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Luque-Carrasco A1,2, Rodriguez-Blanco C1, Valencia-Chulián R1, Piña-Pozo F2, Oliva-Pascual-Vaca A1, Heredia-Rizo AM1
1University of Seville, Physiotherapy Department, Faculty of Nursing, Physiotherapy and Podiatry, Seville, Spain, 2Universitary School of Osuna, Physiotherapy Department, Seville, Spain
Background: Temporomandibular disorders (TMD), defined as a variety of painful conditions affecting the temporomandibular joint, are highly prevalent and represent a substantial physical and psychosocial impact. In mild-moderate presentations of TMD, a conservative approach is preferred over surgery. There is varying evidence about the effectiveness of manual therapy in painful TMD, although further high-quality study designs are needed to strengthen current evidence. While a multimodal intervention seems to be the most effective approach, this remains a matter of debate.
Purpose: The aim was to assess the immediate responses on mechanical sensitivity to pain, cervical range of movement and maximal vertical mouth opening after a multimodal manual therapy protocol combining soft-tissue techniques and spinal manipulation, compared to the isolated use of soft-tissue techniques, in individuals with painful TMD.
Methods: A single-blinded (the assessor collecting the outcome measures remained blinded to participants' allocation group) randomized controlled trial was carried out. Individuals with bilateral and painful TMD for more than 6 months, and with a negative response to the extension-rotation upper cervical spine test, were invited to participate. Sixty-four patients (81.5 % females), mean age of 40.9 ± 13.2 years, were recruited from different private practices. Participants were randomized into a multimodal manual therapy group (MTG, n=29) or a control group (CG, n=35). The MTG underwent a single session combining upper cervical spine manipulation with soft-tissue manoeuvres (suboccipital muscle inhibition technique and neuromuscular techniques over the masticatory muscles). Participants in the CG only received the soft-tissue manoeuvres. Primary measurements were made of pressure pain thresholds (PPTs) over the trigeminal nerve (supraorbital, infraorbital and mental nerves), and the suboccipital, masseter and temporal muscles. PPT levels were assessed on the dominant and non-dominant sides. Secondary outcomes included cervical range of movement, assessed with a digital inclinometer, and maximal pain-free vertical mouth opening, as measured with a digital caliper. Measurements were made before and immediately after intervention. A mixed-model analysis of variance (ANOVA) was used to compare the differences between groups on the primary and secondary outcomes.
Results: In the between-groups analysis, participants in the MTG reported significantly higher PPTs after intervention, compared with the CG, over the infraorbital nerve (dominant side; p=0.016), and the suboccipital muscles (non-dominant side; p=0.003). For the secondary outcomes, cervical extension and right and left neck rotation significantly improved in the MTG compared to controls (all, p 0.001).
Conclusion(s): The combination of cervical spine manipulation with soft-tissue techniques over the masticatory muscles is no superior, in general, to the isolated use of soft-tissue techniques for improving mechanical sensitivity to pain immediately after intervention in individuals with painful TMD. The multimodal protocol including spinal manipulation demonstrated greater impact on increasing cervical range of movement, but not vertical mouth opening.
Implications: The clinical management of TMD may include the combination of spinal articular techniques and soft-tissue manoeuvres with the aim of improving function. The biomechanical relationship between the cervical spine and the temporomandibular joint is a plausible explanation to support the use of manual therapy for the cervical spine in individuals with TMD.
Keywords: Temporomandibular joint disorders, pain threshold, spinal manipulation
Funding acknowledgements: None declared
Purpose: The aim was to assess the immediate responses on mechanical sensitivity to pain, cervical range of movement and maximal vertical mouth opening after a multimodal manual therapy protocol combining soft-tissue techniques and spinal manipulation, compared to the isolated use of soft-tissue techniques, in individuals with painful TMD.
Methods: A single-blinded (the assessor collecting the outcome measures remained blinded to participants' allocation group) randomized controlled trial was carried out. Individuals with bilateral and painful TMD for more than 6 months, and with a negative response to the extension-rotation upper cervical spine test, were invited to participate. Sixty-four patients (81.5 % females), mean age of 40.9 ± 13.2 years, were recruited from different private practices. Participants were randomized into a multimodal manual therapy group (MTG, n=29) or a control group (CG, n=35). The MTG underwent a single session combining upper cervical spine manipulation with soft-tissue manoeuvres (suboccipital muscle inhibition technique and neuromuscular techniques over the masticatory muscles). Participants in the CG only received the soft-tissue manoeuvres. Primary measurements were made of pressure pain thresholds (PPTs) over the trigeminal nerve (supraorbital, infraorbital and mental nerves), and the suboccipital, masseter and temporal muscles. PPT levels were assessed on the dominant and non-dominant sides. Secondary outcomes included cervical range of movement, assessed with a digital inclinometer, and maximal pain-free vertical mouth opening, as measured with a digital caliper. Measurements were made before and immediately after intervention. A mixed-model analysis of variance (ANOVA) was used to compare the differences between groups on the primary and secondary outcomes.
Results: In the between-groups analysis, participants in the MTG reported significantly higher PPTs after intervention, compared with the CG, over the infraorbital nerve (dominant side; p=0.016), and the suboccipital muscles (non-dominant side; p=0.003). For the secondary outcomes, cervical extension and right and left neck rotation significantly improved in the MTG compared to controls (all, p 0.001).
Conclusion(s): The combination of cervical spine manipulation with soft-tissue techniques over the masticatory muscles is no superior, in general, to the isolated use of soft-tissue techniques for improving mechanical sensitivity to pain immediately after intervention in individuals with painful TMD. The multimodal protocol including spinal manipulation demonstrated greater impact on increasing cervical range of movement, but not vertical mouth opening.
Implications: The clinical management of TMD may include the combination of spinal articular techniques and soft-tissue manoeuvres with the aim of improving function. The biomechanical relationship between the cervical spine and the temporomandibular joint is a plausible explanation to support the use of manual therapy for the cervical spine in individuals with TMD.
Keywords: Temporomandibular joint disorders, pain threshold, spinal manipulation
Funding acknowledgements: None declared
Topic: Pain & pain management; Musculoskeletal
Ethics approval required: Yes
Institution: University of Seville, Spain
Ethics committee: Research Ethics Committee of the University of Seville
Ethics number: N/A
All authors, affiliations and abstracts have been published as submitted.
