Abstract

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.

Highlights

  • The term temporomandibular disorder (TMD) is an umbrella generally used to describe a myriad of symptoms including muscle and joint-related pain, decreased jaw mobility, headaches, tinnitus, stiffness, fatigue, or other potential associated-symptoms [1].Nassif et al reported that almost 75% of the general population will experience temporomandibular disorders (TMDs)-associated symptoms at some point during their life [2]

  • The general absence of clinical guidelines concerning physical therapy in patients with TMDs states the evident need for determining further examination and treatment decisions based on proper clinical reasoning

  • We conducted the current narrative literature review aiming to discuss clinical reasoning based on nociceptive 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 TMDs

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Summary

Introduction

The term temporomandibular disorder (TMD) is an umbrella generally used to describe a myriad of symptoms including muscle and joint-related pain, decreased jaw mobility, headaches, tinnitus, stiffness, fatigue, or other potential associated-symptoms [1]. Physical therapy is probably the first therapeutic intervention requested and used by individuals with TMDs for managing their pain. Since the umbrella term TMD includes several pain conditions with different clinical manifestations but potential common underlying mechanisms, their treatment includes different therapeutic strategies [5]. The general absence of clinical guidelines concerning physical therapy in patients with TMDs states the evident need for determining further examination and treatment decisions based on proper clinical reasoning. We conducted the current narrative literature review aiming to discuss clinical reasoning based on nociceptive 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 TMDs. We will propose an algorithm for clinical examination and treatment decisions and a pain model integrating current knowledge of pain neuroscience

Clinical Examination Temporomandibular Pain Disorders
Identification of Central Sensitization
Manual Palpation
Joint Palpation
Muscle Palpation
Musculoskeletal Tests
Physiological Movements
Accessory Movements
Scientific Evidence of Bottom-Up Interventions
Manual Therapies
Therapeutic Exercise
Findings
Pain Neuroscience Education
Full Text
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