Exercise after head and neck cancer: neck and shoulders

Neck and shoulder problems often follow surgery to remove lymph nodes in the neck, called a neck dissection. Gloucestershire Hospitals' leaflet says "You may have some neck stiffness following the operation. Regular neck exercises should help to improve this" [1]. A 2017 review of 75 studies found that "Type of neck dissection was a risk factor for shoulder pain, reduced function and health-related quality of life" [2].

Stiffness that does not settle is worth reporting. The same leaflet says "If the stiffness continues, please tell your consultant or the Head and Neck Clinical Nurse Specialist (CNS) and they will refer you to the physiotherapists for advice" [1].

Shoulder weakness and stiffness after neck dissection can be caused by injury to the accessory nerve (sometimes called the spinal accessory nerve). Norfolk and Norwich University Hospitals describe it as "a nerve which runs from the top to the bottom of the neck and helps you to move your shoulder" [6]. Gloucestershire's leaflet says "Surgeons try hard to protect this nerve but sometimes it is unavoidably damaged", and if so "you may find that your shoulder is stiff and it can be difficult to lift your arm above shoulder height" [1].

How long it lasts depends on what happened to the nerve. Norfolk and Norwich explain that it "is often bruised during a neck dissection" and "If the nerve is bruised it can stop working for several months" [6]. They add: "Rarely the lymph nodes cannot be completely removed without cutting this nerve. Should this be the case then these shoulder problems will be permanent" [6].

The 2017 review found shoulder pain in 10 to 100% of people after radical neck dissection and 9 to 25% after selective neck dissection, and that "accessory nerve preservation lowers, but does not eliminate, the risk of developing musculoskeletal complications" [2]. Ask your surgeon what type of neck dissection you had and whether the nerve was kept.

Start when your own hospital team tells you to, because UK hospitals give different timings. Southampton's factsheet says "Do not do any exercises" for days 0 to 4 and starts on day 5 [7], while at Norfolk and Norwich "You will be given exercises by the physiotherapist whilst you are an inpatient to complete" [6].

What Southampton's factsheet asks for is gentle, regular movement without pushing through pain [7]:

• "We recommend doing these exercises three times a day" [7].
• "You should be able to complete these exercises without experiencing any pain" [7].
• "If you experience any pain while doing an exercise, stop doing it and move on to a different exercise" [7].
• "If you experience any pain, stop doing the exercises and speak to your doctor at your follow-up clinic appointment" [7].

Yes, there is some trial evidence that progressive strength training helps more than standard exercises [3][4]. In one trial, 52 survivors with shoulder problems from accessory nerve damage were randomised to 12 weeks of progressive resistance training or a standard therapeutic exercise programme [3]. The authors concluded "The PRET program significantly reduced shoulder pain and disability" [3]. It also improved upper body strength and endurance [3].

The evidence is still small. A Cochrane review found "Three trials involving 104 people were included" [4] and concluded "Limited evidence from two RCTs demonstrated that PRT is more effective than standard physiotherapy treatment" [4]. It added that "the measured benefits of the intervention may be small" and that "The studies did not demonstrate a statistically significant difference in quality of life" [4].

In UK hospitals, strengthening usually comes through a physiotherapy referral. If shoulder stiffness from nerve damage continues, Gloucestershire's leaflet says your team can refer you "to the physiotherapists who will give you specific exercises to strengthen your shoulder" [1].

While you are having radiotherapy, protect the treated skin. Macmillan advises: "If you have a skin reaction due to radiotherapy, wear loose fitting clothing when exercising" and "You should avoid swimming, as the chemicals in the water can irritate your skin" [8]. "After treatment ends and any skin reaction has gone, it is fine to swim again" [8].

Watch for swelling. Cancer Research UK says "After radiotherapy for head and neck cancer, you are at risk of getting swelling called lymphoedema in your neck or face" and "Or it can take many months or a few years to appear after radiotherapy" [5]. It advises: "Contact your doctor or specialist nurse if you know you're at risk of lymphoedema and you have any symptoms", because "Early treatment can help to control swelling and stop it getting worse" [5]. Our guide to lymphoedema exercises explains how exercise fits with lymphoedema care, and exercise during radiotherapy covers activity through a course of treatment.

If your neck or shoulders feel stiff or tight after radiotherapy, ask your head and neck team whether you need a physiotherapy referral.

Exercise may help with tiredness and physical fitness, but it has not been shown to stop weight and muscle loss during treatment [9][11]. Cancer Research UK says "Radiotherapy to your head and neck area can make you lose weight" [5].

• Fitness and fatigue: a 2023 review of trials during treatment, covering "eight studies involving 452 patients", found that "2/4 and 3/5 investigations found a significant increase in muscle strength and cardiorespiratory fitness, respectively", and "two trials out of 3 detected an amelioration in fatigue" [9]. A 2025 review of 647 people having radiotherapy found exercise may reduce some types of fatigue, but noted most studies were pilot or feasibility trials [10].
• Muscle loss: the same 2023 review reported "Most trials did not report improvements in body mass index or body composition" [9]. In a 2026 trial of 50 people, strength training started with chemoradiotherapy "did not attenuate loss of LSTM or muscle strength" (LSTM means lean soft tissue mass, mostly muscle), "However, PRT did result in significantly increased functional performance" [11].

Less is known about exercise before treatment starts (prehabilitation) in head and neck cancer. The 2023 review found no randomised trials of it: "No trials investigating exercise as prehabilitation were found" [9].

Swallowing and eating are looked after by your speech and language therapist (SLT) and dietitian, not by an exercise professional. Cancer Research UK says "An SLT can assess your swallowing during and after treatment" and "They can teach exercises to support you with swallowing difficulties" [5]. This guide does not give swallowing or jaw exercises: ask your head and neck team for yours.

During radiotherapy "you might see a dietitian once a week who can help to advise you on foods that are easier to eat", and "your doctor or dietitian may give you nutritional supplements, such as high calorie drinks to help keep your weight up" [5]. Some people need a feeding tube: "If eating becomes very difficult you might have a feeding tube put into your stomach through your skin" [5].

For food after treatment, see eating well after cancer treatment.

Stop and speak to a doctor straight away if you get sudden worrying symptoms. Macmillan lists them: "feeling dizzy, chest pain, a racing heart, breathing problems, feeling sick, unusual back or bone pain, unusual muscle pain, a headache that does not go away", and says "Speak to a doctor straight away if you notice any of these, or any other symptoms" [8].

Also tell your team about:

• swelling in your neck or face if you are at risk of lymphoedema [5];
• neck or shoulder stiffness that continues after neck surgery [1];
• pain during your neck dissection exercises [7].

After neck surgery, Gloucestershire's leaflet says "if the swelling worsens, please contact the Head and Neck CNS for advice", and "If the swelling starts to affect your ability to breathe, call 999 and ask for an ambulance" [1].

A physiotherapist usually leads the shoulder and neck rehabilitation after surgery [1][6]. For longer-term fitness, strength and fatigue, a clinical exercise physiologist can help. NHS Health Careers says "Clinical exercise physiologists are responsible for prescribing and delivering evidence-based exercise" [13].

Clinical exercise physiologists (CEPs) work in "oncology with patients with different types of cancer and at different stages of treatment" [13]. If you live in or near the capital, cancer rehabilitation in London explains the support available there.

Request a match with a verified clinical exercise physiologist through The Health Nav.