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.

Reviewer Name

Raymond Huang, CSCS

Reviewer Affiliation(s)

Duke University, School of Medicine, Doctor of Physical Therapy

Paper Abstract

Background: Temporomandibular joint disorders (TMJDs) are the main musculoskeletal cause of orofacial pain. This study aimed to assess the efficacy of manual therapy and routine treatment compared with routine treatment on pain, maximum mouth opening (MMO), and cervical range of motion (ROM) in patients with the temporomandibular joint disorder (TMJD). Methods: This study was performed at the biomechanics laboratory of the physiotherapy department of Iran University of Medical Sciences, Tehran, Iran. A total of 30 patients with TMJD were randomized into 2 groups: an intervention group (manual therapy plus routine treatment) and a control group (conventional treatment). Treatment included 10 sessions. The primary outcome was pain intensity and the secondary outcomes were MMO, and range of cervical flexion and extension. The outcomes were measured at the baseline, at the end of the treatment, and after a 4-week follow-up period. The repeated measures analysis of variance was used to assess group × time interaction, and the Bonferroni adjustment was used for between-group comparisons. The effects size of Cohen’s d was used to determine the magnitude of between-group differences. Results: The results showed that there were significant group × time interactions for pain, MMO, and the cervical flexion ROM (P&lt;0.001). In comparion with the baseline, the intervention group showed significant improvements in jaw pain, MMO, and cervical flexion ROM (P&lt;0.001), while in the control group, compared with the baseline, only pain and MMO significantly improved (P&lt;0.05). Results of between-group comparisons revealed that there were significant and clinical differences between the 2 groups after treatment, and the intervention group had lower jaw pain, more MMO, and cervical flexion than the control group (P&lt;0.001). In addition, the efficacy of manual therapy based on the Cohen’s d was large for the outcomes of pain, MMO, and cervical flexion. Conclusion: The findings showed that adding manual therapy of the upper cervical spine and TMJ to the routine treatment could be an effective intervention for patients with TMD.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

No

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

No

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Yes

Key Finding #1

Manual therapy significantly reduced jaw pain intensity and improved maximum mouth opening and cervical flexion ROM compared to routine treatment.

Key Finding #2

Patients receiving manual therapy demonstrated greater improvements in pain and functionality than those receiving only routine treatment, with effects persisting at a 4-week follow-up.

Please provide your summary of the paper

This study evaluated the effectiveness of adding manual therapy for temporomandibular joint disorders (TMJD) and upper cervical spine to routine conservative treatment in. The researchers compared its impact on pain intensity, maximum mouth opening (MMO), and cervical range of motion (ROM). When the researchers added manual therapy to their patient’s treatment plan, they found that it had better outcomes compared to just conservative treatment.

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

We should be implementing manual therapy in patients TMJD for better outcomes as they are seen to have better persistence in their outcomes.

Article Full Title 

Effectiveness of Manual Therapy, Physical Therapy in Conjunction with Patient Education for Temporomandibular Disorders: A Randomized Controlled Study  

Author Names 

Saeed Ullah Shah, Sana Shakil Khan, Sadia Moin, Shumaila Younus, Hina Jabeen, Kanwal Safeer  

Reviewer Name 

Julie Bottarini, SPT  

Reviewer Affiliation(s) 

Duke University School of Medicine, Doctor of Physical Therapy Division  

Paper Abstract 

Background: Temporomandibular joint (TMJ) disorders represent a significant health concern affecting a substantial portion of the population worldwide. The management of TMJ disorders often involves a multifaceted approach including physiotherapy techniques, manual exercise interventions, patient education, and medication therapy. The purpose of this research is to examine the “Effectiveness of manual therapy, and physical therapy in conjunction with patient education for temporomandibular disorders”. 

Methods: Forty patients with TMDS were randomized into two groups: one for home physical therapy and the other for manual therapy plus physical therapy. Patient education and counseling were done in both groups. the patient had assessments both before and after. 

Results: The study made a comparison of two groups: one received physical therapy only (n=20) and the other group received a combination of physical and manual therapy (n=20). There were no significant differences between the two groups in terms of age, gender distribution, or the affected side of the face (p>0.05). 

Conclusions: For TMJ issues, physical therapy patient education is a useful therapeutic method. Moreover, combining these modalities with manual therapy improves results beyond what would be achieved with just these modalities alone. 

Quality Assessment of Controlled Intervention Studies 

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT 

1. Yes 

1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 

1. Yes 

1. Was the treatment allocation concealed (so that assignments could not be predicted)? 

1. Yes 

1. Were study participants and providers blinded to treatment group assignment? 

1. Yes 

1. Were the people assessing the outcomes blinded to the participants’ group assignments? 

1. Yes 

1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 

1. Yes 

1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 

1. Yes 

1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? 

1. Yes 

1. Was there high adherence to the intervention protocols for each treatment group? 

1. No 

1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

1. Unknown  

1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 

1. Unknown  

1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? 

1. No 

1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 

1. Unknown  

1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? 

1. Yes 

Key Finding #1 

No significant difference in resting VAS after treatment between the groups. 

Key Finding #2 

No significant difference in VAS with function after treatment between groups.  

Please provide your summary of the paper: 

This study looked at two separate groups of patients with TMJ pain. The first group consisted of 20 individuals who received education and a home exercise program. The second group consisted of 20 individuals who received education, a home exercise program, and manual therapy interventions. Education included information on the underlying causes of pain, reducing caffeine intake, eating a soft diet, properly hydrating, controlling muscle hyperactivity, teaching breathing exercises and relaxation techniques, and providing them with mandibular exercises. The manual therapy interventions included TMJ soft tissue mobilization, coordination exercises, mobilization of the cervical spine, and techniques for post-isometric relaxation and stretching. The results of the study showed that pain at rest and with function decreased significantly in both groups post treatment, but there was no significant difference between the treatment groups. Pain-free maximum mouth opening increased significantly in both groups post treatment with no significant difference between treatment groups.  

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

This study shows that improvements can be made in pain management with the use of physical therapy exercises, education, and manual therapy. Manual therapy was not shown to be a superior form of pain management in this study, so therapists should use their clinical judgement to create a treatment plan that is specific to their patient. I would not recommend using this study in clinical practice because it does not outline what interventions were performed, and no parameters for exercise are given. There is conflicting information on what was performed in the two separate groups. The study says that one group received education and an HEP, and the other group received education, an HEP, and manual therapy intervention. However, a different sentence says that both groups received manual therapy 3x per week. This paper should be used with caution due to conflicting statements within the study and an inability to replicate the study due to missing information.  

Article Full Title:  

Manual Therapy Applied to the Cervical Joint Reduces Pain and Improves Jaw Function in Individuals with Temporomandibular Disorders: A Systematic Review on Manual Therapy for Orofacial Disorders 

Author Names:  

Fernanda M.G. Liberato, Thiago V. da Silva, Cintia H. Santuzzi, Néville Ferreira Fachini de Oliveira, and Lucas R. Nascimento 

Reviewer Name:  

Abbie Bushinski, SPT 

Reviewer Affiliation(s):  

Duke University Doctor of Physical Therapy Division  

Paper Abstract: 

Aims: To examine the effect of manual therapy applied to the cervical joint for reducing pain and improving mouth opening and jaw function in people with TMDs. 

Methods: A systematic review of randomized controlled trials was performed. Participants were adults diagnosed with TMDs. The experimental intervention was manual therapy applied to the cervical joint compared to no intervention/placebo. Outcome data relating to orofacial pain intensity, pressure pain threshold (PPT), maximum mouth opening, and jaw function were extracted and combined in meta-analyses. 

Results: The review included five trials involving 213 participants, of which 90% were women. Manual therapy applied to the cervical joint decreased orofacial pain (mean difference: –1.8 cm; 95% CI: –2.8 to –0.9) and improved PPT (mean difference: 0.64 kg/cm2; 95% CI: 0.02 to 1.26) and jaw function (standardized mean difference: 0.65; 95% CI: 0.3 to 1.0). 

Conclusion: Manual therapy applied to the cervical joint had short-term benefits for reducing pain intensity and improving jaw function in women with TMDs. Further studies are needed to improve the quality of the evidence and to investigate the maintenance of benefits beyond the intervention period. J Oral Facial Pain Headache 2023;37:101–111. doi: 10.11607/ofph.3093 

Keywords: manipulation, mobilization, massage, pain, rehabilitation, temporomandibular joint 

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? 

Yes 

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

Yes 

1. Was publication bias assessed? 

Not sure  

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

Not sure 

Key Finding #1 

Low-quality evidence indicated that manual therapy applied to the cervical joint reduced orofacial pain intensity by –1.8 cm in individuals with < 12 months of pain duration and individuals with a pain duration > 12 months. 

Key Finding #2 

Low-quality evidence indicated that manual therapy applied to the cervical joint improved pain pressure threshold (PPT) by 0.64 kg/cm2 in individuals with < 12 months of pain. 

Key Finding #3 

Low-quality evidence indicated that manual therapy applied to the cervical joint may have a small effect on maximum mouth opening (MD 1.5 mm).  

Key Finding #4 

Moderate-quality evidence indicated that manual therapy applied to the cervical joint improved jaw function by an SMD of 0.65 in individuals with pain for > 12 months. 

Please provide your summary of the paper 

This systematic review identified 814 papers for possible inclusion. However, preliminary screenings and inclusion criteria resulted in only 5 papers being included in the review. The 5 included trials had a combined total of 213 participants. Each trial studied the effects of manual therapy to improve orofacial pain intensity, maximum mouth opening, and jaw function when manual therapy was applied to the cervical joint. Participants underwent 4 weeks of interventions; they received 3-9 repetitions of manual therapy 1-3 times per week. Manual therapy consisted of massage therapy, joint mobilization, or manipulation to the cervical joint, muscles, or connective tissues. Each trial measured orofacial pain intensity, pain pressure threshold (PPT), mouth opening, and jaw function. Orofacial pain intensity was measured using the VAS, PPT was measured using a pressure algometer, mouth opening was measured using calipers or a digital ruler, and jaw function was measured by the Mandibular Function Impairment Questionnaire. The results were then compared to control groups in each study with the aim of determining the effects of the manual therapy techniques on jaw function. Overall, the review concluded that manual therapy to the cervical joint can cause short-term benefits to pain intensity and jaw function in patients with TMDs. Further high-quality research is needed to determine the long-term effects of cervical manual therapy on pain and jaw function.  

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

The reviewed literature ranged from low to moderate quality studies. Therefore, a sound conclusion on the effectiveness of manual therapy to improve jaw function is difficult to determine at this time. Additionally, the subject pool of the included studies consisted of 90% females. Due to the lack of research completed on the male population caution should be used when translating the effects to male patients. Future studies need better inclusion criteria for patients to standardize the pain intensity and cervical impairments of the participants so that better conclusions on jaw function can be drawn. In conclusion, further high-quality studies are needed to determine the effectiveness of cervical joint manual therapy to improve jaw function in patients with TMDs before a sound conclusion can be made and before treatment implementation into clinical practice can be fully supported.  

Article Full Title:  

The Efficacy of Manual Therapy Approaches on Pain, Maximum Mouth Opening and Disability in Temporomandibular Disorders: A Systematic Review of Randomised Controlled Trials  

Author Names 

Leonardo Sette Vieira, Priscylla Ruany Mendes Pestana, Priscylla Ruany Mendes Pestana, Luana Aparecida Soares, Fabiana Silva, Marcus Alessandro Alcantara, and Vinicius Cunha Oliveira 

Reviewer Name 

Kaila Claiborne 

Reviewer Affiliation(s) 

Doctor of Physical Therapy Program, Duke University  

Paper Abstract 

Temporomandibular disorder (TMD) is a common condition disabling people and bringing up costs. The aim of this study was to investigate the effects of manual therapy on pain intensity, maximum mouth opening (MMO) and disability. Searches were conducted in six databases for randomized controlled trials (RCTs). Selection of trials, data extraction and methodological quality assessment were conducted by two reviewers with discrepancies resolved by a third reviewer. Estimates were presented as mean differences (MDs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs). Quality of the evidence was assessed using the GRADE approach. Twenty trials met the eligibility criteria and were included. For pain intensity, high and moderate quality evidence demonstrated the additional effects of manual therapy at short- (95% CI −2.12 to −0.82 points) and long-term (95% CI −2.17 to −0.40 points) on the 0–10 points scale. For MMO, moderate to high quality evidence was found in favour of manual therapy alone (95% CI 0.01 to 7.30 mm) and its additional effects (95% CI 1.58 to 3.58 mm) at short- and long-term (95% CI 1.22 to 8.40 mm). Moderate quality evidence demonstrated an additional effect of manual therapy for disability (95% CI = −0.87 to −0.14). Evidence supports manual therapy as effective for 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 

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?  

YES 

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

 YES 

1. Was publication bias assessed?  

NO 

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

NO 

Key Finding #1 

 The first finding of this systematic review is that manual therapy techniques such as myofascial release, joint mobilizations, soft tissue manipulation, and massage helps to decrease the intensity of pain for patients with TMD. The decrease in pain from these interventions were found to provide short term relief.  Despite the small study size which may impact clinical significance, it was concluded that manual therapy leads to pain reduction in patients with temporomandibular disorders. The evidence was deemed to be moderate to high quality in its significance decrease pain intensity.  

Key Finding #2 

Individuals with TMD may experience decreases in their ability to maximally open their mouth. The second key finding from the systematic review is that there was an increase in the ability to maximally open the mouth after receiving manual therapy in patients with TMD. The improvement in mouth opening ROM was supported with moderate to high quality evidence. 

Key Finding #3 

The third key finding focused on the functional ability of patients with TMD and the impact of manual therapy on disability. Patients with TMD may have difficulty with basic functional task such as chewing, speaking, and yawning. Difficulty with these tasks are due to the pain and decreased mobility of the joint. The systematic review found that many studies used the jaw functional limitation scale to measure functional disability. It was concluded that manual therapy improved these scores and decreased limitation in daily functional task.  

Key Finding #4 

The last key finding of the systematic review was that there was much variability in the types of manual therapy implanted and the duration of the techniques used. There were also different types of TMD within the studies. Due to the lack of consistency between the studies it is hard to generalize whether manual therapy for these patients will be beneficial. The review also states that the long-term impact of these interventions are not yet known and that a study of higher quality and longer duration of follow up should be conducted.  

Please provide your summary of the paper 

This systematic review explored the effect of manual therapy on individuals with temporomandibular disorder. The three areas of pain intensity, maximal mouth opening, and functional disability were used to track progress of the interventions. Interventions used included joint mobilization, soft tissue manipulation, and myofascial release. It was concluded that these interventions led to an improvement in the three areas used as outcomes. However, the benefit of these interventions were deemed to be short term. It was determined that there were several limitations in these studies. The lack of longevity of the study, small sample size, and high volume of variability makes it difficult to generalize the findings of these studies on the overall effect on individuals with TMD. Further research is needed with a long term follow up period and an increase in standardization to assess the long-term impact on these interventions as well as the efficacy of the interventions.  

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

As a future clinician, I support the use of joint mobilization, myofascial release, and soft tissue manipulation in the plan of care for patient with temporomandibular disorder. These interventions have been shown to decrease pain intensity, increase maximal mouth opening, and decrease functional mobility. Although the results are deemed to be a short-term relief of pain and improvement of symptoms, they are still very beneficial in increasing functional mobility in these patients and allowing them to get back to simple yet meaningful task such as yawning, chewing, and speaking.  

Article Full Title 

Effectiveness of deep dry needling versus manual therapy in the treatment of myofascial temporomandibular disorders: a systematic review and network meta-analysis 

Author Names 

Ángela Menéndez-Torre,  Aitor Martín Pintado-Zugasti, Juan Nicolás Cuenca Zaldivar, Paula García-Bermejo, Diego Gómez-Costa, Miguel Molina-Álvarez, Alberto Arribas-Romano, Josué Fernández-Carnero 

Reviewer Name 

Julia Douglas 

Reviewer Affiliation(s) 

Duke DPT 

Paper Abstract 

Background: Temporomandibular disorders (TMDs) are the most common cause of orofacial pain of non-dental origin, with approximately 42% of diagnoses corresponding to myofascial pain. Manual therapy and dry needling are commonly used interventions for the treatment of myofascial temporomandibular disorders. However, it is unclear whether one of them could be superior to the other. 

Objectives: The aim of the present systematic review and network meta-analysis was to compare the effectiveness of manual therapy and dry needling in patients with myofascial TMD. 

Methods: This is a systematic review and network meta-analysis. Randomized clinical trials were searched in the databases of Pubmed, PEDro, CINAHL, Web of Science, Scopus, Cochrane, Google Academic and EMBASE. The methodological quality of studies included in this review was judged using the Physiotherapy Evidence Database (PEDro) scale. A frequentist network meta-analysis was carried out, assuming random effects, to estimate the effects of interventions for temporomandibular joint pain measured on a 10-point visual analogue scale. 

Results: Out of 3190 records identified, 17 met the inclusion criteria for qualitative analysis and eight were included in the network meta-analysis. Indirect comparisons between dry needling and manual therapy showed no significant differences in their effects on pain reduction (Odds Ratio [95%CI]; – 0.263 [- 1.517, 0.992]). The ranking of treatments shows that manual therapy (SUCRA = 0.932) followed by deep dry needling (SUCRA = 0.775) present the highest values of estimation and can be considered the most likely to reduce pain. 

Conclusions: The results of the network meta-analysis should be considered with caution due to the low quality of the evidence available and the high variability of the study protocols in terms of the method of application of dry needling and manual therapy interventions. PROSPERO under identifier: (CRD42020186470). 

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? 

Yes 

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

Yes 

1. Was publication bias assessed? 

No 

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

N/A 

Key Finding #1 

Both manual therapy and deep dry needling are effective in reducing pain in patients with TMD. 

Key Finding #2 

There is no statistically significant difference between manual therapy and deep dry needling in terms of pain reduction. 

Key Finding #3 

Manual therapy has a slightly higher probability of being the most effective intervention, when compared to deep dry needling. 

Key Finding #4 

Available evidence exploring the effectiveness of manual therapy versus deep dry needling for patients with TMD is of low quality, and more rigorous, high-quality RCTs are needed to provider stronger conclusions. 

Please provide your summary of the paper 

This systematic review and meta-analysis investigates which treatment tis more effective for reducing pain in patients with myofascial temporomandibular disorders (TMD). TMD is a common cause of orofacial pain, with much of this pain attributed to myofascial pain. This study review 17 randomized controlled trials (RCTs), 8 of which are included in the meta-analysis. It compares the effects of manual therapy and dry needling on pain reduction in TMJ patients. The findings found no significant different between the two treatments, with manual therapy ranking slightly higher in effectiveness when compared with dry needling. Both manual therapy and dry needling were found to be superior to botulinum toxin and cognitive therapy, as well as the placebo. In addition, the study highlighted the limited quality and variability of this evidence, and suggested the need for more consistent and methodologically rigorous research to draw definitive conclusions 

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 and meta-analysis provides insight into the management of TMD by comparison of deep dry needling and manual therapy. The findings show that both treatment modalities are effective for reducing pain, however there is no statistically significant difference between them. Manual therapy demonstrated a slightly higher probability of success in reducing short-term pain. In clinical practice, clinicians should consider both manual therapy and deep dry needling as options for TMD management, and the choice should be tailored based on patient preference, comfort, and clinical presentation.  

Article Full Title  

Evaluation of the Effectiveness of Dry Needling in the Treatment of Myogenous Temporomandibular Joint Disorders 

Author Names 

Dib-Zakkour, J., Flores-Fraile, J., Montero-Martin, J., Dib-Zakkour, S., & Dib-Zaitun, I. 

Reviewer Name 

Kayin Fails  

Reviewer Affiliation(s) 

Duke DPT  

Paper Abstract 

Background and Objectives: The objective of our clinical trial was to determine the effectiveness of the deep dry needling technique (DDN) (neuromuscular deprogramming) as a first step in the treatment of temporomandibular disorders. Methods and Materials: The double-blind randomized clinical trial comprised 36 patients meeting the inclusion criteria who had signed the corresponding informed consent form. The participants were randomly distributed into two groups, the Experimental group (Group E) and the Control group (Group C). Group E received bilateral DDN on the masseter muscle, while Group C received a simulation of the technique (PN). All the participants were evaluated three times: pre-needling, 10 min post-needling, and through a follow-up evaluation after 15 days. These evaluations included, among other tests: pain evaluation using the Visual Analog Scale (VAS) and bilateral muscle palpation with a pressure algometer; evaluation of the opening pattern and range of the mouth, articular sounds and dental occlusion using T-scans; and electromyography, which was used to evaluate the muscle tone of the masseter muscles, in order to control changes in mandibular position. Results: Digital control of occlusion using Tec-Scan (digital occlusion analysis) showed a significant reduction both in the time of posterior disclusion and in the time needed to reach maximum force in an MI position after needling the muscle, which demonstrated that there were variations in the static position and the trajectory of the jaw. The symmetry of the arch while opening and closing the mouth was recovered in a centric relation, with an increase in the opening range of the mouth after the procedure. Conclusions: facial pain is significantly reduced and is accompanied by a notable reduction in muscle activity after needling its trigger points. 

Quality Assessment of Controlled Intervention Studies 

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT 

double-blind randomized clinical trial 

1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 

Yes 

1. Was the treatment allocation concealed (so that assignments could not be predicted)? 

Yes  

1. Were study participants and providers blinded to treatment group assignment? 

Yes 

1. Were the people assessing the outcomes blinded to the participants’ group assignments? 

Yes 

1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 

Yes 

1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 

N/A 

1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? 

N/A 

1. Was there high adherence to the intervention protocols for each treatment group? 

Yes 

1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

N/A 

1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 

Yes 

1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? 

N/A 

1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 

N/A 

1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? 

Yes 

Key Finding #1 

One key finding of the study showed a significant reduction both in the time of posterior disclusion and in the time needed to reach maximum force in an MI position after needling the muscle, which demonstrated that there were variations in the static position and the trajectory of the jaw.  

Key Finding #2 

The second key finding showed the symmetry of the arch while opening and closing the mouth was recovered in a centric relation, with an increase in the opening range of the mouth after the procedure. 

Please provide your summary of the paper 

The study investigates the effectiveness of dry needling as a treatment for musculoskeletal pain and improving functional outcomes. The authors discuss the mechanisms behind dry needling, like its impact on myofascial trigger points, neuromuscular modulation, and central sensitization. The findings suggest that dry needling can provide a significant reduction in facial pain and a reduction in muscle activity after needling trigger points. However, the study also highlights the variability in patient responses and the need for further research to determine long-term efficacy and optimal treatment protocols.  

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

By alleviating muscle tightness, dry needling can help improve jaw mobility and alignment, allowing for better function during chewing and speaking. Patients often experience less jaw clicking, locking, and stiffness after treatment. When combined with manual therapy, graded jaw exercises, and behavioral interventions, dry needling can enhance overall treatment effectiveness. It may also reduce the need for medications or more invasive interventions like injections. 

Article Full Title: 

Effect of Manual Therapy and Therapeutic Exercise Applied to the Cervical Region on Pain and Pressure Pain Sensitivity in Patients with Temporomandibular Disorders: A Systematic Review and Meta-analysis 

Author Names 

La Touche, R., Martínez García, S., Serrano García, B., Proy Acosta, A., Adraos Juárez, D., Fernández Pérez, J. J., Angulo-Díaz-Parreño, S., Cuenca-Martínez, F., Paris-Alemany, A., & Suso-Martí, L. 

Reviewer Name 

Daniela Hernandez Rodriguez 

Reviewer Affiliation(s) 

SPT 

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 levels 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 intensity 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 cervical MT vs cervico-craniomandibular MT interventions and showed statistically significant differences in pain intensity 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. 

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? No 

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 

Cervical manual therapy treatments can be used on patients with Temporomandibular Disorders (TMD) due to its ability to produce statistically significant decrease in short-term pain.  

Key Finding #2 

Cervical manual therapy treatments can be used on patients with TMD due to its ability to produce statistically significant increases in masseter pressure pain thresholds. 

Key Finding #3 

Craniomandibular and cervical manual therapy produced a reduction in short-term pain intensity in patients with TMD.  

Key Finding #4 

Upper cervical and craniomandibular manual therapy have a greater impact when used together, in decreasing pain and improving overall function in a patient with TMD.   

Please provide your summary of the paper 

The article is a systematic review and meta-analysis that has two main objectives. First one is to assess how effective cervical manual therapy is for patients who have TMD. The second objective is to compare the effect of cervical manual therapy and craniomandibular manual therapy interventions for patients who have TMD. The articles findings are as followed. Cervical manual therapy manipulations have a statistically significant decrease in short-term pain. Additionally, cervical manual therapy can increase ROM of the mandibular joint and decrease pain sensitivity. Craniomandibular and cervical manual therapy produced a reduction in short-term pain intensity in patients with TMD. However, this finding should be used with caution because of the limited research and evidence provided.  

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

This article provides evidence for usage of cervical or craniomandibular manual therapy in clinic. These manipulations can be used with the TMD population and can be used adjacent with other interventions that may have otherwise caused too much pain for the patient. It may be possible to provide more aggressive PT with less discomfort for the patient. This article also shows the lack of literature and evidence for the effects of cervical manual therapy and craniomandibular manual therapy interventions. Further research should be conducted in this area so that clinicians have stronger clinical reasoning for their patients. 

Article Full Title:  

Additional effects of therapeutic exercise and education on manual therapy for chronic temporomandibular disorders treatment: a randomized clinical trial 

Authors:  

Cristian Justribó-Manion MSc, PT, Juan Mesa-Jiménez PhD, PT, Javier Bara-Casaus PhD, DDS, MD, Juan-Carlos Zuil-Escobar PhD, PT, Katarzyna Wachowska MSc, PT, and Gerard Álvarez-Bustins PhD, PT 

Reviewer Name: 

Grace Jager, SPT  

Reviewer Affiliation:  

Duke Doctor of Physical Therapy 

Paper Abstract: 

The study “Additional effects of therapeutic exercise and education on manual therapy for chronic temporomandibular disorders treatment: a randomized clinical trial” aimed at examining the benefits of a behavioral approach to treatment of craniofacial pain, evaluated the effects of integrating therapeutic exercise (TE) and pain neuroscience education (PNE) with manual therapy for chronic temporomandibular disorder (TMD) treatment. The study assessed pain intensity, jaw function, quality of life, kinesiophobia, and catastrophizing. 

A total of 34 participants were randomly assigned to either a manual therapy-only group or a behavioral group including a combination of manual therapy, TE, and PNE. Treatment was administered once per week for five weeks, targeting the temporomandibular joints (TMJs) and cervical areas through soft tissue techniques, joint mobilizations, and high-velocity low-amplitude (HVLA) manipulations. The primary outcome measure was the Craniofacial Pain Disability Inventory (CFPDI), along with secondary measures assessing pain, function, and quality of life at baseline, mid-treatment, post-treatment, and follow-up. All outcomes were collected five times: baseline, before the first intervention, before the third session, after the last session, two weeks post-intervention, and three months post-intervention.  

Results showed that while the behavioral approach had a limited immediate effect on craniofacial pain disability, it significantly reduced catastrophizing and kinesiophobia long-term, over time. These findings support the integration of TE and PNE with manual therapy to enhance treatment efficacy, improve pain perception, and promote functional recovery in individuals with chronic TMD. Further research with larger sample sizes and placebo controls is indicated to confirm these conclusions and optimize clinical application. 

 NIH Risk of Bias Tool – Quality Assessment of Controlled Intervention Studies 

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT? Yes 

1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? Yes 

1. Was the treatment allocation concealed (so that assignments could not be predicted)? Yes. 

1. Were study participants and providers blinded to treatment group assignment? Yes 

1. Were the people assessing the outcomes blinded to the participants’ group assignments? Yes 

1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, comorbid conditions)? Yes 

1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? Yes 

1. Was the differential drop-out rate (between treatment groups) at the endpoint 15 percentage points or lower? Yes 

1. Was there high adherence to the intervention protocols for each treatment group? Yes 

1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? Yes 

1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? Yes 

1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? Yes 

1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? Yes 

1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? Yes 

NIH Risk of Bias Score:  

Quality Assessment of Controlled Intervention Studies: 14/14  

High score, indicating the study has low bias, indicating strong reliability of findings.  

Key Finding #1: 

The behavioral group approach receiving manual therapy combined with therapeutic exercise and education showed limited impact on craniofacial pain and disability but significant reduction in long term catastrophizing and kinesiophobia than the group receiving manual therapy alone. 

Key Finding #2:  

Participants in the combined intervention group demonstrated greater functional improvements in jaw function and a reduction in disability. Benefits persisted at long-term follow-ups, indicating lasting improvements beyond the intervention period.  

Summary of Paper: 

This randomized clinical trial investigated the impact of adding therapeutic exercise (TE) and pain neuroscience education (PNE) to manual therapy for treating chronic temporomandibular disorder (TMD). Thirty-four participants were randomly assigned to either a manual therapy-only group or a group receiving manual therapy combined with TE and PNE. Treatments were administered once per week for five weeks, focusing on soft tissue techniques, joint mobilizations, and high-velocity low-amplitude (HVLA) manipulations targeting the temporomandibular joints (TMJs) and cervical spine. Outcome measures included the Craniofacial Pain Disability Inventory (CFPDI), pain intensity, jaw function, and quality of life, assessed at baseline, mid-treatment, post-treatment, and follow-up. While the combined approach had a limited immediate effect on craniofacial pain disability, it significantly reduced catastrophizing and kinesiophobia over time. These findings suggest that incorporating TE and PNE into manual therapy enhances long-term outcomes in chronic TMD management. The study provides preliminary evidence supporting a multimodal approach that integrates patient education and active rehabilitation. Further research with larger sample sizes and placebo controls is needed to validate these results and optimize treatment strategies. 

Clinical Interpretation: 

This study has significant implications for physiotherapists managing chronic TMD. The results support a multimodal behavioral approach incorporating pain neuroscience education (PNE), therapeutic exercise (TE), and active patient participation to enhance treatment outcomes. These findings can help guide physiotherapy protocols to provide more effective and lasting symptom relief for patients with TMD. Physiotherapists should implement treatment strategies focused on improving function, reducing pain, and addressing kinesiophobia. The exercise program in this study included jaw exercises, tongue and facial muscle exercises, biting exercises, and craniocervical flexor muscle exercises. Patients performed these exercises at home three times daily, tracking repetitions and sensations to facilitate necessary exercise modifications. While further research with larger sample sizes and placebo controls is needed to strengthen these conclusions, this study provides preliminary evidence supporting the integration of therapeutic exercise and pain neuroscience into standard care for chronic TMD management. 

Article Full Title:  

Efficacy of Manual Therapy in Temporomandibular Joint Disorders and Its Medium-and Long-Term Effects on Pain and Maximum Mouth Opening: A Systematic Review and Meta-Analysis 

Author Names: 

Andres Herrera-Valencia, Maria Ruiz-Muñoz, Jaime Martin-Martin,  Antonio Cuesta-Vargas, and Manuel González-Sánchez 

Reviewer Name 

Jessica Matsuoka, SPT 

Reviewer Affiliation(s) 

Duke University School of Medicine, Physical Therapy Division 

Paper Abstract 

The aim of this study was to conduct a systematic review of the medium- and long-term efficacy of manual therapy for temporomandibular joint disorders, alone or in combination with therapeutic exercise. Information was compiled from the PubMed, SCOPUS, Cochrane, SciELO and PEDro databases. The inclusion criteria were established: randomized controlled trials only; participants must present any kind of temporomandibular disorder; the treatments must include manual therapy in at least one of the experimental groups; a minimum of 3 months of follow-up; pain must be one of the primary or secondary outcomes; and the article must be available in English, Spanish, Italian, Portuguese or French. Six documents that fulfilled all the criteria were obtained for analysis, two were considered low quality and four were considered high quality. A significant improvement in pain and mouth opening compared to baseline was observed after manual therapy. Manual therapy seems to be an effective treatment for temporomandibular disorders in the medium term, although the effect appears to decrease over time. However, when complemented with therapeutic exercise, these effects can be maintained in the long term. This review underlines the importance of manual therapy and therapeutic exercise for the medium- and long-term treatment of temporomandibular joint disorders in daily practice. 

Keywords: manual therapy; temporomandibular; joint; pain; review 

Quality Assessment of Systematic Reviews and Meta-Analyses 

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

1. Yes  

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

1. Yes  

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

1. Yes  

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

1. 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. Yes  

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

1. Yes 

1. Was publication bias assessed? 

1. No  

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

1. Yes  

Key Finding #1:  

This review found that pain improved in the short term when manual therapy was used for TMD treatment. In the medium term, manual therapy outcomes appeared to be maintained, and in the long term, the effects of manual therapy appeared to diminish over time.   

Key Finding #2:  

For maximal mouth opening, this review found that in the short term, manual therapy with therapeutic exercise caused a significant increase compared with exercise alone. Medium-term effects showed benefits. However, long-term effects were not assessed – follow-up only occurred until 3 months.  

Key Finding #3:  

Overall, for TMD treatment, manual therapy combined with therapeutic exercise performed better and provided longer-lasting effects vs manual therapy alone.  

Please provide your summary of the paper 

This systematic review and meta-analysis aimed to analyze the results of the available literature on the treatment of TMD using manual therapy, alone or in combination with therapeutic exercise. The review also evaluated the short-, medium-, and long-term effects of these interventions. A variety of interventions and treatments were employed in the studies in the review, but the studies most commonly included therapeutic exercise, caudal mobilization of TMJ, health education and good habits communicated in session by the physical therapist, and manual treatment of the temporal and masseter muscles. The most common frequency was 2 sessions/week, however, the total session number varied from 3 to 24 with a median of 9.5 sessions. Pain measured by VAS and maximal mouth opening (MMO) measured by millimeters, were the main outcome measure used in all articles reviewed. Overall, this review found that manual therapy alone is an effective treatment for TMD in the short- and medium-term for decreasing pain and increasing MMO, however, this effect decreases over time unless therapeutic exercise is incorporated into the treatment plan.   

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

In terms of clinical practice, this review provides good evidence that manual therapy and therapeutic exercise used in combination to treat pain and MMO in patients with TMD is a valid treatment plan. However, this review is limited in the number of studies included and therefore limits its abilities to generalize this practice across this patient population. That being said, it does bring another treatment approach to the table that has been shown to be efficacious in patients with TMD that can be considered – the therapist may just need to do a deeper dive into the specific literature, use clinical reasoning and patient presentation to guide their treatment approach.   

Article Full Title 

Manual Therapy in the Treatment of Myofascial Pain Related to Temporomandibular Disorders: A Systematic Review 

Author Names 

Laércio Almeida de Melo, Annie Karoline Bezerra de Medeiros, Maria De Fátima Trindade Pinto Campos, Camila Maria Bastos Machado de Resende, Gustavo Augusto Seabra Barbosa, Erika Oliveira de Almeida 

Reviewer Name 

Sierra Tosten, SPT 

Reviewer Affiliation(s) 

Duke University School of Medicine, Doctor of Physical Therapy Division 

Paper Abstract 

Aims: To evaluate the effectiveness of manual therapy in the treatment of myofascial pain related to temporomandibular disorders. Methods: Randomized clinical trials were searched in the Cochrane Library, MEDLINE, Web of Science, Scopus, LILACS, and SciELO databases using the following keywords: temporomandibular joint disorders; craniomandibular disorders; myofascial pain syndromes; myofascial pain; exercise therapy; myofunctional therapy; physical therapy modalities; clinical trial; prospective studies; and longitudinal studies. Studies using the RDC/TMD and manual therapy for myofascial pain were included. All studies were evaluated using the Cochrane Risk of Bias tool. Results: Five studies were included in the present review. Of 279 total patients, 156 were treated with manual therapy only or manual therapy with counseling. Manual therapy was efficient for pain relief in all studies evaluated; however, manual therapy was not better than counseling or botulinum toxin. Conclusion: Manual therapy was better than no treatment in one study and better than counseling in another study; however, manual therapy combined with counseling was not statistically better than counseling alone, and manual therapy alone was not better than botulinum toxin. Manual therapy combined with home therapy was better than home therapy alone in one study. Further studies are required due to the inconclusive data and poor homogeneity found in this review. 

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? 

Cannot Determine, Not Reported 

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

Yes  

1. Was publication bias assessed? 

No  

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

Not Applicable  

Key Finding #1 

Manual therapy was effective at decreasing myofascial pain associated with temporomandibular disorders (TMD) across all five studies included in the systematic review, but manual therapy did not consistently outperform other treatments such as educational counseling or botulinum toxin for pain reduction.  

Key Finding #2 

The combination of manual therapy with counseling showed greater reduction in myofascial pain related to TMD over manual therapy alone in one study, yet the combination of manual therapy and counseling was not superior to counseling alone in a different study. 

Key Finding #3 

Manual therapy combined with home therapy significantly improved myofascial pain related to TMD both at rest and during stress over home therapy alone, demonstrating benefits of combined therapy.  

Please provide your summary of the paper 

The systematic review by Melo et al. evaluated the effectiveness of manual therapy in the treatment of myofascial pain related to temporomandibular disorder (TMD).  Myofascial pain related to masticatory muscles is the most common type of TMD worldwide. It can be a challenge to treat due to its diverse etiology and the variety of treatment options including physical and manual therapy, muscle relaxants, botulinum toxin injections, acupuncture, counseling, and behavioral therapies. The authors sought to answer the question “Is manual therapy efficient in treatment patients with TMD-related myofascial pain?” through a systematic review (adhering to PRISMA guidelines) of the Cochrane Library, MEDLINE, Web of Science, Scopus, LILACS, and SciELO databases including controlled and randomized trials with a high level of scientific evidence that compared manual therapy to no treatment, educational counseling, botulism toxin injections, and/or home therapy. Eligibility criteria included the use of Research Diagnostic Criteria (RDC) for TMD, manual therapy interventions (including self-relaxation exercises with diaphragmatic breathing, massage of masticatory muscles, stretching, coordination exercises, and intraoral massage techniques), and a comparison/ control group. RCTs were independently and dually screened for inclusion and assessed with the Cochrane Risk of Bias tool. Five RCTs involving 279 patients were ultimately included and all were deemed to include an uncertain risk of bias.  Across all five RCTs, manual therapy interventions consistently decreased myofascial pain associated with TMD but did not consistently outperform the other interventions (counseling, botulism toxin, home therapy) across all studies. Manual therapy outperformed the pain reduction found with no treatment and counseling alone in separate studies. Other studies suggested that manual therapy and counseling combined were superior to manual therapy alone, but that this combination was not superior to counseling alone, conveying mixed results about the effectiveness of manual therapy for pain relief compared to other interventions. One study suggested manual therapy was not more effective than botulism toxin injections for pain relief, and another study demonstrated that manual therapy and home therapy interventions combined were superior to home therapy interventions alone in the reduction of myofascial pain associated with TMD. Overall, this systematic review includes a small sample of RCTs with heterogeneous methodology, poor homogeneity, and uncertain risks of bias, limiting the comparability of manual therapy with other interventions and the conclusions that can be drawn about its effectiveness in the reduction of myofascial pain associated with TMD. Overall, manual therapy is effective in myofascial pain reduction related to TMD, but there is inconclusive evidence for its superiority over other interventions, indicating further research is necessary.  

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

The systematic review by Melo et al. provides insight into the clinical application of manual therapy interventions for reducing of myofascial pain related to temporomandibular disorder (TMD).  The review suggests that manual therapy is an effective, viable, low-cost, reversible, and noninvasive treatment for reducing pain and improving mandibular function over time across all included RCTs. While the systematic review provides inconclusive evidence for the effectiveness of manual therapy over other treatments like botulism toxin, educational counseling, and/or home therapy, manual therapy was effective in myofascial pain reduction in all studies, was superior to no treatment, and could be particularly effective when combined with other intervention like home therapy and educational counseling. Clinically, this evidence supports the inclusion of manual therapy as an effective treatment strategy for patients with myofascial pain related to TMD. The clinical implementation of manual therapy combined with other interventions should be considered due to the lack of superiority of manual therapy over counseling, home therapy, and botulism toxin, suggesting the most impactful clinical benefit may occur from combined, multimodal treatment approaches based on patient needs and responses. The lack of homogenous data, risk of bias, and heterogeneity of methodology for the RCTs included contribute to inconclusive findings regarding the effectiveness of manual therapy compared to other treatments. Additionally, the small sample size, low number of RCTs meeting the inclusion criteria, and the lack of long-term follow-up data demonstrate the low level of scientific evidence of most existing research regarding this topic, and the need for further research to inform clinical decisions regarding implementing manual therapy other over viable treatment options. Evidence favoring educational counseling or combined intervention with counseling suggests the clinical importance of patient education, communication, and addressing psychosocial pain factors. The evidence supporting manual therapy in combination with home therapy highlights the clinical importance of manual therapy performed by clinicians along with a self-managed home intervention program for the most effective pain reduction. In conclusion, the variable findings suggest that the clinical implementation of manual therapy as a multimodal, combined approach with other treatment options provides the most effective reduction of myofascial pain related to TMD since manual therapy, while effective in pain reduction, is not conclusively superior to other interventions. 

Article Full Title:  

Effect of Manual Therapy and Therapeutic Exercise Applied to th Cervical Region on Pain and Pressuer Pain sensitivity in Patients with Temporomandibular Disorders: A systematic Review and Meta-analysis  

Author Names:  

La Touche R., Martinex Garcia S., Serrano Garcia B., Acosta A. P., Juarex D. A., Perez J.J. F., Angulo Diaz Parreno, S., Cuenca Martinez F., Paris Alemany A., Suso Marti L. 

Reviewer Name:  

Mackenzie Whittaker  

Reviewer Affiliations:  

Student of Physical Therapy at Duke University 

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 levels 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 intensity 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 cervical MT vs cervico-craniomandibular MT interventions and showed statistically significant differences in pain intensity 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 painfree MMO over cervical intervention alone in TMD and headache, with low evidence. 

Quality Assessment of Systematic Reviews and Meta-Analysis 

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

1. Yes 

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

1. Yes 

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

1. Yes  

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

1. Yes 

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

1. Yes 

1. Were the included studies listed along with impportant characteristics and results of each study?  

1. Yes  

1. Was the publication biased?  

1. No 

1. Was heterogeneity assessed?  

1. Yes  

Key Finding #1:  

Combining cervical and craniomandibular manual therapy led to greater short term reductions in pain intensity and improved pain-free maximal mouth opening compared to cervical therapy alone.  

Key Finding #2:  

Studies reported a significant increase in pressure pain thresholds for muscles like the masseter and temporalis following manual cervical therapy.  

Key Finding #3:  

Cervical manual therapy significantly reduces pain intensity compared to a placebo or minimal interventions, with moderate evidence supporting its effectiveness.  

Please provide your summary of the paper.  

The paper presents a systematic review and meta-analysis on the effectiveness of cervical disorders (TMD) and related headaches. It compares different manual therapy (MT) interventions, highlighting that cervical MT significantly reduce pain intensity and increases pressure pain thresholds compared to nonmanual therapy interventions. Addiontally, cervico-craniomandibular interventions appear to offer greater short term benefits in pain reduction and pain free mouth opening. However, the evidence for these benefits varies in quality. The study also evaluates the risk of bias in the included trials, identifying performance bias as a notable limitation.