Author Names

Lam, A., Liddle, L., MacLellan, C.

Reviewer Name

Maria Hamilton, SPT

Reviewer Affiliation(s)

Duke School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

Objective: To evaluate the efficacy of upper cervical joint mobilization and/or manipulation on reducing pain and improving maximal mouth opening (MMO) and pressure pain thresh- olds (PPTs) in adults with temporomandibular joint (TMJ) dysfunction compared with sham or other intervention. Data Sources: MEDLINE, CINAHL, EMBASE, and Cochrane Library from inception to June 3, 2022, were searched. Study Selection: Eight randomized controlled trials with 437 participants evaluating manual therapy (MT) vs sham and MT vs other intervention were included. Two reviewers independently extracted data and assessed risk of bias. Data Extraction: Two independent reviewers extracted information about origin, number of study participants, eligibility criteria, type of intervention, and outcome measures.

 

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

  1. Is the review based on a focused question that is adequately formulated and described?
  • Yes
  1. Were eligibility criteria for included and excluded studies predefined and specified?
  • Yes
  1. Did the literature search strategy use a comprehensive, systematic approach?
  • Yes
  1. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
  • Yes
  1. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
  •  
  1. Were the included studies listed along with important characteristics and results of each study?
  • Yes
  1. Was publication bias assessed?
  • Yes
  1. Was heterogeneity assessed? (This question applies only to meta-analyses.)
  • Yes

 

Key Finding #1

Manual therapy significantly increased maximal mouth opening (MMO) compared to the control/sham intervention; this result was homogenous for the majority of the studies, however, it did not meet the MCID for MMO

Key Finding #2

Manual therapy did not significantly increase pressure pain threshold of the masseter and temporalis; this result was found to be heterogenous across studies for both the masseter and temporalis

Key Finding #3

Cervical manual therapy significantly reduced pain compared to other interventions (e.g., control/sham, patient education, exercise, soft tissue massage to the cervical and/or TMJ region) with limited heterogeneity across studies; significance was hard to determine due to few RCTs assessing pain via the VAS or NPRS

 

Please provide your summary of the paper

This systematic review and meta-analysis evaluated the effect of upper cervical mobilization/manipulation (upper cervical defined as C0/1, C1/2, C2/3) on temporomandibular joint (TMJ) pain, maximal mouth opening, and pressure pain thresholds (PPT). Eight trials consisting of 437 total participants were included in this review. Manual therapy was defined as upper cervical spine manipulation in six trials and upper cervical spine mobilization in 2 trials. The sham/control intervention consisted of placing participants in the mobilization and/or manipulation position and maintaining that position for a certain period of time. Other interventions included a combination of patient education, exercise, or soft tissue massage of the cervical and/or TMJ region. When looking at the results of the meta-analysis, it was found that manual therapy had a significant effect on pain reduction and increasing maximal mouth opening in comparison to the control intervention. However, when looking at PPT for the masseter and temporalis, manual therapy did not significantly increase PPT for either muscle. The results were heterogenous for all of the variables, except maximal mouth opening. When comparing manual therapy to other interventions, the findings were similar, except there was heterogeneity for all variables across the studies.

 

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

Based on the results of the systematic review/meta-analysis, upper cervical spine mobilization or manipulation alone does not seem to have a significant impact on symptom reduction for individuals with TMJ dysfunction. When considering the papers that were chosen for the review, there was a lot of heterogeneity in relation to the results of the studies. The authors attributed the heterogeneity to small sample sizes and limited number of trials noted across the studies. When thinking about how this may impact clinical practice, physical therapists should caution using C-spine mobilization and manipulation alone. I believe that mobilization and manipulation in addition to other interventions (e.g., exercise, patient education, etc.) can help create better patient outcomes and improve their quality of life. In addition, using a biopsychosocial approach for treatment to help personalize the patient’s plan of care could help ensure better outcomes as well.