Exercise intervention for the treatment of trismus in head and neck cancer

Figures & data

Figure 1. Jaw exercise devices.

Table I. Characteristics of the intervention and control group.

	Intervention group n = 50 Mean (range)	Control group n = 50 Mean (range)	p-value
Age mean (range)	57.9 (30–75)	58.0 (29–80)	ns
Gender	n (%)	n (%)	ns
Male	31 (62)	31 (62)
Female	19 (38)	19 (38)
Treatment regimens			ns
Radiotheraphy only	7 (14)	8 (16)
Radiochemotherapy	39 (78)	38 (76)
Radiotherapy + surgery	4 (8)	4 (8)
Time from radiation therapy^a			ns
3 months	44 (88)	38 (76)
6 months	6 (12)	12 (24)
Tumor location			ns
Oropharynx	38 (76)	38 (76)
Tumor colli	6 (12)	6 (12)
Oral cavity	1 (2)	1 (2)
Nasopharynx	5 (10)	5 (10)
Tumor staging			ns
I	1 (2.3)	0 (0.0)
II	8 (18.2)	4 (9.1)
III	8 (18.2)	12 (27.3)
IV	27 (61.4)	28 (63.6)
Comorbidity ACE 27			ns
No comorbidity	29 (58)	20 (40)
Mild comorbidity	13 (26)	18 (36)
Moderate comorbidity	7 (14)	10 (20)
Severe comorbidity	1 (2)	2 (4)

^aTime from radiation therapy to start of intervention and measurement of MIO in the intervention group, respectively time from radiation therapy to inclusion in the control group.

Table II. Maximal interincisal opening (MIO) before and 3 months after intervention (10-week structured exercise program).

MIO (mm)	Before intervention Mean (CI)	3-month follow-up Mean (CI)	Change in MIO (mm) (CI)	Change in MIO (%)
Study group	32.2 (31.2–33.2)	38.6 (36.8–40.4)	∆ 6.4 (4.8–8.0)	∆ 20.2 (15.1–25.3)
Control group	33.2 (32.0–34.4)	33.9 (32.7–35.1)	∆ 0.7 (< 0.3–1.7)	∆ 3.2 (1.4–7.8)
p-value	p < 0.05	p < 0.001	p < 0.001	p < 0.001

Table III. GTQ-score, mean value, 95% confidence interval (CI) for H&N cancer patients before study group exercise and 3-month follow-up.

GTQ	Before study group exercise		p	3-month follow-up		p	Intervention Diff ∆	Control Diff ∆
	Intervention group Mean (CI)	Control group Mean (CI)		Intervention group Mean (CI)	Control group Mean (CI)
Jaw-related problems	41.4 (35.7–47.2)	41.5 (34.6–48.4)	ns	22.9 (17.3–28.6)	43.1 (36.9–49.3)	***	−18.5	+1.6
Eating limitation	46.5 (37.4–55.6)	40.0 (33.2–46.8)	ns	28.1 (21.4–34.9)	39.5 (32.7–46.2)	*	−18.4	−0.5
Muscular tension	26.3 (21.9–30.8)	23.8 (18.4–29.3)	ns	13.2 (9.5–16.9)	27.5 (21.9–33.1)	***	−13.2	+3.7
Facial pain (FP)
Facial pain right now	24.3 (17.8–30.8)	20.7 (14.1–27.3)	ns	9.0 (4.5–13.5)	20.7 (15.0–26.3)	***	−15.3	0.0
Facial pain when worst	43.0 (35.5–50.5)	40.3 (33.0–47.6)	ns	22.7 (16.3–29.0)	30.7 (23.8–37.5)	ns	−20.3	−9.7
last month (lm)
Facial pain average value (lm)	38.3 (31.9–44.8)	35.3 (28.1–42.5)	ns	21.0 (15.2–26.8)	30.0 (23.2–36.8)	ns	−17.3	−5.3
Facial pain interfering with social, leisure and family activities (lm)	24.0 (16.1–31.9)	23.5 (15.5–31.4)	ns	15.0 (7.1–22.9)	20.0 (13.1–26.9)	ns	−9.0	−3.6
Facial pain affecting ability to work (lm)	25.0 (16.8–33.2)	23.5 (15.1–31.8)	ns	13.5 (5.9–21.1)	21.0 (13.6–28.4)	*	−11.5	−3.6
Limitation in opening mouth (LOM)	49.0 (42.7–55.3)	45.0 (36.4–53.6)	ns	33.0 (25.9–40.1)	40.0 (33.1–46.9)	ns	−16.0	−5.0
LOM interfering with social, leisure and family activities (lm)	24.0 (17.7–30.3)	24.5 (16.8–32.2)	ns	16.5 (8.3–24.7)	26.5 (19.7–33.3)	**	−7.5	+2.0
LOM affecting ability to work (lm)	24.5 (16.4–32.6)	25.0 (17.0–33.0)	ns	14.0 (6.2–21.8)	22.0 (14.5–29.5)	*	−10.5	−3.0

Domains and single items range 0–100, where 100 indicate maximal amount of symptoms and 0 is equal to no symptoms; *p < 0.05, **p < 0.01, ***p < 0.001. P-values for analysis of statistical significant difference in mean scores between the intervention group and the control group, before intervention and at 3-month follow-up. GTQ, Gothenburg Trismus Questionnaire.

Table IV. EORTC QLQ-C30 and H&N 35 (shortened version) for H&N cancer patients before and after study intervention.

	Before intervention		p-value	Change in score at 3-months follow-up		p-value
	Study group mean (CI)	Control group mean (CI)		Study group Diff ∆ mean (CI)	Control group Diff ∆ mean (CI)
EQRTC QLQ-C30 Functional scales
Role functioning	46.0 (35.9–56.1)	52.3 (43.3–61.4)	ns	15.7 (0.8–30.5) M	11.3 (3.7–19.0) S	*
Social functioning	56.7 (48.3–65.1)	61.0 (52.1–69.9)	ns	14.0 (1.4–26.6) M	6.3 (−0.4–13.1) S	**
Global QL	54.2 (48.5–59.8)	58.0 (52.7–63.3)	ns	12.2 (4.8–19.5) M	−0.8 (−4.8–3.1) No d	***
EQRTC QLQ–H&N 35 Single items
Pain	41.3 (33.8–48.8)	39.4 (31.5–47.4)	ns	−11.3 (−20.2–2.4)	−6.4 (−12.4–0.4)	ns
Social eating	45.4 (37.1–53.6)	42.3 (35.2–49.5)	ns	−13.9 (−22.7–5.1)	−0.0 (−6.1–6.1)	***
Problem with opening of mouth	44.0 (36.7–51.3)	45.3 (37.0–53.6)	ns	−13.3 (−23.1–3.6)	−0.0 (−6.6–6.6)	***

Score range 0–100 points. High scores for a functional scale and the global quality of life scale represent high level of functioning or high level of global quality of life. High scores for a single item represent high levels of symptoms; *p < 0.05, **p < 0.01, ***p < 0.001. P-values for analysis of statistical significant difference in mean scores between the intervention group and the control group before intervention, and analysis of statistical difference in mean change at 3-month follow-up; Interpretation of clinical significance as described by Cocks et al. [20]. M, medium difference; No d, no difference; S, small difference.

Cocks K, King MT, Velikova G, de Castro G Jr., Martyn St-James M, Fayers PM, et al. Evidence-based guidelines for interpreting change scores for the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30. Eur J Cancer 2012; 48:1713–21.

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