Author Names
Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A.
Reviewer Name
Emma Kosbab, LAT, ATC, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
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 The evidence regarding their effectiveness provided by early systematic reviews is outdated.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.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Yes
Key Finding #1
Manual therapy for mixed TMD (examples including atlantoaxial, upper thoracic spine, and cervical spine mobilizations) produced mixed results with some studies demonstrating improvement in mouth ROM and symptoms, but not significantly significant in the majority of literature.
Key Finding #2
Postural control exercises were shown (in the two studies that evaluated this approach) to improve symptoms related to TMD including clinically significant improvement in pain-free mouth opening. Mixed findings were present for jaw specific exercises, but when are shown to reduce symptoms when combined with manual therapy.
Key Finding #3
One study observed drastic decreases in pain intensity and sensitivity related to myogenous TMD with the used of cervical mobilizations at a clinically relevant level.
Please provide your summary of the paper
This study examined the body of literature that is available regarding the effectiveness of physical therapy treatments for temporomandibular disorders (TMD), specifically manual therapy and therapeutic exercise. The article divides the literature into the intervention categories of posture correction exercises, general jaw exercises alone or with neck exercises, manual therapy targeted to the orofacial region, manual therapy mobilization of the cervical spine, jaw and neck exercises alone or as part of conservative management, and manual therapy plus jaw exercises. Each of the above categories was described for effects of one or both types of TMD (myogenous, arthorogenous, or mixed) as was present in the literature.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Overall, it is clear there is more research needed to determine the best interventions for TMD, but there were promising findings for non-surgical, non-pharmacological approaches. The strongest evidence would suggest postural exercises, cervical mobilizations, and general jaw exercises are favorable interventions for addressing myogenous, arthrogenous, and mixed TMD. Manual therapy in addition to exercises showed promising results for symptom management. Focusing manual therapy and exercises on the adjacent joints and body regions (cervical, thoracic), maybe a clinically helpful tool for patients with high pain irritability and sensitivity that appears to be as effective as more direct jaw related manual therapy and exercises.
