Manual Therapy’s Utility in the Treatment of Head/Neck Cancer-Related Trismus — GUEST BLOG POST

Manual therapy (MT) has been my chosen intervention for decades.

This preference began with perceptions of MT having the ability to select a specific tissue for
intervention, specifically connective tissue (fascia). With such a belief, I worked to help
many with a range of functional problems. However, as I moved away from my initial
myofascial release (MFR) training and learned models of MT from other perspectives,
my thoughts on single tissue explanations for both causation and remediation evolved.

While some of these models substituted another tissue-based problem and solution,
mirroring the MFR approach I’d learned initially, others broadened the explanation of
how MT influenced dysfunction. These explanations included systems-based approach
narratives from the neurological and behavioral sciences and became the focus of my
advancement as a clinician (Bialosky et al, 2018; Geri et al, 2019; Kolb et al, 2020).

Initially, I stuck with the term MFR to describe my work, partly due to a lack of a better
description and part of which was selfish. MFR was a popular term and often attracted
clinicians (physical and massage therapists) to my continuing education seminars.

When, as an MT educator, I was invited into the world of the SLP, I began seeing the
need for a more balanced and evidence-informed approach, and the term MFR needed
to evolve. Manual therapy was my choice. While I recognize that I left behind a brand
recognized by more clinicians, intellectual honesty required I move on.
Manual therapy encompasses massage, myofascial release, manual lymphatic drainage
MDL), manual circumlaryngeal treatment, and other named models that have been
regularly included in the SLP literature since at least 1990 (Aronson, 1990). However,
the mention of MT as a successful intervention strategy has been primarily seen in the
dysphonia realm; other areas have been subject to only anecdotal reports with a paucity
of studies showing efficacy with HN cancer-related dysphagia (Krisciunas et al, 2015;
Krisciunas et al, 2019) and none for trismus (Chee et al, 2021).

Last month, the paper Manual Therapy for Patients With Radiation-Associated
Trismus After Head and Neck Cancer was published by McMillan et al, at MD Anderson
Cancer Center, which looked at the application of MT with 46 HN cancer survivors with
a mean of 6.6 years post-radiation and all with trismus. Findings report improvement in
mouth opening of 4.1 mm fowling a single MT session and 6.4 mm following an average
of 6 MT sessions. Treatment consisted of intraoral soft-tissue treatment, mandibular
joint mobilization (passive, active-assistive, and active stretching, MDL, MFR, massage,
and strengthening, all of which would be considered within the scope of practice of SLPs
who have been trained in the work. The study included other factors examined and
determined, but overall, the conclusions stated:

“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 post-treatment) 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.” (McMillan et al, 2022)

The study covers the intervention specifics of the utilized approach in a similar fashion
as similar papers within the general MT field. The details typically range from highly
detailed ones, which may include the protocol used (though not necessary), to vague
references to approaches that leave the reader wanting more. Though not explicitly
worded as such, what was apparent from reading McMillan’s paper is that there was
latitude allowed for both patient-specific issues and preferences as well as for clinician
preferences.

While some may see this as a detriment to evidence-based practice, such an
approach is better in keeping with principles of shared decision-making (Bialosky et al,
2021; Lunghi et al, 2019; Maxwell et al, 2022).

With such studies now available, SLPs can feel validated in reaching for MT as a part of
a larger intervention strategy.

Of particular interest to me was the finding that the greatest gains tended to occur with the first MT session, though additional smaller gains were noted through subsequent sessions.

Though not a part of the education and training of many SLPs, through direct continuing education training and the secondary onsite sharing of educational resources from those trained, the pool of clinicians willing to broaden into the inclusion of MT should allow MT to become commonplace in the
treatment of trismus and related problems.

 

Walt Fritz, PT
Foundations in Manual Therapy Seminars
www.waltfritz.com

 

Walt Fritz, is a physical therapist in the Rochester, NY area who has been using manual therapy as a primary intervention since 1992.

He teaches his Foundations in Manual Therapy: Voice and Swallowing Disorders seminars to SLPs for ASHA credit, and other health professionals across the globe. He now has an online forum for CEUs. Learn more at www.waltfritz.com.

Readers can utilize “NiceSpeechLady” as the discount code for 10% off of the course upon checkout.

 

 

References:

• Aronson, Arnold Elvin. 1990. Clincial Voice Disorders: An Interdiscipinary Approach. New
  York: Thieme.
• Baroni, Francesca et al. 2021. “The Role of Touch in Osteopathic Practice: A Narrative
  Review and Integrative Hypothesis.” Complementary Therapies in Clinical Practice 42.
• Bialosky, Joel E. et al. 2018. “Unraveling the Mechanisms of Manual Therapy: Modeling an
  Approach.” Journal of Orthopaedic and Sports Physical Therapy 48(1): 8–18. 2021.
• “The Healthcare Buffet: Preferences in the Clinical Decision-Making Process for
  Patients with Musculoskeletal Pain.” Journal of Manual and Manipulative Therapy.
• Chee, Shuzhen et al. 2021. “Interventions for Trismus in Head and Neck Cancer Patients: A
  Systematic Review of Randomized Controlled Trials.” Integrative Cancer Therapies 20.
• Geri, Tommaso et al. 2019. “Manual Therapy: Exploiting the Role of Human Touch.”
  Musculoskeletal Science and Practice 44.
• Hutcheson, Katherine et al. 2021. “Manual Therapy for Fibrosis-Related Late Effect
  Dysphagia in Head and Neck Cancer Survivors: The Pilot MANTLE Trial.” BMJ Open
  11(8).
• Kolb, William H., Amy Wallace McDevitt, Jodi Young, and Eric Shamus. 2020. “The
  Evolution of Manual Therapy Education: What Are We Waiting For?” Journal of
  Manual and Manipulative Therapy 28(1): 1–3.
• Krisciunas, G P et al. 2015. A Novel Manual Therapy Programme during Radiation Therapy for Head and Neck Cancer-Our Clinical Experience with Five Patients.
• Krisciunas, Gintas P. et al. 2019. “Application of Manual Therapy for Dysphagia in Head and Neck Cancer Patients: A Preliminary National Survey of Treatment Trends and Adverse Events.” Global Advances In Health and Medicine 8.
• Maxwell, Christina, Karen McCreesh, Jon Salsberg, and Katie Robinson. 2022. “‘Down to the Person, the Individual Patient Themselves’: A Qualitative Study of Treatment Decision‐making for Shoulder Pain.” Health Expectations. https://onlinelibrary.wiley.com/doi/10.1111/hex.13464.

 

 

 

 

 

“NiceSpeechLady” for 10% discount at checkout for courses

                                                                                  sponsored ad

 

 

Resource Summary List

 

Disclosure: Foundations in Manual Therapy: Voice and Swallowing Disorders is a sponsoring advertiser of Nice Speech Lady.