M.D. Anderson Cancer Center, Sections of Speech Pathology and Oral Oncology and Maxillofacial Prosthodontics, Department of Head and Neck Surgery, University of Texas, Houston.
Depatment of Biostatistics, University of Texas Health Science Center, Houston.
JAMA Otolaryngol Head Neck Surg. 2022 May 1;148(5):418-425. doi: 10.1001/jamaoto.2022.0082.
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.
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.
Intraoral MT (including or excluding external head and neck) targeting the muscles of mastication.
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.
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.
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.
张口困难是头颈部癌症（HNC）幸存者中高度普遍的问题。目前，张口困难的治疗标准包括各种基于伸展的运动方案，作为单一的主要治疗方式，而关于手动疗法（MT）在该适应证中的作用的证据有限。
评估在放射治疗相关张口困难的情况下，MT 对增加开口度的效果大小和反应的相关性。
设计、地点和参与者：这项回顾性病例系列研究于 2016 年至 2020 年 3 月（在 COVID-19 中断之前）在德克萨斯大学 MD 安德森癌症中心进行，纳入了 49 名无疾病的 HNC 幸存者，他们因放射治疗相关的张口困难而接受治疗。
针对咀嚼肌的口腔内 MT（包括或不包括头颈部外部）。
与连续 MT 疗程相比，初次 MT 疗程前后的最大切牙开口度（MIO）。检查了协变量，以确定与 MT 治疗张口困难的反应的相关性。
共纳入 49 名 HNC 幸存者（13 名女性[27%]；24 名[49%]64 岁或以下；25 名[51%]65 岁或以上；平均[范围]放疗后 6.6[0-33]年；9 名[18.4%]接受了单次 MT 疗程；40 名[81.6%]接受了多次疗程[平均，6；中位数（范围），3（2-48）]）。单次疗程后 MIO 平均（SD）增加 4.1（1.9）mm（0.45 效应大小），连续 MT 疗程后 MIO 平均（SD）增加 6.4（4.8）mm，效应大小为 0.7。未发现协变量与 MT 后 MIO 改善有临床意义的相关性。
这项病例系列研究的结果表明，在放射治疗相关的张口困难的 HNC 幸存者中，MT 改善了 MIO，其效果大小为中到大。结果表明，在初始治疗后，开口度的增加最大，尽管增加幅度较小，但随着连续治疗，开口度继续改善。协变量与 MT 反应无相关性，这表明通常被认为是治疗抵抗的患者（例如，晚期疾病、多种肿瘤治疗线、治疗后≥5 年）可能受益于 MT 治疗。手动疗法在与传统伸展疗法联合使用时可能是一种有益的一线或辅助治疗方法。口腔开口度的临床显著增加有可能改善吞咽功能、言语、疼痛和生活质量。
