Journal of Oral Rehabilitation 2005 32; 779785

Home-exercise regimes for the management of non-specic 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 *
Maxillofacial Surgery Prosthodontics and Special Dental Care, University of Utrecht, The Netherlands *Section of Orthodontics and Gnathology, Department of Dental, Oral and Maxillo-Facial Sciences, University of Naples Federico II, Italy and Department of Oral-

SUMMARY

There is a consensus on treatment strategies for temporomandibular disorders (TMDs) being reversible. Among reversible therapies, physiotherapy is often chosen for the treatment of TMD pain and dysfunction because it is simple and noninvasive, it has a low cost as compared with other treatments, it allows an easy self-management approach, it allows a good doctorpatient communication, and it can be managed by the general practitioner. Home-exercises regime protocols are reviewed in this article in the context of the biopsychosocial approach. The actual evidence for the efcacy of home physical exercises is weak because of the very limited number of randomized

clinical trials (RCTs) available in literature. Therefore, there is a need for further well-designed studies and RCTs to investigate the therapeutic efcacy. Recent reports and clinical experience, however, suggest that this approach can be promising, particularly if it is tailored towards the individual patient. The favourable cost benet ratio over other treatment modalities seems to indicate that physiotherapy can be regarded as a rst choice approach in selected TMD patients. KEYWORDS: physiotherapy, exercises, counselling, temporomandibular disorders Accepted for publication 20 February 2005

Introduction
Temporomandibular disorder (TMD) is a collective term embracing a number of clinical problems that involve the masticatory musculature, the temporomandibular joint and associated structures, or both (1). Temporomandibular disorder can be specic (with an underlying pathology like a neoplasm, inammation, growth disturbance or underlying systemic disease) or nonspecic. Non-specic TMD is considered a musculoskeletal disorder. This review is about non-specic TMD exclusively. Only few patients with TMDs and/or neck and back pain show pathoanatomically well-dened diseases. Chances are much higher for rst line clinicians to deal with patients with non-specic conditions; in most of these cases the aetiology is not known. For

The present paper is based on a lecture presented at the international meeting on Advances in Oral Physiopathology: From basic research to clinical implication, held in Turin, December 911, 2004. 2005 Blackwell Publishing Ltd

this reason it is not possible to treat these non-specic conditions with a causal therapy. In most cases, especially in acute conditions, counselling and education will sufce to meet the demand of the patient. In chronic conditions however, it is often necessary to perform a symptomatic treatment, which involves multiple interventions and a clinical management. In other words, while treatment aims at the disease, management aims at the patient and involves a range of interventions directed towards reducing the physical, social and psychosocial impact of a chronic condition. For the management of TMD several therapeutic protocols have been suggested (24). Management of TMD has been widely discussed and there is a consensus on treatment strategies being reversible. The need of a low-tech, high prudence therapeutic approach is justied by some well-known considerations about TMD (5, 6). Among these, the most important is that no treatment modality has been proven better than others. The majority of patients suffering from TMD

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achieved sufcient relief of symptoms with reversible therapy (24). Indeed, long-term follow up of TMD patients shows that 5090% of the patients have few or no symptoms after this kind of treatment (1, 711). The reversible therapies commonly used for the management of TMD include physiotherapy, pharmacotherapy (antidepressants), occlusal therapy (occlusal appliances) and psychological therapy (cognitive behavioural therapy). These modalities can be offered together or as a single management strategy. Counselling is always a rst approach. Among the modalities mentioned, physiotherapy can be efcacious for most of the patients with TMD related pain and restricted motion. Physiotherapy is chosen for the treatment of dysfunctions in the orofacial region for several reasons. It is relatively simple, reversible and non-invasive, it has a low cost as compared with other treatments, and it allows for an easy self-management approach which means that the patient is actively involved in his own treatment, being responsible of his well-being (locus of control). Finally, perhaps more importantly, it allows a good communication with the patient improving the patients condence in the care provider, being the basis of a positive coping. Informed patients are more likely to participate actively in their care, make wiser decisions and adhere more fully to treatment (12). Hence physiotherapy can be considered a complex concept which involves the complete functionally based evaluation of the patient in order to reduce impairments, disabilities and participation problems. The goals of the physiotherapeutic regime in general and in the orofacial region specically, are to control pain and discomfort, to reduce muscle tone, to improve kinetic parameters and to improve temporomandibular joint (TMJ) function. Improvement of components of posture and decrease of risk factors related to the upper quarter, by stretching masticatory muscles, increasing TMJ mobility and inuencing muscle strength and proprioception in order to restore normal functioning are other goals. Recognition of a broad biopsychosocial model of health (and illness) and the positive role of activity in health and healing, with emphasis on function rather than impairment only, is paramount. Therefore the physiotherapeutic approach includes cognitive-psychological evaluation of the patient, re-education of patients behaviour, performance of several kinds of exercises and the use of a collection of physical medicine modalities. However, this paper will not discuss the analysis of physical medicine modalities, including thermal, electromagnetic and electrical techniques, such as transcutaneus electrical nerve stimulation, infrared, biofeedback, ultrasound. It will focus on a home exercise programme regime that can be managed by the general practitioner and that has to be performed by the patient. The reason for this choice is also related to the fact that more and more experts have, in recent years, questioned how effective physical medicine modalities are in the treatment of the musculoskeletal disorders (13). The key to success in TMD management seems the success in educating the patient about the disorder in order to enhance the self-care aspects. Self-management programs have been shown to have long-term positive effects (14). Therefore, the home exercise programme regime in physiotherapy includes several procedures, such as counselling, patient education (habit reversal techniques and proper use of the jaw), thermo therapy, auto-massage, stretching exercises, stabilization, coordination, and mobilization exercises, to be described in the following sections. These exercises will be discussed in the context of the biopsychosocial approach. Acute TMD symptoms can be addressed with minimal interventions and generally resolve in short notice. If TMD conditions have become chronic this biopsychosocial approach is paramount in their management. In the next section exercises will be described in general; their indication in different diagnostic TMD subgroups is not indicated. The choice of modalities is tailored to the actual condition. Most of the evidence arises from studies on management of chronic orofacial myofascial pain.

Education
Behavioural therapy is generally considered as a rst conservative approach for the treatment of TMD patients (5, 15) The rationale for choosing behavioural therapy arises from the idea that parafunctional activity and psychosocial factors play a role in the pathogenesis of musculoskeletal pain (1618). The objectives of education are to reassure the patient, to explain the nature, the aetiology and the prognosis of the problem, to reduce repetitive strain of the masticatory system (e.g. daytime bruxism), to encourage relaxation and to control the amount of the masticatory activity (1922). Increased self-management is closely linked to successful rehabilitation. Activity goals should be set in three separate domains: the

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physical (exercise programme, number of exercises, duration and level of difculty), the functional (tasks of every day living or hobbies), and the social (social activities) domain. The patient has to be reassured by explaining the problem, the supposed aetiology and the good prognosis of this benign disorder. Patients require good information to assist them in making choices, overcoming unhelpful beliefs, and modifying behaviour. The relationship between chronic pain and psychosocial distress is also stressed. Normal jaw muscle function has to be explained, stressing to avoid overloading of the masticatory system, which could be the major cause of the complaints. The patients have to pay close attention to the jaw muscle activity, to avoid oral habits and excessive mandibular movements. In acute conditions, they have to avoid hard food, cut hard and tough food in small pieces, chew with back teeth on both sides, and avoid chewing gum. Later in the rehabilitation programme, training of restrictive activities of daily living is part of the procedure in order to return to normal, or desired, levels of activity and participation, and to prevent the development of chronic complaints. Patients must learn to keep the muscles relaxed by holding the mandible in the postural position (teeth apart), rather than in occlusion as this jaw position requires unintentional muscle contraction (23). Mandibular rest position can be determined asking the patients to pronounce several times the letter N and to maintain the tongue behind the upper incisor teeth, with the lips in slight contact. Approaches aiming at changing maladaptive habits and behaviours such as jaw clenching and grinding of the teeth are important in treating painful tissues. Behaviour modication strategies such as habit reversal are commonly used. Although many habits are abandoned when the patients become aware of them, changing persistent habits requires a structured programme. Patients should be aware that habits do not change spontaneously and that they are responsible for the change. For this reason, it is important to stress the need for the patients on practicing what they learned at home and during their common activities by the help of a visual feedback. and restricted motion (6, 2428). Exercise therapy is the cornerstone of rehabilitation of regional musculoskeletal disorders. There is strong evidence that it is effective by a wide spectrum of musculoskeletal, cardiovascular, respiratory and neurological disorders/ diseases (29). No nal conclusion, because of the lack of studies with a high methodological standard, can be given for cervical spine disorders, bromyalgia, repetitive strain injuries and also TMDs. In managing musculoskeletal complaints with rehabilitation therapy it is advised to include exercise therapy in the programme (30). Therapeutic exercise is the prescription of muscular contraction and bodily movement ultimately to improve the overall function of the individual and to help meet the demand of daily living. It involves the positive and progressive application and adjustment of stress and forces of the appropriate type and amount to the body system in order to address impairment improve musculoskeletal function, maintain a state of well-being. The physiotherapy regimen includes several exercises that are widely prescribed by clinicians treating TMDs because of the self-management character of the treatment and amelioration of coping for the patient. It has been suggested that these exercises help to relieve musculoskeletal pain and to restore normal function by reducing inammation, decreasing and coordinating muscle activity, and promoting the repair and regeneration of tissue (1, 31, 32). The programme suggested for TMD patients with muscle pain and/or limited mouth opening includes relaxation exercises with diaphragmatic breathing, auto-massage of the masticatory muscles, application of moist heat pads on the painful muscles, stretching, and co-ordination exercises, including proprioceptive training and posture. In order to perform correctly the home physiotherapy programme, it is very important to motivate and carefully instruct the patient, to achieve a good compliance. To learn normal diaphragmatic breathing the patient has to exhale fully with one hand on the chest and the other on the abdomen and he/she is trained to become 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 second hour; the patient, however, has to be encouraged to use coordinated breathing as often as possible throughout the whole day.

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Exercise therapy
Physiotherapy interventions, as we noticed in daily practice, can be efcacious for patients with TMD pain

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Initial studies have found massage to be effective for persistent back pain (33). In a Cochrane review, Furlan et al. (34) advised massage in combination with exercises and education. Massage therapy is a very old and frequently used kind of therapy. We included massage therapy in a way that it could be done by the patient her/himself. Self-massage is limited to the painful or tense masseter and temporalis muscles because they are both easily accessible. The patient is carefully instructed about the anatomic location of the affected muscle and is asked to exert an amount of pressure slightly higher than the initial pain sensation; the pressure has to be modulated proportionally to the level of pain experienced. The care provider needs to check whether the patient understands the modality technique and goal. Handing written instructions only is not correct. In good communication, it is advised to address the patients experiences and expectations, building partnership, providing evidence (including a balanced discussion of uncertainties), present recommendations and check for understanding and agreement (12). The masseter muscles are massaged by slight rolling movements performed with the index, middle and ring ngers placed extra-orally over the masseter area and the thumb placed intra-orally exerting counter pressure during massage. The patient is instructed to nd the painful area and to knead it for at least one minute; treatment time is related to the speed of adaptation. Thereafter, he/she has to stretch the muscle by pulling the thumb laterally starting from the origin of the masseter on the zygomatic arch up to the insertion on the mandibular angle. The right masseter muscle is massaged by the left hand and vice-versa. The temporalis muscles are massaged by slight circular movements performed with the ipsilateral index, middle and ring ngers or by pressing with one nger tip on the painful area for approximately 10 in order to induce adaptation. Supercial moist heat and cryotherapy can be used as palliative therapy. Ice massage compared with control had a statistically benecial effect on range of motion (ROM), function and strength, whereas cold packs decreased swelling (35). The amount of minutes used on their application is dictated by the goals to be achieved and by the preferences of the patient. The patient is asked to apply moist heat or cold pads on the painful area. Heat at approximately 4050 C (moderately warm) has to be applied bilaterally for 20 min once a day. To make the pad, a wet towel can be micro waved until it is warm, and wrapped around a hotwater bottle to keep it warm longer. For cold, patients can use ice wrapped in a thin washcloth and apply it on the painful area just until the onset of numbness (approximately 10 min). Stretching exercises for the jaw muscles are used mostly in patients with the diagnosis of myofascial pain with limited mouth opening. In order to stretch the muscles, the patient is asked to slowly open the mouth until he experiences an initial pain sensation. Thereafter, he/she is invited to open the mouth a little bit more positioning thumbs on the upper arch approximately on the premolar area and index ngers on the lower arch always on the premolar area. The stretch can be executed in a more dynamic hold-relax strategy or in a static stretch. The patient can also use a number of tongue-depressor piled together, as a reference for the amount of jaw opening, by positioning the tonguedepressors between arches without touching them with teeth; the patient is invited to add one tongue-depressor a day to verify the increased mouth opening. To further stretch the muscles the patient can use the piled tongue depressors with a pen in between to have a leveraction. The exercise has to be performed each day, every 2 h, holding the mandible stretched for 1 min, six times. Coordination exercises are performed by the patient three times daily. This can be performed by opening and closing the mouth slowly 20 times with the index nger on the lateral pole of the TMJs in order to control mandibular movements and maintaining the lower dental midline parallel to a vertical line traced on a small mirror. It can also be useful to include postural adaptation, especially, of the upper quarter, during this exercise, as jaw muscles and neck muscles show a coactivity. Mobilization exercises are very useful for TMJ problems when dealing with anterior disc displacement with or without reduction. The patient is instructed to perform lateral movements of the mandible in order to recapture the disc if it is possible. Thereafter, he/she has to perform little movements in protrusion, retrusion, and side by side, by holding a plastic small tube between teeth. When an anterior disc displacement with reduction is present, the patient is told to start the exercises after having captured the disc and to pay attention to not loose it. In other words he has to work on the disc (36). In such a situation exercises can be tailored to the consequences of the TMJ condition.

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without reduction) a benet of the use of a at occlusal splint over non-treatment control subjects could not be identied, stressing the concept of other modalities being equally effective. Another RCT (6) has been carried out in order to compare over a short term period the efcacy of counselling versus the combination of counselling and the home physiotherapy regime in the treatment of myofascial pain of the jaw muscles. It was found that treatment outcomes and other parameters evaluated were generally not different between education and the combination of education and home physiotherapy with the exception of pain-free maximal jaw opening and a better subjective feeling of recovery found in patients undergoing the home physiotherapy regime. The greater increase of the ROM in the combination of education and home physiotherapy group is probably mostly ascribable to the stretching exercises. The effectiveness of techniques that elongate the muscle and restore it to its full stretch length has also been suggested for other chronic musculoskeletal pain conditions (41). From a RCT contrasting physiotherapy and occlusal appliance therapy in masticatory myofascial pain the authors concluded that both short and long term results (up till 1 year) did not differ signicantly. On the basis of lower costs and (in their protocol) shorter treatment duration they preferred physiotherapy as a rst treatment option (42).

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Discussion
The clinical benets of the home physiotherapy programme are widely reported both in literature and in most of the TMD textbooks. However, it is important to determine which is the current evidence for the efcacy of physiotherapy for TMD. It must be emphasized that physiotherapy for TMD patients is actually not based on evidence that comes from systematic reviews or evidence based guidelines. Although it is generally believed that these treatments are effective in reducing the pain and restricted function associated with myofacial TMDs, few studies of the efcacy of physiotherapy for TMDs have been conducted. A meta-analysis of review articles and controlled clinical trials for TMDs and other similar chronic musculoskeletal pain disorders was carried out by Feine and Lund (37). They concluded that physiotherapy has a good short-term efcacy, whereas the long-term efcacy is similar to placebo, even if any physiotherapy modality is better than no treatment. It is important to realize that this conclusion is based on studies not related to the current physiotherapy practice and methods and the results are based on studies with low methodological scores and different outcomes. Patients do best when clinicians take the time to fully inform them about their condition. This contributes to reduce the fear, the depression and the anxiety that are characteristic of chronic pain patients. This means that enforcing patient responsibilities and thereby addressing psychosocial factors (like coping and locus of control) can be a powerful tool. The most important feature, which raises doubts on scientic evidence of such a treatment, is that the mechanism of action is unknown. Rendering more treatment modalities simultaneously offers a more efcacious outcome (37, 38) The utility of such an approach is especially applicable in complex conditions. Two randomized clinical trials (RCTs) have been published by Dworkin et al. (39, 40) who concluded that carefully structured minimal interventions emphasizing self-management of TMD may offer real benet to a signicant number of TMD patients. Addressing both dental and psychologic factors by an intraoral appliance (IA) and biofeedback training (BF) and stress management (SM) resulted in a better long term outcome than either IA or BF/SM management solely. In arthrogenous TMD patients (disk displacement

Conclusion
The actual evidence for the efcacy of home physical exercises is weak because of the very limited number of RCT available in literature. Therefore there is the need for further well-designed studies and RCT to investigate the therapeutic efcacy, to replicate the results in myofascial pain and to gain more insight in TMD subgroups with arthrogenous conditions like anterior disc displacement with and without reduction, capsular pain and so on. Recent reports and clinical experience, however, suggest that this approach can be promising, particularly if it is tailored towards the individual patient. The favourable cost benet ratio is another advantage over other modalities and helps to consider physiotherapy as a rst approach in selected TMD patients. Competencies rather than professional background will direct the choice of the involved health care providers as well.

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Correspondence: Dr Ambra Michelotti, Department of Dental and Maxillo-Facial Sciences, School of Dentistry, University of Naples Federico II, Via Pansini, 5. I-80131, Naples, Italy. E-mail: michelot@unina.it

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