And for those who like to cut to the chase:
Current Best Evidence in Physical Therapy Treatment
For many years, physical therapy has been used to treat TMD symptoms; however, the evidence supporting its use is limited. In this article, physical therapy treatments are assumed to include manual techniques (i.e., stretching, mobilizations, and manipulations of the TMJ and cervical spine); exercise instruction (i.e., self stretching and mobility strategies for the TMJ and cervical spine); patient education (i.e., postural instruction, relaxation techniques, and parafunctional awareness); and modalities that improve tissue health.
One recent systematic review of the literature on the efficacy of physical therapy interventions for TMD patients found 36 relevant articles, of which 12 met their selection criteria. Only 3 were found “to be of strong methodological quality”34, and 4 of the 12 were dedicated to exercise and manual interventions, and only one did not demonstrate significant benefit from the chosen treatment strategy (an oral exerciser device). The remaining 3 studies evaluated postural training, manual therapy, and exercise, and all demonstrated significant benefit34. The best Jadad score35 obtained for the 4 studies was a 234. This systematic review concluded that “active and passive oral exercises and exercises to improve posture are effective interventions to reduce symptoms associated with TMD”34.
A second recent systematic review that evaluated the literature on the efficacy of physical therapy interventions for TMD patients concluded that active exercise and manual mobilizations may be effective as well as postural training in combination with other TMD interventions36. This review favored the use of multifaceted TMD treatment strategies, which coincided the with review authors' opinions. According to Sackett's rules of evidence37, in general, the study quality was level II for 22 of the 36 studies reviewed36.
Further validation for physical therapy's effectiveness with TMD patients has been published since these two systematic reviews. In general, validity and strength of the studies were weak; however, continued evidence supports that physical therapy may be effectively used as a stand-alone and/or, more effectively, used in a team approach with other conservative TMD therapies38–41. One study suggested that Osteopathic Manipulative Treatment can induce changes in the stomatognathic dynamics, offering a valid support in the clinical approach to TMD”38. A second concluded that “physical therapy seems to have a positive effect on treatment outcomes of patients with TMD”39. A third found that “the combination of orofacial myofunctional therapy and an occlusal splint can be beneficial for patients with TMD-hypermobility”40. An additional study compared four treatment strategies for TMJ close-lock: medical management (education, counseling, self-help, and NSAIDS); rehabilitation (occlusal orthotic, physical therapy, and cognitive-behavioral therapy); arthroscopy with post-operative rehabilitation; and arthroplasty with post-operative rehabilitation (i.e., physical therapy). The results demonstrated that “the four treatment strategies did not differ in magnitude or timing of improved function or pain relief”41. Since the four treatment strategies had similar efficacy, the authors of this article believed that the most cost-effective and conservative methods should be explored prior to progression to more costly, invasive procedures.
Some studies have correlated cervical dysfunction and TMD14,42,43. One found that following a motor vehicle accident, chiropractic treatment alone for cervical spine pain was ineffective; however, providing the patient with an occlusal orthotic relieved the pain with continued chiropractic care14. Although this study evaluated chiropractor intervention, it appears there would be a similar correlation with physical therapy treatment for cervical pain following a motor vehicle accident. There is significant research supporting the use of physical therapy for cervical dysfunction, but more definitive research needs to objectively assess the effectiveness of cervical treatment for TMD pain and the reciprocal relationship.
Current evidence supports the use of physical therapy for TMD patients, but more evidence-based research is needed to firmly establish the role of the physical therapist. Both authors here encourage well-trained physical therapists to inform the dentists in their community about their interest and education in providing TMD treatments for the dentist's TMD patients, enabling the dentist to establish an effective team approach for these patients.
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