Exercise adherence in patients with trismus due to head and neck oncology: a qualitative study into the use of the Therabite®

doi:10.1016/j.ijom.2009.04.003

International Journal of Oral and Maxillofacial Surgery

Volume 38, Issue 9, September 2009, Pages 947-954

https://doi.org/10.1016/j.ijom.2009.04.003 Get rights and content

Abstract

Trismus is a common problem after treatment of head and neck cancer. The Therabite^® is an effective treatment for trismus. To explore the factors that may influence Therabite^® exercise adherence, how these interrelate and to provide aims for interventions to increase adherence, the authors conducted a multi-centre, formal-evaluative qualitative retrospective study. 21 patients treated for head-neck cancer were interviewed in semi-structured, in-depth interviews. Internal motivation to exercise, the perceived effect, self-discipline and having a clear exercise goal influenced Therabite^® exercise adherence positively. Perceiving no effect, limitation in Therabite^® opening range and reaching the exercise goal or a plateau in mouth opening were negative influences. Pain, anxiety and the physiotherapist could influence adherence both positively and negatively. Based on the results, a model for Therabite^® exercise adherence was proposed. It is important to signal and assess the factors negatively influencing Therabite^® adherence, specifically before there is a perceived effect. Research is needed to examine why some patients do not achieve results despite high exercise adherence, to identify effective exercise regimens and to assess proposed interventions aimed to increase Therabite^® exercise adherence.

Section snippets

Methods

The present research was a multi-centre, formal-evaluative, qualitative, retrospective study. Semi-structured, in-depth interviews were conducted with patients who use or had used the Therabite^® after treatment of head and neck cancer.

To be able to identify new factors in, and specifically applicable to, Therabite^® exercise adherence, open-ended questions were asked according to a predefined interview topic guide and participants were encouraged to describe their experiences in depth. To

Results

39 people were contacted of whom 29 (74%) were willing to cooperate. 22 appointments (56%) were made and an equal number of interviews were conducted. One interview was excluded because it was not completely recorded due to a technical error (patient 19). 21 (95%) of the conducted interviews were analysed. Nine participants still used the Therabite^® at the time of the interview. Patient characteristics are presented in Table 1. Therabite^® exercise adherence is summarized in Table 2.

Nearly all

Discussion

This qualitative study gave insight into the plethora of factors influencing Therabite^® exercise adherence in patients suffering from trismus after being treated for head and neck cancer. The most important and most frequently mentioned factors were the internal motivation to exercise and the perceived effect, both having a positive influence on adherence; perceiving no effect had a negative influence. Other frequently mentioned factors were the limitation in the opening range of the Therabite^®

Funding

None

Competing interests

None declared

Ethical approval

Not required

Acknowledgements

The authors would like to thank Mr A.Wietsma and Dr M.Witjes for their expertise and all participants for sharing their time and experiences.

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Cited by (65)

Trismus therapy devices: A systematic review
2022, Oral Oncology
Citation Excerpt :
Additional adverse events reported through MAUDE and DAEN included jaw fracture (n = 1) and finger numbness and pain (n = 1) using Therabite®. One study [40] conducted qualitative interviews with Therabite® users to explore the factors associated with exercise adherence. Their analysis identified the individual’s internal motivation as a critical factor in exercise adherence.
There is a wide range of commercial and custom-made devices available for the treatment of trismus (restricted jaw opening). They are used often in conjunction with a prescribed exercise program with the aim of improving maximal inter-incisal opening (MIO). This study compared the efficacy (MIO and patient reported outcome results), adverse events, consumer experience and cost of the different types of devices available.
Four databases were searched between the years 2001–2021 using the terms ‘trismus’ and ‘device’. Two independent authors assessed each paper for inclusion, then conducted a quality analysis.
Thirty-two studies met the criterion required for inclusion. The majority (n = 27) were in the context of established trismus, where the remaining five used the device preventatively. The trismus device improved MIO in 23 of the rehabilitation programs (pooled mean MIO increased by 9.5 mm in the intervention arm compared to 2.4 mm for controls; p = 0.0001). Improved MIO was not observed in the prevention studies. The Therabite ® was the most common trismus device investigated and with a mean increase in MIO of 10.0 mm and cost of $499AUD. Forces applied by trismus devices were regulated by the perception of pain experienced by the patient, rather than a prescribed force by the treating health professional. Despite this guidance, several adverse events occurred (n = 8), including mandibular and molar fractures. Barriers experienced by consumers included pain, ill-fitting mouthpiece, adverse events, exercise adherence and cost.
Trismus devices which use the application of force to the jaw can improve the MIO of patients with established trismus. However, their role is unproven in the setting of trismus prevention during radiotherapy and several significant barriers such as cost, exercise adherence and safety concerns have been demonstrated for the intervention setting.
Long-term swallowing-related outcomes in oral cancer patients receiving proactive swallowing therapy
2021, Oral Oncology
The present study aimed to evaluate the impact of proactive swallowing rehabilitation on swallowing function and quality of life (QoL) in oral cancer patients in the first two years after definitive treatment.
Consecutive adult patients with locally advanced oral cancer who received radical surgery, free flap reconstruction, and adjuvant radiotherapy were recruited prospectively, to whom proactive swallowing rehabilitation was provided. Body weight (BW); fiberoptic endoscopic evaluation of swallowing (FEES), functional oral intake scale (FOIS), and diet level; 10-item eating assessment tool (EAT-10), and MD Anderson Dysphagia Inventory (MDADI); and adherence at baseline, 1, 3, 6, 12, and 24 months were evaluated.
A total of 104 patients were included during May 2018 to July 2020. Compared to the baseline, significant deterioration in BW, FOIS, and MDADI was noted at one month. However, a trend of recovery was observed in FOIS from one month, and in BW and MDADI from three months. A total of 94% patients were free of tube feeding at 12 months but with a diet requiring special preparations or compensation. Safe swallowing could be achieved in approximately 90% of the participants after six months with diet modification or compensatory maneuvers. BW at 18 and 24 months did not differ significantly from baseline.
Proactive swallowing therapy is feasible for patients with locally advanced oral cancer receiving definitive treatments. It facilitates safe oral intake and adequate nutrition. Patients who performed swallowing exercises had a faster and better recovery in swallowing function and swallowing-related QoL.
Exercise therapy for cancer treatment-induced trismus in patients with head and neck cancer: A systematic review and meta-analysis of randomized controlled trials
2020, Radiotherapy and Oncology
Trismus is a common complication of cancer treatment, particularly radiotherapy, for head and neck cancer. We investigated whether exercise therapy could prevent or manage limited mouth opening in patients before or after the cancer treatment.
We performed a systematic review and meta-analysis to evaluate the effectiveness of exercise therapy combined with a jaw-mobilizing device in the prevention and treatment of cancer treatment-induced trismus. The electronic databases PubMed, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for articles on trismus published before July 2020 with no language restrictions. The primary outcome for prevention was trismus incidence. The treatment outcome for trismus was the improvement of maximal interincisal opening (MIO).
Thirteen randomized controlled trials (RCTs) involving 733 patients were identified. Six studies assessed MIO and found that exercise therapy adjuvant to the use of a jaw-mobilizing device significantly improved the MIO from 4.48 (95% confidence interval [CI] = 0.20, 8.75) to 14.20 (95% CI = 10.73, 17.67) mm. Seven studies evaluating the preventive outcome of incidence of trismus found no significant difference between standard usual care and exercise therapy adjuvant to the use of a jaw-mobilizing device (risk ratio = 1.20; 95% CI = 0.61, 2.34).
The current evidence from RCTs revealed that exercise therapy can lead to MIO improvement following the development of cancer treatment-induced trismus, but does not prevent trismus in patients being treated for head and neck cancer. The clinical exercise programs used in the studies were heterogeneous; therefore, additional high-quality RCTs are required.
Efficacy of exercise therapy during radiotherapy to prevent reduction in mouth opening in patients with head and neck cancer: A randomized controlled trial
2020, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
The aim of this study was to compare the efficacy of 2 protocols of exercise therapy to avoid reduction in mouth opening (MO) in patients undergoing radiotherapy for head and neck cancer.
This was a randomized, controlled, double-blind, 3-arm, parallel-group, prevention clinical trial. Ninety patients were randomized into 3 groups to perform exercises during radiotherapy treatment: intervention group 1 (G1); intervention group 2 (G2); and control group (CG). Maximum MO was measured before (T0), immediately after (T1), and at 12 months (T2) after completion of radiotherapy treatment. Generalized estimating equations model complemented by the least significant difference test was applied to group comparisons.
There was no significant difference in MO measure between the groups at the 3 assessment time points (P = .264). The difference in MO measure from baseline to 12 months after having completed radiotherapy was –1 mm in CG (95% confidence interval [CI] –4.0 to 2.0); 1.3 mm in G1 (95% CI –1.7 to 4.3); and 0.5 mm in G2 (95% CI –3.4 to 4.4).
It was not possible to conclude that the exercise protocols performed in this study are more effective than the usual guidance to prevent reduction in MO in patients undergoing radiotherapy for head and neck cancer.
Effects of a mouth-opening intervention with remote support on adherence, the maximum interincisal opening, and mandibular function of postoperative oral cancer patients: A randomized clinical trial
2019, European Journal of Oncology Nursing
Citation Excerpt :
In general, adherence to mouth-opening exercise regimens is poor (Lee et al., 2018). Factors such as pain, anxiety, motivation, perceived effect, and exercise goals were found to affect adherence to mouth-opening exercise (Melchers et al., 2009). Training upon discharge alone, without follow-up reminders and continuous support, may lead to failure in the execution of correct and routine mouth-opening exercises at home.
The purpose of the study was to investigate the effects of a mouth-opening intervention for postoperative trismus and remote support provided via telephone following hospital discharge for intervention adherence in patients with oral cancer.
The study is a parallel randomized trial. Patients admitted at a general hospital for oral cancer surgery were recruited and randomly assigned to either the experimental or the active control group. Both groups underwent a 12-week intervention program, including warm compress, masticatory muscle massage, and jaw exercise. Subjects in the experimental group received additional support via telephone following hospital discharge. Data on intervention adherence maximum interincisal opening and mandibular function impairment were collected at baseline, week 4, and week 12.
Sixty subjects (30 in each group) that completed the study were included in the analysis. At week 12, the intervention practice time in the experimental group was 299.67 min (95% CI: 223.44–357.89) more than that of the active control group. From baseline to week 12, the change in maximum interincisal opening was 10.30 mm (95% CI: 8.22–12.37) greater in the experimental than in the active control group. The change in mandibular function impairment score was −0.36 (95% CI: −0.44 to −0.28) greater in the experimental than in the active control group.
The study results support the effect of remote support via telephone for enhancing adherence to the intervention protocol, and the effect of the intervention program for alleviating trismus and mandibular function impairments in patients who receive curative surgery for oral cancer.
Comparative study on the maximum mouth opening between dynamic and static jaw exercise in irradiated head and neck cancer patients: A randomized control trial
2018, Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology
To compare the effects of dynamic and static jaw exercises on maximum mouth opening distance (MMOD) in irradiated head and neck cancer patients.
Forty-three head and neck cancer patients who received radiotherapy were divided into two groups, dynamic jaw exercise group (n = 20) or static jaw exercise group (n = 23). The MMOD of the patients in each group, measured by Therabite range of motion scale, revealed excellent validity and reliability pre-radiotherapy, every two weeks during radiotherapy, the last day of radiotherapy, and the 1, 3, 6 and 12 months after treatment. The percentage of MMOD change in the groups pre-treatment and 1 year post-treatment were compared using the independent t-test (α = 0.05).
The average reduction in MMOD in the static group was 7.17% ± 21.34, and in the dynamic group was 9.42% ± 16.91. The independent t-test analysis revealed no significant difference between the groups (p = 0.706).
There was no significant difference in MMOD between head and neck radiotherapy patients using dynamic or static jaw exercises.

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Clinical PaperHead and Neck OncologyExercise adherence in patients with trismus due to head and neck oncology: a qualitative study into the use of the Therabite®

Abstract

Section snippets

Methods

Results

Discussion

Funding

Competing interests

Ethical approval

Acknowledgements

J Oral Maxillofac Surg

Arch Phys Med Rehabil

Oral Oncol

Oral Oncol

Int J Radiat Oncol Biol Phys

Lancet

Int J Radiat Oncol Biol Phys

Perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior

J Appl Soc Psychol

Self-efficacy

A pilot study of pentoxifylline in the treatment of radiation-induced trismus

Am J Clin Oncol

Variations in patients’ adherence to medical recommendations: a quantitive review of 50 years of research

Med Care

Clinical Paper
Head and Neck Oncology
Exercise adherence in patients with trismus due to head and neck oncology: a qualitative study into the use of the Therabite^®