Effectiveness of an 8-week neck exercise training on pain, jaw function, and oral health-related quality of life in women with chronic temporomandibular disorders: a randomized controlled trial

To test the effectiveness of an 8-week exercise program targeted to the neck muscles compared to manual therapy, and placebo treatments on orofacial pain intensity, jaw function, oral health-related quality of life (OHRQoL), and jaw range of motion (ROM) in women with Temporomandibular Disorders (TMD). In this randomized controlled trial, fifty-four women (between 18–45 years old) with a diagnosis of myofascial or mixed TMD according to the Research Diagnostic Criteria for TMD (RDC/TMD) were randomized into three groups: Neck motor control training (NTG), Manual Therapy Group (MTG), and Placebo Group (PG). All patients were evaluated with the Visual Analog Scale, Mandibular Function Impairment Questionnaire, Oral Health Impact Profile-14, and jaw Range of Motion (ROM) at baseline, immediately after treatment (after 8 weeks of treatment), one month, and three-month follow-up. For all outcomes, a mixed analysis of variance (ANOVA) with repeated measures was conducted with a Bonferroni post hoc test. NTG was significantly better than the PG group on pain and jaw function at the end of treatment, one- and three-month follow-up (Effect Size (ES) >0.7). For OHRQoL, NTG was significantly better than MTG and PG at the end of treatment and at three-month follow-up (ES >0.7). The results of this project are encouraging, and they could be used to guide clinical practice in this field. Exercises targeted to the neck (which require low therapeutic supervision) could be a simple and conservative way to improve pain and disability for women with TMD with neck involvement.

Temporomandibular joint disorder; Jaw diseases; Neck muscles; Physical therapy modalities; Exercise therapy

[1] Bevilaqua-Grossi D, Chaves TC, de Oliveira AS, Monteiro-Pedro V. Anamnestic index severity and signs and symptoms of TMD. CRANIO®. 2006; 24: 112–118.

[2] Oliveira ASD, Dias EM, Contato RG, Berzin F. Prevalence study of signs and symptoms of temporomandibular disorder in Brazilian college students. Brazilian Oral Research. 2006; 20: 3–7.

[3] Liu F, Steinkeler A. Epidemiology, diagnosis, and treatment of temporomandibular disorders. Dental Clinics of North America. 2013; 57: 465–479.

[4] Agerberg G, Carlsson GE. Functional disorders of the masticatory system. I. Distribution of symptoms according to age and sex as judged from investigation by questionnaire. Acta Odontologica Scandinavica. 1972; 30: 597–613.

[5] Glass EG, McGlynn FD, Glaros AG, Melton K, Romans K. Prevalence of temporomandibular disorder symptoms in a major metropolitan area. CRANIO®. 1993; 11: 217–220.

[6] Hirata RH, Heft MW, Hernandez B, King GJ. Longitudinal study of signs of temporomandibular disorders (TMD) in orthodontically treated and nontreated groups. American Journal of Orthodontics and Dentofacial Orthopedics. 1992; 101: 35–40.

[7] Riley JL 3rd, Gilbert GH. Orofacial pain symptoms: an interaction between age and sex. Pain. 2001; 90: 245–256.

[8] Bitiniene D, Zamaliauskiene R, Kubilius R, Leketas M, Gailius T, Smirnovaite K. Quality of life in patients with temporomandibular disorders. A systematic review. Stomatologija. 2018; 20: 3–9.

[9] Lamé IE, Peters ML, Vlaeyen JW, Kleef Mv, Patijn J. Quality of life in chronic pain is more associated with beliefs about pain, than with pain intensity. European Journal of Pain. 2005; 9: 15–24.

[10] Schmidt CO, Günther KP, Goronzy J, Albrecht K, Chenot JF, Callhoff J, et al. Frequencies of musculoskeletal symptoms and disorders in the population-based German National Cohort (GNC). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2020; 63: 415–425.

[11] Goldberg MB, Mock D, Ichise M, Proulx G, Gordon A, Shandling M, et al. Neuropsychologic deficits and clinical features of posttraumatic temporomandibular disorders. Journal of Orofacial Pain. 1996; 10: 126–140.

[12] Fernández-de-las-Peñas C, Galán-del-Río F, Fernández-Carnero J, Pesquera J, Arendt-Nielsen L, Svensson P. Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing. The Journal of Pain. 2009; 10: 1170–1178.

[13] Sarlani E, Greenspan JD. Evidence for generalized hyperalgesia in temporomandibular disorders patients. Pain. 2003; 102: 221–226.

[14] Armijo-Olivo S, Silvestre RA, Fuentes JP, da Costa BR, Major PW, Warren S, et al. Patients with temporomandibular disorders have increased fatigability of the cervical extensor muscles. The Clinical Journal of Pain. 2012; 28: 55–64.

[15] Grossi ML, Goldberg MB, Locker D, Tenenbaum HC. Irritable bowel syndrome patients versus responding and nonresponding temporomandibular disorder patients: a neuropsychologic profile comparative study. The International Journal of Prosthodontics. 2008; 21: 201–209.

[16] Ichesco E, Quintero A, Clauw DJ, Peltier S, Sundgren PM, Gerstner GE, et al. Altered functional connectivity between the insula and the cingulate cortex in patients with temporomandibular disorder: a pilot study. Headache: the Journal of Head and Face Pain. 2012; 52: 441–454.

[17] Armijo-Olivo SL, Fuentes JP, Major PW, Warren S, Thie NM, Magee DJ. Is maximal strength of the cervical flexor muscles reduced in patients with temporomandibular disorders? Archives of Physical Medicine and Rehabilitation. 2010; 91: 1236–1242.

[18] Armijo-Olivo S, Magee D. Cervical musculoskeletal impairments and temporomandibular disorders. Journal of Oral & Maxillofacial Research. 2013; 3: e4.

[19] de Oliveira-Souza AIS, de O. Ferro JK, Barros MMMB, Oliveira DA. Cervical musculoskeletal disorders in patients with temporomandibular dysfunction: a systematic review and meta-analysis. Journal of Bodywork and Movement Therapies. 2020; 24: 84–101.

[20] Armijo-Olivo S, Silvestre R, Fuentes J, da Costa BR, Gadotti IC, Warren S, et al. Electromyographic activity of the cervical flexor muscles in patients with temporomandibular disorders while performing the craniocervical flexion test: a cross-sectional study. Physical Therapy. 2011; 91: 1184–1197.

[21] da Costa DR, de Lima Ferreira AP, Pereira TA, Porporatti AL, Conti PC, Costa YM, et al. Neck disability is associated with masticatory myofascial pain and regional muscle sensitivity. Archives of Oral Biology. 2015; 60: 745–752.

[22] Arendt-Nielsen L, Svensson P. Referred muscle pain: basic and clinical findings. The Clinical Journal of Pain. 2001; 17: 11–19.

[23] Sessle BJ. Neural mechanisms and pathways in craniofacial pain. Canadian Journal of Neurological Sciences. 1999; 26: S7–S11.

[24] 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. Physical Therapy. 2016; 96: 9–25.

[25] Wright EF, Domenech MA, Fischer JR Jr. Usefulness of posture training for patients with temporomandibular disorders. The Journal of the American Dental Association. 2000; 131: 202–210.

[26] Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. CRANIO®. 2012; 30: 95–102.

[27] Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Physical Therapy. 2006; 86: 955–973.

[28] Calixtre LB, Oliveira AB, de Sena Rosa LR, Armijo-Olivo S, Visscher CM, Alburquerque-Sendin 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. Journal of Oral Rehabilitation. 2019; 46: 109–119.

[29] Craane B, Dijkstra PU, Stappaerts K, De Laat A. One-year evaluation of the effect of physical therapy for masticatory muscle pain: a randomized controlled trial. European Journal of Pain. 2012; 16: 737–747.

[30] Falla D, Lindstrøm R, Rechter L, Boudreau S, Petzke F. Effectiveness of an 8-week exercise programme on pain and specificity of neck muscle activity in patients with chronic neck pain: a randomized controlled study. European Journal of Pain. 2013; 17: 1517–1528.

[31] Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002; 27: 1835–1843.

[32] Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Manual Therapy. 2009; 14: 696–701.

[33] Boutron I, Altman DG, Moher D, Schulz KF, Ravaud P. CONSORT statement for randomized trials of nonpharmacologic treatments: a 2017 update and a CONSORT extension for nonpharmacologic trial abstracts. Annals of Internal Medicine. 2017; 167: 40–47.

[34] Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. The BMJ. 2014; 348: g1687.

[35] Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet J, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD consortium network* and orofacial pain special interest group†. Journal of Oral & Facial Pain and Headache. 2014; 28: 6–27.

[36] Boonstra AM, Schiphorst Preuper HR, Reneman MF, Posthumus JB, Stewart RE. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. International Journal of Rehabilitation Research. 2008; 31: 165–169.

[37] Le Resche L, Burgess J, Dworkin SF. Reliability of visual analog and verbal descriptor scales for “objective” measurement of temporomandibular disorder pain. Journal of Dental Research. 1988; 67: 33–36.

[38] Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Academic Emergency Medicine. 2001; 8: 1153–1157.

[39] Conti PC, De Azevedo LR, De Souza NV, Ferreira FV. Pain measurement in TMD patients: evaluation of precision and sensitivity of different scales. Journal of Oral Rehabilitation. 2001; 28: 534–539.

[40] Stegenga B, de Bont LG, de Leeuw R, Boering G. Assessment of mandibular function impairment associated with temporomandibular joint osteoarthrosis and internal derangement. Journal of Orofacial Pain. 1993; 7: 183–195.

[41] Campos JA, Carrascosa AC, Maroco J. Validity and reliability of the portuguese version of mandibular function impairment questionnaire. Journal of Oral Rehabilitation. 2012; 39: 377–383.

[42] Afonso A, Silva I, Meneses R, Frias-Bulhosa J. Oral health-related quality of life: portuguese linguistic and cultural adaptation of OHIP-14. Psicologia, Saúde & Doenças. 2017; 18: 374–388.

[43] Slade GD, Spencer AJ. Development and evaluation of the oral health impact profile. Community Dent Health. 1994; 11: 3–11.

[44] Laimi K, Mäkilä A, Bärlund E, Katajapuu N, Oksanen A, Seikkula V, et al. Effectiveness of myofascial release in treatment of chronic musculoskeletal pain: a systematic review. Clinical Rehabilitation. 2018; 32: 440–450.

[45] Ajimsha MS, Al-Mudahka NR, Al-Madzhar JA. Effectiveness of myofascial release: Systematic review of randomized controlled trials. Journal of Bodywork and Movement Therapies. 2015; 19: 102–112.

[46] Hengeveld KBe. Maitland’s clinical companion. 1st edn. Oxford: Toronto. 2010.

[47] Gross A, Langevin P, Burnie SJ, Bédard-Brochu MS, Empey B, Dugas E, et al. Manipulation or mobilisation for neck pain. Cochrane Database of Systematic Reviews. 2010: CD004249.

[48] Wood AM, White IR, Hillsdon M, Carpenter J. Comparison of imputation and modelling methods in the analysis of a physical activity trial with missing outcomes. International Journal of Epidemiology. 2005; 34: 89–99.

[49] Cohen J. Statistical power analysis for the behavioral sciences. 2nd edn. Academic press: New York, USA. 2013.

[50] La Touche R, París-Alemany A, Mannheimer JS, Angulo-Díaz-Parreño S, Bishop MD, Lopéz-Valverde-Centeno A, 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. The Clinical Journal of Pain. 2013; 29: 205–215.

[51] Campi LB, Jordani PC, Tenan HL, Camparis CM, Gonçalves DA. Painful temporomandibular disorders and central sensitization: implications for management—a pilot study. International Journal of Oral and Maxillofacial Surgery. 2017; 46: 104–110.

[52] Fuentes C JP, Armijo-Olivo S, Magee DJ, Gross DP. Effects of exercise therapy on endogenous pain-relieving peptides in musculoskeletal pain. The Clinical Journal of Pain. 2011; 27: 365–374.

[53] Pelletier R, Higgins J, Bourbonnais D. Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders. 2015; 16: 25.

[54] Boudreau SA, Farina D, Falla D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Manual Therapy. 2010; 15: 410–414.

[55] Barbosa MA, Tahara AK, Ferreira IC, Intelangelo L, Barbosa AC. Effects of 8 weeks of masticatory muscles focused endurance exercises on women with oro‐facial pain and temporomandibular disorders: a placebo randomised controlled trial. Journal of Oral Rehabilitation. 2019; 46: 885–894.

[56] Colloca L. Preface: the fascinating mechanisms and implications of the placebo effect. International Review of Neurobiology. 2018; 138: xv–xx.

[57] Testa M, Rossettini G. Enhance placebo, avoid nocebo: how contextual factors affect physiotherapy outcomes. Manual Therapy. 2016; 24: 65–74.

[58] Kaptchuk TJ, Hemond CC, Miller FG. Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice. The BMJ. 2020; 370: m1668.

[59] Sheng X, Xiao X, Song X, Qiao L, Zhang X, Zhong H. Correlation between oral health and quality of life among the elderly in Southwest China from 2013 to 2015. Medicine. 2018; 97: e10777.

[60] Madley-Dowd P, Hughes R, Tilling K, Heron J. The proportion of missing data should not be used to guide decisions on multiple imputation. Journal of Clinical Epidemiology. 2019; 110: 63–73.

[61] Arnab R. Nonsampling errors. In: Arnab R (ed.) Survey sampling theory and applications (pp. 469–504). 1st edn. Elsevier: New York. 2017.

[62] Pickles A. Missing data: problems and solutions. In: Kempf-Leonard K (ed.) Encyclopedia of social measurement (pp. 689–694). 1st edn. Elsevier: New York. 2005.