PREDICTORS OF PAIN REDUCTION FOLLOWING A PROGRAM OF MANUAL THERAPIES FOR PATIENTS WITH TEMPOROMANDIBULAR DISORDERS: A PROSPECTIVE OBSERVATIONAL STUDY

G. Asquini^1,2, D. Falla¹, V. Devecchi¹

¹Birmingham University, Centre of Precision Rehabilitation for Spinal Pain, Birmingham, United Kingdom, ²Italian Stomatologic Institute, Craniomandibular Physiotherapy Service, Milan, Italy

Background: Temporomandibular disorders (TMD) are a health challenge given their prevalence and related socio-economic impact. Clinical guidelines recommend conservative treatment for the management of TMD, and manual therapy (MT) directed to the craniomandibular structures is commonly applied to improve pain and function, although its superiority versus other treatments remains unclear. The clinician’s decision on what specific treatment is the best for a patient with a TMD can be influenced by different factors such as the clinician’s expertise and knowledge of the available evidence, professional attitude and clinical reasoning skills. However, specific features of the individual’s presentation should also be considered when choosing the best treatment for each patient. To date, there has been no attempt to examine whether features of the patient’s presentation can predict pain reduction and functional improvement following a program of manual therapies (MTP) for people with TMD.

Purpose: To identify predictors of pain reduction and functional improvement following a MTP in patients with TMD and develop a first screening tool that could be used in clinical practice to facilitate decision-making.

Methods: This observational prospective study recruited a cohort of 102 adults with TMD at a Dental Hospital in Italy. Patients were treated with four weekly sessions of MT applied to craniomandibular structures. Candidate predictors including demographic variables, general health variables, psychosocial features, TMD characteristics and related clinical tests were collected at baseline. A pain intensity reduction of at least 30% after the MTP was considered a good outcome. Logistic regression was adopted to develop the predictive model and its performance was assessed considering the explained variance, calibration, and discrimination. Internal validation of the prediction models was further evaluated in 500 bootstrapped samples.

Results: Participants with a pain intensity greater than 2/10 during mouth opening, positive expectations of outcome following MT, pain localized in the craniocervical region and a low CSI score had significant pain reduction following the MTP. Participants with a shorter pain duration and limitations in maximal mouth opening showed greater functional improvements. Predictive performance of the identified physical and psychological variables was characterized by high explained variance (R2 = 58%) and discrimination (AUC = 89%) after internal validation. A preliminary screening clinical tool was developed and presented as a nomogram.

Conclusions: This study identified four predictors of pain reduction and two predictors of functional improvement in patients with TMD following a MTP directed to craniomandibular structures. A preliminary screening clinical tool was developed and presented as a nomogram. The high discrimination of the prediction model revealed promising findings, although these need to be externally validated by future research.

Implications: The results will have important clinical implications once externally validated, as they will guide clinicians managing people with TMD to ensure that the right treatment is chosen for the right patient. The predictors identified are simple to measure in clinical settings. The developed nomogram can be easily integrated into the initial clinical assessment. Following validation, a digital online version of the nomogram will be developed which will be made accessible so that it is easy to implement.

Funding acknowledgements: Not supported by external funding.

Keywords:
Temporomandibular Disorders
Manual Therapy
Prediction

Topics:
Musculoskeletal
Pain & pain management

Did this work require ethics approval? Yes

Institution: Istituto Stomatologico Italiano - Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico

Committee: Ethics Committee of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico

Ethics number: acceptance no. “534_2019bis”