I PHYSICAL THERAPY

Manual Physical Therapy Interventions and Exercise for Patients with Temporomandibular Disorders
Eric S. Furto, P.T.; Joshua A. Cleland, D.P.T., Ph.D.; Julie M. Whitman, P.T., D.Sc.; Kenneth A. Olson, P.T., D.H.Sc.

0886-9634/2404000$05.00/0, THE JOURNAL OF CRANIOMANDIBULAR PRACTICE, Copyright 2006 by CHROMA, Inc.

Manuscript received March 16, 2006; revised manuscript received July 10, 2006; accepted August 1, 2006 Address for reprint requests: Eric S. Furto, P.T. Newsome Rehabilitation, Inc. 920 Essington Rd. Joliet, IL 60544 E-mail: niupt2k@yahoo.com

ABSTRACT: The purpose of this study was to investigate the outcome of a series of consecutive patients with temporomandibular disorder (TMD) who were treated with manual physical therapy interventions and exercise. Consecutive patients with the clinical presentation of TMD completed several self-report measures and underwent a standardized historical and physical examination. Following the examination, patients received a multimodal treatment approach incorporating manual physical therapy and exercise. All self-report questionnaires were completed at a 2-week follow-up. Paired t-tests were performed between the baseline and 2-week follow-up scores. The mean TMD Disability Index scores were 32.1% (15.4%) at baseline and 18.3% (12.5%) at the 2-week follow-up, representing an improvement of 13.9% (CI: 8.2%, 19.5%) (p<0.05). Patient Specific Functional Scale (PSFS) scores improved 3.1 points (CI: 2.3, 3.9) (p<0.05). These results suggest that patients with TMD who are treated with a rehabilitation program including manual physical therapy interventions plus exercise, with or without iontophoresis with dexamethasone, can demonstrate clinically meaningful improvements in disability and overall perceived change in a relatively short period of time.

O
Eric Furto is a physical therapist in the Newsome Physical Therapy Center in Plainfield, Illinois and is on faculty at the University of St. Augustine for Health Sciences in St. Augustine, Florida. He obtained his bachelor of physical therapy degree in 2000 from Northern Illinois University. Additionally, Mr. Furto serves as a continuing education instructor on spinal manipulation for the University of St. Augustine.

ver ten million people in the United States suffer from temporomandibular disorders (TMD). 1 Temporomandibular disorders are classified as a musculoskeletal condition resulting in craniofacial pain, functional limitations and disability.2 Symptoms associated with TMD can include temporomandibular joint (TMJ) pain, decreased jaw mobility, joint clicking, headaches, neck pain, tinnitus, and pain of the intraoral structures.3 Temporomandibular disorders may be the result of osteoarthritic degeneration, disk dislocation, or involuntary guarding of the muscles of mastication.3 The debate surrounding the effectiveness of surgical intervention for TMD has led many patients to seek conservative care for the management of their pain and associated loss of function.4,5 A retrospective cohort study by Godden, et al.5 revealed that only 50% of patients who underwent a TMJ arthroplasty viewed their outcomes as favorable. These outcomes were obtained through a six year follow-up survey and demonstrated that patients experienced a reduction in pain, as measured with the visual analog scale, to within 75% of normal; however, the majority of patients still reported their jaw opening was restricted (66%).5 These outcomes were determined

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based on subjective interpretations when they were asked if they were prepared to undergo a further arthroscopy. Conservative treatment options for TMD include occlusion correction with the use of intraoral appliances, orthodontics, cortisone injections, and joint manipulation.3,5,6 Theoretically, intraoral appliances are used to create a natural resting position of the mandible, which in turn should inhibit excessive tension in the muscles of mastication and relieve pain and improve function. 6 However, a decrease in pain does not necessarily correlate with an increase in range of motion (ROM) or improvements in jaw function.5 Manual therapy directed at the TMJ combined with exercise has been shown to be superior to treatment with soft repositioning splint therapy in the management of patients with radiographically confirmed anterior displaced temporomandibular disk syndrome (ADTMD).7 In this study, the manual therapy combined with active exercise group demonstrated significant reductions in pain and increases in ROM, while the soft repositioning splint group failed to show significant changes in either dependent measure.7 Physical therapy management of TMD often consists of manual therapy including TMJ and cervical/thoracic spine mobilization/manipulation, soft tissue mobilization, postural education/ergonomics, therapeutic exercises for neuromuscular stabilization of the TMJ, and physical modalities, such as iontophoresis, electrical stimulation, or ultrasound. 6 Rocabado 6 has described techniques to facilitate neuromuscular stabilization through the use of repetitive lateral deviation motions purportedly used to assist with mobility. Theoretically, the muscles of mastication are then recruited to apply a compressive force to the disk, thereby improving the condylar-disk-eminence congruency and ultimately improving function.6 These techniques can also be used as a proprioceptive exercise to increase functional mobility with lowered pain response.6 However, limited evidence exists to support such a treatment approach. Only preliminary evidence exists to support the use of manual physical therapy in the treatment of TMD.8-10 In a single case design, Cleland, et al.9 described the outcome of a patient with anterior bilateral disk displacement who was treated with a combination of manual physical therapy, exercise, and patient education.9 Over eight visits, the patient achieved a reduction in pain of 48.8 mm on the visual analog scale, an increase in mandibular depression of 17.5 mm, and marked improvements in all three scales of the Steigerwald/Maher TMD disability questionnaire.9,11 In a case series of 20 patients with TMD who received TMJ exercises, postural education, and relaxation techniques, 16 participants experienced a complete

resolution of pain, 13 a full return to function, and only three patients had continued ROM limitations at a six month follow-up.8,10 Furthermore, data collected on these patients at a 12-month follow-up visit continued to suggest favorable results for the use of exercise and manual therapy in the management of TMD. The evidence available regarding noninvasive care for patients with TMD is sparse, and the literature is limited by methodological shortcomings. Future studies should ultimately examine clinical outcomes for patients prospectively, including detailed descriptions of interventions provided, use of well-defined self-report instruments to capture levels of disability, and including a comparison group. The current study is the first step in this process. The purpose of this pilot study is to report clinical outcomes (pain, disability, and function) for a series of patients with TMD treated with manual physical therapy, therapeutic exercise, and iontophoresis. The results of this pilot work will facilitate the design of future randomized controlled trials, as well as develop further hypothesis formation. Materials and Methods During a six month period, fifteen participants were recruited for participation in this case series (14 females). Consecutive subjects referred to Northern Rehabilitation and Sports Medicine Associates in DeKalb, IL with nonspecific orofacial pain were examined for eligibility criteria over a 6-month period. All patients were referred from local dentists, ear-eye-nose-throat physicians, and/or general practitioners with a diagnosis of TMD or orofacial pain. Eligible patients had to present with a primary report of pain in the temporomandibular region. Eligible patients could also exhibit cervical or thoracic spine pain, headaches, radicular pain, and/or shoulder pain; however, their most bothersome area had to be the TMJ. Exclusion criteria included post surgical conditions involving the neck or temporomandibular region. All examination and treatment procedures in this case series were performed by two physical therapists. Both therapists were trained in the examination and treatment of TMD as a requirement of an American Physical Therapy Association credentialed and American Acad-emy of Orthopaedic Manual Physical Therapists recognized Manual Therapy Fellowship Program. All participants signed an informed consent approved by the Institutional Review Board at Franklin Pierce College, Concord, NH prior to the initial evaluation. Data Collection Prior to the initial examination, all participants completed a number of self-report questionnaires including:

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the TMD Disability Index, two pain diagrams and the Numeric Pain Rating Scale (NPRS). The TMD Disability Index consists of ten questions regarding disability associated with TMD, and each question is scored from 0-4. Higher scores represent greater levels of disability. The psychometric properties of this questionnaire have not been reported. The NPRS was used to capture the patients level of pain. Patients were asked to indicate the intensity of current, best, and worst levels of pain over the past 24 hours using an 11-point scale ranging from 0 (no pain) to 10 (worst pain imaginable).12-14 The average of the three ratings was used to represent the patients level of pain over the previous 24 hours. In addition, all patients completed the Patient Specific Functional Scale (PSFS).15 The PSFS is a patient-specific outcome measure, which investigates functional status by asking the patient to nominate activities that are difficult to perform based on their condition, and rate the level of limitation with each activity. The patient rates each activity on a 0-10 scale, with 0 representing the inability to perform the activity, and 10 representing the ability to perform the activity as well as they could prior to the onset of symptoms.16 The PSFS has been shown to identify changes in status and to be valid and responsive to change for patients with various clinical conditions, including neck pain,16 cervical radiculopathy, 17 knee pain, 18 and low back pain, 15 however, the PSFS has not been used to study patients with TMD. Following the completion of the self-report measures, the patients therapist performed a standardized historical and physical examination. The historical examination consisted of recording the patients age, gender, past medical history, symptom location (with the use of a body diagram), duration and nature of symptoms, relieving/aggravating activities, and prior episodes of TMJ pain. The physical examination consisted of a comprehensive evaluation of the TMJ and the upper quarter. Quantity and quality of the bilateral active and passive TMJ, cervical, and thoracic mobility were assessed as described by Paris.19,20 Active range of motion was assessed visually by asking the patient to initially maneuver his/her cervical spine throughout the cardinal planes, followed by an assessment of the thoracic spine.19,20 Passive mobility of the cervical spine was assessed by applying overpressure in the direction of the ROM being tested actively.19,20 Temporomandibular joint active range of motion was assessed by asking the patient to actively depress the mandible, laterally deviate the mandible bilaterally, and protrude the mandible.6,22 The motion was quantified in millimeters utilizing a millimeter ruler between the central incisors of the mandibular and maxillary row. 6,22

Passive overpressure was not applied for the TMJ. The quality of the motion was also assessed for compensatory motions, visible through lateral condylar motion, throughout the range. Accessory motion and joint play of the TMJ, cervical spine and thoracic spine were also assessed in combination with the patients pain response (either increased symptoms, no change, or decreased symptoms).19,20 Each cervical and thoracic vertebral segment was assessed for passive intervertebral mobility. 19,20 Capsular mobility of the temporomandibular joint was assessed by applying a long axis distraction through the mandible for six repetitions.6,22 Other assessments applied included an anterior mandibular glide, a medial mandibular glide, and a lateral mandibular glide.6,22 Mobility was graded on a 0 to 6 scale with three indicating normal capsular mobility, six being unstable, and zero being ankylosed. 19,20 Tissue tension and flexibility were assessed for the cervical musculature, posterior subcranial musculature, and the lateral pterygoid muscles.21,22 Occlusion was also assessed by the evaluating physical therapist using maximal intercuspation (MIC). MIC assesses the closed pack position of the TMJ after swallowing. The patient is asked to bring his/her teeth together with maximal force through biting. The physical therapist can then assess the role the neuromusculoskeletal system will have with maximal muscle contraction (i.e., biting into food).6 Similar to that of a patient with rotator cuff pathology, the neuromuscular control of the musculature surrounding the TMJ can have an effect on the biomechanics of the mandible and directly affect MIC. The MIC can be compared to the loose pack position of the mandible, or freeway space, where the teeth rest together without biting.6,22 If there is a shift with biting during MIC, the neuromuscular control of the muscles of the TMJ are likely participating in the pathology.6,22 Interventions The patients therapist used an impairment-based manual physical therapy approach for the treatment of the TMJ, cervical spine, thoracic spine, posture, and the use of iontophoresis as indicated. In an impairment-based model of care, the therapist prioritizes identified physical impairments in the order of hypothesized importance or contribution to the patients disorder. The therapist then provides treatment, or interventions, targeting these identified physical impairments, such as joint mobility restrictions, muscle length limitations, postural limitations and neuromuscular deficits. Manual physical therapy directed at identified impairments of the cervical spine consisted of nonthrust manipulations for facet upglides and downglides to facilitate

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normal facet joint motion, subcranial forward bending and sidebending non-thrust manipulations, and subcranial myofascial distraction.19,20 Stretches to the surrounding cervical musculature were also applied as described by Kendal.21 Non-thrust temporomandibular joint manipulations consisted of long axis distraction, medial glide, and lateral glide as described by Rocabado.22 Acupressure techniques were also applied to the lateral pterygoid musculature.22 All treatment applications are described in Table 1. Each patient was instructed in a condylar remodeling exercise program as described by Rocabado.22 Phase one of this program consists of painfree lateral deviation away from the side of pain or hypermobility as determined with accessory motion testing with a 0.5 inch piece of surgical tubing resting between the mandibular and maxillary row of teeth. If pain is bilateral, the device is maneuvered away from the side of greatest hypermobility. If painfree, a bite is incorporated.6 The patient was

Table 1 Descriptive Characteristics of Participating Patients at Baseline (N=15)

Number (%) Variable of Patients* Age (years), mean (SD) 50.5 (15.5) Sex - female 14 (93%) - male 1 (7%) Race - Caucasian 15 (100%) Median duration of TMD symptoms (range) 6 mos. (0.07-120) Depression (self-report) 6 (40%) Symptom descriptions 15 (100%) TMJ region symptoms 3 (20%) - bilateral - painful 13 (87%) - sharp 3 (20%) - dull 2 (13%) - aching 13 (87%) Headache symptoms 13 (87%) - median duration 6 mos. (0.07-60) symptoms (range) - dizziness associated 2 (13%) with headache 9 (60%) Cervical spine symptoms - median duration symptoms (range) 30 mos. (2-252) - bilateral symptoms 6 (40%) Thoracic spine symptoms 7 (47%) 5 (33%) Upper extremity symptoms - bilateral symptoms 2 (13%) *n (%) provided unless otherwise noted

instructed to release the contraction before returning to midline. The third phase consists of the same submaximal contraction as phase two, but the contraction is maintained until the tubing returns to midline. The fourth through sixth phases are similar to phases one through three, but are performed for protrusion rather than lateral deviation. Patients were instructed to perform six repetitions every two hours 3 (see Appendix). The exercise program was reviewed at each treatment session. The exercise program focused on ROM and stability exercises for all patients suspected to exhibit anterolateral disk translation during the clinical examination (n=8). The lateral deviation motion that accompanies the condylar reeducation exercise program has been purported to enhance mobility throughout the range of motion. This program can be converted to a controlled neuromuscular stabilization exercise program by incorporating and maintaining a bite throughout the ROM.22 In addition to the aforementioned interventions, iontophoresis with dexamathasone was incorporated with patients where ROM was restricted primarily due to pain (less than 20 mm of mandibular opening). An aqueous solution of 2.5 cc dexamethasone was applied superficially at 40 milliamps minutes to the affected TMJ. The treatment was applied for fifteen minutes and then removed. Follow-Up At the two-week follow-up visits, all patients again completed the TMD Disability Index, PSFS, body diagrams, and NPRS. In addition, all patients completed the Global Rating of Change scale.23 Patients were asked to rate their overall perception of improvement since beginning physical therapy on a scale ranging from 7 (a very great deal worse) to zero (about the same) to +7 (a very great deal better). It is recommended that scores on the GROC between 1 and 3 represent small changes, scores between 4 and 5 represent moderate changes, and scores of 6 or 7 convey large changes in patient status.23 Statistical Analysis Descriptive information including patient gender, age, duration of symptoms, number of physical therapy visits, and interventions provided was recorded for all patients. The mean change score and associated 95% confidence intervals were calculated for all outcome measures assessed at baseline and at the 2-week follow-up. Paired t-tests were performed between the baseline and 2-week follow-up scores (=0.05) to evaluate if the change experienced was significant over time.

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Results All participants were asked to complete the TMD Disability Index, with three (20%) participants electing to bypass the question regarding the level of sexual function limitation. Demographics for all patients can be found in Table 1. The median length of symptoms in the region of the TMJ was six months (range 0.07-120 months). Thirteen (87%) of the patients also experienced headache symptoms with the median duration also being six months (range 0.07 to 60 months). As recorded by the PSFS, the following percentage of patients noted difficulty chewing, yawning, talking, and opening the jaw, respectively: 15 (100%), seven (47%), four (27%), and one (7%). At the two-week follow-up session, the group had received a mean of 4.3 physical therapy intervention sessions. Specific interventions received can be found in Table 2. The mean TMD Disability Index scores were 32.1% at baseline and 18.3% at the 2-week follow up, representing an improvement of 13.9% (CI: 8.2%, 19.5%) (p<0.05) (Figure 1). Eleven patients (73%) reported they were somewhat better to a very great deal better on the GROC (Table 3), and Patient Specific Functional Scale (PSFS) scores improved 3.1 points (CI: 2.3, 3.9) (p<0.05) (Figure 2). Discussion There currently is a lack of conclusive evidence to support the use of conservative management strategies in the management of TMD. The purpose of this study was to describe the outcomes of a cohort of patients undergoing physical therapy management of their TMD. Outcomes were favorable for all patients in this study and are similar to findings of Nicolakis, et al.8 who provided a six and twelve month follow-up supporting the use of manual therapy and exercise with a case series of twenty patients with TMD.10 Interventions used in the Nicolakis, et al.8 study were similar this study and included nonthrust manipulative therapy directed at the TMJ and an isometric exercise program aimed at maximizing stability of the TMJ. We have provided a detailed description of the interventions used to treat TMD in this pilot study and used physical impairment as well as self-report outcomes to capture the patients levels of pain and disability. Our patients, similar to those in the Nicolakis, et al.8 case series, demonstrated an overall reduction in pain and improvement in function following two weeks of physical therapy management. During a six-month period, fifteen participants received intervention for their TMD complaints.10 Of the 15 patients treated in this pilot study,

Table 2 Number (Percentage) of Patients (n=15) Treated With Various Physical Therapy Interventions
Manual technique Cervical spine manipulation - subcranial (occiput-C2) - cervical spine (C2-C7) TMJ manipulation Thoracic spine manipulation Postural education Iontophoresis to the TMJ Number (%) of Patients 11 (73%) 6 (40%) 15 (100%) 4 (27%) 12 (80%) 5 (33%)

13 also experienced headache symptoms at the time of the initial examination. It is hypothesized that poor posture with increased posterior rotation of the cranium on the atlas will place undue strain on the posterior occipital musculature.6,22 This strain may impinge upon the greater occipital nerve and may result in referred pain into the craniofacial region, most typically into the distribution of the trigeminal nerve.24 In a study by Aprill, et al.25 it was discovered that 21 of 34 participants who underwent a nerve block to C1/C2 experienced complete resolution of their headache symptoms. These findings are indicative of the comorbidity between TMJ pain and headache and may also support the possibility of referred pain to the TMJ from the subcranial spine. Therefore, it is possible that participants in the study may have not experienced symptoms related to the TMJ, but they could also have been experiencing symptoms referred from the cervical spine. The exercise program used in this pilot study was aimed at neuromuscular reeducation of the musculature surrounding the temporomandibular joint (Appendix). The exercises prescribed to each patient used a piece of tubing in a similar fashion to that of an anterior loading splint. 6 The piece of tubing was placed between the incisors and a series of motions were performed and combined with biting. Once the patient was able to perform painfree lateral deviation with the exercise program, they were instructed to perform protrusion. Lateral deviation is typically performed initially to ensure appropriate ROM of the affected TMJ before recruiting the opposite joint during protrusion. The patients were instructed to perform the exercises in a pain free fashion, every two hours to enhance functional joint stability.6 Exercise has been shown to be effective in the management of TMD. In a randomized clinical trial, Yoda, et

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Figure 1 TMD Disability Index scores at baseline and at 2-week follow-up.

al.26 compared an exercise program to education on the condition for patients with anterior disk displacement with reduction (ADDWR). The results demonstrated that the exercise group had statistically significant better outcomes for decreased pain and increased ROM (p=0.0001). Forty-two patients participated in the study, of which 61.9% of the exercise group had favorable outcomes (13/21 patients), while 0% of the control group had favorable results.26 Success was measured on the severity of

joint sounds and/or pain with maximal mouth opening. Of the 13 patients that experienced a successful outcome, only 23.1% (three) of the patients TMJ disks were actually recaptured when reexamined on MRI. The authors reported that the 61.9% success rate experienced by the exercise group is similar to that of splint therapy but is a more cost effective option.26 The exercises proposed by Yoda, et al.26 differ from those proposed by Rocabado22 in that maximal ROM is

Figure 2 Patient Specific Functional Scale scores at baseline and at 2-week follow-up.

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required in the Yoda approach from the initiation of the exercise program. In many cases, painful ROM is the reason for consultation by a physical therapist, thus making maximal ROM to the point of reduction a difficult starting point for the initiation of exercises. The program described by Rocabado22 and used in the current study encourages small ranges of motion into lateral deviation, which may accomplish the same objective: reduced pain and improved function. While research exists to support the use of exercise in the management of TMD, limited evidence exists to support the specific exercise regimen used in this study.6,26,27 Additionally, we included the use of iontophoresis with dexamethasone in the treatment of patients within this pilot study. While dexemethasone has been demonstrated to be effective in reducing pain and inflammation, the delivery method of iontophoresis has been questioned. In a study by Majwer, et al.,28 27 of 32 cases of post-traumatic TMD benefited with decreased pain from the application of dexamethasone (n=8) or xylocane (n=24) through iontophoresis. Since different medications were used, it is possible that the patients benefited most from the electrical stimulation of the iontophoresis rather than the medication itself. The present study allows for hypothesis formulation and the development of a future randomized clinical trial. Follow-up studies should include examining the effectiveness of exercise and manual physical therapy when compared to other conservative treatment approaches. The patients in this study exhibited positive outcomes after receiving only two weeks of the above described multimodal physical therapy treatment regimen. Limitations of the current study include the lack of a control or comparison group which precludes the ability to infer a cause and effect relationship between the treatment and outcomes, as well as, only short-term outcomes are provided in this report. It is the aim of the authors to identify the long-term effects of the treatment interventions used in this pilot study and determine if a specific subgroup of patients with TMD exists that would be most likely to benefit from exercise and manual physical therapy. Conclusion

Clinical decision making rules may also be established to enhance the identification of particular patients that are likely to respond rapidly and dramatically to specific interventions. References
1. 2. 3. 4. 5. 6. 7. TMJ Diseases & Disorders - Basics - Overview. www.tmj.org/basics.asp. Merskey H, Bogduk N: Classification of chronic pain. Seattle, WA: IASP Press, 1994. Kraus S: Clinics in Physical Therapy: temporomandibular joint disorders. New York: Churchill Livingstone, 1994. Dolwick MF, Dimitroulis G: Is there a role for temporomandibular joint surgery? Br J Oral 1994; 32:307-313. Godden DRP, Robertson JM: The value of patient feedback in the audit of TMJ arthroscopy. Br Dent J 2000; 188:125. Rocabado M: Intermediate craniofacial. Chicago; 2003. Carmeli E, Sheklow S, Bloomenfeld I: Comparative study of repositioning splint therapy and passive manual range of motion techniques for anterior displaced temporomandibular disks with unstable excursive reduction. Physiother 2001; 87:26-36. Nicolakis P, Burak EC, Kollmitzer J, Kopf A, Piehslinger E, Wiesinger GF, Fialka-Moser V: An investigation of the effectiveness of exercise and manual therapy in treating symptoms of TMJ osteoarthritis. J Craniomandib Pract 2001; 19:26-32. Cleland J ,Palmer J: Effectiveness of manual physical therapy, therapeutic exercise, and patient education on bilateral disk displacement without reduction of the temporomandibular joint: a single-case design. J Orthop Sports Phys Ther 2004; 34:535-548. Nicolakis P, Erdogmus B, Kopf A, Ebenbichler G, Kollmitzer J, Piehslinger E, Fialka-Moser V: Effectiveness of exercise therapy in patients with internal derangement of the temporomandibular joint. J Oral Rehabil 2002; 29:362-368. Steigerwald DP, Maher JH: The Steigerwald/Maher TMD disability questionnaire. Todays Chiropractic 1997; July-August:86-91. Jensen MP, Karoly P, Braver S: The measurement of clinical pain intensity: a comparison of six methods. Pain 1986; 27:117-126. Childs JD, Piva S, Fritz JM: Responsiveness of the numeric pain rating scale in patients with low back pain. Spine 2004: Pengel HM, Refshauge K, Maher C: Responsiveness of pain, disability, and physical impairment outcomes in patients with low back pain. Spine 2004; 29:879-883. Stratford P, Gill C, Westaway M, Binkley J: Assessing disability and change of individual patients: a report of a patient-specific measure. Physiother Can 1995; 47:258-263. Westaway M, Stratford P, Binkley J: The Patient Specific Functional Scale: validation of its use in persons with neck dysfunction. J Orthop Sports Phys Ther 1998; 27:331-338. Cleland JA, Fritz JM, Whitman JM, Palmer J: Construct validity of the Neck Disability Index and Patient Specific Functional Scale in a patient population with cervical radiculopathy. Spine In Press Chatman A, Neel J, Hyams S: The Patient Specific Functional Scale: measurement properties in patients with knee dysfunction. Phys Ther 1997; 77:820-829. Paris SV: Intro to spinal manipulation. 2000; S1. Paris SV: Advanced manipulation of the cervical spine. 2000; S3. Peterson-Kendall F, Kendall-McCreary E, Provance PG: Muscle testing and function. Baltimore: Williams and Wilkins, 1993. Rocabado M, Iglarsh Z: Musculoskeletal approach to maxillofacial pain. New York: JB Lippincott Co., 1991. Jaeschke R, Singer J, Guyatt G: Measurement of health status. Ascertaining the minimal clinically important difference. Controlled Clinical Trials 1989; 10:407-415. Packard RC: The relationship of neck injury and post-traumatic headache. Curr Pain Headache Rep 2002; 6:1-7. Aprill C, Axinn M, Bogduk N: Occipital headaches stemming from the lateral atlanto-axial (C1-C2) joint. Cephal 2002; 22:15-22. Yoda T, et al.: A randomized controlled trial of therapeutic exercise for clicking due to disk anterior displacement with reduction in the temporomandibular joint. J Craniomandib Pract 2003; 21:10-16. Deodato F, Cristiano S, Trusendi R, Giorgetti R: A functional approach to the TMJ disorders. Prog Orthod 2003; 4:20-37. Majwer K, Swider M: Results of treatment with iontophoresis of posttraumatic changes of temporomandibular joints with an apparatus of own design. Prothet Stomatol 1989; 39:172-176.

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19. 20. 21. 22. 23.

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The results of this study demonstrate that physical therapy intervention consisting of manual therapy, a specific exercise program, and iontophoresis with dexamethasone can be beneficial to patients presenting with symptoms similar to that of TMD. Future research should focus on the specific interventions as described above to determine the most beneficial form of treatment.

25. 26.

27. 28.

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Appendix

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Dr. Joshua A. Cleland is currently an assistant professor at Frankline Pierce College and is the research coordinator at Rehabilitation Services of Concord Hospital. He recently completed a fellowship in the manual therapy program through Regis University in Denver, Colorado. Dr. Clelands research interest includes investigating the effectiveness of manual therapy and exercise in patients with extremity and spinal disorders. He recently authored a text on the orthopedic clinical examination and has published numerous articles in peer reviewed journals.

Dr. Kenneth A. Olson is president of the physical therapy private practice, Northern Rehabilitation and Sports Medicine Associates in DeKalb, Illinois. Dr. Olson is also a guest lecturer at Marquette University and serves as a mentor for the University of St. Augustine Manual Therapy Fellowship program. He graduated with a B.S.P.T. from Northern Illinois University, a Master of Science in orthopedic physical therapy from the University of St. Augustine, and a Doctor of Health Science USA. He is also a graduate of the USA Manual Therapy Fellowship Program.

Dr. Julie M. Whitman is an assistant professor in the Department of Physical Therapy at Regis University in Denver, Colorado. She received an M.P.T. degree from the U.S. Army-Baylor University Graduate Program in Physical Therapy from Baylor University in 2001. She completed a manual physical therapy residency program in 2000 and has over 12 years of primary care physical therapy experience in the civilian and military environments. Dr. Whitman is actively involved in clinical research relating to orthopedic/manual physical therapies for musculoskeletal disorders and has over 20 publications in these areas.

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