AND PARTICIPANTS This retrospective case series was conducted at the University of Texas MD Anderson Cancer Center between 2016 and March 2020 (before COVID-19 interruption) and included 49 disease-free survivors of HNC who were referred for treatment of radiation-associated trismus. INTERVENTION Intraoral MT (including or excluding external head and neck) targeting the muscles of mastication. MAIN OUTCOMES AND MEASURES Maximum interincisal opening (MIO) before and after the initial MT session compared with serial MT sessions. Covariates were examined to determine the association with response to MT for trismus. RESULTS A total of 49 survivors of HNC (13 women [27%]; 24 [49%] 64 years or younger; 25 [51%] 65 years or older; mean [range] of 6.6 [0-33] years postradiotherapy were included, 9 [18.4%] of whom underwent a single MT session; 40 [81.6%] who underwent multiple sessions [mean, 6; median (range), 3 (2-48)]). The MIO improved after a single session by a mean (SD) of 4.1 (1.9) mm (0.45 effect size) and after serial MT sessions by a mean (SD) of 6.4 (4.8) mm with an effect size of 0.7. No covariates were found to be clinically meaningfully associated with MIO improvement following MT. CONCLUSIONS AND RELEVANCEThe findings of this case series study suggest that MT improved MIO with a medium to large effect size in survivors of HNC with radiationassociated trismus. The results suggest that the largest increase in oral opening was achieved after the initial treatment and although gains were more modest, oral opening continued to improve with serial treatment. Covariates were not associated with MT response, suggesting that patients with clinical features often considered treatment refractory (eg, advanced disease, multiple lines of oncology treatment, Ն5 years posttreatment) may benefit from treatment with MT. Manual therapy may be a beneficial frontline or adjuvant treatment when combined with traditional stretching therapy. A clinically meaningful increase in oral opening has the potential to improve swallow function, speech, pain, and quality of life.

Oral Complications from Oropharyngeal Cancer Therapy

“…The comprehensive management of trismus within the context of head and neck cancer patients necessitates a multidisciplinary strategy that encompasses the expertise of radiation oncologists, oncology nurses, speech therapists, physiotherapists, and dentists. Physical interventions, such as active and passive jaw exercises, manual stretching, and myofascial release techniques, are employed to ameliorate restricted mouth opening and mitigate fibrotic tissue formation [ 86 ]. The implementation of pharmacological agents, encompassing muscle relaxants and anti-inflammatory medications, may alleviate muscular discomfort in some cases and decrease muscular rigidity.…”

Restorabite™: Phase II trial of jaw stretching exercises using a novel device for patients with trismus following head and neck cancer

“…5,13 Patients with pre-existing compromised dentition or temporomandibular joint disorders are at greatest risk of developing trismus following cancer treatment. 10,14,15 Trismus has been treated using a range of jaw-stretching devices, 16,17 however, they are under-utilized due to factors such as cost, portability, and safety in the setting of compromised bone and dentition. 18 Restorabite™ is a new device which is portable and delivers regulated, measurable, and individualized incremental forces.…”

“…Trismus has been treated using a range of jaw‐stretching devices, 16,17 however, they are under‐utilized due to factors such as cost, portability, and safety in the setting of compromised bone and dentition 18 . Restorabite™ is a new device which is portable and delivers regulated, measurable, and individualized incremental forces.…”

A Survey of Manual Therapy Techniques and Protocols Used to Prevent or Treat Dysphagia in Head and Neck Cancer Patients During and after Radiation Therapy

“… 35 , 36 One study found that MT may be considered for frontline or adjuvant treatment of radiation-associated trismus by demonstrating significant improvement in maximum interincisal opening for HNC patients with post-treatment trismus. 37 Furthermore, the addition of MT to a cervical exercise program has shown statistically significant improvement in chronic neck pain patients in both the short and mid-term. 38 …”