TMJ

Article: Thorp JN, Willson J. Thoracic spine manipulation did not improve maximal mouth opening in participants with temporomandibular dysfunction. Physiother Res Int. 2020 Apr;25(2):e1824.

Full Text

Study Design: Quasi-Experimental Study Abstract: Temporomandibular joint disorders (TMD) have a prevalence of more than 5% in the general population. A positive correlation exists between temporomandibular joint mobility and cervical spine mobility. Similarly, a relationship exists between thoracic and cervical spine mobility. However, it is unknown if interventions to improve the mobility of the thoracic spine positively impact temporomandibular joint motion and pain. This study tested the hypothesis that a single thoracic thrust joint manipulation (TJM) would improve maximum mouth opening (MMO) compared with participants without TMD as well as decrease TMD symptoms. Forty-eight people with TMD (30.9 years old ±11.3) and 55 people without TMD (28.5 years old ±9.2) participated. Both groups received a seated upper thoracic TJM and were measured for MMO before and immediately following the TJM. The duration of TMD symptoms and pre-thrust current pain, using the 11-point Verbal Pain Rating Scale (VPRS), was recorded in the TMD group. Participants in the TMD group were contacted 2-3 days after TJM to report current VPRS and improvement utilizing the Global Rating of Change (GROC) scale. No difference in MMO treatment response over time was observed between groups (p = .56). The MMO in the TMD group improved from 40 to 41.3 mm, and the non-TMD similarly improved from 44.5 to 45.4 mm. The VPRS decreased from 2.4 (±1.8) to 1.3 (±1.5) following thoracic TJM (p < .001), and the average GROC score was 1.8 (±2.25), which was statistically different than zero (no change; p < .001). The duration of TMD symptoms prior to TJM was not associated with GROC scores (r = .018, p = .90) or VPRS change scores (r = -.07, p = .64). The observed treatment effects did not exceed previously reported standards for clinical relevance (5 mm and 2 points, respectively)..

NIH Risk of Bias Score: 6/14 (High Risk of Bias) Key Findings of the Study:

1. The control group appears to have responded to the request for study participation but were placed in the “no TMD” group if they did not have symptoms

2. There were no significant short term differences between groups

3. An upper thoracic based manipulation does not seem to influence maximal mouth opening.

Reviewer Summary: This was a difficult paper to follow. Since it was not an RCT, using the NIH Risk of Bias for comparative studies truly effected its risk of bias score. They did a nice job of capturing cervical range of motion and MMO. The outcomes was only 2 to 3 days after the single treatment. I would not expect an upper thoracic manipulation to change MMO so the results are likely true.

Author Names

La Touche, R., Garcia, S., Garcia, B., Acosta, A., Juarez, D., Perez, J., Angualo-Diaz-Parreno, S., Cuenca-Martinez, F., Paris-Alemany, A., Suso-Marti, L.

Reviewer Name

Anastasia Engelsman

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective. To assess the effectiveness of cervical manual therapy (MT) on patients with temporomandibular disorders (TMDs) and to compare cervico-craniomandibular MT vs cervical MT. Design. Systematic review and meta-analysis (MA). Methods. A search in PubMed, EMBASE, PEDro, and Google Scholar was conducted with an end date of February 2019. Two independent reviewers performed the data analysis, assessing the relevance of the randomized clinical trials regarding the studies’ objectives. The qualitative analysis was based on classifying the results into lev- els of evidence according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Results. Regarding cervical MT, MA included three studies and showed statistically significant differences in pain in- tensity reduction and an increase in masseter pressure pain thresholds (PPTs), with a large clinical effect. In addition, the results showed an increase in temporalis PPT, with a moderate clinical effect. MA included two studies on cervi- cal MT vs cervico-craniomandibular MT interventions and showed statistically significant differences in pain inten- sity reduction and pain-free maximal mouth opening, with a large clinical effect. Conclusions. Cervical MT treatment is more effective in decreasing pain intensity than placebo MT or minimal intervention, with moderate evidence. Cervico-craniomandibular interventions achieved greater short-term reductions in pain intensity and increased pain- free MMO over cervical intervention alone in TMD and headache, with low evidence.

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

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Yes

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

• Yes

Key Finding #1

Tempo mandibular joint disorder can be treated with cervical or craniomandibular manual therapy interventions and may be even more effective than cervical interventions alone.

Key Finding #2

In comparison to no intervention or cervical intervention alone, manual therapy significantly decreased pain intensity and pressure pain thresholds.

Please provide your summary of the paper

It has been well known that manual therapy is an effective treatment for tempo mandibular joint disorder (TMD), however, it is unknown which area or type of intervention may produce the most effective outcomes. The purpose of this study was to analyze current research for the effectiveness of cervical manual therapy (MT) in patient with TMD and to compare the usefulness of cervico-craniomandibular MT treatment vs cervical treatment. Two researchers conducted a PRISMA-based search for relevant literature to complete the systematic review and meta-analysis. Articles were chosen based on their relevance to the studies objectives, inclusion criteria, and publication before 2019. 6 articles were found to fit all criteria, and it was discovered that cervical MT treatment is more effective at reducing pain than no MT intervention. Furthermore, cervico-craniomandibular MT interventions achieved greater short-term reductions in pain intensity than cervical intervention alone in individuals with TMD.

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

This review demonstrated that TMD may be treated successfully with cervical or craniomandibular MT interventions and may be even more effective than cervical interventions alone. In comparison to no intervention or cervical intervention, MT significantly decreased pain intensity and pressure pain thresholds. Due to the nature of the review, however, the forms of MT intervention were not uniform in terms of type of manipulation, amplitude, and frequency. More research is needed to determine the most advantageous type and frequency of manipulations for tempo mandibular disorders. In the present, clinicians should utilize MT in the treatment of TMD in addition to other cervical or cervico-craniomandibular interventions.

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

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Yes

8. 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.

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

1. Is the review based on a focused question that is adequately formulated and described?

• Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Yes

8. 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.

Author Names

Asquini, G., Pitance, L., Michelotti, A., Falla, D.

Reviewer Name

Wes Pritzlaff, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Within physical therapy, manual therapy is known to be effective for managing temporomandibular disorders (TMDs). However, manual therapy is a broad term including different approaches applied to different body regions.  Aims: This is the first systematic review that aims to evaluate the effectiveness of manual therapy applied specifically to the craniomandibular structures (Cranio-Mandibular Manual Therapy [CMMT]) on pain and maximum mouth opening in people with TMD.  Material and methods: This systematic review was developed based on a pre-determined published protocol which was prospectively registered with PROSPERO (CRD42019160213). A search of MEDLINE, Embase, CINAHL, ZETOC, Web of Science, SCOPUS, PEDro, PubMed, Cochrane Library and Best Evidence, EBM reviews-Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature ChiroAccess and Google Scholar databases was conducted from inception until October 2020. Randomised controlled trials comparing the effect of CMMT on pain and maximum mouth opening versus other types of treatment in TMDs were included. Two reviewers independently screened articles for inclusion, extracted data, assessed risk of bias with the revised Cochrane risk of bias tool for randomised trials and evaluated the overall quality of evidence with the Grading of Recommendations, Assessment, Development and Evaluations.  Results: A total of 2720 records were screened, of which only 6 (293 participants) satisfied the inclusion criteria. All studies showed some concerns in risk of bias, except for one, which was high risk of bias. The overall quality of evidence was very low for all outcomes because of high heterogeneity and small sample sizes. All studies showed a significant improvement in pain and maximum mouth opening for CMMT from baseline in the mid-term, but only two showed superiority compared to other interventions. Given the high heterogeneity and small sample sizes of the included studies, a quantitative synthesis was not performed.  Discussion and conclusion: There is the need for future high methodology research investigating different manual therapy techniques applied to different regions and different populations (e.g., chronic versus acute TMD) to determine what is most effective for pain and maximum mouth opening in patients with TMDs.

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

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Yes

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

• Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Due to heterogeneity in types of Cranio-Mandibular Manual Therapy (CMMT), temporomandibular disorders (TMD), comparison groups, and time points of assessment, there is very low quality of evidence supporting that Cranio-Mandibular Manual Therapy (CMMT) alone reduces pain and increases maximum mouth opening (MMO) by clinically significant amounts.

Key Finding #2

CMMT is suggested to be superior to sham therapy and self-care with exercise therapy, however, not superior to Kinesio tape or photobiomodulation therapy in reducing pain intensity (very low quality of evidence).

Key Finding #3

CMMT is suggested to be superior to sham therapy and no treatment, however, not superior to self-care with exercise, splint therapy, or photobiomodulation therapy in increasing maximum mouth opening (very low quality of evidence).

Key Finding #4

There are limited studies with a high methodology quality comparing CMMT alone to other interventions. More randomized controlled trials are needed to understand whether CMMT is superior to other treatments in reducing pain, increasing MMO, or improving other outcome measures in individuals with TMD.

Please provide your summary of the paper

This systematic review without meta-analysis (due to heterogeneity and small sample sizes) sought to evaluate the effectiveness of Cranio-Mandibular Manual Therapy (CMMT) on pain and temporomandibular joint (TMJ) range of motion in people with temporomandibular disorders (TMD). Primary outcome measures included maximum mouth opening (MMO; measured using a ruler) and pain intensity (measured via VAS or NPRS). While 2,720 articles were screened based on search criteria, only six were included in this systematic review. These articles were randomized controlled trials that did not combine CMMT with other interventions in treating patients with TMD. There was high heterogeneity in types of CMMT, TMD, comparison group, and time point of assessment of primary outcomes. CMMT techniques utilized across the six studies included intraoral myofascial therapy, oscillatory Grade IV TMJ mobilizations, facial massage, manual therapy applied to TMJ and masticatory muscles, and masticatory muscle trigger point release. TMD diagnoses across the six studies included chronic, acute, myogenic, arthrogenic, and mixed. Comparison groups to CMMT across the six studies included sham treatment, control group, self-care and exercise, splint, Kinesio tape, and photobiomodulation therapy. Lastly, the time of assessment of pain and MMO varied from immediate, five days, and from four weeks to one-year post-treatment across the six studies. All studies showed a moderate-to-high risk of bias based on the randomization procedure, failure to publish a study protocol a priori, the selection of the reported results, assessor awareness of interventions received, or small sample sizes. While all six included studies demonstrated clinically significant improvements in pain intensity and MMO, the quality of evidence is considered very low due to small sample sizes, high heterogeneity, and moderate-to-high risk of bias. These results suggest that CMMT may be more effective than sham therapy or no treatment, but do not suggest CMMT’s superiority to splint therapy, photobiomodulation, Kinesio tape, or self-care with exercise therapy in reducing pain or improving MMO at various time points in individuals with varying types of TMD. There were many limitations to this systematic review, including an inability to complete a meta-analysis due to bias, heterogeneity, and sample sizes.

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

The limitations of moderate-to-high bias, heterogeneity in the type of CMMT, TMD, comparison group, and time point of assessment, and small sample sizes across the six studies result in conclusions with a very low quality of evidence. While the results of this systematic review support the use of CMMT to reduce pain intensity and improve MMO across time points in individuals with varying types of TMD, clinicians should be curious and critical about these recommendations. Clinicians may utilize motivational interviewing and shared-decision making to understand if an individual with TMD is appropriate for CMMT alone or in conjunction with other therapy to reduce pain and improve MMO. This systematic review identifies the lack of high-quality randomized controlled trials comparing CMMT alone compared to other treatments; therefore, more research is necessary to better understand how various types of CMMT may affect patients with various types of TMD at various time points post-treatment compared to various interventions.

Author Names

Armijo-Olivo, Susan; Pitance, Laurent; Singh, Vandana; Neto, Francisco; Thie, Norman; Michelotti, Ambra

Reviewer Name

Gabrielle Stanley, Duke SPT 2

Reviewer Affiliation(s)

University of California-Davis B.S. Human Development 2019

Paper Abstract

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. 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. Electronic data searches of 6 databases were performed, in addition to a manual search.   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.nData were extracted in duplicate on specific study characteristics.  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. Quality of the evidence and heterogeneity of the studies were limitations of the study. 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

1. Is the review based on a focused question that is adequately formulated and described?

• Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• Cannot Determine, Not Reported, Not Applicable

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Cannot Determine, Not Reported, Not Applicable

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Cannot Determine, Not Reported, Not Applicable

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

• No 

Key Finding #1

No high-quality evidence was found indicating the uncertainty of effectiveness for manual therapy in the treatment of TMD; however, low quality evidence does indicate that a combination of manual therapy of the orofacial region in conjunction with manual therapy of the cervical spine is more effective than home exercises in treatment of people with mixed TMD.

Key Finding #2

Cervical spine manual therapy appears to be more effective in the treatment of pain reduction in patients with myogenous TMD more so than the orofacial region manual therapy.

Please provide your summary of the paper

This research includes systemically selected research protocols comparing groups who received manual therapy or manual therapy in conjunction with exercise to control groups who received only exercise or no treatment at all. While the method for collecting data was systemic, and risk of bias was analyzed, the research itself that was being reviewed was low to moderate quality. This research indicates that cervical manual therapy in conjunction with orofacial manual therapy is the most effective manual therapy intervention for TMD, followed by solely cervical treatment, and lastly solely orofacial treatment. However, for these claims to be incorporated into best practice interventions, higher quality research must first be assessed.

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

While this meta-analysis gathered data suggesting that combined orofacial and cervical manual therapy are successful in the treatment of pain reduction in mixed TMD, the quality of the evidence which suggests this is low. In order to incorporate manual therapy into recommended clinical practice guideline for treating TMD, first higher quality research must be conducted.