Author Names
Wagner Rodrigues Martins, Juscelino Castro Blasczyk, Micaele Aparecida Furlan de Oliveira, Karina Ferreira Lagoa Gonçalves, Ana Clara Bonini-Rocha, Pierre-Michel Dugailly, Ricardo Jaco de Oliveira
Reviewer Name
Timothy Dow, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background: Temporomandibular joint disorder (TMD) requires a complex diagnostic and therapeutic approach, which usually involves a multidisciplinary management. Among these treatments, musculo- skeletal manual techniques are used to improve health and healing. Objectives: To assess the effectiveness of musculoskeletal manual approach in temporomandibular joint disorder patients. Design: A systematic review with meta-analysis. Methods: During August 2014 a systematic review of relevant databases (PubMed, The Cochrane Library, PEDro and ISI web of knowledge) was performed to identify controlled clinical trials without date re- striction and restricted to the English language. Clinical outcomes were pain and range of motion focalized in temporomandibular joint. The mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) and overall effect size were calculated at every post treatment. The PEDro scale was used to demonstrate the quality of the included studies. Results/findings: From the 308 articles identified by the search strategy, 8 articles met the inclusion criteria. The meta-analysis showed a significant difference (p < 0.0001) and large effect on active mouth opening (SMD, 0.83; 95% CI, 0.42 to 1.25) and on pain during active mouth opening (MD, 1.69; 95% CI, 1.09 to 2.30) in favor of musculoskeletal manual techniques when compared to other conservative treatments for TMD. Conclusions: Musculoskeletal manual approaches are effective for treating TMD. In the short term, there is a larger effect regarding the latter when compared to other conservative treatments for TMD. Key Indexing Terms: Spinal Manipulation; Scoliosis; Adolescent; Cobb Angle; Systematic Review
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
Musculoskeletal manual techniques have a significant effect in treating pain during active mouth opening and increasing active ROM for patients with TMD compared to other conservative therapy treatments.
Key Finding #2
Musculoskeletal manual techniques have no significant effects in increasing passive ROM for patients with TMD compared to other conservative treatments.
Key Finding #3
Musculoskeletal manual techniques have no significant effects in decreasing resting pain in patients with TMD compared to other conservative treatments.
Please provide your summary of the paper
In this study, the authors performed a systematic review and meta-analysis to assess the effectiveness of musculoskeletal manual techniques in addressing pain (resting and with jaw movement) and ROM (both active and passive) in patients with temporomandibular joint disorder (TMD). The authors performed searches in PubMed, Cochrane Library, PEDro, and ISI web of knowledge databases, which yielded 308 articles. After assessing these articles against selection criteria, 8 articles were selected for this systematic review. The authors only included randomized control trials (RCTs) in an attempt to strictly assess the effect that musculoskeletal manual techniques have on TMD patients in comparison to other conservative techniques. They also excluded studies where patients had a history of surgery for TMD or when musculoskeletal manual techniques were used in conjunction with other interventions. This was done in an attempt to fully isolate musculoskeletal manual interventions as the sole independent variable. For the meta-analysis component of this study, the authors selected data from each study that was the closest data point to the last recorded intervention. To assess the quality of each study in the systematic review, the authors used the PEDro scale. As a result, the authors found that 5 of the 8 studies were of high quality and 3 were of low quality. The interventions that were used in the studies and categorized as musculoskeletal manual techniques ranged widely in type and dosage. They ranged from utilizing the intervention during a single session to utilizing it for 24 weeks at a frequency of 1-3 times/week. The number of musculoskeletal manual techniques used ranged widely across studies from 1-5 techniques used as did the number of interventions used within the control groups (ranged 1-5). The types of interventions used in the experimental groups were highly variable and included but were not limited to mandibular distraction mobilization, mandibular passive traction and translation, myofascial release in jaw elevator muscle, muscle energy thrusts, and accessory movements. Control group interventions included but were not limited to superficial massage, splint therapy, TENS, hot and cold packs, stretching, breathing exercises, and resistance exercises. For the quantitative component portion of the study, the authors utilized Standardized Mean Difference (SMD) for ROM outcomes and Mean Difference (MD) for pain outcomes. Both the SMD and MD values were separately pooled using a random effects model to determine the effect size that musculoskeletal manual techniques had on pain and ROM. The analysis found that the musculoskeletal manual techniques had a significant difference compared to control groups in improving pain with mouth opening and active ROM improvements for TMD patients. They analysis also found that musculoskeletal manual techniques did not have significant effects in increasing passive ROM or decreasing resting pain for TMD patients.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This systematic review found that a statistically meaningful effect exists for the use of musculoskeletal manual techniques in comparison to control groups for alleviating pain with jaw motion and increasing active ROM for patients with TMD. They also found that musculoskeletal manual techniques do not have a statistically significant difference in alleviating resting pain and passive ROM compared to control groups for patients with TMD. These findings are important as they indicate there is clinical utility in utilizing musculoskeletal manual techniques for TMD patients. The study also did a good job of delineating the patient outcomes that these techniques help improve versus outcomes that they do not help improve. Therefore, based on these findings, musculoskeletal manual techniques could be used for patients with TMD who are seeking improvements in reducing pain associated with jaw motions and seeking increases in jaw active ROM. While these findings are significant and meaningful, the study does have certain limitations to consider. First, only 8 total studies were included in this systematic analysis and of the 8, only 5 were identified as high-quality studies while the remaining 3 were considered low quality. Across the 8 studies, there was also significant heterogeneity, which introduces a challenge when drawing conclusions. Lastly, a wide range of intervention techniques and dosing choices of these techniques were utilized across the studies. This makes it difficult for the reader to determine which techniques are most useful and at what dosage parameters. Instead, the reader can only conclude that, in general, musculoskeletal manual techniques have positive effects on alleviating pain with jaw motion and increasing active ROM for TMD patients.
