Effectiveness of Manual Therapyand Therapeutic Exercise forTemporomandibular Disorders:Systematic Review and Meta-AnalysisSusan Armijo-Olivo, Laurent Pitance, Vandana Singh, Francisco Neto,Norman Thie, Ambra Michelotti
Background. Manual therapy (MT) and exercise have been extensively used to treatpeople with musculoskeletal conditions such as temporomandibular disorders (TMD). Theevidence regarding their effectiveness provided by early systematic reviews is outdated.
Purpose. The aim of this study was to summarize evidence from and evaluate the meth-odological quality of randomized controlled trials that examined the effectiveness of MT andtherapeutic exercise interventions compared with other active interventions or standard carefor treatment of TMD.
Data Sources. Electronic data searches of 6 databases were performed, in addition to amanual search.
Study Selection. Randomized controlled trials involving adults with TMD that comparedany type of MT intervention (eg, mobilization, manipulation) or exercise therapy with aplacebo intervention, controlled comparison intervention, or standard care were included. Themain 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. Thetrials included in this review had unclear or high risk of bias. Thus, the evidence was generallydowngraded based on assessments of risk of bias. Most of the effect sizes were low tomoderate, with no clear indication of superiority of exercises versus other conservativetreatments for TMD. However, MT alone or in combination with exercises at the jaw orcervical level showed promising effects.
Limitations. Quality of the evidence and heterogeneity of the studies were limitations ofthe study.
Conclusions. No high-quality evidence was found, indicating that there is great uncer-tainty about the effectiveness of exercise and MT for treatment of TMD.
S. Armijo-Olivo, PT, BScPT,MScPT, PhD, Department of Phys-ical Therapy, Faculty of Rehabilita-tion Medicine, 3-48 Corbett Hall,University of Alberta, Edmonton,Alberta, Canada T6G 2G4.Address all correspondence to DrArmijo-Olivo at: [email protected][email protected].
L. Pitance, PT, MT, PhD, UniversiteCatholique de Louvain–Institute ofNeuroscience, Brussels, Belgium,and Stomatology and Maxillofa-cial Surgery Department, Clin-iques Universitaires Saint-Luc,Brussels, Belgium.
V. Singh, DDS, MS, MSc, Depart-ment of Dentistry, Faculty of Med-icine, TMD/Orofacial Pain Clinic,Kaye Edmonton Clinic, Edmon-ton, Alberta, Canada.
F. Neto, PT, FisioNeto–TerapiaManual Ortopedica and PilatesClınico, Povoa de Varzim,Portugal.
N. Thie, BSc, MSc, MMSc, DDS,School of Dentistry, Faculty ofMedicine and Dentistry, TMD/Orofacial Pain Graduate Program,Edmonton Clinic Health Academy,Edmonton, Alberta, Canada.
A. Michelotti, BSc, DDS, Ortho-dontic Post-Graduate Programand TMD/Orofacial Pain MasterProgram, School of Medicine Fed-erico II–Dental School, Naples,Italy.
[Armijo-Olivo S, Pitance L, SinghV, et al. Effectiveness of manualtherapy and therapeutic exercisefor temporomandibular disorders:systematic review and meta-analysis. Phys Ther. 2016;96:9–25.]
Accepted: August 1, 2015Submitted: December 12, 2014
Research Report
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January 2016 Volume 96 Number 1 Physical Therapy f 9
Temporomandibular disorders(TMD) consist of a group ofpathologies affecting the
masticatory muscles, the temporoman-dibular joint, and related structures.1,2
Temporomandibular disorders consti-tute a major public health problem, asthey are one of the main sources ofchronic orofacial pain interfering withdaily activities. These disorders also arecommonly associated with other symp-toms affecting the head and neck region,such as headache, ear-related symptoms,cervical spine dysfunction,3,4 and alteredhead and cervical posture.5–15
Physical therapy has been usedfor decades for treating craniomandibu-lar disorders using thermal packs, vapo-coolants, and transcutaneous electricalnerve stimulation (TENS).16 In 1997,Feine and Lund17 recognized that den-tists valued physical therapy treatmentfor TMD, and a recent national survey inthe United Kingdom showed that,despite limited evidence, 72% of respon-dents considered physical therapy to bean effective treatment option for TMD,with jaw exercise (79%), ultrasound(52%), manual therapy (MT) (48%), acu-puncture (41%), and laser therapy (15%)as the most effective modalities formanaging TMD.18 To date, evidence sup-ports the use of conservative and revers-ible treatment approaches for TMD treat-ment, although a multidisciplinaryhealth care approach may be required.Physical therapy is among the 10 mostcommonly used treatments for TMD,19
focused on decreasing neck and jawpain, improving range of motion (ROM),and promoting exercise to maintainhealthy function.
The goals of physical therapy in the treat-ment of TMD are to decrease pain,enable muscle relaxation, reduce muscu-lar hyperactivity, and re-establish musclefunction and joint mobility.20 Physicaltherapy treatment is reversible and non-invasive and provides self-care manage-ment in an environment to create patientresponsibility for their own health. Phys-ical therapy modalities include electro-physical modalities (ultrasound, micro-wave, laser), electroanalgesic modalities(TENS, interferential current, biofeed-back), acupuncture, therapeutic exer-
cise, and MT. Therapeutic exercise andMT are used to improve strength, coor-dination, and mobility and to reducepain,21 and treatment may include andfocus on poor posture, cervical musclespasm or pain, and treatment for referredcervical origin orofacial pain (painreferred from upper levels of the cervicalspine).22 The evidence for the effect ofelectrophysical modalities has beenquestioned.23
Manual therapy (including joint mobiliza-tion, manipulation, or treatment of thesoft tissues) and therapeutic exercises inphysical therapy treatments have beenincreasingly used by clinicians andresearched due to positive outcomes insome conditions, especially for low backpain, neck pain, and related disorders.24
Manual therapy has been used to restorenormal ROM, reduce local ischemia,stimulate proprioception, break fibrousadhesions, stimulate synovial fluid pro-duction, and reduce pain. In the area oforofacial pain, several systematic reviewshave been conducted regarding physicaltherapy and specifically MT and exerciseinterventions for TMD.19,23,25 Most ofthese early systematic reviews high-lighted the positive effects of exercisesand MT to improve symptoms and func-tion in people with TMD. However, 2reviews19,23 were conducted 9 years pre-viously and included few randomizedcontrolled trials (RCTs). Research hasexpanded over the last few years, andnew RCTs have been conducted, whichimplies that the information from earliestreviews is now outdated. Another recentsystematic review25 combined patholo-gies of the upper extremity and TMD.That review included several types ofdesigns and did not focus on RCTs,which are the best evidence when look-ing at interventions. In addition, basedon a preliminary search performed byour team, it was realized that this reviewmissed important RCTs in the area(included only 5 studies). In addition,none of these systematic reviews pro-vided a meta-analysis of the trials. There-fore, the objectives of this systematicreview were: (1) to summarize the evi-dence from and evaluate the method-ological quality of RCTs that examinedthe effectiveness of MT and therapeuticexercise interventions in the manage-
ment of TMD and (2) to determine themagnitude of the effect of these interven-tions to manage TMD.
MethodThe reporting of this systematic review isbased on the PRISMA (Preferred Report-ing Items for Systematic reviews andMeta-Analyses) guidelines.26 The aim ofthe PRISMA statement is to help authorsimprove the reporting of systematicreviews and meta-analyses. It consistsof a 27-item checklist and 4-phaseflow diagram. This systematic reviewwas registered in PROSPERO(CRD42013005628).
Study SelectionInclusion criteria for this review were asfollows.
Participants. This review was re-stricted to trials with participants meet-ing the following criteria: (1) diagnosis ofTMD according to the research diagnos-tic criteria for temporomandibular disor-ders (RDC/TMD) established by Dworkinand LeResche27 or any clinical diagnosisinvolving signs and symptoms ofTMD,28,29 (2) adult (�18 years of age),(3) musculoskeletal dysfunction, (4) painimpairment, (5) no previous surgery inthe temporomandibular region, and (6)no other serious comorbid conditions(eg, fracture in region, cancer, neurolog-ical disease).
Studies. This review targeted RCTscomparing any type of MT intervention(eg, mobilization, manipulation, soft tis-sue mobilization) or exercise therapyalone or in combination with other ther-apies with a placebo intervention, con-trolled comparison intervention, or stan-dard care (ie, treatment that normally isoffered).
Available WithThis Article atptjournal.apta.org
• eTable 1: Characteristics ofIncluded Studies
• eTable 2: Risk of Bias of IncludedStudies
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OutcomesThe primary outcomes of interest for thissystematic review were pain, ROM, andoral function. Oral function for this sys-tematic review focused on limitations ofdaily activities of patients with TMD mea-sured through different questionnaires. Asecondary outcome of interest was pres-sure pain threshold (PPT).
The minimal clinically important differ-ence for pain has been reported to rangefrom 1.5 to 3.2 points.30–34 The smallestdetectable difference of maximal mouthopening in healthy people has beenreported to be 5 mm, indicating that animportant change of at least 5 mm can beconsidered clinically relevant.35 Measure-ments of PPT have been shown to havegood or excellent interrater and intra-rater reliability.36–38 The minimal impor-tant difference for PPTs has beenreported to be �1.10 kg/cm2/s.39,40 Thissystematic review was open to all timepoints: immediately posttreatment andshort-term, intermediate-term, and long-term follow-up.
Data Sources and SearchesA bibliographic search of 6 electronicdatabases was conducted:
• MEDLINE (database root [1966]–April 7, 2015),
• EMBASE (database root [1988)]–April 7, 2015),
• Cochrane Library and Best Evi-dence (database root [1991]–April7, 2015),
• ISI Web of Science (database root[1965]–April 7, 2015),
Key words and medical subject headingswere identified with the assistance of alibrarian who specialized in health sci-ence databases and experts in the orofa-cial pain field. No restrictions were maderegarding the language of publication. Amanual search of the references ofselected studies was conducted as well(refer to the Appendix for an example ofthe search strategy).
Data ScreeningTwo independent investigators screenedthe titles of publications found in thedatabases and, if available, the abstractof the publication. The Early ReviewOrganizing Software (EROS) (http://www.eros-systematic-review.org/) Webplatform was used for screening the arti-cles for inclusion. In order for papers tobe included in the review, the paper hadto meet all inclusion criteria of this sys-tematic review on the rating form cre-ated in EROS software. Studies were ana-lyzed with the available information.Authors were not contacted.
Disagreements between reviewers oninclusion were resolved by consensus.The kappa statistic was calculated usingSTATA software, version 12, (StataCorpLP, College Station, Texas) to determinethe level of agreement between raters ontrial inclusion before consensus. Criteriaproposed by Byrt41 were used to inter-pret kappa values.
Data ExtractionThe information of each study includedin this review was extracted and enteredinto Excel or Microsoft Word (MicrosoftCorp, Redmond, Washington) files. Foreach part of the review, data extractionwas carried out independently by 2reviewers. Data were extracted on studycharacteristics, including the design,type of TMD, type of interventions, mainand secondary outcomes, and treatmentestimates. Any disagreements on dataextraction were resolved by consensus.
Quality Assessment (Risk of Bias)Assessments of quality (risk of bias) werecompleted by 2 independent reviewers(any 2 members of the research team).For the assessment of RCTs, our teamused a compiled set of items based onthe 7 tools most commonly used to eval-uate the risk of bias in complex physicaltherapy trials.42 In addition, the risk ofbias tool was used with the main out-come of each study to make the assess-ments. We followed the guidelines estab-lished by the Cochrane Collaboration toperform assessments of risk of bias; how-ever, we developed specific decisionrules to make decisions as described else-where.43 For the overall assessment ofrisk of bias, a trial was considered at low
risk of bias if it was rated as low risk in allindividual domains, if the rating wasunclear in at least one domain and theother domains were unclear or low, or ifthe overall assessment of risk of bias wasunclear. Finally, an overall assessment ofhigh risk of bias was considered if at leastone domain was rated as high. Thesecriteria have been used previously by ourteam and other authors.43,44
Any discrepancies in quality ratings wereresolved by discussion. If consensuscould not be reached, a third member ofthe review team with expertise in qualityassessments (S.A-O.) acted as an arbitra-tor and made a final decision.
Data Analysis and SynthesisData analysis was performed based ontype of intervention (ie, exercise, mobi-lization, and manipulation), TMD diagno-sis (myogenous TMD, arthrogenousTMD, mixed TMD), and type of outcome(eg, pain intensity, range of mouth open-ing [ROM], oral function (oral-relatedquality of life]). For analysis of continu-ous outcome data, we used the meandifference (MD) and the standardizedmean difference (SMD) with 95% confi-dence interval (95% CI) to pool data.Heterogeneity was evaluated statisticallyusing the I2 statistic. The MD and SMDwere defined according to the CochraneCollaboration,45 as follows:
MD is a standard statistic that measures theabsolute difference between the meanvalue in 2 groups in a clinical trial. It esti-mates the amount by which the experi-mental intervention changes the outcomeon average compared with the control. Itcan be used as a summary statistic in meta-analysis when outcome measurements inall studies are made on the same scale.
The SMD is used as a summary statistic inmeta-analysis when the studies assess thesame outcome but measure it in a varietyof ways (ie, use different psychometricscales). In this circumstance, it is neces-sary to standardize the results of the stud-ies to a uniform scale before they can becombined. The standardized mean differ-ence expresses the size of the interventioneffect in each study relative to the variabil-ity observed in that study.
We decided to pool studies based onTMD diagnosis, intervention provided,and outcome. We grouped studiesthat had the same diagnosis (myogenous,arthrogenous, or mixed), similar inter-vention of interest (ie, MT, exercises),and the same underlying outcome. Thus,
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we created groups of studies that weresimilar in terms of these characteristicsand pooled them. In the presence of clin-ical heterogeneity in the study popula-tion or intervention, the DerSimonianand Laird random-effects model of pool-ing was used based on the assumption ofthe presence of interstudy variability toprovide a more conservative estimate ofthe true effect.46,47
Cohen’s criteria were used to interpretvalues of effect sizes found for ourpooled estimates.48 Cohen described 0.2,0.5, and 0.8 as small, moderate, and largeeffect sizes, respectively.48 Review Man-ager (RevMan) version 5.0 software (TheNordic Cochrane Centre, The CochraneCollaboration, Copenhagen, Denmark,2008) was used to summarize the effects(ie, pooled MD values) and construct for-est plots for all comparisons.
Subgroup and sensitivity ana-lysis. In order to investigate andaccommodate heterogeneity (clinicalheterogeneity in the study population orintervention) as explained above, arandom-effects model was used across allthe comparisons. Furthermore, in orderto explain the heterogeneity in terms ofstudy-level covariates, we could haveattempted a meta-regression model.However, because of the small numberof studies (�10) for comparison, thisanalysis was not possible. We attemptedto perform sensitivity analyses whenpossible.
We did not perform sensitivity analysesbased on quality because the risk of biasof the analyzed studies was eitherunclear or high, with no study being clas-sified as low risk. These factors pre-cluded sensitivity analyses by differentlevels of biases. Therefore, the pooleddata should be interpreted carefully.
Data synthesis. The quality of thebody of the evidence was assessed usingthe GRADE approach.49 The evidencewas classified as high, moderate, low,and very low, as described by Guyattet al.49 Domains that may decrease thequality of the evidence are: (1) the studydesign, (2) risk of bias, (3) inconsistencyof results, (4) indirectness (not general-izable), (5) imprecision (insufficient
data), and (6) other factors (eg, reportingbias).
Role of the Funding SourceDr Armijo-Olivo is supported by theCanadian Institutes of Health Research(CIHR) through a full-time Banting fel-lowship, by the Alberta Innovates HealthSolution through an incentive award, bythe STIHR Training Program of Knowl-edge Translation (KT) Canada, and bythe Music and Motion Fellowship fromthe Faculty of Rehabilitation Medicine ofthe University of Alberta. The fundingbodies had no input in the design, col-lection, analysis, or interpretation ofdata; writing of the manuscript; or thedecision to submit the manuscript forpublication.
ResultsThe search of the literature resulted in atotal of 3,549 published articles. Of the3,549 published articles, 106 were con-sidered to be potentially relevant. Inde-pendent review (in duplicate) of these106 articles led to the inclusion of 58articles representing 50 studies (somestudies reported data from the same pop-ulation in 2 manuscripts). There were 5articles in other languages50–54 that werenot possible to translate by our studyteam and were not included in the finalanalysis. Thus, 45 studies were includedfor this review from the search of thedatabases. In addition, 3 studies55–57
were obtained through a manual search.Therefore, a total of 48 studies wereincluded in the final analysis (Fig. 1). Theagreement between reviewers to selectthe articles for this review waskappa�0.98 (95% CI�0.977, 0.99).According to Byrt’s criteria,41 theagreement between reviewers wasexcellent. Details of included studies areprovided in eTable 1 (available atptjournal.apta.org).
DiagnosisThere was considerable diversity in theclinical presentations and diagnoses ofparticipants with TMD among theincluded studies (eTab. 1). Fourteen ofthe studies examined the effectiveness ofthe exercise or MT interventions in mus-cular TMD (myogenous TMD), 14 studiesexamined the effectiveness in patientswith articular TMD (arthrogenous TMD),
and 19 studies examined the effective-ness in patients with mixed diagnoses ofTMD (including both myogenous andarthrogenous TMD).28,29 One studylooked at both myogenous and arthrog-enous TMD.58 Twenty-one of the stud-ies57–76 used the RDC/TMD establishedby Dworkin and LeResche27 to classifythe patients as having TMD. The remain-ing 27 studies used their own diagnosticcriteria, based on signs and symptoms ofthe patients.
Methodological QualityAssessmentThe results of the critical appraisal of theselected studies are presented in eTable2 (available at ptjournal.apta.org). Only 6studies accomplished more than 60% ofthe items listed in eTable 2.57,66,67,76–78
Most of the studies did not accomplishitems with important methodologicalindicators of risk of bias, such as random-ization, allocation concealment, blind-ing, and intention to treat (ITT). Forexample, study flaws regarding patientselection were mainly related to descrip-tion and appropriateness of the random-ization procedure and concealment ofallocation, with only 20 (41.6%) and 4(8.3%) of the studies meeting these cri-teria, respectively. As expected, itemsrelated to blinding were not achieved bythe majority of the studies. Only 3 of thestudies used a double-blinded design andcould blind participants. These studiesused a placebo arm, which is hard toobtain in these types of interventions. Inaddition, only 12 (25%) of the studiesused blinded assessment of outcomes,and none of the studies blinded the ther-apist. Thus, blinding was the area thatwas the hardest section to be met by theanalyzed studies. When analyzing issuesregarding intervention, we found thatalthough it is expected that interventionswould be well described to be reproduc-ible, only 64.6% (n�30) of the studiesdescribed the main intervention to betested. In addition, most studies failed tocontrol for cointerventions. Only 6 stud-ies met this item.
Testing participants’ adherence to inter-vention and having adequate adherencewas another issue that was not met bymany studies (only 11 and 7 studies,respectively). Furthermore, adverse
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effects were reported on only 10 of thestudies, but there was no specificdescription of such events when theyoccurred in all of the studies.
Despite the fact that the adequate han-dling of dropouts is considered an impor-tant method used to prevent bias in dataanalysis, only 17 of the analyzed studies
included information regarding the rea-sons of withdrawals and dropouts, andonly 16 studies used intention-to-treatanalysis. The outcome measures werenot described well in terms of validity,reliability, or responsiveness. Only a fewstudies reported these items (11, 17, and3 studies, respectively). Moreover, theauthors did not report intrarater or inter-
rater reliability of the assessors who per-formed outcome measurements. Regard-ing statistical issues, it was uncertain ifsample size was adequate in 30 of thestudies, and only 18 studies reported anevaluation of the clinical significance oftheir results. Risk of bias assessmentsusing the risk of bias tool determinedthat none of the studies was consideredas low risk of bias. Most of them wereclassified as either unclear (58.4%) orhigh risk of bias (41.6%).
Effectiveness of Interventionby TMD Diagnoses: PostureCorrection Exercises inMyogenous TMDTwo studies59,60 evaluated the effective-ness of posture correction exercises forpatients with myofascial pain. Both stud-ies showed positive results of posturalexercises for improving symptoms ofmuscular TMD. When pooling the datafor these 2 studies, which had similarinterventions, diagnoses, and outcomes,maximum pain-free mouth opening sig-nificantly increased in patients receivingpostural training compared with a con-trol group. The MD in maximum pain-free mouth opening was 5.54 mm (95%CI�2.93, 8.15) (Fig. 2), which was clin-ically significant in favor of postural train-ing.35 Furthermore, patients treated withpostural training had significantly fewersymptoms and disturbance with daily liv-ing compared with a control group. TheSMD in symptoms and disturbance ofsymptoms with daily life was 1.13 (95%CI�0.48, 1.78), indicating a large, clini-cally significant effect size for this pooledoutcome.
Figure 1.Flowchart of trial selection based on PRISMA guidelines.
Figure 2.Maximum pain-free opening: postural training versus control group in patients with myogenous temporomandibular disorders.CI�confidence interval, IV�inverse variance.
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General Jaw Exercises Alone orCombined With Neck ExerciseProgram in Myogenous TMDEight studies56–58,62,63,66,79,80 looked atthe effect of exercises alone or combinedwith other therapies for myogenousTMD. The results of these studies wereequivocal. Five of them did not find sig-nificant differences between a generalphysical therapy exercise program tar-geted to the jaw56,62,79,80 or jaw andneck57 compared with a control or otheractive treatments, such as biofeedback,TENS, use of the TheraBite Jaw MotionRehabilitation System (ATOS Medical AB,Hörby, Sweden), or oral splint therapy.However, 3 studies58,63,66 showed betteroutcomes, especially on pain and ROM,compared with control groups.
Data were pooled from studies that hadsimilar outcomes and diagnoses andcompared an exercise program andother forms of therapy, such as educa-tion,62,66 or splint therapy.56,58 Data fromthese studies56,58,62,66 indicated thatthere was a trend to favor exercise ther-apy for pain-free maximum mouth open-ing and pain intensity compared with acontrol group. The MD for pain-free max-imum mouth opening was 5.94 mm (95%CI��1.0, 12.87), which is consideredclinically relevant.35 The SMD for painintensity pooling 5 studies57,58,62,63,66
was 0.43 (95% CI��0.02, 0.87), with amoderate effect size according toCohen’s guidelines.48 When performingsensitivity analyses, grouping studiescomparing exercise therapy and educa-tion,62,66 a nonsignificant effect wasfound on pain-free maximum mouthopening (1.92 mm; 95% CI��0.57,4.41). However, when comparing exer-cises and splint therapy,56,58 a statisti-cally and clinically meaningful effect wasfound (12.31 mm; 95% CI�7.73, 16.89).
Manual Therapy Targeted to theOrofacial Region in MyogenousTMDFour studies64,65,77,81 looked at MT tech-niques, such as facial manipulation ver-sus botulinum toxin81 or intraoral myo-fascial therapy versus waiting list, andself-care education and exercises for peo-ple with myogenous TMD.64,65,77 Theresults of these studies support the use ofMT to treat myogenous TMD, as people
treated with all of these approaches hadimproved mouth opening and reducedjaw pain from baseline. Although theresults for the intraoral myofascial ther-apy and exercise groups were superiorto the results for the waiting-list controlgroup, there was no statistically signifi-cant difference between them. In addi-tion, facial manipulation had an equiva-lent effect as botulinum toxin. However,at 3 months after treatment, facial manip-ulation was slightly superior in reducingsubjective pain perception, and botuli-num toxin injections were slightly supe-rior in increasing ROM. When poolingthe results from 3 of these studies basedon similar outcomes and diagnoses andcomparing similar interventions regard-ing MT,64,65,81 we found that MT signifi-cantly reduced pain at 4 to 6 weeks oftreatment compared with botulinumtoxin or waiting list, approaching a clin-ically relevant value. The MD for painintensity was 1.35 cm (95% CI�0.91,1.78). When pooling the studies thatconsidered the comparison of MT versusa waiting list only, similar results wereobtained (1.31 cm; 95% CI�0.86, 1.76).
Manual Therapy Mobilizationof the Cervical Spine andMyogenous TMDA recent RCT conducted by La Touche etal67 testing a more specific approachdirected to the cervical spine to treatpatients with cervico-craniofacial pain ofmyofascial origin was performed. Thispreliminary study showed that mobiliza-tions targeted to the cervical spine dras-tically decreased pain intensity and painsensitivity (via PPT evaluation) inpatients with cervico-craniofacial pain ofmyofascial origin immediately after theapplication of the technique comparedwith placebo treatment. The effect sizesfound in this study for pain intensity(28.75 points; 95% CI�21.65, 35.85) andPPT (1.12 kg/cm2; 95% CI�0.96, 1.29)were considered clinically relevant.
Jaw and Neck Exercises Aloneor as Part of a ConservativeRegimen in Arthrogenous TMDEight studies58,61,68,82–86 that examinedpatients with arthrogenous TMDfocused on jaw and neck exercises aloneor combined with other therapies, suchas medications, surgery, or self-care rec-
ommendations. Six studies58,61,68,84–86
focused on exercise therapy alone,85,86
exercise therapy combined with conven-tional treatment,61 or the combination ofjaw exercises with TheraBite58 or myo-functional therapy.68 The remaining 2studies82,83 looked at the effectiveness ofsurgery (arthrocentesis or arthroscopy)combined with conservative treatmentincluding exercises for the jaw versusjaw exercises alone.
Although the results were mixed, mostof the studies favored the use of exer-cises alone or as part of a general regi-men to treat people with arthrogenousTMD, including disk displacements withor without reduction.58,68,84–86 How-ever, one study61 did not find that exer-cises were superior to a control groupinvolving general physical therapytreatment.
Data were pooled from studies with sim-ilar outcomes and diagnoses that com-pared an exercise program with otherforms of therapy, such as education61 orsplint therapy,58 or with a controlgroup.68,86 When pooling the results ofthe studies investigating the effective-ness of exercise alone or in combinationwith other conservative therapies onpain intensity,58,61,68,86 we found thatthere was no statistically significant dif-ference in pain between exercise andcontrol groups. Nevertheless, there wasa trend to favor the exercise group com-pared with the control group. The SMDfor pain intensity was 0.68 (95%CI��0.04, 1.40), with a moderate effectsize according to Cohen’s guidelines.48
When pooling was focused on thosestudies including only a controlgroup,68,86 similar results were found,although the SMD increased (SMD�1.11;95% CI��0.73, 2.94). Regarding activemouth opening, a nonsignificant effectwas found between general jaw exer-cises and education, splint therapy, or acontrol group when pooling 3 stud-ies.58,61,86 The MD for active mouthopening was 3.13 mm (95% CI��1.96,8.23). A trend favoring exercises wasobserved based on the 95% CI values.
When pooling the studies82,83 thatlooked at exercises plus arthrocentesisor arthroscopy versus conservative ther-
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apy including exercises alone on activemouth opening at 6 months, wefound no differences between theseapproaches. The MD was �1.01 mm(95% CI��5.43, 3.42), implying thatconservative treatment plus exercises isappropriate to treat disk displacementwithout reduction or when patients haverestricted mandibular movement. Theresults indicate noninvasive proceduresas a first line of treatment.
Manual Therapy Plus JawExercises in Arthrogenous TMDSeven studies69,70,78,87–91 looked at thecombined effect of MT plus jaw exer-cises for people with arthrogenous TMD.Three studies69,87,88 compared MT andexercises versus splint therapy, 1study89,90 compared MT and exercisewith self-care and advice regarding prog-nosis, and 2 studies78,91 used medicationas a comparison. In addition, one study70
compared anesthetic blockage of theauriculotemporal nerve and MT andexercises in addition to blockage of theauriculotemporal nerve.
In general, we found that MT plus exer-cises reduced symptoms and increasedROM for patients with arthrogenousTMD, particularly for those with reducedROM due to disk displacements withoutreduction (“closed lock”). Five of thesestudies69,78,87,88,91 favored the use of MTin conjunction with exercises comparedwith splints69,87,88 or with medications91
or other nonconservative treatments forarthrogenous TMD, such as arthroscopyand arthroplasty.78
When pooling the results from the stud-ies with homogeneous interventions and
similar outcomes, diagnoses, and avail-able data,69,78,87,88,90 we found that painwas significantly reduced in patientsreceiving MT combined with exercisescompared with splint therapy, self-care,or medications. The SMD for pain inten-sity at 4 weeks to 3 months was 0.40(95% CI�0.13, 0.68), with a moderateeffect size according to Cohen’s guide-lines48 (Fig. 3).
When looking at active mouth open-ing,69,87,88,90 we found that MT plus exer-cises significantly increased active mouthopening compared with splint therapy,self-care, or medications. The MD foractive mouth opening at 4 weeks to 3months was 3.58 mm (95% CI�1.46,5.70).
General Jaw Exercise Program inMixed TMDEleven studies55,71–74,92–99 looked atexercises alone or as part of a generalconservative therapeutic regimen totreat patients with mixed TMD. In gen-eral, exercises for mixed TMD comparedwith control groups had better resultsfor decreasing pain and improving func-tion and pain sensitivity of the mastica-tory muscles.55,71,96,97 However, com-pared with other forms of activetreatments, such as splints, a global pos-tural re-education program, or acupunc-ture,72–74,95,95,98,99 no significant differ-ences between these treatments werefound.
When pooling the results of studies withavailable data and similar interventionsand outcomes,55,71,73,93,94 we found thatexercises in the form of general jaw exer-cises plus conventional treatment or
with the addition of an oral device94
were not superior to other treatmentmodalities, such as splint therapy, globalre-education posture, splint plus counsel-ing, acupuncture, or standard conserva-tive care, in improving pain intensity.The SMD for pain intensity was �0.06(95% CI��0.50, 0.38), with a very smalleffect size according to Cohen’sguidelines.48
When pooling results for mouth open-ing,55,71,73,92,94,95,97 nonsignificant differ-ences were obtained between generaljaw exercises and splint therapy, globalre-education posture, splint plus counsel-ing, or standard conservative care. TheMD for mouth opening was �0.25 mm(95% CI��2.08, 1.57) (Fig. 4).
Manual Therapy and Mixed TMDSix studies76,100–104 looked at MT alone,such as mobilization of atlantoaxialjoint,101,103 mobilization at the level ofcervical spine,102 manipulation of theupper thoracic spine (D1),76 massage tomasticatory muscles,104 or mobilizationsat the level of TMJ joint,100 for treatingpatients with mixed TMD. Results weremixed. The studies by Mansilla-Ferragudet al101 and Otano and Legal103 showedpositive results at improving mouth ROMand increasing PPT in the orofacialregion when comparing mobilization ofthe atlantoaxial joint versus placebo.However, no statistical differences werefound between MT targeted to the jawand jaw exercises plus splint therapy,100
between cervical chiropractic adjust-ment and cervical trigger point ther-apy,102 upper thoracic manipulation andplacebo,76 or masticatory muscle mas-
Figure 3.Pain intensity at 4 weeks to 3 months: manual therapy plus excercises versus control group in patients with arthrogenous temporomandibulardisorders. CI�confidence interval, IV�inverse variance, sp�splint, sc�standard care, med�medications.
Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders
January 2016 Volume 96 Number 1 Physical Therapy f 15
sage and splint104 for improving symp-toms of patients with mixed TMD.
When pooling data from the 2 studiesthat looked at similar manual techniques,TMD diagnoses, and outcomes,101,103
although there was no significant differ-ence between mobilization of atlantoax-ial joint or control group receiving nomobilization, the MD in mouth openingbetween control and MT groups was17.33 mm (95% CI��10.39, 45.06). Thisdifference can be considered as a clini-cally relevant improvement in mouthopening favoring MT treatment.
Manual Therapy Plus Exercisesfor Mixed TMDTwo studies75,105,106 investigated theeffect of MT combined with exercises inpeople with mixed TMD. Tuncer et al75
looked at the specific effect of orofacialand cervical MT combined with stretch-ing techniques for the masticatory andneck muscles compared with exercisesfor the jaw and neck alone and education(home physical therapy). Von Piekartzand Ludtke106 compared the effect oforofacial physical therapy and neck exer-cises and MT techniques targeted to bothorofacial and cervical regions plus homeexercises compared with treatment tar-geted to the cervical spine only in peoplewith mixed TMD. Pooling the results ofthe 2 studies75,105,106 with similar inter-ventions, outcomes, and diagnoses, wefound that MT targeted to the orofacialregion or in combination with cervicaltreatment was better than home exer-cises for the jaw and neck alone or treat-ment to cervical spine alone for improv-ing mouth opening. The mouth opening
between control and MT groups was6.10 mm (95% CI�1.11, 11.09) favoringMT groups. This difference was clinicallyrelevant.35
Adverse EventsAdverse effects were reported in only 10of the 48 included trials. Eight of thetrials57,65,67,74,75,77,87,88 reported noadverse events with the treatments. Nas-cimento et al70 reported some adverseevents due to the anesthetic blockagesprocedure. In that study, 29.4% of thepatients (66/224) had temporary facialnerve paralysis, 0.44% (1/224) had hema-toma, and 2.23% (5/224) had positiveaspirations. Niemela et al73 reported thatpain on TMJ palpation increased signifi-cantly in the splint group compared withthe control group. No adverse eventsregarding exercise therapy or MT treat-ments were reported among the trialsincluded.
Data SynthesisThe overall quality of evidence for mostcomparisons was low to moderateaccording to the GRADE approach.49
The trials included in this review hadunclear or high risk of bias. Thus, theevidence was generally downgraded for3 reasons: (1) risk of bias, 2) level ofheterogeneity (inconsistency), and (3)some imprecision surrounding the effectestimate. Details of GRADE assessment ofthe included studies are displayed in theTable. From the 14 analyses performed,most of the evidence was consideredmoderate (9 analyses). The rest of theevidence was considered low. Thus, wecan say that the total evidence was con-sidered low.
DiscussionMain ResultsAlthough the quality of the evidence ismostly uncertain and low, the results ofour systematic review showed positiveresults when using postural exercisesand jaw exercises to treat both myoge-nous and arthrogenous TMD disorders.Manual therapy alone or in combinationwith exercises shows promising effects.Manual therapy targeted to the cervicalspine decreased pain and increasedmouth ROM in patients with myogenousTMD. Exercises did not show superiorityover other treatments for treating mixedTMD. A general exercise program waseffective compared with arthrocentesisor arthrography for treatment of arthrog-enous TMD, with conservative treat-ments as a first line of treatment. Thereremain limited RCTs of high quality thathave investigated the effectiveness of MTand exercises to treat TMD.
Effect of Exercise for TreatingTMDExercise programs are advocated fortreating people with musculoskeletal dis-orders. Therapeutic exercises are pre-scribed to address TMD. Passive andactive stretching of muscles are per-formed to increase mouth ROM andreduce pain. Postural exercises are help-ful.21 The results of our systematicreview are consistent with previousreviews,19,23 showing positive effectswhen using exercises to treat myoge-nous and arthrogenous TMD. In particu-lar, interventions including exercises tocorrect head and neck posture and activeand passive oral exercises can be effec-
Figure 4.Mouth opening: general jaw excercises versus splint therapy, global re-education posture, splint plus counseling, or standard conservativecare in patients with mixed temporomandibular disorders. CI�confidence interval, IV�inverse variance.
Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders
16 f Physical Therapy Volume 96 Number 1 January 2016
Tab
le.
GRA
DE
Evid
ence
Profi
lea
Qu
alit
yA
sses
smen
t
Sum
mar
yo
fFi
nd
ing
s
Nu
mb
ero
fP
atie
nts
Nu
mb
ero
fSt
ud
ies
(Des
ign
)R
isk
of
Bia
sIn
con
sist
ency
Ind
irec
tnes
sIm
pre
cisi
on
Pu
bli
cati
on
Bia
s
Pat
ien
tsin
Tre
atm
ent
Gro
up
Pat
ien
tsin
Co
ntr
ol
Gro
up
Esti
mat
e(S
MD
or
MD
)[9
5%
CI]
Qu
alit
y
Po
stu
reC
orr
ecti
on
Exer
cise
sin
Myo
gen
ou
sT
MD
Ou
tco
me:
max
imu
mp
ain
-fre
eo
pen
ing
2(R
CTs
)U
ncle
arris
kof
bias
for
both
stud
ies.
Con
ceal
men
tof
allo
catio
nno
tcl
ear
for
both
stud
ies,
noin
tent
ion-
to-t
reat
anal
ysis
.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.30,
I2�
6%N
oin
cons
iste
ncy
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
5050
MD
�5.
54m
m[2
.93,
8.15
]M
oder
ate
qua
lity
beca
use
ofris
kof
bias
Ou
tco
me:
dis
turb
ance
of
sym
pto
ms
wit
hd
aily
life
2(R
CTs
)U
ncle
arris
kof
bias
for
both
stud
ies.
Con
ceal
men
tof
allo
catio
nno
tcl
ear
for
both
stud
ies,
noin
tent
ion-
to-t
reat
anal
ysis
.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.15,
I2�
51%
No
serio
usin
cons
iste
ncy
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
5050
SMD
�1.
13[0
.48,
1.78
]M
oder
ate
qua
lity
beca
use
ofris
kof
bias
.U
pgr
adin
gbe
caus
eof
larg
eef
fect
size
and
narr
owC
I.
Gen
eral
Jaw
Exer
cise
sA
lon
eo
rC
om
bin
edW
ith
Exer
cise
Pro
gra
min
Myo
gen
ou
sT
MD
Ou
tco
me:
pai
n-f
ree
max
imu
mo
pen
ing
4(R
CTs
)U
ncle
arris
kof
bias
for
mos
tof
the
stud
ies.
Con
ceal
men
tof
allo
catio
nno
tcl
ear
for
3st
udie
s,an
d1
stud
yw
asno
tco
ncea
led.
All
stud
ies
did
not
per
form
inte
ntio
n-to
-tre
atan
alys
is.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.000
01,
I2�
88%
Hig
h hete
roge
neity
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
6467
MD
�5.
94m
m[�
1.0,
12.8
7]Lo
wq
ualit
ybe
caus
eof
risk
ofbi
asan
din
cons
iste
ncy
Ou
tco
me:
pai
nin
ten
sity
5(R
CTs
)H
igh
risk
ofbi
asfo
rm
ost
ofth
est
udie
s.C
once
alm
ent
ofal
loca
tion
not
clea
rfo
r4
stud
ies,
and
1st
udy
was
not
conc
eale
d.A
dher
ence
and
coin
terv
entio
nsun
clea
rfo
rm
ost
ofth
est
udie
s.N
oin
tent
ion
totr
eat
for
4st
udie
s.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.10,
I2�
49%
No
serio
usin
cons
iste
ncy
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
8590
SMD
�0.
43[�
0.02
,0.8
7]M
oder
ate
qua
lity
beca
use
ofris
kof
bias
(Con
tinue
d)
Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders
January 2016 Volume 96 Number 1 Physical Therapy f 17
Tab
le.
Con
tinue
d
Qu
alit
yA
sses
smen
t
Sum
mar
yo
fFi
nd
ing
s
Nu
mb
ero
fP
atie
nts
Nu
mb
ero
fSt
ud
ies
(Des
ign
)R
isk
of
Bia
sIn
con
sist
ency
Ind
irec
tnes
sIm
pre
cisi
on
Pu
bli
cati
on
Bia
s
Pat
ien
tsin
Tre
atm
ent
Gro
up
Pat
ien
tsin
Co
ntr
ol
Gro
up
Esti
mat
e(S
MD
or
MD
)[9
5%
CI]
Qu
alit
y
Man
ual
Th
erap
yT
arg
eted
toth
eO
rofa
cial
Reg
ion
inM
yog
eno
us
TM
D
Ou
tco
me:
pai
nin
ten
sity
3(R
CTs
)C
once
alm
ent
ofal
loca
tion
not
clea
rfo
r2
ofth
est
udie
s,an
d1
stud
yw
asno
tco
ncea
led.
Adh
eren
cean
dco
inte
rven
tions
uncl
ear
for
allo
fth
est
udie
s.N
oin
tent
ion
totr
eat
for
2st
udie
s.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.78,
I2�
0%N
ose
rious
inco
nsis
tenc
y
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
4444
MD
�1.
35cm
[0.9
1,1.
78]
Mod
erat
eq
ualit
ybe
caus
eof
risk
ofbi
as
Jaw
/Nec
kEx
erci
ses
Alo
ne
or
asP
art
of
aC
on
serv
ativ
eR
egim
enin
Art
hro
gen
ou
sT
MD
Ou
tco
me:
pai
nin
ten
sity
4(R
CTs
)C
once
alm
ent
ofal
loca
tion
not
clea
rfo
ral
lof
the
stud
ies.
Blin
ding
was
uncl
ear
for
3of
the
stud
ies,
and
1st
udy
did
not
have
app
rop
riate
blin
ding
.A
dher
ence
and
coin
terv
entio
nsun
clea
rfo
ral
lof
the
stud
ies.
No
inte
ntio
n-to
-tre
atan
alys
isfo
r2
stud
ies.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.01,
I2�
73%
Hig
h inco
nsis
tenc
y
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
7373
SMD
�0.
68[�
0.04
,1.4
0]Lo
wq
ualit
ybe
caus
eof
risk
ofbi
asan
din
cons
iste
ncy
Ou
tco
me:
acti
vem
ou
tho
pen
ing
3(R
CTs
)C
once
alm
ent
ofal
loca
tion
not
clea
rfo
ral
lof
the
stud
ies.
Blin
ding
was
uncl
ear
for
2of
the
stud
ies,
and
1st
udy
did
not
have
app
rop
riate
blin
ding
.A
dher
ence
and
coin
terv
entio
nsun
clea
rfo
ral
lof
the
stud
ies.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.009
,I2
�79
%H
igh inco
nsis
tenc
y
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
6363
3.13
mm
[�1.
96,8
.23]
Low
qua
lity
beca
use
ofris
kof
bias
and
inco
nsis
tenc
y
Jaw
/Nec
kEx
erci
ses
Alo
ne
or
asP
art
of
aC
on
serv
ativ
eR
egim
envs
Surg
ery
inA
rth
rog
eno
us
TM
D
2(R
CTs
)C
once
alm
ent
ofal
loca
tion
not
app
rop
riate
for
both
stud
ies.
Blin
ding
was
not
app
rop
riate
for
both
stud
ies.
Adh
eren
cean
dco
inte
rven
tions
uncl
ear
for
both
stud
ies.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.04,
I2�
76%
Hig
h inco
nsis
tenc
y
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
6863
MD
��
1.01
mm
[�5.
43,3
.42]
Low
qua
lity
beca
use
ofris
kof
bias
and
inco
nsis
tenc
y
(Con
tinue
d)
Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders
18 f Physical Therapy Volume 96 Number 1 January 2016
Tab
le.
Con
tinue
d
Qu
alit
yA
sses
smen
t
Sum
mar
yo
fFi
nd
ing
s
Nu
mb
ero
fP
atie
nts
Nu
mb
ero
fSt
ud
ies
(Des
ign
)R
isk
of
Bia
sIn
con
sist
ency
Ind
irec
tnes
sIm
pre
cisi
on
Pu
bli
cati
on
Bia
s
Pat
ien
tsin
Tre
atm
ent
Gro
up
Pat
ien
tsin
Co
ntr
ol
Gro
up
Esti
mat
e(S
MD
or
MD
)[9
5%
CI]
Qu
alit
y
Man
ual
Th
erap
yP
lus
Jaw
Exer
cise
sin
Art
hro
gen
ou
sT
MD
Ou
tco
me:
pai
nin
ten
sity
5(R
CTs
)C
once
alm
ent
ofal
loca
tion
uncl
ear
for
mos
tof
the
stud
ies.
Blin
ding
was
app
rop
riate
for
mos
tof
the
stud
ies.
Adh
eren
ceun
clea
rfo
rm
ost
ofth
est
udie
s.N
oor
uncl
ear
inte
ntio
nto
trea
tfo
r2
stud
ies.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.58,
I2�
0%N
oin
cons
iste
ncy
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
9911
4SM
D�
0.40
[0.1
3,0.
68]
Mod
erat
eq
ualit
ybe
caus
eof
risk
ofbi
as
Ou
tco
me:
acti
vem
ou
tho
pen
ing
4(R
CTs
)C
once
alm
ent
ofal
loca
tion
uncl
ear
for
allo
fth
est
udie
s.Bl
indi
ngw
asap
pro
pria
tefo
rm
ost
ofth
est
udie
s.A
dher
ence
uncl
ear
for
all
ofth
est
udie
s.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.93,
I2�
0%N
oin
cons
iste
ncy
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
7577
3.58
mm
[1.4
6,5.
70]
Mod
erat
eq
ualit
ybe
caus
eof
risk
ofbi
as
Gen
eral
Jaw
Exer
cise
Pro
gra
min
Mix
edT
MD
Ou
tco
me:
pai
nin
ten
sity
5(R
CTs
)C
once
alm
ent
ofal
loca
tion
uncl
ear
for
4of
the
stud
ies.
One
stud
ydi
dno
tha
veap
pro
pria
ted
allo
catio
nco
ncea
lmen
t.A
pp
rop
riate
blin
ding
was
uncl
ear
for
mos
tof
the
stud
ies.
Adh
eren
cean
dco
inte
rven
tions
uncl
ear
for
allo
fth
est
udie
s.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.14,
I2�
41%
No
serio
usin
cons
iste
ncy
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
8181
SDM
��
0.06
[�0.
50,0
.38]
Mod
erat
eq
ualit
ybe
caus
eof
risk
ofbi
as
Ou
tco
me:
mo
uth
op
enin
g
7(R
CTs
)C
once
alm
ent
ofal
loca
tion
uncl
ear
for
4of
the
stud
ies.
Thre
est
udie
sdi
dno
tha
veap
pro
pria
teal
loca
tion
conc
ealm
ent.
Ap
pro
pria
tebl
indi
ngw
asun
clea
rfo
rm
ost
ofth
est
udie
s.A
dher
ence
and
coin
terv
entio
nsun
clea
rfo
ral
lof
the
stud
ies.
Mos
tof
the
stud
ies
did
not
per
form
anin
tent
ion-
to-t
reat
anal
ysis
.
Pva
lue
onte
stfo
rhe
tero
gene
ityP�
.85,
I2�
0%N
oin
cons
iste
ncy
No
serio
usin
dire
ctne
ssN
ose
rious
imp
reci
sion
No
serio
usp
ublic
atio
nbi
as
132
138
MD
��
0.25
[�2.
08,1
.57]
Mod
erat
eq
ualit
ybe
caus
eof
risk
ofbi
as
(Con
tinue
d)
Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders
January 2016 Volume 96 Number 1 Physical Therapy f 19
tive for reducing musculoskeletal painand improving oromotor function.59,60
However, most of these exercise pro-grams were part of a general conserva-tive treatment regimen including othertherapies and did not provide clear infor-mation regarding dosage, frequency, oradherence, so the isolated effect of exer-cise to treat TMD and the optimal regi-men are uncertain at this time. Generalaerobic exercises have been shown toimprove muscle strength, flexibility, andfunctional capacity and could induceanalgesia.107 Further research is neededto investigate the usefulness of aerobicexercise and focused muscular training,especially exercises targeted to cervicalmuscles in people with TMD.
Effect of Manual Therapy forTreating TMDManual therapy has been used to restorenormal ROM, reduce local ischemia,stimulate proprioception, break fibrousadhesions, stimulate synovial fluid pro-duction, and reduce pain. Based on theresults of this systematic review, MTshows promising results for treatment ofmyogenous, arthrogenous, and mixedTMD, although the evidence is limitedand low. A combination of MT for theorofacial region plus MT of the cervicalspine was more effective than homeexercises or treatment to cervical spinealone in people with mixed TMD.Research, to date, suggests that a mixedtherapy involving MT techniques andexercises improves patient outcome.Other systematic reviews have shownsimilar results.24
Mobilization of the cervical spineresulted in decreases in pain intensityand pain sensitivity (via PPT evaluation)in patients with myogenous TMD thatexceed suggested values for minimumclinically important differences for painand treatment of the cervical spine. Man-ual therapy techniques such as mobiliza-tion of the cervical spine could have aninfluence on orofacial pain and move-ment in the jaw through the connectionsof these 2 systems in the trigeminocervi-cal nucleus.108
Tab
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Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders
20 f Physical Therapy Volume 96 Number 1 January 2016
Methodological Elements andOverall Quality of the EvidenceAffecting Observed EffectThe overall rating of the evidence for thisreview was low. This finding was duemainly to the risk of bias of the analyzedstudies. The methodological biases com-mon to the included studies could havean impact on results. Selection bias couldhave existed, as only 20 trials reportedappropriate randomization and only 4reported concealment of allocation.
Another important bias was the lack ofblinding, especially of the patients andassessors. Only 12 studies used blindedassessment of clinician-assessed out-comes such as mouth opening. How-ever, we also were interested in pain,which is a subjective outcome anddependent on the patient’s report. It islikely that lack of blinding could haveaffected the results of these studies.However, because of the nature of theinterventions investigated, blindingwould not be possible in many of them.There is empirical evidence showing thattrials without appropriate randomiza-tion, concealment of allocation, andblinding tend to report an inaccuratetreatment effect compared with trialsthat include these features.109 Thus, theresults of this systematic review shouldbe interpreted with caution, especiallyin trials with subjective self-reportedoutcomes.
Other potential biases that could poten-tially have affected observed effects wereinappropriate handling of withdrawalsand dropouts (only 16 trials used ITTanalysis). Effect sizes from trials thatexcluded participants in their analysis orthat used a modified ITT protocol tendedto be more beneficial than those fromtrials without exclusions, demonstratingthat the ITT principle is important topreserve the benefits of randomizationand keep unbiased estimates when theobjective of the trial is to investigateeffectiveness.110
Studies did not report interventions insufficient detail to be reproducible. Inaddition, they did not control for coint-erventions and did not have adequateadherence to treatment. These issues areof importance for this study, as it is
unclear if the effects on selected out-comes were due to the effect of exercise,MT, or other cointerventions. In addi-tion, it is unclear if the participantsreceived enough dosage of treatments, asadequate adherence was accomplishedby only a very small proportion of studies(15.2%). Adherence testing should besystematically studied in future studieswith exercise prescriptions.
The present study used a compilation ofitems from all of the scales used in thereviewed physical therapy literature inaddition to the risk of bias tool. Ourrecent analysis of health scales used toevaluate methodological quality deter-mined that none of these scales are ade-quate for use alone.44,111 Therefore, wedecided to use all of the scales, using acompilation of their items, to provide acomprehensive and sensitive evaluationof the quality of individual trials.Research investigating methodologicalpredictors for determining trial quality inphysical therapy is needed.
LimitationsThe findings of this review are specific toTMD (nonsurgical) and to exercise andMT. As with any systematic review, thereis the potential for selection bias, yet ourgroup used a comprehensive searchstrategy and included databases as wellas manual search. There was a small pro-portion of studies in other languages thatour team could not translate. However,we believe that most of the representa-tive studies were included in the finalanalysis of this systematic review. Inaddition, it has been reported thatlanguage-restricted meta-analyses onlyminimally overestimate treatment effects(�2% on average) compared withlanguage-inclusive meta-analyses.112
Therefore, language-restricted meta-analyses do not appear to lead tobiased estimates of interventioneffectiveness.112,113
The heterogeneity among studies, partic-ularly with respect to TMD diagnosis,study intervention, and chosen controlor comparison intervention was a chal-lenge. Many studies included the use ofexercises or MT as part of a general treat-ment program, which made the evalua-tion of these treatments in isolation dif-
ficult. Moreover, different diagnosticcriteria for TMD were used. Only 21 outof 48 studies included a diagnostic toolthat had been demonstrated as beingvalid, reliable, and reproducible to diag-nose TMD. Thus, diagnoses used for theanalyzed studies might not be appropri-ate. Despite this lack of standardizeddiagnosis, the study populations in alltrials appeared to be representative ofpatients seen in clinical practice. Weencourage clinicians and researchersusing the new diagnostic criteria forTMD (RDC/TMD) in future studies toallow consistent diagnoses according tothe same criteria, taxonomy, and nomen-clature to avoid confusion andmisunderstanding.114
Research ImplicationsNo high-quality evidence was found,indicating that there is great uncertaintyabout the effectiveness of exercise andmanual MT for TMD. There is a clearneed for well-designed RCTs examiningexercise and MT interventions for TMD.Specifically, it is necessary that trials beperformed isolating the type of exerciseand manual technique that is under test-ing to allow understanding the effective-ness of this type of treatment. In addi-tion, details of exercise, dosage, andfrequency as well as details on manualtechniques should be reported to createreproducible results. High-quality trialswith larger sample sizes are needed.
Clinical ImplicationsAlthough the overall level of evidence islow, exercises and MT are safe and sim-ple interventions that could potentiallybe beneficial for patients with TMD.Active and passive exercise for the jaw,postural exercises, and neck exercisesappear to have favorable effects forpatients with TMD. Manual therapyalone or in combination with exercisesshows promising effects. Exercises didnot show clear superiority over otherconservative treatments for TMD.
Dr Armijo-Olivo, Dr Pitance, and Dr Michel-otti provided concept/idea/research design.All authors provided writing, data collection,data analysis, and consultation (includingreview of manuscript before submission).
Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders
January 2016 Volume 96 Number 1 Physical Therapy f 21
Dr Armijo-Olivo is supported by the Cana-dian Institutes of Health Research (CIHR)through a full-time Banting fellowship,by the Alberta Innovates Health Solutionthrough an incentive award, by the STIHRTraining Program of Knowledge Translation(KT) Canada, and by the Music and MotionFellowship from the Faculty of RehabilitationMedicine of the University of Alberta.
DOI: 10.2522/ptj.20140548
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Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders
24 f Physical Therapy Volume 96 Number 1 January 2016
Appendix.Search Strategy Example: Ovid MEDLINE in Process and Other Nonindexed Citations and Ovid MEDLINE, 1946–Present
No. Searches Results
1 temporomandibular disorders.mp. or exp Temporomandibular Joint Disorders/ 14,629
2 exp Temporomandibular Joint/ or craniomandibular disorders.mp. or exp Temporomandibular Joint Dysfunction Syndrome/or exp Craniomandibular Disorders/ or exp Temporomandibular Joint Disorders/
