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Clinical Reasoning for the Examination and Physical Therapy Treatment of Temporomandibular Disorders (TMD): A Narrative Literature Review. J Clin Med 2020; 9:jcm9113686. [PMID: 33212937 PMCID: PMC7698332 DOI: 10.3390/jcm9113686] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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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. J Orthop Sports Phys Ther 2020; 50:455-465. [PMID: 31905097 DOI: 10.2519/jospt.2020.9175] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Blanchard L, Goostree S, Duncombe A. Graded exposure and orthopedic manual physical therapy for kinesiophobia and function in chronic temporomandibular dysfunction: A case report. Cranio 2020; 40:454-467. [PMID: 32552574 DOI: 10.1080/08869634.2020.1779483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND This case report describes the successful use of multi-modal physical therapy (PT), including orthopedic manual physical therapy (OMPT) and graded exposure, in a patient with chronic temporomandibular dysfunction (TMD). CLINICAL PRESENTATION A 41-yr old female presented with a five-year history of bilateral chronic myofascial TMD and comorbid neck/right arm pain. The patient was treated for 12 weeks with a focus on OMPT and graded exposure. The patient demonstrated clinically significant improvements on the Tampa Scale of Kinesiophobia-TMD, maximal mouth opening, Global Rating of Change, and Jaw Functional Limitation Scale. CLINICAL RELEVANCE Mechanisms underlying chronic TMD are complex. Current evidence supports PT management of physical impairments; however, neglecting central drivers or psychosocial factors may result in suboptimal outcomes. Physical therapists are able to address both peripheral and central mechanisms of pain, and future research should examine the utilization of multi-modal PT to improve kinesiophobia and function in patients with chronic TMD.
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Affiliation(s)
- Leanna Blanchard
- Department of Rehabilitation Services, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | | | - Alison Duncombe
- Department of Rehabilitation Services, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
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Mansfield CJ, Domnisch C, Iglar L, Boucher L, Onate J, Briggs M. Systematic review of the diagnostic accuracy, reliability, and safety of the sharp-purser test. J Man Manip Ther 2019; 28:72-81. [PMID: 31526113 DOI: 10.1080/10669817.2019.1667045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Introduction: The Sharp-Purser Test (SPT) is used to assess for atlantoaxial instability (AI) in patients with rheumatoid arthritis (RA). The test is commonly used by clinicians; however, many experts argue it lacks reliability and validity along with concerns of safety. The primary purpose of this review is to determine the diagnostic accuracy of the SPT to detect AI.Methods: A search of five databases was performed from inception to 19 December 2018 using search terms related to the SPT. Studies were eligible for inclusion if the SPT was used on a patient/participant. Methodological quality assessment of diagnostic studies was performed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) for studies that reported data to calculate sensitivity (SN), specificity (SP), positive likelihood ratio (+LR), and negative likelihood ratio (-LR).Results: The search yielded 1009 articles, and 32 studies met the inclusion criteria for analysis. Meta-analysis on diagnostic accuracy studies assessing the SPT was not possible due to statistical heterogeneity. Six diagnostic accuracy studies assessed the SN of the SPT ranging from 0.19 to 1.00. Four of the studies assessed SP of the SPT ranging from 0.71 to 0.98. The +LR was identified in 4 studies was 0.655, 1.73, 22, and 17.25. The -LR was 1.14, 0.799, 0.571, and 0.323. Seven RCTs utilized the SPT to screen for AI, and the SPT was used in 18 case reports.Conclusion: The SPT may be inappropriate to use due to inconsistent validity, poor inter-rater reliability, and potential to cause harm.Level of evidence: 1.
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Affiliation(s)
- Cody J Mansfield
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, USA.,OSU Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Orthopaedic Manual Physical Therapy Fellowship, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Charlie Domnisch
- OSU Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Laura Iglar
- OSU Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Orthopaedic Manual Physical Therapy Fellowship, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Laura Boucher
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - James Onate
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Matthew Briggs
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, USA.,OSU Sports Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Orthopaedic Manual Physical Therapy Fellowship, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Chane L, Kily JP, Marangelli G, Gebeile-Chauty S. [Somatic dysfunctions of the cervical spine and fixed orthodontic treatment: a 145 subjects-cross sectional study]. Orthod Fr 2019; 90:119-126. [PMID: 31241454 DOI: 10.1051/orthodfr/2019014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 02/10/2019] [Indexed: 06/09/2023]
Abstract
UNLABELLED Objectives : The aim of this blind cross-sectional study is to evaluate the influence of a fixed orthodontic appliance on the cervical spine. MATERIALS AND METHODS Number and severity of somatic dysfunctions (i.e. alteration of the function of an element constituting the somatic system or SD) of the cervical spine have been searched on patients sorted out in three groups: subjects without orthodontic treatment (group 1), subjects wearing fixed orthodontic appliance (group 2) and subjects in a retention period after removal of the fixed orthodontic appliance (group 3) and were compared thanks to khi2 test. RESULTS A total of 145 patients from 6 to 17 years old was included. There are more SD in the second group (p = 0.006) than in the first group. There is no difference between the 1st and the 3rd group (p = 0.2), between the 2nd and the 3rd group (p = 0.4) and between the three groups (p = 0.6) concerning the severity of SD. CONCLUSION Cervical disorders should not be attributed to long-term multi-attachment treatment since once the active orthodontic treatment is finished, the SD are not significantly increased compared to the control group. These results may encourage to make a study to evaluate benefits of cervical osteopathic follow-up for patients at risk after the setting of the fixed appliance.
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Affiliation(s)
- Loïc Chane
- CEESO Lyon, 39 rue Pasteur, Lyon 69007, France
| | - Jean-Pascal Kily
- Maison médicale, 17 impasse Petrus Vitel, 69700 Loire sur Rhone, France
| | | | - Sarah Gebeile-Chauty
- Département d'Orthopédie Dento-Faciale, Faculté d'Odontologie, 11 rue Guillaume Paradin, 69372 Lyon cedex 08, France
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Butts R, Dunning J, Pavkovich R, Mettille J, Mourad F. Conservative management of temporomandibular dysfunction: A literature review with implications for clinical practice guidelines (Narrative review part 2). J Bodyw Mov Ther 2017; 21:541-548. [DOI: 10.1016/j.jbmt.2017.05.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/22/2017] [Accepted: 05/26/2017] [Indexed: 10/19/2022]
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