Intraoral myofascial therapy for chronic myogenous temporomandibular disorder: a randomized controlled trial

Evaluation of the efficacy of pharmacological treatment in patients with temporomandibular joint dysfunctions using ultrasonography

STATEMENT OF PROBLEM

Temporomandibular joint dysfunctions (TMDs) are complex problems affecting the temporomandibular joints (TMJs), masticatory muscles, or both. TMDs are considered muscle pain caused by contraction and ischemia in the masticatory muscles, but evaluation of the efficacy of pharmacological treatment is lacking.

PURPOSE

The purpose of this clinical study was to evaluate the changes in masticatory muscles, joint space, and main arteries supplying the TMJs after pharmacological therapy in patients with TMDs using ultrasonography (USG).

MATERIAL AND METHODS

The TMJ space, masseter and temporal muscles, temporal superficial artery (TSA), and facial artery (FA) were examined using USG in 30 participants with acute TMD pain before and after 10 days of symptomatic treatment with analgesic and myorelaxant. The bilateral masseter and temporal muscle thicknesses, joint space, and end-diastolic minimum velocity (Ved), minimum end-diastolic minimum velocity (Vmin), peak systolic maximum velocity (Vmax), pulsatility index (PI), and resistance index (RI) values of the TSA and FA were measured and compared before and after pharmacological treatment. The relationship between the masseter muscle thickness and the Ved and Vmin values of the TSA and FA before and after pharmacological treatment was analyzed using the paired sample t test; the relationship between the temporal muscle thickness, TMJ spaces, and Vmax, PI, and RI values of the TSA and FA was analyzed using the Wilcoxon signed-rank test (α=.05).

RESULTS

A significant difference was found between the right temporal muscle thickness before and after medication (P=.01), whereas no statistically significant difference was found in the left temporal muscle thickness (P>.05). A significant difference was found between pretreatment and posttreatment bilateral masseter thicknesses at rest (right P=.014; left P=.004). No statistically significant difference was found in the bilateral joint space or Vmax, Vmin, Ved, PI, and RI values of the TSA and FA before and after treatment (P>.05).

CONCLUSIONS

Pharmacological treatment in participants with acute TMD led to a reduction in masseter and temporal muscle thickness but did not significantly affect joint space and local blood flow. USG is a useful diagnostic tool in the diagnosis and follow-up of TMDs.

Physical therapy in addition to occlusal splint in myogenic temporomandibular disorders: A randomised controlled trial

BACKGROUND

Myogenic temporomandibular disorders (M-TMD) commonly involve occlusal splint (OS) therapy and musculoskeletal physiotherapy (MPT).

OBJECTIVES

To compare the effects of combining OS with MPT and education (EG) against OS and education (CG), in chronic M-TMD patients.

METHODS

In this double-blind randomised controlled trial, 62 participants were assigned to either EG or CG. The primary outcomes, pain levels at rest (VAS rest), maximum oral opening (VAS open) and during chewing (VAS chew), were measured by Visual Analogue Scale (VAS) in cm. The secondary outcome was the range of motion (ROM) for maximum oral opening. Both interventions lasted 3 months, with outcomes assessed at baseline (T0), post-treatment (T1) and 3 months post-treatment (T2).

RESULTS

Intention-to-treat analysis revealed significant improvements favouring EG (VAS rest = -1.50 cm [CI95%: -2.67, -0.32], p = .04; VAS open = -2.00 cm [CI95%: -3.23, -0.75], p < .01; VAS chew = -1.71 cm [CI95%: -2.90, -0.52], p = .01; ROM = 4.61 [CI95%: 0.93, 8.30], p = .04). Additionally, VAS measures were influenced by follow-up times (VAS rest = -0.73 cm [CI95%: -1.30, -0.17], p = 0.03; VAS open = -0.97 cm [CI95%: -1.57, -0.37], p < .01; VAS chew = -1.15 cm [CI95%: -1.73, -0.58], p < .01). At T1, EG demonstrated higher number of responders compared to CG for VAS open (χ2(1) = 4.39, p = .04) and VAS chew (χ2(1) = 11.58, p < .01).

CONCLUSION

Adding MPT to education and OS yields better outcomes in terms of pain reduction and ROM improvement, in chronic M-TMD.

TRIAL REGISTRATION NUMBER

NCT03726060.

Training of the lateral pterygoid muscle in the treatment of temporomandibular joint disc displacement with reduction: A randomised clinical trial

BACKGROUND

Disc displacement with reduction (DDwR) therapy should be performed only when pain or discomfort is presented. Data on treatment options for painful DDwR are very limited.

OBJECTIVE

The aim was to investigate whether isometric training of the lateral pterygoid muscle (LPM) is equivalent to stabilisation appliance therapy with regard to the treatment of painful DDwR. The training program is based on the science of Janda.

METHODS

This was a prospective, randomised study with a comparative treatment group. Sixty patients (≥18 years) with DDwR and pain were randomly assigned to two groups: (1) muscle training and (2) stabilisation appliance. The following variables were recorded at baseline examination and after 2, 4 and 6 months: changes in orofacial pain, clicking sounds of the temporomandibular joint (TMJ), force degrees for the lateral movement of the mandible and interincisal opening distance. p values of <.05 were considered statistically significant but 95% confidence intervals were also presented.

RESULTS

A decrease in orofacial pain intensity was seen in both groups (p < .0001). Registered TMJ clicking disappeared after 6 months of treatment in 37% (n = 11) of the patients in the training group and in 27% (n = 8) of the appliance group (p = .0009 and p = .0047). Muscle training showed 27 improvements in Janda force degrees at the end of the study (p < .0001).

CONCLUSION

Muscle training and appliance therapy improved mouth opening and reduced pain intensity in both patient groups. Muscle training might be a promising option in the treatment of patients suffering from painful DDwR.

Education-Enhanced Conventional Care versus Conventional Care Alone for Temporomandibular Disorders: A Randomized Controlled Trial

The objective of this study was to determine the effect of enhancing conventional care for people with chronic painful temporomandibular disorders (TMD) with an individualised contemporary pain science education (PSE) intervention. In this randomized controlled trial, a consecutive sample of 148 participants (18-55 years of age) was randomized into 2 groups: PSE-enhanced conventional care or Conventional care alone. Conventional care involved a 6-week, 12-session manual therapy and exercise program. The PSE enhancement involved 2 sessions of modern PSE, undertaken in the first 2 treatment sessions. Primary outcomes were pain intensity, assessed with a numeric pain rating scale, and disability, assessed with the craniofacial pain and disability inventory, post-treatment. Linear mixed model analyses were used to investigate between-group differences over time. There was a statistically and clinically meaningful effect of PSE enhancement on disability (Mean Difference = 6.1, 95% CI: 3.3-8.8), but not on pain intensity, post-treatment. Secondary analyses suggested clinically meaningful benefit of PSE enhancement on pain and disability ratings at 10-week and 18-week follow-ups, raising the possibility that preceding conventional care with a PSE intervention may result in long-term benefits. PERSPECTIVE: The addition of modern Pain Science Education (PSE) intervention improved disability for people with chronic TMD receiving manual therapy and exercise, but not pain. A mean difference in pain and disability favoring the PSE group at the 10- and 18-week follow-ups, respectively, suggests that PSE addition resulted in longer-lasting effects. Trial registration: NCT03926767. Registered on April 29, 2019. https://clinicaltrials.gov/ct2/show/NCT03926767.

Is Exercise Rehabilitation an Effective Adjuvant to Clinical Treatment for Myofascial Trigger Points? A Systematic Review and Meta-Analysis

Purpose

To systematically evaluate the effect of exercise rehabilitation as an adjuvant to clinical treatment for myofascial trigger points (MTrPs).

Patients and Methods

ESBCO, PubMed, Science Direct, Web of Science, China Knowledge Network (CNKI), and Wanfang databases were comprehensively searched from database inception date through July 2022. Randomized controlled trials comparing MTrPs treatments that included exercise rehabilitation with a single clinical treatment. Two researchers independently screened articles using inclusion/exclusion criteria, scored methodologic quality, and extracted data including patient demographics, interventions, and outcomes.

Results

We included 14 RCTs (N = 734). Results showed short-term (mean difference [MD], -2.25; 95% confidence interval [CI], -4.08 to -0.41; Z = 2.40; P = 0.02) and long-term (MD = -0.47; 95% CI: -0.80 to -0.17; Z = 3.05; P = 0.02) adjuvant exercise rehabilitation treatments were superior in reducing musculoskeletal pain intensity to single clinical treatment in controls, but long-term versus short-term effectiveness was not significantly different. The exercise rehabilitation group more effectively increased the range of motion (ROM) (standardized mean difference [SMD], 1.04; 95% CI: 0.32 to 1.77; Z = 2.84; P = 0.005) and decreased dysfunction (SMD = -0.93; 95% CI: -1.82 to -0.05; Z = 2.06; P = 0.04) than controls; no significant difference was observed in the pressure pain threshold (PPT) between two groups.

Conclusion

Exercise rehabilitation as an adjuvant to clinical treatment for MTrPs was moderately effective in relieving pain intensity, increasing ROM, and improving dysfunction versus single clinical intervention. These findings must be validated by larger, higher-quality studies.

The Efficacy of Manual Therapy Approaches on Pain, Maximum Mouth Opening and Disability in Temporomandibular Disorders: A Systematic Review of Randomised Controlled Trials

Temporomandibular disorder (TMD) is a common condition disabling people and bringing up costs. The aim of this study was to investigate the effects of manual therapy on pain intensity, maximum mouth opening (MMO) and disability. Searches were conducted in six databases for randomised controlled trials (RCTs). Selection of trials, data extraction and methodological quality assessment were conducted by two reviewers with discrepancies resolved by a third reviewer. Estimates were presented as mean differences (MDs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs). Quality of the evidence was assessed using the GRADE approach. Twenty trials met the eligibility criteria and were included. For pain intensity, high and moderate quality evidence demonstrated the additional effects of manual therapy at short- (95% CI -2.12 to -0.82 points) and long-term (95% CI -2.17 to -0.40 points) on the 0-10 points scale. For MMO, moderate to high quality evidence was found in favour of manual therapy alone (95% CI 0.01 to 7.30 mm) and its additional effects (95% CI 1.58 to 3.58 mm) at short- and long-term (95% CI 1.22 to 8.40 mm). Moderate quality evidence demonstrated an additional effect of manual therapy for disability (95% CI = -0.87 to -0.14). Evidence supports manual therapy as effective for TMD.

A novel treatment modality for myogenous temporomandibular disorders using aromatherapy massage with lavender oil: A randomized controlled clinical trial

OBJECTIVE

To investigate the effect of aromatherapy massage on pain intensity and maximal mouth opening (MMO) in patients with myogenous TMD.

METHODS

Ninety-one patients were randomly assigned to three groups: Group L (aromatherapy massage with lavender oil, test), group P (massage with sweet almond oil, placebo), and group C (control). Participants were evaluated at T0 (before the intervention), T1 (immediately after the intervention), and T2 (2-month follow-up). Data were analyzed using one-way ANOVA, Tukey's HSD, and Kruskal-Wallis tests.

RESULTS

For T1 and T2, group L showed the greatest MMO values (48.01 ± 0.85 mm; 45.67 ± 0.84 mm), while group C exhibited the lowest values (39.13 ± 0.49 mm; 39.66 ± 0.82 mm) (p < 0.001). For VAS, group L revealed the lowest pain values at T1 (2) and T2 (2) (p < 0.001).

DISCUSSION

Aromatherapy massage with lavender oil was effective in the management of painful TMD conditions and limited mouth opening.

UYKU BRUKSİZMİ OLAN MİYOFASYAL TEMPOROMANDİBULAR DİSFONKSİYON TANILI HASTALARDA MANUEL TEDAVİ İLE SPLİNT TEDAVİSİNİN KARŞILAŞTIRILMASI

Purpose: The aim of this study was to examine the effect of manual therapy on temporomandibular pain, range of motion, functionality level of the jaw, sleep quality, and patient satisfaction, and to compare the efficacy with splint therapy among female patients with myofascial temporomandibular dysfunction (M-TMD) accompanied by sleep bruxism (SB). Methods: A total of 29 female patients, aged 18-50 years, diagnosed with M-TMD were separated into two groups using a simple random sampling method as the manual therapy group (MT; n:15) and the splint therapy group (ST; n:14). All the patients were informed about bruxism and its effects and were given home exercises. The patients in the ST group were instructed to use a static splint for one month. The MT group patients received a total of 8 sessions, 45 minutes twice a week of treatment, including joint and soft tissue mobilizations to the temporomandibular joint (TMJ) and cervical region. Pain severity, symptoms, TMJ range of motion, jaw functionality, sleep quality, and patient satisfaction were evaluated. The evaluations were repeated after 4 weeks and compared with baseline values. Results: A statistically significant difference was determined in both groups in pain, TMJ range of motion, and sleep quality (p

Potential adjunct therapies for the management of temporomandibular disorders: An evidence-based review

OBJECTIVE

The aim was to review the role of adjuvant therapies that may potentially contribute toward the management of temporomandibular disorders (TMD).

METHODS

The addressed focused question was, "Are there any adjuvant therapies that may contribute toward the management of TMD?". Indexed databases were searched up to June 2021. The eligibility criteria were the following: (a) original clinical studies and (b) randomized controlled clinical trials (RCTs).

RESULTS

Adjuvant therapies were comprised of acupuncture, manual therapy, jaw exercises, dietary modifications, botulinum toxin therapy, and photobiomodulation. Short-term follow-up results from each of these RCTs showed beneficial effects in terms of pain reduction and improvements in jaw movement among patients with TMD. There are no long-term follow-up results in this regard.

CONCLUSION

The most effective adjunct treatment for managing TMD remains unknown, primarily due to a lack of sufficient scientific evidence.

The effectiveness of manual therapy applied to craniomandibular structures in temporomandibular disorders: a systematic review

Within physical therapy, manual therapy is known to be effective for managing temporomandibular disorders (TMDs). However, manual therapy is a broad term including different approaches applied to different body regions. This is the first systematic review that aims to evaluate the effectiveness of manual therapy applied specifically to the craniomandibular structures (Cranio-Mandibular Manual Therapy (CMMT)) on pain and maximum mouth opening in people with TMD. This systematic review was developed based on a pre-determined published protocol which was prospectively registered with PROSPERO (CRD42019160213). A search of MEDLINE, Embase, CINAHL, ZETOC, Web of Science, SCOPUS, PEDro, PubMed, Cochrane Library and Best Evidence, EBM reviews-Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature ChiroAccess and Google Scholar databases was conducted from inception until October 2020. Randomised controlled trials comparing the effect of CMMT on pain and maximum mouth opening versus other types of treatment in TMDs were included. Two reviewers independently screened articles for inclusion, extracted data, assessed risk of bias with the revised Cochrane risk of bias tool for randomised trials and evaluated the overall quality of evidence with the Grading of Recommendations, Assessment, Development and Evaluations. A total of 2720 records were screened, of which only 6 (293 participants) satisfied the inclusion criteria. All studies showed some concerns in risk of bias, except for one, which was high risk of bias. The overall quality of evidence was very low for all outcomes because of high heterogeneity and small sample sizes. All studies showed a significant improvement in pain and maximum mouth opening for CMMT from baseline in the mid-term, but only two showed superiority compared to other interventions. Given the high heterogeneity and small sample sizes of the included studies, a quantitative synthesis was not performed. There is the need for future high methodology research investigating different manual therapy techniques applied to different regions and different populations (e.g., chronic versus acute TMD) to determine what is most effective for pain and maximum mouth opening in patients with TMDs.

Additional effect of pain neuroscience education to craniocervical manual therapy and exercises for pain intensity and disability in temporomandibular disorders: a study protocol for a randomized controlled trial

Abstract

The objective of this study will be to investigate the additional effect of pain neuroscience education program compared to a craniocervical manual therapy and exercises program for pain intensity and disability in patients with temporomandibular disorders (TMD). This study will be a randomized controlled trial comprising a sample of 148 participants. Subjects between 18 and 55 years, both genders, will undergo a screening process to confirm painful TMD by the Research Diagnostic Criteria (RDC/TMD), and then the volunteers will be randomized into two groups (G1: pain neuroscience education + craniocervical manual therapy and exercises vs. G2: craniocervical manual therapy and exercises). The volunteers will be recruited at the dentistry clinic. The intervention will be administered twice a week for 6 weeks by a single therapist lasting 1 h per session. The primary outcome will be pain intensity and disability and the secondary outcomes will be pain self-efficacy, kinesiophobia, and global perceived effect of improvement. The participants will be assessed immediately after the last session and at one- and three-month follow-ups. All statistical analyses will be conducted following intention-to-treat principles, and the treatment effects will be calculated using linear mixed models. The results of this study may contribute to understand the additional effect of pain neuroscience education intervention on TMD patients submitted to manual therapy and exercise.

Trial registration

ClinicalTrials.gov NCT03926767. Registered on April 29, 2019.

The effectiveness of manual therapy applied to craniomandibular structures in the treatment of temporomandibular disorders: protocol for a systematic review

BACKGROUND

The term temporomandibular disorder (TMD) includes disorders of the temporomandibular joints (TMJ), masticatory muscles and adjacent tissues. Several studies have examined the effectiveness of manual therapy (MT) for TMDs by evaluating changes in pain and maximum mouth opening (MMO). Nevertheless, the effectiveness of MT exclusively applied to the craniomandibular structures (craniomandibular manual therapy (CMMT)) on pain and TMJ range of motion remains unclear. This review aims to evaluate the effectiveness of CMMT on pain and TMJ range of motion in people with TMDs.

METHODS

This protocol is reported in line with the preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P). Databases including MEDLINE, Embase, CINAHL, ZETOC, Web of Science, SCOPUS, PEDro, PubMed, Cochrane Library and Best Evidence, EBM reviews-Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature ChiroAccess and Google Scholar will be searched from inception as well as key journals and grey literature. Randomised controlled trials involving adults with TMD that compare the effect of any type of CMMT (e.g. mobilisation) on pain and range of motion with a placebo intervention, controlled care intervention or other types of treatment will be included. Two reviewers will independently screen articles for inclusion, extract data, assess risk of bias (revised Cochrane risk of bias tool) for included studies and evaluate overall quality of evidence (Grading of Recommendations Assessment, Development and Evaluation). A meta-analysis will be conducted if possible. If not, a narrative synthesis will be conducted reporting the effectiveness of CMMT according to disorder type (TMJ disorders, masticatory muscle disorders and mixed disorders).

DISCUSSION

In this review, the effectiveness of MT applied to craniomandibular structures for the treatment of TMD will be evaluated. Results will be submitted for publication in a peer-reviewed journal and presented at conferences. We expect our findings will facilitate treatment planning for manual therapists managing patients with TMD and provide future clinical research implications.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019160213.

Clinical Reasoning for the Examination and Physical Therapy Treatment of Temporomandibular Disorders (TMD): A Narrative Literature Review

The current narrative literature review aims to discuss clinical reasoning based on nociceptive pain mechanisms for determining the most appropriate assessment and therapeutic strategy and to identify/map the most updated scientific evidence in relation to physical therapy interventions for patients with temporomandibular disorders (TMDs). We will also propose an algorithm for clinical examination and treatment decisions and a pain model integrating current knowledge of pain neuroscience. The clinical examination of patients with TMDs should be based on nociceptive mechanisms and include the potential identification of the dominant, central, or peripheral sensitization driver. Additionally, the musculoskeletal drivers of these sensitization processes should be assessed with the aim of reproducing symptoms. Therapeutic strategies applied for managing TMDs can be grouped into tissue-based impairment treatments (bottom-up interventions) and strategies targeting the central nervous system (top-down interventions). Bottom-up strategies include joint-, soft tissue-, and nerve-targeting interventions, as well as needling therapies, whereas top-down strategies include exercises, grade motor imagery, and also pain neuroscience education. Evidence shows that the effectiveness of these interventions depends on the clinical reasoning applied, since not all strategies are equally effective for the different TMD subgroups. In fact, the presence or absence of a central sensitization driver could lead to different treatment outcomes. It seems that multimodal approaches are more effective and should be applied in patients with TMDs. The current paper also proposes a clinical decision algorithm integrating clinical diagnosis with nociceptive mechanisms for the application of the most appropriate treatment approach.

Effcacy of Manual Therapy in TemporomandibularJoint Disorders and Its Medium-and Long-TermEffects on Pain and Maximum Mouth Opening:A Systematic Review and Meta-Analysis

The aim of this study was to conduct a systematic review of the medium- and long-term efficacy of manual therapy for temporomandibular joint disorders, alone or in combination with therapeutic exercise. Information was compiled from the PubMed, SCOPUS, Cochrane, SciELO and PEDro databases. The inclusion criteria were established: randomized controlled trials only; participants must present any kind of temporomandibular disorder; the treatments must include manual therapy in at least one of the experimental groups; a minimum of 3 months of follow-up; pain must be one of the primary or secondary outcomes; and the article must be available in English, Spanish, Italian, Portuguese or French. Six documents that fulfilled all the criteria were obtained for analysis, two of them considered low quality and four considered high quality. A significant improvement in pain and mouth opening compared to baseline was observed after manual therapy treatment. Manual therapy seems to be an effective treatment for temporomandibular disorders in the medium term, although the effect appears to decrease over time. However, when complemented with therapeutic exercise, these effects can be maintained in the long term. This review underlines the importance of manual therapy and therapeutic exercise for the medium- and long-term treatment of temporomandibular joint disorders in daily practice.

Effectiveness of Cervical Spine High-Velocity, Low-Amplitude Thrust Added to Behavioral Education, Soft Tissue Mobilization, and Exercise for People With Temporomandibular Disorder With Myalgia: A Randomized Clinical Trial

OBJECTIVE

To determine the immediate and short-term effects of adding cervical spine high-velocity, low-amplitude thrust (HVLAT) to behavioral education, soft tissue mobilization, and a home exercise program on pain and dysfunction for people with a primary complaint of temporomandibular disorder (TMD) with myalgia.

DESIGN

Randomized clinical trial.

METHODS

Fifty individuals with TMD were randomly assigned to receive cervical HVLAT or sham manipulation for 4 visits over 4 weeks. Participants in both groups received other treatments, including standardized behavioral education, soft tissue mobilization, and a home exercise program. Primary outcomes included maximal mouth opening, the numeric pain-rating scale, the Jaw Functional Limitation Scale (JFLS), the Tampa Scale of Kinesiophobia for TMD (TSK-TMD), and a global rating of change (GROC). Self-report and objective measurements were taken at baseline, immediately after initial treatment, and follow-ups of 1 week and 4 weeks. A 2-by-4 mixed-model analysis of variance was used, with intervention group as the between-subjects factor and time as the within-subject factor. Separate analyses of variance were performed for dependent variables, and the hypothesis of interest was the group-by-time interaction.

RESULTS

There was no significant interaction for maximal mouth opening, the numeric pain-rating scale, or secondary measures. There were significant 2-way interactions for the JFLS (d = 0.60) and TSK-TMD (d = 0.80). The HVLAT group had lower fear at 4 weeks and improved jaw function earlier (1 week). The GROC favored the HVLAT group, with significant differences in successful outcomes noted immediately after baseline treatment (thrust, 6/25; sham, 0/25) and at 4 weeks (thrust, 17/25; sham, 10/25).

CONCLUSION

Both groups improved over time; however, differences between groups were small. There were significant differences between groups for the JFLS, TSK-TMD, and GROC. The additive clinical effect of cervical HVLAT to standard care remains unclear for treating TMD. J Orthop Sports Phys Ther 2020;50(8):455-465. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9175.

The treatment modalities of masticatory muscle pain a network meta-analysis

BACKGROUND

Numerous treatment modalities have been attempted for masticatory muscle pain in patients with temporomandibular disorders (TMD). To compare the treatment efficacy of more than 2 competing treatments, a network meta-analysis (NMA) was conducted.

METHODS

This study was reported with reference to the extended Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for reporting of systematic reviews incorporating network meta-analyses. Medline via Pubmed, Embase via OVID, and Cochrane Library Central were searched (up to February 11, 2019). Axis I protocol of Diagnostic Criteria or Research Diagnostic Criteria for Temporomandibular Disorders (DC/TMD, RDC/TMD) were chosen as diagnostic standards. The PICOS (Problem/patient, Intervention, Comparison, Outcome, Study design) method was used to screen trials under eligibility criteria. And the NMA was performed with mvmeta commands in Stata (StataCorp, Tex).

RESULTS

Of 766 studies searched, 12 randomized clinical trials (RCTs) were finally included. Nineteen different therapies were found and further categorized into 9 treatment modalities. The general heterogeneity was not found among included trials. But predictive intervals (PrIs) were conspicuously wider than confidential intervals (CIs) of all pairwise comparisons, indicating that heterogeneity may exist between studies. Complementary therapy showed the greatest probability (42.7%) to be the best intervention. It also had the highest mean rank (2.3) in the rankogram and the biggest value of surface under the cumulative ranking (SUCRA, 84.1%).

CONCLUSIONS

Based on the limited evidence of available trials, complementary therapy seemed to be slightly more effective than remaining treatment modalities for pain reduction in TMD patients with masticatory muscle pain. High-quality randomized controlled trials are expected to validate the findings.

Efficacy of mandibular manipulation technique for temporomandibular disorders patients with mouth opening limitation: a randomized controlled trial for comparison with improved multimodal therapy

PURPOSE

Manual therapy has been used for the treatment of patients with temporomandibular disorders (TMD) with mouth-opening limitations. However, the curative effect of manipulation differs among researchers, and its necessity remains controversial. The purpose of this study was to confirm the efficacy of manipulation using a randomized controlled trial (RCT).

METHODS

A total of 61 TMD patients who had mouth-opening limitation (upper and lower middle incisor distance ≤35mm) were selected. They were divided into two treatment groups: conventional treatment (n=30) and conventional treatment plus manipulation (n=31). The conventional treatment included two types of self-exercise: cognitive behavioral therapy for bruxism and education. Mouth-opening limitation, orofacial pain, and temporomandibular joint (TMJ) sounds were recorded from baseline to 18 weeks after baseline. These parameters were statistically compared between the two treatment groups by using analysis of variance (ANOVA) and Scheffe's test to assess mouth opening distance and pain; TMJ sounds were compared using Mann-Whitney U test.

RESULTS

No statistical difference was observed between the two treatment groups except for mouth-opening limitation after treatment at the first visit. Subgroup analyses, stratified according to the pathological type of TMD, indicated a similar trend.

CONCLUSIONS

The efficacy of manipulation seems to be limited, in contrast to our expectations, and improved execution of therapeutic exercises has a similar effect to that of manipulation during long-term observation. The advantage of manipulation was observed only during the first treatment session. The RCT was registered in the University Hospital Medical Information Network in Japan (UMIN-CTR: 000010437).

Comparison of Compressive Myofascial Release and the Graston Technique for Improving Ankle-Dorsiflexion Range of Motion

CONTEXT

  Restricted dorsiflexion (DF) at the ankle joint can cause acute and chronic injuries at the ankle and knee. Myofascial release and instrument-assisted soft tissue mobilization (IASTM) techniques have been used to increase range of motion (ROM); however, evidence directly comparing their effectiveness is limited.

OBJECTIVE

  To compare the effects of a single session of compressive myofascial release (CMR) or IASTM using the Graston Technique (GT) on closed chain ankle-DF ROM.

DESIGN

  Randomized controlled trial.

SETTING

  Laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Participants were 44 physically active people (53 limbs) with less than 30° of DF.

INTERVENTION(S)

  Limbs were randomly assigned to 1 of 3 groups: control, CMR, or GT. Both treatment groups received one 5-minute treatment that included scanning the area and treating specific restrictions. The control group sat for 5 minutes before measurements were retaken.

MAIN OUTCOME MEASURE(S)

  Standing and kneeling ankle DF were measured before and immediately after treatment. Change scores were calculated for both positions, and two 1-way analyses of variance were conducted.

RESULTS

  A difference between groups was found in the standing ( F_2,52 = 13.78, P = .001) and kneeling ( F_2,52 = 5.85, P = .01) positions. Post hoc testing showed DF improvements in the standing position after CMR compared with the GT and control groups (both P = .001). In the kneeling position, DF improved after CMR compared with the control group ( P = .005).

CONCLUSIONS

  Compressive myofascial release increased ankle DF after a single treatment in participants with DF ROM deficits. Clinicians should consider adding CMR as a treatment intervention for patients with DF deficits.

Multimodal physiotherapy treatment based on a biobehavioral approach for patients with chronic cervico-craniofacial pain: a prospective case series

The purpose of this prospective case series was to observe and describe changes in patients with chronic cervico-craniofacial pain of muscular origin treated with multimodal physiotherapy based on a biobehavioral approach. Nine patients diagnosed with chronic myofascial temporomandibular disorder and neck pain were treated with 6 sessions over the course of 2 weeks including: (1) orthopedic manual physiotherapy (joint mobilizations, neurodynamic mobilization, and dynamic soft tissue mobilizations); (2) therapeutic exercises (motor control and muscular endurance exercises); and (3) patient education. The outcome measures of craniofacial (CF-PDI) and neck disability (NDI), kinesiophobia (TSK-11) and catastrophizing (PCS), and range of cervical and mandibular motion (ROM) and posture were collected at baseline, and at 2 and 14 weeks post-baseline. Compared to baseline, statistically significant (p < 0.01) and clinically meaningful improvements that surpassed the minimal detectable change were observed at 14 weeks in CF-PDI (mean change, 8.11 points; 95% confidence interval (CI): 2.55 to 13.69; d = 1.38), in NDI (mean change, 5 cm; 95% CI: 1.74-8.25; d = 0.98), and in the TSK-11 (mean change, 6.55 cm; 95% CI: 2.79-10.32; d = 1.44). Clinically meaningful improvements in self-reported disability, psychological factors, ROM, and craniocervical posture were observed following a multimodal physiotherapy treatment based on a biobehavioral approach.

Towards an optimal therapy strategy for myogenous TMD, physiotherapy compared with occlusal splint therapy in an RCT with therapy-and-patient-specific treatment durations

BACKGROUND

Temporomandibular Disorders (TMD) may be characterized by pain and restricted jaw movements. In the absence of somatic factors in the temporomandibular joint, mainly myogenous, psychobiological, and psychosocial factors may be involved in the aetiology of myogenous TMD. An occlusal appliance (splint) is commonly used as a basic therapy of the dental practice. Alternatively, a type of physiotherapy which includes, apart from massage of sore muscles, aspects of cognitive-behavioural therapy might be a basic therapy for myogenous TMD. Treatment outcome of physiotherapy (Ph-Tx) was evaluated in comparison to that of splint therapy (Sp-Tx), using the index Treatment Duration Control (TDC) that enabled a randomized controlled trial with, comparable to clinical care, therapy-and-patient-specific treatment durations.

METHODS

Seventy-two patients were randomly assigned to either Ph-Tx or Sp-Tx, with an intended treatment duration between 10 and 21 or 12 and 30 weeks respectively. Using TDC, the clinician controlled treatment duration and the number of visits needed. A blinded assessor recorded anamnestic and clinical data to determine TDC-values following treatment and a 1-year follow-up, yielding success rate (SR) and effectiveness (mean TDC) as treatment outcomes. Cohen's d, was determined for pain intensity. Overall SR for stepped-care was assessed in a theoretical model, i.e. a second of the two studied therapies was applied if the first treatment was unsuccessful, and the effect of therapy sequence and difference in success rates was examined.

RESULTS

SR and effectiveness were similar for Ph-Tx and Sp-Tx (long-term SR: 51-60%; TDC: -0.512- -0.575). Cohen's d was 0.86 (Ph-Tx) and 1.39 (Sp-Tx). Treatment duration was shorter for Ph-Tx (on average 10.4 weeks less; p < 0.001). Sp-Tx needed 7.1 less visits (p < 0.001).

CONCLUSIONS

Physiotherapy may be preferred as initial therapy over occlusal splint therapy in stepped-care of myogenous TMD. With a similar SR and effectiveness, physiotherapy has a shorter duration. Thus patients whose initial physiotherapy is unsuccessful can continue earlier with subsequent treatment. The stepped-care model reinforces the conclusion on therapy preference as the overall SR hardly depends on therapy sequence.

TRIAL REGISTRATION

isrctn.com/ISRCTN17469828 . Retrospectively registered: 11/11/2016.

The effectiveness of exercise therapy for temporomandibular dysfunction: a systematic review and meta-analysis

Objective:

To investigate the effectiveness of exercise therapy on pain, function, and mobility outcomes in patients with temporomandibular joint dysfunction.

Study design:

Systematic review with meta-analysis.

Methods:

A systematic review and meta-analysis undertaken following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that met the inclusion criteria: (1) randomized controlled trials; (2) a population with the diagnosis of temporomandibular joint dysfunction; and (3) interventions that included exercise therapy were considered for review. When studies demonstrated homogeneity on outcome measures, the mean differences or standardized mean differences with 95% confidence interval were calculated and pooled in a meta-analysis for pooled synthesis.

Results:

Six articles with a total of 419 participants were included in the review and only four studies were included in the meta-analysis. Mobility and mixed exercise therapy approaches appear to be the most common exercise approaches utilized for management of temporomandibular joint dysfunction. Exercise therapy and the associated dosage provide moderate short-term and varying long-term benefits in reduction of pain and improvement of range of motion of the in patients with temporomandibular joint dysfunction.

Conclusion:

Included studies suggest a mobility or a mixed approach to exercise therapies have impact on reducing pain, significant impact for increasing range of motion, but lack a significant impact for functional improvement.

Level of evidence:

Therapy, level 1a-.

Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence regarding their effectiveness provided by early systematic reviews is outdated.

PURPOSE

The aim of this study was to summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions compared with other active interventions or standard care for treatment of TMD.

DATA SOURCES

Electronic data searches of 6 databases were performed, in addition to a manual search.

STUDY SELECTION

Randomized controlled trials involving adults with TMD that compared any type of MT intervention (eg, mobilization, manipulation) or exercise therapy with a placebo intervention, controlled comparison intervention, or standard care were included. The main outcomes of this systematic review were pain, range of motion, and oral function. Forty-eight studies met the inclusion criteria and were analyzed.

DATA EXTRACTION

Data were extracted in duplicate on specific study characteristics.

DATA SYNTHESIS

The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects.

LIMITATIONS

Quality of the evidence and heterogeneity of the studies were limitations of the study.

CONCLUSIONS

No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD.

Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials

There is a lack of knowledge about the effectiveness of manual therapy (MT) on subjects with temporomandibular disorders (TMD). The aim of this systematic review is to synthetise evidence regarding the isolated effect of MT in improving maximum mouth opening (MMO) and pain in subjects with signs and symptoms of TMD. MEDLINE(®) , Cochrane, Web of Science, SciELO and EMBASE(™) electronic databases were consulted, searching for randomised controlled trials applying MT for TMD compared to other intervention, no intervention or placebo. Two authors independently extracted data, PEDro scale was used to assess risk of bias, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) was applied to synthetise overall quality of the body of evidence. Treatment effect size was calculated for pain, MMO and pressure pain threshold (PPT). Eight trials were included, seven of high methodological quality. Myofascial release and massage techniques applied on the masticatory muscles are more effective than control (low to moderate evidence) but as effective as toxin botulinum injections (moderate evidence). Upper cervical spine thrust manipulation or mobilisation techniques are more effective than control (low to high evidence), while thoracic manipulations are not. There is moderate-to-high evidence that MT techniques protocols are effective. The methodological heterogeneity across trials protocols frequently contributed to decrease quality of evidence. In conclusion, there is widely varying evidence that MT improves pain, MMO and PPT in subjects with TMD signs and symptoms, depending on the technique. Further studies should consider using standardised evaluations and better study designs to strengthen clinical relevance.

Immediate Effects of Combining Local Techniques in the Craniomandibular Area and Hamstring Muscle Stretching in Subjects with Temporomandibular Disorders: A Randomized Controlled Study

OBJECTIVE

To assess the immediate effects on vertical mouth opening, orofacial mechanosensitivity, and lumbar and suboccipital mobility after adding a myofascial induction technique to a multimodal protocol in subjects with temporomandibular disorders (TMD).

DESIGN

A randomized and double-blind controlled trial was carried out.

SETTINGS/LOCATION

University-based physical therapy research clinic.

SUBJECTS

Sixty subjects (35±11.22 years) with TMD, and restricted mobility of the mandibular condyles and the first cervical vertebrae, were recruited and randomized to either a control group (CG) (n=30) or an experimental group (EG) (n=30).

INTERVENTIONS

The CG underwent a neuromuscular technique over the masseter muscles and passive hamstring muscle stretching. A suboccipital muscle inhibition technique was added to this protocol in the EG.

OUTCOME MEASURES

Primary measurements were made of vertical mouth opening and pressure pain threshold of the masseter muscles. Secondary outcome measures included pressure algometry of the trigeminal nerve, suboccipital range of motion, and lumbar spine mobility, assessed with the sit-and-reach (SAR) test and lumbar forward bending. All evaluations were collected at baseline and immediately after intervention.

RESULTS

In the intragroup comparison, the EG observed an increase in suboccipital flexion (p<0.001; F1,29=14.47; R(2)=0.33) and the SAR test (p=0.009; F1,29=7.89; R(2)=0.21). No significant differences were found in the between-group comparison for any variable (p>0.05).

CONCLUSION

The inclusion of a myofascial induction maneuver in a protocol combining local (neuromuscular treatment) and distal techniques (hamstring stretching) in subjects with TMD has no impact on improving mouth opening, suboccipital and lumbar mobility, and orofacial sensitivity to mechanical pressure.

Transcranial direct current stimulation and exercises for treatment of chronic temporomandibular disorders: a blind randomised-controlled trial

To evaluate the effect of adding transcranial direct current stimulation (tDCS) to exercises for chronic pain, dysfunction and quality of life in subjects with temporomandibular disorders (TMD). Participants were selected based on the RDC/TMD criteria and assessed for pain intensity, pressure pain threshold over temporomandibular joint and cervical muscles and quality of life. After initial assessment, all individuals underwent a 4-week protocol of exercises and manual therapy, together with active or sham primary motor cortex tDCS. Stimulation was delivered through sponge electrodes, with 2 mA amplitude, for 20 min daily, over the first 5 days of the trial. A total of 32 subjects (mean age 24.7 ± 6.8 years) participated in the evaluations and treatment protocol. Mean pain intensity pre-treatment was 5.5 ± 1.4 for active tDCS group, and 6.3 ± 1.2 for sham tDCS. Both groups showed a decrease in pain intensity scores during the trial period (time factor--F(4.5,137.5) = 28.7, P < 0.001; group factor--F(1.0,30.0 = 7.7), P < 0.05). However, there were no differences between the groups regarding change in pain intensity (time*group interaction--F(4.5,137.5) = 1.5, P = 0.137). This result remained the same after 5 months (t-test t = 0.29, P > 0.05). Pressure pain thresholds decrease and improvement in quality of life were also noticeable in both groups, but again without significant differences between them. Absolute benefit increase was 37.5% (CI 95%: -15.9% to 90.9%), and number needed to treat was 2.66. This study suggests that there is no additional benefit in adding tDCS to exercises for the treatment of chronic TMD in young adults.

Multimodal physiotherapeutic approach: effects on the temporomandibular disorder diagnosis and severity

Introduction The temporomandibular disorder (TMD) consists of a set of signs and symptoms that affect the masticatory structures, which may cause joint and/or muscular pain. The physiotherapy approach aims at the pain relief and the functional recovery by means of several modalities.Objective To investigate the effects, short and medium-term, of a multimodal physiotherapeutic approach on TMD diagnosis and severity.Methodology Individuals with diagnosis of TMD, confirmed by the Axis I of the RDC/TMD, took part in the study. From this evaluation, the Temporomandibular Index (TMI) and its sub-indices were calculated. The participants were treated during ten sessions of physiotherapy, which included therapeutic ultrasound, thermotherapy, manual therapy, stretching and neuromuscular exercises, as well as self-care and home exercises instructions. Assessments were carried out before treatment (AV1), immediately after treatment (AV2) and two months after the end of the treatment (AV3). The values of indices and the diagnosis prevalence were compared between the different periods by the t paired test (p < 0.05).Results The number of diagnoses reduced in all the subgroups and 41.7% of the 24 participants presented no diagnosis after the treatment. A significant decrease in the TMI was observed between AV1 and AV2 (p = 0.000). There was no difference between AV2 and AV3 (p = 0.204) in 13 participants assessed two months after the end of the treatment.Conclusion The multimodal physiotherapeutic approach resulted in positive effects, short and medium-term, on the symptoms and clinical signs, with deletion of the dysfunction or reduction of its severity in treated patients.

A collaborative approach between chiropractic and dentistry to address temporomandibular dysfunction: a case report

OBJECTIVE

The purpose of this case report is to describe the chiropractic and dental comanagement of a patient with temporomandibular dysfunction, headaches, and myalgia.

CLINICAL FEATURES

A 38-year-old black female patient presented for chiropractic care with a chief concern of jaw pain, tinnitus, headaches, and neck and shoulder soreness of 8 months' duration. The patient rated the pain a 6/10. The patient had a maximum mouth opening of 42 mm, graphed evidence of disk displacement, loss of translation on opening of the right temporomandibular joint viewed on the lateral radiograph, and numerous areas of point tenderness on the Kinnie-Funt Chief Complaint Visual Index. She had decreased lateral cervical flexion.

INTERVENTION AND OUTCOME

Dental treatment consisted of an anterior repositioning splint. Chiropractic care consisted of Activator treatment to the pelvis and the thoracic and cervical spine. Manual manipulation of the temporomandibular joint was performed along with a soft tissue technique intraorally on the lateral pterygoid. Postisometric relaxation in the head and neck region was also done. The patient was treated 6 times over 3 weeks. At the end of treatment, the patient had a pain rating of 0/10, maximum mouth opening of 49 mm, no tender points on the follow-up Kinnie-Funt, and increased cervical range of motion.

CONCLUSION

The patient demonstrated increased mouth opening, decreased pain rating, improved Kinnie-Funt visual index, and an increased cervical lateral flexion range of motion after 3 weeks of a combination of chiropractic and dental care.

Intra-oral myofascial therapy versus education and self-care in the treatment of chronic, myogenous temporomandibular disorder: a randomised, clinical trial

BACKGROUND

Myogenous temporomandibular disorders (TMD) are considered to be a common musculoskeletal condition. No studies exist comparing intra-oral myofascial therapies to education, self-care and exercise (ESC) for TMD. This study evaluated short-term differences in pain and mouth opening range between intra-oral myofascial therapy (IMT) and an ESC program.

METHODS

Forty-six participants with chronic myogenous TMD (as assessed according to the Research Diagnostic Criteria Axis 1 procedure) were consecutively block randomised into either an IMT group or an ESC group. Each group received two sessions per week (for five weeks) of either IMT or short talks on the anatomy, physiology and biomechanics of the jaw plus instruction and supervision of self-care exercises. The sessions were conducted at the first author's jaw pain and chiropractic clinic in Sydney, Australia. Primary outcome measures included pain at rest, upon opening and clenching, using an eleven point ordinal self reported pain scale. A secondary outcome measure consisted of maximum voluntary opening range in millimetres. Data were analysed using linear models for means and logistic regression for responder analysis.

RESULTS

After adjusting for baseline, the IMT group had significantly lower average pain for all primary outcomes at 6 weeks compared to the ESC group (p < 0.001). These differences were not clinically significant but the IMT group had significantly higher odds of a clinically significant change (p < 0.045). There was no significant difference in opening range between the IMT and ESC groups. Both groups achieved statistically significant decreases in all three pain measures at six weeks (p ≤ 0.05), but only the IMT group achieved clinically significant changes of 2 or more points.

CONCLUSION

This study showed evidence of superiority of IMT compared to ESC over the short-term but not at clinically significant levels. Positive changes over time for both IMT and ESC protocols were noted. A longer term, multi-centre study is warranted.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12610000508077.

Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review

OBJECTIVE

The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ).

METHODS

A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied.

RESULTS

Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term.

CONCLUSION

The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence.