Skip to main content
NCBI home page
Journal of Oral & Facial Pain and Headache logoLink to Journal of Oral & Facial Pain and Headache
. 2023 Nov 6;37(2):3093. doi: 10.11607/ofph.3093

Manual Therapy Applied to the Cervical Joint Reduces Pain and Improves Jaw Function in Individuals with Temporomandibular Disorders: A Systematic Review on Manual Therapy for Orofacial Disorders

Fernanda MG Liberato 1,2, Thiago V da Silva 3,4, Cintia H Santuzzi 5,6, Néville Ferreira Fachini de Oliveira 7,8, Lucas R Nascimento 9,10
PMCID: PMC10627199  PMID: 37389837

Abstract

Aims:

To examine the effect of manual therapy applied to the cervical joint for reducing pain and improving mouth opening and jaw function in people with TMDs.

Methods:

A systematic review of randomized controlled trials was performed. Participants were adults diagnosed with TMDs. The experimental intervention was manual therapy applied to the cervical joint compared to no intervention/placebo. Outcome data relating to orofacial pain intensity, pressure pain threshold (PPT), maximum mouth opening, and jaw function were extracted and combined in meta-analyses.

Results:

The review included five trials involving 213 participants, of which 90% were women. Manual therapy applied to the cervical joint decreased orofacial pain (mean difference: –1.8 cm; 95% CI: –2.8 to –0.9) and improved PPT (mean difference: 0.64 kg/cm2; 95% CI: 0.02 to 1.26) and jaw function (standardized mean difference: 0.65; 95% CI: 0.3 to 1.0).

Conclusion:

Manual therapy applied to the cervical joint had short-term benefits for reducing pain intensity and improving jaw function in women with TMDs. Further studies are needed to improve the quality of the evidence and to investigate the maintenance of benefits beyond the intervention period. J Oral Facial Pain Headache 2023;37:101–111. doi: 10.11607/ofph.3093

Keywords: manipulation, mobilization, massage, pain, rehabilitation, temporomandibular joint

Temporomandibular disorders (TMDs) are defined as a group of conditions that affect the masticatory muscles, the temporomandibular joint (TMJ), and/or associated structures.1 About 10% of the adult population suffers from TMDs, which are the main cause of nonodontogenic orofacial pain in women 20 to 40 years of age.2–4 The prognosis of TMDs is controversial, and acute episodes may progress to recurrent or chronic orofacial pain.5 Orofacial pain typically limits mouth opening and the performance of everyday activities that require mandibular movements, such as biting, chewing, talking, and kissing.6,7 This may ultimately reduce an individual’s quality of life and community participation.8,9

Over 50% of patients with TMDs also present with complaints of neck pain.10 A relationship between orofacial and neck pain has been described in patients with TMDs attributed to neuronal and biomechanical associations with the cervical spine.1,11–13 Nociceptive afferents from the trigeminal nerve and the cervical spine both synapse in the subnucleus caudalis; therefore, cervical nociceptive afferents can excite second-order neurons that also receive input from facial tissues. The convergence of nociceptive stimuli to the same brain region alters pain modulation, which may trigger referred pain and change the activity of the masticatory and cervical muscles.14,15 In addition, potential pain input from regions outside trigeminal receptive fields (eg, the dorsal horn of the spinal cord) may excite brain structures that communicate with the trigeminal nuclei and modulate their functions. Changes in the mobility of the cervical joint are also observed in people with TMDs, as well as less activation of the deep cervical flexor musculature.15–17 Although a causative relationship is not fully established, the literature suggests a comorbidity between these two conditions.10,17 Therefore, a broad cervical spine examination is recommended in patients with TMDs, and the addition of interventions focused on the cervical joint may help reduce the presence and intensity of the disorder.

Many interventions are recommended to treat neck pain, such as exercises, laser treatment, dry needling, and manual therapy.18 Manual therapy includes any manual technique such as manipulation (ie, localized force of high velocity and low amplitude directed at specific spinal segments) or mobilization (ie, low-velocity or small- or large-amplitude passive movement or neuromuscular techniques within the patient’s physiologic range of motion).19,20 The effectiveness of manual therapy applied to the cervical joint may be due to neuroanatomical interactions1 and/or to neurophysiologic effects that influence pain, motor control, and sympathetic nervous system activity.21 One systematic review,22 which included a meta-analysis based on three randomized trials, reported that manual therapy applied to the cervical joint may reduce orofacial pain (standardized mean difference [SMD]: –1.4; 95% CI: –2.4 to –0.5, I2 = 81%) and improve the pressure pain threshold (PPT) of the masticatory muscles (SMD: 1.2; 95% CI: 0.06 to 2.4, I2 = 89%). However, the review did not examine the carryover of improved pain to activities of daily living.

Therefore, the aim of the present systematic review was to update the evidence for manual therapy applied to the cervical joint for reducing orofacial pain and to examine effects on mouth opening and jaw function in people with TMDs. The specific research questions were as follows: (1) In people with TMDs, does manual therapy applied to the cervical joint reduce pain and increase mouth opening?; and (2) Are any benefits carried over to activity?

Materials and Methods

This review was prospectively registered at PROSPERO (CRD42020192734) and is reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines (www.prisma-statement.org).

Identification and Selection of Trials

Searches were conducted in the MEDLINE (1946 to March 2021), AMED (1986 to March 2021), Embase (1947 to March 2021), Cochrane (2005 to March 2021), Global Health (1910 to March 2021), and PEDro (to March 2021) databases for relevant studies without date or language restrictions. The search strategy was registered at PubMed/MEDLINE, so the authors received monthly notifications of potential papers related to this systematic review. Search terms included words related to TMDs, the cervical joint, and randomized clinical trials (Appendix Table 1). Titles and abstracts were displayed and screened to identify relevant studies. The full texts of the relevant peer-reviewed papers were retrieved, and their reference lists were screened to identify further relevant studies. The Methods sections of the retrieved papers were extracted and reviewed independently by two reviewers (C.H.S. and F.M.G.L.) using predetermined criteria (Table 1). Both reviewers were blinded to authors, titles, journals, and results. Disagreements or ambiguities were resolved by consensus after discussion with a third reviewer (T.V.S.).

Table 1.

Inclusion Criteria

Design
Randomized controlled trials
Participants
Adults (> 18 y)
Diagnosis of TMDs
Intervention
Experimental intervention = manual therapy applied to the cervical joint
Outcome measures
Measures of pain, mouth opening, and/or mandibular activity
Open in a new tab

Assessment of Characteristics of Trials

Methodologic quality

The methodologic quality of the included trials was assessed by extracting the PEDro scores from the Physiotherapy Evidence Database (www.pedro.org.au). The PEDro scale is an 11-item scale designed for rating the methodologic quality (internal validity and statistical information) of randomized trials. Each item, except for item 1, contributes 1 point to the total score (range: 0 to 10 points). When a trial was not included in the database, it was scored by a reviewer who had completed the PEDro scale training tutorial (F.M.G.L.).

Participants

Trials involving adults with diagnoses of TMDs were included. Number of participants, age, pain duration, and diagnostic criteria were recorded to assess the similarity of the studies.

Intervention

Trials were included if the experimental intervention was manual therapy applied to the cervical joint. Manual therapy was defined as the application of manual force to the cervical joint, muscles, or connective tissues using techniques such as massage therapy, joint mobilization, and/or manipulation.23 The control intervention could be no intervention or a placebo intervention. Session duration, session frequency, and program duration were recorded to assess the similarity of the studies.

Measures

Four outcomes were of interest: orofacial pain intensity, PPT, maximum mouth opening, and jaw function. The measurement of orofacial pain intensity had to be based on validated self-report methods (eg, visual analog scale [VAS] or numeric rating scale). When multiple measures of pain intensity were reported in one study (eg, pain at rest, worst pain, minimum pain), the results of the individual measurements were averaged.24 The measurement of PPT had to be a direct measure of the minimum amount of pressure needed to trigger a pain sensation (eg, using a pressure algometer).25,26 When multiple measures of PPT were reported in one study (eg, for the masseter and temporalis muscles), the results of the individual measurements were averaged.24 The measurement of maximum mouth opening had to be a direct measure of the distance between the incisal edges of the maxillary and the mandibular reference teeth, corrected for anterior overbite or open bite27,28 (eg, using a caliper or analog/digital rulers). The measurement of activity had to be representative of everyday jaw function, such as eating or laughing (eg, the Mandibular Function Impairment Questionnaire). When multiple questionnaires assessing jaw function were reported in one study, the questionnaire with more activities was used. The timing of the measurements and the procedure(s) used to measure the outcomes were recorded to assess the appropriateness of combining studies in a meta-analysis.

Data Analysis

Information about the methods (ie, design, participants, intervention, measures) and results (ie, number of participants and mean and SD values of the outcomes of interest) were extracted by two reviewers (F.M.G.L. and T.V.S.) and checked by a third reviewer (L.R.N.). If the information was not available in the published trials, details were requested from the corresponding author.

The postintervention scores were used to obtain the pooled estimate of the effect of intervention using a random-effects model. A visual inspection of the distribution of effect sizes in the forest plots was performed, and the I2 value was calculated to indicate the proportion of variance that was due to heterogeneity.29 I2 values > 50% are indicative of important heterogeneity.29,30 The analyses were performed using Review Manager version 5.4 (The Nordic Cochrane Centre). For all outcome measures, the critical value for rejecting the null hypothesis was set at a level of .05 (two-tailed). The pooled data for each outcome were reported as the weighted mean difference (MD) or as the SMD between groups with the corresponding 95% CI. When trial data could not be included in a pooled analysis, the between-group result was reported.

The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system was used to summarize the overall quality of evidence for each outcome, which could range from very low to high quality.32 High-quality evidence was downgraded by one rating level if one of the following prespecified criteria was present: low methodologic quality (most trials had PEDro score < 6); inconsistency of estimates among pooled studies (I2 > 50%) or assessment was not possible (no pooling); indirectness of participants (most trials did not report pain duration or the analyses mixed acute and chronic participants); and imprecision (pooling < 300 participants for each outcome).24,33 Two reviewers (F.M.G.L. and L.R.N.) assessed the quality of the evidence using the GRADE system, with potential disagreements resolved by consensus (T.V.S.).

RESULTS

Flow of Trials through the Review

The electronic search strategy identified 814 papers. After screening titles, abstracts, and reference lists, 18 potentially relevant full papers were retrieved, but 10 were duplicates. From the remaining 8 papers, 3 failed to meet the inclusion criteria (see Appendix Table 1), resulting in 5 papers included in the review (Fig 1). All information was extracted from the original publications, and no authors needed to be contacted for more detailed information.

Fig 1.

Fig 1

Open in a new tab

Flowchart of study inclusion. a Trials may have been excluded for failing to meet more than one inclusion criterion (see Appendix Table 2).

Characteristics of Included Trials

The 5 trials involved 213 participants (90% women) and investigated the effects of manual therapy applied to the cervical joint for improving orofacial pain intensity (n = 4), PPT (n = 3), maximum mouth opening (n = 3), and jaw function (n = 2; Table 2).

Table 2.

Characteristics of the Included Trials (n = 5)

Study Participants Intervention Outcome measures
Bortolazzo et al34 (2015) n = 10 Mean (SD) age = 25 (7) y Female sex = 100% Pain duration = 1–5 y Type of TMD = myalgia Experimental = cervical manipulation; 3–9 reps x 1/wk x 5 wk Control = sham cervical manipulation; 30 s x 1/wk x 5 wk Mouth opening = caliper ruler (mm) Measurements = 0, 5 wk
Calixtre et al38 (2018) n = 61 Mean (SD) age = 26 (5) y Female sex = 100% Pain duration = 5 (range 2–10) y Type of TMD = myalgia or mixed (myalgia + arthralgia or myalgia + disc displacement) Experimental = cervical mobilization and cervical exercises; 15–20 min × 3/wk × 5 wk Control = no treatment Orofacial pain intensity = VAS (0–10 cm; anchors were not reported) PPT = caliper (kg/cm2) Jaw function = MFIQ (0–52) Measurement = 0, 5 wk
Corum et al35 (2018) n = 60 Mean (SD) age = 27 (7) y Female sex = 100% Pain duration = > 6 mo Type of TMD = myalgia or disc displacement or mixed (myalgia + disc displacement) Experimental = cervical manipulation; 1/wk × 6 wk Control = sham cervical manipulation; 1/wk × 6 wk Both = education and cervical exercises Orofacial pain intensity = VAS (0–10 cm; anchors: no pain to pain as bad as could be) PPT = caliper (kg/cm2) Mouth opening = 10-cm ruler (mm) Measurements = 0, 6 wk
La Touche et al37 (2013) n = 32 Mean (SD) age = 34 (8) y Female sex = 66% Pain duration = 11 (6) mo Type of TMD = myalgia Experimental = cervical mobilization; 7 min x 1–2/wk × 2 wk Control = sham cervical mobilization; 7 min x 1–2/wk × 2 wk Orofacial pain intensity = VAS (0–100 mm; anchors: no pain to worst pain) PPT = caliper (kg/cm2) Measurements = 0, 2 wk
Reynolds et al36 (2020) n = 50 Mean (SD) age = 35 (13) y Female sex = 86% Pain duration = 6 (7) y Type of TMD = myalgia or mixed (not specified) Experimental = suboccipital release + cervical manipulation; 4–8 reps x 1/wk × 4 wk Control = suboccipital release + sham cervical manipulation; 4–8 reps × 1/wk × 4 wk Both = education and home-based exercises Orofacial pain intensity = VAS (0–10; anchors not reported) Mouth opening = caliper ruler (mm) Jaw function = JFLS (0–200) Measurements = 0, 4 wk
Open in a new tab

MFIQ = Mandibular Function Impairment Questionnaire ; JFLS = Jaw Function Limitation Scale.

Methodologic quality

The mean PEDro score of the trials was 7 (range: 5 to 8; Table 3). All trials randomly allocated their participants, had < 15% dropouts, and reported point estimate, variability, and between-group differences. Most trials had similar groups at baseline (80%), blinded assessors (80%), and concealed allocation (60%). On the other hand, most trials did not blind participants (80%) or therapists (100%), which is difficult or impossible during complex interventions, and did not report whether an intention-to-treat analysis had been undertaken (60%).

Table 3.

PEDro Criteria and Scores of the Included Trials (n = 5)

Study Random allocation Concealed allocation Groups similar at baseline Participant blinding Therapist blinding Assessor blinding < 15% dropouts Intention-to-treat analysis Between-group difference reported Point estimate and variability reported Total (0 to 10)
Bortolazzo et al34 (2015) Y N N N N Y Y N Y Y 5
Calixtre et al38 (2018) Y Y Y N N Y Y Y Y Y 8
Corum et al35 (2018) Y N Y N N N Y N Y Y 5
La Touche et al37 (2013) Y Y Y Y N Y Y N Y Y 8
Reynolds et al36 (2020) Y Y Y N N Y Y Y Y Y 8
Open in a new tab

Y = yes; N = no.

Participants

Trials included participants with a mean age ranging from 25 to 35 years. Most participants were women (90%). The included participants were diagnosed with myalgia or mixed TMDs according to the Diagnostic Criteria for TMDs (DC/TMD) or Research Diagnostic Criteria for TMDs (RDC/TMD). On average, the participants had orofacial pain ranging from 6 months to 6 years across trials.

Intervention

In all trials, the experimental intervention was manual therapy delivered as manipulation,34–36 mobilization,37 or mobilization associated with exercises,38 carried out in rehabilitation centers. Participants received, on average, three to nine repetitions (or 7 to 20 minutes) of manual therapy, one to three times per week, over 4 weeks (SD: 1.5). The control group received no intervention38 or a placebo intervention.34–37 Two trials35,36 delivered additional interventions (eg, cervical exercises, education, or home-based exercises) to both groups.

Outcome measures

Four trials35–38 measured orofacial pain intensity using a 0 to 10 VAS. Three trials35,37,38 measured PPT using an algometer (kg/cm2). Three trials34–36 measured unassisted maximum mouth opening without pain using either an analog or a digital ruler (millimeters). Two trials36,38 measured jaw function using self-report questionnaires.

Effect of Manual Therapy Applied to the Cervical Joint

Orofacial pain intensity

The effect of manual therapy applied to the cervical joint on orofacial pain intensity was examined by pooling postintervention data from four trials.35–38 Overall, low-quality evidence indicated that manual therapy applied to the cervical joint reduced orofacial pain intensity by –1.8 cm (95% CI: –2.8 to –0.9, I2 = 74%, P < .01, Appendix Fig 1). When the trials were grouped according to the duration of pain, pain intensity was reduced in individuals with < 12 months of pain duration (MD: –2.7 cm; 95% CI: –3.3 to –2.1, I2 = 0%, P < .01) and with a duration > 12 months (MD: –1.1 cm; 95%: CI: –1.8 to –0.4, I2 = 0%, P < .01).

Pressure pain threshold

The effect of manual therapy applied to the cervical joint on PPT was examined by pooling postintervention data from three trials.35,37,38 Overall, low-quality evidence indicated that manual therapy applied to the cervical joint improved PPT by 0.64 kg/cm2 (95% CI: 0.02 to 1.26, I2 = 92%, P < .01, Appendix Fig 2). When trials were grouped according to the duration of pain, the PPT improved in individuals with less than 12 months of pain duration (MD: 0.92 kg/cm2; 95% CI: 0.51 to 1.34, I2 = 65%, P < .01). Only one trial suggested a small positive effect on PPT in individuals with pain duration > 12 months (MD: 0.10 kg/cm2), but this estimate was very imprecise (95% CI: –0.15 to 0.35, P = .43).

Maximum mouth opening

The effect of manual therapy applied to the cervical joint on maximum mouth opening was examined by pooling postintervention data from three trials.34–36 Overall, low-quality evidence indicated that manual therapy applied to the cervical joint may have had a small beneficial effect on maximum mouth opening (MD 1.5 mm), but this estimate was very imprecise (95% CI: –1.8 to 4.9, I2 = 0%, P = .37, Appendix Fig 3).

Jaw function

The effect of manual therapy applied to the cervical joint on jaw function was examined by pooling postintervention data from two trials.36,37 Overall, moderate-quality evidence indicated that manual therapy applied to the cervical joint improved jaw function by an SMD of 0.65 (95% CI 0.3 to 1.0, I2 = 0%, P < .01, Appendix Fig 4) in individuals with pain duration > 12 months. No trials examined jaw function in individuals with pain duration < 12 months.

DISCUSSION

This systematic review provided low-quality evidence that manual therapy applied to the cervical joint reduces pain in people diagnosed with TMDs. Moreover, moderate-quality evidence indicated that benefits were carried over to improving jaw function.

Orofacial pain intensity was measured using a validated self-report scale, which provides patient-centered data that are unique in capturing patients’ own opinions regarding the effect of the intervention.39,40 Although this review was not designed to determine the mechanisms that lead to orofacial pain improvements, which could be neurologic, biomechanical, or improvements in the general mood and well-being of patients, the results provided support for using manual therapy applied to the cervical joint because the magnitude of the effect was not only statistically significant but also clinically relevant. Previous trials have indicated that reductions > 1.7 are associated with significant clinical improvements in individuals with chronic pain, and therefore the mean reduction of 1.8 (out of 10) found in the present review could be considered clinically relevant.41,42 Moreover, as the mean baseline pain intensity across trials was 4.8 (SD: 1.5), a reduction of 1.8 represents nearly a 40% reduction, which is beyond the cutoff scores for changes in pain scales.43 There was some statistical heterogeneity in meta-analyses that disappeared when trials were grouped according to the duration of pain symptoms. Preliminary analysis of the 95% CI suggests that manual therapy is effective in people reporting pain duration of < 12 months. Manual therapy also showed beneficial effects in people reporting pain duration for > 12 months, but the estimate was imprecise. Due to the small number of available trials, subgroup analyses could not be performed.44 On the other hand, improvements in self-reported pain intensity were supported by validated and reliable measurements of PPT.45 Larger trials are recommended to strengthen the quality of evidence regarding pain intensity.

Moreover, moderate-quality evidence indicated that the benefits regarding pain were carried over to improving jaw function, as also measured using self-report questionnaires. Neurophysiologic mechanisms such as innervation14 and the biomechanical interaction between the cervical joint and the TMJ46 may explain improvements in jaw function that require submaximal mouth opening. The magnitude of the effect was positive and moderate, but imprecision in the CIs suggests that further trials should include measures of jaw function as outcomes instead of maximum mouth opening. Since publication of the International Classification of Functioning, Disability, and Health, patient-reported outcome measures have been recommended to guide routine patient care because they are unique in capturing the patients’ own opinions about the impact of their health condition and the treatment on their lives that the outcomes reflect.47,48 Although maximum mouth opening is a quite common outcome in trials related to the cervical joint, most jaw function in everyday activities does not require extreme ranges of motion. Previous trials suggest that interventions focused on the TMJ appear to be more effective for improving maximum mouth opening.18,49

A limitation of the trials included in this review was the fact that, despite achieving good methodologic quality, the quality of the evidence varied from low to moderate due to small samples and indirectness of the participants caused by a varied range of pain duration. Furthermore, the included clinical trials did not provide clear evaluations of the cervical joint and might have included individuals with no cervical impairments, which gives little room for improvements. On the other hand, studies were clinically homogenous regarding the characteristics of the intervention, which indicate that three to nine repetitions (or 7 to 20 minutes) of manual therapy applied to the cervical joint, one to three times per week, over 4 weeks (SD: 1.5) reduces pain and improves jaw function in women with TMDs. In addition, it is important to highlight that participants in the included trials were predominantly women, as TMDs are more prevalent in women. Therefore, caution should be taken when extending these results to men. Larger trials are warranted to reduce the indirectness of participants by establishing proper inclusion criteria regarding pain intensity and cervical impairments, which may reduce the imprecision related to the CI of the estimates of effect.

Conclusions

This systematic review provides low- to moderate-quality evidence that manual therapy applied to the cervical joint had short-term benefits for reducing pain and improving jaw function in women with TMDs. Therefore, manual therapy emerges as an adjoint treatment to be recommended after full biopsychosocial and interdisciplinary evaluation of each patient. There is still work to be done in this area; in particular, larger high-quality trials to strengthen the quality of the evidence and to include examination of long-term benefits are warranted.

HIGHLIGHTS

  • Manual therapy applied to the cervical joint reduces pain in individuals with TMDs.

  • Benefits are carried over to improving jaw function.

ACKNOWLEDGMENTS

The authors report no conflicts of interest. Author contributions: F.M.G.L.: research design and supervision, selection of trials, data extraction, statistical analysis (execution), writing of the first draft, manuscript review; T.V.S, C.H.S., and N.F.F.O.: selection of trials, data extraction, statistical analysis (design and execution), writing of the first draft, manuscript review; L.R.N.: research design and supervision, selection of trials, data extraction, statistical analysis (design and execution), writing of the first draft, English editing, and manuscript review.

Appendix Fig 1 Mean difference (SD) of the effect of manual therapy applied to the cervical joint on orofacial pain intensity (0–10 points).

graphic file with name ofph-37-2-101-g002.jpg

Open in a new tab

Appendix Fig 2 Mean difference (SD) of the effect of manual therapy applied to the cervical joint on PPT (kg/cm2).

graphic file with name ofph-37-2-101-g003.jpg

Open in a new tab

Appendix Fig 3 Mean difference (SD) of the effect of manual therapy applied to the cervical joint on maximum mouth opening (mm).

graphic file with name ofph-37-2-101-g004.jpg

Open in a new tab

Appendix Fig 4 Standardized mean difference (SD) of the effect of manual therapy applied to the cervical joint on jaw function.

graphic file with name ofph-37-2-101-g005.jpg

Open in a new tab

Appendix Table 1 Search Strategy

MEDLINE, AMED, Embase, Cochrane, Global Health
1. exp Craniomandibular Disorders/ or exp Myofascial Pain Syndromes/ (40235)
2. ((masticat$ or myofasc$ or orofacial$) and (pain$ or dysfunction$ or syndrom$)).mp. (34750)
3. (temporomandibular$ or temporo-mandibular$ or craniomandibular$ or craniomandibular$).mp. (62254)
4. (facial pain adj3 (psychogenic$ or atypical or chronic)).mp. (1573)
5. (tmj$ or cmd$ or tmd$ or ’facial arthromyalgia$’).mp. (43979)
6 (mpds not (myeloprolif$ or myelo-prolif$)).mp. (612)
7. 1 or 2 or 3 or 4 or 6 (88031)
8. neck/ or neck muscles/ or exp cervical plexus/ or exp cervical vertebrae/ or Atlanto-Axial Joint/ or atlanto-occipital joint/ or axis/ or atlas/ or spinal nerve roots/ or exp brachial plexus/ (250811)
9. (odontoid or cervical or occip$ or atlant$).tw. (801559)
10. 8 or 9 (981281)
11. double-blind method/ or single blind method/ or placebos/ (623785)
12. exp clinical trial/ (2418772)
13. clinical trial.pt. (523179)
14. random$.ti,ab,sh. (3345483)
15. 11 or 12 or 13 or 14 (4625415)
16. 7 and 10 and 15 (748)
17. limit 16 to human [Limit not valid in AMED,CDSR,Global Health; records were retained] (692)
PEDro>
Abstract and Title:
Search 1: Temporomandibular and neck
Search 2: Temporomandibular joint disorders and neck
When Searching: Match all search terms (AND)
Open in a new tab

Appendix Table 2 Excluded Papers (n = 12)

Studies Reasons for exclusion
1 2 3 4 5
Calixtre et al (2016) ✓
Cuccia et al (2009) ✓
Ferragud and Gandia (2008) ✓
Garrigós-Pedrón et al (2018) ✓
Gesslbauer et al (2018) ✓
La Touche et al (2009) ✓
Oliveira et al (2015) ✓
Oliveira-Campelo et al (2010) ✓
Serna et al (2020) ✓
Tuncer et al (2013) ✓
Von Piekartz and Ludtke (2011) ✓
Von Piekartz and Hall (2013) ✓
Open in a new tab

1 = Research design not RCT.

2 = Experimental intervention not manual therapy applied to the cervical joint.

3 = Both groups received manual therapy applied to the cervical joint.

4 = Participants did not have TMDs.

5 = Single session of treatment.

References of Excluded Papers

  1. Calixtre LB, Grüninger BL, Haik MN, et al. Effects of cervical mobilization and exercise on pain, movement and function in subjects with temporomandibular disorders: A single group pre-post test. J Appl Oral Sci. 2016;24:188–197. doi: 10.1590/1678-775720150240. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Cuccia AM, Caradonna C, Annunziata V, Caradonna D. Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: A randomized controlled trial. J Bodyw Mov Ther. 2010;14:179–184. doi: 10.1016/j.jbmt.2009.08.002. [DOI] [PubMed] [Google Scholar]
  3. Ferragud PM, Gandia JJ. Efecto de la manipulación de la charnela occipito-atlo-axoidea en la apertura de la boca. Osteopatia Cientifica. 2008;3:45–51. [Google Scholar]
  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. [DOI] [PubMed] [Google Scholar]
  5. Gesslbauer C, Vavti N, Keilani M, Mickel M, Crevenna R. Effectiveness of osteopathic manipulative treatment versus osteopathy in the cranial field in temporomandibular disorders: A pilot study. Disabil Rehabil. 2018;40:631–636. doi: 10.1080/09638288.2016.1269368. [DOI] [PubMed] [Google Scholar]
  6. La Touche R, Fernández-de-la-Peñas C, Fernández-Carnero J, et al. The effects of manual therapy and exercise directed at the cervical spine on pain and pressure pain sensitivity in patients with myofascial temporomandibular disorders. J Oral Rehabil. 2009;36:644–652. doi: 10.1111/j.1365-2842.2009.01980.x. [DOI] [PubMed] [Google Scholar]
  7. Oliveira-Campelo NM, Rebelatto JR, Vallejo FJ, Alburquerque-Sendín F, Fernández-de-las-Peñas C. The immediate effects of atlanto-occipital joint manipulation and suboccipital muscle inhibition technique on active mouth opening and pressure pain sensitivity over latent myofascial trigger points in the masticatory muscles. J Orthop Sports Phys Ther. 2010;40:310–317. doi: 10.2519/jospt.2010.3257. [DOI] [PubMed] [Google Scholar]
  8. Oliveira LB, Lops TS, Soares C, et al. Transcranial direct current stimulation and exercises for treatment of chronic temporomandibular disorders: a blind randomised-controlled trial. J Oral Rehabil. 2015;42:723–732. doi: 10.1111/joor.12300. [DOI] [PubMed] [Google Scholar]
  9. Rodriguez-Blanco C, Morata FM, Heredia-Rizo AM, Ricard F, Almazán-Campos G, Oliva-Pascual-Vaca A. Immediate effects of combining local techniques in the craniomandibular area and hamstring muscle stretching in subjects with temporomandibular disorders: A randomized controlled study. J Altern Complement Med. 2015;21:451–459. doi: 10.1089/acm.2014.0332. [DOI] [PubMed] [Google Scholar]
  10. Serna PD, Plaza-Manzano G, Cleland J, Fernández-de-las-Peñas C, Martín-Casas P, Díaz-Arribas M. Effects of cervico-mandibular manual therapy in patients with temporomandibular pain disorders and associated somatic tinnitus: A randomized clinical trial. Pain Med. 2020;21:613–624. doi: 10.1093/pm/pnz278. [DOI] [PubMed] [Google Scholar]
  11. Tuncer AB, Ergun N, Tuncer AH, Karahan S. Effectiveness of manual therapy and home physical therapy in patients with temporomandibular disorders: A randomized controlled trial. J Bodyw Mov Ther. 2013;17:302–308. doi: 10.1016/j.jbmt.2012.10.006. [DOI] [PubMed] [Google Scholar]
  12. Von Piekartz H, Lüdtke K. Effect of Treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: A single-blind, randomized controlled study. Cranio. 2011;29:43–56. doi: 10.1179/crn.2011.008. [DOI] [PubMed] [Google Scholar]
  13. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: A randomized controlled trial. Man Ther. 2013;18:345–350. doi: 10.1016/j.math.2012.12.005. [DOI] [PubMed] [Google Scholar]

Contributor Information

Fernanda M.G. Liberato, Center of Health Sciences; Universidade Federal do Espírito Santo; Vitória, Brazil.

Thiago V. da Silva, Center of Health Sciences; Universidade Federal do Espírito Santo; Vitória, Brazil.

Cintia H. Santuzzi, Center of Health Sciences; Universidade Federal do Espírito Santo; Vitória, Brazil.

Néville Ferreira Fachini de Oliveira, Center of Health Sciences; Universidade Federal do Espírito Santo; Vitória, Brazil.

Lucas R. Nascimento, Center of Health Sciences; Universidade Federal do Espírito Santo; Vitória, Brazil.

References

  1. De Leeuw R, Klasser GD.(ed). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. ed 6. Quintessence; 2018. [Google Scholar]
  2. LeResche L. Epidemiology of temporomandibular disorders: Implications for the investigation of etiologic factors. Crit Rev Oral Biol Med. 1997;8:291–305. doi: 10.1177/10454411970080030401. [DOI] [PubMed] [Google Scholar]
  3. Manfredini D, Guarda-Nardini L, Winocur E, Piccotti F, Ahlberg J, Lobbezoo F. Research diagnostic criteria for temporomandibular disorders: A systematic review of axis I epidemiologic findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112:453–462. doi: 10.1016/j.tripleo.2011.04.021. [DOI] [PubMed] [Google Scholar]
  4. Schmid-Schwap M, Bristela M, Kundi M, Piehslinger E. Sex-specific differences in patients with temporomandibular disorders. J Orofac Pain. 2013;27:42–50. doi: 10.11607/jop.970. [DOI] [PubMed] [Google Scholar]
  5. Rammelsberg P, LeResche L, Dworkin S, Mancl L. Longitudinal outcome of temporomandibular disorders: A 5-year epidemiologic study of muscle disorders defined by research diagnostic criteria for temporomandibular disorders. J Orofac Pain. 2003;17:9–20. [PubMed] [Google Scholar]
  6. Dahlström L, Carlsson GE. Temporomandibular disorders and oral health-related quality of life. A systematic review. Acta Odontol Scand. 2010;68:80–85. doi: 10.3109/00016350903431118. [DOI] [PubMed] [Google Scholar]
  7. De Resende CMBM, Alves ACM, Coelho LT, Alchieri JC, Roncalli AG, Barbosa GAS. Quality of life and general health in patients with temporomandibular disorders. Braz Oral Res. 2013;27:116–121. doi: 10.1590/s1806-83242013005000006. [DOI] [PubMed] [Google Scholar]
  8. Armijo-Olivo S, Silvestre R, Fuentes J, et al. Electromyographic activity of the cervical flexor muscles in patients with temporomandibular disorders while performing the craniocervical flexion test: A cross-sectional study. Phys Ther. 2011;91:1184–1197. doi: 10.2522/ptj.20100233. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Wadhwa S, Kapila S. TMJ disorders: Future innovations in diagnostics and therapeutics. J Dent Educ. 2008;72:930–947. [PMC free article] [PubMed] [Google Scholar]
  10. Plesh O, Adams SH, Gansky SA. Temporomandibular joint and muscle disorder-type pain and comorbid pains in a national US sample. J Orofac Pain. 2011;25:190–198. [PMC free article] [PubMed] [Google Scholar]
  11. Ballenberger N, von Piekartz H, Paris-Alemany A, La Touche R, Angulo-Diaz-Parreño S. Influence of different upper cervical positions on electromyography activity of the masticatory muscles. J Manipulative Physiol Ther. 2012;35:308–318. doi: 10.1016/j.jmpt.2012.04.020. [DOI] [PubMed] [Google Scholar]
  12. Watson DH, Drummond PD. Head pain referral during examination of the neck in migraine and tension-type headache. Headache. 2012;52:1226–1235. doi: 10.1111/j.1526-4610.2012.02169.x. [DOI] [PubMed] [Google Scholar]
  13. Velly AM, Botros J, Bolla MM, et al. Painful and non-painful comorbidities associated with short- and long-term painful temporomandibular disorders: A cross-sectional study among adolescents from Brazil, Canada and France. J Oral Rehabil. 2022;49:273–282. doi: 10.1111/joor.13280. [DOI] [PubMed] [Google Scholar]
  14. Armijo-Olivo S, Magee D. Cervical musculoskeletal impairments and temporomandibular disorders. J Oral Maxillofac Res. 2013;3:e4. doi: 10.5037/jomr.2012.3404. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Greenbaum T, Dvir Z, Reiter S, Winocur E. Cervical flexion-rotation test and physiological range of motion—A comparative study of patients with myogenic temporomandibular disorder versus healthy subjects. Musculoskelet Sci Pract. 2017;27:7–13. doi: 10.1016/j.msksp.2016.11.010. [DOI] [PubMed] [Google Scholar]
  16. Grondin F, Hall T, Laurentjoye M, Ella B. Upper cervical range of motion is impaired in patients with temporomandibular disorders. Cranio. 2015;33:91–99. doi: 10.1179/0886963414Z.00000000053. [DOI] [PubMed] [Google Scholar]
  17. Von Piekartz H, Pudelko A, Danzeisen M, Hall T, Ballenberger N. Do subjects with acute/subacute temporomandibular disorder have associated cervical impairments: A cross-sectional study. Man Ther. 2016;26:208–215. doi: 10.1016/j.math.2016.09.001. [DOI] [PubMed] [Google Scholar]
  18. Blanpied PR, Gross AR, Elliott JM, et al. Neck pain: Revision 2017. J Orthop Sports Phys Ther. 2017;47:A1–A83. doi: 10.2519/jospt.2017.0302. [DOI] [PubMed] [Google Scholar]
  19. Miller J, Gross A, D’Sylva J, et al. Manual therapy and exercise for neck pain: A systematic review. Man Ther. 2010;15:334–354. [PubMed] [Google Scholar]
  20. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Man Ther. 2009;14:531–538. doi: 10.1016/j.math.2008.09.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Perry J, Green A. An investigation into the effects of a unilaterally applied lumbar mobilization technique on peripheral sympathetic nervous system activity in the lower limbs. Manual therap. 2008;13:492–499. doi: 10.1016/j.math.2007.05.015. [DOI] [PubMed] [Google Scholar]
  22. La Touche R, García SM, García BS, et al. Effect of manual therapy and therapeutic exercise applied to the cervical region on pain and pressure pain sensitivity in patients with temporomandibular disorders: A systematic review and meta-analysis. Pain Med. 2020;21:2373–2384. doi: 10.1093/pm/pnaa021. [DOI] [PubMed] [Google Scholar]
  23. French HP, Brennan A, White B, Cusack T. Manual therapy for osteoarthritis of the hip or knee—A systematic review. Man Ther. 2011;16:109–117. doi: 10.1016/j.math.2010.10.011. [DOI] [PubMed] [Google Scholar]
  24. Nascimento LR, Teixeira-Salmela LF, Souza RB, Resende RA. Hip and knee strengthening is more effective than knee strengthening alone for reducing pain and improving activity in individuals with patellofemoral pain: A systematic review with meta-analysis. J Orthop Sports Phys Ther. 2018;48:19–31. doi: 10.2519/jospt.2018.7365. [DOI] [PubMed] [Google Scholar]
  25. Fredriksson L, Alstergren P, Kopp S. Pressure pain thresholds in the craniofacial of female patients with rheumatoid arthritis. J Orofac Pain. 2003;17:326–332. [PubMed] [Google Scholar]
  26. Svensson P, Arendt-Nielsen L, Nielsen H, Larsen JK. Effect of chronic and experimental jaw muscle pain on pain-pressure thresholds and stimulus-response curves. J Orofac Pain. 1995;9:347–356. [PubMed] [Google Scholar]
  27. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord. 1992;6:301–355. [PubMed] [Google Scholar]
  28. Ohrbach R, Gonzalez Y, List T, Michelotti A, Schiffman E. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) Clinical Examination Protocol. Version: June 2, 2013. Accessed 1 May 2023. www.rdc-tmdinternational.org . [Google Scholar]
  29. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to Meta-Analysis. John Wiley and Sons; 2011. [Google Scholar]
  30. Bagg MK, McLachlan AJ, Maher CG, et al. Paracetamol, NSAIDS and opioid analgesics for chronic low back pain: A network meta-analysis. Cochrane Database Syst Rev. 2018;2018:CD013045. [Google Scholar]
  31. Higgins JPT, Green S, et al. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Accessed May 1, 2023. www.handbook-5-1.cochrane.org. [Google Scholar]
  32. Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64:401–406. doi: 10.1016/j.jclinepi.2010.07.015. [DOI] [PubMed] [Google Scholar]
  33. Nicholson V, Watts N, Chani Y, Keogh JWI. Motor imagery training improves balance and mobility outcomes in older adults: A systematic review. J Physiother. 2019;65:200–207. doi: 10.1016/j.jphys.2019.08.007. [DOI] [PubMed] [Google Scholar]
  34. Bortolazzo G, Pires PF, Dibai-Filho AV, Berni KCS, Rodrigues BM, Rodrigues-Bigaton D. Effects of upper cervical manipulation on the electromyographic activity of the masticatory muscles and the opening range of motion of the mouth in women with temporomandibular disorder: Randomized and blind clinical trial. Fisioter e Pesqui. 2015;22:426–434. [Google Scholar]
  35. Corum M, Basoglu C, Topaloglu M, Diracoglu D, Aksoy C. Spinal high-velocity low-amplitude manipulation with exercise in women with chronic temporomandibular disorders. A randomized controlled trial comparing to patient education. Manuella Med. 2018;56:230–238. [Google Scholar]
  36. Reynolds B, Puentedura EJ, Kolber MJ, Cleland JA. Effectiveness of cervical spine high-velocity-low amplitude thrust added to behavioral education, soft tissue mobilization, and exercise for people with temporomandibular disorder with myalgia: A randomized clinical trial. J Orthop Sports Phys Ther. 2020;50:455–465. doi: 10.2519/jospt.2020.9175. [DOI] [PubMed] [Google Scholar]
  37. La Touche R, París-Alemany A, Mannheimer JS, et al. Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervico-craniofacial pain?: A randomized-controlled trial. Clin J Pain. 2013;29:205–215. doi: 10.1097/AJP.0b013e318250f3cd. [DOI] [PubMed] [Google Scholar]
  38. Calixtre LB, Oliveira AB, Rosa LRS, Armijo-Olivo S, Visscher CM, Alburquerque-Sendín F. Effectiveness of mobilisation of the upper cervical region and craniocervical flexor training on orofacial pain, mandibular function and headache in women with TMD. A randomised, controlled trial. J Oral Rehabil. 2018;46:109–119. doi: 10.1111/joor.12733. [DOI] [PubMed] [Google Scholar]
  39. Rose M, Bezjak A. Logistics of collecting patient-reported outcomes (PROs) in clinical practice: An overview and practical examples. Qual Life Res. 2009;18:125–136. doi: 10.1007/s11136-008-9436-0. [DOI] [PubMed] [Google Scholar]
  40. Pitance L, De Longhi B, Gerard E, et al. Digital pain drawings are a useful and reliable tool for assessing patients with temporomandibular disorders. J Oral Rehab. 2021;48:798–808. doi: 10.1111/joor.13168. [DOI] [PubMed] [Google Scholar]
  41. Dworkin RH, Turk DC, McDermott MP, et al. Interpreting the clinical importance of group differences in chronic pain clinical trials: IMMPACT recommendations. Pain. 2009;146:238–244. doi: 10.1016/j.pain.2009.08.019. [DOI] [PubMed] [Google Scholar]
  42. Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole MR. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149–158. doi: 10.1016/S0304-3959(01)00349-9. [DOI] [PubMed] [Google Scholar]
  43. Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287–294. doi: 10.1016/S0304-3959(00)00339-0. [DOI] [PubMed] [Google Scholar]
  44. Ryan R. Heterogeneity and subgroup analyses in Cochrane consumers and communication group reviews: Planning the analysis at protocol stage. Cochrane Consumers and Communication Review Group. December 2016. Accessed 1 May 2023. http://cccrg.cochrane.org. [Google Scholar]
  45. Costa YM, Morita-Neto O, Araújo-Júnior ENS, Sampaio FA, Conti PCR, Bonjardim LR. Test-retest reliability of quantitative sensory testing for mechanical somatosensory and pain modulation assessment of masticatory structures. J Oral Rehabil. 2017;44:197–204. doi: 10.1111/joor.12477. [DOI] [PubMed] [Google Scholar]
  46. Eriksson PO, Häggman-Henrikson B, Nordh E, Zafar H. Co-ordinated mandibular and head-neck movements during rhythmic jaw activities in man. J Dent Res. 2000;79:1378–1384. doi: 10.1177/00220345000790060501. [DOI] [PubMed] [Google Scholar]
  47. Kyte DG, Calvert M, van der Wees PJ, ten Hove R, Tolan S, Hill JC. An introduction to patient-reported outcome measures (PROMs) in physiotherapy. Physiotherapy. 2015;101:119–25. doi: 10.1016/j.physio.2014.11.003. [DOI] [PubMed] [Google Scholar]
  48. Üstün TB, Chatterji S, Bickenbach J, Kostanjsek N, Schneider M. The international classification of functioning, disability and health: A new tool for understanding disability and health. Disabil Rehabil. 2003;25:565–571. doi: 10.1080/0963828031000137063. [DOI] [PubMed] [Google Scholar]
  49. Calixtre LB, Moreira RFC, Franchini GH, Alburquerque-Sendín F, Oliveira AB. Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: A systematic review of randomised controlled trials. J Oral Rehabil. 2015;42:847–861. doi: 10.1111/joor.12321. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Oral & Facial Pain and Headache are provided here courtesy of MRE Press

RESOURCES