Chiropractic care of a patient with temporomandibular disorder and atlas subluxation

Multimodal non-invasive non-pharmacological therapies for chronic pain: mechanisms and progress

BACKGROUND

Chronic pain conditions impose significant burdens worldwide. Pharmacological treatments like opioids have limitations. Non-invasive non-pharmacological therapies (NINPT) encompass diverse interventions including physical, psychological, complementary and alternative approaches, and other innovative techniques that provide analgesic options for chronic pain without medications.

MAIN BODY

This review elucidates the mechanisms of major NINPT modalities and synthesizes evidence for their clinical potential across chronic pain populations. NINPT leverages peripheral, spinal, and supraspinal mechanisms to restore normal pain processing and limit central sensitization. However, heterogeneity in treatment protocols and individual responses warrants optimization through precision medicine approaches.

CONCLUSION

Future adoption of NINPT requires addressing limitations in standardization and accessibility as well as synergistic combination with emerging therapies. Overall, this review highlights the promise of NINPT as a valuable complementary option ready for integration into contemporary pain medicine paradigms to improve patient care and outcomes.

Physiotherapy assessment and treatment of chronic subjective tinnitus using mechanical diagnosis and therapy: a case report

Objectives: Tinnitus is the perception of sound without any external auditory stimulus. Cervicogenic somatic tinnitus (CST) is a subset in which symptoms are modulated by maneuvers of the neck. The evidence for effective diagnosis and treatment of CST is limited. Mechanical Diagnosis and Therapy (MDT) is a biopsychosocial assessment and management system that uses the response to mechanical forces to classify clinical presentations accurately. The purpose of this case report is to describe the MDT assessment and management of a patient with chronic subjective tinnitus.Methods: A 67-year-old female with a 5-year history of left-sided subjective tinnitus, neck pain, and headache was referred for physiotherapy. Outcome measures included the Visual Analogue Scale (VAS), Tinnitus Handicap Inventory (THI), and Neck Disability Index (NDI). She was evaluated and treated according to MDT principles with management consisting of individualized directional preference exercises and postural correction.Results: Significant improvements in symptoms, cervical range of motion, function, and psychosocial status were observed over the long-term. At 6 months, THI scores dropped from 62/100 to 18/100 and NDI scores dropped from 18/50 to 3/50.Discussion: A comprehensive MDT assessment led to a classification of Derangement, with treatment focusing on tailored self-management. Contrary to other interventions described for CST, the patient was able to make significant and lasting changes to her symptoms without the need for any externally applied interventions. The emphasis on self-management dovetails well with the biopsychosocial model of care. This case provides preliminary evidence for the utility of screening for Derangement in conservative tinnitus assessments.Level of Evidence: 4.

Somatosensory tinnitus: Current evidence and future perspectives

In some individuals, tinnitus can be modulated by specific maneuvers of the temporomandibular joint, head and neck, eyes, and limbs. Neuroplasticity seems to play a central role in this capacity for modulation, suggesting that abnormal interactions between the sensory modalities, sensorimotor systems, and neurocognitive and neuroemotional networks may contribute to the development of somatosensory tinnitus. Current evidence supports a link between somatic disorders and higher modulation of tinnitus, especially in patients with a normal hearing threshold. Patients with tinnitus who have somatic disorders seems to have a higher chance of modulating their tinnitus with somatic maneuvers; consistent improvements in tinnitus symptoms have been observed in patients with temporomandibular joint disease following targeted therapy for temporomandibular disorders. Somatosensory tinnitus is often overlooked by otolaryngologists and not fully investigated during the diagnostic process. Somatic disorders, when identified and treated, can be a valid therapeutic target for tinnitus; however, somatic screening of subjects for somatosensory tinnitus is imperative for correct selection of patients who would benefit from a multidisciplinary somatic approach.

Pathophysiology, Diagnosis and Treatment of Somatosensory Tinnitus: A Scoping Review

Somatosensory tinnitus is a generally agreed subtype of tinnitus that is associated with activation of the somatosensory, somatomotor, and visual-motor systems. A key characteristic of somatosensory tinnitus is that is modulated by physical contact or movement. Although it seems common, its pathophysiology, assessment and treatment are not well defined. We present a scoping review on the pathophysiology, diagnosis, and treatment of somatosensory tinnitus, and identify priority directions for further research. Methods: Literature searches were conducted in Google Scholar, PubMed, and EMBASE databases. Additional broad hand searches were conducted with the additional terms etiology, diagnose, treatment. Results: Most evidence on the pathophysiology of somatosensory tinnitus suggests that somatic modulations are the result of altered or cross-modal synaptic activity within the dorsal cochlear nucleus or between the auditory nervous system and other sensory subsystems of central nervous system (e.g., visual or tactile). Presentations of somatosensory tinnitus are varied and evidence for the various approaches to treatment promising but limited. Discussion and Conclusions: Despite the apparent prevalence of somatosensory tinnitus its underlying neural processes are still not well understood. Necessary involvement of multidisciplinary teams in its diagnosis and treatment has led to a large heterogeneity of approaches whereby tinnitus improvement is often only a secondary effect. Hence there are no evidence-based clinical guidelines, and patient care is empirical rather than research-evidence-based. Somatic testing should receive further attention considering the breath of evidence on the ability of patients to modulate their tinnitus through manouvers. Specific questions for further research and review are indicated.

Cervical spine dysfunctions in patients with chronic subjective tinnitus

OBJECTIVE

To assess, characterize, and quantify cervical spine dysfunction in patients with cervicogenic somatic tinnitus (CST) compared to patients suffering from other forms of chronic subjective non-pulsatile tinnitus.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary referral center.

PATIENTS

Consecutive adult patients suffering from chronic subjective non-pulsatile tinnitus were included.

EXCLUSION CRITERIA

Ménière's disease, middle ear pathology, intracranial pathology, cervical spine surgery, whiplash trauma, temporomandibular dysfunction.

INTERVENTION

Assessment comprises medical history, ENT examination with micro-otoscopy, audiometry, tinnitus assessment, temporomandibular and cervical spine investigation, and brain MRI. Patients were classified into CST and non-CST population. Cervical spine dysfunction was investigated using the Neck Bournemouth Questionnaire (NBQ) and clinical tests of the cervical spine, containing range of motion, pain provocation (adapted Spurling test, AST), and muscle tests (tenderness via trigger points, strength and endurance of deep neck flexors).

MAIN OUTCOME MEASURES

Between-group analysis was performed. The prevalence of cervical spine dysfunction was described for the total group and for CST and non-CST groups.

RESULTS

In total, 87 patients were included, of which 37 (43%) were diagnosed with CST. In comparison with the non-CST group, the CST group demonstrated a significantly higher prevalence of cervical spine dysfunction. In the CST group, 68% had a positive manual rotation test, 47% a positive AST, 49% a positive score on both, and 81% had positive trigger points. In the non-CST group, these percentages were 36, 18, 10, and 50%, respectively. Furthermore, 79% of the CST group had a positive NBQ versus 40% in the non-CST group. Significant differences between the both groups were found for all the aforementioned variables (all p < 0.005).

CONCLUSIONS

Although a higher prevalence of neck dysfunction was found in the CST group, neck dysfunction is often in non-CST patients.

Physical therapy treatment in patients suffering from cervicogenic somatic tinnitus: study protocol for a randomized controlled trial

BACKGROUND

Tinnitus occurs in a large part of the general population with prevalences ranging from 10% to 15% in an adult population. One subtype is cervicogenic somatic tinnitus, arising from cervical spine dysfunctions, justifying cervical spine assessment and treatment. This study aims to investigate the effect of a standardized physical therapy treatment, directed to the cervical spine, on tinnitus. Additionally, a second aim is to identify a subgroup within the tinnitus population that benefits from physical therapy treatment.

METHODS AND DESIGN

This study is designed as a randomized controlled trial with delayed treatment design. Patients with severe subjective tinnitus (Tinnitus Functional Index (TFI) between 25 and 90 points), in combination with neck complaints (Neck Bournemouth Questionnaire (NBQ) >14 points) will be recruited from the University Hospital of Antwerp. Patients suffering from tinnitus with clear otological etiologies, severe depression, traumatic cervical spine injury, tumors, cervical spine surgery, or conditions in which physical therapy is contra-indicated, will be excluded.After screening for eligibility, baseline data such as TFI, NBQ, and a set of cervical biomechanical and sensorimotor tests will be collected. Patients are randomized in an immediate therapy group and in a group with a delayed start of therapy by 6 weeks. Patients will receive physical therapy with a maximum of 12 sessions of 30 min for a 6-week program. Data from the TFI and NBQ will be collected at baseline (week 0), at the start of therapy (weeks 0 or 6), at the end of therapy (weeks 6 or 12), 6 weeks after therapy (weeks 12 or 18), and 3 months after therapy (weeks 18 or 24). Secondary outcome measures will be collected at baseline and 6 weeks after the therapy (weeks 12 or 18), as the maximal therapy effect on the cervical spine dysfunctions is expected at that moment.

DISCUSSION

This study is the first to investigate the effect of a standardized physical therapy treatment protocol on somatic tinnitus with a prospective comparative delayed design and with blinded evaluator for baseline, end of therapy, and 6 and 12 weeks after therapy.

TRIAL REGISTRATION

12 September 2013, ClinicalTrials.gov: NCT02016313.

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.

Chiropractic spinal manipulative treatment of migraine headache of 40-year duration using Gonstead method: a case study

OBJECTIVE

The purpose of this article is to present a case study of chiropractic spinal manipulative treatment (CSMT) using the Gonstead method for a patient with migraines.

CLINICAL FEATURES

The patient was a 52-year-old married woman with a long-term history of chronic migraines, which included nausea, vomiting, and photophobia. The patient had endometriosis, but did not relate the migraines to her menstrual cycles. She also reported not using medication for her migraines due to previous drug-related issues. The average frequency of episodes before treatment was 1 per month, and her migraines often included an aura. The pain was moderate, was located on the right side, was pulsating, and lasted for approximately 15 hours. The numeric pain scale for an average episode was 8 out of a possible 10. The aura involved nausea, photophobia, and visual disturbances including black dots in the visual field lasting for approximately 10 minutes.

INTERVENTION AND OUTCOME

The patient reported all episodes being eliminated following CSMT. At 6-month follow-up, the patient had not had a single migraine episode in this period. The patient was certain that there had been no other lifestyle changes that could have contributed to her improvement.

CONCLUSION

This case adds to previous research suggesting that some migraine patients may respond favorably to CSMT. The case also provides information on the Gonstead method. A case study does not represent significant scientific evidence in context with other studies conducted; this study suggests that a trial of CSMT using the Gonstead methods could be considered for chronic, nonresponsive migraines.

Conservative care of temporomandibular joint disorder in a 35-year-old patient with spinal muscular atrophy type III: a case study

OBJECTIVE

This article describes the chiropractic clinical management and therapeutic benefits accruing to a patient with temporomandibular joint (TMJ) disorder and spinal muscular atrophy type III.

CLINICAL FEATURES

A 35-year-old white man presented at the university chiropractic outpatient clinic with a complaint of masseter muscle pain and mouth-opening restriction. Temporomandibular joint range of motion evaluation revealed restricted opening (11 mm interincisival), and pain was rated by the patient at an intensity of 5 on a pain scale of 0 to 10.

INTERVENTION AND OUTCOME

Chiropractic care was provided and included TMJ mobilization, myofascial therapy, trigger point therapy, and light spinal mobilizations of the upper cervical vertebrae. Final evaluation of TMJ range of motion showed active opening of 12 mm with absence of pain and muscle tenderness of the jaw.

CONCLUSION

This case suggests that a patient with musculoskeletal disorders related to underlying neurodegenerative pathologies may benefit from chiropractic management adapted to their condition. In the present case, chiropractic treatment of the TMJ represented a viable, low-cost approach with limited adverse effects compared with surgery.

Diagnosis and management of somatosensory tinnitus: review article

Tinnitus is the perception of sound in the absence of an acoustic external stimulus. It affects 10-17% of the world's population and it a complex symptom with multiple causes, which is influenced by pathways other than the auditory one. Recently, it has been observed that tinnitus may be provoked or modulated by stimulation arising from the somatosensorial system, as well as from the somatomotor and visual-motor systems. This specific subgroup -somatosensory tinnitus - is present in 65% of cases, even though it tends to be underdiagnosed. As a consequence, it is necessary to establish evaluation protocols and specific treatments focusing on both the auditory pathway and the musculoskeletal system.

Chiropractic management of a 40-year-old female patient with Ménière disease

OBJECTIVE

The purpose of this case report is to describe the chiropractic management of a patient with Ménière disease.

CLINICAL FEATURES

A 40-year-old woman presented with a diagnosis of Ménière disease including a 2-month history of vertigo and a 16-month history of left-sided tinnitus, low-frequency hearing loss, and aural fullness. The patient's other symptoms included left-sided neck pain, temporomandibular joint pain, and headaches. Examination revealed left-sided upper cervical joint dysfunction along with myofascial trigger points in the middle and upper trapezius muscle.

INTERVENTION AND OUTCOME

Treatment included primarily high-velocity, low-amplitude spinal manipulation to the upper cervical and thoracic spine, along with soft-tissue trigger-point therapy, and stretching exercises. Within 2 weeks of treatment, the patient's tinnitus had resolved; and all other symptoms (including vertigo) were improved. The patient's headaches, neck pain, and vertigo were subsequently resolved within 3 months of treatment. The patient experienced only 2 minor episodes of self-resolving "light-headedness" over that time. After 2½ years of follow-up, any occasional episodes of mild aural fullness and/or light-headedness are either self-resolving or relieved with cervical spinal manipulation and soft-tissue treatment.

CONCLUSION

This case report suggests that chiropractic care, including upper cervical spinal manipulation and soft-tissue therapy, may be beneficial in treating some patients with Ménière disease.

Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: a randomized controlled trial

OBJECTIVE

Temporomandibular disorders (TMD) is a term reflecting chronic, painful, craniofacial conditions usually of unclear etiology with impaired jaw function. The effect of osteopathic manual therapy (OMT) in patients with TMD is largely unknown, and its use in such patients is controversial. Nevertheless, empiric evidence suggests that OMT might be effective in alleviating symptoms. A randomized controlled clinical trial of efficacy was performed to test this hypothesis.

METHODS

We performed a randomized, controlled trial that involved adult patients who had TMD. Patients were randomly divided into two groups: an OMT group (25 patients, 12 males and 13 females, age 40.6+/-11.03) and a conventional conservative therapy (CCT) group (25 patients, 10 males and 15 females, age 38.4+/-15.33). At the first visit (T0), at the end of treatment (after six months, T1) and two months after the end of treatment (T2), all patients were subjected to clinical evaluation. Assessments were performed by subjective pain intensity (visual analogue pain scale, VAS), clinical evaluation (Temporomandibular index) and measurements of the range of maximal mouth opening and lateral movement of the head around its axis.

RESULTS

Patients in both groups improved during the six months. The OMT group required significantly less medication (non-steroidal medication and muscle relaxants) (P<0.001).

CONCLUSIONS

The two therapeutic modalities had similar clinical results in patients with TMD, even if the use of medication was greater in CCT group. Our findings suggest that OMT is a valid option for the treatment of TMD.

Immediate effects of atlanto-occipital joint manipulation on active mouth opening and pressure pain sensitivity in women with mechanical neck pain

OBJECTIVE

The purpose of this study was to investigate the effects of a spinal thrust manipulation directed to the upper cervical segments (atlanto-occipital joint) on active mouth opening and pressure pain sensitivity in a trigeminal nerve innervated region (sphenoid bone) in women with mechanical neck pain.

METHODS

Thirty-seven women, ages 21 to 50 years old (mean age, 35 +/- 8 years) with mechanical neck pain were recruited for this study. Participants were randomly assigned into 1 of 2 groups as follows: an experimental group that received a spinal manipulation of the atlanto-occipital joint and a control group that received a manual contact placebo intervention. Outcomes collected were assessed pretreatment and 5 minutes posttreatment by an assessor blinded to the treatment allocation and included active mouth opening and pressure pain thresholds (PPTs) over both sides of the sphenoid bone. A 2-way repeated measures analysis of variance (ANOVA) with time (pre-post) as the within subjects variable and group (control, experimental) as the between subjects variable was used to examine the effects of the intervention. The hypothesis of interest was group-time interaction.

RESULTS

The ANOVA showed a significant effect for time (F = 23.1; P < .001) and an interaction between group and time (F = 37.7; P < .001) for active mouth opening as follows: the experimental group showed a greater improvement when compared to the control group. A large positive within-group effect size (d > 1.5) for the experimental group, whereas a negative medium within-group effect size (d = -0.5) for the control group were identified. The ANOVA showed a significant interaction between group and time (F = 14.4; P < .001) for PPT levels at the sphenoid bone as follows: the experimental group showed a greater improvement when compared to the control group. A medium positive within-group effect size (d = -0.5) for the experimental group, whereas a negative medium within-group effect size (d = -0.5) for the control group was found.

CONCLUSIONS

Our findings suggest that the application of an atlantoaxial joint thrust manipulation resulted in an increase in active mouth opening and PPT over a trigeminal nerve distribution area (sphenoid bone) in women with mechanical neck pain.

Masticatory muscle activity during maximum voluntary clench in different research diagnostic criteria for temporomandibular disorders (RDC/TMD) groups

The research diagnostic criteria for temporomandibular disorders (RDC/TMD) are used for the classification of patients with temporomandibular disorders (TMD). Surface electromyography of the right and left masseter and temporalis muscles was performed during maximum teeth clenching in 103 TMD patients subdivided according to the RDC/TMD into 3 non-overlapping groups: (a) 25 myogenous; (b) 61 arthrogenous; and (c) 17 psycogenous patients. Thirty-two control subjects matched for sex and age were also measured. During clenching, standardized total muscle activities (electromyographic potentials over time) significantly differed: 131.7 microV/muVs % in the normal subjects, 117.6 microV/microVs % in the myogenous patients, 105.3 microV/microVs % in the arthrogenous patients, 88.7 microV/microVs % in the psycogenous patients (p<0.001, analysis of covariance). Symmetry in the temporalis muscles was larger in normal subjects (86.3%) and in myogenous patients (84.9%) than in arthrogenous (82.7%), and psycogenous patients (80.5%) (p=0.041). No differences were found for masseter muscle symmetry and torque coefficient (p>0.05). Surface electromyography of the masticatory muscles allowed an objective discrimination among different RDC/TMD subgroups. This evaluation could assist conventional clinical assessments.

The use of surface electromyography as a tool in differentiating temporomandibular disorders from neck disorders

The aim of this study was to assess the electromyographic characteristics of the masticatory muscles (masseter and temporalis) of patients with either "temporomandibular joint disorder" or "neck pain". Surface electromyography of the right and left masseter and temporalis muscles was performed during maximum teeth clenching in 38 patients aged 21-67 years who had either (a) temporomandibular joint disorder (24 patients); (b) "neck pain" (13 patients). Ninety-five control, healthy subjects were also examined. During clenching, standardized total muscle activities (electromyographic potentials over time) were significantly different in the three groups: 75 microV/microVs% in the temporomandibular joint disorder patients, 124 microV/microVs% in the neck pain patients, and 95 microV/microVs% in the control subjects (analysis of variance, P<0.001). The temporomandibular joint disorder patients also had significantly (P<0.001) more asymmetric muscle potentials (78%) than either neck pain patients (87%) or control subjects (92%). A linear discriminant function analysis allowed a significant separation between the two patient groups, with a single patient error of 18.2%. Surface electromyographic analysis during clenching allowed to differentiate between patients with a temporomandibular joint disorder and patients with a neck pain problem.

Chiropractic treatment of temporomandibular disorders using the activator adjusting instrument: a prospective case series

OBJECTIVE

To determine if there was a basis for the treatment of temporomandibular disease (TMD) using the chiropractic protocol developed by Activator Methods, International.

SETTING

Private, solo practice of an Activator advanced proficiency rated chiropractor with 15 years experience.

DESIGN

Prospective case series.

PARTICIPANTS

Nine adult volunteers with articular TMD recruited from the practice of the treating clinician. Main outcome measures Change from baseline to follow-up of Visual Analog Scale (VAS) for temporomandibular joint (TMJ) pain and maximum active mouth opening without pain.

INTERVENTIONS

Full spine and TMJ adjusting in accordance with the advanced protocol of Activator Methods, International. Participants were typically seen 3 times per week for 2 weeks and according to individual progress thereafter for 6 more weeks.

RESULTS

Eight participants completed outcome assessments. The median VAS decrease was 45 mm (range 21-71); all experienced improvement. The median increase of mouth opening was 9 mm (range 1-15); all showed improvement.

CONCLUSION

The results of this prospective case series indicated that the TMD symptoms of these participants improved following a course of treatment using the Activator Methods, International protocol. Consequently, further investigation of this type of chiropractic treatment for patients with the articular type of TMD is warranted.

Chiropractic care of a patient with vertebral subluxation and Bell's palsy

OBJECTIVE

To describe the chiropractic care of a patient medically diagnosed with Bell's palsy and discuss issues clinically relevant to this disorder, such as its epidemiology, etiology, diagnosis, care, and prognosis.

CLINICAL FEATURES

A 49-year-old woman with a medical diagnosis of Bell's palsy sought chiropractic care. Her symptoms included right facial paralysis, extreme phonophobia, pain in the right temporomandibular joint (TMJ), and neck pain. Signs of cervical vertebral and TMJ subluxations included edema, tenderness, asymmetry of motion and posture, and malalignment detected from plain film radiographs.

INTERVENTION AND OUTCOME

The patient was cared for with full spine contact-specific, high-velocity, low-amplitude adjustments (Gonstead Technique) to sites of vertebral and occipital subluxations. The patient's left TMJ was also adjusted. The initial symptomatic response to care was positive, and the patient made continued improvements during the 6 months of care.

CONCLUSION

There are indications that patients suffering from Bell's palsy may benefit from a holistic chiropractic approach that not only includes a focus of examination and care of the primary regional areas of complaint (eg, face, TMJ) but also potentially from significant vertebral subluxation concomitants.