| |

Received: 25 January 2018    Revised: 30 December 2018    Accepted: 13 January 2019

DOI: 10.1111/joor.12770

REVIEW

Effects of exercise therapy on painful temporomandibular

disorders

Akiko Shimada1,2,3  | Shoichi Ishigaki4  | Yoshizo Matsuka5  | Osamu Komiyama6  |

7 8 9 10
Tetsurou Torisu  | Yuka Oono  | Hitoshi Sato  | Takuya Naganawa  |
4 11 5
Atsushi Mine  | Yoko Yamazaki  | Kazuo Okura  | Yasushi Sakuma12 | Keiichi Sasaki13
1
Department of Oral Rehabilitation, Osaka Dental University Hospital, Osaka, Japan
2
Section of Orofacial Pain and Jaw Function, Department of Dentistry and Oral Health, Faculty of Health, Aarhus University, Aarhus, Denmark
3
Scandinavian Center for Orofacial Neurosciences, Aarhus, Denmark
4
Department of Fixed Prosthodontics, Osaka University Graduate School of Dentistry, Suita, Japan
5
Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
6
Department of Oral Function and Rehabilitation, Nihon University School of Dentistry at Matsudo, Chiba, Japan
7
Department of Prosthetic Dentistry, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
8
Division of Dental Anesthesiology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Saitama, Japan
9
Department of Oral and Maxillofacial Surgery, School of Dentistry, Showa University, Tokyo, Japan
10
Department of Oral and Maxillofacial Surgery, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
11
Orofacial Pain Clinic, Tokyo Medical and Dental University Hospital of Dentistry, Tokyo, Japan
12
Department of Anesthesiology, Osaka Dental University Graduate School, Osaka, Japan
13
Division of Advanced Prosthetic Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan

Correspondence
Yoshizo Matsuka, Department of
Stomatognathic Function and Occlusal
Reconstruction, Graduate School of
Biomedical Sciences, Tokushima University,
Tokushima, Japan.
Email: matsuka@tokushima-u.ac.jp
Funding information
Japanese Dental Science Federation, Grant/
Award Number: JDSF-DSP2-2016-221-1
Summary
Temporomandibular disorders (TMD) are common chronic musculoskeletal pain con-
ditions among orofacial pain. Painful TMD condition such as myalgia and arthralgia
can be managed by exercise therapy. However, as it is hard to access actual effect of
each modality that is included in an exercise therapy programme due to multiple
choice of the management modality, their efficacy remains controversial. Therefore,
this review focused on the effects of exercise therapy for the management of painful
TMD. The aims of this review were to summarise the effects of exercise therapy for
major symptoms of painful TMD and to establish a guideline for the management of
painful TMD, resulting in higher quality and reliability of dental treatment. In this re-
view, exercise modalities are clearly defined as follows: mobilisation exercise, muscle
strengthening exercise (resistance training), coordination exercise and postural exer-
cise. Furthermore, pain intensity and range of movements were focused as outcome
parameters in this review. Mobilisation exercise including manual therapy, passive
jaw mobilisation with oral appliances and voluntary jaw exercise appeared to be a
promising option for painful TMD conditions such as myalgia and arthralgia. This re-
view addressed not only the effects of exercise therapy on various clinical conditions
of painful TMD shown in the past, but also an urgent need for consensus among

J Oral Rehabil. 2019;46:475–481. © 2019 John Wiley & Sons Ltd |  475
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476       SHIMADA et al.
dentists and clinicians in terms of the management of each condition, as well as
terminology.
KEYWORDS
exercise therapy, orofacial pain, physical therapy modalities, temporomandibular disorders
1 |  I NTRO D U C TI O N
Orofacial pain (OFP) is a common condition with symptoms of pain
and disability affecting various craniofacial regions such as teeth,
masticatory muscles, temporomandibular joint and tongue. Among
the OFP conditions, temporomandibular disorders (TMD) are chronic
musculoskeletal pain conditions in the craniofacial region that af-
fects more than 10% of the population.1 According to a past study,
around 30% of university students had self report of TMD symp-
toms in Japan. 2 In the last decade, research on TMD has provided
3
multiple treatment options such as medication, occlusal splints,
cognitive behavioural therapy5 and exercise therapy6 to manage
pain in masticatory muscles and temporomandibular joints.7 Among
these treatment options, this review focused on exercise therapy
which is widely used for management of OFP including painful TMD
conditions and is a good option due to its low invasive character and
economical effectiveness.
Exercise therapy aims to reduce clinical symptoms such as pain
in the muscles and joints, and improve motor function by moving
whole or part of the body.8 Exercise can be classified into self exer-
cise by patients and manual therapy that physiotherapists apply to
9
patients. Self exercise is often offered as home exercise or self‐care
programme that can be done at home. 10
Basic exercise therapy in-
11
cludes mobilisation, stretch, 12
muscle strengthening exercise 13
and
endurance exercise.14
It is difficult to propose concrete TMD management plans if all
kinds of exercise therapies are lumped together. Thus, for the pur-
pose of this review, we define exercise therapy as introduced in The
Guide Book of Orofacial Pain for Diagnosis and Treatment, 2nd edi-
tion”,15 edited by members of the Japanese Society of Orofacial Pain.
The book has been published to introduce pathology, clinical symp-
toms and management of OFP and its definitions are the foundation
for official clinical guidelines for treatment of OFP in Japan. Exercise
therapy is categorised in four different types: mobilisation exercise,
muscle strengthening exercise (resistance training), coordination ex-
ercise16 and postural exercise.17
2 |  D E FI N I N G E X E RC I S E TH E R A PY
In the MeSH database (https://www.ncbi.nlm.nih.gov/
mesh/68005081), exercise therapy is defined as a regimen or plan
of physical activities designed and prescribed for specific therapeu-
tic goals. Its purpose is to restore normal musculoskeletal function
or to reduce pain caused by diseases or injuries. There are various
modalities of exercise therapy applied for management of painful
TMD condition.
The exercise therapies focused on in this review were defined
based on the following four types of exercise therapy (A‐D).15
A: Mobilisation exercise
This exercise aims to improve flexibility of muscle, fascia, tendon
and ligament, as well as movements of the temporomandibular joint,
impaired by disc displacement without reduction, fibrous ankylosis
or other similar conditions.18 Mobilisation exercise includes manual
therapy (A‐1), passive jaw mobilisation with oral appliances (A‐2) and
4 voluntary jaw opening exercise (A‐3). The manual therapy refers to
passive manipulation a therapist manipulates patient's mandibular
joint on the ipsilateral side of the affected area, whereas the volun-
tary jaw opening exercise includes maximum jaw opening and maxi-
mum self‐assisted jaw opening. Oral appliances used for mobilisation
exercise include tongue depressors19 and commercial products such
as Therabite®. 20 Mobilising the temporomandibular joints, the exer-
cise aim to improve flexibility and extensibility of muscles, muscle
fascia, tendons and ligaments of masticatory muscles, as well as the
facial muscles around the mouth so as to result in pain relief.
B: Muscle strengthening exercise (Resistance training)
Resistance training is often used to strengthen the power of tar-
geted muscles. 21 In case of TMD, isotonic jaw opening exercise (B‐1)
is applied to train jaw opening muscles with resistance and isotonic
jaw closing exercise (B‐2) is applied to train jaw closing muscles with
resistance, respectively. Thus, resistance training is considered to be
effective for relief of muscle pain and improvement of limited range
of motion of the mandibular. The mechanism behind this is thought
to be an inhibitory effect Golgi tendon is involved. 22 Golgi tendons
located in the target muscle are stretched by the isometric contrac-
tion, which induces inhibitory effect on the muscle activity via Ib
muscle fibres. Based on this mechanism, the isotonic jaw opening
exercise with resistance reflexively inhibits muscle activity of the
jaw‐closing muscles such as the masseter and the temporalis, ac-
companied by the activation of the jaw opening muscles. As a result,
relaxation of tonic muscles contributes to increase in jaw opening
range. On the other hand, the isotonic jaw‐closing exercise releases
tension in the masseter and temporalis, which yields relief of muscle
pain.
C: Coordination exercise
Coordination exercise refers to rhythmical movements that in-
volves and activates both agonist and antagonist muscles. 23 For the
orofacial region, open‐close or lateral movements of the mandibular
are effective to obtain coordination of muscle activity in masticatory
muscles. Thus, this exercise can be effective to improve imbalanced
SHIMADA et al. |
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TA B L E 1   Summary of general characteristics of the included studies

Ref Authors, Pain

# Year OFP symptoms Exercise Control intensity Mobility Other
26
Michelotti et Myalgia A‐1, A‐3 Education +
al (2004)
27
Carlson et al A‐1, A‐3 Postural relaxation + Recovery of electro-
(1991) myography (EMG)
activity at rest
28
Kraaijenga et A‐2 A‐1, A‐3 + + + The score in the jaw
al (2014) functional disorder
scale
29
Oliveira et al A‐1, A‐3 Trans cranial direct + +
(2015) current stimulation
30
Magnusson A‐3, B‐1 Stabilisation splint +
et al (1999)
31
Craane et al A‐1, A‐3 Education + +
(2012)
32
Kalamir et al A‐3 D‐3 (intra‐oral + +
(2012) myofascial therapies)
33
Packer et al A‐1 Sham manipulation − −
(2015)
34
Mulet et al, D‐1, D‐2 A‐3 +
(2007)
35
Komiyama et D‐1, D‐2 Cognitive behavioural +
al (1999) treatment
36
Wright et al D‐1 Education +
(2000)
37
Kalamir et al D‐3 A‐3 and education, + +
(2010) education only
38
Kalamir et al D‐3 A‐3 + −
(2013)
39
Maloney et al Arthralgia A‐2 Stabilisation splint + +
(2002)
40
Yoshida et al A‐3 Untreated +
(2011)
41
Haketa et al B‐1, C Stabilisation splint + +
(2010)
42
Craane et al A‐1, A‐2, Education + +
(2012) D‐2
50
de Felicio et Myalgia + Arthralgia A‐1, A‐3 Non‐TMD group + +
al (2010)
51
Machado et A‐3 Laser, non‐TMD +
al (2016) group
52
von Piekartz A‐1 Only cervical manual +
et al (2011) therapy
54
Tuncer et al A‐1 + A‐3, A‐3, B, D‐2 + +
(2013) B, D‐2
55
Tavera et al A‐3 Stabilisation splint +
(2012)
56
Grace et al A‐2 A‐3 −
(2002)
57
Burgess et al B‐1 Education + −
(1988)
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478       SHIMADA et al.
muscle activity of painful muscles by repetitive alternate movements
and to, as a result, relief the muscle pain.
D: Postural exercise
Postural exercise is commonly used for pain/tension in neck or
back, 24,25 but can also be applied in the orofacial region, aiming to
relief muscle symptoms such as pain, tension, stiffness and tired-
ness, by improving the position of the head or the mandibular. It is
believed that wrong head position can cause muscle pain due to ac-
celeration of muscle activity in the neck and jaw muscles, as well as
postural reflex. Postural exercise includes head posture correction
(D‐1), correction of mandibular position including tongue postural
exercise (D‐2) and myofascial release (D‐3).
3 |  FO CU S E D O U TCO M E PA R A M E TE R S
This review was conducted based on the following focus questions.
• Is exercise therapy effective to reduce clinical pain intensity in
patients with painful temporomandibular disorders (TMD) com-
pared to control group investigated by randomised controlled tri-
als (RCTs)?
• Is exercise therapy effective to improve jaw movements in pa-
tients with painful temporomandibular disorders (TMD) com-
pared to control group investigated by RCTs?
Pain intensity and range of movement of the mandibular were se-
lected to evaluate the effect of above‐mentioned exercise therapy. For
this review, painful TMD conditions include myalgia, arthralgia and my-
algia associated with arthralgia.
In the following sections, effect of the exercise therapy is ex-
plained for each painful TMD. Table 1 shows overall summary of the
reported results.
3.1 | Myalgia
Compared to control group with patient education only, the inter-
vention group with combined exercises of massage in the masseter
muscle and self‐performed exercise of mouth opening (A‐3) as part
of home care has been shown to significantly increase the pain free
jaw opening range. This suggests a positive effect of voluntary jaw
opening exercise to patients with myogenic TMD. 26
Another study found that recovery of electromyography (EMG)
activity at rest after stress loading was faster with muscle stretch
relaxation (A‐3) than postural relaxation.27 Furthermore, in a study
where passive mouth opening stretch with a manipulative instrument
(A‐2) was compared with standard manipulative massage over the
temporalis and masseter muscles and stretch exercises (A‐3), both
groups improved in jaw opening range, intensity of pain and the score
in the jaw functional disorder scale, and there were no significant dif-
ferences between the groups. However, the onset of the effect of
passive therapy with manipulative instruments (A‐2) appears to occur
earlier than that of a standard manipulative muscle massage.28
An RCT study showed the effect of transcranial direct current
stimulation (tDCS) together with exercises such as manipulative
stretch and self‐training of mouth opening (A‐3) that decreased pain
intensity and improved jaw opening range in patients with myogenic
TMD. 29 On the other hand, therapeutic exercises including active
mouth opening exercise (A‐3), muscle strengthening exercise (B) and
stretch (A‐3) did not show significant differences compared to in-
terocclusal appliance treatment, even though both treatments were
significantly effective in decreasing pain intensity.30 It has also been
reported that intervention with physiotherapy including stretching
the masseter muscle (A‐3) did not show a significant difference from
controls with only patient education.31
Although some reported a better long‐term prognosis with mus-
cle strengthening exercises (B) than with myofascial release (D‐3),32
the muscle strengthening exercises did not show a significant im-
provement compared to interventions with neck stretch,33 simple
self care34 and occlusal splints.30 Thus, additional detailed RCT in-
vestigations are needed to confirm the effect.
As a result of postural exercises, compared to the control group,
the intervention group improved in jaw opening range and intensity
of pain in the early phase,35 as well as EMG assessment,36 which
indicates its effectiveness.
Finally, regarding myofascial release (D‐3), although a positive
effect in reduction of pain intensity and improvement of jaw mobil-
ity, compared to a control group without any treatments has been
reported,37 in the long term, muscle strengthening exercises (B)
showed significantly greater improvement than myofascial release
(D‐3). A higher degree of improvement in pain reduction after mus-
cle strengthening exercises (B) was also shown, compared to myo-
fascial release (D‐3).38
3.2 | Arthralgia
Among studies where the effects of single or several exercise ther-
apies were investigated comparing an intervention group with a
control group, one study showed that the application of a passive
jaw motion device (A‐2) showed significant effect on improvement
of jaw opening range, but not on intensity of pain.39 With respect
to voluntary jaw opening exercises (A‐3), it was also reported that
mandibular condylar movement exercises significantly increased
jaw opening range.40 Furthermore, the effect of patient self‐exer-
cises (A‐3) to improve the range of jaw mobility was investigated
by comparing with a control group who used a stabilisation splint.41
The range of jaw mobility improved in both groups, and the relative
change in range was significantly greater in the self‐exercise group.
However, there was no significant difference in the intensity of pain
between the groups. Another study that investigated the effect of
combined therapies (A‐1, A‐2, D‐2) showed no significant effect of
physical therapy.42
There are some studies in which the effect of exercise therapy
cannot be compared directly, because no single exercise therapy was
compared to a control group, but single or several exercises were
compared with other treatment options: NSAIDs + occlusal splint,43
SHIMADA et al.
NSAIDs + occlusal splint + self‐care,44 NSAIDs + self‐management
consisting of the use of a cold or hot pack, following a soft food diet,
and performing gentle mouth opening exercises,45 NSAIDs + cogni-
tive behavioural therapy (education on the participant's condition
with optimistic counselling, a self‐help programme) + medication
(a six‐day regimen of oral methylprednisolone followed by nonste-
roidal anti‐inflammatory drugs for 3‐6 weeks; muscle relaxants and
over‐the‐counter analgesics were used as needed),46,47 and a cycle
of eight anaesthetic blockages of the auriculotemporal nerve with
injections (1 per week) of 1 ml of bupivacaine 0.5% without vasocon-
strictor for 8 weeks.48 In summary, exercise therapy showed a signif-
icant effect on the range of jaw opening40,43,45,46,49 and intensity of
48
pain ; however, some studies did not find any significant effects of
exercise therapy compared to other treatments such as pharmaco-
logical or surgical treatment.44,46
3.3 | Myalgia and arthralgia
Orofacial myofunctional therapy including passive and active jaw
movements (A‐1, A‐3) has been shown to significantly relieve pain in
the masticatory muscles and the temporomandibular joint compared
to splint therapy. 50
It was reported that all of the following four different therapeu-
tic conditions in their report could improve clinical symptoms: (a) oral
motor exercise group (jaw muscle exercise A‐3, exercises for tongue,
lips and cheeks); (b) orofacial myofunctional therapy group (instruc-
tion about TMD, oral motor exercise, thermotherapy, massage,
training); (c) laser therapy group; and (d) combined group of oral
motor exercise and laser therapy. A greater effect was seen in the
combined group of oral motor exercise and laser therapy than the
single laser therapy group.51 In patients with cervicogenic headache
accompanied by TMD, by adding passive exercise therapy (A‐1) to
cervical exercise therapy, a greater effect of treatment for headache,
hypomobility of the cervical spine, neck pain and range of jaw open-
ing was observed, and it lasted for 6 months, compared to single ma-
nipulative therapy. 52 This result is consistent with a previous review
that pointed out similar combined effect of several exercise modal-
ities.53 A combination of exercise therapy administered by physical
therapists and home physical therapy such as jaw open‐close move-
ments, muscle‐strengthening exercises, stretch, breathing exercises
and posture correction exercises (A‐3, B, D‐2) has been reported to
reduce the intensity of pain and the range of jaw opening signifi-
cantly, compared to single home therapy.54 Thus, some studies with
a combination of different therapies showed a greater treatment
effect. However, it is important to observe the clinical conditions
carefully for application of these therapies.
In a study where a jaw exercise regimen group (stretch at the
maximum jaw opening position without pain (A‐3)), a device group
(custom‐fit ear inserts to aid in reducing TMD pain) and a splint
group were compared, a significant decrease in the intensity of
pain was observed in the device group 1 month after the start of
the intervention, whereas the jaw exercise regimen group showed
the lowest improvement rate. 55 Three months after the start of the
|
      479
intervention, all three of these groups showed a significant improve-
ment, even though there was no significant difference among the
groups. However, there was no control group without intervention
included in this study. The effects of specialised oral devices have
also been investigated. As a result, the devices did not show any sig-
nificant difference compared to a standard therapy.56
In another study where a muscle‐strengthening exercises (B‐1)
group, stretch of the masticatory and neck muscles after an appli-
cation of cold spray group, and a control group were compared, the
intensity of facial pain decreased significantly in the stretch + cold
spray group, whereas there was no improvement in the muscle‐
strengthening exercises group.57
4 | D I S CU S S I O N
Since it is important to select and apply an exercise therapy appro-
priately according to clinical condition/pathology of each patient
based on accurate diagnosis, dentists should understand aims and
methods of each exercise, when choosing exercise therapy as treat-
ment option for orofacial pain.
Unfortunately, the diagnostic criteria for myogenic TMD used in
each study were different, and that management methods were not
standardised and overlapped, even though these methods were used
for the same purpose. Therefore, future clinical studies with stan-
dardised criteria and management plans are highly needed. Similarly,
the effect of exercise therapy on arthralgia remains difficult to pre-
dict, because it is hard to compare these studies due to diversity in
treatment options and non‐standardised terminology, which should
be considered for future studies. When myalgia and arthralgia were
not clearly differentiated in an article, these were investigated sep-
arately in this review. Also, there does not seem to be a consensus
between studies designed as RCTs regarding how to assess the clin-
ical condition of patients. Therefore, assessment and comparison
of treatments need to be carefully performed. Furthermore, even
though the study designs in all the included articles was RCTs, the
control groups were not completely standardised, which should be
considered as a limitation. In general, it appears that there is a lack
of consensus in clinical RCT study on what proper control group en-
tails. Thus, it would be valuable in future studies to standardise such
control study.
Setting of a control group compared to an intervention group
to see the effect of exercise therapy seemed very divergent, even
though the articles were designed as RCTs. Therefore, it was hard
to access pure effect of exercise therapy on the focused outcome
in this review.
Regardless of the limitation mentioned above, exercise therapy
appeared to have a significant effect on both pain intensity and jaw
mobility. Mobilisation therapy including manual therapy, passive
jaw mobilisation with oral appliances and voluntary jaw exercise ap-
peared to show its stable effectiveness on painful TMD conditions
such as myalgia and arthralgia. For myalgia, posture correction also
seems effective. It was also suggested that intensity and duration
 |
480       SHIMADA et al.
of exercise should be considered to exert the effect of exercise
therapy. Since there was also a large diversity regarding duration of
the exercise therapy included in this study (between 4 weeks and
6 months), it seems necessary to investigate optimised duration of
exercise therapy.
In conclusion, this review demonstrated that past studies on
exercise therapy applied for management of painful TMD showed
its positive effects on various clinical conditions of painful TMD. In
addition to arguments on inconsistency in terms of the management
of each condition, as well as terminology, one of these problems to
be considered for future studies is to clarify duration of the exercise
therapy according to each diagnosis of TMD. This should be consid-
ered for consensus among all researchers and clinicians. We hope
that this review will help this in this matter.
AC K N OW L E D G M E N T
This study was supported in part by a grant from Japanese Dental
Science Federation, JDSF‐DSP2‐2016‐221‐1.
D I S C LO S U R E
The authors declare that there are no conflicts of interest in the pub-
lication of this manuscript.
ORCID
Akiko Shimada  https://orcid.org/0000-0002-5071-6408
Shoichi Ishigaki  https://orcid.org/0000-0002-1328-081X
Yoshizo Matsuka  https://orcid.org/0000-0003-1069-2605
Osamu Komiyama  https://orcid.org/0000-0003-0849-8117
Tetsurou Torisu  https://orcid.org/0000-0001-8751-1388
Yuka Oono  https://orcid.org/0000-0003-1787-7143
Hitoshi Sato  https://orcid.org/0000-0002-4293-5125
Yoko Yamazaki  https://orcid.org/0000-0003-2549-1216
Kazuo Okura  https://orcid.org/0000-0002-7079-5596
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How to cite this article: Shimada A, Ishigaki S, Matsuka Y, et al.
Effects of exercise therapy on painful temporomandibular
disorders. J Oral Rehabil. 2019;46:475–481. https://doi.
org/10.1111/joor.12770