The Rationale and Explanation for Rehabilitation Interventions in the Management of Treatment-Induced Trismus in People with Head and Neck Cancer: A Scoping Review of Randomized Controlled Trials
Abstract
1. Introduction
2. Materials and Methods
2.1. Identifying the Research Question
2.2. Identifying Relevant Studies
Eligibility Criteria
2.3. Information Sources
2.3.1. Search Strategy
2.3.2. Selecting the Studies
2.4. Charting the Data
2.4.1. Data Extraction
2.4.2. Data Charting
2.4.3. Collating, Summarizing, and Reporting the Results
3. Results
3.1. Interventions
3.2. Rationale
3.3. Explanation of Treatment Effects
4. Discussion
4.1. Study Limitations
4.2. Implications for Future Research
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
Appendix A
P: Population | People with treatment-induced trismus associated with head and neck cancer |
C: Concept | Characteristics of different rehabilitation modalities for the management of treatment-induced trismus in people with head and neck cancer |
C: Context | Studies including observational or interventional trials are of interest for this review if they include the implementation of rehabilitation strategies for the management of trismus |
Appendix B
Search Strategy | |
---|---|
Terms | |
#1 | “Physical Therapy Modalities” “[Mesh]” |
#2 | “Rehabilitation” “[Mesh]” |
#3 | “Education” “[Mesh]” |
#4 | “Exercise” “[Mesh]” |
#5 | “Exercise Therapy” [Mesh] |
#6 | “Electrotherapy” “[Mesh]” |
#7 | “Manual Therapy” “[Mesh]” |
#8 | “jaw exercises” |
#9 | “physiotherapy” |
#10 | “physical therapy” |
#11 | “Trismus” “[Mesh]” |
#12 | “trismus” |
#13 | “mouth opening” |
#14 | “jaw opening” |
#15 | “Neck” “[Mesh]” |
#16 | “Head” “[Mesh]” |
#17 | “Neoplasms” “[Mesh]” |
#18 | “Head and Neck Neoplasm” “[Mesh]” |
#19 | “head and neck cancer” |
#20 | #1 OR #2 OR #3 OR #4 OR #5 OR#6 OR #7 OR #8 OR #9 OR #10 |
#21 | #11 OR #12 OR #13 OR #14 |
#22 | #15 OR #16 OR #17 OR #18 OR #19 |
#23 | #20 AND #21 AND #22 |
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Study | Intervention | Rationale | Findings | Explanation |
---|---|---|---|---|
Hajdú et al., 2022 [17] | Preventive exercise therapy | Loss of body mass in HNC and loss of functionality in swallowing | At the end of the treatment, significant effects on mouth opening were found (p = 0.01) | Absence of explanation of pathophysiological mechanisms |
Petersson et al., 2024 [18] | Preventive exercise therapy | Exercise is effective but adherence is low: there is a need for simple protocols | At follow-up, no significant effects on mouth opening were found (0.78) | Absence of explanation of pathophysiological mechanisms |
Messing et al., 2017 [19] | Preventive exercise therapy | Swallowing exercises lead to less muscle deterioration | Significant differences were found 24 months after CRT (p = 0.04) | Absence of explanation of pathophysiological mechanisms |
Saghafi et al., 2024 [20] | Preventive exercise therapy | Exercise can improve radiation-induced inflammation, hypoxia, endothelial injury, and fibrosis | At 6 and 12 months from baseline, significant differences were found (p = 0.01 and p = 0.012, respectively). | Jaw exercises may help to improve subcutaneous fibrosis |
Ortiz-Comino et al., 2022 [21] | Manual therapy | Manual therapy can relieve fibrosis and fascial restrictions | After treatment, MIO was significantly higher in the IG | Manual therapy may improve myofascial impairments. The fact of including intra- and extraoral techniques allowed the researchers to cover all the musculature potentially involved in trismus |
Dai et al., 2024 [22] | Exercise therapy + manual therapy | Exercise can reverse damage to temporomandibular structures | 3 months after radiotherapy, the IG demonstrated statistically significant differences (p = 0.001) | Absence of explanation of pathophysiological mechanisms |
Hu et al., 2021 [23] | Exercise therapy | Resistance exercise improves perception of fatigue and reduces symptom severity | 12 weeks post-discharge, the IG demonstrated less difficulties in mouth opening (p = 0.049) | Absence of explanation of pathophysiological mechanisms |
Elgohary et al., 2018 [24] | Electrotherapy + exercise therapy | LIUS: the increase in local tissue temperature and improvement in flexibility and extensibility of tissue may improve trismus LLLT: the reduction in swelling and subsequent pain may help in trismus TET: may help to improve functional movements and diminish pain | Both interventions demonstrated significant differences when compared to the control group (p < 0.001) | LIUS can reduce inflammation, improve blood circulation to the target tissue, produce micro massage, remove waste products, accelerate lymphatic drainage, improve metabolic activities, and increase the extensibility of soft tissue. Absence of explanation of the pathophysiological mechanisms of LLLT |
Wang et al., 2019 [25] | Exercise therapy + manual therapy + thermotherapy | Thermotherapy: reduces pain and relieves muscle tension Manual therapy: improves pain Exercise: improves trismus | Twelve weeks after baseline, the IG demonstrated higher MIO that the CG (p < 0.001) | Absence of explanation of pathophysiological mechanisms |
Lee et al., 2018 [26] | Electrotherapy | Pain relief can help to increase mouth opening | No statistical differences were found | Since no changes were found in pain or function, and TENS aims to improve function through a reduction in pain, function did not improve |
Wen et al., 2022 [27] | Exercise therapy | Exercise can help to improve negative effects of cancer treatment | At the 12-week follow-up, the improvement in mouth opening difficulties was higher in the IG (p = 0.009) | Exercise can reverse the diverse effects of radiation, such as inflammation, cell death, and matrix remodeling |
Hogdal et al., 2015 [28] | Preventive exercise therapy | Positive effect on swallowing and maximal interincisor distance | The early exercise intervention showed no significant benefits in MID at 12 months (p = 0.07) | Absence of explanation of pathophysiological mechanisms |
Carnaby-Mann et al., 2012 [29] | Preventive exercise therapy | Swallowing exercises facilitate maintenance of oropharyngeal muscle function | The functional swallowing ability deteriorated less (p ≤ 0.03) in the IG than in the CG or SG (p < 0.06) | The reduction in relaxation time and maintenance of muscle size might reflect a deterrent to inflammatory changes. The reduction in muscle edema or fatty infiltration is likely to be a contributing factor. Absence of explanation of pathophysiological mechanisms |
Bragante et al., 2020 [30] | Preventive exercise therapy | Preventing the development of trismus | There was no significant difference in MO measure between the groups at the 3 assessment time points (p = 0.264) | Absence of explanation of pathophysiological mechanisms |
Sekar et al., 2024 [31] | Exercise therapy and manual therapy | Exercise therapy is useful for increasing jaw range of motion and reducing pain. Myofascial release of the restricted fascia around the head and neck may help alleviate facial and neck pain | The IG demonstrated statistically significant differences (p = 0.002) | Therapeutic massage increases blood flow and relaxes the masticatory muscles, as do exercises to break down myofascial adhesions and fibrosis, especially in the first six weeks of treatment |
Loorents et al., 2014 [32] | Preventive exercise therapy | Device developed specifically for trismus | There were no significant differences in MIO between the IG and CG | Absence of explanation of pathophysiological mechanisms |
Yang et al., 2025 [33] | Preventive exercise therapy | Early exercises are particularly effective in preventing trismus | The MIO in the experimental group was significantly higher than that in the control group. This difference persisted in the twelfth week post-surgery (three weeks after the end of radiotherapy) (38.778 ± 1.267 mm vs. 35.167 ± 1.254 mm, t = 12.154, p < 0.001) | Regular mouth opening activities can inhibit excessive scar tissue formation to some extent, helping to maintain or enhance mouth opening. Early mouth opening exercises can reduce the risk of inflammation and fibrosis by increasing local blood circulation and tissue elasticity before radiation damage occurs, thus protecting mouth opening function to some extent |
Fong et al., 2015 [34] | Exercise therapy | Short-term Qigong training can reduce neck–shoulder pain and disability in individuals with neck pain | The deterioration in mouth opening capacity appears to have been less severe in the Tai Chi Qigong group (p = 0.181) than in the control group (p < 0.001) over time | Possible mechanisms include range-of-motion exercises increasing temporomandibular joint mobility and improving the flexibility and elasticity of the connective tissues surrounding the joint and Tai Chi Qigong training improving blood circulation and decreasing the local inflammatory response |
Retèl et al., 2016 [35] | Preventive exercise therapy | TheraBite has proven its effectiveness in both preventive and treatment settings for trismus | After treatment, trismus was significantly lower in the IG | Absence of explanation of pathophysiological mechanisms |
Van der Molen et al., 2011 [36] | Preventive exercise therapy | Tolerance of TheraBite is good, it is easy to use, and compliance tends to be high | Comparing the pre- and post-treatment maximum mouth opening (MIO), a significant decrease over time was found (from 50 to 47 mm, respectively; p < 0.01), but not in the occurrence of trismus (MIO < 35 mm; from 5 to 7 patients; p = 0.70) | Training seems to have a positive effect on the presence of post-swallow residue after concomitant chemoradiotherapy, which might suggest better mucosal clearance and improved muscle activity. Absence of explanation of pathophysiological mechanisms |
Lee et al., 2018 [37] | Preventive exercise therapy | Relieve or prevent trismus | The difference between the two interventions was not significant, although the power of the study was low, because the authors failed to achieve the target recruitment rate and the attrition rate was higher than anticipated. The estimated difference in mean mouth opening at six months after was −2.43 mm. This was not significant (p = 0.39) | Absence of explanation of pathophysiological mechanisms |
Aboelez et al., 2025 [38] | Electrotherapy | Combined trismus appliances improve mouth opening. Threaded tapered screw appliance gradually wedges the teeth apart. Low-level laser therapy helps the tissue heal by reducing pain and swelling and reducing inflammatory conditions | There was a statistically significant difference at different times of evaluation within all groups (p < 0.0001). Group C recorded the lowest values for trismus symptoms, followed by group B, followed by group A. For example, the three groups recorded values of (9.83 ± 1.75), (18.00 ± 2.09), (21.33 ± 2.02), respectively, in the item describing problems yawning in the last six months of the evaluation period | Both therapies could be explained by the fact that both increase vasodilation |
Sirapracha et Sessirisombat, 2018 [39] | Exercise therapy | The most convenient and widely used technique to improve trismus is jaw exercise | At 1 year after radiotherapy, the average percentage of MIO reduction in the dynamic group was greater compared with the static group; however, the difference was not significant (p = 0.706) | It is possible that jaw exercise with the tongue blade stack (static group) stretched the masticatory muscles continuously and the force was greater compared with the force from the patients’ fingers (dynamic group). The force from the patients’ fingers was related to the patients’ physical strength and their ability to separate their fingers |
Tang et al., 2011 [40] | Exercise therapy | Effective therapeutic effect | The mean interincisor distance in patients of both groups decreased at the 3-month follow-up; the decrease in the rehabilitation group was less than that of the control group (0.19 ± 0.5 cm vs. 0.69 ± 0.56 cm, p = 0.004) | Range-of-motion exercises for the jaw and tongue and resistance exercises could strengthen the musculature, increase mobility, and improve the flexibility and elasticity of the temporomandibular joint. In addition, exercises may improve blood circulation |
Castro-Martín et al., 2021 [41] | Manual therapy | MIT can assist in eliminating functional limitations by helping to restore general health and reducing or eliminating pain owing to its systemic effects | MIO improved significantly after MIT (score change + 3.36 mm; p < 0.004) but not after the placebo session (score change −0.36). | One session of MIT on the cervical region increased MIO; this may be explained by the dynamic biomechanical relationship that exists between the cervical spine and the temporomandibular joint during active mouth opening |
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Anarte-Lazo, E.; Bravo-Vazquez, A.; Bernal-Utrera, C.; Torres-Lagares, D.; Falla, D.; Rodríguez-Blanco, C. The Rationale and Explanation for Rehabilitation Interventions in the Management of Treatment-Induced Trismus in People with Head and Neck Cancer: A Scoping Review of Randomized Controlled Trials. Medicina 2025, 61, 1392. https://doi.org/10.3390/medicina61081392
Anarte-Lazo E, Bravo-Vazquez A, Bernal-Utrera C, Torres-Lagares D, Falla D, Rodríguez-Blanco C. The Rationale and Explanation for Rehabilitation Interventions in the Management of Treatment-Induced Trismus in People with Head and Neck Cancer: A Scoping Review of Randomized Controlled Trials. Medicina. 2025; 61(8):1392. https://doi.org/10.3390/medicina61081392
Chicago/Turabian StyleAnarte-Lazo, Ernesto, Ana Bravo-Vazquez, Carlos Bernal-Utrera, Daniel Torres-Lagares, Deborah Falla, and Cleofas Rodríguez-Blanco. 2025. "The Rationale and Explanation for Rehabilitation Interventions in the Management of Treatment-Induced Trismus in People with Head and Neck Cancer: A Scoping Review of Randomized Controlled Trials" Medicina 61, no. 8: 1392. https://doi.org/10.3390/medicina61081392
APA StyleAnarte-Lazo, E., Bravo-Vazquez, A., Bernal-Utrera, C., Torres-Lagares, D., Falla, D., & Rodríguez-Blanco, C. (2025). The Rationale and Explanation for Rehabilitation Interventions in the Management of Treatment-Induced Trismus in People with Head and Neck Cancer: A Scoping Review of Randomized Controlled Trials. Medicina, 61(8), 1392. https://doi.org/10.3390/medicina61081392