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 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 23-33

Effectiveness of cervical spine manual therapy in the management of temporomandibular joint disorders: A systematic review

1 Department of Physiotherapy, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
2 Department of Preventive and Restorative Dentistry, College of Dentistry, University of Sharjah, Sharjah, United Arab Emirates

Date of Submission27-Sep-2021
Date of Decision24-Dec-2021
Date of Acceptance26-Dec-2021
Date of Web Publication19-Jan-2022

Correspondence Address:
Fatma A Hegazy
Department of Physiotherapy, College of Health Sciences, University of Sharjah, Sharjah.
United Arab Emirates
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/abhs.abhs_10_21

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Background: Temporomandibular joint disorder (TMD) is a complex condition involving temporomandibular joint (TMJ), masticatory muscles, and adjoining myofascial structures. In the present review, we attempted to evaluate the manual cervical therapy (MT) effect in reducing TMJ pain of myogenous origin and increasing mandibular range of motion (ROM) in TMD cases in relevance to the duration of therapy and posttherapy follow-up period. Materials and Methods: English language manuscripts using PUBMED/MEDLINE, COCHRANE, EMBASE, CINAHLPlus, PsycINFO, Web of Science, CDR, and PEDro databases were accessed between January 01, 2011, and January 2021. Following PRISMA guidelines, eight articles met the inclusion criteria. Results: The analysis included 383 patients with TMD, primarily women aged ±27 (18–72) years. Employing varied techniques of manual cervical therapies, the reviewed RCT results demonstrated either immediate or short-term effectiveness in orofacial pain reduction and improvement in jaw function. Conclusion: This review presented the short-term effectiveness of cervical manual therapy and limited high-quality evidence determining the optimal procedure of cervical manual therapy approaches and duration of the session provided to treat cases with TMD of myogenous origin.

Keywords: Cervical manual therapy, mandibular range of motion, myogenous-temporomandibular joint disorder, temporomandibular joint disorder

How to cite this article:
Bahlool SW, Fakhruddin KS, Hegazy FA. Effectiveness of cervical spine manual therapy in the management of temporomandibular joint disorders: A systematic review. Adv Biomed Health Sci 2022;1:23-33

How to cite this URL:
Bahlool SW, Fakhruddin KS, Hegazy FA. Effectiveness of cervical spine manual therapy in the management of temporomandibular joint disorders: A systematic review. Adv Biomed Health Sci [serial online] 2022 [cited 2022 Dec 3];1:23-33. Available from: http://www.abhsjournal.net/text.asp?2022/1/1/23/335718

  Background Top

The temporomandibular joint (TMJ) comprises the mandibular condyle that resides in the mandibular fossa of the temporal bone [1]. Four powerful masticatory muscles, including the masseter, temporalis, medial, and lateral pterygoid, are primarily responsible for the movement of the joint [2]. Masticatory muscles facilitate the elevation, protrusion, retrusion, and lateral deviation and resist mandibular depression [2,3]. The functional component of the TMJ makes a connection to the cranium and cervical areas via muscles and ligaments, forming a functional cranio-cervico-mandibular complex [4]. Additionally, the cervical spine is connected to the masticatory and cranium regions through complex joint and muscle attachments and neurovascular innervations. Any imbalance of harmony in the cranio-cervico-mandibular system leads to temporomandibular disorders (TMD) [4,5].

TMD is characterized by craniofacial pain involving the masticatory muscles or muscle innervations of the head and neck region and joint [6]. The spectrum of TMD symptoms includes mild discomfort to debilitating pain in the preauricular, masseter, or temple region and limited jaw movement [4,7]. The limitations of jaw function affect the opening and closing of the mouth and chewing actions. The limited range of jaw movement is every so often accompanied by clicking, popping, grating, crepitus sounds of the jaw [1].

TMD is characterized as either intra-articular (within the joint) or extra-articular (involving the surrounding muscle of the joint) [8] or can be classified as arthrogenous or myogenous origin. According to several reports [9,10], extra-articular (musculoskeletal conditions) or myogenous origin are the most common cause of TMD, which accounts for at least 50% of the cases [1,11]. Some of the conservative management options for TMD include occlusal splints, medication, physical therapy [12-14].

In the treatment of myogenic-TMD, physical therapy employs a wide-ranging technique. One of the options for treating TMD is ‘manual therapy’ (MT). Manual physical therapy or manual therapy is a treatment provided by the physical therapist to reduce pain and improve motion in neuro-musculoskeletal conditions that involve hands-on [15]. Several studies postulated [16-18] that manual therapy techniques trigger neurophysiological mechanisms responsible for pain relief and reduction of muscle activity. Manual therapy includes joint mobilization and manipulation, manual muscle stretches, passive range of motion exercises, and soft tissue techniques as trigger-point therapy (TPs) or massage [7]. Therefore, in the present systematic review, we intended to evaluate the manual cervical therapy effect in reducing TMJ pain and increasing mandibular range of motion (ROM) in myogenous-TMD cases. We also aimed to review the duration/frequency of intervention and follow-up time to assess the effectiveness of manual cervical therapy reported in the studies.

  Materials and methods Top

Data sources

The data search of English language manuscript using PUBMED/MEDLINE, COCHRANE, EMBASE, CINAHLPlus, PsycINFO, Web of Science, CDR, and PEDro databases was performed by two investigators (S.W.B and M.J.L). Published data were accessed between January 01, 2011, and January 2021. After screening various electronic databases, clinical studies on TMD and manual cervical therapy were identified. A specific review question was formulated using the PICO framework as follows. Does manual cervical therapy (I), compared with placebo therapy, or controlled comparison therapy (C), results in the reduction of TMJ-related myofascial pain and increasing mandibular range of motion (ROM) (O) in cases with temporomandibular disorder (P).

Electronic data search and analysis

For ensuring a systematic and comprehensive methodological approach, we followed the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [19,20] and were registered in PROSPERO (CRD42020152785). The search approach used and the results engendered are presented in [Figure 1].
Figure 1: PRISMA flow chart of the literature search and study selection

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Inclusion criteria

The inclusion criteria included (a) studies involving human subjects with TMD of myogenous origin (b) studies including adults (>18 years) with myogenic-TMD and who have received manual cervical therapy. No limit on the setting and duration of study intervention and follow-up.

Exclusion criteria

The exclusion criteria included (a) manuscripts in a language other than English, (b) observational studies, (c) studies not explicitly related to TMD, d) child participants, (e) applying other physiotherapy modalities as a treatment, and (f) studies with data containing no manual therapy for TMD. The characteristics of the included studies are displayed in [Table 1].
Table 1: Summary characteristics of the included studies

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Key search terms

The keyword search terms used were “manual cervical therapy,” “cervical manipulative therapy,” “manual therapy,” “manipulative therapy,” “myogenic,” “myogenous,” “TMJ,” “temporomandibular joint,” “temporomandibular disorders,” “temporomandibular joint disorders,” and “TMD.”

Type of interventions

The intervention was manual cervical therapy in the patient with myogenous-TMD. The manual therapy provided was cervical spine manipulation, mobilization, stretching, and soft tissue release.


Controls were comparable patients who received manual therapy treatment may or may not in conjunction with other treatment modalities for TMD or no treatment (placebo effect).

Outcome measurement

The studied outcome measure was the reduction of TMJ-related myofascial pain (VAS) and increased mandibular range of motion (ROM).

Search strategy and data extraction

The search strategy designed to access published materials was done in three stages: In stage- one: two reviewers (SWB and MJL) screened the titles and abstracts of the relevant studies that meet the set inclusion criteria. During step two, the two reviewers (SWB and MJL) independently screened the full-text review of all the relevant articles and extracted the data for a thorough account of the data. In the event of any uncertainty of the data, the third reviewer (HG) was consulted. References of the included trials were checked as a backward search. In stage three, the two reviewers (SWB and MJL) together with (HG) finally reexamined and endorsed the data. Summary characteristics of the included trials and the reported results are presented in [Table 1]. The identified articles were recorded using Endnote version 9 (Clarivate Analytics, USA) bibliographic software tool.

Risk of bias in individual studies

The two investigators (SWB and MJL) independently performed the quality assessment of the relevant studies. In case if of any disagreement, a third reviewer (HG) was consulted. The Joanna Briggs Institute Critical Appraisal tools (JBI), including systematic reviews checklist for Randomized Controlled Trials, case series, case-control, and Quasi-Experimental to assess the risk of bias of the eligible studies,[29] were used to determine the included study’s methodological quality shown in [Table 2]. JBI checklists consist of 9–13 questions that are answered with “yes,” “no,” “Unclear,” or “N/A.” These questions included evaluating randomization, allocation-concealment, blinding of the assessors, and other sources of biases in the given study and documented as low, unclear, or high-risk [Table 2].
Table 2: Risk of bias of the included studies

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  Results Top

A total of 281 studies were retrieved after a literature search in the databases (PUBMED/MEDLINE, COCHRANE, EMBASE, CINAHLPlus, PsycINFO, Web of Science, CDR, and PEDro), and 58 articles remained after duplicate removal [Figure 1]. After reviewing titles and abstracts, 28 studies remained for full-text reading and data extraction. Twenty studies were excluded since there were not related explicitly to myogenous-TMD and manual therapy treatment, had unclear study design and methodology. The remaining eight studies [21-28] were subjected to complete analysis.

In total, the analysis included 383 people who suffered from myogenous-TMD, most of whom were women. The average subject age was ±27 (18–72) years. The studied pathologies in the reviewed articles have TMJ-related masticatory muscles pain, TMJ-related ROM limitations, oral functionality challenges, and segmental dysfunction of the upper cervical spine.

Among the intervention group, manual manipulation, and mobilization therapies include stabilization exercises with biofeedback, cervical range of motion, stretching exercises of the neck, suboccipital muscles inhibition, TMJ stabilization, coordination exercises, postisometric relaxation. Conversely, the comparator groups received either no treatment or static stretching exercises for the cervical spine, head, upper limbs, and mandibular muscles (masseter and ant. temporalis). For instance, in their comparison group, Bortolazzo et al. [22] used manual muscle manipulation without traction and a quick boost in rotation exercises. Although, as well, some studies only impart educational interventions concerning postural correction and information on limiting jaw activities, breathing exercises, advice on a soft diet, and application of heat and ice therapy among comparators [23, 26, 28].

The frequency of manual cervical therapy sessions varied between studies [Table 3]. Two of the included studies had a single intervention over 4–5 weeks [22,24]. Oliveira and the team evaluated the immediate posttreatment effect two minutes after their intervention [23]. Corum et al. [25] had given six treatment sessions without details on the duration of therapy. Two reviewed studies provided three sessions/week for four weeks [26] to two interventions/week for five weeks [21], respectively. The other two included studies [27,28] only detailed the number of sessions without information on the duration over the week.
Table 3: Cervical manual therapy sessions for patients with TMD

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The most frequent outcome was cranio-myofascial pain intensity, evaluated via VAS or NPRS pain rating scales, and pain-free maximum mouth opening. Other outcomes measured were the pain pressure threshold (PPT) in the temporal region, electromyographic activities of masticatory muscles, oral functionality challenges using the Jaw Functional Limitation Scale, and Fonseca’s Questionnaire. A recently published study by Reynolds and team (2020) also measures fear of movement beliefs in chronic complaints using the Tampa Scale of Kinesiophobia (TSK) among the test and comparison groups [21].

Oliveira et al. (2010) suggest that suboccipital muscle inhibition and atlantooccipital joint thrust manipulation helped improve maximum active mouth opening. Also, it showed increases in pressure pain thresholds that support the postulate of the activation of segmental inhibitory pathways by the trigeminal nucleus caudalis after applying the upper cervical manipulation [23]. An RCT conducted by Maluf et al. (2010), including 28 subjects, randomized into two different interventions groups (GPR-global postural re-education and SS-static stretching exercises), observed similar effects for treating TMDs muscular component. Both methods similarly reduced the pain intensity with increased pain thresholds and decreased electromyographic activity [28].

A four-week TMD therapy by Tuncer et al. (2013) showed that manual cervical therapy, including TMJ and cervical spine mobilization and stabilization with relaxation and stretching techniques for the masticatory and neck muscles, is more effective than mere ergonomic, breathing exercise, or relaxation techniques [26].

Patients with myogenous-TMD have an increase in the electrical activity of their masticatory muscles. Bortolazzo and colleagues’ (2015) findings demonstrated that upper cervical manipulation assisted in the relaxation of the mandible elevator muscles, which increased the mouth opening range of motion [22]. Calixtre et al. (2016) reported a significant change in pain-free maximum mouth opening and functionality of the stomatognathic system regardless of joint involvement after cervical mobilization intervention among TMD cases [27].

Upper cervical spine manipulation or high-velocity low amplitude thrust (HVLAT), the oldest and most frequently used technique combined with neck exercises, helps improve chronic myogenous-TMD [25]. Alternatively, very recently, the Reynolds team (2020) applied cervical spine HVLAT using a distraction technique at C0/125 and a rotational up-slope method at C2/3 on each side. Regarding maximum mouth opening and myofascial pain reduction, they observed no significant improvement among the test and comparator groups. However, those in the intervention group rated the substantial progress in reducing fear of movement, jaw functional limitations, and overall TMD conditions with physical therapy intervention [24].

Methodological quality

Nearly all of the studies addressed precise randomization methods. However, in most studies, measures to ensure blinding of participants and assessors and the procedures for allocation concealment were not adequately addressed. Generalizability was another issue observed in different studies because specific gender, age group, and small sample sizes were selected. In addition, researchers did not specifically address the participant’s compliance, which might influence the study results. Finally, selection bias was also noted in some reviewed reports. For example, a study used advertisements by Calixtre et al. (2019) to recruit their study population, which might be considered a selection bias [21].

  Discussion Top

Analysis of the reviewed studies highlights the effectiveness of manual cervical therapy in care for signs and symptoms related to the temporomandibular joint disorder of myogenous origin. Therefore, a thorough search of the relevant literature has been conducted. This is the first reviewed report focusing on the duration/frequency of intervention and effectiveness of manual cervical therapy via patients’ posttreatment follow-up for myogenous TMD, in particular.

The present review evaluated results of manual cervical therapy among patients diagnosed with myogenous TMD, specifically. Consistent with previous reports [27,30], the current systematic review also inferred that manual cervical therapy might improve myogenous TMD symptoms. However, these results could be taken with some restraint as the available data are based on short-term analysis. Nevertheless, the reported effectiveness could be substantiated because there is an established relationship between TMD and the cervical spine through the neurophysiological neuromuscular mechanisms [30]. And a strong correlation between neck disability and jaw dysfunction was reported in TMD patients [30,31]. Sensory input travels from the mandible and face to the spine via the trigeminal afferent’s pathway to the trigeminal nucleus and then descend by the subnucleus caudalis fibers to C2-C3 and even C6. In addition, the superficial sensory distribution of the upper cervical nerves (the ventral cervical roots 2 and 3) comprising parts of the face, especially the mandibular angle, explains the referred pain mechanism between the neck and face [31]. Thus, as described, there is a recognized relationship between TMD and the cervical spine. Also, neurophysiological and biomechanical relationships between TMJ and cervical spine support the potential benefit of cervical spine treatment in TMD-related pain and dysfunction [32].

TMD is a complex condition encompassing temporomandibular joints, masticatory muscles, and adjacent tissues [33]. Aside from myogenous TMD cause, other etiological factors contributing to TMD conditions include TMJ disc displacements, arthritis, trauma, inflammation, or infection of the joint and supporting tissue [1]. In addition, previous surgeries related to the masticatory system or cervical spine also contribute to TMD conditions. Therefore, obtaining a detailed case history with a thorough examination, including assessing patients’ psychological state, is essential in making an appropriate treatment plan for treating TMD [1,33]. Varied cervical manual therapy approaches were reviewed, showing effectiveness in oro-facial pain reduction and range of maximal mouth opening. For instance, few studies [23,29] in the present review employed cervical spine high volume low amplitude thrust manipulation versus Sham technique to treat TMD symptoms. Corum’s team [25] observed significant pain-free maximal mouth opening and pain reduction at 72-hours posttreatment and one-month follow-up. Hence, they suggested adding cervical manipulation to the rehabilitation program for TMD. Conversely, Reynolds’ team [24] observed that both groups (HVLAT and Sham) improved over time, demonstrating treatment to some plausible psychological trigger contributing to the TMD manifestations in the Sham group [1,33].

Related to duration of treatment and posttreatment follow-ups, the reviewed RCT results demonstrated either immediate or short-term effectiveness for treating orofacial pain and improvement in jaw function. The common consensus among short-term-minded studies concluded immediate satisfactory results yet lacked validity. Moreover, there is significant variation in the frequency of treatment, further enforcing inconsistent authority within findings. For instance, Oliveira-Campelo et al. (2010) reported immediate (2 minutes) -post-treatment hypoalgesic effects in patients who have received atlanto-occipital joint thrust [23]. Calixtre et al. (2016) also observed an immediate improvement in the functionality of the stomatognathic system after manual therapy, muscle stretching, and conditioning exercises [27]. However, Bortolazzo’s team (2015) only presented a 48-hours posttreatment assessment of improved electric activity in the masticatory muscles at rest and during maximal isometric contraction rather than functional joint tasks [22]. Changes in MMO were more significant for the HVLAT group observed immediate, short-term posttreatment effects during scheduled sessions among subjects in Reynolds’ studies [24].

Although more prolonged than the majority of the reviewed studies, the maximum duration of follow-up was limited to a span of two months. For example, intriguingly, hypoalgesic effect and pain-free maximum mouth opening (MMO) initially observed by Tuncer et al. (2013) were reduced at the two-months mark [26]. On the other hand, Corum’s team [25] observed significant improvement in TMD cases evaluated at 72-hours posttreatment and one-month follow-up. Hence, they suggested adding cervical manipulation to the rehabilitation program for TMD. Opposingly, Calixtre et al.’s (2019) study observed a significant change in oro-facial pain and headache impact in the group receiving upper cervical mobilization, neck motor control, and stabilization exercises. However, found no effects on pressure pain thresholds and mandibular function at five-week follow-up [21].

In summary, these studies [24,25] present a short-term analysis, even though long-term research is deemed necessary to yield information. Furthermore, a minimal subset of data that incorporated information upon the patient’s condition posttreatment was a maximum of only two months. Based on this, there is difficulty in ascertaining the optimal procedure or combination of varied manual therapy approaches to treating TMD conditions. This emphasized the necessity of long-term follow-up data in future studies in determining long-term effectiveness.

Additionally, participants in the reviewed studies only primarily comprised younger age groups. Thus, presented results may not be generalizable to men and women of the older age group.

The patients in the case or comparison groups in the included studies were relatively homogeneous. However, similar to the intervention group, the treatments employed were diverse among the comparator groups, with wide variability in the techniques used. Therefore, it is plausible to see the placebo effect of manual cervical therapy among comparators. Nevertheless, only two studies [23,24] reported no remarkable difference among the two groups. This can be described by the fact that most of the reviewed studies, even though randomized, do not fulfill the criteria of blinded observation [34], a requisite in observational reports [Table 3].

Study limitations

Overall, there was limited high-quality evidence for the effectiveness of manual cervical therapy in the myogenous TMD, primarily due to inconsistent methodological approaches and duration of treatment. In addition, most of the evidence could be inconclusive due to either no or no long-term follow-up requiring further research.

  Conclusion Top

Compared to the baseline, a significant improvement in myofascial pain and mouth opening was observed post- manual therapy treatment in cases with myogenous-TMD. Manual therapy appears to be an effective treatment for temporomandibular disorders in the short term, as the existing data presented a short-term analysis, the preferable treatment is mobilization and manipulation of the upper cervical spine. Moreover, there is limited high-quality evidence ascertaining the optimal procedure or combination of varied manual therapy approaches and treatment duration to treat TMD conditions. In addition, the pieces of evidence are more inconclusive due to either not any or no long-term follow-up. Hence, emphasizing the necessity of long-term follow-up data in future studies to determine the effectiveness of manual cervical therapy in patients with TMD.

Authors contributions

S.W.B and F.A.H conceived the research concept, K.S.F and F.A.H developed research design, S.W.B and K.S.F performed field work and data analysis. S.W.B prepared the first draft and all authours (S.W.B, K.S.F and F.A.H) reviewed and approved final draft of the manuscript. All authors are responsible for the contents and integrity of this manuscript.

Ethical statement

This systematic review study was reported according to PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and registered in PROSPERO with the following registration number: (CRD42020152785).

Financial disclosure

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Data availability statement

All relevant data are available within the manuscript.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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