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5.5.1.2 Interventions for (suspected) shoulder complaints resulting from head and neck cancer treatment\u000DVarious physical therapy treatment programmes after neck dissection are described in the literature. Methodologically sound studies, however, are scarce. Interventions are largely aimed at improving range of motion, reducing pain and monitoring impairments. No intervention studies have so far been aimed at return to work. In a small randomised study (n=32), with a high risk of bias, patients were divided over a control group who received advice only, and an intervention group who received physical therapy aimed at improving passive and active range of motion, stability and posture (Lauchlan, McCaul et al. 2011). The effect was assessed on the basis of differences in scores for shoulder function (ASSESSA and Constant) and quality of life (SF12 component scores) at the post- operative stage and 12 months after. No significant differences were found, although the intervention group did show a bigger improvement in the physical component score than the control group. The results of this study are difficult to interpret, since no information is given on the extent to which the function of the accessory nerve was lost, and thus to what extent physical therapy was required in the first place. In any case, the study does not justify the standard inclusion of extensive physical therapy for all patients after neck dissection, regardless of their clinical status.\u000DPre-selection of patients with current complaints or disabilities or with a heightened risk of developing them, in combination with a care need, is probably the more effective approach.\u000DIn one randomised study (n=62) the effect of protocol-based exercise therapy under the supervision of a physiotherapist on shoulder function and impairment was investigated, when compared with a group who only received general advice and a brochure with non-tailored exercises to be performed at home (McGarvey, Hoffman et al. 2015). In this study, all patients with loss of the accessory nerve after neck dissection were included. A small effect was found on recovery of shoulder abduction, but only at three months follow-up and only for the per-protocol analysis. Compliance with the intervention was moderate to poor, but there was evidence of contamination (25%). In both groups, recovery at twelve months follow-up was acceptable. The supervised programme did not bring any benefits in terms of patient-reported outcomes.\u000DAn earlier randomised clinical trial (RCT) (n=52) into the effect of progressive resistance exercise training (twice a week, for 12 weeks) found that patients in the intervention group reported significantly better upper extremity strength and endurance after completion of the training than the control group, who had performed mobility exercises only. Furthermore, the intervention group reported reduced shoulder pain and lower scores on the Shoulder Pain and Disability Index (SPADI), but not on the NDII nor on quality of life, as measured with the FACT-AN (McNeely, Parliament et al. 2008). In this study, patients were included who had been diagnosed with loss of the accessory nerve and who were at 12 to 15 months post-treatment. Also, they had already scored for shoulder pain and disability on the SPADI at baseline. The results of this study were pooled in a meta-analysis with the results of the pilot RCT that preceded it in a Cochrane systematic review (Carvalho, Vital et al. 2014), in which a significant reduction of both the disability score and the pain score on the SPADI was found, as well as improvements in muscle strength and endurance, and (passive) shoulder mobility. The pooled estimate for active shoulder mobility (external rotation) was in favor for the exercise group compared to standard care. However, there is no strong evidence that an exercise programme with a focus on shoulder dysfunction can improve quality of life in these patients.\u000DBased on these studies, progressive resistance exercise training seems to be the most suitable intervention for those patients who present with current shoulder pain and disability, who experience loss of the accessory nerve after neck dissection, and who have a care need. Evidence for the\u000D122\u000D