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Journal of Oral Rehabilitation 2005 32; 779–785 Home-exercise regimes for the management of non-specific temporomandibular disorders A. M I C H E L O T T I * , A. D E W I J E R †, M. S T E E N K S † & M. F A R E L L A * *Section of Orthodontics and Gnathology, Department of Dental,...

Journal of Oral Rehabilitation 2005 32; 779–785 Home-exercise regimes for the management of non-specific temporomandibular disorders A. M I C H E L O T T I * , A. D E W I J E R †, M. S T E E N K S † & M. F A R E L L A * *Section of Orthodontics and Gnathology, Department of Dental, Oral and Maxillo-Facial Sciences, University of Naples ‘Federico II’, Italy and †Department of Oral- Maxillofacial Surgery Prosthodontics and Special Dental Care, University of Utrecht, The Netherlands SUMMARY There is a consensus on treatment strat- clinical trials (RCTs) available in literature. There- egies for temporomandibular disorders (TMDs) fore, there is a need for further well-designed being reversible. Among reversible therapies, phy- studies and RCTs to investigate the therapeutic siotherapy is often chosen for the treatment of TMD efficacy. Recent reports and clinical experience, pain and dysfunction because it is simple and non- however, suggest that this approach can be promis- invasive, it has a low cost as compared with other ing, particularly if it is tailored towards the individ- treatments, it allows an easy self-management ual patient. The favourable cost benefit ratio over approach, it allows a good doctor–patient commu- other treatment modalities seems to indicate that nication, and it can be managed by the general physiotherapy can be regarded as a first choice practitioner. Home-exercises regime protocols are approach in selected TMD patients. reviewed in this article in the context of the KEYWORDS: physiotherapy, exercises, counselling, biopsychosocial approach. The actual evidence for temporomandibular disorders the efficacy of home physical exercises is weak because of the very limited number of randomized Accepted for publication 20 February 2005 this reason it is not possible to ‘treat’ these non-specific Introduction conditions with a causal therapy. In most cases, Temporomandibular disorder (TMD) is a collective term especially in acute conditions, counselling and educa- embracing a number of clinical problems that involve tion will suffice to meet the demand of the patient. In the masticatory musculature, the temporomandibular chronic conditions however, it is often necessary to joint and associated structures, or both (1). Temporo- perform a symptomatic treatment, which involves mandibular disorder can be specific (with an underly- multiple interventions and a clinical management. In ing pathology like a neoplasm, inflammation, growth other words, while treatment aims at the disease, disturbance or underlying systemic disease) or non- management aims at the patient and involves a range specific. Non-specific TMD is considered a musculo- of interventions directed towards reducing the physical, skeletal disorder. This review is about non-specific TMD social and psychosocial impact of a chronic condition. exclusively. Only few patients with TMDs and/or neck For the management of TMD several therapeutic and back pain show pathoanatomically well-defined protocols have been suggested (2–4). Management of diseases. Chances are much higher for first line clini- TMD has been widely discussed and there is a consen- cians to deal with patients with non-specific conditions; sus on treatment strategies being reversible. The need of in most of these cases the aetiology is not known. For a low-tech, high prudence therapeutic approach is justified by some well-known considerations about TMD (5, 6). Among these, the most important is that The present paper is based on a lecture presented at the international meeting on Advances in Oral Physiopathology: From basic research to no treatment modality has been proven better than clinical implication, held in Turin, December 9–11, 2004. others. The majority of patients suffering from TMD ª 2005 Blackwell Publishing Ltd 779 780 A. M I C H E L O T T I et al. achieved sufficient relief of symptoms with reversible including thermal, electromagnetic and electrical tech- therapy (2–4). Indeed, long-term follow up of TMD niques, such as transcutaneus electrical nerve stimula- patients shows that 50–90% of the patients have few or tion, infrared, biofeedback, ultrasound. It will focus on no symptoms after this kind of treatment (1, 7–11). The a home exercise programme regime that can be reversible therapies commonly used for the manage- managed by the general practitioner and that has to ment of TMD include physiotherapy, pharmacotherapy be performed by the patient. The reason for this choice (antidepressants), occlusal therapy (occlusal appliances) is also related to the fact that more and more experts and psychological therapy (cognitive behavioural ther- have, in recent years, questioned how effective physical apy). These modalities can be offered together or as a medicine modalities are in the treatment of the mus- single management strategy. Counselling is always a culoskeletal disorders (13). first approach. Among the modalities mentioned, phy- The key to success in TMD management seems the siotherapy can be efficacious for most of the patients success in educating the patient about the disorder in with TMD related pain and restricted motion. order to enhance the self-care aspects. Self-manage- Physiotherapy is chosen for the treatment of dys- ment programs have been shown to have long-term functions in the orofacial region for several reasons. It is positive effects (14). Therefore, the home exercise relatively simple, reversible and non-invasive, it has a programme regime in physiotherapy includes several low cost as compared with other treatments, and it procedures, such as counselling, patient education allows for an easy self-management approach which (habit reversal techniques and proper use of the jaw), means that the patient is actively involved in his own thermo therapy, auto-massage, stretching exercises, treatment, being responsible of his well-being (locus of stabilization, coordination, and mobilization exercises, control). Finally, perhaps more importantly, it allows a to be described in the following sections. These exer- good communication with the patient improving the cises will be discussed in the context of the biopsycho- patient’s confidence in the care provider, being the social approach. Acute TMD symptoms can be basis of a positive coping. Informed patients are more addressed with minimal interventions and generally likely to participate actively in their care, make wiser resolve in short notice. If TMD conditions have become decisions and adhere more fully to treatment (12). chronic this biopsychosocial approach is paramount in Hence physiotherapy can be considered a complex their management. In the next section exercises will be concept which involves the complete functionally described in general; their indication in different diag- based evaluation of the patient in order to reduce nostic TMD subgroups is not indicated. The choice impairments, disabilities and participation problems. of modalities is tailored to the actual condition. Most The goals of the physiotherapeutic regime in general of the evidence arises from studies on management of and in the orofacial region specifically, are to control chronic orofacial myofascial pain. pain and discomfort, to reduce muscle tone, to improve kinetic parameters and to improve temporomandibular Education joint (TMJ) function. Improvement of components of posture and decrease of risk factors related to the upper Behavioural therapy is generally considered as a first quarter, by stretching masticatory muscles, increasing conservative approach for the treatment of TMD TMJ mobility and influencing muscle strength and patients (5, 15) The rationale for choosing behavioural proprioception in order to restore normal functioning therapy arises from the idea that parafunctional are other goals. Recognition of a broad biopsychosocial activity and psychosocial factors play a role in the model of health (and illness) and the positive role of pathogenesis of musculoskeletal pain (16–18). The activity in health and healing, with emphasis on objectives of education are to reassure the patient, to function rather than impairment only, is paramount. explain the nature, the aetiology and the prognosis of Therefore the physiotherapeutic approach includes the problem, to reduce repetitive strain of the masti- cognitive-psychological evaluation of the patient, catory system (e.g. daytime bruxism), to encourage re-education of patient’s behaviour, performance of relaxation and to control the amount of the mastica- several kinds of exercises and the use of a collection of tory activity (19–22). Increased self-management is physical medicine modalities. However, this paper will closely linked to successful rehabilitation. Activity not discuss the analysis of physical medicine modalities, goals should be set in three separate domains: the ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 779–785  PHYSIOTHERAPY AND TEMPOROMANDIBULAR DISORDERS 781 physical (exercise programme, number of exercises, and restricted motion (6, 24–28). Exercise therapy is duration and level of difficulty), the functional (tasks the cornerstone of rehabilitation of regional musculo- of every day living or hobbies), and the social (social skeletal disorders. There is strong evidence that it is activities) domain. effective by a wide spectrum of musculoskeletal, The patient has to be reassured by explaining the cardiovascular, respiratory and neurological disorders/ problem, the supposed aetiology and the good progno- diseases (29). No final conclusion, because of the lack of sis of this benign disorder. Patients require good studies with a high methodological standard, can be information to assist them in making choices, over- given for cervical spine disorders, fibromyalgia, repet- coming unhelpful beliefs, and modifying behaviour. itive strain injuries and also TMDs. In managing The relationship between chronic pain and psychoso- musculoskeletal complaints with rehabilitation therapy cial distress is also stressed. Normal jaw muscle function it is advised to include exercise therapy in the pro- has to be explained, stressing to avoid overloading of gramme (30). the masticatory system, which could be the major cause Therapeutic exercise is the prescription of muscular of the complaints. The patients have to pay close contraction and bodily movement ultimately to attention to the jaw muscle activity, to avoid oral habits improve the overall function of the individual and to and excessive mandibular movements. In acute condi- help meet the demand of daily living. It involves the tions, they have to avoid hard food, cut hard and tough positive and progressive application and adjustment of food in small pieces, chew with back teeth on both stress and forces of the appropriate type and amount to sides, and avoid chewing gum. Later in the rehabilit- the body system in order to address impairment ation programme, training of restrictive activities of improve musculoskeletal function, maintain a state of daily living is part of the procedure in order to return to well-being. normal, or desired, levels of activity and participation, The physiotherapy regimen includes several exerci- and to prevent the development of chronic complaints. ses that are widely prescribed by clinicians treating Patients must learn to keep the muscles relaxed by TMDs because of the ‘self-management character’ of holding the mandible in the postural position (teeth the treatment and amelioration of coping for the apart), rather than in occlusion as this jaw position patient. It has been suggested that these exercises help requires ‘unintentional’ muscle contraction (23). Man- to relieve musculoskeletal pain and to restore normal dibular rest position can be determined asking the function by reducing inflammation, decreasing and patients to pronounce several times the letter ‘N’ and to coordinating muscle activity, and promoting the repair maintain the tongue behind the upper incisor teeth, and regeneration of tissue (1, 31, 32). The programme with the lips in slight contact. Approaches aiming at suggested for TMD patients with muscle pain and/or changing maladaptive habits and behaviours such as limited mouth opening includes relaxation exercises jaw clenching and grinding of the teeth are important with diaphragmatic breathing, auto-massage of the in treating painful tissues. Behaviour modification masticatory muscles, application of moist heat pads on strategies such as habit reversal are commonly used. the painful muscles, stretching, and co-ordination Although many habits are abandoned when the exercises, including proprioceptive training and pos- patients become aware of them, changing persistent ture. In order to perform correctly the home physio- habits requires a structured programme. Patients should therapy programme, it is very important to motivate be aware that habits do not change spontaneously and and carefully instruct the patient, to achieve a good that they are responsible for the change. For this compliance. reason, it is important to stress the need for the patients To learn normal diaphragmatic breathing the patient on practicing what they learned at home and during has to exhale fully with one hand on the chest and the their common activities by the help of a visual other on the abdomen and he/she is trained to become feedback. aware of the respiratory mechanism by feeling the position and movement of the hands. Diaphragmatic breathing has to be performed 5 min every day every Exercise therapy second hour; the patient, however, has to be encour- Physiotherapy interventions, as we noticed in daily aged to use coordinated breathing as often as possible practice, can be efficacious for patients with TMD pain throughout the whole day. ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 779–785 782 A. M I C H E L O T T I et al. Initial studies have found massage to be effective for waved until it is warm, and wrapped around a hot- persistent back pain (33). In a Cochrane review, Furlan water bottle to keep it warm longer. For cold, patients et al. (34) advised massage in combination with exer- can use ice wrapped in a thin washcloth and apply it on cises and education. Massage therapy is a very old and the painful area just until the onset of numbness frequently used kind of therapy. We included massage (approximately 10 min). therapy in a way that it could be done by the patient Stretching exercises for the jaw muscles are used her/himself. Self-massage is limited to the painful or mostly in patients with the diagnosis of myofascial pain tense masseter and temporalis muscles because they are with limited mouth opening. In order to stretch the both easily accessible. The patient is carefully instructed muscles, the patient is asked to slowly open the mouth about the anatomic location of the affected muscle and until he experiences an initial pain sensation. Thereaf- is asked to exert an amount of pressure slightly higher ter, he/she is invited to open the mouth a little bit more than the initial pain sensation; the pressure has to be positioning thumbs on the upper arch approximately modulated proportionally to the level of pain experi- on the premolar area and index fingers on the lower enced. The care provider needs to check whether the arch always on the premolar area. The stretch can be patient understands the modality technique and goal. executed in a more dynamic hold-relax strategy or in a Handing written instructions only is not correct. In static stretch. The patient can also use a number of good communication, it is advised to address the tongue-depressor piled together, as a reference for the patient’s experiences and expectations, building part- amount of jaw opening, by positioning the tongue- nership, providing evidence (including a balanced depressors between arches without touching them with discussion of uncertainties), present recommendations teeth; the patient is invited to add one tongue-depressor and check for understanding and agreement (12). The a day to verify the increased mouth opening. To further masseter muscles are massaged by slight rolling move- stretch the muscles the patient can use the piled tongue ments performed with the index, middle and ring depressors with a pen in between to have a lever- fingers placed extra-orally over the masseter area and action. The exercise has to be performed each day, the thumb placed intra-orally exerting counter pressure every 2 h, holding the mandible stretched for 1 min, six during massage. The patient is instructed to find the times. painful area and to knead it for at least one minute; Coordination exercises are performed by the patient treatment time is related to the speed of adaptation. three times daily. This can be performed by opening Thereafter, he/she has to stretch the muscle by pulling and closing the mouth slowly 20 times with the index the thumb laterally starting from the origin of the finger on the lateral pole of the TMJs in order to control masseter on the zygomatic arch up to the insertion on mandibular movements and maintaining the lower the mandibular angle. The right masseter muscle is dental midline parallel to a vertical line traced on a massaged by the left hand and vice-versa. The tempo- small mirror. It can also be useful to include postural ralis muscles are massaged by slight circular movements adaptation, especially, of the upper quarter, during this performed with the ipsilateral index, middle and ring exercise, as jaw muscles and neck muscles show a fingers or by pressing with one finger tip on the painful coactivity. area for approximately 10¢¢ in order to induce adapta- Mobilization exercises are very useful for TMJ prob- tion. lems when dealing with anterior disc displacement with Superficial moist heat and cryotherapy can be used as or without reduction. The patient is instructed to palliative therapy. Ice massage compared with control perform lateral movements of the mandible in order had a statistically beneficial effect on range of motion to recapture the disc if it is possible. Thereafter, he/she (ROM), function and strength, whereas cold packs has to perform little movements in protrusion, retru- decreased swelling (35). The amount of minutes used sion, and side by side, by holding a plastic small tube on their application is dictated by the goals to be between teeth. When an anterior disc displacement achieved and by the preferences of the patient. The with reduction is present, the patient is told to start the patient is asked to apply moist heat or cold pads on the exercises after having captured the disc and to pay painful area. Heat at approximately 40–50
C (moder- attention to not loose it. In other words he has to ‘work’ ately warm) has to be applied bilaterally for 20 min on the disc (36). In such a situation exercises can be once a day. To make the pad, a wet towel can be micro tailored to the consequences of the TMJ condition. ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 779–785  PHYSIOTHERAPY AND TEMPOROMANDIBULAR DISORDERS 783 without reduction) a benefit of the use of a flat occlusal Discussion splint over non-treatment control subjects could not be The clinical benefits of the home physiotherapy pro- identified, stressing the concept of other modalities gramme are widely reported both in literature and in being equally effective. most of the TMD textbooks. However, it is important to Another RCT (6) has been carried out in order to determine which is the current evidence for the efficacy compare over a short term period the efficacy of of physiotherapy for TMD. It must be emphasized that counselling versus the combination of counselling and physiotherapy for TMD patients is actually not based on the home physiotherapy regime in the treatment of evidence that comes from systematic reviews or evi- myofascial pain of the jaw muscles. It was found that dence based guidelines. Although it is generally treatment outcomes and other parameters evaluated believed that these treatments are effective in reducing were generally not different between education and the the pain and restricted function associated with myo- combination of education and home physiotherapy facial TMDs, few studies of the efficacy of physiother- with the exception of pain-free maximal jaw opening apy for TMDs have been conducted. A meta-analysis of and a better subjective feeling of recovery found in review articles and controlled clinical trials for TMDs patients undergoing the home physiotherapy regime. and other similar chronic musculoskeletal pain disor- The greater increase of the ROM in the combination of ders was carried out by Feine and Lund (37). They education and home physiotherapy group is probably concluded that physiotherapy has a good short-term mostly ascribable to the stretching exercises. The efficacy, whereas the long-term efficacy is similar to effectiveness of techniques that elongate the muscle placebo, even if any physiotherapy modality is better and restore it to its full stretch length has also been than no treatment. It is important to realize that this suggested for other chronic musculoskeletal pain con- conclusion is based on studies not related to the current ditions (41). From a RCT contrasting physiotherapy and physiotherapy practice and methods and the results are occlusal appliance therapy in masticatory myofascial based on studies with low methodological scores and pain the authors concluded that both short and long different outcomes. Patients do best when clinicians term results (up till 1 year) did not differ significantly. take the time to fully inform them about their condi- On the basis of lower costs and (in their protocol) tion. This contributes to reduce the fear, the depression shorter treatment duration they preferred physiother- and the anxiety that are characteristic of chronic pain apy as a first treatment option (42). patients. This means that enforcing patient responsibil- ities and thereby addressing psychosocial factors (like Conclusion coping and locus of control) can be a powerful tool. The most important feature, which raises doubts on scien- The actual evidence for the efficacy of home physical tific evidence of such a treatment, is that the mechan- exercises is weak because of the very limited number of ism of action is unknown. Rendering more treatment RCT available in literature. Therefore there is the need for modalities simultaneously offers a more efficacious further well-designed studies and RCT to investigate the outcome (37, 38) The utility of such an approach is therapeutic efficacy, to replicate the results in myofascial especially applicable in complex conditions. pain and to gain more insight in TMD subgroups with Two randomized clinical trials (RCTs) have been arthrogenous conditions like anterior disc displacement published by Dworkin et al. (39, 40) who concluded with and without reduction, capsular pain and so on. that carefully structured minimal interventions empha- Recent reports and clinical experience, however, suggest sizing self-management of TMD may offer real benefit that this approach can be promising, particularly if it is to a significant number of TMD patients. Addressing tailored towards the individual patient. The favourable both dental and psychologic factors by an intraoral cost benefit ratio is another advantage over other appliance (IA) and biofeedback training (BF) and stress modalities and helps to consider physiotherapy as a first management (SM) resulted in a better long term approach in selected TMD patients. 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Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner EA, disorders. J Orofac Pain. 1998;12:244. Massoth D, Le Resche L, Truelove E. A randomized clinical trial using research diagnostic criteria for temporomandib- Correspondence: Dr Ambra Michelotti, Department of Dental and ular disorders – Axis II to target clinical cases for a tailored Maxillo-Facial Sciences, School of Dentistry, University of Naples self-care TMD treatment program. J Orofac Pain. ‘Federico II’, Via Pansini, 5. I-80131, Naples, Italy. 2002;16:48–63. E-mail: [email protected] ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 779–785