Critically Appraised Topic
I have seen a variety of methods used to treat headaches that are associated with temporomandibular pain and other indications of temporomandibular joint (TMJ) dysfunction during my clinical rotations. One treatment that I was instructed in was soft tissue manipulation (STM) for the face externally, intraoral massage, and upper thoracic/cervical STM. While many patients appeared to benefit from this form of treatment in addition to their home exercise program (HEP), it was unclear whether our STM was influencing the recovery process in a significant way.
Does soft tissue manipulation produce superior results to a home exercise program in treatment of temporomandibular disorders, as measured by decrease in pain and improved range of motion?
Clinical Bottom Line
The research by Kalamir et al found that manual therapy or a combination treatment of manual therapy and home exercise program provides greater pain relief than no treatment at one year follow up. It was not possible to determine the clinical importance of these treatment effects because there were insufficient data to calculate the size of treatment effects between manual therapy and no treatment and between combination treatment and no treatment. When comparing the two interventions, there was a clinically important difference in reduced pain during mouth opening at 1-year follow up that favored combined treatment.
Tuncer et al compared a combination treatment of manual therapy and home program with “home program only” treatment. This study design more closely matches my clinical question. The only clinically important difference between groups after completing the intervention (4 weeks) was a greater reduction in “pain with stress” (pain during gum chewing) that favored the combination treatment group. There was no clinically important difference between groups for pain-free maximal mouth opening. There was no long-term follow up in this study so it is unclear whether these differences are maintained beyond the 4-week follow up.
The inclusion criteria in both studies created a population of participants who are likely to come into any outpatient clinic, suggesting that the results are applicable to the patient population of my clinical PICO. Due to the high applicability of this study to my clinical PICO, the low cost of learning the techniques, the positive outcome measures, and the overall feasibility of treatment, I would feel comfortable replicating these methods of treatment on individuals that present with signs and symptoms consistent with TMD. The difference in intervention groups between studies creates some disconnect when comparing results (ideally both would have had a manual group, home exercise group, and combination group), however both concluded that the combination treatment was the most beneficial for individuals with TMD in reducing pain. The consistent results favoring combination treatment suggest that it might be more appropriate to combine manual therapy with a home program when treating patients experiencing TMD in order to maximize pain relief. The results from both studies suggest that manual therapy or combination treatment is better than no treatment for improving ROM in patients with TMD, but one approach is not better than the other. Ideally, to clarify the results of these studies and increase their applicability, future studies should include the combination treatment group and one group per intervention within the combination treatment (ie, combination of manual and home program, home program only, and manual only).
Owens, Krystyna, "The effectiveness of soft tissue manipulation as compared to a home program in decreasing pain and increasing range of motion for individuals with temporomandibular disorders" (2014). PT Critically Appraised Topics. 40.