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Objective
The aim of this study was to assess the influence of cranio-cervical posture on the maximal mouth opening (MMO) and pressure pain threshold (PPT) in patients with myofascial temporomandibular pain disorders.
Materials and Methods
A total of 29 patients (19 females and 10 males) with myofascial temporomandibular pain disorders, aged 19 to 59 years participated in the study (mean years±SD; 34.69±10.83 y). MMO and the PPT (on the right side) of patients in neutral, retracted, and forward head postures were measured. A 1-way repeated measures analysis of variance followed by 3 pair-wise comparisons were used to determine differences.
Results
Comparisons indicated significant differences in PPT at 3 points within the trigeminal innervated musculature [masseter (M1 and M2) and anterior temporalis (T1)] among the 3 head postures [M1 (F=117.78; P<0.001), M2 (F=129.04; P<0.001), and T1 (F=195.44; P<0.001)]. There were also significant differences in MMO among the 3 head postures (F=208.06; P<0.001). The intrarater reliability on a given day-to-day basis was good with the interclass correlation coefficient ranging from 0.89 to 0.94 and 0.92 to 0.94 for PPT and MMO, respectively, among the different head postures.
Conclusions
The results of this study shows that the experimental induction of different cranio-cervical postures influences the MMO and PPT values of the temporomandibular joint and muscles of mastication that receive motor and sensory innervation by the trigeminal nerve. Our results provide data that supports the biomechanical relationship between the cranio-cervical region and the dynamics of the temporomandibular joint, as well as trigeminal nociceptive processing in different cranio-cervical postures.
The current narrative literature review aims to discuss clinical reasoning based on nociceptive pain mechanisms for determining the most appropriate assessment and therapeutic strategy and to identify/map the most updated scientific evidence in relation to physical therapy interventions for patients with temporomandibular disorders (TMDs). We will also propose an algorithm for clinical examination and treatment decisions and a pain model integrating current knowledge of pain neuroscience. The clinical examination of patients with TMDs should be based on nociceptive mechanisms and include the potential identification of the dominant, central, or peripheral sensitization driver. Additionally, the musculoskeletal drivers of these sensitization processes should be assessed with the aim of reproducing symptoms. Therapeutic strategies applied for managing TMDs can be grouped into tissue-based impairment treatments (bottom-up interventions) and strategies targeting the central nervous system (top-down interventions). Bottom-up strategies include joint-, soft tissue-, and nerve-targeting interventions, as well as needling therapies, whereas top-down strategies include exercises, grade motor imagery, and also pain neuroscience education. Evidence shows that the effectiveness of these interventions depends on the clinical reasoning applied, since not all strategies are equally effective for the different TMD subgroups. In fact, the presence or absence of a central sensitization driver could lead to different treatment outcomes. It seems that multimodal approaches are more effective and should be applied in patients with TMDs. The current paper also proposes a clinical decision algorithm integrating clinical diagnosis with nociceptive mechanisms for the application of the most appropriate treatment approach.