Amelioration of Trismus during and beyond a course of radiotherapy

Abstract

Abstract Introduction: The primary factor limiting jaw movement in head and neck cancer patients is rapid formation of collagen caused by radiation and/or surgery leading to fibrosis and contraction in the muscles used for mastication. Trismus can negatively affect all aspects of Health Related Quality of Life (HRQoL). Overall Aims: The overall aims of the thesis are to put together a systematic, robust and critically assessed original piece of work concerning amelioration of trismus in head and neck cancer patients and to gain insight into the acceptability of the intervention from the patient perspective. Methods: To identify risk factors and prevalence for trismus in head and neck patients, mouth opening measurements and HRQoL were monitored in a longitudinal, prospective study. Measurements and questionnaires were completed prior to surgery, after radiotherapy and again at 3 and 6 months post radiotherapy. Subsequently, a randomised feasibility study comparing the efficacy of two approaches to relieve and prevent trismus was undertaken in patients with head and neck cancer who reported subjective tightening of the jaw prior to radiotherapy. Participants received one of two jaw mobilising devices (therabite versus wooden spatulas), commencing a proactive exercise regimen before radiotherapy and continuing for up to 6 months after the start of the intervention. The feasibility of conducting a randomised trial with the two different devices was examined using clinical, HRQoL and health economic assessments. Patient acceptability was explored using qualitative methods, from a sub-sample of fifteen participants. Results: The longitudinal prospective study (N=87) showed that 47% of patients receiving major surgery for head and neck cancer presented with trismus, 71% had post-surgical trismus and 79% had trismus six months post-surgery/radiotherapy. Males and those with heavy alcohol consumption were less likely to have trismus post-treatment. In the randomised feasibility study, 37 patients received the therabite device and 34 the wooden spatulas for jaw exercises. All patients had some sense of jaw tightening prior to study entry. Mean mouth opening after 6 months increased in both groups following the exercise intervention, with non-significant differences between the two arms (p=0.39). Completion rates of the 3 health economic measures were good. There was no significant difference between the two groups in frequency of contact with care services nor in quality of life between the two groups. Patients did not find either device more acceptable to use, both groups reporting that exercises were stopped temporarily whilst side effects of the radiotherapy were at their worst. Discussion: This novel body of work used an exercise regimen proactively, pre, during and beyond a course of radiotherapy, and the study design also included health economics and a qualitative aspect to gauge acceptability of intervention from patients’ perspectives. The results of both the quantitative and qualitative aspects of the study design will influence healthcare professionals to develop evidence-based decisions about patient management and resource use. Conclusion: This novel work has expanded the knowledge base and can be applicable to the general body of evidence for this intervention in clinical practice. Treatment of objective and subjective trismus should be encouraged prior to radiotherapy and continued post treatment to maintain mouth opening with a jaw mobilising device although this data is not from a definitive Randomised Controlled Trial (RCT). Patients were able to perform proactive exercises throughout radiotherapy and found them acceptable, provided there was a structured break (reduction or cessation of exercises) when the side effects of the radiotherapy were at their worst. This body of work has tentatively shown amelioration in mouth opening in patients who have a subjective tightening of the jaw prior to radiotherapy for head a

Date of Award	31 Dec 2018
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Ann-Louise Caress (Supervisor) & Nicholas Slevin (Supervisor)