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 Table of Contents  
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 61-67

Role of physiotherapy in rehabilitation of oral potentially malignant disorder (OPMD) and oral cavity cancers: Systematic review of literature

1 Department of Oncology, Fortis Hospital, Mulund, Mumbai, India
2 Department of Head and Neck Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Department of Surgical Oncology, Fortis Hospital, Mulund, Mumbai, Maharashtra, India
4 Department of Physiotherapy, Fortis Hospital, Mulund, Mumbai, Maharashtra, India

Date of Submission07-Nov-2021
Date of Decision25-Dec-2021
Date of Acceptance07-May-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Hitesh Rajendra Singhavi
1136, OPD B, Department of Surgical Oncology, Fortis Hospital, Mulund, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jhnps.jhnps_70_21

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Oral cavity cancer (OCC) treatment is associated with functional defects, morbidity, and significant chances of recurrence. Functional defect in terms of restriction of movement, reduced mouth opening, dysphagia, difficulty in speech results in poor quality of life (QoL). However, with timely physiotherapy majority of the functional loss can be rehabilitated. Training of physiotherapy needs to be started from preoperative time period setting up the mindset for postoperative rehabilitation. Literature lacks the robust data on the effects of physiotherapy for each step of cancer management (pretreatment, perioperative, and postoperative stage). In this systematic narrative review, we lay down the available evidence through extensive search of the available literature on the role of timely physical therapy in improving QoL in oral submucous fibrosis, preoperative and perioperative setting in OCC patients. The reviewed articles also shed light on perioperative role of physiotherapy in tracheostomy care, chest physiotherapy, prevention of deep vein thrombosis, speech, swallowing function, neck, shoulder movement, donor site hand, and leg mobility is highlighted. The review also highlights post-treatment management of trismus, dysphagia, lymphedema, and its recent advances.

Keywords: Chemotherapy, head-and-neck cancer, oral cancer, physical therapy, physiotherapy, radiotherapy

How to cite this article:
Singhavi HR, Pai AA, Khan A, Patel H, Nandakumar N, Heroor A. Role of physiotherapy in rehabilitation of oral potentially malignant disorder (OPMD) and oral cavity cancers: Systematic review of literature. J Head Neck Physicians Surg 2022;10:61-7

How to cite this URL:
Singhavi HR, Pai AA, Khan A, Patel H, Nandakumar N, Heroor A. Role of physiotherapy in rehabilitation of oral potentially malignant disorder (OPMD) and oral cavity cancers: Systematic review of literature. J Head Neck Physicians Surg [serial online] 2022 [cited 2022 Jun 27];10:61-7. Available from: https://www.jhnps.org/text.asp?2022/10/1/61/347993

  Introduction Top

Oral cavity cancers (OCCs) are one of the most common cancers in India.[1] Tobacco,[2] alcohol,[3] areca nut[4] along with poor oral hygiene,[5] and chronic mucosa trauma[6] are the probable etiological factors of OCC. More than 135,000 new OCC are registered every year only in India.[1] Majority of the OCC are presented in advanced stage, which warrants multimodality therapy involving surgery followed by radiotherapy and sometimes concomitant chemotherapy in adjuvant settings. Multimodality therapy for OCC causes various short-term and long-term side effects. Survival of OCCs has increased since the last decade.[7] Thus, rehabilitation after the definitive treatment has taken priority with improving functional defect. Physiotherapy plays a significant role in preventing various complications of surgery, radiotherapy, and restoring function of oral cavity, face, chest, shoulder, and legs. However, advantages of physiotherapy are lesser known, and review of the current evidence on the role of physiotherapy on the different time periods of treatment of OCC is warranted.

  Methods Top

Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed in this review. As per PICOS format, P: Population consisted of those patients who underwent treatment for OCC, I: OCC patients or oral submucous fibrosis (OSMF) patients receiving physiotherapy, C: Comparison of patients receiving physiotherapy with those who do not O: outcome in terms of quality of life (QoL) after definitive treatment of OCC patients S: Study-Retrospective and Prospective study. We searched PubMed, reporting role of physiotherapy and physical therapy in treated OCC cases. All electronic searches were last updated in April 2021. The studies were also searched manually through various textbooks and journals. Search keywords used were “physical therapy” AND “oral cancer,” “physiotherapy” AND “radiation,” “physiotherapy” AND “oral cancer” AND “chemotherapy.” Articles published in languages other than English and articles with only abstracts were excluded. Articles with insufficient, missing data, personal communications, case series, case reports, animal studies were excluded. Literature search was done by two independent reviewers (H.S. and H.P), and each study was assessed for inclusion. The third reviewer's opinion was used to solve any disagreement (A.A). This search yielded 1794 articles [Figure 1]. Among these articles, only 42 articles met our inclusion criteria and were considered in this review.
Figure 1: Search strategy using PRISMA guideline

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Role of physiotherapy in oral potentially malignant disorders like oral submucous fibrosis

OSMF is an oral potentially malignant condition characterized by submucosal fibrosis leading to reduced mouth opening and rigidity.[8] It has a high malignant transformation rate of up to 7.6%.[9] The management of OSMF is primarily concentrated on improving or preventing the worsening of mouth opening and prevention or early detection of oral malignancy. Gondivikar et al. summarize the various devices used for increasing the mouth opening.[10] EZbite was developed by Li et al. especially for patients with mouth opening up to 5 mm, Nallan C-H overnight appliance is a compatible device which stays in mouth and hyrax screws are released 1 mm in every monthly visit.[11] Another device extra orally placed with the help of orthodontic wire mouth opening device is also documented to improve mouth opening. There are postsurgical stents available including oral stents and Cox et al. used wooden spatulas between the incisor and they were added till the patient were comfortable. Cox et al. also advised the use of NSAIDS (pain killers) to improve the compliance. Grade I, grade II, and grade III (Intermediate stage) respond significantly to physiotherapy while in advanced OSMF surgery followed by intensive physiotherapy gives good mouth opening results.[12]

Role of physiotherapy in oral cavity cancers in preoperative settings

OCCs involve a significant structural, functional and cosmetic burden. Dysphagia and pulmonary concern are always associated with surgery. Swallowing rehabilitation and exercises prior to surgery helps to manage dysphagia in OCC patients as stated by Riffat et al. Lumb AB 2019[13],[14] has shown the importance of physical therapy in preoperative setup to avoid complications related to lungs likes low oxygen saturation and respiratory infections. Preoperative physiotherapy helps to reduce anxiety as well make patients aware about their active role in postoperative settings.

Role of physiotherapy in perioperative setting

Tracheostomy and chest physiotherapy

Majority of the OCC patients are presented in advanced stage thus undergo large resection including part of mandible and sometimes the entire tongue. Thus, a large percentage of these patients undergo elective tracheostomies. Physiotherapy plays a significant role in maintenance of form and function of the lungs in perioperative stage.[15] In tracheostomy patients, chest physiotherapy is an important aspect when it comes to tracheostomy patients or mechanically ventilated patients, as shown by Spapen et al.[16] Chest physiotherapy is beneficial in airway clearance, alveolar recruitment while Wang et al., 2018[17] has shown early mobilization and chest physiotherapy improves extubation outcome. Proprioceptive neuromuscular facilitatory techniques of respirations help to regain respiratory muscles strength and outcome. Hence, chest physiotherapy and proprioceptive neuromuscular facilitatory techniques should be integrated in perioperative settings. Physiotherapy techniques including percussion,vibration,active cycles of breathing techniques are important for better outcome for pulmonary rehabilitation. Physioneurological facilitation of respiration using spirometer helps to recover faster.[18],[19]

Respiratory complications and deep vein thrombosis

Venous thromboembolism (VTE) including deep vein thrombosis and pulmonary embolism are common in perioperative care of OCC management. It is also responsible for major morbidity and mortality. Incidence of VTE is up to 18% if the patient is not on any anticoagulation or if the patient is immobilized. Oral cancer patients are tobacco smokers or chewer with compromised lung function. Definitive treatment of oral cancer involves debilitating surgery disturbing the swallowing mechanism. Thus, immediate postoperative physical care with active chest and shoulder physiotherapy with mobilization is a mandate.

Speech and swallowing physiotherapy

Swallowing is anatomically divided into three phases. In OCC, resection of tongue hampers the oral phase of swallowing. Resection of tongue specifically is responsible for prolonged preparatory phases and delayed transfer phases. This leads to improper mixing of food with saliva, incomplete bolus formation, and spill in transfer phases leading to oral and pharyngeal residue. Therefore, swallowing physiotherapy will help the patient with better recovery of function. It includes number of postures that are effective in treating OCC patients. Chin-down posture is useful for patients who have undergone resection including part of base tongue leading to reduced tongue base retraction. Also, these patients undergo bilateral neck dissection leading to disturbance in suprahyoid and infrahyoid muscle hampering laryngeal elevation during swallowing. The chin down posture, head rotation, and head back to chin down movement have been reported to be successful in eliminating aspiration up to 70%. Various swallowing maneuvers including supraglottic swallow and super-supraglottic swallow maneuver, effortful swallow maneuver, Mendelsohn maneuver, and tongue hold maneuver have been suggested to improve both speech and swallowing outcome.[20],[21],[22]

Shoulder physiotherapy

Shoulder dysfunctions are associated with OCC as accessory nerve is handled and sometimes injured during the neck dissection. Many studies have shown that technique of neck dissection influences outcome of shoulder movements.[23] Previously surgeons used to perform radical neck dissection (RND) sacrificing spinal accessory nerve (SAN), internal jugular vein, and sternocleidomastoid, but with the advent of studies showing no oncological compromise in selective neck dissection (SND), more surgeons are offering SND preserving SAN. Studies from literature have shown that shoulder stability and range of motion are better in SND as compared to MRND and RND.[24] Reason behind the shoulder morbidity is handling of spinal accessory nerve which supplies both sternocliedomastoid and trapezius muscle. Hence progressive resistance training exercises are of great importance to deal with dyskinesia as well dysfunctions associated with OCC patients. Alternate days of therapy sessions for 4–6 weeks would be preferable for better outcome. Aims of shoulder physiotherapy includes: Active and assisted range of motion, with strengthening of elevators of scapula is useful in prevention of frozen shoulder, along with neuromuscular retraining of shoulder girdle muscles, electrical stimulation of trapezius, and usage of orthosis. A systematic review and meta-analysis found progressive resistance training to be better at relieving pain and achieving higher function of shoulder movement after neck dissection.[25]

Mouth opening physiotherapy

Trismus is characterized by a chronic reduction in the mouth opening. Reduced mouth opening significantly affects QoL including chewing, swallowing, speech, and maintenance of oral hygiene. It can be caused by the tumor itself or arises as a complication after H&N cancer ablative surgery and/or radiation therapy. Once trismus occurs, it is progressive, long-lasting, and affects the patient's QoL. Also, reduced mouth opening hinders the complete examination of the operated site in the follow-up phase, thus making it difficult to diagnose and treat the recurrence if any in the early stage. All the efforts of physiotherapy are aimed at providing preventive measures and thus establish a better control over the form, function, and the QoL for the patient. There has been a serious paucity of literature evidence investigating the impact of exercise therapy on trismus related to OCC and hence there is no consensus on how to treat trismus related to OCC. However, there have been retrospective studies that have found evidence that jaw stretching exercises with simple jaw mobilizing devices such as the TheraBite® or the Dynasplint Systems® are useful and effective in the treatment of trismus when used in the immediate posttreatment settings.[19],[20]

Physiotherapy for mouth opening has been shown to be most effective when started early in the postsurgery healing period. There has been evidence to prove that mouth opening exercises started as early as the second postoperative day and continued in the adjuvant treatment phase helps in preventing the trismus from setting in and helps maintain the mouth opening satisfactorily.

Jaw stretching exercises include the opening and closing of the mouth either with the use of the inherent muscle power or with simple devices like mouth props, wooden spatula sticks, or bite blocks. These exercises need to be practiced on regular basis. Studies that mention the use of jaw exercises recommend repetitions from 3 to 10 times per day or once every hour per day in the postoperative settings.[25],[26],[27] Ideally, patients need to continue with their exercises throughout their lives, and this should be emphasized to them. Patient compliance and progress in mouth opening should be monitored and documented at every follow-up appointment to ensure that adequate and proper exercises are being done. Psychological positive reinforcement helps the patient to stay motivated. Adding in hot fomentations, before and after exercise, medications such as anti-inflammatory and muscle relaxant medications, may help with achieving better results as it exerts a synergistic effect and also aids in better patient compliance. Patients can use tongue depressors stacked onto each other and taped together to help with the mouth opening exercises. Usage of tongue depressor enables the patient to monitor his own progress depending on the number of sticks he can hold interdentally. These maneuvers may be difficult for patients who are edentulous as they are more likely to have ill-fitting dentures due to poorly predictable and aggravated basal bone loss, attributable to the radiotherapy treatment side effect. This set of patients may mandate the use of additional mechanical devices like commercially available TheraBite® or Dynasplint Systems.

There are commercial mouth opening devices available, like the mouth-opening screw and ingeniously designed wooden blocks with slots at 5 mm distance can be done by patients themselves, TheraBite is another device that is designed to recover jaw mobility after trismus and mandibular hypomobility, and also play a role in reduction of inflamed joint pain and prevention of reducing muscle strength during chemotherapy or radiation in the head-and-neck area. [Figure 2] shows recent randomized control studies showing the impact of physical therapy on mouth opening after interventional physiotherapy/mouth opening exercises.
Figure 2: Comparison of maximal interincisal mouth opening in various RCTs after interventional physical exercise (mouth opening in millimeters)

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Neck physiotherapy

RND involves removal of internal jugular vein, sternocleidomastoid, and SAN. However, in advent of studies suggesting equivalence in oncological outcome with SND, RND is rarely done except for advanced neck disease. But even with SND entire SCM is barred of vascular supply and nerve supply of SCM comes from SAN which may be injured or handled during neck dissection. Therefore, persistent pain or involuntary movement is common after SND. Also, in patients undergoing reconstruction with pectoralis major myocutaneous flap, neck movement is restricted to the ipsilateral side. In such condition, physical therapy plays an important role in improving the range of motion. Tightness, associated pain with neck movement and restricted movement postneck dissection are similar to cervical dystonia. Studies have shown that physical therapy increases the postural awareness, smoothens the movement of neck, and improves range of motion. Zetterberg et al. in their experimental studies have shown that supervised physical therapy had a better compliance rate and outcome as compared to home-based exercises.[26]

Donor site hand and leg physiotherapy

Free fibular graft (FFOCF) is the workhorse for reconstruction of OCC bony defects. During the harvest of the FFOCF, muscles including extensor hallucis longus muscle, extensor digitorum longus muscle, fibularis longus, fibularis brevis, soleus muscle, tibialis posterior muscle, and flexor hallucis longus muscle lose their attachment over fibula. Muscles responsible for foot eversion and inversion, foot abduction, plantar flexion lose their attachment resulting in lower walking endurance, reduced walk speed, and ankle stability. Thus it becomes important for the rest of the muscles to be strengthened by the physical therapy. A study led by Liu et al.[27] compared the donor leg with contralateral leg for functional ability. It is demonstrated that with home-based physical exercise significantly improves the strength of dorsiflexion and foot aversion of the donor leg. It also improved ankle motor function. Similarly, free anterolateral thigh flap is myocutaneous flap common used in OCC reconstruction. Studies have shown that exercises and microcurrent therapy helps to reduced paresthesia and stiffness associated with it.[27]

Donor site Hand physiotherapy

Free radial forearm free flap is one of the commonly used soft-tissue flaps to reconstruct OCC soft-tissue defects. Along with cosmetic, it also renders functional deformity to the arm. It may result in reduced range of motion, reduced hand strength, and paresthesia. Supervised exercises including flexion, extension, pronation, and supination reduce the functional deformity.[28]

Role of physiotherapy in postoperative setting


Trismus is one of the most common complaints after radiotherapy in OCC. It results in poor oral hygiene, difficulty in swallowing, and chewing tendency leading to poor QoL and malnutrition. A study led by Pauli et al.[29] has stated a 38% incidence of trismus postsurgery and radiation in OCC patients. It was highest at 6th month while it reduced by 10% after 1 year. Indian study led by Agarwal et al. demonstrated a higher incidence of trismus (86%) after curative surgery and radiation which improved to 65% after 6 months.[30] Another study by Kamstra et al. found that stretching exercises has positive effects of mouth opening which increased from 17 to 24 mm however it did not report any specific exercise tool or regime superior than others.[31] A randomized control study led by Sarah compared two stretching devices for trismus. Both the devices demonstrated increased mouth opening after 3 months of exercise therapy. Thus explaining the significance of mouth exercises.[32] Another prospective study compared three arms consisting of HNSCC patients, OSMF, and noncancer trismus patients. A study found mouth opening significantly better in those groups undergoing regular physical exercise. A pilot and explorative study led by Sandler found that timings of the jaw exercise may not play an important role in improvement of jaw opening, but early jaw opening exercises would benefit certain QoL parameters, thus paving the way for researchers to compare the outcome of QoL depending on the timings commencement and frequency of exercises.[33] A study led by Scott et al. showed that postoperative radiotherapy and preoperative trismus were the most important factor predicting trismus after the treatment.[34] Early mouth opening exercises significantly improves mouth opening. A meta-analysis of randomized controlled trial led by Shao assessing 733 patients concluded that physical therapy doesn't influence the incidence of trismus but it significantly improves maximal interincisal mouth opening.[35]


Half of all the OCC patients undergoing definitive management experience difficulty in swallowing (dysphagia).[36] Dysphagia is strongly dependent on site, type of resection, and reconstruction. Tongue is one of the most important organs responsible for swallowing function. The percentage of patients having dysphagia was much higher (80%) in advanced tongue cancers. Posttreatment of advanced tongue cancers, there is an increase in time to bolus formation, and base tongue may completely or partially be absent to form a seal with soft palate, thus leading to potential aspiration. Also the pharyngeal residue will be greater in postpharyngeal phase with higher chances of aspiration. Dysphagia after chemotherapy and radiotherapy is worse due to increased mucositis, xerostomia, and fibrosis. Chapter by Pauloski has demonstrated the importance of early rehabilitation of swallowing mechanism after definitive cancer therapy before the fibrosis sets in.[37] It has recommended chin-down posture, tongue movement and strengthening exercises, bolus manipulation exercises for reduced tongue control. In near-total glossectomy or total glossectomy which involves more than two-third loss of the tongue, head-back posture, breath-holding exercises, multiple swallows, and bolus manipulation exercises may be helpful. Treatment of dysphagia can be started even before the commencement of the cancer treatment providing patients with knowledge and ways to practice exercise after the treatment. Studies have shown them to have improved compliance posttreatment, thus enhancing the outcome.[38] A randomized control trial by Messing assessing the impact of prophylactic swallowing therapy in those head-and-neck cancer patients receiving chemoradiation found prophylactic swallowing therapy to be useful in improving oromotor function, pharyngeal impairment, oral pharyngeal swallow efficiency, and incisal opening on short-term basis although improvements are not significant in long term.[39]

Lymphedema management

Studies have shown that more than 50% of the OCC patient after definitive treatment will have some degree of lymphedema. MD Anderson has classified secondary lymphedema depending on the pitting, nature of swelling, and reversible characteristics into four types. Studies led by Smith et al. have demonstrated that incidence of secondary lymphedema post-HNCC treatment was 60% while majority of lymphedema reported was type 1b (soft pitting and reversible).[40] Another study analyzing head-and-neck lymphedema (HNL) has found that 98% of HNCC patients have some degree of HNL. While postoperative radiation is an independent factor influencing external lymphedema while concurrent chemoradiotherapy was more likely to have internal edema.[41]

Manual lymphatic drainage (MLD) was the standard of care in the treatment of lymphedema. MLD involves physical exercises of the local area along with tissue massage. While in recent times, along with MLD, customized compression bags and skincare is added to form complete decongestive therapy (CDT). According to the systematic review by Tyker et al.,[42] there is not enough evidence to suggest evidence-based therapy for lymphedema. Majority of the studies were conducted for MLD, CDT therapy however, they were all case report accounting for low quality evidence. One of the retrospective studies led by Smit has stated that 60% of the lymphedema responded positively to the MLD and CDT. This review also discussed the potential of selenium nitrate, liposuction as a treatment option for secondary lymphedema.

Recent advances in physiotherapy in head-and-neck cancers

Transcutaneous electrical nerve stimulation

Oral mucositis is one of the most common acute complications after radiotherapy leading to feeding tube dependence, hospitalization, and treatment delays. Transcutaneous electrical nerve stimulation (TENS) is a safe, noninvasive procedure for allaying pain related to mucositis. It provides a symptomatic pain relief by stimulating sensory nerves through gate control theory. It also blocks A-beta fibers. TENS may influence physiological actions at peripheral, spinal, and supraspinal sites of the nervous system. A randomized control trial led by Lee on forty HNC patients receiving radiation demonstrated a significant decrease in the resting pain in those patients receiving TENS as compared to those individuals who were on placebo. Also, fatigue was significantly lesser in TENS group. However, there was no significant decrease in functional pain in TENS group.[43] Thus practical use of TENS still requires real-world evidence for its application.

  Conclusion Top

Physiotherapy is an integral part of the rehabilitative management of OCC patients. Adjuvant physiotherapy can considerably influence postoperative/radiation therapy speech, swallowing function, increase the range of motion of neck and shoulder movement, reduce pain, enhance mouth opening and alleviate lymphedema Physiotherapy management of OCC patients from pretreatment set up through perioperative management to posttreatment rehabilitation can improve the QOL of OCC patients.

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