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

Abstract

Importance: Trismus 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 relevance: The findings of this case series study suggest that MT improved MIO with a medium to large effect size in survivors of HNC with radiation-associated 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, ≥5 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.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hutcheson reported grants from the National Institutes of Health, National Cancer Institute, National Institute of Dental and Craniofacial Disorders, Patient-Centered Outcomes Research Institute, Atos Medical, grants from Health and Environmental Sciences Institute/Thrive Foundation, and from the US Department of Defense outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Changes in Oral Opening Following Manual Therapy (MT)

MIO indicates maximum interincisal opening.

Figure 2.. Maximum Interincisal Opening (MIO) Across Time and Changes Following Manual Therapy (MT)

The boxes indicate quartiles; the whiskers, minimum and maximum MIO; the small white squares, mean MIO; the horizontal lines, median MIO; and the small white circles, outliers.

Figure 3.. Maximum Interincisal Opening (MIO) Severity

NA indicates not applicable; WNL, within normal limit.