The ARK-J (Amplification, Resistance, and Kinetics-of the Jaw) Program is the first and only CEU certification course for Speech-Language Pathologists (SLPs) who treat adults who suffer from trismus as a result of cancer treatment, CVA, or trauma. The ARK-J Program encourages clinicians to more closely examine the neuroanatomy and pathophysiology of the jaw, as well as the exercise science behind rehabilitating the muscles of mastication and managing radiation fibrosis, surgical scarring, or spasticity. The ARK-J Program is not a protocol for evaluating and treating trismus. Rather, the ARK-J Program is an evidenced-based approach that relies heavily on the exercise science behind the therapeutic principles of active and passive range of motion exercises (i.e. application of amplification and resistance exercises to improve the kinetics of the jaw) and best practices in trismus management in order to more effectively tailor safe, effective, and progressive trismus treatment programs.

Trismus is a jaw disorder that leads to a reduction in the jaw’s range of motion. Ultimately, trismus can lead to malnutrition, social isolation, depression, chronic pain, and in severe cases, trismus can even be fatal as a result of a compromised airway. There are many possible etiologies of trismus, such as oral radiation, oral surgery, maxillofacial trauma, central nervous system infection, upper motor neuron lesions from stroke or traumatic brain injury, and certain pharmaceutical drugs. Some etiologies of trismus are stimulable to jaw mobility exercises, while other forms of trismus are not stimulable to jaw mobility exercises. Certain forms of trismus may only respond to pharmaceutical or surgical interventions. Treatment courses are dependent upon the patient's trismus etiology, medical situation, and goals. Thus, it is crucial for SLPs to understand the different origins, pathophysiology of trismus, and various treatment pathways in order to provide safe and effective therapy services to patients.

Speech-language pathologists will typically see various forms of trismus from four kinds etiologies: Head and neck cancer, UMN lesions from TBI or CVA, or progressive neurological disease. Head and neck cancer (HNC) patients have especially high rates of acquiring trismus. Patients with oral cancer, oropharyngeal cancer, oral surgery, and/or radiation therapy to the masseter, buccinator, and pterygoid musculature frequently acquire trismus within 6 months s/p radiotherapy.

• Lee and colleagues reported a 47% prevalence before treatment for head and neck cancer, an incidence of 71% after surgery and an increase to 79% after surgery associated with radiotherapy (Lee 2012).
• Incidence and prevalence data of trismus from other etiologies is not as readily available as the rates in HNC, unfortunately, but we know that patients who suffer mandibular trauma often present with hypertonia in muscles of mastication (Trompetto et al. 2014).
• Examples of common UMN lesions include multiple sclerosis, cerebral palsy, cerebral injury as a result of stroke or traumatic brain injury, Parkinson's Disease, and suprasacral cord injuries.

TMJ disorder and trismus are not interchangeable terms; they are not the same jaw disorder. 'TMJ' is an acronym for temporomandibular joint. A patient who has been diagnosed with a TMJ disorder (TMJD) can have trismus as a result of the TMJ disorder. However, a patient who is diagnosed with trismus does not necessarily have a TMJ disorder.

• A TMJ disorder stems from an injury to the cartilage in the TMJ. This can, in turn, cause the musculature surrounding the TMJ to become guarded or contracted in an effort to prevent further damage. Muscle-guarding, in both TMJ disorder and trismus, is a physiological response to injury and often leads to reduced range of motion in muscle function, muscle atrophy, and pain.
• Trismus is a physiological response to damage of the muscles of mastication (masseter, buccinator, medial and lateral pterygoids, and temporalis) and/or to the facial cranial nerve and the trigeminal/mandibular cranial nerve as a result of oral surgery, oral radiation, mandibular trauma, stroke, and many other potential etiologies.

As a result of differing etiologies, trismus and TMJ disorders are treated with different therapeutic approaches. TMJD is often treated with heat, ice, ultrasound, gentle stretching, massage, injections, and if severe, surgery is also an option. Challenging jaw-stretching exercises can increase pain and lead to lock-jaw in patients with TMJ disorders. Trismus, on the other hand, often involves active and passive jaw-stretching exercises with passive jaw mobility devices and other oral motor tools. Heat and ice are not recommended for patients who have trismus as a result of oral cancer. However, surgery and injections are therapeutic options for both kinds of patients.

The ARK-J Program is appropriate to use certain etiologies of trismus, such as radiation-induced trismus and oral, CVA, and maxillofacial trauma patients. A physician's order is required for trismus treatment. Patients must be able to follow instructions and communicate pain, discomfort, and other feelings related to therapy. To justify speech-language pathology therapy services, a patient must have one or more of the following impairments:

• Reduced quality of life (due to discomfort, pain, malnutrition, social isolation)
• Reduced ability to maintain proper oral hygiene
• Reduced oral access for necessary dental care
• Impaired masticatory function
• Impaired speech intelligibility
• Compromised airway

The only certification that ASHA recognizes is the Certificate of Clinical Competence (CCC). Thus, while a SLP does not need certification to treat trismus, trismus is a complex and serious medical condition that necessitates knowledge and training on the part of the clinician. Inexperienced and poor clinical knowledge of the SLP could result in prolonged trismus therapy, ineffective or unnecessary treatments, increased pain, and mandibular fractures for the trismus patient.

Based on the response we received from BCS-S on our course syllabus, CEUs from the ARK-J Program certification course could go toward the 7.5 CEU requirement for the Board Certified Specialist in Swallowing and Swallowing Disorders certification since this course is ASHA-approved and is directly related to dysphagia. According to the BCS-S, "Each continuing education activity is evaluated in the context of the application," thus the AB-SSD cannot pre-approve or endorse any CEU. Please see the "Requirements for Applicants" page on the BCS-S website for details.

There are no standard protocols in the evaluation and treatment of trismus. However, numerous research studies and white papers from leading researchers of trismus in the fields of otolaryngology, oral and maxillofacial surgery, dentistry, and radiation oncology indicate that active and passive jaw stretching exercises and jaw mobility devices are, without a doubt, effective in the rehabilitation of jaw range of motion. Research also supports the application of exercise science principles in the treatment of trismus. The ARK-J Program incorporates established exercise science-based techniques and evidence-based practices that involve progressive, therapeutic active and passive jaw stretching exercises tailored to the needs of the patients.

No, the ARK-J Program does not endorse any specific jaw-stretching device or company. In fact, current research suggests there are no significant differences in effectiveness of any one device over another, but research also shows that jaw-stretching devices are essential in trismus therapy.

The homemade ARK-J Stretching Device was developed by Brian Kanapkey and Byron Kubik, both CCC-SLPs who specialize in head and neck cancer. They created the device in response to an overwhelming need to offer patients a jaw-stretching device because either they could not afford the device or insurance would not cover the cost of a device. The cost of the device was a major barrier to providing effective trismus treatment to their patients. Thus, Kanapkey and Kubik used easily-obtained medical supplies to make a jaw-stretching device that was comfortable for patients, dynamic enough to reduce the pressure on the teeth, gums, and TMJ, could be made more or less challenging for patients, and was easy to make. The ARK-JPSD device is not a competitor to other passive jaw mobility devices on the market, but rather a safer, more effective jaw mobility tool than ineffective method of stacked tongue depressors. Our hope is that by showing other clinicians how to make this homemade device, we will remove the financial barrier that prevents so many patients from participating in trismus treatment and put an end to the harmful stacked tongue depressors technique. I am someone who suffers from trismus. Can I attend the course or obtain course materials? Unfortunately, this course is for certified rehabilitation therapists only. We are also unable to offer course materials to people other than therapists. We recommend finding a speech-language pathologist (SLP) in your area or via our "Certified Therapist Directory page" so that you can receive safe, effective treatment for your trismus. There are many pitfalls of treating trismus, thus working with a trained therapist will ensure your best possible outcome.