Innovative Manual Therapy Approaches for Temporomandibular Disorders

Introduction:

The temporomandibular joint (TMJ) comprises two synovial joints that collaborate in function. Nonetheless, this distinctive feature can lead to certain issues, making the treatment of these problems complex. Conditions associated with the masticatory system are termed "temporomandibular disorders" (TMD), which are recognized as the primary musculoskeletal source of orofacial pain. (1) TMD affects a significant portion of the global population, with an estimated 25% of adults displaying signs and/or symptoms. Females are impacted by TMD at a rate 1.5 to 2.5 times higher than males. The classification of TMD can be intricate, as these disorders may stem from articular issues, displaced discs, hypermobility syndrome, or masticatory muscle problems, among other factors. Disc displacement is often identified as a common source of pain, categorized into two groups: disc displacement with reduction, where the disc returns to its original position after movement, and disc displacement without reduction, where the disc fails to return to its normal position. (2) Disc displacement with reduction typically lacks pain or mouth opening restriction, often leading to delayed treatment, while disc displacement without reduction frequently results in pain and limited mouth opening [8]. Pain is frequently a key outcome in TMD, affecting the function and quality of life of patients, even if it does not directly stem from the physiopathology itself. (3)

Treatment for TMD typically involves various therapies, such as splints, psychotherapy, acupuncture, and various physiotherapy techniques including transcutaneous electrical nerve stimulation (TENS), lasers, massage therapy, joint mobilization, and therapeutic exercise (TE). (4)

Numerous studies have investigated the effectiveness of TE in different subacute and chronic musculoskeletal pathologies, often recommending TE for TMD in conjunction with manual therapy (MT). (5) Although the effectiveness of these therapies has been examined in the short and medium term, yielding varied results, no systematic reviews have analyzed the medium- and long-term effects of MT and TE for TMD.(6)

Manual therapy techniques:

Joint Mobilization: Joint mobilization involves manually applying pressure to a joint by a therapist to enhance its mobility and range of motion. This technique is beneficial for individuals experiencing stiffness or discomfort in their joints, such as those with conditions like a golfer's elbow or shoulder tendinitis. (7)

Soft Tissue Mobilization: Soft tissue mobilization comprises manually stretching and applying pressure to muscles and ligaments by a therapist. It aims to alleviate tension, reduce inflammation, and enhance flexibility in the affected tissues. This technique is commonly used to restore mobility in restricted joints. (8)

Strain-Counterstrain Therapy: Strain-counterstrain therapy, also known as positional release therapy, involves holding the body in strategic positions for short intervals to induce muscle relaxation. By positioning the body comfortably, this gentle technique helps relieve muscle tension effectively. (8)

Myofascial Release: Myofascial release targets the fascia, the connective tissue enveloping muscles and bones. Therapists manually manipulate stiff or tight areas in the fascia to restore flexibility and relieve pressure on muscles and joints. It's often utilized for conditions like back pain and sciatica. (9)

Instrument-Assisted Soft Tissue Mobilization (IASTM): IASTM employs specialized tools to mobilize muscles and joints effectively. Therapists use these contoured instruments to apply pressure to specific areas of the body, aiding in the release of tension and restoration of mobility. (10)

Dry Needling: Dry needling involves the insertion of thin needles into trigger points within muscles to alleviate tension, reduce pain, and improve blood flow. Unlike acupuncture, dry needling targets active trigger points and is often integrated into broader treatment plans alongside therapeutic exercise. (11)

Active Release Techniques (ART): ART is a proprietary manual therapy technique that combines therapist-applied pressure on affected soft tissues with patient-directed movements. This approach is particularly useful for addressing chronic pain resulting from repetitive strain injuries or acute trauma. (12)

Comparative Analysis of Techniques:

Efficacy:

Studies have reported varying degrees of efficacy for different manual therapy techniques in the management of TMD. While joint mobilization may yield immediate improvements in joint mobility and pain relief, soft tissue techniques and trigger point therapy may be more effective in addressing muscular tension and myofascial pain syndromes. (13)

Mechanisms of Action:

Manual therapy techniques exert their effects through diverse mechanisms, including modulation of pain perception, promotion of tissue healing, and normalization of neuromuscular function. Joint mobilization may enhance synovial fluid circulation and joint lubrication, while soft tissue techniques facilitate tissue remodeling and improve microcirculation. (14)

Clinical Outcomes:

Clinical outcomes following manual therapy interventions for TMD are influenced by various factors, including patient characteristics, treatment duration, and therapist expertise. Integrated approaches combining multiple manual therapy techniques with patient education and self-management strategies may yield superior outcomes compared to isolated interventions. (15)

Conclusion:

 Manual therapy represents a valuable adjunctive intervention in the comprehensive management of temporomandibular joint dysfunction. By targeting musculoskeletal imbalances, reducing pain, and improving joint mobility, manual therapy techniques offer promising benefits for individuals with TMD. However, further research is warranted to elucidate optimal treatment protocols, long-term outcomes, and the comparative effectiveness of different manual therapy approaches in this population.

References:

1.       Isberg A. Temporomandibular Joint Dysfunction: A Practitioner’s Guide. CRC Press; Boca Raton, FL, USA: 2001.

2.       Peck C.C., Goulet J.-P., Lobbezoo F., Schiffman E.L., Alstergren P., Anderson G.C., de Leeuw R., Jensen R., Michelotti A., Ohrbach R., et al. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J. Oral Rehabil. 2014;41:2–23. doi: 10.1111/joor.12132.

3.       Tjakkes G.-H.E., Reinders J.-J., Tenvergert E.M., Stegenga B. TMD pain: The effect on health-related quality of life and the influence of pain duration. Health Qual. Life Outcomes. 2010;8:46. doi: 10.1186/1477-7525-8-46.

4.       Garrigós-Pedrón M., La Touche R., Navarro-Desentre P., Gracia-Naya M., Segura-Ortí E. Effects of a Physical Therapy Protocol in Patients with Chronic Migraine and Temporomandibular Disorders: A Randomized, Single-Blinded, Clinical Trial. J. Oral Facial Pain Headache. 2018;32:137–150. doi: 10.11607/ofph.1912.

5.       Martins W.R., Blasczyk J.C., de Aparecida Furlan Oliveira M., Lagôa Gonçalves K.F., Bonini-Rocha A.C., Dugailly P.-M., de Oliveira R.J. Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis. Man. Ther. 2016;21:10–17. doi: 10.1016/j.math.2015.06.009.

6.       Armijo-Olivo S., Pitance L., Singh V., Neto F., Thie N., Michelotti A. Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. Phys. Ther. 2016;96:9–25. doi: 10.2522/ptj.20140548.

7.       Krøll, L. S., Callesen, H. E., Carlsen, L. N., Birkefoss, K., Beier, D., Christensen, H. W., Jensen, M., Tómasdóttir, H., Würtzen, H., Høst, C. V., & Hansen, J. M. (2021). Manual joint mobilization techniques, supervised physical activity, psychological treatment, acupuncture, and patient education for patients with tension-type headaches. A systematic review and meta-analysis. The journal of headache and pain, 22(1), 96. https://doi.org/10.1186/s10194-021-01298-4.

8.       Pianese, L., & Bordoni, B. (2022). The Use of Instrument-Assisted Soft-Tissue Mobilization for Manual Medicine: Aiding Hand Health in Clinical Practice. Cureus, 14(8), e28623. https://doi.org/10.7759/cureus.28623.

9.       Ajimsha MS, Al-Mudahka NR, Al-Madzhar JA. Effectiveness of myofascial release: systematic review of randomized controlled trials. J Bodyw Mov Ther. 2015;19(1):102-112. doi:10.1016/j.jbmt.2014.06.001.

10.     Cheatham, S. W., Lee, M., Cain, M., & Baker, R. (2016). The efficacy of instrument assisted soft tissue mobilization: a systematic review. The Journal of the Canadian Chiropractic Association, 60(3), 200–211.

11.     Tejera-Falcón, E., Toledo-Martel, N. D. C., Sosa-Medina, F. M., Santana-González, F., Quintana-de la Fe, M. D. P., Gallego-Izquierdo, T., & Pecos-Martín, D. (2017). Dry needling in a manual physiotherapy and therapeutic exercise protocol for patients with chronic mechanical shoulder pain of unspecific origin: a protocol for a randomized control trial. BMC musculoskeletal disorders, 18(1), 400. https://doi.org/10.1186/s12891-017-1746-3.

12.     Barnes P, Rivera M. The Effect of Active Release Technique® on Clinician and Patient-Reported Outcomes: A Systematic Review. J Sport Rehabil. 2022;31(3):331-336. doi:10.1123/jsr.2021-0106.

13.     Herrera-Valencia, A., Ruiz-Muñoz, M., Martin-Martin, J., Cuesta-Vargas, A., & González-Sánchez, M. (2020). Efficacy of Manual Therapy in Temporomandibular Joint Disorders and Its Medium-and Long-Term Effects on Pain and Maximum Mouth Opening: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 9(11), 3404. https://doi.org/10.3390/jcm9113404.

14.     Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy, 14(5), 531–538. https://doi.org/10.1016/j.math.2008.09.001.

15.     MacDonald CW, Whitman JM, Cleland JA, Smith M, Hoeksma HL. Clinical outcomes following manual physical therapy and exercise for hip osteoarthritis: A case series. J Orthop Sports Phys Ther. 2006;36(8):588-599. doi:10.2519/jospt.2006.2233.

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