Lee et al.

BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 BMC Sports Science, Medicine
https://doi.org/10.1186/s13102-023-00644-0
and Rehabilitation

RESEARCH Open Access

Effectiveness of manual therapy

and cervical spine stretching exercises
on pain and disability in myofascial
temporomandibular disorders accompanied
by headaches: a single-center cohort study
In-su Lee1 and Suhn-yeop Kim2*

Abstract
Background Previous studies have demonstrated a relationship between headaches and temporomandibular
disorders (TMDs). Moreover, recent studies have shown functional, anatomical, and neurological associations between
the temporomandibular joint (TMJ) and upper cervical spine. This study aimed to investigate the effectiveness
of manual therapy and cervical spine stretching exercises for pain and disability in patients with myofascial TMDs
accompanied by headaches.
Methods Thirty-four patients recruited from Gyeryong Hospital with headaches and diagnosed with TMDs were
randomly assigned to the experimental (n = 17) and control (n = 17) groups. Headache impact was assessed using
the Korean Headache Impact Test-6. Masseter myofascial pain was measured using the visual analog scale, and
TMJ pressure pain threshold levels were evaluated using an algometer. Neck pain intensity was assessed using
the numerical rating scale. Once per week for 10 weeks, the experimental group received cervical spine-focused
manual therapy and stretching exercises alongside conservative physical therapy, and the control group received
conservative physical therapy alone. Patients were evaluated at baseline and 5 and 10 weeks post-intervention.
Results After the intervention, the experimental group exhibited significant reductions in the cervical kyphotic angle,
Korean Headache Impact Assessment score, neck pain intensity, TMJ pain pressure threshold, Neck Disability Index
score, and Jaw Functional Limitation Scale level compared with the control group (p < 0.01).
Conclusion Manual therapy and stretching exercises could help resolve TMDs accompanied by headaches through
biomechanical changes in the cervical spine. These findings may guide protocols and clinical trials involving manual
therapy that align morphological structures.
Keywords Cervical spine, Conservative therapy, Headache, Manual therapy, Neck pain, Temporomandibular disorders

2
*Correspondence: Department of Physical Therapy, College of Health and Medical Science,
Suhn-yeop Kim Daejeon University, 62 Daehak-ro, Dong-gu, Daejeon
[email protected] 34520, Republic of Korea
1
Department of Physical Therapy, Graduate School, Daejeon University,
Daejeon, Republic of Korea

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Lee et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 Page 2 of 11

Background variety of associated techniques [16]. Research suggests

Temporomandibular disorder (TMD) is the second most that manual therapy for TMD could be beneficial in tar-
common musculoskeletal disorder that causes pain and geting the oral facial region and cervical spine [16]. The
disability [1]. TMDs are associated with various abnor- purpose of stretching is to restore the efficiency of lubri-
malities that promote structural and functional dysfunc- cation and stimulate the synthesis of glycol-aminoglycan
tions [2], which in turn result in symptoms and signs between collagen fibers that allow movement in the peri-
associated with the masticatory muscles and temporo- articular structures. Stretching exercises are beneficial for
mandibular joint (TMJ) [3]. TMDs primarily prevent both arthrogenous and myogenous TMDs [17]. There-
chewing, swallowing, and speaking. The most common fore, manual therapy and stretching for the cervical spine
symptom is pain in the upper portion of the face dur- could increase the efficacy of interventions in patients
ing mastication [4]. Several clinical and epidemiological with TMDs or those who cannot undergo manual ther-
studies have reported an association between headaches apy to the mandible. Notably, various authors considered
and TMDs through the efforts of TMJ specialists who it appropriate to apply the same type of manual therapy
develop the best evidence-based paradigms by integrat- to the cervical spine area, particularly the upper cervical
ing clinical reasoning with up-to-date neurophysiological spine, with a TMD-focused approach [18].
evidence [5, 6]. Regarding the association between the neck, headache,
Recently, functional, anatomical, and neurophysiologi- and TMJ, it can be hypothesized that interventions tar-
cal relationships have been reported between the TMJ geting the cervical spine may also affect patients with
and upper cervical spine. Associations between the cer- TMD-related headaches. Therefore, we explored the
vical spine, TMDs, and head and neck conditions, such effects of cervical spine-focused manual therapy on head-
as neck pain (NP) and headaches, are widely recognized aches and cervical pain intensities, TMJ pressure pain
[7]. Gonçalves et al. [8] reported that individuals with threshold (PPT), cervical kyphotic angle, Neck Disability
myofascial TMDs are more likely to experience chronic Index (NDI), and Jaw Functional Limitation Scale score
daily headaches than those without myofascial TMDs. (JFLS) without administering medications to patients
Similarly, trend analysis for pain-stricken TMD groups with myofascial TMD accompanied by headaches over a
associated with an increased frequency of temporal specific period.
headaches revealed considerable exacerbation of all signs
and symptoms of TMDs [9]. Ferrillo et al. [10] reported Methods
a higher prevalence of headaches in patients with myog- Aim
enous TMD. The prevalence of these TMDs is higher in This study aimed to investigate the effectiveness of
chronic primary pain conditions related to central ner- manual therapy and cervical spine stretching exercises
vous system dysfunction, including fibromyalgia and pri- for pain and disability in patients with myofascial TMD
mary headaches, probably through the phenomenon of accompanied by headaches.
central sensitization (mainly allodynia and hyperalgesia)
[11]. Study participants
The association between NP and TMD has also been Patients who experienced headaches and were diag-
studied extensively [10]. There is evidence regarding nosed with one or more symptoms of TMD (such as TMJ
the relationship between cervical spine impairment and pain, mouth-opening restrictions, and TMJ clicks) at the
TMDs, as shown by a significant correlation between Gyeryong Hospital (Gyeryong-si, Chungcheongnam-do,
jaw and neck disabilities (r = 0.82) and the finding of sig- South Korea) from July to September 2022 were included
nificantly greater pain during neck movement in patients in this study. The required sample size was calculated
with TMDs than in asymptomatic persons [12]. based on Cohen’s sampling formula using the G-power
Moreover, patients with TMDs exhibit reduced neck program (G*Power ver. 3.1.9.4; University of Kiel, Kiel,
flexor and extensor muscle endurance [13]. The authors Germany). The effect size, significance level, and power
previously analyzed TMJ pain, TMD disability levels, and were set to 0.25, 0.8, and 0.8, respectively. The inclusion
the severity of the cervical kyphotic angle and reported and exclusion criteria were based on the study of La Tou-
that greater TMD disability was associated with an che et al. [18].
increased cervical kyphotic angle [14]. The inclusion criteria were as follows: (1) headaches
Catanzariti et al. [15] reported that patients with NP experienced after the diagnosis of TMD, accompanied by
may respond to interventions applied to the TMJ and one or more symptoms such as mouth-opening restric-
that techniques applied to the cervical spine may also tion, TMJ pain, and TMJ clicks; (2) a Korean Headache
affect the TMJ. Manual therapy can be classified into the Impact Test-6 (KHIT-6) score of ≥ 50 points indicating
following three main types: manipulation, mobilization, the need for medical care [19]; (3) ability to participate
and soft tissue (muscle energy) approaches, with a wide in the experiment (from 24 h before the assessment and
Lee et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 Page 3 of 11

during the intervention period) without using analgesics to assess headache intensity in patients. It comprises six
or muscle relaxants; (4) met the primary Diagnostic Cri- questions that evaluate social functioning, role func-
teria for TMD (DC/TMD) Axis I, Group I: muscle disor- tioning, cognitive functioning, psychological distress,
ders (including myofascial pain with and without mouth and vitality. Each question contains six items, each with
opening limitation) [20]; (5) a pain intensity of ≥ 30 mm five response options (never, 6; rarely, 8; sometimes,
in the masseter muscle fascia on the 100-mm visual 10; very often, 11; and always, 13 points). Total scores
analog scale (VAS), according to the diagnostic crite- of 36 and 78 indicate mild and excruciating headaches,
ria described by Bergman [21]; (6) a history of pain of at respectively, and total scores of ≥ 50 indicate the need
least three months before the study; and (7) understand- for medical care and specialist consultation [19]. In this
ing of the purpose of the study and provision of written study, patients with KHIT-6 scores of ≥ 50 who therefore
informed consent. required medical care were targeted. A study by Kosinski
The exclusion criteria were as follows: (1) the DC/ et al. [22] revealed that the HIT-6 had an internal consis-
TMD Axis I, Group II: including disc displacement with tency of 0.89 and Cronbach’s alpha (α) values of 0.80 and
or without reduction and mouth opening limitation; or 0.90. Headache intensity was evaluated at baseline and 5
Group III: arthralgia, arthritis, and arthrosis [20]; (2) a and 10 weeks post-intervention.
history of traumatic injury to the mandible or neck; (3)
diagnosis of a systemic disease (rheumatoid arthritis, sys- Cervical function and pain level
temic iris lupus, or psoriasis arthritis); (4) fibromyalgia Cervical kyphotic angles
syndrome; (5) nervous system disorders, such as trigemi- A radiographic imaging device (PRIMA; Fujifilm Co.,
nal neuralgia; (6) history of any form of treatment (such Tokyo, Japan) was used to measure the cervical kyphotic
as physical therapy, splint therapy, acupuncture, or Botox angle. Depending on the patient’s age, sex, and physique,
treatment) within three months preceding the study; (7) the exposure was administered for 0.02 s at 200 mA,
inability to stand upright for radiographic evaluation; and 70–80 kV, and at a distance of approximately 2 m. The
(8) congenital deformities of the head and neck areas. images were captured using digital films.
The patients’ radiographs were obtained with the
Procedures Frankfurt plane parallel to the floor and the jaw in the
The study’s purpose and procedures were explained intercuspal position. The average value of the angles mea-
to the participants. Subsequently, only those who pro- sured from the imaging data was used for the analysis
vided written consent to participate were included. The (Fig. 2).
patients were evaluated using a pre-prepared question- The cervical kyphotic angle was measured at base-
naire to determine eligibility. To meet the inclusion cri- line and 5 and 10 weeks post-intervention based on the
teria, after ruling out dental pain, patients who reported Ishihara index (ISHIHAR-I). The category of 5–25% is
referred pain in response to masticatory muscle palpa- defined as the normal range; >25% is defined as excessive
tion were diagnosed as having masticatory myofascial forward bending; 0–5% is defined as straightening; and
pain. Patients who met the criteria for arthralgia and/or < 0% is defined as kyphosis [23]. Takeshita et al. [23] dem-
intraarticular TMD were excluded. onstrated a significant correlation (95% confidence inter-
First, the Headache Impact Assessment Questionnaire val [CI]: 0.94–0.96) between ISHIHAR-I and the cervical
was used to select patients with a KHIT-6 score of ≥ 50 kyphotic angle (C2–7).
points, indicating the need for medical care [19]. The
masseter muscle fascia was measured by the VAS after NDI
the cervical kyphotic angle was measured radiographi- The NDI is a self-rated evaluation tool used to assess the
cally. Further, the neck disability level, jaw functional limitations in daily life due to NP. Individual item scores
limitation, and TMJ PPT levels were evaluated. Active range from 0 (no disability) to 5 (total disability), with a
participation was encouraged through wired and wire- total possible score of 50. Higher total scores indicate a
less telephone consultations. The study design is illus- greater severity of neck disorder. Scores of 0–4, 5–14,
trated in Fig. 1. The study was conducted after obtaining 15–24, 25–34, and ≥ 35 are classified as no, mild, moder-
approval from the Agency Bioethics Committee of Dae- ate, severe, and complete disability, respectively. Vernon
jeon University during the design phase (Approval No. and Mior [24] identified eight studies and measured the
1040647-202006-HR-003). test-retest reliability of the NDI with a high consistency
of 0.90–0.93. Furthermore, results from seven of the
Evaluation methods and measurement tools studies revealed that the measured Cronbach’s α values
Headache intensity: KHIT-6 ranged from 0.74 to 0.93. The NDI was measured at base-
The Korean version of the Headache Impact Assessment line and 5 and 10 weeks post-intervention..
Questionnaire standardized by Chu et al. [19] was used
Lee et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 Page 4 of 11

Fig. 1 Study flow diagram

NP intensity
NP intensity was assessed based on the intensity of pain in this study. The internal consistency of the JFLS-20 is
experienced by the participants during the study using reportedly 0.90, whereas that of the JFLS-8 ranges from
the numerical rating scale (NRS). The NRS is a pain mea- 0.84 to 0.86, indicating excellent reliability, sensitivity, and
surement tool developed by Sartain and Barry [25] that validity [26]. Furthermore, the JFLS-8 was abbreviated for
presents a single question, after which the current pain the evaluation of TMDs [26]. Each item of the JFLS-8 was
is scored numerically. Its advantage is that its reliability coded as 0–3 (0 = 0; 1 = 1–3; 2 = 4–7; and 3 = 8–10) and
(r = 0.90) is verified, allowing pain evaluation to be con- scored. When coded, the reliability increased from 0.67
ducted in the outpatient department or over the phone. to 0.82, and the intra-class correlation coefficient (ICC)
The scores are assigned as follows: 0, no pain; 1–3, mild was 0.82 [26]. The JFLS-8 was administered at baseline
pain; 4–6, moderate pain; and 7–10, severe pain. Higher and 5 and 10 weeks post-intervention.
scores indicate more severe pain. The NP level was evalu-
ated at baseline and 5 and 10 weeks post-intervention. TMJ PPT assessment
The pressure pain threshold was measured using an
Jaw function and pain intensity: JFLS-8 algometer (Baseline; Fabrication Enterprises, Inc., Irving-
The Jaw Functional Limitation Scale-20 (JFLS-20) evalu- ton, NY, USA) to assess TMJ pain levels. The device was
ates functional jaw impairment. However, this scale pointed toward the skin, overlaying a tender point in the
includes sexual questions that do not conform to Korean TMJ (masseter muscles). The average score was calcu-
culture; therefore, its short version, the JFLS-8, was used lated to obtain a single score.
Lee et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 Page 5 of 11

Fig. 2 Formula for calculating the Ishihara index using radiographic images: (Ishihara index (%) = ([a1 + a2 + a3 + a4] / A) × 100)

According to Chesterton et al. [27], when this assess- Conservative physical therapy
ment was applied to healthy individuals at 5 N, the ICC Conservative physical therapy was initiated in both
was high (ICC: 0.91, 95% CI: 0.82–0.97). However, the groups, and it comprised surface heat treatment, infra-
ICC was moderate for patients with TMD (ICC: 0.64). red therapy, interference current therapy, and ultrasound
The PPT values were measured at baseline and 5 and 10 treatment, once per week for 10 weeks. The procedure
weeks post-intervention. was as follows.

Experimental procedures Manual therapy and stretching exercises of the

In total, 42 individuals with myofascial TMD accompa- cervical region
nied by headaches were recruited and 34 with minimum The protocols reported by La Touche et al. [18] and
scores ≥ 50 points on the KHIT-6 were selected. The pain Calixtre et al. [4] were used as references. Accordingly,
intensity of the trigger points in the masseter muscle of manual therapy directed at the cervical bone was per-
these patients was > 30 mm on the 100-mm VAS. The formed. Direct intervention was applied to the cervical
34 selected patients were assigned to two groups with spine for approximately 35 min (25 min for manual ther-
17 participants each: the experimental group (compris- apy and 10 min for muscle stabilization exercises), once
ing patients who received cervical spine-focused manual per week for 10 weeks. In addition, stretching exercises
therapy and stretching exercises) and the control group focused on the cervical region were applied for approxi-
(comprising patients who underwent conservative physi- mately 5 min once per week for 10 weeks. The proce-
cal therapy only). Patients were assigned using a random- dures are described in detail below:
ized allocation method (www.randomize.org). (1) Modified upper and lower cervical flexion mobili-
The intervention comprised conservative physical ther- zation (C0–C4): Patients were asked to lie supine with
apy for 60 min in both groups and an additional 40 min the cervical spine in a neutral position. The therapist
of cervical spine-focused manual therapy and stretch- held the occipital bone with the first finger and medial
ing exercises in the experimental group. Treatment was aspect of one hand, while the other hand was placed on
administered weekly for 10 weeks (10 treatment ses- the patient’s forehead. The mobilization force was suffi-
sions in total). Interventions were performed by the same cient to bend the upper and lower cervical spines as the
physiotherapist with over 20 years of experience in man- hand provided cephalic traction; caudal pressure was
ual therapy. Patients in both groups were evaluated after applied using the hand on the forehead. This technique
5 and 10 weeks of intervention. promoted flexion of the upper and lower cervical spines
(C0–C4), at a slow rate of 2 s per oscillation (0–5 Hz) for
a total of 10 min. In a previous study, this cervical flexion
Lee et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 Page 6 of 11

mobilization was used for the upper cervical spine [18]. process. The therapist’s right little finger was subse-
Furthermore, the authors’ previous study [14]revealed quently placed over the lateral border of the thenar emi-
that the shape of the cervical spine is usually kyphotic nence, and gentle pressure was applied (via the thenar
at the C3–C4 region in patients with TMD. Therefore, eminence over the little finger) in a ventral direction on
an additional procedure was performed on the C3–C4 the spinous process of C2, whereas the skull remained
region. under the control of the therapist’s right forearm. The
(2) Modified central posterior-anterior mobilization pressure applied by the index finger moved the lower
(C4–C5) [18]: Patients were asked to lie prone with the vertebra forward under the first vertebra until the slack
C1–C4 vertebrae in a neutral position. The therapist was taken up. Consequently, the first vertebra moved
placed the tip of the thumb on the posterior surface of forward under the base of the skull. This vertebra was
the C4–C5 spinous process, one thumb each on the C4– quickly moved forward until the end range was palpable,
C5 spinous processes, and the other fingers were gently and this position was maintained for at least 10 s. This
placed around the neck. Mobilization was applied at a procedure was repeated for 5 min. A study by Hall et al.
slow rate of two oscillations per second (2 Hz). This pro- [31] revealed that performing sustained natural apophy-
cedure was performed three times and lasted for 3 min seal glides on patients with a headache of upper cervical
each time, with intervening 1-min rest periods; there- origin significantly increased the flexion of the neck bone
fore, the total procedure time was 11 min. In a previ- by 15° (p < 0.001).
ous study [18], only the lower cervical region (C5) was (5) Stretching exercises in the cervical region: The
treated; however, in this study, C4 was also included in upper trapezius, scalene, semispinalis capitis, splenius
the treatment based on evidence that a kyphotic shape is capitis, and sternocleidomastoid muscles are directly
commonly observed at the C4 level in patients with TMD involved in head positioning. Misalignment of the head
[14]. and neck has been reported when these muscles are
(3) Craniocervical flexor stabilization exercises: For the shortened due to contraction [32]. Stretching exercises
craniocervical flexor stabilization exercises, we followed for the abovementioned muscles were performed with
the protocol described by Falla et al. [28], which focuses the patients seated. Each stretch was performed accord-
on the deep cervical flexor muscles. Craniocervical flex- ing to patient perception (a score of 8 on a scale of 0–10:
ion, involving neck and head flexion, was performed with 0, no stretching; 10, the maximum height of the muscle)
the patient in the supine position. Furthermore, the head at high intensity for 25–30 s.
was maintained in contact with the supporting surface
to facilitate activation of the deep craniocervical flexor Statistical analysis
musculature (particularly the longus capitis muscle), with SPSS (version 25.0; IBM Corp., Armonk, NY, USA)
minimal activity of the superficial cervical flexors (ster- was used for all statistical analyses. Descriptive statis-
nocleidomastoid and scalene muscles) [29]. The contrac- tics (means and standard deviations) and frequency
tion was confirmed using a pressure sensor (Stabilizer; analyses were used to assess the baseline characteristics
Chattanooga Group, Inc., Chattanooga, TN, USA). In of patients. The Shapiro–Wilk test was performed to
addition, the patients were instructed to maintain the determine data distribution normality in both groups.
pressure using visual feedback for 10 s, with no contrac- Repeated-measures analysis of variance, with time (pre-
tion of the superficial neck flexor muscles. The therapist intervention, after 5 and 10 weeks of intervention) as the
assessed the condition of the muscles by facilitation and within-subject variable, was performed to investigate
confirmed that the patient could maintain a pressure of the effect of cervical spine-focused manual therapy and
20–22 mmHg at the target level of the head–neck flex- stretching exercises on pain and disability in patients with
ion for 10 s, without flexing the superficial neck muscles myofascial TMD accompanied by headaches. The Bon-
or making any sudden movement. The contraction was ferroni test was conducted for post-hoc analysis; p < 0.05
repeated 10 times every 10 s, with a 10-s interval between was considered statistically significant for all analyses.
each contraction. The number and duration of each set of
contractions remained constant. Falla et al. [30] demon- Results
strated that the craniocervical flexion test accompanied Baseline patient characteristics
increased electromyographic activity in the deep cervical Baseline characteristics of the patients are presented in
flexor muscles. Table 1. The average duration of symptoms in patients
(4) Sustained natural apophyseal glide for headache with myofascial TMD headache was 4.1 (95% CI: 1.5–
[31]: The patient sat on a chair beside the therapist. The 10.2) years. All patients were right-handed, and none of
therapist placed the right index, middle, and ring fingers them received medications during the study period.
at the base of the occiput, while the middle finger of the
same hand and the little finger lay over the C2 spinous
Lee et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 Page 7 of 11

Table 1 Patient characteristics Table 3 Changes in neck dysfunction in the experimental and
Variables EG (n = 17) CG (n2 = 17) t/χ2 control groups
Sex (male/female) 5/12a 2/15 0.000 Variables EG (n = 17) CG (n = 17) t F
Age (years) 34.47 ± 10.51b 37.59 ± 15.16 0.063 (Group
× time)
Height (cm) 163.00 ± 9.34 164.06 ± 6.39 0.141
ISHIHAR-Ib Baseline -5.42 ± 6.14a -3.19 ± 6.94 -0.988 8.205**
Weight (kg) 58.35 ± 11.47 58.82 ± 9.36 0.234
5 weeks -4.09 ± 5.65† -3.66 ± 6.96 -0.200
BMIc (kg/m2) 21.81 ± 2.91 21.86 ± 3.31 0.233
EG: Experimental group, CG: Control group, aNumbers, bMean ± standard 10 weeks -2.80 ± 4.92† -3.15 ± 6.97 0.166
deviation, cBMI: Body mass index F 10.142** 1.314
NDIc Baseline 30.94 ± 8.05 32.88 ± 7.39 -0.732 22.092**
Table 2 Changes in headache, neck pain intensity, and TMJ pain 5 weeks 25.12 ± 7.56† 32.59 ± 6.97 -2.29**
levels between the two groups 10 weeks 15.94 ± 7.73†,‡ 31.88 ± 6.61 -6.459**
Variables EG (n = 17) CG (n = 17) t F F 27.902** 4.026*
(Group JFLS-8d Baseline 14.12 ± 4.07 16.35 ± 2.31 -1.966 15.232**
× time) 5 weeks 12.18 ± 3.57† 16.18 ± 2.24 -3.098**
KHIT-6b Base- 61.53 ± 8.04a 59.88 ± 8.03 0.597 12.015** 10 weeks 10.29 ± 3.21†,‡ 15.29 ± 1.64† -5.703**
line F 36.054** 9.518**
5 57.29 ± 6.62† 60.06 ± 7.72 -1.120 EG: Experimental group, CG: Control group, aMean ± standard deviation,
weeks b
Cervical kyphotic angle, cNeck Disability Index (range: 0–50), dKorean Jaw
10 48.88 ± 9.76† 59.82 ± 6.88 -3.780** Functional Limitation Scale-8 (range: 0–48), †There is a significant difference
weeks from the baseline (p < 0.05), ‡There is a significant difference from 5 weeks after
intervention (p < 0.05), *p < 0.05, **p < 0.01.
F 13.745** 0.201
NRSc Base- 7.82 ± 1.51 7.53 ± 1.41 0.585 29.219**
line intensity and left TMJ pain showed significant reduction
5 6.12 ± 1.21† 7.53 ± 1.23 -3.361** after 10 weeks of intervention compared with those after
weeks 5 weeks of intervention (p < 0.01). In the control group,
10 4.24 ± 1.48†,‡ 7.24 ± 1.20 -6.490** the right TMJ PPT showed a significant decrease after 10
weeks weeks of intervention (p < 0.05; Table 2).
F 49.892** 1.995
d
PPT Base- 1.19 ± 0.43/ 1.17 ± 0.42/ 0.079/ 21.933**/ Between-group comparison of changes in neck
line 1.39 ± 0.46 1.45 ± 0.48 -0.360 15.137**
(L/R)
dysfunction
5 1.35 ± 0.37†/ 1.18 ± 0.43/ 1.177/ Findings of the between-group comparison of changes in
weeks 1.50 ± 0.44† 1.44 ± 0.48 0.424 pain and neck dysfunction levels after the intervention
(L/R) period are presented in Table 3.
10 1.47 ± 0.37†,‡ 1.16 ± 0.42/ 2.210*/
weeks 1.60 ± 0.45† 1.47 ± 0.48 0.824 Discussion
(L/R)
The results of our study demonstrated that patients
F 25.708**/19.666** 0.397/3.782*
with myofascial TMD accompanied by headaches who
(L/R)
EG: Experimental group, CG: Control group, aMean ± standard deviation,
received manual therapy and stretching exercise therapy
b
Korean Headache Impact Test-6 (range: 36–78), cNeck pain intensity (range: for the cervical spine experienced significant treatment
0–10), dTemporomandibular joint pain pressure threshold, †There is a significant duration-related reductions in headache severity, NP
difference from the baseline (p < 0.05), ‡There is a significant difference from 5
weeks after intervention (p < 0.05), *p < 0.05, **p < 0.01 intensity, and TMJ pain (p < 0.01) after the intervention.
Significant between-group interactions were observed
in terms of changes in the cervical spine kyphotic angle
Between-group comparison of changes in pain (ISHIHAR-I), neck disability level (NDI), and JFLS-8
levels scores (p < 0.01). The level of neck dysfunction improve-
Findings of the between-group comparison of the ment was also statistically significant (p < 0.01). Although
changes in pain levels after the interventions are pre- limited improvements were observed in the con-
sented in Table 2. trol group, conservative physical therapy significantly
A greater reduction was noted in the intensity of reduced the PPT, NDI, and JFLS levels after 10 weeks of
headaches, NP, and TMJ pain evaluated after 10 weeks intervention. This can be understood in the context of
of intervention in the experimental group than in the a study by Suvinen et al. [33], who reported that 81% of
control group (p < 0.01). Additionally, the headache, patients with TMD experienced a significant subjective
NP severity, and TMJ pain levels in the experimental and objective improvement in symptoms and functions
group decreased significantly from their baseline val- through physical therapy.
ues (p < 0.01) after 5 and 10 weeks of intervention. NP
Lee et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 Page 8 of 11

The DC/TMD includes a new classification called lumbar deformation [39]. This position causes a forward
headache attributed to TMD (HATMD), indicating that head posture, so that the center of gravity of the head is
myalgia and TMJ arthralgia are related to headaches [20]. located forward [40] on the vertical axis, and increases
The International Classification of Headache Disorders, the load on the posterior neck muscles. This affects the
Third Edition Beta (ICHD-3 beta) describes headaches muscles, tendons, and ligaments of the neck region,
and facial pain caused by problems with TMJ, mastica- which can lead to muscular imbalance, and this biome-
tory muscles, and/or related structures as secondary chanical strain can weaken the core stabilization of the
headaches [34]. Secondary headaches caused by mastica- neck muscle system and worsen forward head posture-
tory muscle pain and TMJ joint pain, which are classified related symptoms [41, 42]. Accordingly, it is known to
and described in these two diagnostic criteria, probably lead to a cervical kyphotic angle of the neck bone [43].
refer to the same condition [35]. People with TMDs, often have a cervical kyphotic angle
The DC/TMD suggests that headaches originate from of the neck bone, but it is difficult to presume that a
a myofascial trigger point, induced during palpation of cervical kyphotic angle of the neck bone occurs due to
jaw joint muscles and extensive jaw movement, and not TMDs. This may be a secondary phenomenon due to
from the intracranial structure [13, 35]. According to causes that affect both TMD and cervical kyphotic angle
the results of a systematic review by Armijo-Olivo et al. of the neck bone [44, 45]. However, our study aimed to
[36], although the evidence for manual therapy is lim- see if manual therapy can improve the cervical kyphotic
ited, it has shown significant results in treating myog- angle of the neck bone, induce morphological changes in
enous, arthrogenous, and mixed TMDs. Kalamir et al. the neck bone, and improve pain and dysfunction. After
[37] reported that manual therapy, which targets the intervention the authors observed an average increase
oral facial region in myogenous TMD, improves mouth of 2.62% (measured value by the Ishihara index) in the
opening and reduces jaw pain compared to botulinum cervical kyphotic angle (i.e., anterior bending) (Fig. 3).
toxin, indicating manual therapy effectively treats myog- Since this study used a single-center cohort design with
enous TMD. Ferrillo et al. [38] suggested in a systematic a short experiment duration (i.e., 10 weeks), we could not
review that manual therapy is effective in treating myog- determine whether the results were directly attributable
enous TMD, while laser and occlusal splints are mainly to the treatment of the cervical spine or other variables.
effective in relieving pain in arthogeonus TMD. These However, the findings suggested that manual therapy and
studies suggest manual therapy is effective mainly in stretching exercises can be applied clinically to induce
myogenous rather than in arthrogenous TMD; therefore, morphological changes in the cervical spine and improve
only patients with myogenous TMD were included in this pain and neck dysfunction.
study. De Laat et al. [46] reported that upper cervical spine
In this study, we also looked into changes in the cer- movement was limited in patients with TMD. Accord-
vical kyphotic angle to improve the diagnosis of the pre- ing to the current International Classification of Diseases
sumed cause of headache secondary to TMJ dysfunction. guidelines, headaches are classified into 300 different sub-
The causes of “turtle neck”, “straight neck” and “cervical types. Among these, physical therapy is very effective for
kyphotic angle” include trauma and muscle tension, neck cervicogenic headaches [47]. La Touche et al. [18] applied
disc, post-neck facet joint syndrome, long-term neck upper cervical (C1–C2) flexion mobilization based on
flexion, and secondary phenomena due to thoracic or the association between cervicogenic headaches and
the upper cervical spine. O’Leary et al. [48] stated that
applying a craniocervical flexor exercise protocol induces
an immediate local hypoalgesic inhibition response in
patients with NP. Therefore, various researchers consider
it appropriate to apply manual therapy to the neck area,
particularly the upper cervical spine [4, 17].
However, in a previous study [14], the authors noted
that the typical shape of the cervical spine in patients
with TMD exhibited similar variations in the C3–C4
region. Hence, the authors modified the manual therapy
to the lower part of the cervical spine by additionally
applying it to C3 and C4. Distinct morphological changes
(an average increase of 2.62% in the cervical kyphotic
angle) were noted in the results obtained for the cervical
spine levels C3 and C4.
Fig. 3 Changes in the cervical kyphotic angle after intervention
Lee et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 Page 9 of 11

There were no statistically significant results confirm- improve our understanding of the biomechanical basis of
ing whether the increase in the cervical kyphotic angle TMDs accompanied by headaches.
correlated with headache, neck pain, and TMJ pain lev- Nevertheless, this study has some limitations. First, the
els; however, the results showed a significant reduction in control group received 40 min less total therapy per week
headache, neck pain, TMJ pain, cervical dysfunction, and than the experimental group. In future studies, to better
JFLS levels after 10 treatments. Therefore, the PPT lev- evaluate the significance of between-group differences,
els for the masseter muscles and headaches indicate that the control group should receive the same duration of
morphological changes induced by cervical spine treat- therapy as the experimental group. Second, the therapist
ment can produce hypoalgesic effects. and patients were not blinded because of the patients’
To the best of our knowledge, no study has demon- control of the medication. Third, changes in the cervical
strated the activation of descending inhibitory pathways kyphotic angle of the neck bone, headaches, TMD symp-
or the occurrence of bilateral hypoalgesic effects in the toms, and pain significantly improved after therapy, but
trigeminal region after applying cervical spine-focused future studies are needed to determine whether this is a
manual therapy and stretching exercises in patients with minimal clinical importance difference that can be recog-
myofascial TMD accompanied by headaches [18]. How- nized and valued by patients.
ever, the authors’ previous study reported a positive cor-
relation between the cervical kyphotic angle and TMJ Conclusion
PPT and a negative correlation between the current and The application of manual therapy and cervical spine
usual pain intensity levels at the TMJ in patients with stretching exercises improved the intensity of headaches,
TMDs [14]. These results suggest that changes in the NP, and TMJ pain evaluated after 10 weeks of interven-
cervical kyphotic angle can relieve or worsen TMJ symp- tion in the experimental group compared to that in the
toms. Moreover, the interaction of the trigeminal nerves control group. Additionally, the headache, NP severity,
and the cervical spine can also increase the incidence of TMJ pain levels, and neck dysfunction in the experimen-
headaches by causing hyperalgesia and allodynia. There- tal group decreased significantly from their baseline val-
fore, TMD-related headaches, which may have a struc- ues after 5 and 10 weeks of intervention. After 10 weeks
tural cause, can be influenced by changes in the shape of of intervention, the cervical spine kyphotic angle and
the cervical spine. neck disability levels decreased significantly more in the
Generally, manual therapy, including TMJ mobilization experimental group than in the control group. The cur-
and the soft tissue technique [49], improves TMJ func- rent findings are significant as they suggest the possibility
tion and reduces pain when applied to the cervical spine. of pain recovery and improvement of function by achiev-
This procedure alleviates pain via the neurological mech- ing structural changes in the cervical spine in patients
anisms responsible for reducing muscle activity, which with TMDs accompanied by headaches. Moreover, these
may be due to the neuroanatomical connection and bio- findings may guide protocols and clinical trials involving
mechanical relationship between these two components manual therapy that align morphological structures.
of the trigeminocervical complex [50]. In addition, previ-
List of abbreviations
ous studies demonstrated that the application of manual ICC Intra-class correlation coefficient
therapy or mobilization of the cervical spine could posi- JFLS Jaw Functional Limitation Scale score
tively affect pain intensity in patients with TMD [33]. NDI Neck Disability Index
NP Neck pain
The manual therapy and stretching exercises performed NRS Numerical rating scale
in this study may have improved TMD-related headaches TMD Temporomandibular disorder
through biomechanical changes in the cervical spine. TMJ Temporomandibular joint
VAS Visual analog scale
Alternatively, the patients’ symptoms may have simply
improved over time. However, in comparing the duration Acknowledgements
of the study to the average duration of patient symptoms The authors would like to express their sincerest gratitude to the patients for
their participation, thereby enabling the acquisition of data.
(4.1 years, 95% CI: 1.5–10.2 years), it is unlikely that the
pain would have significantly improved over time with- Authors’ contributions
out the intervention. IL was responsible for the following: Conceptualization, methodology,
formal analysis, investigation, resources, data curation, writing—original
Our study results showed that manual therapy and draft preparation, writing—review and editing, and visualization. SK was
cervical spine stretching exercises were associated with responsible for the following, Conceptualization, methodology, validation,
improvements in the function and pain of patients with formal analysis, data curation, writing—review and editing, and supervision.
All authors read and approved the final manuscript.
TMDs and improvements in the biomechanics of the
cervical spine. Pain and disability were successfully alle- Funding
viated with physical therapy designed for TMD symp- Not applicable.
toms accompanied by headaches. These study results will
Lee et al. BMC Sports Science, Medicine and Rehabilitation (2023) 15:39 Page 10 of 11

Data Availability 13. Bevilaqua-Grossi D, Chaves TC, de Oliveira AS. Cervical spine signs and
The datasets used and/or analysed during the current study are available from symptoms: perpetuating rather than predisposing factors for temporoman-
the corresponding author on reasonable request. dibular disorders in women. J Appl Oral Sci Aug. 2007;15:259–64. https://doi.
org/10.1590/S1678-77572007000400004.
14. Lee I, Kim S. Correlation among the cervical kyphotic angle, pain, and disabil-
Declarations ity level in patients with temporomandibular disorders. Phys Ther Korea May.
2020;27:102–10. https://doi.org/10.12674/ptk.2020.27.2.102.
Competing interests 15. Catanzariti JF, Debuse T, Duquesnoy B. Chronic neck pain and masticatory
The authors declare that they have no competing interests. dysfunction. Jt Bone Spine Dec. 2005;72:515–9. https://doi.org/10.1016/j.
jbspin.2004.10.007.
Ethics approval and consent to participate 16. Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P. Clinical
The study was conducted after obtaining approval from the Agency Bioethics effectiveness of manual therapy for the management of musculoskeletal
Committee of Daejeon University during the design phase (Approval and non-musculoskeletal conditions: systematic review and update of
No. 1040647-202006-HR-003). Informed consent was obtained from all UK evidence report. Chiropr Man Therap Dec. 2014;22:12. https://doi.
participants prior to inclusion in this study. All methods were performed in org/10.1186/2045-709X-22-12.
accordance with the Declaration of Helsinki. 17. Carmeli E, Sheklow SL, Bloomenfeld I. Comparative study of repositioning
splint therapy and passive manual range of motion techniques for anterior
Consent for publication displaced temporomandibular discs with unstable excursive reduction. Phys-
Not applicable. iotherapy. 2001;87:26–36. https://doi.org/10.1016/S0031-9406(05)61189-3.
18. La Touche R, Fernández-de-las-Peñas C, Fernández-Carnero J, Escalante K,
Received: 3 December 2022 / Accepted: 11 March 2023 Angulo-Díaz-Parreño S, Paris-Alemany A, et al. The effects of manual therapy
and exercise directed at the cervical spine on pain and pressure pain sensitiv-
ity in patients with myofascial temporomandibular disorders. J Oral Rehabil
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