Author: Heather Bolan, MA, CCC-SLP
Edited by: Ainsley Martin, MS, CCC-SLP
Name of Course: Amplification, Resistance, & Kinetics of the Jaw (ARK-J) Program Trismus Intervention Certification Course
Instructors: Megan Nosol, M.S.Ed., M.S., CCC-SLP; Brian Kanapkey, M.A., CCC-SLP
Cost: $346.42
Number of CEUs Earned: 1.1-1.3 CEUs
Format: Live lecture with trismus expert guest speakers, evidence-based intervention lecture, and hands-on breakout sessions.
Duration: Two days
Subject: Trismus induced Dysphagia/Dysarthria
Level of Difficulty: Advanced
Applicable Patients/Disorders: Head and neck cancer patients, patients who had oral surgery, patients with mandible injury or TMJ, CVA, TBI. Trismus intervention and training is useful for a vast number of clinical settings including; acute hospital SLPs, oncological SLPs, outpatient SLPs, home health, and skilled nursing facility SLPs.
Content: Trismus is disorder resulting in a reduction in the mandibular (jaw) range of motion (ROM). Skilled trismus intervention can be an effective tool for motivated patients who have an order for trismus treatment, are able to follow instructions, can verbally or non-verbally communicate pain, and whose reduced mandibular ROM impacts them negatively with their quality of life. Such negative impacts include reduced ability to maintain oral hygiene, decreased speech intelligibility, impaired mastication, and difficult airway management. The ARK-J certification course was developed for SLPs by SLPs to provide evidence based evaluation, diagnosis, and treatment involving progressive, active and passive jaw stretching tailored to the needs of the individual patient. SLPs who are certified in ARK-J are trained in using low-cost therapy tools found in your clinic that are just as effective as jaw-mobility devices such as the Therabite that are often too expensive for our patients as they are not currently covered by insurance.
Usefulness of Resources: Resources provided in this CEU course include; a ARK-J device kit, PowerPoint slide of all information covered, and a flash drive with 30 (yes 30!) clinical resources involving items such as patient education handouts, treatment goals and discharge recommendations, patient home exercise journal, and the Gothenburg Trismus Questionnaire (GTQ). And these are only a few of the resources provided!
Managing a head and neck cancer dysphagia program is a daunting task to tackle. If you're anything like me, it was probably overwhelming to identify the essential continuing education courses needed to get your program off the ground. Given the fact that so many patients with oropharyngeal cancer experience trismus, my colleague and I didn’t think twice to hop on a flight to Raleigh to attend this course!
Did you know that patients with oropharyngeal cancer who are treated with radiation therapy are at a 70% risk of developing trismus (1)?
The latest predictors for trismus found that patients who have greater than 58 Gy to the ipsilateral masseter and medial pterygoid will acquire trismus (2). Let's think about this for a second... Head and neck radiation treatment is well above 60 Gy (typically 65-75 Gy). For these patients trismus is not an issue of if, but when. When it comes to trismus intervention in the USA, there is no standardized protocol and there is a large variation in research methodology with no exercise therapy being clearly superior to another (3). Trismus continues to be the second most reported oral symptom from oropharyngeal cancer patients (4), causing eating limitations, speech disturbances, pain, and social/professional interference (5). Seeking hands on instruction through the ARK-J Program instead of simply handing a Therabite to our patients and providing unskilled treatment using manual frequency recommendations is imperative to restore our patients swallowing, speech, and quality of life.
The ARK-J training course took place over two days and was taught by Megan Nosol, M.S.Ed., M.S., CCC-SLP and Brian Kanapkey, M.A., CCC-SLP. They hold combined experience in a variety of settings including ENT clinics, skilled nursing, outpatient, and non-profit organizations. Brian manufactured a dual-valved tracheoesophageal voice prosthesis and Megan serves on ASHA's 2019 Issues in Head and Neck Cancer Topic Committee.
The focus of the first day was placed on reviewing important anatomical and physiological considerations for assessment with a particular focus on cerebral brain damage, trauma, resection/reconstruction, and head and neck cancer. Trismus after a stroke with bilateral cerebral cortical lesions or a severe TBI is relatively common, occurring with an upper motor neuron impairment and will present with spasticity of the jaw. A continued progressive intervention program after administration of botox to the masseter/temporalis (in order to relieve spasms) can lead to significant gains for these patients (6, 7). Although botox has been proven to be successful for neurogenic reasons, this is not an effective intervention for patients with head and neck cancer (HNC), as botox cannot alleviate acquired radiation fibrosis syndrome (RFS).
RFS is not well discussed in the SLP literature, but can result in an amplitude of complications for our patients with HNC. Unfortunately, there is no way to prevent RFS due to changes at the cellular level following radiation therapy. Radiation fibrosis is comprised of dense/ patchy fibrotic tissue and inflamed endothelial cells that result in a loss of repairing ability and regressive fibrosis. It’s a lifetime condition with trismus normally occurring 3 to 6 months post treatment (8). This can be a very problematic issue as we typically don’t have these patients on our caseload when trismus sets in either due to discharging the patient or simply not getting the referral from the patient’s physician. While there is still a need for additional research, this may indicate that a prophylactic approach to trismus may be beneficial to our head and neck cancer patients. Proactive rehab regimens should be considered as they may increase patient comprehension of side-effects from chemoradiation/radiation treatment, and improve patient adherence with follow-up appointments and exercise routines post-treatment.
Treatment of trismus including training patients to properly utilize devices for increasing range of motion, gaining functional chewing skills, and progressing swallowing and/or speech processes are within the SLP’s scope of practice (9) . However, in ALL cases a physician’s order is required to treat trismus.
Throughout the course, practical guidelines and case studies were reviewed to determine therapeutic tools that should be considered and format for typical therapy session for patients with trismus from various etiologies including:
post arch bar removal from trauma
TMJ replacement
total glossectomy
maxillectomy
osteoradionecrosis.
Prior to proceeding with treatment, it is essential to ensure we have the appropriate diagnostic information before to determine the etiology of trismus (e.g., fracture, trauma, RFS, etc), when/where/why they may be experiencing pain in a particular area, and to determine candidacy for treatment.
Pain is often a significant barrier to treatment for trismus. When a patient is experiencing pain, frequent reassessment and record keeping of the patient's pain levels are necessary to determine if re-examination of treatment or a referral to the patient's physician for pain management is required. I highly appreciated the emphasis that was placed on using pain, intensity, and fatigue scales to optimize therapeutic gains. Megan spoke in depth on frequent utilization of the OMNI scale (i.e. scale to assess difficulty level of an exercise) to develop individualized intensity and durations for each of our referred patients (12).
A significant amount of time and care went into applying the five pillars of exercise science principles (mode, intensity, duration, frequency, and progression) to trismus management. Knowing how to apply these principles is imperative to developing progressive treatment plans, identifying safe therapy approaches, and utilizing effective and efficient therapy (10). Tailored treatment plans and patient adherence to trismus exercise regimens have been shown to be effective in improving the mouth opening cavity significantly (11) and are important in long-term treatment of radiation-induced trismus (1). This is the difference between unskilled and skilled trismus intervention. According to the instructors, skilled trismus intervention should result in a 1 to 1⅕ mm gain per week in maximum jaw opening! If they aren’t achieving therapeutic gains then we may need to have a counseling session with our patient. Barriers to treatment for HNC involve;
poor patient comprehension of the rationale for an exercise program
forgetting to complete exercises or not having a system to keep track of exercises
feeling of being overwhelmed by the information, pain, or fatigue (13)
Counseling our patients allows the clinician to troubleshoot barriers and collaborate with their patients to develop new habits and routines for exercise.
The intervention practice and ARK-J device building sections on day two provided the hands-on learning and individualized feedback needed to bring the lecture full circle. Participants started with measuring their partner’s interincisal (i.e. mm between the bottom of upper teeth to the top of the upper teeth) and lateral excursion through different measuring tools. Sherin Joseph, DPT, CLT, a guest speaker at the course, provided a thorough review of physical factors that can impact trismus and hands on training for intra-oral and external techniques for release. The small class size allowed the instructors and Sherin to provide manual adjustments to clinicians practicing release techniques. Having a skilled clinician alter our technique with verbal explanation made this course stand out.
Brian verbally and visually detailed the steps involved in constructing the ARK-J Device for Trismus treatment, while providing recommendations for further tailoring the device based on a patient’s specific needs. Participants were also provided with their own ARK-J Device Toolbox and were able to make our own stretching device. Vendors from ATOS Medical and CranioRehab were present and provided participants with detailed information on products, provided demonstration, and discussed how patients can acquire devices through insurance and private pay.
My heart breaks for the people who could have benefited from skilled trismus intervention. Unfortunately, many patients continue to slip through the cracks.
In my own experience, I recently received a baseline MBSS referral for a new cancer patient with T4N0M0 squamous cell carcinoma of the nasopharynx and ethmoid sinuses, post subtotal rhinectomy with maxillectomy and skull base resection. She is about to start radiation treatment to the areas of concern (66 Gy) and is undergoing elective neck radiation secondary to several high-risk features involved in her case. During her oral mechanism examination, she was found to have a mild severity of trismus, with the assumed etiology of maxillectomy. Unfortunately the patient was not referred to a SLP until the radiation oncologist referred me for her baseline MBSS/prophylactic intervention. With the location of her radiation therapy and findings of a baseline mild trismus we are able to start addressing her issues by exploring different device options and which ones may be covered by her insurance. As a result of this course, my patient and I were able to have a much more productive conversation about what trismus is, how it is established, and how we are planning to address management and maintenance.
If you are interested in learning more about assessment and treatment of trismus, please review the references and additional resources provided.
Check out the ARK-J Program website here: http://www.arkjprogram.com/
1. Pauli, N., Olsson, C., Pettersson, N., Johansson, M., Haugen, H., Wilderäng, U., Finizia, C. (2016). Risk structures for radiation-induced trismus in head and neck cancer. Acta Oncologica,55(6), 788-792. doi:10.3109/0284186x.2016.1143564
2. Kraaijenga, S. A., Hamming‐Vrieze, O., Verheijen, S., Lamers, E., Molen, L., Hilgers, F. J., Heemsbergen, W. D. (2019). Radiation dose to the masseter and medial pterygoid muscle in relation to trismus after chemoradiotherapy for advanced head and neck cancer. Head & Neck,41(5), 1387-1394. doi:10.1002/hed.25573
3. Kamstra, J. I., Leeuwen, M. V., Roodenburg, J. L., & Dijkstra, P. U. (2017). Exercise therapy for trismus secondary to head and neck cancer: A systematic review. Head & Neck, 39(11), 2352-2362. doi:10.1002/hed.24859
4.Kamstra, J.I., Jager-Wittenaar, H., Dijkstra, P.U. et al. Support Care Cancer (2011) 19: 1327. https://doi.org/10.1007/s00520-010-0952-4
5. Pauli, N., Johnson, J., Finizia, C., & Andréll, P. (2012). The incidence of trismus and long-term impact on health-related quality of life in patients with head and neck cancer. Acta Oncologica,52(6), 1137-1145. doi:10.3109/0284186x.2012.744466
6. Schwerdtfeger K, Jelasic F. Trismus in postoperative, posttraumatic and other brain stem lesions caused by paradoxical activity of masticatory muscles. Acta Neurochir 1985; 76: 62-66
7. Seo, J., Kim, D., Kang, S. H., Seo, K., & Seok, J. W. (2012). Severe Spastic Trismus without Generalized Spasticity after Unilateral Brain Stem Stroke. Annals of Rehabilitation Medicine, 36(1), 154. doi:10.5535/arm.2012.36.1.154
8. Hojan, K., & Milecki, P. (2014). Opportunities for rehabilitation of patients with radiation fibrosis syndrome. Reports of Practical Oncology & Radiotherapy, 19(1), 1-6. doi:10.1016/j.rpor.2013.07.007
9. American Speech Language and Hearing Association (2018). Practice portal: Head and Neck Cancer. Accessed May 23, 2019 from https://www.asha.org/PRPSpecificTopic.aspx? folderid=8589943346§ion=References
10. Melchers, L., Weert, E. V., Beurskens, C., Reintsema, H., Slagter, A., Roodenburg, J., & Dijkstra, P. (2009). Exercise adherence in patients with trismus due to head and neck oncology: A qualitative study into the use of the Therabite®. International Journal of Oral and Maxillofacial Surgery, 38(9), 947-954. doi:10.1016/j.ijom.2009.04.003
11. Pauli, N., Fagerberg-Mohlin, B., Andréll, P., & Finizia, C. (2013). Exercise intervention for the treatment of trismus in head and neck cancer. Acta Oncologica, 53(4), 502-509. doi:10.3109/0284186x.2013.837583
12. Robertson, R. J., Goss, F. L., Andreacci, J. L., Dub??, J. J., Rutkowski, J. J., Snee, B. M., . . . Metz, K. F. (2005). Validation of the Children??s OMNI RPE Scale for Stepping Exercise. Medicine & Science in Sports & Exercise, 37(2), 290-298. doi:10.1249/01.mss.0000149888.39928.9f
13. Govender, R., Smith, C. H., Taylor, S. A., Barratt, H., & Gardner, B. (2017). Swallowing interventions for the treatment of dysphagia after head and neck cancer: A systematic review of behavioural strategies used to promote patient adherence to swallowing exercises. BMC Cancer, 17(1). doi:10.1186/s12885-016-2990-x
Special thank you to CranioRehab for providing all participants with a free model of their OraStretch Press Jaw Motion Rehab System.
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