Maxfacts

Trauma to the head and neck region, as well as major oral and maxillofacial surgery can all have profound effects not only on the head and neck area but on other body parts too (for example, reconstructive surgery may have made use of your lower leg or your pelvis).

For some planned (elective) major surgery it may be a good idea, if time permits, to consider physiotherapy as a pre-habilitation option: the best possible degree of fitness and well-conditioned muscles in crucial body areas lead to faster mobilisation and recovery, and to better overall outcomes (a tried and tested approach in many places for orthopaedic surgery, such as replacement of hip or knee joints).  

Our collection of exercises is demonstrated in short videos and it is subdivided into different body parts. While these bundles do give some guidance, a wider picture and inclusion of more exercises than one might think initially, are useful. The gentle exercises demonstrated in these video clips are all aimed at maintaining or improving movement, function and strength. Some are designed to support short-term recovery and mobilisation, some are suitable for long-term management and training, some are useful for prevention of undesirable effects.

Exercises should be done regularly, ideally 2 to 3 times a day. If you have any questions or problems, you should always consult a health professional.

Spine: the cervical spine (neck)

The spine consists of 24 vertebrae (33 if one includes the 9 fused bones of the sacrum and coccyx (bottom of the spine, tailbone)). The top seven vertebrae are classed as the cervical spine or neck. The neck is a well-engineered structure of bones, nerves, muscles, ligaments and tendons that is remarkably strong and flexible, allowing movement in three degrees of freedom (or three planes of movement). These movements are flexion and extension (moving your head forwards and backwards), rotation (looking over your shoulders) and side flexion (taking your ear to your shoulder).

The cervical spine performs several crucial roles, including: housing and protecting the spinal cord, supporting the head and its movements, and facilitating the flow of blood to the brain. The seven vertebrae of the neck begin at the base of the skull and extend down to the next section of the spine, the thoracic spine. At each level, the seven neck vertebrae protect their segment of the spinal cord and work with muscles, tendons, ligaments, and joints to provide a combination of support, structure, and flexibility to the neck. Different movements typically originate from different joints. For example, 50 % of flexion and extension movements occur from the uppermost vertebra next to the base of the skull, C1. Likewise, 50 % of rotational movements occur from the next vertebra down, C2. There is a large number of muscles involved in the head, face and neck, providing for a wide variety of movements. Some movements are facilitated primarily by one muscle, others require cooperative action of groups of muscles.

The set of exercises specifically for the neck cover the obvious tasks of improving strength and mobility of the neck but also aim, for example, to improve neck posture. Neck posture is an important component of enabling safe swallowing. Depending on the individual situation, additional exercises targeting muscle groups in other body areas should be included in the daily exercise regime.

Neck exercises are particularly beneficial for

• facial pain syndrome when neck stiffness is a feature
• all patients having neck surgery
• patients following local trauma where neck stiffness / pain is an issue
• patients undergoing radiotherapy in the head and neck region

Spine: the thoracic spine (upper and mid back)

The thoracic spine consists of twelve vertebrae. It connects from the bottom of the the cervical spine to the lumbar spine (low back). Whereas the cervical spine is built for flexibility (head movement), the thoracic spine is designed for stability as it has to support the torso. At each level its vertebrae (T1-T12) attach to the rib cage, therefore there is limited flexibility in the thoracic spine.

Because of this relative inflexibility, the thoracic spine can be more prone to pain. Along the entire spine there lie discs between the vertebrae (the intervertebral discs), these act as shock absorbers. These discs are thinner in the thoracic spine adding to its inflexibility. Despite these thinner discs in the thoracic spin region, problems with these discs are rare.

Following oral and/or maxillofacial surgical intervention or radiotherapy treatment to the neck, problems can occur in the shoulder region. Any shoulder, or shoulder region, dysfunction can lead to discomfort or dysfunction at the thoracic spine.

The set of exercises specifically for the shoulder region cover the obvious tasks of improving strength and reducing tension in the shoulder region (see below). Shoulder and back exercises typically are a good complement to neck exercises. In addition, for example, they may help to cope better with some temporary issues arising from, say having to use a crutch or walking stick for a while.

Back exercises are particularly beneficial for

• all patients having neck surgery
• patients after trauma where ‘whiplash’ may be a problem

Spine: the lumbar spine (low back)

The lumbar spine consists of five vertebrae. It connects the bottom of the thoracic spine to the top of the sacrum (a large wedge shaped vertebra at the bottom of the spine, it forms the solid base of the spinal column). The individual vertebrae are known as L1-L5. These five vertebrae are the biggest unfused vertebrae in the spine. This enables them to support the weight of the entire torso.

The lumbar spine is designed for completing powerful tasks (such as lifting, twisting and bending) as well as being flexible, similar to the cervical spine. The lower down a vertebra is located in the lumbar spine, the more weight it must bear. The lowest two spinal segments, L4-L5 (including the intervertebral discs) bear the most weight and are therefore the most prone to degeneration and injury.

Exercises addressing low-back issues tend to include muscle groups in the whole body region, including thigh, back and pelvis.

Low back exercises are particularly beneficial for

• general exercise for everbody
• after hip graft / flap reconstructive surgery (see below for donor sites)
• after graft / flap reconstructive surgery involving the abdominal muscles

Glenohumeral joint (shoulder)

The bones of the shoulder consist of the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone). The shoulder joint is a ball and socket joint between the head of the humerus (ball) and the glenoid cavity (socket) of the scapula. The shoulder joint connects the upper limb to the body.

The nature of the ball and socket joint allows a wide range of movement. These are flexion and extension (moving your arm forwards and backwards), internal and external rotation (moving your hand behind your back and behind your head) and abduction and adduction (taking your arm out sideways and inwards across your body).

The shoulder joint is one of the most mobile joints in the body. This can, however, come at the expense of stability. There are many muscles and ligaments that assist with movement and stability of the shoulder. The larger muscles in and around the shoulder are powerful and assist to move the shoulder joint. The ligaments and smaller muscles (for example, the four small muscles known as the rotator cuff) assist with certain movements but mainly act as stabilisers. They ensure that the head of the humerus remains in the glenoid cavity throughout the movements that the upper limb provides.

Surgery in the head and neck region as well as surgical reconstruction can give rise to discomfort or dysfunction in the shoulder region for a variety of reasons, directly or indirectly.

The video clips of shoulder and shoulder blade exercises largely cover all these circumstances; some exercises strengthen major muscle groups in the area, other exercises aim to improve the stability of the shoulder.

Shoulder exercises are beneficial for

• everyone who has had significant neck surgery
• everybody undergoing head and neck radiotherapy

Shoulder blade exercises generally aim to improve posture. As such, it is a good idea to include these exercises in any exercise regime to improve problems with the neck, shoulder or upper back.

Donor sites for surgical reconstruction

Many major oral and maxillofacial surgical interventions include reconstruction of surgical defects by hard and/or soft tissues, grafts and flaps, from other body parts. In fact, the discipline is not shy in using more or less all body areas as reservoirs for repairing defects in the head and neck region in order to restore and maintain as much function as possible, alongside with aiming for the best possible cosmetic results.

Some of the more common donor sites include the iliac crest (pelvis), fibula (lower leg), muscles such as the quadriceps (thigh), latissimus dorsi (back) or rectus abdominus (abdomen) or the forearm (for free flaps, as well as skin grafts).

Post-surgical areas used as donor sites do need to be rehabilitated to ensure a swift mobilisation and return to smooth movement and function.

Iliac crest

The iliac crests are the uppermost edges of the pelvis. The edges are easily felt by digging your fingers into the sides around your waistline.

There are a lot of muscles and ligaments in and around the pelvis. There are muscles that connect the lower limbs to the pelvis, and muscles that connect the torso and trunk to the lower body. It is important to ensure these are moved and worked to allow normal levels of mobility and function after surgery.

Any surgical site can be painful but the iliac crest has often been described as painful for a period of a few weeks after surgery. This is normal (given that access to the iliac crest requires cutting some major muscles) and will recover with time.

The iliac crest is a common donor site to repair surgical defects in oral and maxillofacial surgery. This is true for bone grafts as well as for free flaps and is simply the consequence of the pelvis providing a large amount of suitable bone material for the repair of many different types, shapes and volumes of defects. Recovery of this donor site benefits greatly from suitable exercises. Not only does exercise support and accelerate mobilisation, it also prevents the developing of strange limping habits. The most suitable set of exercises for the pelvis region depends a little bit on the exact nature of the surgical cuts used (access to the iliac crest may be from different directions and may involve the cutting of different groups of muscles).

Hip / pelvis exercises are beneficial for

• everyone who has had iliac crest graft or flap surgery (exercises to strengthen the low back, and/or thigh muscles and/or abdominal muscles are good additional options)

Fibula

The fibula is the long, thin bone of the lower leg. It runs alongside the tibia (shin bone) and plays a significant role in stabilising the ankle and supporting the muscles of the lower leg. The fibula does not carry weight and is not needed for that purpose, so can be used as a reservoir for replacing lost bone (plus some soft tissue alongside) in the head and neck region, for example to replace parts of the mandible.

The fibula is close to both joints of the lower leg, the knee and the ankle. Both joints need to be moved to ensure full and swift recovery of movement and function of the lower leg.

Due to the fibula’s role in providing stability for the ankle, it may feel a little ‘off your feet’ for a short period after surgery. Gentle lower leg exercises, as soon as possible after surgery, are extremely useful to return quickly to normal mobility.

Lower-leg exercises are beneficial for

• everyone after fibula flap reconstructive surgery

Forearm

The forearm contains two bones, the radius and the ulna. These bones extend parallel from the elbow, where they articulate with the humerus (upper arm bone) to the wrist, where they articulate with the carpals (wrist bones).

Many muscles and ligaments are located within the forearm and assist in movement of the elbow and wrist joints. As the wrist and hand have many, often delicate, movements and functions there are many small muscles and ligaments. Like other joints affected by surgery they need movement to regain and maintain their function.

The lower arm is a common site for taking free flaps as well as a variety of skin grafts; these need some time to heal. The area may feel tight and sore but this is normal, the healing process can be 6 to 8 weeks (minimum) and lower-arm exercise is an important part of the healing process. It is important to look well after these scars to ensure full recovery.

Forearm exercises are beneficial

• after radial or ulnar flap surgery

Other donor sites

Other commonly used donor sites include the muscles latissimus dorsi (muscle at the upper back/ lower shoulder), pectoralis major (chest muscle) and rectus abdominis (stomach muscle). These sites can provide functional bulk soft tissue, usually as flaps, for repairing large defects. Just like for any other donor site, these donor-site muscles and associated joints/limbs need exercising for returning to normal movement and function. Some of the actions of these muscles are simple basic everyday tasks, for example the rectus abdominis assists you sitting up in bed.

Exercises for chest donor sites, back donor sites, latissimius dorsi and rectus abdominis specifically address these sites but usually are augmented by additional general exercises or exercises targetting the head and neck region, depending on individual circumstances.

Scar massage

Scar tissue may have a tendency to contract. Contracted scar tissue, in turn, can lead to reduced function, depending on the location of scars. Regular scar massage is a good way to minimise such effects.

Lymphoedema of the neck region

Some surgical procedures, but in particular radiotherapy applied to the head and neck region, can lead to lymphoedema of the neck. Some simple self-massage, when used patiently and regularly, can help with decongestion and moving lymph fluid to areas where the fluid can be drained by the lymphatic system. This kind of self-massage may remain beneficial for the long term.

Trismus

Some surgical procedures, but in particular radiotherapy applied to the head and neck region, can lead to difficulties with opening the mouth (trismus) and with moving the jaw. Some conditions affecting the jaw joint can also cause trismus. For acute trismus, such as after surgery or as a symptom of jaw joint problems, exercises that help to re-establish mouth opening and jaw movement, are obviously useful.

As far as long term, and often late onset, trismus as a consequence of radiotherapy is concerned, prevention is far better than any attempts at cure: jaw exercises that maintain and support mobility of the jaws should be done regularly throughout the course of treatment and beyond, before any problems arise.

Temporomandibular (jaw) joint problems

For jaw joint problems, in most instances intense physiotherapy and exercise are the first line treatment. Some gentle exercises are identical to those we demonstrate for trismus, some slightly more intense jaw exercise regimes with (progressing) gentle nudges for mouth opening and jaw mobility are particularly suitable for dealing with a range of common jaw-joint problems. Also exercises to strengthen and stabilise the neck and improve posture are usually helpful in reducing jaw joint problems.