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Manual Therapy beneficial in survivors of head and neck cancer with radiation associated trismus: JAMA

Written By : Dr Ishan Kataria |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2022-12-19T09:30:29+05:30  |  Updated On 19 Dec 2022 12:54 PM IST
Manual Therapy beneficial in survivors of head and neck cancer with radiation associated trismus: JAMA
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Trismus, defined as the inability to fully open the mouth, is a common oral morbidity associated with head and neck cancer (HNC) therapy. After xerostomia, trismus was reported as the second most burdensome morbidity for survivors of HNC. Radiation-related trismus is often attributed to fibrosis, scar tissue formation, nerve damage, muscle atrophy, or a combination thereof, thus restricting the muscles of mastication. Associated deficits have physical, psychosocial, and safety implications, affecting function such as swallowing (difficulty with food insertion, biting, chewing, oral transfer), communication (voice, resonance, and speech), and oral access (dental restoration/examination, oral intubation, hygiene, emesis).

Manual therapy (MT) is an umbrella term for soft tissue mobilization techniques that uses physical and movement related manipulations of the body. Manual therapy encompasses various techniques, including manual lymphatic drainage, myofascial release, massage, and passive and active stretching. These techniques apply variable amounts of pressure and stretch connective tissue and joints to restore fluid transport and range of motion. Manual therapy techniques improve circulation, reduce local ischemia, stimulate proprioception, decrease muscle spasms and adhesions, and improve MIO in patients with temporomandibular joint disorders.

A study by Holly McMillan et al aimed to demonstrate that MT can be considered either as a frontline or adjuvant treatment for radiation induced trismus. The purpose of this study was to estimate effect size of MT to increase MIO in the setting of radiation associated trismus, specifically after a single session and serial sessions, and explore factors associated with response to MT in the treatment of radiation-associated trismus.

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.

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.

Clinical response to MT as a frontline or adjuvant treatment for radiation-associated trismus is unknown. This case series, mostly comprising patients with moderate to severe radiation-associated trismus, found clinically meaningful improvement in MIO with a moderate 0.45 effect size after a single session of MT and a large 0.7 effect size exceeding MCID after serial MT sessions.

In this case series study, following treatment with MT, oral opening increased an average of 4.1mm (95% CI, 4-5) after a single session and 6.4mm (95% CI, 5-8) after serial MT sessions in patients with radiation-associated trismus. The largest increase in oral opening was achieved after the initial treatment; however, oral opening may continue to improve with serial treatment. Risk factor analyses suggest that even patients who have been traditionally considered treatment-refractory and are 5 years or longer posttreatment with coexisting morbidities, advanced disease, and/or received aggressive oncology treatment have the potential to benefit from treatment with MT. Partial and full compliance with an HEP likely improves MIO gains. Increased oral opening has the potential to improve swallow function, speech, pain, and quality of life; however, more research is needed to determine effect of oral opening and these functional outcomes. Based on these findings, MT may potentially be considered as a frontline treatment modality to improve oral opening quickly as a noninvasive method or adjuvant treatment to improve trismus outcomes.

Source: Holly McMillan; Carly E. A. Barbon; Richard Cardoso; JAMA Otolaryngol Head Neck Surg.

doi:10.1001/jamaoto.2022.0082

Trismus, defined as the inability to fully open the mouth, is a common oral morbidity associated with head and neck cancer (HNC) therapy. After xerostomia, trismus was reported as the second most burdensome morbidity for survivors of HNC. Radiation-related trismus is often attributed to fibrosis, scar tissue formation, nerve damage, muscle atrophy, or a combination thereof, thus restricting the muscles of mastication. Associated deficits have physical, psychosocial, and safety implications, affecting function such as swallowing (difficulty with food insertion, biting, chewing, oral transfer), communication (voice, resonance, and speech), and oral access (dental restoration/examination, oral intubation, hygiene, emesis).

Manual therapy (MT) is an umbrella term for soft tissue mobilization techniques that uses physical and movement related manipulations of the body. Manual therapy encompasses various techniques, including manual lymphatic drainage, myofascial release, massage, and passive and active stretching. These techniques apply variable amounts of pressure and stretch connective tissue and joints to restore fluid transport and range of motion. Manual therapy techniques improve circulation, reduce local ischemia, stimulate proprioception, decrease muscle spasms and adhesions, and improve MIO in patients with temporomandibular joint disorders.

A study by Holly McMillan et al aimed to demonstrate that MT can be considered either as a frontline or adjuvant treatment for radiation induced trismus. The purpose of this study was to estimate effect size of MT to increase MIO in the setting of radiation associated trismus, specifically after a single session and serial sessions, and explore factors associated with response to MT in the treatment of radiation-associated trismus.

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.

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.

Clinical response to MT as a frontline or adjuvant treatment for radiation-associated trismus is unknown. This case series, mostly comprising patients with moderate to severe radiation-associated trismus, found clinically meaningful improvement in MIO with a moderate 0.45 effect size after a single session of MT and a large 0.7 effect size exceeding MCID after serial MT sessions.

In this case series study, following treatment with MT, oral opening increased an average of 4.1mm (95% CI, 4-5) after a single session and 6.4mm (95% CI, 5-8) after serial MT sessions in patients with radiation-associated trismus. The largest increase in oral opening was achieved after the initial treatment; however, oral opening may continue to improve with serial treatment. Risk factor analyses suggest that even patients who have been traditionally considered treatment-refractory and are 5 years or longer posttreatment with coexisting morbidities, advanced disease, and/or received aggressive oncology treatment have the potential to benefit from treatment with MT. Partial and full compliance with an HEP likely improves MIO gains. Increased oral opening has the potential to improve swallow function, speech, pain, and quality of life; however, more research is needed to determine effect of oral opening and these functional outcomes. Based on these findings, MT may potentially be considered as a frontline treatment modality to improve oral opening quickly as a noninvasive method or adjuvant treatment to improve trismus outcomes.

Source: Holly McMillan; Carly E. A. Barbon; Richard Cardoso; JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2022.0082

head and neck cancerTrismus
Source : JAMA Otolaryngology Head Neck Surgery
Dr Ishan Kataria
Dr Ishan Kataria

    Dr Ishan Kataria has done his MBBS from Medical College Bijapur and MS in Ophthalmology from Dr Vasant Rao Pawar Medical College, Nasik. Post completing MD, he pursuid Anterior Segment Fellowship from Sankara Eye Hospital and worked as a competent phaco and anterior segment consultant surgeon in a trust hospital in Bathinda for 2 years.He is currently pursuing Fellowship in Vitreo-Retina at Dr Sohan Singh Eye hospital Amritsar and is actively involved in various research activities under the guidance of the faculty.

    Dr. Kamal Kant Kohli
    Dr. Kamal Kant Kohli

    Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751

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