Pain-free bite force in a healthy population: Within-session test-retest reliability in different sitting positions.

BACKGROUND: Pain-free bite force (PFBF) is a promising measure to evaluate bite function in temporomandibular disorders (TMDs), yet the reliability of the measure is unknown. OBJECTIVES: Establish the (1) within-session test-retest reliability of PFBF in a healthy population for a single and mean of three trials in supported and unsupported sitting; (2) standard error of measurement (SEM) and minimal detectable change (MDC). METHODS: Thirty healthy participants (n = 15 female, mean [SD] age = 34.4 [11.0] years) completed two sessions (30-60 min apart) comprising three PFBF trials on each side, in both supported and unsupported sitting, to provide data for 60 (30 participants × two sides) test-retest assessments. Test-retest reliability for the first trial and mean of three trials in each position were determined using intraclass correlation coefficients (ICCs), before calculating the corresponding SEM and MDC for males (M) and females (F) respectively. RESULTS: Within-session reliability was considered excellent for a single trial in supported sitting (ICC = 0.85; SEM M/F = 99/84 N; MDC M/F = 275/232 N) and unsupported sitting (ICC = 0.91; SEM M/F = 72/59 N, MDC M/F = 200/163 N), and for a mean of three trials in supported sitting (ICC = 0.89; SEM M/F = 66/79 N, MDC M/F = 182/220 N) and unsupported sitting (ICC = 0.92; SEM M/F = 64/59 N, MDC M/F = 177/164 N). CONCLUSION: Single and a mean of three trials in supported and unsupported sitting appear reliable methods to measure PFBF in a healthy population. Testing PFBF using a mean of three trials in unsupported sitting appears superior over other methods though due to higher test-retest reliability, and lower SEM and MDC. Future studies should examine the reliability of PFBF in TMD populations.

Is proprioception affected in those with persistent intra-articular temporomandibular disorders? A cross-sectional study exploring joint position sense and force sense of the jaw.

BACKGROUND: Proprioception is an important component of normal jaw function, although to date it is unknown if and how proprioception is affected in those with intra-articular temporomandibular disorders (IA-TMDs). This challenges effective management of this subgroup. OBJECTIVES: Determine whether differences in local joint position sense and force sense exist between individuals with IA-TMD and those without a jaw problem. DESIGN: Cross-sectional study. METHOD: Sixty age and sex matched participants were recruited (n = 30 IA-TMD, n = 30 healthy controls). Temporomandibular joint position sense was tested to one target (50% of maximal mouth opening) using a ruler. Temporomandibular force sense was tested to two targets (50% and 70% of maximal molar pain-free bite force) using a bite sensor. Constant, absolute and variable errors were calculated for each outcome and compared between groups using p-values and 95% confidence intervals for effect size (d). RESULTS: Significantly greater degrees of constant, absolute and variable error were seen for force sense testing at the 50% target (p < 0.05). No statistically significant difference was observed between groups for joint position sense, or for constant or variable force sense error at the 70% target (p > 0.05). Despite this, all joint position sense and force sense measures demonstrated possible clinical significance (upper limits 95% CI d ≥ 0.5). CONCLUSIONS: Force sense, particularly at lower levels, appears impaired in those with IA-TMD. Joint position sense and force sense at higher levels appear less affected, although may still be important to consider in the management of IA-TMD in some patients.

Exploring the workplace and workforce intentions of early career physiotherapists in Australia.

BACKGROUND: Previous research has indicated significant concerns regarding attrition of early career physiotherapists in Australia. Despite the importance of retaining skilled and experienced professionals within the profession, the workplace and workforce intentions of early career physiotherapists remain relatively unexplored. PURPOSE: The aim of this study was to investigate and explore factors influencing the workplace and workforce intentions of early career physiotherapists in Australia. METHODS: The Turnover Intention Theory was used to guide a whole-of-person qualitative exploration through semi-structured interviews with 14 participants. Transcribed interview data was subjected to reflexive thematic analysis. RESULTS: Four themes were generated, constructed as questions to represent participants' temporary holding of intentions: 1) What drives me?; 2) Do my expectations align?; 3) Do my values align?; and 4) What does the future hold? CONCLUSION: Early career physiotherapists' perspectives encompass diverse and varied experiences that reflect an alignment, or in some cases a misalignment, of the expectations, values and resulting practices of becoming and being a physiotherapist. Early career physiotherapists experience a range of challenges within their workplaces, including significant experiences of stress, yet they express an underlying commitment to the wider profession.

Do intra-articular temporomandibular disorders show an association between physical bite function, self-perceived bite limitation and kinesiophobia? A case-control study.

BACKGROUND: Little is known about the impact of intra-articular temporomandibular disorders (TMDs) on bite function, or how bite impairments in this subgroup relate to self-perceived bite limitation or kinesiophobia. This presents a challenge to practitioners involved in delivering care. OBJECTIVES: To determine what bite impairments are associated with intra-articular TMDs, and explore how these impairments relate to self-perceived bite limitations and kinesiophobia. DESIGN: Observational, case-control study. METHOD: Sixty participants (n = 30 intra-articular TMDs, n = 30 healthy controls) were recruited via convenience sampling. Bite function was explored using pain-free bite force and bite endurance/steadiness (submaximal bite hold) measures. Self-perceived bite function and kinesiophobia were evaluated via the Patient specific functional scale (PSFS) and the Tampa Scale for kinesiophobia of Temporomandibular disorders (TSK-TMD) respectively. Between-group data were compared and associations between physical bite impairments, self-perceived bite limitation and kinesiophobia were explored in the intra-articular TMD group. RESULTS: Pain-free bite force was significantly impaired in the intra-articular TMD group (-108N, p < 0.01, d = 0.9), and this impairment demonstrated moderate association with degree of kinesiophobia (p < 0.01, r = -0.4). No significant between-group difference was observed for bite endurance or force steadiness (p > 0.05). No association was observed between pain-free bite force and self-perceived bite limitation, or self-perceived bite limitation and kinesiophobia (p > 0.05). CONCLUSIONS: Impaired pain-free bite force appears to be an important feature of intra-articular TMDs which should be considered within management. Kinesiophobia may be important to consider when assessing bite function in this subgroup. Future research is needed to guide optimal interventions and inform subsequent management guidelines.

What conservative interventions improve bite function in those with temporomandibular disorders? A systematic review using self-reported and physical measures.

BACKGROUND: Bite is an important function of the human stomatognathic system. Despite this, it is commonly impaired in temporomandibular disorder (TMD) populations. The aim of this review is to evaluate the effectiveness of conservative interventions on self-reported and physical measures of bite function in individuals with TMD. METHODS: This review was performed in compliance with PRISMA guidelines. An electronic search was performed on databases including PubMed, CINAHL, Embase, and Cochrane Central. Inclusion criteria were journal articles evaluating the effect of any non-pharmacological conservative interventions on bite function in participants diagnosed with TMD. Risk of bias for individual studies was assessed using the Cochrane risk-of-bias v2 tool, and the NIH NHLBI pre-post tool. Data was synthesised based on outcome measures of bite function, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Eleven studies were eligible for this review. Interventions included splinting, photobiomodulation, needling, exercise, manual therapy, and patient education, which were evaluated using mastication-related pain, self-reported chewing difficulty, and bite force/endurance outcome measures. Findings suggested manual therapy, needling, oral splinting, exercise, and PBM interventions may improve bite function in TMD, although confidence in cumulative evidence ranged from moderate to very low. There was no evidence that patient education improved bite function. CONCLUSION: Conservative interventions may be helpful to address bite-related impairments associated with TMD, although further research is needed to improve the quality of evidence and direct clinical guidelines.

Weighing up the benefits and challenges of hosting physiotherapy student placements in private practice; a qualitative exploration.

INTRODUCTION: New graduate physiotherapists are entering private practice in increasing numbers despite limited opportunity to experience this setting during training. Exploring the perceived benefits and challenges of physiotherapy private practices in hosting students is important to help understand what motivates private practices to engage in clinical education and inform how practices can be best supported in student placement provision. OBJECTIVE: The aim of this study was to explore the benefits and challenges of hosting physiotherapy students from the perspective of private practice providers. METHODS: A qualitative study with an inductive thematic analytical approach was used. Semi-structured interviews of 10 physiotherapy private practice placement providers responsible for student placement provision were undertaken. RESULTS: Five themes emerged: 1) value to client care; 2) value to staff; 3) value to future planning; 4) contribution to students and the profession; and 5) stress associated with resources. DISCUSSION AND CONCLUSION: Private practice placement providers perceive a range of benefits to their practice, staff and clients, including rich opportunities for future recruitment when hosting physiotherapy students. These benefits are carefully weighed up against the required resources of time, physical space and opportunities for students to participate in client care. This study has identified implications for education providers in supporting physiotherapy student placements within private practice and may enhance placement capacity within this sector.

The management experiences, needs and preferences of individuals seeking care for persistent intra-articular temporomandibular disorders: A qualitative study.

BACKGROUND: Little is known about the management experiences, needs and preferences of individuals seeking care for persistent intra-articular temporomandibular disorders (TMD). Investigating these experiences may improve understanding of the impact management has on individuals, and factors that shape these experiences. This information may advance current practice and guide future management of individuals with intra-articular TMD. OBJECTIVES: To investigate the management experiences, needs and preferences of individuals with persistent intra-articular TMD. METHODS: A qualitative study was performed. Thirteen eligible participants (mean age 32.7 years, 12 female) were recruited via purposive sampling, and interviewed using a semi-structured framework. Data were analysed using a thematic analysis approach. RESULTS: Four themes were established from interview data: (i) searching for help; (ii) wanting answers; (iii) wanting to regain control; and (iv) meeting needs, preferences and expectations, and the implications on care. Numerous factors influenced the experiences of those seeking care, including the ability to navigate care and management expectations. Specific to intra-articular TMD, the absence of pain made seeking care harder, and often, patients perceived neglect of mechanical symptoms by healthcare practitioners, which negatively impacted care. Often, those wanting management expressed the need for answers and to regain control over their jaw symptoms. CONCLUSIONS: Strategies to improve healthcare navigation are needed for those wanting help for intra-articular TMD. Within management, a person-centred approach is encouraged. Practitioners should respect individuals' specific needs and preferences, and address underlying management expectations, to facilitate positive care experiences. Consideration of symptoms other than pain in intra-articular TMD populations is paramount.

Physiotherapy student clinical placements in Australian private practice: Patient-reported outcomes with supervised student care.

BACKGROUND AND PURPOSE: The sustainability of physiotherapy clinical placements is an ongoing challenge, yet there is potential to increase placement capacity within the private practice sector. Barriers to hosting students, including perceived impacts on patient care, reportedly limit the uptake of hosting students within this setting. This study aimed to evaluate the effect of physiotherapy student involvement on patient-reported Global Rating of Change (GRoC) in Australian physiotherapy private practice care. METHODS: A cross-sectional, patient survey study was conducted in three private physiotherapy practices over two 5-week periods. At their completion of care, participants completed the survey seeking demographic information, GRoC and aspects of care including number of consultations involving students, proportion of physiotherapy time involving students and frequency of student involvement in treatment delivery. After accounting for clinic-level differences, ordinal logistic regression analyses were performed to explore the impact of supervised student care on GRoC. RESULTS: 119 participants across three practices completed the survey. There were no significant associations between patient-reported GRoC and: (1) student involvement in patient care; (2) number of consultations involving students; (3) proportion of physiotherapy time involving students; or (4) frequency of student involvement in treatment delivery (p > 0.05). CONCLUSIONS: Supervised student care in private physiotherapy practice does not appear to have a detrimental impact on patient-reported outcomes. These findings may address concerns relating to student involvement in patient care within this setting. Future research should address economic and service delivery impacts of supervised student care on private practices.

"What if it doesn't unlock?": A qualitative study into the lived experiences of adults with persistent intra-articular temporomandibular disorders.

BACKGROUND: Temporomandibular disorders (TMD) are associated with increased self-reported disability and psychosocial issues, although little is known about those who specifically experience mechanical signs and symptoms such as clicking and locking. Understanding the lived experiences of individuals with persistent intra-articular TMD is an important first step to gaining insight into specific domains of self-reported disability associated with these conditions. This information can be helpful to improve clinical management of this subgroup. OBJECTIVES: To explore the lived experiences of adults with persistent intra-articular TMD, including its impact on activity, participation and psychological wellbeing, and the influence of contextual factors on disability. DESIGN: Qualitative study. METHODS: Semi-structured interviews explored the lived experiences of adults with persistent intra-articular TMD, and data were analysed using thematic analysis. Participants were recruited via convenience sampling from private physiotherapy and dental practices, and the community. RESULTS: Sixteen participants were interviewed. Four themes emerged from the data: i) The challenge of living with intra-articular TMD, ii) Living with uncertainty, iii) Seeking control, and iv) Learning to live with it. Novel findings included the impact of persistent intra-articular TMD on dreams, work, intimacy and socialising; and the role of non-pain symptoms (e.g. locking) in disability. CONCLUSIONS: Persistent intra-articular TMD are associated with numerous activity limitations, participation restrictions and psychological issues. Disability is complex and multi-directional, and influenced by various contextual factors including individuals' thoughts, beliefs and support networks. These findings emphasise the need for biopsychosocial and person-centred care in clinical practice.

Hosting pre-registration physiotherapy students in Australian private practices does not change service and economic outcomes; an economic analysis.

BACKGROUND: Despite perceived economic barriers to hosting physiotherapy students in private practice settings, no research to date has investigated the effect of hosting students on service delivery and income during clinical placements. OBJECTIVES: The aim of this study was to determine the effect of student placement provision on service delivery and income in private practice settings. METHODS: A retrospective economic analysis using a temporal synthetic control period was undertaken. Physiotherapy private practices who had hosted at least one pre-registration physiotherapy student with a matched control period in the subsequent or previous year were invited to participate. Direct service and economic comparisons were conducted across five-week periods and individual placement weeks. RESULTS: No significant differences in occasions of service and income were found when students were hosted and not hosted, and this remained non-significant after controlling for practice-specific characteristics. The overall mean income per practice was higher for week one of the student placement (95% CI: 657.35 to 1240.95) as compared to week one of the control period, but this finding was not significant. Overall mean income per practice was significantly higher in weeks two to five of the student placement (95% CI: 29.03 to 1732.19) when compared to weeks two to five of the control period. CONCLUSION: Hosting pre-registration physiotherapy students within private practice settings is not associated with a reduction in service and economic outcomes. Hosting physiotherapy students has a positive economic effect following their initial placement week.

Is jaw muscle activity impaired in adults with persistent temporomandibular disorders? A systematic review and meta-analysis.

Understanding jaw muscle activity changes in temporomandibular disorders (TMD) is crucial to guide clinical management. The nature of these changes is currently unclear. Explore changes in jaw muscle activity in TMD. Electronic databases (PubMed, EMBASE, CINAHL, Scopus, Web of Science, Cochrane) and bibliographies were searched from inception to 9 July 2020 for eligible studies, including grey literature. Case-control and interventional studies reporting time-domain and frequency-domain electromyographic measures of jaw muscle activity in TMD and control groups were included. SIGN checklist for case-control studies was used to evaluate risk of bias. Results were pooled for meta-analysis using random-effects model. Confidence in cumulative evidence was established using American Academy of Neurology guidelines. Forty-five studies were included. Most were rated moderate risk of bias. Activity of four muscles (masseter, temporalis, lateral pterygoid, suprahyoids) was assessed across six domains (resting, clenching, chewing, swallowing, concentrating, resisted mandibular movements), with partial meta-analysis scope. Masseter and temporalis activity were significantly higher at rest (P = .05, P < .0001), but lower during brief maximal clenching (P = .005, P = .04) in TMD vs controls. Insufficient data precluded meta-analysis of remaining outcomes and subgroup analysis. Confidence in cumulative evidence ranged from moderate to very low. Changes in jaw muscle activity exist in TMD, which are both task-specific and muscle-specific. It remains unclear whether jaw muscle activity changes vary between TMD subgroups. Muscle function should be considered in clinical management of TMD. Insufficient subgroup data highlight future direction for research.

Are jaw range of motion, muscle function and proprioception impaired in adults with persistent temporomandibular disorders? A systematic review and meta-analysis.

BACKGROUND: The nature of certain musculoskeletal impairments associated with temporomandibular disorders (TMD) is unclear. Understanding impairments within TMD subgroups is important to guide management. OBJECTIVES: Characterise local musculoskeletal impairments in adults with persistent TMD. METHODS: PubMed, EMBASE, CINAHL, Scopus, Web of Science and Cochrane databases were searched from inception to 12 January 2020. Bibliographies were searched for additional articles, including grey literature. Case-control and interventional studies reporting temporomandibular range of motion (ROM), muscle function (MF) or proprioception in TMD and control groups were included. Risk of bias was assessed using SIGN checklist for case-control studies. Results were pooled using random-effects model. Confidence in cumulative evidence was determined using American Academy of Neurology guidelines. RESULTS: Sixty-six studies were included, most rated moderate risk of bias. Twelve primary outcomes were assessed, with partial scope for meta-analysis. Significant reductions were found for active maximal mouth opening (P < .00001, MD=-4.65 mm), protrusion (P < .0001, MD=-0.76 mm) and maximum bite force (P < .00001) in TMD versus controls. Subgroup analysis scope was limited. Reduced AMMO was found in myogenic TMD subgroups versus controls (P = .001, MD= -3.28 mm). Few studies measured proprioception, with high methodological variability. Confidence in cumulative evidence ranged from high to very low. CONCLUSION: ROM and bite force impairments accompany TMD. Insufficient data were available to investigate impairments within TMD subgroups. IMPLICATIONS: Several musculoskeletal impairments have been identified, which may guide clinical management of TMD. Lack of subgroup data, and data for proprioception and MF, highlights future direction for research. PROSPERO: CRD42020150734.