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Effectiveness of Manual Therapy and Therapeutic
Exercise for Temporomandibular Disorders:

Systematic Review and Meta-Analysis
Susan Armijo-Olivo, Laurent Pitance, Vandana Singh,
Francisco Neto, Norman Thie and Ambra Michelotti
PHYS THER. Published online August 20, 2015
doi: 10.2522/ptj.20140548
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Running head: Manual Therapy and Therapeutic Exercise for Temporomandibular
Disorders
Research Report
Effectiveness of Manual Therapy and Therapeutic Exercise for
Temporomandibular Disorders: Systematic Review and Meta-Analysis
Susan Armijo-Olivo, Laurent Pitance, Vandana Singh, Francisco Neto, Norman Thie,
Ambra Michelotti
S. Armijo-Olivo, PT, BScPT, MScPT, PhD, Department of Physical Therapy, Faculty of
Rehabilitation Medicine, 3-48 Corbett Hall, University of Alberta, Edmonton, Alberta,
Canada T6G 2G4. Address all correspondence to Dr Armijo-Olivo at: sla4@ualberta.ca
or susanarmijo@gmail.com.
L. Pitance, PT, MT, PhD, Université Catholique de Louvain‒Institute of Neuroscience,
Brussels, Belgium, and Stomatology and Maxillofacial Surgery Department, Cliniques
Universitaires Saint-Luc, Brussels, Belgium.
V. Singh, DDS,MS, MSc, Department of Dentistry, Faculty of Medicine, TMD/Orofacial
Pain Clinic, Kaye Edmonton Clinic, Edmonton, Alberta, Canada.
1
F. Neto, PT, FisioNeto–Terapia Manual Ortopédica and Pilates Clínico, Póvoa de
Varzim, Portugal.
N. Thie, BSc, MSc, MMSc, DDS, School of Dentistry, Faculty of Medicine and
Dentistry, TMD/Orofacial Pain Graduate Program, Edmonton Clinic Health Academy,
Edmonton, Alberta, Canada.
A. Michelotti, BSc, DDS, Orthodontic Post-Graduate Program and TMD/Orofacial Pain
Master Program, School of Medicine Federico II‒Dental School, Naples, Italy.
[Armijo-Olivo S, Pitance L, Singh V, et al. Effectiveness of manual therapy and
therapeutic exercise for temporomandibular disorders: systematic review and meta-
analysis. Phys Ther. 2015;95:xxx–xxx.]
© 2015 American Physical Therapy Association
Published Ahead of Print: xxxx
Accepted: August 1, 2015
Submitted: December 12, 2014
2
ABSTRACT
Background: Manual therapy and exercise have been extensively used to treat
musculoskeletal conditions such as Temporomandibular disorders (TMD). The evidence
regarding their effectiveness provided by early systematic reviews is outdated.
Purpose: Summarize evidence from and evaluate the methodological quality of
randomized controlled trial’s (RCT) that examined the effectiveness of manual therapy
(MT) and therapeutic exercise interventions when compared with other active
interventions or standard care for treatment of TMD.
Data sources: Electronic data searches were performed including 6 databases in addition
to manual search.
Study Selection: RCTs involving adults with TMD, comparing any type of MT
intervention (e.g. mobilization, manipulation) or exercise therapy compared to 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. 48
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 risk of bias assessments. Most of the effect sizes were
low to moderate with no clear indication of superiority of exercises vs. other conservative
treatments to treat 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 studies
3
Conclusions: No high quality evidence was found, indicating that there is great
uncertainty about the effectiveness of exercise and manual therapy for TMD.
4
INTRODUCTION
Temporomandibular disorders (TMD) consist of a group of pathologies affecting
the masticatory muscles, the temporomandibular joint, and related structures.1,2 TMD
constitute a major public health problem as they are one of the main sources of chronic
orofacial pain interfering with daily activities. TMD are also commonly associated with
other symptoms affecting the head and neck region such as headache, ear related
symptoms, cervical spine dysfunction, 3,4 and altered head and cervical posture. 5-15
Physical therapy (PT) has been used for decades treating craniomandibular
disorders using thermal packs, vapocoolants and transcutaneous electrical nerve
stimulation (TENS)16. In 1997, Feine and Lund 17 recognized that dentists valued PT
treatment for TMD and recently a national survey in the United Kingdom found that
despite limited evidence, 72% of respondents considered PT as an effective treatment
option for TMD, with jaw exercise (79%), ultrasound (52%), manual therapy (MT)
(48%), acupuncture (41%) and laser therapy (15%) as the most effective modalities for
managing TMD.18 To date evidence supports the use of conservative and reversible
treatment approaches for TMD treatment, although a multidisciplinary health care
approach may be required. PT is amongst the 10 most common treatments used for
TMD19 focused on decreasing neck and jaw pain, improve range of motion and promote
exercise to maintain healthy function.
Goals of PT are to decrease pain, enable muscle relaxation, reduce muscular
hyperactivity, and re-establish muscle function and joint mobility.20 PT treatment is
reversible, non-invasive, provides self-care management in an environment to create
5
patient responsibility of their own health. PT modalities include electrophysical
(ultrasound, microwave, laser), electro-analgesic (TENS, interferential current,
biofeedback), acupuncture, therapeutic exercise and MT. Therapeutic exercise and MT
are used to improve strength, coordination, mobility, reduce pain 21 and treatment may
include and focus on, poor posture, cervical muscle spasm/pain and treatment for referred
cervical origin orofacial.22 The evidence for the effect of electrophysical modalities has
been questioned.23
MT (including joint mobilization, manipulation, and or MT of the soft tissues) and
therapeutic exercises within PT treatments have been increasingly used by clinicians and
researched due to positive outcomes in conditions especially for low back pain, neck pain
and related disorders. 24 MT has been used to restore normal range of motion, reduce
local ischemia, stimulate proprioception, break fibrous adhesions, stimulate synovial fluid
production, and reduce pain. In the area of orofacial pain, several systematic reviews
have been conducted regarding PT and specifically MT and exercise interventions for
TMD. 19,23,25 Most of these early systematic reviews highlighted the positive effects of
exercises and MT to improve symptoms and function in subjects with TMD. However,
two19,23 of them were conducted almost 8 years ago including few randomized controlled
trials. Research has expanded over the last few years and new RCTs have been conducted
which implies that the information from them is now outdated. Another recent systematic
review 25 combined pathologies from upper extremity and TMD. This review 25 included
several types of designs and did not focus on RCT which are the best evidence when
looking at interventions. In addition, based on a preliminary search performed by our
team, it was realized that this review missed important RCT in the area (included only 5
6
studies). In addition, none of these systematic reviews provided a meta-analysis of the
trials. Therefore, the objectives of this systematic review were:
1) Summarize the evidence from, and evaluate the methodological quality of RCTs
that examined the effectiveness of MT and therapeutic exercise interventions in
the management of TMD.
2) Determine the magnitude of the effect of these interventions to manage TMD.
METHOD
The reporting of this systematic review is based on the PRISMA (Preferred Reporting
Items for Systematic reviews and Meta-Analyses) guidelines.26 The aim of the PRISMA
Statement is to help authors improve the reporting of systematic reviews and meta-
analyses. It consists of a 27-item checklist and four-phase flow diagram
This systematic review was registered in PROSPERO (CRD42013005628).
STUDY SELECTION
Inclusion criteria for this review was as follows:
Participants:
This review was restricted to trials with participants meeting the following criteria: (1)
diagnosis of TMD as stated by the RDC/TMD27 or any clinical diagnosis involving signs
and symptoms of TMD28,29, (2) adult (>18 years of age), (3) musculoskeletal dysfunction,
(4) pain impairment, (5) no previous surgery in the temporomandibular region, and (6) no
other serious comorbid conditions (e.g., fracture in region, cancer, neurological disease).
7
Studies:
This review targeted RCTs comparing any type of MT intervention (e.g. mobilization,
manipulation, soft tissue mobilization) or exercise therapy alone or in combination with
other therapies compared to a placebo intervention, controlled comparison intervention,
or standard care (i.e. treatment that normally is offered).
Outcomes:
The primary outcomes of interest for this systematic review included pain, range of
motion, and oral function. Oral function for this systematic review focused on limitations
of daily activities of patients with TMD measured through different questionnaires.
Secondary outcome of interest was pressure pain threshold (PPT).
The minimal clinically important difference (MCID) for pain has been reported to range
from 1.5 to 3.2 points.30-34 The smallest detectable difference of maximal mouth opening
in healthy subjects has been reported to be 5 mm, indicating that an important change of
at least 5 mm can be considered clinically relevant.35 PPT measurements have been
shown to have good or excellent inter-rater and intra-rater reliability 36 37,38 The Minimal
Important Difference (MID) for PPTs has been reported to be ≥ 1.10 Kg/cm2/s. 39,40
This systematic review was open to all time-points: immediate post treatment, short-term,
intermediate-term, and long-term follow-up.
DATA SOURCES AND SEARCHES
A search of bibliographic databases was conducted in 6 electronic databases and included
• MEDLINE (database root (1966)–April 7, 2015),
8
• EMBASE (database root (1988)– April 7, 2015),
• Cochrane Library and Best Evidence (database root (1991)– April 7, 2015),
• ISI Web of Science (database root (1965)– April 7, 2015),
• EBM reviews–Cochrane Central Register of Controlled Trials (database root
(1991)– April 7, 2015), and
• CINAHL (database root (1982) – April 7, 2015).
Key words and medical subject headings were identified with the assistance of a librarian
who specialized in health science databases and experts in the orofacial pain field. No
restrictions were made regarding the language of publication. Manual search of selected
studies by looking at their references was conducted as well.
Refer to Appendix 1 for search strategy.
DATA SCREENING
Two independent investigators screened the titles of publications found on the databases,
and, if available, the abstract of the publication. The Early Review Organizing Software
(EROS) (http://www.eros-systematic-review.org/) web platform was used for screening
the articles for inclusion. In order for papers to be included in the review, the paper had
to meet all inclusion criteria of this systematic review on the rating form created in EROS
software. Studies were analyzed with the available information. Authors were not
contacted.
Disagreements between reviewers on inclusion were resolved by consensus. Kappa
statistic was calculated using STATA software (version 12) to determine the level of
agreement between raters on trial inclusion before consensus. Criteria proposed by Byrt
9
41
were used to interpret kappa values.
DATA EXTRACTION
The information of each study included in this review was extracted and entered into
excel or word files. For each part of the review, data extraction was carried out
independently by two reviewers. Data were extracted on study characteristics that
included; the design, type of TMD, type of interventions, main and secondary outcomes,
and treatment estimates. Any disagreements on data extraction were resolved by
consensus.
QUALITY ASSESSMENT (RISK OF BIAS)
Assessments of quality (risk of bias- RoB) were completed by two independent reviewers
( any of these LP, VS, FN, NT, AM, SAO) For the assessment of RCTs, our team
currently used a compiled set of items based on the seven most commonly used tools to
evaluate the RoB in complex PT trials.42 In addition, the risk of bias (RoB) tool was used
using the main outcome of each study to make the assessments. We followed the
guidelines established by the Cochrane Collaboration to perform RoB assessments;
however we developed specific decision rules to make decisions as described
elsewhere.43 For the overall assessment of RoB, a trial was considered at low risk of bias
if it was rated as low risk in all individual domains; if the rating was unclear in at least
one domain, and the other domains were unclear or low, the overall assessment of RoB
was unclear. Finally, an overall assessment of high risk of bias was considered if at least
one domain was rated as high. These criteria have been used previously by our team and
10
others.43,44
Any discrepancies in quality ratings were resolved by discussion. If consensus could not
be reached, a third member of the review team with expertise in quality assessments
(SAO) acted as an arbitrator and made a final decision.
DATA ANALYSIS AND SYNTHESIS
Data analysis was performed based on type of intervention (i.e. exercise, mobilization, and
manipulation), TMD diagnosis (myogenous TMD, arthrogenous TMD, mixed TMD), and
based on type of outcome [e.g. pain intensity, range of mouth opening (ROM), oral
function (oral related quality of life)]. For analysis of continuous outcome data, we used
mean difference (MD) and standardized mean difference (SMD) with 95%confidence
intervals to pool data. Heterogeneity was evaluated statistically using the I2 statistic. The
MD and SMD were defined according to Cochrane collaboration. 45 “MD is a standard
statistic that measures the absolute difference between the mean value in two groups in a
clinical trial. It estimates the amount by which the experimental intervention changes the
outcome on average compared with the control. It can be used as a summary statistic in
meta-analysis when outcome measurements in all studies are made on the same scale”.
“The SMD is used as a summary statistic in meta-analysis when the studies assess the same
outcome but measure it in a variety of ways (i.e. use different psychometric scales). In this
circumstance it is necessary to standardize the results of the studies to a uniform scale
before they can be combined. The standardized mean difference expresses the size of the
intervention effect in each study relative to the variability observed in that study”.
11
We decided to pool studies based on TMD diagnosis, intervention provided, and outcome.
We grouped studies that had the same diagnosis (myogenous, arthrogenous or mixed),
similar intervention of interest (i.e. manual therapy, exercises) and also had the same
underlying outcome. Thus, we created groups of studies that were similar in terms of these
characteristics and pool them. In the presence of clinical heterogeneity in the study
population or intervention, the DerSimonian and Laird Random Effects Model of Pooling
was used based on the assumption of the presence of inter-study variability to provide more
conservative estimate of the true effect.46,47
Cohen criteria was used to interpret values of effect sizes found for our pooled estimates.
48
Cohen described 0.2, 0.5, and 0.8 as small, moderate and large effect size respectively.
48
Revman 5.0 Software† was used to summarize the effects (i.e. pooled mean
differences) and construct the forest plots for all comparisons.
(† Review Manager (RevMan) [Computer program]. Version 5.0. Copenhagen: The
Nordic Cochrane Centre, The Cochrane Collaboration, 2008.
Subgroup and Sensitivity Analysis
In order to investigate and accommodate heterogeneity (clinical heterogeneity in the
study population or intervention) as explained above, a random effects model was used
across all the comparisons. Furthermore, in order to explain the heterogeneity in terms of
study- level covariates, we could have attempted a meta-regression model. However,
12
because the small number of studies (< 10) for comparison this analysis was not possible.
We attempted to perform sensitivity analysis when possible.
We did not perform sensitivity analyses based on quality because the risk of bias of
analyzed studies was either unclear or high with no study being classified as low risk.
This precluded sensitivity analyses by different levels of biases. Therefore, the pooled
data should be interpreted carefully
Data synthesis
The quality of the body of the evidence was assessed using the GRADE approach.49 The
evidence was classified as high, moderate, low, and very low as described by Guyatt et
al.49 Domains that may decrease the quality of the evidence are: 1) the study design, 2)
risk of bias, 3) inconsistency of results, 4) indirectness (not generalizable), 5) imprecision
(insufficient data), other factors (e.g. reporting bias).
RESULTS
The search of the literature resulted in a total of 3549 published articles. Of the 3549
published articles, 106 were considered to be potentially relevant. Independent review (in
duplicate) of these 106 articles led to the inclusion of 58 articles representing 50 studies
(some studies reported data from the same population in 2 manuscripts). There were 5
articles in other languages 50-54 that were not possible to translate by our study team and
were not included in the final analysis. Thus there were 45 studies included for this
review from databases search. In addition, three studies 55-57 were obtained through
13
manual search. Therefore, a total of 48 studies were included in the final analysis (Figure
1). The agreement between reviewers to select the articles for this review was
kappa=0.98 (95%CI 0.977 - 0.99). According to Byrt,41 the agreement between reviewers
was excellent. Table 1 provides details of included studies.
Diagnosis
There was considerable diversity in the clinical presentation and diagnosis of participants
with TMD among the included studies (Table 1). Fourteen of the studies examined the
effectiveness of the exercise and/or MT interventions in muscular TMD (myogenous
TMD), 14 studies in patients with articular TMD (arthrogenous TMD), and 19 studies in
patients with mixed diagnoses of TMD (included both myogenous and arthrogenous
TMD).28,29 One study looked at both myogenous and arthrogenous TMD.58 Twenty one
of the studies 57-76 used the research diagnostic criteria for temporomandibular disorders
(RDC/TMD) established by Dworkin and LeResche 27 to classify the patients as having
TMD. The remaining 27 studies used their own diagnostic criteria, based on signs and
symptoms of the patients.
METHODOLOGICAL QUALITY ASSESSMENT
The results of the critical appraisal for the selected studies are presented in Table 2. Only
6 studies accomplished more than 60% of the items. 57,66,67,76-78 Most of the studies did
not accomplish with important methodological indicators of risk of bias such as
randomization, allocation concealment, blinding and intention to treat. For example,
study flaws regarding patient selection were mainly related to description and
14
appropriateness of the randomization procedure and concealment of allocation, with only
20 (41.6%) and 4 (8.3%) of the studies meeting these criteria respectively. As expected,
items related to blinding were not achieved by the majority of the studies. Only 3 of the
studies used a double-blinded design and could blind participants. These studies used a
placebo arm, which is hard to obtain in these types of interventions. In addition, only 12
of the studies (25%) used blinded assessment of outcomes and none of the studies blinded
the therapist. Thus, blinding was the area that was the hardest section to be met by the
analyzed studies. When analyzing issues regarding intervention, it was found that
although it is expected that interventions would be well described to be reproducible,
only 64.6% (n=30) of the studies described the main intervention to be tested. In addition,
most studies failed to control for co-interventions. Only 6 studies met this item.
Testing subjects’ compliance to intervention and having adequate compliance was
another issue that was not met by many studies (only 11 and 7 studies respectively).
Furthermore, adverse effects were only reported by 10 of the studies but there was no a
specific description of such events when they occurred in all of the studies.
Despite the fact that the adequate handling of dropouts is considered an important
method used to prevent bias in data analysis, only 17 of the analyzed studies included
information regarding the reasons of withdrawals/dropouts and only 16 studies used
intention to treat analysis. The outcome measures were not described well in terms of
validity, reliability, or responsiveness. Only few studies reported these items (11, 17 and
3 studies respectively). Moreover, the authors did not report intra- and/or inter-rater
reliability of the assessors who performed outcome measurements.
15
Regarding statistical issues, it was uncertain if sample size was adequate in 30 of
the studies and only 18 studies reported an evaluation of the clinical significance of their
results.
Risk of bias assessments using the risk of bias tool determined that none of the studies
was considered low risk of bias. Most of them were classified as either unclear (58.4%)
or high risk of bias (41.6 %).
EFFECTIVENESS OF INTERVENTION BY TMD DIAGNOSES
EXERCISES AND MYOGENOUS TMD
POSTURE CORRECTION EXERCISES IN MYOGENOUS TMD
Two studies59,60 evaluated the effectiveness of posture correction exercises for
patients with myofascial pain. Both studies found positives results of postural exercises
for improving symptoms of muscular TMD. When pooling the data for these 2 studies
which had similar interventions, diagnosis and outcomes, maximum pain-free opening
significantly increased in patients receiving postural training when compared with a
control group. MD in maximum pain-free opening was 5.54mm [95%CI 2.93, 8.15]
(Figure 2), clinically significant in favor of postural training.35 Furthermore, patients
treated with postural training had significantly less symptoms and disturbance with daily
living when compared with a control group. The SMD in symptoms and disturbance of
symptoms with daily life was 1.13 [95%CI 0.48, 1.78], indicating a large effect size,
clinically significant, for this pooled outcome.
16
GENERAL JAW EXERCISES ALONE OR COMBINED WITH NECK EXERCISE
PROGRAM IN MYOGENOUS TMD
Eight studies 56-58,62,63,66,79,80 looked at the effect of exercises alone or combined with
other therapies for myogenous TMD. The results of these studies were equivocal. Five of
them56,57,62,79 did not find significant differences between a general PT exercise program
targeted to the jaw 56,62,79,80 or jaw/neck57 when compared with a control or other active
treatments such as biofeedback, TENS, TherabiteH, or oral splint therapy. However,
three of them58,63,66 found better outcomes especially on pain and ROM when compared
with control groups.
Data were pooled from studies with similar outcomes, diagnosis, and comparing an
exercise program vs. other forms of therapy such as education,62,66 or splint therapy.56,58
Data from all of these studies,56,58,62,66 indicated that there was a trend to favor exercise
therapy for pain free maximum opening and pain intensity when compared with a control
group. The MD for pain free maximum opening was 5.94 mm [95%CI -1.0, 12.87]
considered clinically relevant.35 The SMD for pain intensity pooling 5 studies57,58,62,63,66
was 0.43 [95%CI -0.02, 0.87] with a moderate effect size according to Cohen
guidelines.48 When performing sensitivity analyses, grouping studies comparing exercises
therapy vs education,62,66 a non-significant effect was found on pain free maximum
opening (1.92mm [95%CI -0.57, 4.41]). However, when comparing exercises vs. splint
therapy,56,58 a statistically and clinically meaningful effect was found (12.31mm [95%CI
7.73, 16.89).
MANUAL THERAPY TARGETED TO THE OROFACIAL REGION IN
MYOGENOUS TMD
17
Four studies 64,65,77,81 looked at MT techniques such as facial manipulation vs. botulinum
toxin, 81, or intra-oral myofascial therapy vs. waiting list, and self-care education and
exercises for subjects with myogenous TMD. 64,65,77 The results of these studies support
the use of MT to treat myogenous TMD since subjects treated with all of these
approaches improved mouth opening and reduced jaw pain from baseline. Although
intra-oral myofascial therapy and exercise groups were superior to waiting list control
group, they did not have any statistical significant difference between them. In addition,
facial manipulation had equivalent effect as botulinum toxin. However, facial
manipulation was slightly superior in reducing subjective pain perception and botulinum
toxin injections was slightly superior in increasing ROM at 3 months after treatment.
When pooling the results from 3 of these studies based on similar outcomes, diagnosis,
and comparing similar intervention regarding MT, 64,65,81 it was found that MT
significantly improve pain at 4 to 6 weeks of treatment when compared with waiting list
or botulinum toxin, approaching a clinically relevant value. The MD for pain intensity
was 1.35 cm [95%CI 0.91, 1.78]. When pooling the studies that considered the
comparison of MT versus a waiting list only, similar results were obtained 1.31cm
[95%CI 0.86, 1.76].
MANUAL THERAPY MOBILIZATION OF THE CERVICAL SPINE AND

MYOGENOUS TMD
A very recent RCT conducted by La Touche 67 testing a more specific approach
directed to the cervical spine to treat patients with cervico-craniofacial pain of myofascial
origin was performed. This preliminary study found that mobilizations targeted to the
18
cervical spine drastically decreased pain intensity and pain sensitivity [via pain pressure
threshold (PPT) evaluation] in patients with cervico-craniofacial pain of myofascial
origin immediately after the application of the technique when compared with placebo
treatment. The effects sizes found by this study for pain intensity 28.75 points [95%CI
(21.65, 35.85)] and 1.12kg/cm2 [95%CI (0.96, 1.29)] for pain and PTT respectively were
considered clinically relevant.
JAW/NECK EXERCISES ALONE OR AS PART OF A CONSERVATIVE
REGIME IN ARTHROGENOUS TMD
Eight studies58,61,68,82-86 looking at subjects with arthrogenous TMD, focused on jaw/neck
exercises alone or combined with other therapies such as medications, surgery or self-
care recommendations. Six studies 58,61,68,84-86 focused on exercise therapy alone 85,86 or
combined with conventional treatment,61 or the combination of jaw exercises with
Therabite® 58 or myofunctional therapy.68 The remaining 2 studies 82,83 looked at the
effectiveness of surgery (arthrocentesis or arthroscopy) combined with conservative
treatment including exercises for the jaw vs. jaw exercises alone.
Results were mixed, however, most of the studies favored the use of exercises alone or
as part of a general regime to treat subjects with arthrogenous TMD including disc
displacements with or without reduction.58,68,84-86 However, one study 61 did not find that
exercises were superior to a control group involving general physical therapy treatment.
19
Data were pooled from studies with similar outcomes, diagnosis, and comparing an
exercise program vs. other forms of therapy such as education,61 splint therapy58, or
control group. 68,87 When pooling the results of the studies investigating the effectiveness
of exercise alone or in combination with other conservative therapies on pain
intensity,58,61,68,86 it was found that there was no statistical significant difference in pain
between exercise and control groups. Nevertheless, there was a trend to favor the
exercise group when compared to the control group. The SMD for pain intensity was
0.68 [95%CI -0.04, 1.40] with a moderate effect size according to Cohen guidelines.48
When pooling was focus on those studies including only a control group, 68,87 similar
results were found, although the SMD increased (SMD 1.11 [95%CI -0.73, 2.94].
Regarding active mouth opening, a non-significant effect was found between general jaw
exercises vs. education, splint therapy or a control group when pooling 3 studies. 58,61,86
The MD for active mouth opening was 3.13mm [95%CI -1.96, 8.23]. A trend to favor
exercises was observed based on the 95% confidence intervals.
When pooling the studies,82,83 that looked at exercises plus arthrocentesis or arthroscopy
vs. conservative therapy including exercises alone on active mouth opening at 6 months,
it was found that no differences between these approaches existed. The MD was -1.01
mm [95%CI -5.43, 3.42] implying that conservative treatment plus exercises is
appropriate to treat disc displacement without reduction or when subjects have restricted
mandibular movement. The results indicate non-invasive procedures as a first line of
treatment.
20
MANUAL THERAPY PLUS JAW EXERCISES IN ARTHROGENOUS TMD
Seven studies 69,70,78,88-92 looked at the combined effect of MT plus jaw exercises for
subjects with arthrogenous TMD. Three studies 69,88,89 compared MT and exercises vs
splint therapy, one study 90,91 compared with self-care and advice regarding prognosis,
and two studies used as comparison the use of medications. 78,92 In addition one study 70
compared anesthetic blockage of the auriculotemporal nerve vs. MT and exercises in
addition to blockage of the auriculotemporal nerve
In general, it was found that MT plus exercises reduced symptoms and increased ROM
for patients with arthrogenous TMD, particularly for those with reduced ROM due to
from disc displacements without reduction (“closed lock”). Five of these studies
69,78,88,89,92
favor the use of manual therapy in conjunction with exercises when compared
with splint69,88,89 or when compared with medications92 or other non-conservative
treatments for arthrogenous TMD such as arthroscopy and arthroplasty.78
When pooling the results from the studies with homogenous interventions, similar
outcomes, diagnoses, and available data,69,78,88,89,91 it was found that pain was
significantly reduced in subjects receiving MT combined with exercises when compared
with splint therapy, self-care or medications. The SMD for pain intensity at 4 weeks to 3
months was 0.40 [95%C 0.13,0.68] with a moderate effect size according to Cohen
guidelines48 (Figure 3).
21
When looking at active mouth opening,69,88,89,91 it was found that MT plus exercises
significantly increase active mouth opening when compared with splint therapy, self-
care or medications. The MD for active mouth opening at 4 weeks to 3 months was
3.58mm [95%C 1.46, 5.70].
GENERAL JAW EXERCISE PROGRAM IN MIXED TMD
Eleven studies 55,71-74,93-100 looked at exercises alone or as part of a general conservative
therapeutic regime to treat subjects with mixed TMD. In general, exercises for mixed
TMD when compared with control groups had better results for decreasing pain and
improving function and pain sensitivity of the masticatory muscles.55,71,97,98 However
when compared with other forms of active treatments such as splints, global postural re-
education program, or acupuncture,72-74,93-96,99,100 no significant differences between
these treatments were found.
When pooling the results of studies with available data, similar interventions and
outcomes, 55,71,73,94,95 it was found that exercises in the form of general jaw exercises plus
conventional treatment, or with the addition of an oral device 95 were not superior to other
treatment modalities such as splint therapy, global re-education posture, splint plus
counselling, acupuncture, or standard conservative care to improve pain intensity. The
SMD for pain intensity was -0.06 [95%C -0.50; 0.38] with a very small effect size
according to Cohen guidelines.48
22
When pooling results for mouth opening,55,71,73,93,95,96,98 non-significant differences were
obtained between general jaw exercises vs. splint therapy, global re-education posture,
splint plus counselling, or standard conservative care. The MD for mouth opening was -
0.25mm [95%C -2.08, 1.57]. (Figure 4)
MANUAL THERAPY AND MIXED TMD
Six studies 76,101-105 looked at MT alone such as mobilization of atlantoaxial joint, 102,104
mobilization at the level of cervical spine;103 manipulation of the upper thoracic spine
(D1),76 massage to masticatory muscles, 105 or mobilizations at the level of TMJ joint 101
for treating subjects with mixed TMD. Results were mixed. The studies by Mansilla-
Ferragud et al.,102 and Otano et al.,104 found positive results at improving mouth range of
motion and increasing PPT in the orofacial region when comparing mobilization of the
atlantoaxial joint vs. placebo. However, no statistical differences were found between
manual therapy targeted to the jaw when compared with jaw exercises plus splint
therapy, 101 or cervical chiropractic adjustment vs. cervical trigger point therapy,103 upper
thoracic manipulation vs. placebo76 or masticatory muscles’ massage vs. splint 105 to
improve symptoms of subjects with mixed TMD.
When pooling data from the two studies that looked at similar manual technique, TMD
diagnosis, and outcomes, 102,104 although there was no significant difference between
mobilization of atlantoaxial joint or control group receiving no mobilization, the MD in
mouth opening between control and MT groups was 17.33 mm [95%C -10.39, 45.06]).
23
This difference can be considered as clinically relevant improvement in mouth opening
favoring MT treatment.
MANUAL THERAPY PLUS EXERCISES FOR MIXED TMD
Two studies 75,106,107 investigated the effect of MT combined with exercises in subjects
with mixed TMD. Tuncer et al 75 looked at the specific effect of orofacial and cervical
MT combined with stretching techniques for the masticatory and neck muscles compared
with exercises for the jaw/neck alone and education (home physical therapy). Von
Piekartz et al 107 compared the effect of orofacial physical therapy and neck exercises and
MT techniques targeted to both orofacial and cervical regions plus home exercises
compared with treatment targetted to the cervical spine only in subjects mixed TMD.
Pooling the results of these 2 studies75,106,107 that had similar interventions, outcomes and
diagnosis, it was found that MT targetted to the orofacial region or in combination with
cervical treatment was better than home exercises for the jaw/neck alone or treatment to
cervical spine alone for improving mouth opening. The mouth opening between control
and MT groups was 6.10 mm [95%C 1.11, 11.09] favoring MT groups. This difference
was clinically relevant.35
ADVERSE EVENTS
Adverse effects were only reported in 10 trials of the 48 included. Eight of the trials
57,65,67,74,75,77,87,89
reported no adverse events with the treatments. Nascimiento et al.,70
reported some adverse events due to the anaesthetic blockages procedure. 29.4% of the
patients (66/224) had temporary facial nerve paralysis, 0.44% (1/224) had hematoma, and
24
2.23% (5/224) positive aspirations. Niemela et al.,73 reported that pain on TMJ palpation
increased significantly in the splint group compared to the control group. No adverse
events regarding exercise therapy or manual therapy treatments were reported among the
trials included.
DATA SYNTHESIS
The overall quality of evidence for most comparisons was low to moderate according to
the GRADE approach. 49 The trials included in this review had unclear or high risk of
bias. Thus, the evidence was generally downgraded for three reasons: (1) risk of bias; 2)
level of heterogeneity (inconsistency) and (3) some imprecision surrounded the effect
estimate. For details of GRADE assessment of the included studies is displayed in Table
3. From the 14 analyses performed, most of the evidence was considered moderate (nine
analyses). The rest of the evidence was considered low. Thus we can say that the total
evidence was considered low.
DISCUSSION
MAIN RESULTS
Although the quality of the evidence is mostly uncertain and low, the results of our
systematic review found positive results when using postural exercises as well as jaw
exercises to treat both myogenous and arthrogenous TMD disorders. MT alone or in
combination with exercises shows promising effects. MT targeted to the cervical spine
decreased pain and also increased mouth ROM in subjects with myogenous TMD.
25
Exercises did not show superiority over other treatments for treating mixed TMD. A
general exercise program was effective compared to arthrocentesis/arthrography for
treatment of arthrogenous TMD, with conservative treatments as a first line of treatment.
There remain limited RCTs of high quality that have investigated the effectiveness of MT
and exercises to treat TMD.
Detailed discussion of our results are:
Effect of exercise for treating TMD
Exercises programs are advocated for treating musculoskeletal disorders.
Therapeutic exercises are prescribed to address TMD. Passive and active stretching of
muscles are performed to increase mouth ROM and reduce pain. Postural exercises are
helpful. 21 The results of our systematic review are consistent with previous reviews,19,23
showing positive effects when using exercises to treat myogenous and arthrogenous
TMD. In particular, interventions including exercises to correct head and neck posture
and active and passive oral exercises can be effective for musculoskeletal pain and
improve oro-motor function.59,60 However, most of these exercise programs were part of
a general conservative treatment regime including other therapies and did not provide
clear information regarding dosage, frequency or compliance, so the isolated effect of
exercise to treat TMD and the optimal regime is uncertain at this time. General aerobic
exercises have shown to improve muscle strength, flexibility, and functional capacity and
could induce analgesia.108 Further research is required to investigate the usefulness of
aerobic exercise as well as focused muscular training, especially exercises targeted to
cervical muscles in subjects with TMD.
26
Effect of Manual Therapy for treating TMD
MT has been used to restore normal range of motion, reduce local ischemia,
stimulate proprioception, break fibrous adhesions, stimulate synovial fluid production,
and reduce pain. Based on the results of this systematic review, MT shows promising
results to treat myogenous, arthrogenous and mixed TMD, although the evidence is
limited and low. A combination of MT for the orofacial region plus MT of the cervical
spine was more effective than home exercises or treatment to cervical spine alone in
subjects with mixed TMD. Research to date suggests that a mixed therapy involving MT
techniques as well as exercises improve patient outcome. Other systematic reviews have
found similar results. 24
Mobilization of the cervical spine decreased pain intensity and pain sensitivity
(via PPT evaluation) in subjects with myogenous TMD that exceed suggested values for
minimum clinically important differences for pain and treatment of the cervical spine.
MT techniques such as mobilization of the cervical spine could have an influence on
orofacial pain as well as movement in the jaw through the connections of these two
systems in the trigeminocervical nucleus.109
Methodological elements and overall quality of the evidence affecting observed

effect
The overall rating of the evidence for this review was low. This was due mainly to the
risk of bias of the analyzed studies. These methodological biases common to the included
studies could have an impact on results. Selection bias could have existed since only 20
trials reported appropriate randomization and only 4 reported concealment of allocation.
27
Another important bias was the lack of blinding, especially of the patients and assessors.
Only 12 studies used blinded assessment of outcomes, obtained when the outcome was
clinician assessed, such as mouth opening. However, we were also interested in pain
which is a subjective outcome and dependent on the subject’s report. It is likely that lack
of blinding could have affected the results of these studies. However, because of the
nature of the interventions investigated, blinding would not be possible in many of them.
There is empirical evidence that shows that trials without appropriate randomization,
concealment of allocation and blinding tend to report an inaccurate treatment effect
compared to trials that include these features.110 Thus, the results of this systematic
review should be interpreted with caution, especially in trials with subjective self-
reported outcomes.
Other potential biases that could potentially have affected observed effects were
inappropriate handling of withdrawals and drop outs (only 16 trials used intention to treat
analysis). Effect sizes from trials that excluded subjects in their analysis or considered a
modified intention to treat (ITT) tended to be more beneficial than those from trials
without exclusions, demonstrating that ITT principle is important to preserve the benefits
of randomization and keep unbiased estimates when the objective of the trial is an
effectiveness one.111
Studies did not report interventions in detail to be reproducible. In addition, they did not
control for co-interventions and did not have an adequate compliance with treatment.
These issues are of importance for this study as it is unclear if the effects on selected
28
outcomes were due to the effect of exercise, MT or were the result of other co-
interventions. In addition, it is unclear if the subjects received enough dosage of
treatments since adequate compliance was only accomplished by a very small proportion
of studies (15.2 %). Compliance and adherence testing should be systematically studied
in future studies with exercise prescriptions.
The present study used a compilation of items from all of the scales used in the PT
literature in addition to the risk of bias tool. Our recent analysis of health scales used to
evaluate methodological quality determined that none of these scales are adequate for use
alone.42,112 Therefore, it was decided that all of these scales using a compilation of items
to provide a comprehensive and sensitive evaluation of the quality of individual trials.
Research investigating methodological predictors for determining trial quality in PT is
needed.
Limitations
The findings of this review are specific to TMD (non-surgical) and to exercise and MT.
As with any systematic review there is the potential for selection bias yet our group used
a comprehensive search strategy and included databases as well as manual search. There
was a small proportion of studies in other languages that our team could not translate.
However, we feel most of the representative studies were included in the final analysis of
this systematic review. In addition, it has been reported that language-restricted meta-
analyses only minimally overestimate treatment effects (~2% on average) when
compared with language-inclusive meta-analyses.114 Therefore, language-restricted meta-
analyses do not appear to lead to biased estimates of intervention effectiveness.113,114
29
The heterogeneity among studies, particularly with respect to TMD diagnosis, study
intervention, and chosen control/comparison intervention was a challenge. Many studies
included the use of exercises or MT as part of a general treatment program which made
the evaluation of these treatments in isolation difficult. Moreover, different diagnostic
criteria for TMD were used. Only 21 out of 48 studies included a diagnostic tool that has
been demonstrated as being valid, reliable and reproducible to diagnose TMD. Thus,
diagnoses used for the analysed studies might not be appropriate. Despite this, the study
populations in all trials appeared to be representative of patients seen in clinical practice.
We encourage clinicians and researchers using the new diagnostic criteria for TMD
(DC/TMD) in future studies to allow consistent diagnoses according to the same criteria,
taxonomy, and nomenclature to avoid future data
inclusion/confusion/misunderstanding.115
CONCLUSIONS
Research implications
No high quality evidence was found, indicating that there is great uncertainty about the
effectiveness of exercise and manual therapy for TMD. There is a clear need for well-
designed RCT examining exercise and MT interventions for TMD. Specifically, it is
necessary that trials be performed isolating the type of exercise and manual technique
that is under testing to allow understanding the effectiveness of this type of treatment
and easy to determine. In addition, details of exercise, dosage, and frequency as well as
30
details on manual techniques should be reported to create reproducible results. High-
quality trials with larger sample sizes are required.
Clinical implications
Although the overall level of evidence is low, exercises and manual therapy are safe and
simple interventions which could potentially be beneficial for patients with TMD. Active
and passive exercise for the jaw, postural exercises and neck exercises seem to have
favorable effects for patients with TMD. MT alone or in combination with exercises
shows promising effects. Exercises did not show clear superiority over other
conservative treatments for treating TMD.
31
Acknowledgments
Dr Armijo-Olivo, Dr Pitance, and Dr Michelotti provided concept/idea/research design.
All authors provided writing, data collection, data analysis, and consultation (including
review of manuscript before submission).
Dr Susan Armijo-Olivo is supported by the Canadian Institutes of Health Research
(CIHR) through a full-time Banting fellowship, the Alberta Innovates Health Solution
through an incentive award, the STIHR Training Program of Knowledge Translation
(KT) Canada, and the Music and Motion Fellowship from the Faculty of Rehabilitation
Medicine of the University of Alberta. The funding bodies had no input in the design,
collection, analysis, or interpretation of data; writing of the manuscript; or the decision to
submit the manuscript for publication.
DOI: 10.2522/ptj.20140548
32
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41
Table 1. Characteristics of Included Studies
EXERCISE AND MANUAL THERAPY INTERVENTION
POSTURE CORRECTION EXERCISES FOR MYOGENOUS TMD

First Participants Intervention and Frequency and Primary End Results Authors’
author, Control/Compariso Duration Points Conclusions
year, n Groups (outcomes)
location
Komiyam N=60 Cognitive 1 session per Oral opening Posture group Posture
a et al,59 Sex: behavioral (CB): month (mo) (pain-free range had a statistically correction in
1999 Female:49 Information about for 12 mo: of motion) significant daily life has a
Japan Male: 11 the dysfunction and both improvement in positive effect
its management + intervention Pain intensity at oral opening on myofascial
Age: mean=26 y Pain education + groups maximum compared to pain associated
coping strategies mouth opening control (P<0.05) with limited
TMD Diagnosis (Visual at all time points mouth opening
Myofascial pain vs. Analogue Scale -
with limited VAS 100-mm Pain: both
opening CB with posture scale) intervention
according to correction: groups
Dworkin and Le Instructions about Disturbance in significantly
Resche.27 correction of posture daily life (VAS better than
and information 100-mm scale) control at 6 and 9
about its importance mo (P<0.05)
+ CB program
Disturbance in
vs. daily life: both
intervention
Control group groups
43
significantly
better than
control group at
6 mo (P<0.05)
No statistically
significant
difference
between groups
for any outcomes
at 12 mo
Wright et N=60 TMD self- 4 weeks (wk) Maximum pain- Maximum pain- Posture training
al,60 management duration free oral free opening and TMD self-
2000 Sex: instructions alone: opening (mm) significantly management
USA Female:51 rest masticatory Posture group: greater together are
Male: 9 muscles, avoid 2 sessions with Pressure Pain improvement in more effective
Age: 18–60 y parafunctional physical Threshold posture group than self-
habits, apply heat or therapist (PPT): with (P<0.05) management
TMD Diagnosis: cold, use pressure alone for
Myofascial pain nonprescription anti- Each exercise algometer at 2 There was a muscular TMD
according to inflammatory had specific points (masseter statistically
Dworkin and Le medications instructions for and trapezius significant
Resche27 number of muscles in improvement in
vs. repetitions kg/cm2) the modified
symptom
Posture training Modified severity index for
and TMD self- symptom both TMJ and
management severity index (5 neck (P<0.001)
instructions Posture VAS each for in favor of
training exercises TMJ and neck) posture group
taught by a Physical
44
Therapist and
performed as a home
program.
GENERAL JAW/NECK EXERCISE PROGRAM OR MANUAL THERAPY IN MYOGENOUS TMD

location
Crockett N=21 Dental program 8 weekly 1 hour 3 categories of All three All treatment
79
et al. (DPT): Occlusal session + 30 dependent treatment groups conditions
1986 Male: 0 splint + Physical min of daily measures: displayed produced
Canada Female : 21 therapy sessions home work significant significant
Age: ? (hot/cold, posture Dental rating: changes on worst improvement as
advise and pain to palpation pain rating. The reflected in
TMD Diagnosis: correction, jaw and mouth BER group dental ratings,
- complaint of exercises, advise opening. displayed greater self-reported
pain with about diet) changes than the frequency and
chronicity of at Subject self- TENS group on intensity of pain
least 6 Mo vs. report: worth average weekly and reduction
- tenderness to pain rating, Mc pain intensity, of masseter
palpation of The biofeedback- Gill pain and the DPT EMG during
masticatory enhanced questionnaire, group displayed both resting and
muscles progressive average weekly greater changes task condition
- limitation or relaxation program pain intensity, than the TENS
deviation of jaw (BER): progressive average weekly group on average
mobility muscle relaxation frequency of pain weekly
- Absence of training program frequency of
radiographic with combined EMG Electromyograp pain.
evidence of joint training hic (EMG)
disease or trauma activity
45
vs.
Nonspecific
Transcutaneous factors:
Electrical Nerve treatment
Stimulation (TENS) expectancy and
program: Sub- perceptions of
threshold electrical therapist
stimulations from qualities
electrodes placed in
a similar location to
that used in the BER
program.
Guarda- N=30 (15 Fascial Fascial Pain intensity: Pain intensity: Both treatments
Nardini et treatment; 15 Manipulation Manipulation on a 10-point Both treatment allowed an
al.81 control) (treatment): deep : three (±1) 50 VAS scale protocols improvement
2012 digital pressure is min sessions provided with respect to
Italy Sex: 22 females, exerted over specific on a weekly Jaw range of significant pre-treatment
8 males, centers of basis, for a motion: in improvement pain levels. In
Age: range 23-69 Coordination points total of 150 millimetres (mm) over time. the short-term
years (±50) min over (maximum period, viz.,
vs. a two- to four- mouth opening, Jaw range of three months,
TMD diagnosis: week span. protrusion, right motion: control the two
myofascial pain, Botulinum toxin and left patients showed treatments seem
with or without injections (control) Botulin toxin laterotrusion) slight increases to be almost
limited opening in the temporalis and single session in jaw motion equally
according to masseter muscles of multiple parameters; effective,
Dworkin and Le injections in treatment Fascial
Resche27 and the temporalis patients Manipulation
bilateral pain and masseter remained almost being slightly
superior in
46
lasting for at constant over reducing
least six months time subjective pain
perception and
botulinum toxin
injections being
slightly
superior in
increasing jaw
range of
motion.
Craane et N=53 General Physical 9 treatments in Pain Intensity: Both groups Independent of
al.,62 Therapy (PT) 6 weeks for evaluated though improved over the treatment
2012 Sex: treatment: Patient PT treatment (VAS) and time for VAS provided, all
Belgium Female : 40 education + Muscle McGill pain pain intensity, participants
Male: 13 relaxation and questionnaire, PPTs , PRtotal, improved over
Age: 39.6 y stretching (also as a and Total pain PPT, Mandibular time. The
average home program) + Rating Index Function, and results indicate
Axial extension of (PRtotal) Active and the there is no
TMD Diagnosis: the neck exercises + passive mouth specific effect
myofascial pain Advise about diet PPTs: masseter opening (P<0.05) of PT in
with or without and avoiding and temporalis myogenous
limited opening parafunctional muscles TMD
according to habits.
Dworkin and Le Mandibular
Resche27. vs. function
impairment
Control group: questionnaire
education:
Information about
jaw function and
47
dysfunction + Active and
Education about the Passive mouth
resting position of opening (mm)
the TMJ and advise
to avoid All outcomes
parafunctional were measure at
habits. 3, 6, 12, 26 and
52 weeks
Gavish et N=20 Chewing protocol Subjects had to Muscular The exercise Although the
al.,63 Female:20 exercise: Two units chew a performance: group showed a exercise group
2006 Male: 0 of sugarless chewing sugarless Electromyograph significant presented with
Israel Age: 20-45 y gum were chewed chewing gum ic (EMG) increase of the significant
three times daily for 3 times per analysis EMG activity reduction of
TMD Diagnosis: 10 min (weeks 1 and day for 10 min during the pain and
Myofascial Pain 2), increasing to 15 (weeks 1 and Muscular chewing exercise disability after
without limited min three times daily 2) tenderness by (P=0.007) the treatment,
opening (weeks 3 and 4), 20 palpation only pain relief
according to min three times daily 15 min 3 * day The exercise was
Dworkin and Le (weeks 5 and 6), and (weeks 3 and Mouth opening group showed a significantly
27
Resche . 30 min three times 4) (mm) significant different
daily (weeks 7 and reduction in pain between groups
8). 20 min 3 * day Pain perception during rest, pain at 8 weeks of
(weeks 5 and and relief (mm) during chewing treatment.
vs. 6) test, and in
Pain at chewing disability score Future studies in
Control: 30 min 3 * day test (VAS) (p<0.05) larger samples
Explanations, (weeks 7 and should be
support 8) Pain relief was performed
and encouragement significantly before a more
greater in the substantial
48
exercise group conclusion can
than in the be reached.
control group
(p=0.019)
Kalamir et N= 93 Intraoral IMT: 2 3 pain measures: Both treatment The use of IMT
al. 77 Female: 32 Myofascial treatment Jaw pain at rest groups were techniques
2012 Male: 31 Therapy (IMT) session (10 to Jaw pain upon significantly combined with
Australia Age:? Intraoral temporalis 15min) per maximal active different than the education and
release technique week for 5 opening control group self-care showed
TMD Diagnosis: weeks. Jaw pain upon after the that these
Myogenous Intraoral medial and clenching treatment and at 6 techniques can
TMD lateral pterygoid 11-point graded months and one be safely used
Between 18 and release technique: chronic pain year. and may be
50 years scale superior to no-
Daily history of Intraoral At one year, The treatment as
preauricular pain sphenopalatine Interincisal IMTESC group well as IMT
with or without ganglion release range of had significantly alone at 1 year.
joint sounds for technique opening (mm) lower pain score
49
at least 3 months than did the IMT
of duration vs. Global group
reporting of
IMTESC = IMT + change
Education and self-
care exercises
Mandibular body-
condylar cross-
pressure chewing
techniques
Post-isometric
relaxation stretches
– laterotrusion and
opening
vs.
Waiting list
Kalamir et N=30 Intraoral Each treatment Jaw pain at The results This study
al.,65 myofascial group received rest - Numeric showed suggests that
2010 Female:17 therapy (IMT) two Rating Scale statistically IMT alone or
Australia Male: 13 Intraoral temporalis sessions per (NRS) significant with the addition
Age: 33.3 y release technique week for five differences in of self-care may
average weeks Jaw pain upon resting, opening, be of some
Intraoral medial and maximal active and clenching benefit in the
lateral pterygoid IMT consisting opening (NRS) pain and opening management of
TMD Diagnosis: release technique: of two range scores chronic TMD
Myofascial Pain treatment Jaw pain (P,0.05) in both over the short-
according to Intraoral interventions upon clenching treatment groups medium term.
Dworkin and Le sphenopalatine per week for 5 (NRS) compared to
Resche27 weeks control at 6
50
experiencing ganglion release Each treatment Maximal months. No
chronic jaw pain technique session lasted voluntary significant
of longer than 3- approximately interincisal differences were
month duration. vs. 15 minutes opening (mm) observed between
the two treatment
IMT plus groups during the
education, self-care Measurements course of the trial
and exercise were taken at
baseline, 6 weeks
Vs. post-treatment,
Wait list control. and 6 months
post-treatment.
Kalamir et N=46 Intra-oral Each treatment Jaw pain at After adjusting IMT was
al., 64 myofascial group received rest (NRS) for baseline, the superior to
2013 Female:29 therapy (IMT) two IMT group had education, self-
Australia Male: 17 intraoral temporalis sessions per Jaw pain upon significantly care and
Age: 27.5 y release technique week for five maximal active lower average exercise (ESC)
average weeks opening (NRS) pain for all over the short-
Intraoral medial and primary outcomes term but not at
TMD Diagnosis: lateral pterygoid Jaw pain at clinically
Myofascial Pain release technique: upon clenching 6 weeks significant
according to (NRS) compared to the levels.
Dworkin and Le Intraoral ESC group (p <
Resche27 sphenopalatine Maximal 0.001). These Positive changes
ganglion release voluntary differences were over time for
technique interincisal not clinically both IMT and
opening (mm) significant but the ESC protocols
vs. IMT group had were noted.
significantly A longer term,
51
Education, self-care higher odds of a multi-centre
and exercise (ESC) clinically study is
significant warranted.
change (p <
0.045).
There was no
significant
difference in
opening range
between the IMT
and ESC groups.
However, only
the IMT group
achieved
clinically
significant
changes of 2 or
more points.
Kraaijeng N=79 TheraBiteH (TB) One session, The mandibular After six-week Both treatment
a et al., 80 Jaw function follow-up, modalities are
2014 Female:69 Motion impairment patients using the equally effective
Netherlan Male: 10 Rehabilitation questionnaire TB device in relieving
ds Age: 37.561.5 y System: Patients (MFIQ). reported a myogenic TMD
average were instructed significantly symptoms. The
how to hold the TB Four physical Pain Intensity: greater functional use of the TB
TMD Diagnosis: device in their therapist visits (VAS) improvement device has the
Myogenous (preferred) hand, * 30 minutes (MFIQ score) benefit of
TMD with the Exercises need than the patients achieving a
mouthpieces placed to be performed Maximum receiving regular significantly
five times a inter-incisor PT greater
52
between the upper day, by linking (mouth) exercises functional
and the exercises to opening (MIO) (P<0.0050). improvement in
lower teeth their daily (mm) the short term
activities. At 6 weeks, no
significant
vs. differences in
pain, and active
standard physical or passive MIO
therapy (PT) were found
exercise regimen: between the two
combination of groups.
techniques to
improve mobility At 3 months,
and reduce pain ( patients in both
massage, jaw treatment groups
movements, did equally well,
stretching and showed a
significant
improvement in
all parameters
assessed
Michelotti N=70 Home Physical Home PT PPT: Success rate was Over a period of
et al.,66 Therapy (PT) +education: Algometry on 77% for the 3 months,
2004 Sex: program (self- Exercises were Masseter and Home PT Home PT
Italy Female : 62 relaxation exercises, performed Temporalis +education and program
Male: 8 diaphragmatic daily. Some 3 muscles (right 57% for the +education
Age: 30y average breathing, self- times *day and and left). education group. seems more
massage, application others every 2 The only variable clinically
TMD Diagnosis: of moist, heat pads hours with Pain on chewing that was effective than
Subjects with on the painful different (VAS) statistically education alone
myofascial pain muscles, stretching, repetitions significant in patients with
53
with or without and coordination depending on Pain-free between groups myofascial
limited opening exercises) plus the exercise maximal Jaw was the Pain- TMD
according to education opening (mm) free maximal
Dworkin and Le Education + Jaw opening
Resche27 vs. general (mm) (p=0.017)
information:
Patient education Not reported
plus general frequency and
information about duration of the
self-care (i.e. session
education about
aetiology, bad habit
avoidance, and keep
soft diet)
Mulet et N=45 Home exercises: 4 weeks Intensity of Jaw Both groups The 6x6
al,57 6x6 exercises (rest duration pain: (NRS) presented with exercises
2007 Female: 43 position of the statistical and program was
USA Male: 2 tongue, shoulder Exercise Intensity of Jaw clinical not significant
Age: 24y average posture, stabilized program: 6 pain: Verbal improvement in more beneficial
head flexion, axial times per day* rating Scale Jaw pain than self-care
TMD Diagnosis: extension of the 6 repetitions (VRS) intensity and alone at
Subjects with neck, control of TMJ neck pain reducing jaw
myofascial pain rotation, and Intensity of (p<0.05) and neck pain
with or without rhythmic neck pain (NRS in patients with
limited opening stabilization and VRS) There were not myofascial
according to technique) plus self- significant TMD
Dworkin and Le care Change in Head differences in
Resche27 posture any of the
vs. outcome
variables
between groups
54
Self-care (optimist
counselling,
education,
reassurance about
TMD symptoms,
encouragement,
application of heat
and ice, control bad
habits, soft diet, and
intake of calcium)
Maloney N=19 Passive Jaw motion 4 weeks Pain Intensity: Pain Intensity The results
et al., 58 device (Therabite- [Numerical was significantly suggest that
2002 Female :? device controlled by Therabite and Rating Scale- reduced in Therabite
USA Male:? the patient to wooden (NRS)-0-10mm] Therabite group device is
Age:? y average increase mouth depressors: when compared effective at
opening) to achieve Force mouth Mouth Opening with wooden reducing pain
TMD Diagnosis: and sustain a open for 1 min, (mm) depressors and increasing
Subjects with comfortable stretch and repeat 3 (p=0.05) and mouth opening
myofascial pain of the jaw muscles + times in Lateral control group and improve
with or without splint succession movements (splint) (p=0.001) mobility of the
limited opening (right and left) jaw in patients
according to vs. This cycle was (mm) Mouth opening with myofascial
Dworkin and Le repeated 5 improved TMD when
Resche27 Wooden Tongue times *day Protrusive significantly in compared with
depressors therapy movement (mm) Therabite group splint therapy.
(standard wooden when compared
depressors, 1.25mm with other groups
thick and 14mm in (wooden
width) to achieve depressor and
and sustain a splint (p=0.0001)
comfortable stretch
55
of the jaw muscles + All of the other
splint movements
(protrusive, and
vs. lateral
excursions) were
Control group significantly
(splint therapy better in
alone) Flat bite plane Therabite group
appliance when compared
with splint
therapy (p<0.05)
Magnusso N=26 Therapeutic jaw Duration of the Maximal Jaw Both groups Therapeutic jaw
n& exercises study: 6 opening (mm) improve exercises are a
Syren, 56 Female :? months significantly cost effective
1999 Male:? vs. Clinical symptoms over treatment with a
Sweden Age: 34.5 y Dysfunction time prognosis
average Michigan splint Jaw exercises: Index (Helkimo comparable to a
3 times per day Index) No significant treatment with
TMD Diagnosis: for 2-3 differences on splint therapy.
Subjects with minutes. Impaired signs and It can be the
TMD of mainly mandibular symptoms first therapy of
muscular origin. Splint used at mobility between groups choice in
nights subjects with
TMJ pain muscular TMD
Muscle Pain
Pain on
movement
56
MANUAL THERAPY: MOBILIZATION OF THE CERVICAL SPINE AND CERVICAL EXERCISES IN MYOGENOUS
TMD
location
La Touche N=32 Anterior-Posterior 3 sessions of PPT: The PPT in the This study
et al., 67 Antero-posterior treatment over (algometer) on craniofacial and provided
2013 Female: 21 Upper Cervical 2 weeks masseter and cervical regions preliminary
Spain Male: 11 Mobilization temporalis significantly evidence of a
Age: 33.8 y (APUCM) applied The total time muscles and increased short-term
average to the cervical spine of cervical points (P<0.001) and hypoalgesic
(mobilization mobilization (suboccipital pain intensity effect of
TMD Diagnosis: applied at a rate of 1 was 6 min. muscles, significantly APUCM on
Subjects with oscillation per 2 Mobilization zygapophyseal decreased craniofacial and
myofascial pain seconds (0.5Hz). was applied in joint, and upper (P<0.001) in the cervical regions
with or without 3 intervals of 2 trapezius treatment group of patients with
limited opening vs. min, with 30 muscle) compared with cervico-
according to sec of rest in placebo. craniofacial pain
Dworkin and Le Placebo between for a Pain Intensity of myofascial
Resche27 Same manual total of 7 min (VAS) APUCM origin,
contact, but no produced a suggesting that
technique was sympatho- APUCM may
applied. The same Sympathetic excitatory cause an
frequency and nervous system response immediate
duration as the variables: skin demonstrated by nociceptive
experimental group conductance, a significant modulation in
was used. breathing rate, increase in skin the
heart rate, skin conductance, trigeminocervica
temperature) breathing rate, l complex
57
and heart rate
(P<0.001), but
not in skin
temperature
(P=0.071), after
application of the
technique
compared with
placebo.
EXERCISES AND MANUAL THERAPY FOR INTRA-CAPSULAR TMJ DISORDERS (ARTHROGENOUS TMD)
location
Carmeli et N=36 Manual 4 wk treatment: Active range of Manual therapy Manual
al,88 mobilization and motion: and exercises mobilization
2001 Sex: active exercises: Manual therapy maximum significantly and active
Israel Female: 26 Grade I or grade II every 2nd or mouth opening better than splint exercises more
Male: 10 oscilatory 3rd day; active (mm) in reducing pain effective to
mobilisations. exercises 4-6× (P<.05) and improve pain
Age: 19–43 y per day for 5 Pain scale: improving oral and range of
vs. min duration 0=“no pain” to opening (P<.05) motion than
TMD Diagnosis: 5=“severe pain” soft
Diagnosis of Soft, flat-plane Splint worn 24 (Pain repositioning
anterior occlusal hr/d Physiopathology splint
temporomandibul repositioning Instrument-PPI)
ar discs with splint :
unstable
excursive Both groups
reduction (no received self-care
education
58
further details information (diet
provided) restrictions, sleeping
positions, and
postural correction
advice)
Craane et N=49 General PT 9 treatments in Pain Intensity: Both groups Independent of
al.,61 treatment 6 weeks for evaluated though improved over the treatment
2012 Sex: (education in oral PT treatment (VAS) and time for VAS provided, all
Belgium Female: 47 habits, instruction on McGill pain pain intensity, participants
Male: 2 how to relax questionnaire, PPTs , PRtotal, improved over
masticatory muscles and Total pain PPT, Mandibular time. The
Age: 36.6 y plus stretching Rating Index Function, and results indicate
average exercises) (PRtotal) Active and the there is no
passive mouth specific effect
TMD Diagnosis: vs. PPT: masseter opening (P<0.05) of PT in
Subjects meeting and temporalis myogenous
the RDC-TMD Control group: muscles TMD
criteria for disc education on the
displacement days of evaluation Mandibular
without function
reduction, with impairment
(group Ib) or questionnaire
without (group (MFIQ)
IIc) limitation of
mouth opening Active and
27
. Passive mouth
opening (mm)
All outcomes
were measure at
59
3, 6, 12, 26 and
52 weeks
De Felicio N=20 (being part Orofacial OMT was Tenderness to Subjects in the OMT may help
et al., 68 of Treatment myofunctional tailored. palpation (0-10 OMT group had reduce
2008 program) therapy (OMT Subjects scale) lower pain levels symptoms and
Brazil group): mandibular received a at palpation in signs of TMD
Sex: posture and minimum of 9 Identification of masseter, and help with
Female: 20 mobility without and maximum Joint noises temporalis muscle
Male: 0 deviation of 13 sessions muscles, and coordination
with average Self-assessment Temporomandib
Age: 31.5 y of 11.8 of TMD signs ular joints when
average vs. sesssions, 45 and symptoms compared to a
min each week (0-10 scale) control group
TMD Diagnosis: Control group: or every 2 (p<0.05).
Subjects meeting waiting list weeks Asymmetry
the research Index (EMG Severity of
diagnostic analysis) tinnitus was
criteria for lower in the
articular TMD OMT group than
(RDC-TMD) 27. All outcomes for the control
were measure at group (p<0.05).
baseline and at
the end of
treatment
Diracoglu N=120 Arthrocentesis (2 Splints were Pain ( VAS) Subjects in the Early treatment
et al., 82 mL local anaesthetic used day and arthrocentesis either with
2009 Sex: was applied night for 6 Mouth Opening group presented conservative
Turkey Female: 104 subcutaneously and months except (mm) significantly methods or with
Male: 16 around the joint during higher reduction arthrocentesis is
capsule) of pain than beneficial in
60
Age: 34 y eating and tooth Lateral subjects in the disc
average vs. brushing movements conventional displacement
(right and left) group. without
TMD Diagnosis: Conventional The treatment (mm) reduction.
Diagnosis of disc treatment (splint, lasted for 6 No significant
displacement hot packs, and home months Protrusive differences in Arthrocentesis
without reduction exercise program- movement mandibular range seems to be
TMJ active and (mm)) of motion superior
gentle range of (ROM) between regarding pain
motion, isometric groups at 3 and 6 management.
exercises, posture Outcomes were months Therefore,
exercises, and measured at evaluations arthrocentesis
relaxation baseline, 3 may be
techniques) months and 6 indicated in
months patients
with
predominant
pain
over other
conservative
treatments
Haketa et N=52 Exercise and joint The mouth- Active mouth All outcomes The
al., 89 mobilization: opening opening with were improvement in
2010 Sex: Manual and jaw position was and without significantly mouth opening
Japan Female: 46 opening exercises held for 30 sec. pain (mm) improved in both was more
Male: 6 and jaw mobilization The participants groups (p<0.001) significant in the
Age: 37.6 y slowly pulling the in the exercise Current exercise group
average mandible down until group maximum daily when compared
pain occurred on the performed 4 pain intensity with the control
TMD Diagnosis: TMJ-affected. Three sets per day, (VAS) group after 8
Subjects meeting cycles of this one after
61
the anterior disc stretching movement each meal and Pain-related weeks of
displacement were defined as a one while limitation of treatment.
without reduction single set. bathing daily function The joint
(ADDwoR ) questionnaire mobilization
diagnosis, based vs. Splint was used (LDFQ) self-exercise is
on an magnetic during night an effective
resonance Splint therapy: treatment option
imaging (MRI) Maxillary for improving
with a maximum stabilization jaw function and
opening of less appliance. The splint reducing pain
than 40mm were was a 1.5-mm-thick and limitations
included hard, clear acrylic of daily
sheet that was activities in
vacuum-adapted to patients with
the maxillary cast. ADDwoR.
Both groups
received self-care
education
information (diet
restrictions, sleeping
positions, and
postural correction
advice)
Ismail et N=52 Physical Treatment Exercise group: Active and Active mouth PT seems to
al.,69 Passive traction and All patients passive mouth opening was have a positive
2007 Sex: translation were treated for opening (mm) significantly effect on
Germany Female: 46 movements were 45 min twice a higher in treatment
Male: 6 carried out in every week (total: 90 Pain intensity Exercise group outcome in
Age: 37.6 y restricted direction. min) by the (total) (VAS) when compared patients with
average This mobilizing
62
procedure was same physical Pain intensity with splint group arthrogenous
TMD Diagnosis: accompanied by therapist during (p<0.05) TMD
Subjects meeting detoning exercise of mandibular
the criteria for jaw elevator muscles movement Passive mouth
the diagnosis of and a detoning (VAS) opening was not
an arthrogenous massage) + splint statistically
TMD based on therapy Pain intensity different between
the RDC/TMD after groups
criteria with a vs. mandibular
limited (<38 loading (VAS) Pain intensity
mm) and painful Splint therapy: was not
jaw opening. 27 Michigan All patients were significantly
The diagnosis splint therapy evaluated at 1, different between
was confirmed 4, 8 and 12 groups
by magnetic weeks after the
resonance start of the
imaging (MRI). treatment.
Maloney N=24 Passive Jaw motion 4 weeks Pain Intensity: Pain Intensity The results
et al., 58 device (Therabite- Numerical was significantly suggest that
2002 Sex: device controlled by Therabite and Rating Scale- reduced in Therabite
USA Female: ? the patient to wooden (NRS)-0-10mm] Therabite group device is
Male: ? increase mouth depressors: when compared effective at
Age:? y average opening) to achieve Force mouth Mouth Opening with wooden reducing pain
and sustain a open for 1 min, (mm) depressors and increasing
TMD Diagnosis: comfortable stretch and repeat 3 (p=0.013) and mouth opening
Subjects meeting of the jaw muscles + times in Lateral control group in patients with
the criteria for splint succession movements (splint) (p=0.053) arthrogenous
the diagnosis of (right and left) TMD when
an arthrogenous vs. (mm)
63
TMD based on This cycle was Mouth opening compared with
the RDC/TMD Wooden Tongue repeated 5 Protrusive improved splint therapy.
criteria.27 depressors therapy times *day movement (mm) significantly in
(standard wooden Therabite group
depressors, 1.25mm when compared
thick and 14mm in with other groups
width) to achieve (wooden
and sustain a depressor and
comfortable stretch splint (p=0.0001)
of the jaw muscles +
splint
vs.
Control group
(splint therapy
alone) Flat bite plane
appliance
Minacuchi N=69 Palliative group: For Physical Pain intensity All of the groups These results
et al., 91 Self-care plus Non- medicine Group (VAS) showed a suggest that
2001 Sex: steroidal anti- each session a significant ADDwor
Japan Female: 63 inflammatory drugs 20 min of change in the subjects will
Male: 6 (NSAIDs) intermittent jaw Maximum outcomes in the improve with
Age: 34 y (diclofenac sodium mobilization Mouth Opening two month only minimal
average of 25 mg, 3 times was performed (mm) period (p<0.05). treatment
*day). Self-care However, none intervention, and
TMD Diagnosis: consisted on Occlusal Daily Activity of the variables no significant
Subjects meeting instructions how to appliance were Limitation (18- were difference was
the anterior disc apply cold/hot packs used at night item significantly evident for the
displacement and gentle mouth questionnaire) different among treatments tested
without reduction opening exercises groups
64
(ADDwoR ) All and the control
diagnosis, based vs. measurements condition.
on an MRI plus were performed
clinical Physical medicine at initial visit, 2,
symptoms of Group: splint 4, and after 8
pain and chewing therapy plus jaw weeks of
difficulty were mobilization plus treatment
included. self-care and
NSAIDS
vs.
Control group:
Self-care and advice
regarding prognosis
Nascimien N=20 (28 TMJs) Positive control 1 treatment per Maximal mouth In group 1, there This study
to et al.70 group (group 1): week for 8 opening (mm) was significant support that the
2013 Sex: 8 anaesthetic weeks for the decrease in anaesthetic
Brazil Female: 20 blockages of the positive Jaw Protrusion average pain blockage of the
Male:0 auriculotemporal control group (mm) levels at two auriculotempora
Age: >18 years nerve with injections months of follow l nerve and
(average 41.5 of 1 ml of 1 treatment VAS up these patients physical therapy
±10.1 years) Bupivacaine 0.5% per week for 8 suffered less pain are effective in
without weeks for the All in the joint the reduction of
TMD Diagnosis: vasoconstrictor experimental measurements the patient pain
subjects were group with 30 were performed In group 2, the of subjects with
diagnosed using Experimental min physical at baseline, 1st average levels of temporomandib
the RDC-TMD. group (group 2): therapy session. week, 4th week pain decreased in ular disorders
Patients with disc Anaesthetic After the 3 first and 2 months during the
displacement and blockage + physical appointment, after the last clinical trial
arthralgia (group therapy (Mobilizing patients were injection
65
II and IIIa RDC- joint, passive asked to All patients of
TMD) with a traction and perform both groups
score from 3 to 9 translation exercises alone improved in their
on a VAS movement, massage at home, 3-4 the mouth
of temporal and series of 2 opening and
masseter muscles minutes each in protrusion
and muscular front of the
stretching exercises) mirror
Schiffman N=106 Medical Medical Primary Group means did Primary
et al., 78 Management: Management: outcomes: not differ at any treatment for
2007 Sex: Education on the NSAIDs for 3-6 Craniomandibu follow-up for patients with
USA Female: 100 participant's wks. lar Index (CMI) either CMI closed lock
Male: 6 condition, with (function) (p > should consist of
Age: 31.7 y optimistic All care The modified 0.3) or SSI (pain medical
average counselling, a self- providers Symptom relief) (p≥ 0.08). management or
help program, and a followed their Severity Index rehabilitation.
TMD Diagnosis: six-day regimen of assigned (SSI). All groups
Subjects meeting oral participants for improved over
the anterior disc methylprednisolone 6 mos, with baseline (p <
displacement followed by NSAIDs additional Clinical 0.0001) at all
without reduction for 3-6 wks follow-up as examinations and follow-up times
(ADDwoR ) needed. questionnaires for both CMI and
diagnosis, based vs. were completed SSI
on an clinical at baseline and
symptoms of Rehabilitation plus three-, six-, 12-,
pain were medical treatment 18-,
included. Medical 24-, and 60-
management plus an month follow-
intra-oral orthotic ups
(splint), physical
therapy, and
66
cognitive-
behavioural therapy.
Physical therapy
involved joint
mobilization,
physical therapy
modalities, and a
home exercise
program. Cognitive-
behavioural therapy
included assessment
of oral habits,
maladaptive habits,
and
psychopathology.
vs.
Arthroscopy plus
PT: The superior
joint space was
lavage, intracapsular
adhesions underwent
lysis, and
intracapsular
betamethasone was
injected
vs.
67
Arthroplasty plus
PT: A disc
repositioning
procedure
(discoplasty) was
attempted. If the
tissues had
degenerated too
greatly, disc removal
(discectomy) was
performed.
Stegenga N= 21 Surgical (ASURG): For Assessment at 4 Both treatments Patients treated
et al. 83 Counselling + physiotherapy weeks and 6 change most with
1993 Sex Arthroscopy + PT programme: months dependent arthroscopic
The Female: 19 + home exercise 3 weeks – 2 variables. The surgery reported
Netherlan Male: 2 program times/week TMJ PAIN most striking a more rapid
ds Age: 23,7 ± 6,7 changes were reduction of
vs. 30 min each Static joint observed in pain and a
TMD Diagnosis: treatment tenderness variables related higher
Painful Non-surgical Unload dynamic to pain and appreciation of
restriction of (NONSURG): pain function overall
mandibular Counselling + PT Loaded dynamic impairment improvement.
movement OR NOT PT + home tenderness The sample was
Preauricular pain exercise program Total clinical The treatment- to small to draw
Perceived joint tenderness type effect was firm conclusions
restriction of score not significant for
mandibular any of the
movement of Bite strength variable
sudden onset and bite force categories
Restriction of endurance and indicating the
horizontal arthroscopic
68
excursion toward mastication surgery and
the opposite side time nonsurgical
of < 8 mm treatment had
Mouth opening comparable
ROM (mm) beneficial effect
on pain,
Mandibular movement
function restriction,
impairment function
questionnaire impairment and
interference with
Global pain daily life
impact
Yoda et N=42 Exercises for ADD Exercises were Discomfort Disappearance The therapeutic
al.,84 with Reduction: repeated for caused by the of clicking for exercise for
2003 Sex: according to Yoda et five minutes clicking and three months clicking due to
Japan Female: 29 al. (recapture disc after each meal interference after ADDWR
Male: 13 exercises);open and maintained with daily life randomization ( is significantly
Age: 27.1 y mouth maximally, the disk (e.g. eating or success or not) effective in
average close in protrusion at repositioning speaking) was reducing
edge to edge mandibular investigated clicking
TMD Diagnosis position, retrude position all day, [five point scale compared
Unilateral mandible before if possible, (l=no, with no
reciprocal click happens, open except during 5=all the time treatment. This
clicking which again meals and without stopping) modality is
was eliminated sleeping. thought to be
by a protrusive Vs. much more
position of the conservative,
mandible, and simple, and
69
who were Control group (no cost-effective
diagnosed as exercises for 3 than splint
having ADD months) therapy or
with Reduction surgery.
using Magnetic
Resonance
Imaging
(MRI)
Yoshida et N=148 Mandibular Each movement Mouth Opening There was a The results of
al., 85 Exercises in was repeated 2 (mm) significant this study
2011 Sex: different directions or 3 times for difference suggest that
Japan Female: 148 jaw manipulation on 10 min. Lateral between the exercise of the
Male:0 initial presentation + movements experimental mandibular
mouth opening (right and left) (50/74, 68%) and condyle is an
Age: between 19- exercises. The (mm) control groups efficient initial
75 y patients were given (3/74, 4%) in the treatment for
non- steroidal anti- Protrusive degree of patients with
TMD Diagnosis: inflammatory drugs movement increased mouth- closed lock.
Subjects meeting (NSAIDs) on the (mm) opening.
the anterior disc night of their first
displacement attendance Rate of success
without reduction
(ADDwoR – vs. Measurements
close lock-) were taken on
diagnosis were Control Group (no initial
included exercises) NSAIDS presentation and
only again after
10 min, after
mandibular
condylar
exercises for Tx
70
group and 10
min after no
exercises in
Control group
Yoshida et N=305 Jaw manipulation Exercises were TMJ pain score: The success of Simple jaw
al.,92 plus jaw exercises performed each VAS manipulation in manipulation for
2005 Sex: (jaw protrusion and morning, before Maximum younger patients the treatment of
Japan Female: ? lateral and after meals Mouth Opening (18 to 19 years closed lock can
Male: ? shift)+NSAIDs anti- and before bed. (mm) age) given on the be useful if
Age: between 10- inflammatory drugs Presence of day of diagnosis applied early
79 y clicking or was 100.0%. after the onset of
vs. crepitus In patients symptoms,
TMD Diagnosis: between 20 and especially for
Subjects meeting NSAIDs only 49 years, the younger
the anterior disc success rate for patients.
displacement manipulation was
without reduction 87.5%, and
(ADDwoR ) between 50 and
diagnosis were 59 years age
included. range, the success
rate was 78.2%.
Treatment given
within 1 to 2 days
of the onset of
closed lock
symptoms
resulted in
100.0% success.
Treatment by
manipulation
was unsuccessful
71
if given 2 months
or more after the
onset of
symptoms.
Yuasa et N=60 PT motion 2 weeks and at Pain intensity: There was 60% A combination
al.,86 exercises. Jaw 4 weeks VAS improvement in of NSAID and
2001 Sex: opening, lateral and -At rest the treatment physical therapy
Japan Female: 48 anterior movement Motion -With group compared for 4 weeks is
Male: 12 exercises +NSAIDs exercises: 4 mandibular with 33% in the effective as a
once a day times per day (3 motion control group primary
Age: between 16- times after each -On chewing during the entire treatment of
69 y and 28 y vs. meal and once -Interference 4 patients with
average before bedtime) with daily life weeks of the ADDwoR and
Control group study. without osseous
TMD Diagnosis: Maximal Mouth changes
Subjects meeting Opening (mm) Maximal Mouth
the anterior disc Opening
displacement (p=0.005) and
without reduction interference
(ADDwoR ) and with daily life
confirmed by (p=0.040) were
MRI diagnosis significantly
were included. better for the
exercise group
when compared
with the control
group.
The rest of the

outcomes were
not significantly
72
different between
groups.
EXERCISES AND MANUAL THERAPY FOR MIXED TMD (INTRACAPSULAR AND MUSCULAR TMD PATIENTS)
location
De Felicio N=30 Orofacial Treatment Helkimo Index Sensitivity to OMT may help
71
et al., myofunctional duration of palpation: reduce
2010 Sex: therapy (OMT 120 days Subjects symptoms and
Brazil Female: 30 group) Frequency and receiving sign sof TMD
Male: 0 (focus on pain relief, OMT was severity of treatment with and help with
mandibular posture tailored. Each signs and OMT reduced muscle
Age: between 13- and mobility, session lasted symptoms of pain sensitivity to coordination
68 y and 31.3 y symmetry and 45 min each. TMD palpation on
average coordination of Treatment masticatory
muscles) frequency was Mouth Opening muscles but not
TMD Diagnosis: every week for (mm) on the TMJ joints
Subjects have to Vs. 30 days and
present long- every 2 weeks Lateral Signs and
lasting associated Occlusal splint for the movements Symptoms of
articular and therapy (Michigan remaining (right and left) TMD: OTM
muscular TMD Splint) days (mm) decreased
based on the dysfunction of
RDC/TMD Vs. Splint therapy Protrusive TMJ (as
lasted 45 days. movement evaluated by the
Control Continuous (mm) Helkimo Index)
( untreated ) use of splint and severity of
for 15 days Orofacial TMD signs and
and only at myofunctional symptoms when
function compared to
73
night after this (evaluated by a splint therapy and
period therapist) control group.
Mandibular
All outcomes Range of Motion
measured at (ROM)
baseline and at No statistical
the end of Tx differences were
observed between
treated groups in
mandibular ROM
Ficnar et N=63 Conservative 2.5 months Pain at palpation- No significant TMD should
al.,72 therapy: Included duration for masticatory differences initially be
2013 Sex: the use of self- all groups muscles. between the three treated with
Germany Female: 79.4% exercises (muscle groups with conservative
Male: 20.6% exercise form Patients with Number of regard to therapy
according to Prof. splints were affected areas therapeutic consisting of
Age: 34.66 years Schulte, self- told to wear the between the start effectiveness. self-exercises
(median) massage techniques, occlusal of the study and as well as drug-
mouth opening appliance every the first based and
TMD Diagnosis: exercises), night and two follow-up manual
patients who had medication-based hours during examination. treatment
been diagnosed therapy using non- the day
with RDC/TMD steroidal anti- pain-free, active
Ia or Ib inflammatory drugs vertical
(myofascial pain) (NSAID), muscle movement of the
also in relaxants as well as lower jaw,
combination with manual therapy.
arthralgia (IIIa)
and/or disk vs. Findings were
displacement collected and
74
with reduction Conservative documented at
(IIa) therapy + a the start of each
laboratory-made patient’s therapy,
stabilization splint two weeks after
therapy
vs. commencement
as well as three
Conservative months after the
therapy + the start of the
SOLUBrux splint: therapy
semi-finished
occlusal appliance
made from malleable
thermoplastic
material was
produced and/or
fitted in line with the
manufacturer’s
instructions.
Gomes et N=28 Massage therapy Massage Maximum Significant Massage and

al.,105 Administered by therapy: active pain-free increases in ROM occlusal therapy
2014 Sex: experienced therapist 3 weekly oral opening were have similar
Brazil Female: 20 consisted on sliding sessions of 30 (mm) found for all effects at
Male: 28 and kneading minutes for 4 measures in the increasing
manoeuvers on the weeks. Lateral massage and mandibular
Age: between 18- masseter and movements occlusal splint range of motion
40 years temporalis muscles (right and left) groups. in subjects with
Average: 30 y Occlusal splint (mm) TMD
No statistical
vs. differences
75
TMD Diagnosis: Indications to between occlusal
Not specified. Occlusal splint wear it at night and massage
However, it was Michigan-type for 4 weeks. groups.
assumed that occlusal splint with a
subjects included flat occlusal Small to
had both surface, contact with moderate effect
myogenous and the antagonist teeth, sizes favouring
arthrogenous and the presence occlusal therapy
of canine and were found for
protrusive guides. lateral excursion
movements (0.36,
0.47 for right and
left sizes
respectively)
Mansilla N=52 Fryette's occipito- Fryette's Mouth Opening Temporomandibu Upper cervical
Ferragud atlanto-axial global occipito- (mm) lar joint opening spine
et al., 102 Sex: technique (OAAT) atlanto-axial significantly manipulation
2008 Female: 40 global increased in the using Fryette's
Spain Male: 12 vs. technique Pressure pain OAAT group OAAT
(OAAT) was threshold (PPT) compared with immediately
Age: between 21- Control group (no done in one of the pterion that in the increases the
50 y and 36.5 y technique) session point Control group (p range of motion
average (Algometer) < 0.001 ). of
kg/cm2 active oral
TMD Diagnosis: The PPT of the opening and
General pterion showed a tends to increase
classification of All nearly significant the PPT of the
TMD. Subjects measurements increase in the pterion.
have to present were perfromed OAAT group
reduced mouth before the (p = 0.055)
opening Fryette's versus that in the
76
(<40mm) with or occipito-atlanto- control group,
without other axial global which
signs or technique significantly
symptoms in the (OAAT) and decreased.
TMJ joint after
Niemela N= 80 Splint Therapy: Splint Questionnaire The number of Stabilization

et al.73 Stabilisation splint + Therapy: and clinical subjects with splint treatment
2012 Sex: Counselling + Stabilisation examination TMJ pain on in combination
Finland Female: 62 masticatory muscle splint made by (RDC-TMD)2 palpation with counselling
Male: 18 exercises: (active heat-cured increased in the and exercises
resisted mouth acrylic. The splint group has no
Age: 43,2 ± 13.3 openings, occlusion of the whereas additional
in splint group laterotrusive splint is decreased in the benefit in
and 44.1 ± 13.1 movements and designed in the control group. relieving facial
in control group protrusive centric relation pain and
movements) occlusion The differences increasing the
TMD Diagnosis: in change in any mobility of the
Clinically Exercises for of the outcome mandible than
diagnosed TMD Control group: both groups: variables between counselling and
as defined by the Counselling and Active mouth groups were not masticatory
RDC-TMD.2 masticatory muscle openings, statistically muscle exercises
exercises laterotrusive significant. alone in a short
movements and time interval (1
protrusive month)
movements.
Mandible
maintained at
the end of the
movement for a
77
few seconds on
each
movement.
After, those
movements
were performed
against
resistance
(using patient’s
own fingers).
After, jaw wide
opening with
finger
stretching for
10-20 seconds.
Those exercises
were repeated
7-10 times per
session with 2-3
times per day
O’Reilly N=12 Chiropractic Chiropractic McGill Pain The treatment This research
and cervical spine adjustments: Questionnaire outcome for the does suggest
Pollard,103 Sex: adjustments on a once- two groups was that further
1996 Female: 40 . weekly considered to be exploration into
UK Male: 12 basis for six equal (p = the effectiveness
weeks (a total 0.9025). Thus, of chiropractic
Age: between 18- Trigger point of six chiropractic treatment on
65 y and 36.5 y therapy: treatments). treatment was not temporomandib
average Ischaemic superior than ular
compression trigger point
78
TMD Diagnosis: technique to cervico Trigger point therapy to reduce joint
General -thoracic muscles therapy: pain in subject dysfunction is
classification of weekly for six with TMD well warranted
TMD. TMJ weeks (a total
symptoms, of six Very small
including one or treatments). sample size
more of the which reduced
following: the power of
• pain in or study to find
around the TMJ differences
• clicks in TMJ
• bruxism
• headaches
• decreased
opening of the
mouth
tenderness over
the TMJ and/or
the muscles of
mastication
• trigger point
pain from the
muscles of
mastication
and/or
anterior
cervical/hyoid
muscles
Otano et N=44 Fryette's occipito- Fryette's Distance There was an The technique
al.,104 atlanto-axial global occipito- between Atlas increase in the (OAA) and the
2010 Sex: atlanto-axial and occiput pressure pain use of the oral
79
Female: 27 technique (OAAT) global base threshold and the splint produce
Argentina Male: 17 plus splint therapy technique (cephalometric active opening of radiological
(OAAT) was analysis with the mouth (P < changes
Age: 38.5 y vs. done in 3 Rx) .00) compared to between the
average sessions: the controlled base of occipital
Placebo group (no baseline, 15 Mouth Opening group. and the atlas in
TMD Diagnosis: technique) Therapist days and 30 (mm) patients with
General applied a pressure in days bruxism. In the
classification of the first metacarpal Pressure pain opening of the
TMD. Subjects joint bilaterally threshold (PPT) mouth and pain
have to present of the pterion threshold it was
bruxism and point shown to be
orofacial pain, (Algometer) more effective
click or crepitus kg/cm2 than using the
as well as oral splint only.
headaches ROM and PPTs
were measured at
baseline, at 15
days, and 30
days.
Distance
between occiput
and Atlas was
measured 7 days
after the last
Treatment
80
Packer et N=32 Thoracic Both Pressure pain No significant Upper thoracic
al.,76 manipulation: techniques threshold (PPT) differences spinal
2014 Female :32 The upper thoracic were of the pterion between the 2 manipulation
Brazil Male:0 manipulation performed point groups in PPT or does not lead to
Age:25 y average technique was once (Algometer) VAS a reduction in
applied to the T1 kg/cm2 pain and
TMD Diagnosis: vertebral segment in muscular
Subjects with supine position. A sensitivity in
myofascial pain high-velocity, low- Pain intensity: women with
with or without amplitude thrust in VAS TMD
limited opening the postero-superior
according to direction of T1 was
Dworkin and Le applied.
Resche 27
women with
simultaneous vs.
diagnoses
of disk Placebo thoracic
displacement manipulation:
with reduction Same position as the
(IIa), disk active group, but no
displacement manipulation was
without reduction performed
and with limited
ROM (IIb), disk
displacement
without reduction
and
without limited
ROM (IIc),
81
and/or arthralgia
(IIIa)
were included in
this study as
well.
Raustia et N=50 Acupuncture Acupuncture: Clinical The immediate Neither

al., 93 three sessions dysfunction results seem to treatment
1985- Sex: Vs. of at least 20 index (Di) of favor method was
1986, Female: 39 minutes each, Helkimo conventional shown to be
1987 Male: 11 Stomatognathic within 1 dental treatment statistically
Finland treatment month. The Mouth Opening for decreasing superior after 3
Age: 27.1 y counselling, occlusal acupuncturist (mm) dysfunction months, and the
average adjustment, adjusted the index, although results
muscular treatment by Measurements this was not suggested that
TMD Diagnosis: exercises for the eliciting patient
performed before evident acupuncture
General lower jaw, splint reactions. treatment, within statistically could be an
Diagnosis of therapy, or a 1 3 months after alternative
TMJ dysfunction combination Stomatognathi week of treatment. method of
of these c treatment: treatment treatment and is
No details and 3 months Acupuncture was worthy
about frequency after more effective of further study
treatment. than conventional
82
and duration of treatment in
treatment. increasing mouth
opening when
subjects had
reduced mouth
opening at the
beginning of the
treatment (p
=.05)
Tavera et N= 152 External auditory Subjects were RDC/TMD tools All three Safety and
al.99 canal TMD device instructed to treatment groups effectiveness of
2011 Sex: (TMDes) device: daily diary to Craniomandibu displayed the TMDes was
Mexico Female: 126 wear the TMDes track the lar index (CMI) reductions demonstrated to
Male: 26 device as much as number of (improvement) be comparable
Age: 26,5 possible day and hours of the VAS (subject from baseline in to that of the
night device was perceived pain) mean CMI, VAS, stabilization
TMD Diagnosis worn or the SSI scores and splint in a well-
RDC/TMD vs. number of Symptoms improvement of characterized
diagnosis that exercise severity index the TMJ scale. population of
included at least Stabilization splint: repetitions questionnaire No statistical TMD patients.
one of the intraoral flat planed completed (SSI) differences The jaw exercise
following: splint full coverage between groups regimen was not
myofascial pain, plastic hard orthotic TMJ Scale for each variables found to be
arthralgia, disc that fits over the statistically
displacement occlusal one-third significantly
with reduction inferior to either
83
with one or more surfaces of the Evaluations the stabilization
of the following: dentition performed at 1,2 splint treatment
VAS > 4, and 3 months or TMDes
increased vs. treatment but
(>60mm) or demonstrates a
decreased Jaw exercises: 10 trend towards a
(<40mm) range times mouth opening lower
of jaw opening, + hold the position 5 percentage of
pain any jaw sec + 10 seconds rest improvement.
movement, pain before next opening.
on digital Apply warm
palpation of compress to the jaw
preauricular area area
or external
auditory meatal
areas , palpation
in two or more
muscles of
mastication, joint
sound with pain
Truelove N=200 Usual treatment: Hard and Soft Primary Pain: All of the Self-reported
E et al., 74 68= usual conservative and splint: both outcome groups showed pain and
2006 treatment + hard reversible self-care groups wear measure was comparable symptoms and
USA splint; 87% strategies (jaw their splints at Chronic Pain decreases in pain muscle and joint
females relaxation, reduction night and two Index (CPI) across the study palpation scores
68= usual of parafunction, hours each day (P > .40) decreased
treatment + soft thermal packs, while awake Pain on muscle significantly
splint; 90% NSAIDs, passive throughout the and TMJ Range of across all three
females opening stretches three-month palpation motion. There groups over
and suggestions follow-up and were no time. Non-
84
64= usual about stress 12-month significant splint,
treatment; 81% reduction); follow-up differences conservative
females among groups. treatments also
Usual treatment + Usual appear to be as
Age: 36±11 hard splint: acrylic treatment: Muscle and effective as the
heat- processed flat- recommendati TMJ palpation two splint types
TMD diagnosis: plane maxillary ons (jaw pain: No in reducing self-
RDC/TMD Axis splint relaxation, significant reported
I mixed diagnosis reduction of differences across parafunction
Usual treatment + parafunction, groups
soft splint: soft thermal packs,
thermoplastic vinyl NSAIDs,
athletic mouth guard passive
splint opening
stretches and
suggestions
about stress
reduction)
von N=43 Orofacial physical The duration of Colored analog CAS displayed a The beneficial
Piekartz et Female: 27 therapy: Translatory the treatment scale (CAS): significant treatment effect
al.,106,107 Male: 16 movements of the was intensity of the difference in the
2011 Age: range 18-65 temporomandibular maximally 30 craniofacial between groups. experimental
The years: average region and/or minutes. complaints In the usual care group remains
Netherlan age 36±7.7 years masticatory muscle The six group, there was or is improved
d techniques, such as treatments had Mouth opening a significant at six months
TMD diagnosis: tender-trigger point to be increase of the follow- up and a
a minimum of treatment and concluded VAS during average value, decreased
one of the four muscle stretching. after a mouth opening indicating a chronification.
signs of TMD: Active and passive minimum of possible
85
joint sounds, movements 21 and a maxi- Pain Pressure deterioration of In contrast, the
deviation during facilitating optimal mum of 42 Threshold the headache usual care group
mouth opening, function of cranial days. (PPT): complaints remains status
extraoral muscle nerve tissue, Masticatory quo or worsens
pain at a coordination Muscles The results of the after discharge
minimum of two exercises, and home second from the
tender points in exercises. measurement for treatment and
the masseter or Additionally the CAS, Neck indicates that
temporalis therapist provided Disability Index TMD may be a
muscles and pain treatment to the (NDI), the TMD contributing or
during passive cervical spine. signs (mouth etiological
mouth opening, opening, range factor in chronic
had to be present. vs. and pain) and cervicogenic
PPT from the headache
Usual care anterior temporal patients.
treatment (Control muscles) of the
group) experimental
Cervical manual group differed
therapy significantly from
individualized to the the results of the
patient. This regime usual care group
included cervical
joint mobilization
and if necessary high
velocity
thrust, muscle
stretching and
strengthening, and
other home exercises
(joint ROM, muscle
strengthening and
86
stretching) designed
for the neck.
Maluf et N= 28 Global Postural Eight treatment Symptoms and Comparing the For the
al,94 (4 drop out) Re-education group sessions lasting Pain Intensity: pain assessments participants of
2010 (GPR) (n = 14) 40 minutes each Visual analogue using the visual this study, both
Brazil Age: 19-40 y Muscle stretching of (weekly) were scale (VAS) analogue scale, GPR and SS
the posterior and performed. Symptoms no significant were similarly
TMD Diagnosis: anterior muscle included pain at differences were effective for the
chronic pain chains, according to the TMJ, seen with the treatment of
(duration>3mont the Global Postural headache, exception of TMD with
hs), Helkimo Re-education cervicalgia, and severity of muscular
index III, Method, difficulties for headaches at component.
myogenic TMD mastication. treatment end. They equally
vs. reduced pain
Pain Threshold: In addition, no intensity,
Static Stretching Pain threshold significant increased PTs,
group (SS): was considered differences were and decreased
Conventional muscle positive when seen for pain EMG activity.
static stretching values were thresholds and for
(cervical spine, head, lower than 2.6 electromyographi
upper limbs and c activity.
mandibular kg/cm.
muscles),
EMG Activity:
8-channel EMG
equipment. A
total of 3
measures with 7
seconds of
duration
87
All evaluations
and interventions
were made at
baseline, after
treatment end,
and at a follow-
up 8 weeks after
treatment.
Tuncer et N= 40 Group I: home Manual Pain intensity VAS scores, both In the short
al., 75 Sex: physical therapy Therapy three (VAS) at rest and with term, manual
Female: 31 (HPT) times a week stress, therapy in
2013 Male: 9 Subject education during the Pain-free significantly conjunction
Turkey. Age: 18-72 y concerning the four- week maximum decreased in both with home
presumed aetiology treatment mouth opening groups over time physical
TMD Diagnosis: of the pain, period. Each (MMO) (mm) (p < 0.001). therapy is more
TMD diagnosis ergonomic advice, treatment VAS with stress effective than
was made breathing exercises, session lasted significantly home physical
according to relaxation 30 min and decreased in the therapy alone
RDC/TMD. techniques, was adapted MTeHPT group for the
Mixed TMD: posture correction individually to compared with treatment of
myogenous; exercises and the needs of that in the HPT TMD,
anterior disc mandibular exercises each subject. group. particularly
displacement such as active and with regard to
with reduction; repetitive assisted Pain-free MMO decreasing pain
painful clicking, muscle stretching, significantly and increasing
crepitation or mouth opening and increased in both pain-free
pain on opening closing, medial and groups over time maximum
and loaded lateral (p < 0.001). mouth opening.
closing Time*treatment
88
gliding and effect was
resistance exercises significant
between groups
vs. (p= 0.009), with
a greater increase
Group II: Manual in the MTeHPT
Therapy (MT) in group than in the
conjunction with HPT group.
home physical Clinical
therapy effectiveness of
(MTeHPT) treatment in the
MT included soft MTeHPT group.
tissue mobilization
(intra- and
extra-oral deep
friction massage of
painful muscles),
TMJ
mobilization (caudal
and ventro-caudal
traction, ventral and
mediolateral
translation), TMJ
stabilization (gentle
isometric tension
exercises against
resistance),
coordination
exercises (guided
opening and closing
jaw movements),
89
cervical spine
mobilization
(traction and
translation) and
post-isometric
relaxation and
stretching techniques
for the masticatory
and neck muscles
Grace et N=45 Traditional 2× per week for Mouth opening No statistically Results
al,95 therapies:(oral 2 mo and lateral significant indicated
2002 Sex: stabilizatim:1applian deviation (mm) differences that all three
USA Female: 38 ces, prescription or Oral device: 2× within/between groups
Male: 7 over-the-counter per day for 1– Pain VAS: groups for any demonstrated
Age: 18–76 y medications, 2 min at a 0=“no pain” to outcomes significant
(mean=39.1 y) instruction in home time; 10=“very overall patient
physiotherapy and resistance painful” (3 time clinical and
TMD Diagnosis: exercises, patient progressed points: today; subjective
Temporomandib education, training in over last week; improvement
ular joint stress reduction, use predict next
dysfunction with of thermal week) Further research
a primary modalities and/or needed:
diagnosis of physical therapy) Joint noises: increased
muscular vs auscultation exercise times
dysfunction with and larger
(51.1%). Traditional plus stethoscope sample size
However, 42.2% oral exercise
had a secondary device Wellness scale:
diagnosis of a 5 questions
functional vs
90
problem
(reducing disk Education plus
displacement) Oral exercise
and 6.7% had a device: (Facial flex
secondary device)
diagnosis of an
inflammatory
TMD problem.
Klobas et N=55 Therapeutic Jaw 6 months Maximum There were no The therapeutic
al.,96 exercises (i.e. small follow up active mouth inter- or intra- jaw exercises, in
2006 Sex: active mandibular The patients opening (mm) group differences addition to the
Sweden Female: 39 movements, active were instructed in symptoms and regular whiplash
Male: 16 movements against to repeat each Pain on signs of rehabilitation
resistance, rest part of the mandibular temporomandibul program, did not
Age: 21-60 y mouth closing, program 5-10 movement ar disorders at reduce
(mean=37.4 y) stretching of mouth times, three baseline, nor at symptoms and
opening)+ times daily. Pain Drawings the 3-week and 6- signs of
TMD Diagnosis: conventional PT+ month follow- temporomandib
Patients were whiplash Masticatory ups, except for an ular disorders in
classified by the rehabilitation muscle pain on increase of patients with
Helkimo Index. program palpation (0-7) maximum active chronic
They had to have mouth-opening whiplash
at least score vs. Neck muscle capacity in the associated
Dysfunction pain on control group. disorders.
Index (Di) II or Control group ( no palpation (0-7)
pain on palpation exercises) plus
of at least 3 whiplash TMJ pain
masticatory rehabilitation ( lateral and
muscles. program
91
posterior ) on
palpation(0-7)
Tegelberg N=60 General program Exercises Maximum Both groups Physical training
and Kopp, of PT exercises (i.e. performed active mouth reported less of the
98
Sex: opening, twice a day opening(mm) severity of stomatognathic
Female :?? laterotrusion and temporomandibul system improves
1988, Male:?? protrusion without Clinical ar joint disorder the mandibular
1996 Age: 49 y and with resistance) Dysfunction at the follow-up mobility in
Sweden average age Score (Helkimo study after individuals with
vs. Index) physical training. RA and AS and
TMD Diagnosis: reduces the
Subjects had the Control group Mean number The maximum clinical
diagnosis of of tender Points voluntary mouth dysfunction
rheumatoid (palpation) opening capacity extent in
arthritis (RA) and Measurements increased, and the individuals with
ankylosing taken at 3 weeks clinical RA
spondylitis (AS) after starting dysfunction score
plus symptoms of treatment and 3 of Helkimo
TMJ dysfunction years after decreased only in
treatment the treatment
group but not in
the Control group
(p<0.05).
Cuccia et N= 50 Osteopathic Treatment VAS (0-10) OMT and CCT The favourable
al.101 Manual Therapy every two groups did not cost benefit ratio
2010 Sex: (OMT): weeks Maximal mouth demonstrate any of physiotherapy
Italy Female: 28 manipulative opening (MOV) significant over other
Male: 22 procedure design to difference. treatment
Age: 18-50 years reduce the Cervical range modalities
(mean for OMT dysfunction –pain of motion - seems to
92
group = 40.6 / and restriction- of ROM (rotation The use of indicate that
mean for control the ligaments of of cervical spine medication was physiotherapy,
group = 38.4) TMJ and to retrain on the transvers greater in the in general, can
the involuntary plane) CCT group than be regarded as a
TMD Diagnosis: neuromuscular, in the OMT first choice
subjects had a reflexive control of TMI : clinical group with approach in
temporomandibul posture and balance index including a significant selected TMD
ar index (TMI) function index differences for patients.
reference value vs. (FI), muscle non-steroidal OMT, in
of >0.08 ±0.10 index (MI) and anti- particular, had a
and a minimum Conventional joint index (JI) inflammatory positive effect
pain intensity of Conservative (p<0.001) on physical
40 mm on a VAS Therapy (CCT): The use of non- symptoms of
oral appliance, steroidal anti- Improvement in TMD and it is
physical therapy inflammatory values of VAS, recommendable
(gentle muscles drugs and MOV and ROM as an effective
stretching and muscle relaxant in both groups treatment in
relaxing therapy), were monitored was observed at patients
hot and/or cold pack T1 and at T2 suffering from
and TENS Patient where than at T0 TMD
assessed at 24
(T1) and 32 (T2)
weeks.
Burgess et N=29 Stretching of Stretching of Maximum Pain was Ice and stretch
al, 55 masticatory masticatory active mouth significantly for the
1988 Sex: muscles muscles were opening (mm) reduce in the masticatory and
USA Female :21 (Masseter and performed 15 stretching group cervical muscles
Male:8 Temporalis) and times Pain (McGill when compared appears to be a
Age: 34 y neck muscles Pain Rating with the PNF and good short-term
average age (sternocleidomastoid Intensity –PRI) adjunctive
93
and trapezius with a Stretching of control groups therapy to
TMD Diagnosis: ethyl chloride neck muscles Pain at (p=0.03) control pain
Myofascial pain followed by stretch were palpation with little risk of
according to as described by performed 5 No statistical negative effects.
Laskin. Subjects Travell and times Electromyograp significant
presented with Simmons hic muscle differences
pain in TMJs as Both stretching activity (EMG) between groups
well vs. performed on maximal
between 2-4 Maximum mouth opening
Proprioceptive times daily active mouth
Neuromuscular opening (mm)
Facilitation (PNF) PNF: 15 times
technique of the with mouth
masticatory opening
muscles resistance
vs.
Control Group
(education on good
habits. Also a
brochure with the
instructions was
provided)
94
Table 2. Risk of Bias of Included Studies
Items Carmeli, Craane 2012 Craane 2012 Crockett, Cuccia, 2010 De Felicio, De Felicio, Diracoglu, Ficnar, 2013 Gavish, 2006 Grace, 2002 Guarda- Haketa, 2010 Ismail, 2007 Kalamir, Kalamir,
2001 (myogenous) (arthrogenous) 1986 2010 2008 2009 Nardini, 2012 2012 2013
Inclusion and exclusion criteria clearly defined consensus unclear yes yes yes yes yes yes yes Yes Yes Yes Yes yes yes Yes yes
Study described as randomized consensus yes yes yes yes yes yes yes no Yes Yes Yes Yes yes yes Yes yes
Method of randomization described and appropriate consensus unclear yes yes unclear unclear yes unclear no Unclear unclear No Unclear yes unclear Yes yes
Method of randomization concealed Consensus unclear unclear unclear unclear unclear unclear unclear no Unclear unclear No Unclear unclear unclear Yes unclear
Baseline comparability regarding the most important prognostic indicators consensus unclear yes yes yes yes unclear yes unclear Unclear Yes Yes Yes yes yes Yes yes
Study described as double blind consensus no no no no no no no no No No No No no no No no
Method of blinding appropriate consensus yes no no unclear yes unclear unclear no No Yes Unclear Unclear yes unclear Unclear unclear
Blinding investigator consensus unclear unclear unclear unclear unclear unclear unclear unclear Unclear Unclear Unclear Unclear unclear unclear Yes unclear
Blinding of assessors consensus yes no no unclear yes unclear unclear no Unclear Unclear Unclear Unclear yes unclear Yes unclear
Blinding of participants consensus unclear no no unclear unclear unclear unclear no Unclear Unclear No No unclear unclear Unclear unclear
Blinding of therapist consensus no no no no no no no no Unclear Unclear Unclear No no no no no
Blinding of outcomes analysis (statistician) consensus unclear unclear unclear unclear unclear unclear unclear unclear Unclear Unclear Unclear Unclear yes yes Unclear yes
Treatment protocol adequately described for treatment group consensus yes yes yes unclear unclear yes unclear no Unclear Yes No Yes yes yes Yes yes
Treatment protocol adequately described for treatment group consensus yes no yes unclear unclear yes unclear no Unclear Yes No Yes yes yes Yes yes
Treatment protocol adequately described for treatment group consensus NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
Control group adequate consensus no no no no no yes yes no No No No No no no Yes no
Placebo group adequate consensus NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
Co-interventions avoided or comparable consensus yes unclear unclear unclear no unclear unclear unclear Unclear Unclear Unclear Unclear yes unclear No unclear
Co-interventions reported for each group separately consensus yes no no no yes no no no Unclear Unclear Unclear No yes no No yes
Testing of subject compliance to treatment protocol consensus unclear unclear unclear unclear unclear unclear unclear unclear Unclear Unclear No Unclear unclear unclear Unclear unclear
Compliance acceptable in all group consensus unclear unclear unclear unclear unclear unclear unclear unclear Unclear Unclear Unclear Unclear unclear unclear Unclear unclear
Description of w ithdraw s and droupouts consensus no yes yes yes no yes yes yes Yes Yes Yes Yes yes yes Yes yes
Withdraw al/dropouts rate described and acceptable consensus unclear yes yes no unclear yes no yes Yes Yes No Yes no yes Yes yes
Reasons for dropouts consensus no yes yes yes no yes yes no Yes NA Yes No no NA Yes no
Adverse effects described consensus no no no no no no no no No No No No yes no Yes no
Short term follow measurement performed consensus yes yes yes yes yes yes no yes Yes Yes Yes Yes yes yes Yes yes
Long term follow measurement performed consensus NA yes yes unclear no unclear NA yes Yes No No Yes NA NA Yes NA
The timing of the outcome assesment w as comparable in all groups consensus yes yes yes yes yes yes no yes Yes Yes Yes Yes yes yes Yes yes
Description of outcome measures consensus yes yes yes yes yes yes yes yes Yes Yes Yes Yes yes yes Yes yes
Relevant outcomes w ere used consensus yes yes yes yes yes yes yes yes Yes Yes Yes Yes yes yes Yes yes
Validity reported for the main outcome measure consensus yes yes yes no no yes no no No No No No no no Yes no
Responsiveness reported for the main outcome measure consensus no yes yes no no no no no No No No No no no No no
Reliability reported for the main outcome measure consensus yes yes yes no no yes yes no No No No No no yes Yes no
Use of objective outcome measures consensus yes yes yes yes yes yes yes yes Yes Yes Yes Yes yes yes Yes yes
Descriptive measures identified and reported for the primary outcome consensus yes yes yes yes yes yes no yes Yes Yes No Yes yes yes Yes yes
Appropriate statistical analysis used consensus yes yes yes yes yes yes yes yes Yes Yes Yes Yes yes yes Yes yes
Betw een-group statistical comparisons reported Consensus yes yes yes yes yes yes yes yes Unclear Unclear Unclear Unclear yes yes Unclear yes
Sample size calculation prior to initiation of the study consensus no yes yes no no no no no Yes No No Yes yes yes Yes yes
Adequate sample size consensus unclear yes yes unclear unclear unclear unclear unclear Yes Unclear Unclear Yes no yes Yes yes
Sample size described for each group consensus yes yes yes yes yes yes yes yes Yes Yes Yes Yes yes yes Yes yes
Intention to treat analysis used consensus unclear no no no unclear yes yes no No Yes No Unclear no yes Yes no
Clinical significance reported consensus yes unclear unclear unclear no yes no no No No No No no yes No yes
Number of items accomplished/total of applicable items 19/39 23/40 24/40 14/40 15/40 22/40 14/40 13/40 16/40 17/39 12 out of 40 18/40 23/39 22/38 28/40 22/40
Risk of Bias Tool Assessment Unclear Unclear Unclear High High Unclear High High High High High High Unclear Unclear High Unclear

Items Kalamir, Klobas, 2006 La Touche, Maloney, Maluf, 2010 Mansilla- Michelotti, Minacuchi, Nascimento, Niemela, Otano, 2010 Raustia, Reilly, 1986 Schiffman, Stegenga B, Tavera , 2012
2010 2013 2002 Faragud, 2008 2000 2001 and 2004 2013 2012 1986, 1987 2007 1993
Inclusion and exclusion criteria clearly defined consensus yes yes yes yes yes yes yes yes Yes Yes yes No Yes Yes Yes Yes
Study described as randomized consensus yes yes yes yes yes yes yes yes Yes Yes yes Yes Yes Yes Yes Yes
Method of randomization described and appropriate consensus yes unclear yes unclear unclear unclear yes yes Unclear Yes yes Unclear Yes Yes unclear unclear
Method of randomization concealed Consensus unclear unclear unclear unclear unclear unclear no unclear Unclear Unclear unclear Unclear Unclear Yes unclear unclear
Baseline comparability regarding the most important prognostic indicators consensus yes yes yes yes unclear yes yes yes Yes Yes unclear Unclear Unclear Yes Yes Yes
Study described as double blind consensus no no yes no no no no no No No yes No No No No No
Method of blinding appropriate consensus unclear yes yes unclear unclear unclear yes yes Unclear Unclear yes Unclear No Yes No Unclear
Blinding investigator consensus yes unclear unclear unclear unclear unclear no unclear Unclear Unclear unclear Unclear Unclear Yes Unclear Unclear
Blinding of assessors consensus unclear yes yes unclear unclear unclear yes yes Unclear Unclear yes Unclear Unclear Yes Unclear Unclear
Blinding of participants consensus unclear unclear yes unclear unclear unclear no unclear Unclear Unclear yes Unclear No No No No
Blinding of therapist consensus no no no no no no no no Unclear No no Unclear Unclear Yes No Unclear
Blinding of outcomes analysis (statistician) consensus unclear unclear unclear unclear unclear unclear yes unclear Unclear Unclear unclear Unclear Unclear Unclear Unclear Unclear
Treatment protocol adequately described for treatment group consensus yes yes yes yes unclear unclear yes unclear Unclear Yes unclear No No No Yes Yes
Treatment protocol adequately described for treatment group consensus yes unclear yes unclear unclear yes yes unclear Unclear Yes unclear No No No Yes Yes
Treatment protocol adequately described for treatment group consensus NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
Control group adequate consensus yes no yes unclear no yes no no No No yes No No No No yes
Placebo group adequate consensus NA NA yes NA NA NA NA NA NA NA yes NA NA NA NA NA
Co-interventions avoided or comparable consensus unclear no unclear unclear yes NA yes unclear Unclear Unclear unclear Unclear Unclear Unclear Unclear Unclear
Co-interventions reported for each group separately consensus no no no no NA NA NA no Unclear No no No No Unclear Unclear Unclear
Testing of subject compliance to treatment protocol consensus no yes unclear no unclear NA yes unclear Unclear Unclear unclear No No Yes Yes Yes
Compliance acceptable in all group consensus unclear yes unclear unclear unclear NA yes unclear Unclear Unclear unclear Unclear No Yes No Yes
Description of w ithdraw s and droupouts consensus yes yes NA no yes NA yes yes No Yes no No Yes Yes Yes No
Withdraw al/dropouts rate described and acceptable consensus yes yes yes unclear yes NA no yes Unclear Yes unclear Unclear Yes Yes Yes Unclear
Reasons for dropouts consensus yes yes NA no yes NA yes no No Yes no No No Yes Yes No
Adverse effects described consensus yes no yes no no no no no Yes Yes no No No No No No
Short term follow measurement performed consensus yes yes yes yes yes yes yes yes Yes Yes yes Yes Yes Yes Yes Yes
Long term follow measurement performed consensus yes yes NA NA no NA NA NA No No NA Yes No Yes Yes Yes
The timing of the outcome assesment w as comparable in all groups consensus yes yes yes yes yes yes yes yes Yes Yes yes Yes Unclear Yes Yes Yes
Description of outcome measures consensus yes yes yes yes yes yes yes yes Yes Yes yes No Yes Yes Yes No
Relevant outcomes w ere used consensus yes yes yes yes yes yes yes yes Yes Yes yes Yes yes Yes Yes Yes
Validity reported for the main outcome measure consensus no no no no no no no no No No no No No Yes No No
Responsiveness reported for the main outcome measure consensus no no no no no no no no No No no No No No No No
Reliability reported for the main outcome measure consensus no no yes no yes no no yes No No yes No No Yes No No
Use of objective outcome measures consensus yes yes yes yes yes yes yes yes Yes Yes yes Yes Yes Yes Yes Yes
Descriptive measures identified and reported for the primary outcome consensus yes yes yes yes yes yes yes yes Yes Yes yes Yes Yes Yes Yes No
Appropriate statistical analysis used consensus yes yes yes yes unclear yes yes yes Yes Yes unclear Yes Yes Yes yes No
Betw een-group statistical comparisons reported Consensus yes yes yes yes unclear yes yes yes Unclear Unclear unclear Unclear Unclear Unclear Unclear Unclear
Sample size calculation prior to initiation of the study consensus no no yes no yes no yes no No Yes no No No No No No
Adequate sample size consensus unclear unclear yes unclear yes unclear no unclear Unclear Yes unclear Unclear No Yes Unclear Unclear
Sample size described for each group consensus yes yes yes yes yes yes yes yes Yes Yes yes No Yes Yes Yes Yes
Intention to treat analysis used consensus no no yes unclear no yes no yes Unclear No unclear No No Yes No No
Clinical significance reported consensus yes no yes no no yes yes no No No no No No No No No
Number of items accomplished/total of applicable items 23/40 21/40 28/38 13/39 16/40 16/32 25/38 19/40 12 out of 40 20/40 17/40 8 out 40 11 out of 40 27/40 18/40 14/40
Risk of Bias Tool Assessment Unclear High Unclear Unclear Unclear Unclear High Unclear Unclear Unclear Unclear High High Unclear High High

Items Tagelberg, Truelove, Tuncer, 2013 Von Piekartz, Wright, 2000 Yoda, 2003 Yoshida, Yoshida, Yuasa, 2001 Magnusson and Mulet, 2007 Komiyama, Gomes et Packer et al., Kraaijenga Burgess, Final Final %
1988, 1996 2006 2011, 2013 2005 2011 Syren, 1998 1999 al., 2014 2014 et al., 2014 1988
Inclusion and exclusion criteria clearly defined consensus Yes yes yes yes yes yes yes yes yes yes yes yes unclear yes unclear unclear 43 out 48 89.60
Study described as randomized consensus Yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes 47 out 48 97.90
Method of randomization described and appropriate consensus Unclear unclear yes yes unclear yes yes yes unclear unclear yes unclear unclear unclear unclear unclear 20 out 48 41.60
Method of randomization concealed Consensus no unclear unclear unclear unclear yes yes unclear unclear unclear unclear unclear unclear unclear unclear unclear 4 out 48 8.30
Baseline comparability regarding the most important prognostic indicators consensus Unclear yes yes yes yes yes yes unclear yes unclear yes yes unclear yes yes yes 36 out 48 75.00
Study described as double blind consensus No no no no no no no no no no no no no yes no no 3 out 48 6.25
Method of blinding appropriate consensus Unclear unclear unclear no no unclear unclear unclear unclear unclear no no yes yes no no 12 out 48 25.00
Blinding investigator consensus Unclear unclear unclear unclear unclear unclear unclear unclear unclear unclear unclear unclear unclear unclear unclear unclear 3 out 48 6.25
Blinding of assessors consensus Unclear unclear unclear no no unclear unclear unclear unclear unclear no unclear yes yes no no 12 out 48 25.00
Blinding of participants consensus No unclear unclear no unclear unclear unclear unclear no no no no unclear yes no no 3 out 48 6.25
Blinding of therapist consensus Unclear no no no no no no no no no no no no no no unclear 0 out 45 0.00
Blinding of outcomes analysis (statistician) consensus Unclear unclear unclear unclear no unclear unclear unclear unclear unclear unclear unclear yes yes unclear unclear 6 out 48 12.50
Treatment protocol adequately described for treatment group consensus No yes yes unclear yes yes yes yes yes yes yes yes yes yes yes unclear 31 out 48 64.60
Treatment protocol adequately described for treatment group consensus No yes unclear unclear no unclear unclear no unclear yes yes yes yes unclear yes unclear 22 out 48 45.80
Treatment protocol adequately described for treatment group consensus NA NA NA NA NA NA NA NA NA NA NA NA unclear NA NA NA NA NA
Control group adequate consensus Yes no no no no yes yes unclear unclear no no no no yes no no 12 out 48 25.00
Placebo group adequate consensus NA NA NA NA NA NA NA NA NA NA NA NA NA yes NA NA 3 out 48 6.25
Co-interventions avoided or comparable consensus Unclear unclear yes unclear unclear unclear unclear NA unclear unclear yes unclear unclear unclear unclear unclear 6 out 46 13.00
Co-interventions reported for each group separately consensus Unclear no NA no no no no NA no unclear yes unclear no no no unclear 5 out 48 10.40
Testing of subject compliance to treatment protocol consensus Unclear yes no yes yes unclear unclear NA unclear unclear yes unclear unclear yes yes unclear 11 out 46 23.90
Compliance acceptable in all group consensus Unclear no unclear yes no unclear unclear NA unclear unclear yes unclear unclear yes unclear unclear 7 out 46 15.22
Description of w ithdraw s and droupouts consensus No yes unclear yes yes yes yes NA yes yes yes yes yes yes yes no 35 out 45 77.80
Withdraw al/dropouts rate described and acceptable consensus Unclear yes unclear yes yes yes yes NA yes yes yes yes yes yes no unclear 30 out 46 65.20
Reasons for dropouts consensus No no no yes no unclear NA NA NA yes no no NA NA unclear no 17 out 39 43.60
Adverse effects described consensus No yes yes no no no no no yes no yes no no no no no 10 out 48 20.83
Short term follow measurement performed consensus Yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes 47 out 48 97.90
Long term follow measurement performed consensus No NA NA yes NA NA NA NA NA yes NA NA NA NA yes NA 15 out 25 60.00
The timing of the outcome assesment w as comparable in all groups consensus Yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes 46 out 48 95.80
Description of outcome measures consensus Yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes 46 out 48 95.80
Relevant outcomes w ere used consensus Yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes 48 out 48 100.00
Validity reported for the main outcome measure consensus No no yes yes yes no no no no no yes no no no yes no 11 out 48 22.91
Responsiveness reported for the main outcome measure consensus No no no yes no no no no no no no no no no no no 3 out 48 6.25
Reliability reported for the main outcome measure consensus No no yes no yes no no no no no no no yes yes yes no 17 out 48 35.42
Use of objective outcome measures consensus Yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes 48 out 48 100.00
Descriptive measures identified and reported for the primary outcome consensus No yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes 44 out 48 91.70
Appropriate statistical analysis used consensus No yes yes unclear yes yes yes unclear yes no yes yes yes yes yes yes 41 out 48 85.40
Betw een-group statistical comparisons reported Consensus Unclear yes yes unclear yes yes yes unclear yes no yes yes yes yes yes yes 30 out 48 62.50
Sample size calculation prior to initiation of the study consensus No yes no yes no yes yes no yes no yes no yes yes yes no 21 out 48 43.80
Adequate sample size consensus Unclear unclear unclear yes unclear yes yes unclear yes unclear yes unclear yes yes no unclear 18 out 48 37.50
Sample size described for each group consensus Yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes 47 out 48 97.90
Intention to treat analysis used consensus No yes unclear no no yes yes yes yes no no no yes yes no no 16 out 48 33.30
Clinical significance reported consensus No yes yes yes no yes yes yes yes no yes no yes yes no no 18 out 48 37.50
Number of items accomplished/total of applicable items 9 out 40 21/39 19/38 22/40 18/39 22/39 22/38 13/32 20/38 15/40 26/39 16/39 22 out of 41 29 out of 41 19 out of 39 11 out of 39
Risk of Bias Tool Assessment High Unclear Unclear Unclear High Unclear Unclear unclear Unclear Unclear High High unclear unclear unclear High

Table 3 . GRADE Evidence profile
Quality Assessment Summary of Findings

Number of
Patients
Number Risk of Bias Inconsistency Indirectness Imprecision Publication Patients Patients Estimate Quality
of Bias in Tx in (SMD or
Studies group Control MD) [95%CI]
(Design) Group
POSTURE CORRECTION EXERCISES IN MYOGENOUS TMD
Outcome: Maximum pain-free opening

Two Unclear risk of P value on No serious No serious No serious 50 50 MD=5.54 Moderate
(RCTs) bias for both test for indirectness imprecision publication mm [2.93, Quality
studies. heterogeneity bias 8.15] because of
Concealment of p=0.30; I2=6% risk of bias
allocation not
clear for both No
studies, no inconsistency
intention to
treat
Outcome: Disturbance of symptoms with daily life
Two Unclear risk of P value on No serious No serious No serious 50 50 SMD=1.13 Moderate
(RCTs) bias for both test for indirectness imprecision publication [0.48, 1.78] Quality
studies. heterogeneity bias because of
Concealment of p=0.15; risk of bias
allocation not I2=51% Upgrading
clear for both because of
studies, no No serious large effect
intention to inconsistency size and
treat narrow
confidence
interval

GENERAL JAW EXERCISES ALONE OR COMBINED WITH NECK EXERCISE PROGRAM IN MYOGENOUS TMD
Outcome: Pain free maximum opening
Four Unclear risk of P value on No serious No serious No serious 64 67 MD=5.94mm Low Quality
(RCTs) bias for most of test for indirectness imprecision publication [-1.0, 12.87] because of
the studies. heterogeneity bias risk of bias
Concealment of p<0.00001; and
allocation not I2=88% inconsistency
clear for 3
studies and one High
study was not heterogeneity
concealed. All
studies did not
perform
intention to
treat
Outcome: Pain Intensity
Five High risk of bias P value on No serious No serious No serious 85 90 SMD=0.43 [- Moderate
(RCTs) for most of the test for indirectness imprecision publication 0.02, 0.87] quality
studies. heterogeneity bias because of
Concealment of p=0.10; risk of bias
allocation not I2=49%
clear for 4
studies and one No serious
study was not inconsistency
concealed.
Compliance and
co-
interventions
unclear for
most of the
studies. No
intention to
treat for 4
studies

MANUAL THERAPY TARGETED TO THE OROFACIAL REGION IN MYOGENOUS TMD
Three Concealment of P value on No serious No serious No serious 44 44 MD=1.35cm Moderate
(RCTs) allocation not test for indirectness imprecision publication [0.91, 1.78] quality
clear for 2 of heterogeneity bias because of
the studies and p=0.78; I2=0% risk of bias
one study was
not concealed. No serious
Compliance and inconsistency
co-
interventions
unclear for all
of the studies.
No intention to
treat for 2
studies
JAW/NECK EXERCISES ALONE OR AS PART OF A CONSERVATIVE REGIME IN ARTHROGENOUS TMD
Four Concealment of P value on No serious No serious No serious 73 73 SMD=0.68 [- Low quality
(RCTs) allocation not test for indirectness imprecision publication 0.04, 1.40] because of
clear for all of heterogeneity bias risk of bias
the studies. p=0.01; and
Blinding was I2=73% inconsistency
unclear for 3 of
the studies and High
1 study did not Inconsistency
have
appropriate
blinding.
Compliance and
co-
interventions
unclear for all
of the studies.

No intention to
treat for 2
studies
Outcome: active mouth opening
Three Concealment of P value on No serious No serious No serious 63 63 3.13mm Low quality
(RCTs) allocation not test for indirectness imprecision publication [95%CI -1.96, because of
clear for all of heterogeneity bias 8.23] risk of bias
the studies. p=0.009; and
unclear for 2 of
the studies and High
1 study did not Inconsistency
have
appropriate
blinding.
Compliance and
co-
interventions
unclear for all
of the studies.
JAW/NECK EXERCISES ALONE OR AS PART OF A CONSERVATIVE REGIME vs. SURGERY IN ARTHROGENOUS TMD
Two Concealment of P value on No serious No serious No serious 68 63 MD=-1.01 Low quality
(RCTs) allocation not test for indirectness imprecision publication mm [95%CI - because of
appropriate for heterogeneity bias 5.43, 3.42] risk of bias
both studies. p=0.04; and
not appropriate
for both studies High
Compliance and Inconsistency
co-
interventions
unclear for all
of the studies.

MANUAL THERAPY PLUS JAW EXERCISES IN ARTHROGENOUS TMD
Five Concealment of P value on No serious No serious No serious 99 114 SMD=0.40 Moderate
(RCTs) allocation test for indirectness imprecision publication [95%C quality
unclear for heterogeneity bias 0.13,0.68] because of
most of the p=0.58; I2=0% risk of bias
studies.
Blinding was No
appropriate for Inconsistency
most of the
studies.
Compliance
unclear for
most of the
studies.
No/unclear
intention to
treat for 2
studies
Outcome: active mouth opening
Four Concealment of P value on No serious No serious No serious 75 77 3.58mm Moderate
(RCTs) allocation test for indirectness imprecision publication [95%C 1.46, quality
unclear for all heterogeneity bias 5.70]. because of
of the studies. p=0.93; I2=0% risk of bias
Blinding was
appropriate for No
most of the Inconsistency
studies.
Compliance
unclear for all
of the studies.
GENERAL JAW EXERCISE PROGRAM IN MIXED TMD

Five Concealment of P value on No serious No serious No serious 81 81 SDM=-0.06 Moderate
(RCTs) allocation test for indirectness imprecision publication [95%CI - quality
unclear for four heterogeneity bias 0.50, 0.38]. because of
of the studies. p=0.14; risk of bias
One study did I2=41%
not have
appropriated No serious
allocation Inconsistency
concealment.
Appropriate
blinding was
unclear for
most of the
studies.
Compliance and
co-
interventions
unclear for all
of the studies.
Outcome: Mouth Opening
Seven Concealment of P value on No serious No serious No serious 132 138 MD=-0.25 Moderate
RCTs allocation test for indirectness imprecision publication [95%CI -2.08, quality
unclear for four heterogeneity bias 1.57]. because of
of the studies. p=0.85; I2=0% risk of bias
Three studies
did not have No
appropriated Inconsistency
allocation
concealment.
Appropriate
blinding was
unclear for
most of the
studies.

Compliance and
co-
interventions
unclear for all
of the studies.
Most of the
studies did not
perform an
intention to
treat analysis
MANUAL THERAPY AND MIXED TMD
Outcome: Mouth opening
Two Concealment of P value on No serious Moderate No serious 47 49 MD=17.33 Low quality
RCTs allocation test for indirectness imprecision publication mm [95%CI - because of
unclear for both heterogeneity bias 10.39, 45.08]. risk of bias,
studies. p=0.000001; inconsistency
Appropriate I2=100% and
blinding was imprecision
unclear for one serious
of the studies. Inconsistency
Intention to
treat unclear
for one study
MANUAL THERAPY PLUS EXERCISES FOR MIXED TMD
Outcome: Mouth Opening
Two Concealment of P value on No serious No serious No serious 42 41 MD=6.10 mm Moderate
RCTs allocation test for indirectness imprecision publication [95%CI 1.11, quality
unclear for both heterogeneity bias 11.09]. because of
studies. p=0.02; inconsistency.
Appropriate I2=82%
blinding was
unclear for one serious
of the studies Inconsistency
and not

appropriate for
the other one.
Intention to
treat unclear
for one study
and not
performed by
the other study

Figure 1. Flowchart of trial selection based on PRISMA guidelines
Relevant records
Identificationn
identified through Records excluded,
database searching duplicates (n=1244)
(n=3549)
Records screened based Records excluded based
Screening
on title/abstract (n=2305) on title/abstract (n=2199)
Full text articles retrieved Articles excluded based on

for more detailed inclusion-exclusion criteria
evaluation (n=106) (n=48)
Eligibility
Studies met the inclusion
Articles excluded based on
criteria (n=58 articles; 50
other languages (n=5)
studies)
Studies met the inclusion

criteria and included in
systematic review (n=53 RCTs identified through
articles; 45 studies) other sources (n=3)
Included
Finally Included (n=56

articles; 48 studies)
95
Figure 2

Figure 3

Figure 4

Appendix 1
Search Strategy Example:
Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R)
1946 to Present
Search History
#
Searches Results
▲
temporomandibular disorders.mp. or exp Temporomandibular Joint
1 14629
Disorders/
exp Temporomandibular Joint/ or craniomandibular disorders.mp. or exp
2 Temporomandibular Joint Dysfunction Syndrome/ or exp 20872
Craniomandibular Disorders/ or exp Temporomandibular Joint Disorders/
3 exp Temporomandibular Joint/ 10155
temporomandibular joint syndrome.mp. or exp Temporomandibular Joint
4 4662
Dysfunction Syndrome/
5 exp Facial Pain/ 7137
6 exp Temporomandibular Joint Disorders/ or TMD.mp. 15668
exp Temporomandibular Joint Disorders/ or TMD.mp. or exp
7 15668
Temporomandibular Joint Dysfunction Syndrome/
8 TMJ.mp. or exp Temporomandibular Joint/ 13266
9 myofascial pain syndrome.mp. or exp Myofascial Pain Syndromes/ 5922
exp Temporomandibular Joint Dysfunction Syndrome/ or exp Facial Pain/
10 or exp Myofascial Pain Syndromes/ or exp Masticatory Muscles/ or 22449
myofascial pain.mp.
11 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 37590
exp Manipulation, Orthopedic/ or manipulation.mp. or exp Manipulation,
12 66454
Chiropractic/ or exp Manipulation, Spinal/
13 exp Manipulation, Spinal/ or exp Chiropractic/ or spinal adjustment.mp. 4130
exp Manipulation, Osteopathic/ or exp Osteopathic Medicine/ or
14 3812
osteopathic.mp.
15 orthopedic.mp. or exp Orthopedics/ 58939
16 exp Orthopedics/ or orthopaedic*.mp. 37827
17 musculoskeletal therapy.mp. 14
18 exp Musculoskeletal Manipulations/ or musculoskeletal therapy.mp. 12254
19 manual therapy.mp. or exp Musculoskeletal Manipulations/ 12850
20 manual ther*.mp. 1315
exp Physical Therapy Modalities/ or physical therapy.mp. or exp Exercise
21 131424
Therapy/
22 physiotherapy.mp. 11552

exp Exercise/ or exp Exercise Movement Techniques/ or exercise.mp. or
23 277733
exp Exercise Therapy/
rehabilitation.mp. or exp "Physical and Rehabilitation Medicine"/ or exp
24 230191
Mouth Rehabilitation/ or exp Rehabilitation/
25 manipula*.mp. 129940
26 relaxation therapy.mp. or exp Relaxation Therapy/ 7438
27 relaxation training.mp. 1093
28 exp Physical Therapy Modalities/ or exp Posture/ or posture training.mp. 184092
29 passive jaw motion device.mp. or exp Exercise Therapy/ 30403
30 continuous passive motion.mp. 513
31 physiotherap*.mp. 15563
32 physical Therap*.mp. 37928
12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or
33 803497
25 or 26 or 27 or 28 or 29 or 30 or 32
34 randomized controlled trial.mp. or exp Randomized Controlled Trial/ 400223
35 exp Random Allocation/ or randomised controlled trial.mp. 93682
36 34 or 35 467379
37 11 and 33 and 36 270
exp Clinical trial/ or randomized.tw. or placebo.tw. or dt.fs. or
38 3645258
randomly.tw. or trial.tw. or groups.tw.
39 11 and 33 and 38 772

Effectiveness of Manual Therapy and Therapeutic
Exercise for Temporomandibular Disorders:
Systematic Review and Meta-Analysis
Susan Armijo-Olivo, Laurent Pitance, Vandana Singh,
Francisco Neto, Norman Thie and Ambra Michelotti
PHYS THER. Published online August 20, 2015
doi: 10.2522/ptj.20140548
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Permissions and Reprints http://ptjournal.apta.org/site/misc/terms.xhtml
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Effectiveness of Manual Therapy and Therapeutic

Exercise for Temporomandibular Disorders:

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Downloaded from http://ptjournal.apta.org/ by Amanda Lawrance on August 24, 2015

Effectiveness of Manual Therapy and Therapeutic Exercise for

Temporomandibular Disorders: Systematic Review and Meta-Analysis

S. Armijo-Olivo, PT, BScPT, MScPT, PhD, Department of Physical Therapy, Faculty of

Rehabilitation Medicine, 3-48 Corbett Hall, University of Alberta, Edmonton, Alberta,

Canada T6G 2G4. Address all correspondence to Dr Armijo-Olivo at: sla4@ualberta.ca

L. Pitance, PT, MT, PhD, Université Catholique de Louvain‒Institute of Neuroscience,

Brussels, Belgium, and Stomatology and Maxillofacial Surgery Department, Cliniques

Universitaires Saint-Luc, Brussels, Belgium.

V. Singh, DDS,MS, MSc, Department of Dentistry, Faculty of Medicine, TMD/Orofacial

Pain Clinic, Kaye Edmonton Clinic, Edmonton, Alberta, Canada.

Dentistry, TMD/Orofacial Pain Graduate Program, Edmonton Clinic Health Academy,

Edmonton, Alberta, Canada.

A. Michelotti, BSc, DDS, Orthodontic Post-Graduate Program and TMD/Orofacial Pain

Master Program, School of Medicine Federico II‒Dental School, Naples, Italy.

[Armijo-Olivo S, Pitance L, Singh V, et al. Effectiveness of manual therapy and

therapeutic exercise for temporomandibular disorders: systematic review and meta-

analysis. Phys Ther. 2015;95:xxx–xxx.]

© 2015 American Physical Therapy Association

Published Ahead of Print: xxxx

Accepted: August 1, 2015

Submitted: December 12, 2014

musculoskeletal conditions such as Temporomandibular disorders (TMD). The evidence

regarding their effectiveness provided by early systematic reviews is outdated.

Purpose: Summarize evidence from and evaluate the methodological quality of

interventions or standard care for treatment of TMD.

intervention (e.g. mobilization, manipulation) or exercise therapy compared to a placebo

intervention, controlled comparison intervention, or standard care were included. The

studies met the inclusion criteria and were analyzed.

Data Extraction: Data were extracted in duplicate on specific study characteristics.

or cervical level showed promising effects.

Limitations: quality of the evidence, and heterogeneity of studies

Temporomandibular disorders (TMD) consist of a group of pathologies affecting

disorders using thermal packs, vapocoolants and transcutaneous electrical nerve

despite limited evidence, 72% of respondents considered PT as an effective treatment

treatment approaches for TMD treatment, although a multidisciplinary health care

exercise to maintain healthy function.

Goals of PT are to decrease pain, enable muscle relaxation, reduce muscular

hyperactivity, and re-establish muscle function and joint mobility.20 PT treatment is

reversible, non-invasive, provides self-care management in an environment to create

(ultrasound, microwave, laser), electro-analgesic (TENS, interferential current,

biofeedback), acupuncture, therapeutic exercise and MT. Therapeutic exercise and MT

MT (including joint mobilization, manipulation, and or MT of the soft tissues) and

looking at interventions. In addition, based on a preliminary search performed by our

trials. Therefore, the objectives of this systematic review were:

that examined the effectiveness of MT and therapeutic exercise interventions in

the management of TMD.

2) Determine the magnitude of the effect of these interventions to manage TMD.

analyses. It consists of a 27-item checklist and four-phase flow diagram

This systematic review was registered in PROSPERO (CRD42013005628).

Inclusion criteria for this review was as follows:

manipulation, soft tissue mobilization) or exercise therapy alone or in combination with

other therapies compared to a placebo intervention, controlled comparison intervention,

or standard care (i.e. treatment that normally is offered).

of daily activities of patients with TMD measured through different questionnaires.

Secondary outcome of interest was pressure pain threshold (PPT).

at least 5 mm can be considered clinically relevant.35 PPT measurements have been

intermediate-term, and long-term follow-up.

DATA SOURCES AND SEARCHES

A search of bibliographic databases was conducted in 6 electronic databases and included