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Review
. 2022 Nov 2;5(1):100242.
doi: 10.1016/j.arrct.2022.100242. eCollection 2023 Mar.

The Effect of Upper Cervical Mobilization/Manipulation on Temporomandibular Joint Pain, Maximal Mouth Opening, and Pressure Pain Thresholds: A Systematic Review and Meta-Analysis

Alan C Lam  1 , Lane J Liddle  2 , Crystal L MacLellan  3
Affiliations
Review

The Effect of Upper Cervical Mobilization/Manipulation on Temporomandibular Joint Pain, Maximal Mouth Opening, and Pressure Pain Thresholds: A Systematic Review and Meta-Analysis

Alan C Lam et al. Arch Rehabil Res Clin Transl. .

Abstract

Objective: To evaluate the efficacy of upper cervical joint mobilization and/or manipulation on reducing pain and improving maximal mouth opening (MMO) and pressure pain thresholds (PPTs) in adults with temporomandibular joint (TMJ) dysfunction compared with sham or other intervention.

Data sources: MEDLINE, CINAHL, EMBASE, and Cochrane Library from inception to June 3, 2022, were searched.

Study selection: Eight randomized controlled trials with 437 participants evaluating manual therapy (MT) vs sham and MT vs other intervention were included. Two reviewers independently extracted data and assessed risk of bias.

Data extraction: Two independent reviewers extracted information about origin, number of study participants, eligibility criteria, type of intervention, and outcome measures.

Data synthesis: Manual therapy was statistically significant in reducing pain compared with sham (mean difference [MD]: -1.93 points, 95% confidence interval [CI]: -3.61 to -0.24, P=.03), and other intervention (MD: -1.03 points, 95% CI: -1.73 to -0.33, P=.004), improved MMO compared with sham (MD: 2.11 mm, 95% CI: 0.26 to 3.96, P=.03), and other intervention (MD: 2.25 mm, 95% CI: 1.01 to 3.48, P<.001), but not statistically significant in improving PPT of masseter compared with sham (MD: 0.45 kg/cm2, 95% CI: -0.21 to 1.11, P=.18), and other intervention (MD: 0.42 kg/cm2, 95% CI: -0.19 to 1.03, P=.18), or the PPT of temporalis compared with sham (MD: 0.37 kg/cm2, 95% CI: -0.03 to 0.77, P=.07), and other intervention (MD: 0.43 kg/cm2, 95% CI: -0.60 to 1.45, P=.42).

Conclusion: There appears to be limited benefit of upper cervical spine MT on TMJ dysfunction, but definitive conclusions cannot be made because of heterogeneity and imprecision of treatment effects.

Keywords: Cervical vertebrae; Manipulation, spinal; Meta-analysis; Musculoskeletal manipulations; Pain; Rehabilitation; Systematic review; Temporomandibular joint.

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Figures

Fig 1
Fig 1
Flow of trial selection based on Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.
Fig 2
Fig 2
Risk of bias in the included studies. For each domain the - indicates high risk of bias, a question mark indicates some or unknown risk of bias, and a checkmark indicates low risk of bias.
Fig 3
Fig 3
(A) Forest plot depicting mean difference (95% CI) of the effect of upper cervical manual therapy vs sham intervention on subjective pain ratings. (B) Funnel plot to assess publication bias in trials comparing cervical manual therapy and sham interventions that assessed subjective pain ratings. (C) Forest plot depicting mean difference (95% CI) of the effect of upper cervical manual therapy vs other intervention on subjective pain ratings. (D) Funnel plot to assess publication bias in trials comparing cervical manual therapy vs other interventions that assessed subjective pain ratings. Overall, the forest plots returned significant results, demonstrating that MT improved subjective pain ratings, but the studies were heterogenous and publication bias was difficult to assess.
Fig 4
Fig 4
(A) Forest plot depicting mean difference (95% CI) of the effect of upper cervical manual therapy vs sham interventions on maximal mouth opening. (B) Funnel plot to assess publication bias in trials comparing cervical manual therapy and sham interventions that assessed maximal mouth opening. (C) Forest plot depicting mean difference (95% CI) of the effect of upper cervical manual therapy vs other interventions on maximal mouth opening. (D) Funnel plot to assess publication bias in trials comparing cervical manual therapy vs other interventions that assessed maximal mouth opening. Overall, both forest plots showed improved MMO in MT-treated patients, and studies did not appear to be heterogenous. Publication bias was difficult to assess via funnel plots and Egger regression.
Fig 5
Fig 5
(A) Forest plot depicting mean difference (95% CI) of the effect of upper cervical manual therapy vs sham interventions on pressure pain threshold of the masseter. (B) Funnel plot to assess publication bias in trials comparing cervical manual therapy and sham interventions assessing pressure pain threshold of the masseter. (C) Forest plot depicting mean difference (95% CI) of the effect of upper cervical manual therapy vs other interventions on pressure pain threshold of the masseter. (D) Funnel plot to assess publication bias in trials comparing cervical manual therapy and other interventions assessing pressure pain threshold of the masseter. Overall, the forest plots demonstrated significant heterogeneity, with no significant effect of MT on PPT thresholds of the masseter muscle, and publication bias was difficult to assess.
Fig 6
Fig 6
(A) Forest plot depicting mean difference (95% CI) of the effect of upper cervical manual therapy vs sham intervention on pressure pain threshold of the temporalis. (B) Funnel plot to assess publication bias in trials comparing cervical manual therapy and sham interventions assessing pressure pain threshold of the temporalis. (C) Forest plot depicting mean difference (95% CI) of the effect of upper cervical manual therapy vs other intervention on pressure pain threshold of the temporalis. (D) Funnel plot to assess publication bias in trials comparing cervical manual therapy and other interventions assessing pressure pain threshold of the temporalis. Overall, the forest plots demonstrated significant heterogeneity, with no significant effect of MT on PPT thresholds of the temporalis muscle, and publication bias was difficult to assess.
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