Effects of an Interdisciplinary Approach in the Management of Temporomandibular Disorders: A Scoping Review.

Temporomandibular disorders (TMD) is an umbrella term that encompasses many musculoskeletal problems that include the masticatory muscles, the temporomandibular joint, and other associated structures. TMD can be divided into two large groups: those that affect the musculature and those that affect the joint. The treatment of TMD requires the combined skills of physiotherapists and dentists, as well as sometimes psychologists and other medical specialists. This study aims to examine the effectiveness of the interdisciplinary approach using physiotherapy and dental techniques on pain in patients with temporomandibular disorders (TMDs). This is a Scoping Review of studies investigating the effects of combined therapy on patients with TMD. PRISMA guidelines were followed during this review's design, search, and reporting stages. The search was carried out in the MEDLINE, CINHAL, and EMBASE databases. A total of 1031 studies were detected and analyzed by performing the proposed searches in the detailed databases. After removing duplicates and analyzing the titles and abstracts of the remaining articles, six studies were ultimately selected for this review. All the included studies showed a positive effect on pain decreasing after a combined intervention. The interdisciplinary approach characterized by the combination of manual therapy and splint or electrotherapy can positively influence the perceived symptoms; positively decrease pain; and reduce disability, occlusal impairments, and perception of change.

Robot-Assisted Rehabilitation of Hand Paralysis After Stroke Reduces Wrist Edema and Pain: A Prospective Clinical Trial.

OBJECTIVE: The purpose of this study was to determine whether passive robotic-assisted hand motion, in addition to standard rehabilitation, would reduce hand pain, edema, or spasticity in all patients following acute stroke, in patients with and without hand paralysis. METHODS: Thirty-five participants, aged 45 to 80 years, with functional impairments of their upper extremities after a stroke were recruited for the study from September 2013 to October 2013. One group consisted of 16 patients (mean age ± SD, 68 ± 9 years) with full paralysis and the other groups included 14 patients (mean age ± SD, 67 ± 8 years) with partial paralysis. Patients in the both groups used the Gloreha device for passive mobilization of the hand twice a day for 2 consecutive weeks. The primary outcome measure was hand edema. Secondary outcome measures included pain intensity and spasticity. All outcome measures were collected at baseline and immediately after the intervention (2 weeks). RESULTS: Analysis of variance revealed that the partial paralysis group experienced a significantly greater reduction of edema at the wrist (P = .005) and pain (P = .04) when compared with the full paralysis group. Other outcomes were similar for the groups. CONCLUSION: The results of the current study suggest that the partial paralysis group experienced a significantly greater reduction of edema at the wrist and pain when compared with the full paralysis group. The reduction in pain did not meet the threshold of a minimal clinically important difference.

Conflicting results of robot-assisted versus usual gait training during postacute rehabilitation of stroke patients: a randomized clinical trial.

Robot gait training has the potential to increase the effectiveness of walking therapy. Clinical outcomes after robotic training are often not superior to conventional therapy. We evaluated the effectiveness of a robot training compared with a usual gait training physiotherapy during a standardized rehabilitation protocol in inpatient participants with poststroke hemiparesis. This was a randomized double-blind clinical trial in a postacute physical and rehabilitation medicine hospital. Twenty-eight patients, 39.3% women (72±6 years), with hemiparesis (<6 months after stroke) receiving a conventional treatment according to the Bobath approach were assigned randomly to an experimental or a control intervention of robot gait training to improve walking (five sessions a week for 5 weeks). Outcome measures included the 6-min walk test, the 10 m walk test, Functional Independence Measure, SF-36 physical functioning and the Tinetti scale. Outcomes were collected at baseline, immediately following the intervention period and 3 months following the end of the intervention. The experimental group showed a significant increase in functional independence and gait speed (10 m walk test) at the end of the treatment and follow-up, higher than the minimal detectable change. The control group showed a significant increase in the gait endurance (6-min walk test) at the follow-up, higher than the minimal detectable change. Both treatments were effective in the improvement of gait performances, although the statistical analysis of functional independence showed a significant improvement in the experimental group, indicating possible advantages during generic activities of daily living compared with overground treatment.

Multimodal treatment of distal sensorimotor polyneuropathy in diabetic patients: a randomized clinical trial.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of the application of analyzing treadmill, muscle strengthening, and balance training compared with a standard care intervention in patients with diabetic neuropathy. METHODS: Twenty-seven patients, 63% female (mean ± standard deviations age, 72 ±9 years), with diabetic neuropathy randomly assigned to receive a multimodal manual treatment approach including analyzing treadmill with feedback focused, isokinetic dynamometric muscle strengthening, and balance retraining on dynamic balance platform or a standard care intervention for activities targeted to improve endurance, manual exercises of muscle strengthening, stretching exercises, gait, and balance exercises (5 weekly over 4 weeks). This study was designed as a double-blind, randomized clinical trial. Measures were assessed at pretreatment, 4 weeks posttreatment, and 2-month follow-up. RESULTS: No important baseline differences were observed between groups. At the end of the treatment period, the experimental group showed a significant increase in gait endurance in a 6-minute walk test, 65.6 m (F[2.0] = 9.636; P = .001). In addition, the 6-minute walk test increased after the intervention, and an even greater difference was found at follow-up (P = .005) for the standard care group. The Functional Independence Measure in both groups increased (P < .01) and continued until the follow-up in the standard care group (P = .003). CONCLUSIONS: The results suggest that the experimental rehabilitation program showed positive effects on the gait endurance after 4 weeks of treatment, whereas it did not produce significant improvements of the gait speed. Both the treatments produced significant improvement of functionalities of the patient.

Combined thumb abduction and index finger extension strength: a comparison of older adults with and without thumb carpometacarpal osteoarthritis.

OBJECTIVE: The objectives of this study were to compare thumb combined abduction/index finger extension (hand opening) strength between subjects with carpometacarpal (CMC) osteoarthritis (OA) and normal controls and to assess the reproducibility of hand opening strength and abduction range of motion (ROM) measurements in patients with thumb CMC OA to establish the cutoff values scores for minimal detectable change. METHODS: Seventy-seven subjects, 96% female (age, 77 ± 7 years), participated in the study. The CMC OA group consisted of 39 patients (mean ± SD, 81 ±7) and 38 healthy subjects (mean ± SD, 78 ± 6). Mixed models analysis of variance was conducted to determine the differences between groups. RESULTS: The post hoc testing revealed statistically significant differences in pain pressure threshold, opening strength, and ROM measurements within the CMC OA group as compared with the healthy group (all, P < .01) in the dominant right hand. The average measure of CMC OA in the right hand did differ from that of the left hand for opening strength and abduction measurements. No statistical differences were revealed between groups nondominant left (all, P > .05), except in case of opening strength (P < .001). There was also large effect size between the means of the Disabilities of the Arm, Shoulder, and Hand scores between the healthy group and the CMC OA group of 1.17 (confidence interval, 1.19-2.14). CONCLUSION: Subjects with CMC OA exhibited decreased combined thumb abduction and index finger extension strength, reduced thumb abduction ROM, and increased pain sensitivity when compared with their healthy counterparts. The minimal detectable change score in this patient population was 0.23 to 0.25 kg/cm(2) for pain pressure threshold, 0.12 to 0.13 lb for opening force, and 1.24° to 1.46° for abduction ROM measurement.

Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis.

OBJECTIVE: The purpose of this study was to investigate changes in pressure sensitivity and pinch grip force in the nonsymptomatic side in patients with thumb carpometacarpal (CMC) osteoarthritis (OA) after the application of a unilateral passive accessory mobilization to the symptomatic hand. METHODS: Secondary analysis of data from a randomized trial with concealed allocation, blinded assessor, and intention-to-treat analysis was performed. Twenty-eight patients (72% females), with unilateral CMC OA and mean age ± SD of 82 ± 6 years, met all the inclusion criteria and agreed to participate. The experimental group received passive accessory mobilization to the CMC OA, and the control group received a nontherapeutic dose of intermittent ultrasound on the affected side for 4 sessions over 2 weeks. Outcome measures including pressure pain thresholds (PPTs) at the lateral epicondyle, thumb CMC joint, tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone and tip and tripod pinch and grip strength of the contralateral/unaffected hand were assessed at baseline as well as 1 and 2 weeks after treatment by an assessor blinded to the group allocation. A repeated measures analysis of variance was used to determine changes in PPT and pinch and grip strength. RESULTS: No important baseline differences were observed between groups. At the end of the follow-up period, the experimental group exhibited a significant increase in PPT at the CMC joint as compared with the control group 0.6 kg/cm(2) (95% confidence interval, 0.3-1.0; F3.0 = 4.89; P = .009). Although PPT changes in the experimental group were higher than the control group at the remaining sites, differences did not reach statistically significance. Similarly, tip, tripod pinch, and grip strength remained unchanged after the intervention. CONCLUSION: This secondary analysis found that the application of a unilateral passive accessory mobilization targeted to the symptomatic CMC joint induced an increase of PPT levels 2 weeks after treatment; however, differences were small and likely of limited clinical value. No contralateral motor effects were observed. Future studies including larger sample sizes are needed to examine the effects of joint mobilization on motor and sensory effects.

The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

STUDY DESIGN: Double-blind, randomized controlled trial. OBJECTIVE: To examine the effectiveness of a manual therapy and exercise approach relative to a placebo intervention in individuals with carpometacarpal (CMC) joint osteoarthritis (OA). BACKGROUND: Recent studies have reported the outcomes of exercise, joint mobilization, and neural mobilization interventions used in isolation in patients with CMC joint OA. However, it is not known if using a combination of these interventions as a multimodal approach to treatment would further improve outcomes in this patient population. METHODS: Sixty patients, 90% female (mean ± SD age, 82 ± 6 years), with CMC joint OA were randomly assigned to receive a multimodal manual treatment approach that included joint mobilization, neural mobilization, and exercise, or a sham intervention, for 12 sessions over 4 weeks. The primary outcome measure was pain. Secondary outcome measures included pressure pain threshold over the first CMC joint, scaphoid, and hamate, as well as pinch and strength measurements. All outcome measures were collected at baseline, immediately following the intervention, and at 1 and 2 months following the end of the intervention. Mixed-model analyses of variance were used to examine the effects of the interventions on each outcome, with group as the between-subject variable and time as the within-subject variable. RESULTS: The mixed-model analysis of variance revealed a group-by-time interaction (F = 47.58, P<.001) for pain intensity, with the patients receiving the multimodal intervention experiencing a greater reduction in pain compared to those receiving the placebo intervention at the end of the intervention, as well as at 1 and 2 months after the intervention (P<.001; all group differences greater than 3.0 cm, which is greater than the minimal clinically important difference of 2.0 cm). A significant group-by-time interaction (F = 3.19, P = .025) was found for pressure pain threshold over the hamate bone immediately after the intervention; however, the interaction was no longer significant at 1 and 2 months postintervention. CONCLUSION: This clinical trial provides evidence that a combination of joint mobilization, neural mobilization, and exercise is more beneficial in treating pain than a sham intervention in patients with CMC joint OA. However, the treatment approach has limited value in improving pressure pain thresholds, as well as pinch and grip strength. Future studies should include several therapists, a measure of function, and long-term outcomes. TRIAL REGISTRATION: Current Controlled Trials ISRCTN37143779. LEVEL OF EVIDENCE: Therapy, level 1b.

Effects of passive upper extremity joint mobilization on pain sensitivity and function in participants with secondary carpometacarpal osteoarthritis: a case series.

OBJECTIVE: The purpose of this case series is to report on the effects of passive joint mobilization (PJM) of the shoulder, elbow, and wrist on pain intensity, pain sensitivity, and function in elderly participants with secondary carpometacarpal osteoarthritis (CMC OA). METHODS: Fifteen inpatients from the Department of Physical Therapy, Residenze Sanitarie Assistenziali, Collegno (Italy), with secondary CMC OA (70-90 years old) were included in this study. All patients received PJM of the dominant arm (shoulder, elbow, and wrist) for 4 sessions for 2 weeks. Pain severity was measured by visual analog scale, and pain sensitivity was measured with pressure pain threshold (PPT) at CMC joint, at the tubercle of the scaphoid bone, and at the unciform apophysis of the hamate bone. Tip and tripod pinch strength were measured by a pinch gauge. RESULTS: Passive joint mobilization reduced pain severity after the first follow-up by 30%, in addition to increased PPT by 13% in the hamate bone. Strength was enhanced after treatment. Tripod pinch increased by 18% in the dominant hand after treatment. CONCLUSIONS: This case series provides preliminary evidence that PJM of upper extremity joints diminished pain and may increase PPT tip and tripod pinch in some participants with secondary CMC OA.

Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis.

OBJECTIVE: This study evaluated the effects of Maitland's passive accessory mobilization on local hypoalgesia and strength in thumb carpometacarpal osteoarthritis (TCOA). METHODS: Twenty-eight patients between 70 and 90 years old with secondary TCOA were randomized into glide mobilization and sham groups. This study was designed as a double-blind, randomized controlled trial. Therapy consisted of Maitland's passive accessory mobilization of the dominant hand during 4 sessions over 2 weeks. We measured pressure pain threshold (PPT) at the trapeziometacarpal joint (TMJ), the tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone by algometry. The tip and tripod pinch strength was also measured. Grip strength was measured by a grip dynamometer. Measurements were taken before treatment and after 1 week (first follow-up [FU]) and 2 weeks (second FU). RESULTS: All values in sham group remained unchanged along the treatment period. In the treated group, the PPT in the TMJ was 3.85 ± 0.35 kg/cm(2), which increased after treatment to 3.99 ± 0.37 and was maintained at the same level during the first FU 3.94 ± 0.39 and second FU 4.74 ± 0.40. In contrast, we found no differences in PPT in the other studied structures after treatment. Similarly, tip, tripod pinch, and grip strength remained without change after treatment. CONCLUSIONS: Passive accessory mobilization increased PPT in the TMJ; however, it did not increase motor function in patients with TCOA.

Radial nerve mobilization decreases pain sensitivity and improves motor performance in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

OBJECTIVE: To examine the effects of radial nerve mobilization on pain sensitivity and motor performance in subjects with secondary thumb carpometacarpal osteoarthritis. DESIGN: Randomized controlled trial. Treatment and placebo were given for 4 weeks. Measurements were taken before intervention, after 1 month (first follow-up), and after 2 months (second follow-up). SETTING: Patients from the Department of Physical Therapy, Azienda Sanitaria Locale 3, Collegno (Italy). PARTICIPANTS: Participants (N=60; age range, 70-90y) with right-dominant hand secondary thumb carpometacarpal osteoarthritis without other motor-related pathology. All patients completed the study. No patients were withdrawn from the study. INTERVENTIONS: Sliding mobilization of the proximal-distal radial nerve or intermittent ultrasound therapy, used as placebo. MAIN OUTCOME MEASURES: We hypothesized that radial nerve mobilization induces hypoalgesia and increases strength in secondary thumb carpometacarpal osteoarthritis. We measured pressure pain threshold (PPT) at the trapeziometacarpal joint, the tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone by algometry. Tip pinch strength and tripod pinch strength were measured by a mechanical pinch gauge. RESULTS: Treatment increased PPT by 3.33±.24 kg/cm(2) (P<.001) in the trapeziometacarpal joint and was maintained until first follow-up and second follow-up. Also, PPT in the scaphoid bone and hamate bone was increased (P<.001 and P<.02, respectively). Variables in the placebo group remained unchanged. Tip pinch strength increased by 2.22±.22 kg (P<.04) and tripod pinch strength by 2.83±.24 kg (P<.019). CONCLUSIONS: Radial nerve mobilization decreases pain sensitivity in the trapeziometacarpal joint and increases tip pinch strength.

Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial.

OBJECTIVE: This study evaluated the effects of Kaltenborn manual therapy on sensory and motor function in elderly patients with secondary carpometacarpal osteoarthritis (CMC OA). METHOD: Twenty-nine female patients with secondary CMC OA (70-90 years old) were randomized into Kaltenborn manual therapy and sham groups. This study was designed as a double-blind, randomized controlled trial (RCT). Therapy consisted of Kaltenborn mobilization of posterior-anterior gliding with distraction in grade 3 of the carpometacarpal (CMC) joint of the dominant hand during 6 sessions over 2 weeks. Pain was measured by algometry, as the pressure pain threshold (PPT) at the CMC joint and tubercle of the scaphoid bone. The tip and tripod pinch strength was also measured. Grip strength was measured by a grip dynamometer. Measurements were taken before treatment and after 1 week (first follow-up [FU]) and 2 weeks (second FU). RESULTS: All values in the sham group remained unchanged during the treatment period. In the treated group, the PPT in the CMC joint was 2.98 ± 0.30 kg/cm(2), which increased after treatment to 4.07 ± 0.53, and was maintained at the same level during the first FU (3.46 ± 0.31) and second FU (3.84 ± 0.36). Similarly, the PPT in the scaphoid bone was 3.61 ± 0.29 kg/cm(2), which increased after treatment to 4.87 ± 0.37, and was maintained at the same level during the first FU (4.44 ± 0.43) and second FU (4.22 ± 0.32). In contrast, we found no differences in the tip, tripod pinch, and grip strength measurements between the treatment and sham groups. CONCLUSIONS: This study showed that Kaltenborn manual therapy decreased pain in the CMC joint and scaphoid bone areas of elderly female patients; however, it did not confer an increase in motor function in patients with CMC OA.

Short-term effects of neurodynamic mobilization in 15 patients with secondary thumb carpometacarpal osteoarthritis.

OBJECTIVE: The purpose of this study is to evaluate whether neurodynamic mobilization of the median nerve improves pressure pain threshold (PPT) and pinch and grip strength in patients with secondary thumb carpometacarpal osteoarthritis (TCOA). METHOD: Fifteen patients with secondary TCOA (13 women and 2 men) between 70 and 90 years old were received by neurodynamic therapy. All patients received median nerve mobilization of the dominant hand by sliding technique during 4 sessions over 2 weeks. The outcome measures of this case series were monitored by using PPT measured by algometry as PPT at the trapeziometacarpal (TM) joint, tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone. Tip and tripod pinch strength was also measured. Grip strength was measured by a grip dynamometer. These variables were measured at pretreatment, 5 minutes posttreatment, 1 week (first follow-up [FU]) and 2 weeks after treatment (second FU). RESULTS: Pressure pain threshold in the TM joint was 3.54 ± 0.04 kg/cm(2). After treatment, it increased to 4.38 ± 0.04 kg/cm(2) (P < .01) and maintained in the first FU (4.27 ± 0.04 kg/cm(2), P < .02) and second FU (4.08 ± 0.04 kg/cm(2), P < .02). In contrast, we found no differences in PPT in the other studied structures after treatment. Similarly, tip and tripod pinch strength remained without change after treatment. Grip strength was 10.77 ± 0.18 kg, and after treatment, it increased to 11.55 ± 0.16 kg (P < .05) and maintained in first FU (11.73 ± 0.18 kg, P < .02) and second FU (11.2 ± 0.17 kg, P < .05). CONCLUSIONS: Median nerve mobilization decreased pain in the TM joint and increased grip strength in this group of patients with TCOA.