Additional Effects of Therapeutic Exercises Under a Behavioral Umbrella for Chronic Temporomandibular Disorders Treatment
Condition: Temporomandibular Joint Dysfunction Syndrome
MeSH terms: Temporomandibular Joint Disorders; Temporomandibular Joint Dysfunction Syndrome; Joint Diseases
Study type: Interventional

Summary: 
      Temporomandibular dysfunction (TMD) It's one of the main causes of oro-facial chronic pain.
      The psychological aspects of patients with TMD have a huge importance, affecting their
      ability to manage pain and interfering with the resolution of the picture.

      Different studies analyse Manual therapy (MT) and motor control exercises (MC) as a whole or
      separately. In these cases, MT with MC shows promising results. Despite this, MC do not
      suggest adding significant improvement at least at short term. In the other side, according
      to a recent research line, MC with education is the clue for chronic pain management. This
      leads us to think that it should be studied more carefully if MC performed with a cognitive
      approach adds beneficial effect to MT not only in purely mechanical aspects but also in
      psycho-social aspects of the individual and at longer term.

      HYPOTHESIS The combination of MT and MC is more effective than MT applied in a unique way for
      the treatment of pain, function and psycho-social symptoms associated with chronic TMD.
    

Detailed description: 
      TMD is an alteration of the jaw function associated with disorders at the mastication
      muscles, mandibular joint and its associated tissues. It constitutes a major health problem
      since it's one of the main causes of oro-facial chronic pain and interferes with daily life.
      It is associated with headache, otological symptoms, cervical dysfunction and alterations in
      posture at the cervical level. The TMD involves genetic, anatomical, hormonal factors,
      traumatisms, motor behaviour, psycho-social aspects and occlusal problems.

      The psychological aspects of patients with TMD have a huge importance, affecting their
      ability to manage pain and interfering with the resolution of the picture. It can even cause
      the pain to become chronic. The most prevalent symptoms in TMD are somatization and
      depression. Chronic pain can lead to plastic changes in the brain that lead to
      hyper-excitability of the central nervous system. Persistent pain produces protective
      memories that involve antalgic behaviour, avoidance and kinesiophobia. The literature shows
      that somatization, depression, fear of pain, fear of movement and catastrophism in
      conjunction with the amplification of pain are key factors in the chronification of TMD.

      The TMD treatment must provide the ideal circumstances for the repair and adaptation. The TMD
      is usually a benign self-limiting process, so the guidelines always recommend non-invasive,
      reversible treatments in the first instance and within the bio-psycho-social approach.

      For conservative management, the most evidence-based approach is manual therapy (MT). The one
      that has demonstrated more effectiveness is the mobilisation with impulse and / or
      mobilisation both at cervical and mandibular level. MT improves motor response, range of
      motion and modulates pain intensity via peripheral, medullary and supraspinal mechanisms.
      Theories suggest that hypoalgesia is caused by several mechanisms mediated by the
      periaqueductal gray substance.

      Different studies analyse MT and motor control exercises (MC) as a whole or separately,
      comparing them with other therapies such as education, splints, medication, botulinum toxin,
      arthroplasty and arthroscopy. In these cases, MT with MC are superior to these therapies.
      Despite this, MC exercises do not suggest adding significant improvement in the treatment of
      TMD, at least in the short term. Shafer et al., In a recent systematic review, state that
      there is currently no evidence for the use of MC exercises of any kind for the management of
      TMD in general. However, according to a recent research line MC with education is the clue
      for the management of chronic pain. The objective of the exercises is to perform a cognitive
      approach to provide the desensitization of the central nervous system, generate new memories
      and eliminate the protective movement associated with chronic pain. It also promotes
      eliminating catastrophism, avoidance and fear of pain behaviour associated with
      chronification. This leads us to think that it should be studied more carefully if CM
      performed with a cognitive approach adds beneficial effect to MT in the treatment of chronic
      TMD not only in purely mechanical aspects but also in psycho social aspects of the individual
      and longer term.

      The current studies are of low quality, have biases in the selection, randomisation and
      allocation concealment. Patient selection and diagnostic criteria are not standardised. There
      is a lack of blind of the evaluator and examiner. The therapy or exercise is not well
      described making them difficult to reproduce. The new lines of research require more detail
      about the type of exercise to be performed and the MT applied as recommended by the
      intervention report guides.

      HYPOTHESIS The combination of MT and Myofunctional MC (MMC) is more effective than MT applied
      in a unique way for the treatment of pain, function and psycho social symptoms associated
      with chronic TMD.
    

Intervention name(s): Manual Treatment; Myofunctional Motor control exercises
Intervention type(s): Procedure; Procedure
Intervention description(s): The manual treatment will be adapted to each patient at the discretion of the therapist, being able to select all or part of the following osteopathic techniques in each session.
Soft tissue techniques.
Articulatory techniques applied at cervical level
Osteopathic manipulation techniques applied at the affected jaw/s.
Functional Indirect technique at the level of the affected jaw/s: For Type I or II diagnosis.; The protocol is a set of 8 exercises to improve the execution of the function in the stomatognathic and cervical area.
The therapist explains the objectives of the exercises and the patient performs it after each session and at home three times a day.
The first day before performing the myofunctional exercises, will be an explanatory talk prior to the exercises in order to educate the patient. The second day, before doing the exercises, will review the concept of memory of pain and the benefits of doing the exercises
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Both groups will be treated with Osteopathic Treatment and in one of them it will be added the intervention with cognition targeted myofunctional motor control exercises.
Masking: Single (Investigator)
Primary purpose: Treatment
Keywords: Chronic Facial Pain; Osteopathic Manual treatment; Therapeutic Exercise