Review Article

Page 1 of 13

Physical therapy for temporomandibular disorders:

evidence-based improvements and enhancements for diagnosis
and management
Janey Prodoehl1, Emily Kahnert2
1
Physical Therapy Program, Midwestern University, Downers Grove, IL, USA; 2TMD, Orofacial Pain & Dental Sleep Medicine Clinic, School of
Dentistry, University of Minnesota, Minneapolis, MN, USA
Contributions: (I) Conception and design: Both authors; (II) Administrative support: Both authors; (III) Provision of study materials or patients: None;
(IV) Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: Both authors; (VII) Final approval
of manuscript: Both authors.
Correspondence to: Janey Prodoehl, PT, PhD, CCTT. Physical Therapy Program, Midwestern University, 555 31st Street, Downers Grove, IL 60515,
USA. Email: [email protected].

Abstract: The most common oral and maxillofacial disorders treated by physical therapists are
temporomandibular disorders (TMD), and rehabilitation strategies continue to evolve with advancements in
research and technology. While physical therapy is an evidence-supported approach to the management of
TMD, difficulties with referral to and access to appropriately trained physical therapists can create disparity
in care for patients. Lack of interdisciplinary collaboration and practice is an ongoing issue, particularly
among dentists and physical therapists and this can translate to less than optimal care for individuals with
TMD. While dentists and physical therapists may utilize similar diagnostic criteria, implementation gaps
in use of consistent diagnostic criteria still exist across both professions. Additionally, possibilities exist for
the future expansion of such criteria to recognize the contribution of structures and comorbidities outside
of the masticatory system such as the cervical spine and central nervous system changes that can promote
the persistence of pain in some individuals with TMD. Pain neuroscience education, epigenetics, and other
rehabilitation tools such as virtual reality may allow physical therapists to address the central nervous system
changes associated with pain persistence and a fear of movement seen in some individuals with TMD.
Applying biomechanical knowledge gained from real-time ultrasound muscle imaging and musculoskeletal
modeling will enhance diagnostic management and post-surgical rehabilitation approaches. The purpose
of this review paper is to describe novel evidence-based rehabilitative tools or concepts that can be used
to improve the diagnosis and management of individuals with TMD. Continued growth and development
in research and clinical practice related to TMD will ultimately lead to improved care for individuals with
TMD, both conservatively and post-surgically.

Keywords: Rehabilitation; physical therapists; dentists; orofacial pain; facial pain; interdisciplinary care; physical
medicine

Received: 22 July 2020; Accepted: 31 May 2021; Published: 10 June 2022.

doi: 10.21037/fomm-20-44
View this article at: http://dx.doi.org/10.21037/fomm-20-44

© Frontiers of Oral and Maxillofacial Medicine. All rights reserved. Front Oral Maxillofac Med 2022;4:16 | http://dx.doi.org/10.21037/fomm-20-44
Page 2 of 13 Frontiers of Oral and Maxillofacial Medicine, 2022

Introduction is the dual-axis Diagnostic Criteria for TMD (DC/TMD)

(13,14). The DC/TMD includes validated physical (Axis
The most common oral and maxillofacial disorders treated
I) diagnostic algorithms and consideration of psychosocial
by physical therapists are temporomandibular disorders
status and pain-related disability (Axis II). The DC/TMD
(TMD), and rehabilitation strategies continue to evolve
progressed diagnostic capabilities of clinicians and provides
with advancements in research and technology. The
a consistent classification framework to guide clinical
diverse conditions included under the TMD heading are
decision-making and research across disciplines. Physical
complex and can greatly impact an individual’s quality
therapists utilize the DC/TMD for classification of TMD
of life. In general, physical therapy aims to prevent,
symptoms (15,16). However, implementation gaps still exist,
correct and/or alleviate movement dysfunction which
with inconsistencies across disciplines, and areas needing
commonly interferes with eating, talking, yawning and
refinement. For example, the prevalence of myalgic TMD
chewing in individuals with TMD. Physical therapy is well
is greater than that of arthralgic and degenerative causes,
recognized as a conservative method for the management
yet myogenous involvement in TMD lacks quantitative
of symptoms associated with TMD (1-4). However, validation (14,17,18). New avenues supporting identification
difficulties with referral to and availability of appropriately of myogenous involvement in TMD would therefore be
trained physical therapists can create disparity in care (5). helpful.
Lack of interdisciplinary collaboration and practice is an Another opportunity for refinement concerns the
ongoing issue, particularly among dentists and physical contribution of structures and systems outside of the
therapists. This can translate to less than optimal care masticatory system such as the cervical spine and central
of individuals with TMD. By promoting innovation in nervous system which can contribute to the persistence of
care and interdisciplinary collaboration, the management pain in individuals with TMD. The connection between
of individuals with TMD will continue to progress with the cervical spine and TMD is well-documented in
exciting potential for improvement in conservative and pre- the literature (19-25) but is minimally addressed in the
and post-operative rehabilitation. dentistry-focused DC/TMD. Similarly, the central nervous
The need for improved interdisciplinary collaboration system provides an accessible link between DC/TMD
and prioritized TMD research were two of many care gaps Axis I and II symptoms without guidance for inclusion
recently highlighted in the 2020 report of the National in rehabilitation. As the understanding of the biological
Academies of Science, Engineering and Medicine on mechanisms of persistent pain in other musculoskeletal
Temporomandibular Disorders: Priorities for Research and conditions such as chronic low back pain has grown, novel
Care (5). The report identified poorly coordinated care as approaches to improving movement dysfunction and pain in
a contributing factor to TMD overtreatment, and called individuals with chronic TMD are emerging. Therapeutic
for improved evidence for physical therapy interventions pain neuroscience education (PNE), epigenetics, and other
in discussing physical therapy as one component of rehabilitation tools such as virtual reality allow physical
conservative management (5). Expanding existing clinical therapists to address the central nervous system changes
and biomechanical research to the temporomandibular associated with pain persistence and fear of movement in
joint (TMJ) will contribute additional knowledge of joint individuals with chronic pain. Expanding diagnosis and
behavior and stability over time to inform rehabilitation management to include these areas will greatly improve
and surgical protocols (6-8). Increasing recognition of the ability of physical therapists to implement effective
the role of structured physical therapy in improving post- rehabilitation strategies for individuals with TMD.
surgical patient outcomes lends support to interprofessional The purpose of this review is to describe novel evidence-
collaboration for improving patient outcomes following based rehabilitative tools or concepts that can be used to
TMJ surgery (9,10). However, education of healthcare improve the diagnosis and management of individuals with
professionals within each discipline involved in the care of TMD. Specifically, we will (I) review future directions
individuals with TMD must expand beyond its current state in interdisciplinary care and collaboration, (II) discuss
of training to meet the inter- and multi-disciplinary needs expansion of existing diagnostic considerations to account
of this patient population (5,11,12). for the cervical spine and improved muscle imaging
The current international diagnostic standard for with real time ultrasound, (III) explore applications of
clinical and research application in individuals with TMD musculoskeletal modeling in the study of in-vivo TMJ

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Frontiers of Oral and Maxillofacial Medicine, 2022 Page 3 of 13

biomechanics, (IV) describe implications for TMJ pre- with TMD. An example of this are the results of a recent
and post-surgical physical therapy, and (V) discuss the survey of dentists in Florida which indicated that 41% of
incorporation of therapeutic PNE and epigenetics to respondent dentists were not aware that physical therapists
address central sensitization in individuals with persistent can treat TMD (19) despite the recognition of physical
TMD pain. therapy as a recommended evidence based conservative
treatment for TMD. Lack of recognition of physical therapy
as an appropriate option for individual with TMD by some
Interdisciplinary practice
healthcare professionals must be addressed to improve
The interdisciplinary team in the diagnosis and access of care to individuals with TMD. Differences in
management of TMD international standards for each profession can also be a
barrier to effective collaboration. A recent study of Filipino
Increased recognition of the biopsychosocial factors
dentists and physical therapists showed low education and
associated with TMD has led to support for an
knowledge among dentists and physical therapists (20).
interdisciplinary biopsychosocial model of TMD that is Looking to the future, more practical opportunities for
focused on an individual’s health and well-being beyond interprofessional training and collaboration among physical
structures in the head and face (5). Some patients with therapists, dentists and physicians during both pre-doctoral
chronic TMD may have significant underlying comorbidities education and post-doctoral practice is one way to address
which require specific intervention from a trained such discrepancies.
psychologist. For example, a relationship has been shown One factor that may contribute to lack of understanding
between post-traumatic stress disorder and chronic pain of the role of different health professions in the
incidence (26). Failure to identify these comorbidities and management of individuals with TMD are differences in
seek appropriate resources for these individuals is a concern. the scope of practice and training of healthcare practitioners
However, for the majority of individuals with TMD, an regionally across the US and in different parts of the
interdisciplinary approach to the management of individuals world. Dental schools in the US with an orofacial pain
with TMD is recommended (4,11,12). program may provide more training to student dentists
One of the challenges to achieving an interdisciplinary on interdisciplinary care compared to those programs
approach in clinical practice is the varied availability of without these resources (21). Similarly, not all physical
appropriately trained professionals who can work effectively therapy education programs have equal levels of entry
in an interdisciplinary manner. An interdisciplinary level training related to TMD content (22), and nor are
team for individuals with chronic TMD may consist of all physical therapists confident in treating this patient
dentists, physical therapists, psychologists, and physicians, population (23). In the US, all 50 states, the District of
but interdisciplinary care coordination does not always Columbia, and the US Virgin Islands allow patients to
occur. Clearly understanding the role of each healthcare seek some level of treatment from a licensed physical
professional and working effectively together with good therapist without a referral (24). This level of access has
communication promotes safe, quality health care (27). Too been made possible by elevating entry-level educational
often in healthcare, including the care of individuals with standards of physical therapists in the US to the doctoral
TMD, each discipline operates in a silo, and neither clinical level, including additional differential diagnosis and medical
nor research efforts are sufficiently collaborative. Yet in screening training to ensure patient safety. Moving forward,
individuals with orofacial pain, outcomes have been shown physical therapists must do a better job communicating
to improve with an interdisciplinary program approach and collaborating with dentists and physicians to establish
including a dentist, psychologist, and physical therapist (28). their role in the interdisciplinary team. Challenges exist
at the international level however where discrepancies
in training standards across disciplines lead to difficulty
Interprofessional collaboration and training
applying evidence into practice. Looking to the future, a
One of the barriers to excellence in interprofessional clear standard of care is needed to ensure that rehabilitation
practice is lack of recognition of the role of other efforts for care of individuals with TMD are comprehensive,
professions and the need for interprofessional practice evidence based and collaborative. To promote team
by each discipline involved in the care of individuals based collaborative practice, interprofessional attitudes

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Page 4 of 13 Frontiers of Oral and Maxillofacial Medicine, 2022

among healthcare disciplines which can negatively impact asymptomatic subjects with TMJ disc displacement (35-37)
communication and collaboration must be modified and and MRI findings alone cannot identify a condition that
addressed (27). needs treatment from that which does not. Considering the
cost and inconvenience of MRI, the rate of false positive
findings negates its usefulness in routine clinical practice.
Expanding diagnostic considerations
RTUS imaging is one imaging modality that holds
Cervical spine and TMD promise for both the diagnosis of and management
guidance of joint and muscle dysfunction for individuals
Physical therapists include examination of the cervical
with TMD. RTUS imaging is used by physical therapists
spine in their examination of individuals with TMD.
to document changes in the clinical condition, identify
Individuals with TMD have been shown to have signs of
when to progress exercises or activities, localize specific
upper cervical spine movement impairment which can be
targets for intervention, guide needle placement for trigger
greater in those with headache complaints (25). Silveira
point dry needling or electroneuromyography, and to help
et al. (29) found a strong correlation between jaw dysfunction guide clinical decision making relative to prognosis and
and neck disability. In addition, tender cervical points in progression based on tissue structure (38). RTUS has shown
individuals with TMD have been found in multiple studies good intra- and inter-rater reliability for use in assessing
(29-32). A recent Delphi study of international expert TMD joint translation at the shoulder, even for a physical therapist
physical therapists recognized that manually screening the with minimal RTUS training (39). In the TMJ, Ho et al. (40)
cervical spine and testing neck muscle function in addition determined that RTUS can reliably image anterior condylar
to examining masticatory muscles and jaw movements translation, reporting a linear relationship between
may improve clinical evaluation of pain and dysfunction translation and mouth opening which could aid clinical
in individuals with TMD (33). A randomized controlled estimation of rehabilitation potential. In combination with
trial in women with TMD found that treatment aimed providing opportunities for improved patient education,
at improving upper cervical spine mobility improved RTUS can improve diagnosis and management for
orofacial pain and headache after 5 weeks of treatment (34). individuals with TMD.
Moving forward, appropriately screening for contributing Assessing myogenous disorders has inherent challenges
or concomitant cervical involvement should be included as shown by the lack of sensitivity and specificity data
in examination of individuals with TMD in order to fully for these diagnoses (14). The overlapping symptoms
understand the impairments that may contribute to or often seen in individuals with joint and muscle TMD
perpetuate TMD symptoms. This is an area where dentists require accurate physical therapy diagnosis to maximize
and physical therapists must work together in order to rehabilitation outcomes. Real time ultrasound can assess
provide appropriate treatment for their patients. As physical skeletal muscle, and in combination with visualization of
therapists must be trained to recognize the need for an oral condylar translation data, can identify muscle disorders
appliance and appropriately refer a patient to a dentist, a more accurately. RTUS can reveal muscle characteristics
dentist should be trained to recognize a cervical component such as cross-sectional area, thickness, fascicle length and
to TMD symptoms and appropriately refer a patient to a pennation angle (41), and has been used to quantify muscle
physical therapist. function in neuromuscular disorders (42). Combining
muscle cross-sectional area with condylar translation data
could quantify muscle function in joint disorders, which
Real-time ultrasound (RTUS) used for TMJ and muscle
may improve diagnostic accuracy and help predict post-
imaging
surgical rehabilitation responses. Overstretching muscles
Long understood as a modality for imaging in other already in spasm can negatively impact recovery, so reliably
regions, real-time musculoskeletal ultrasound imaging improving clinical assessment accuracy is of great interest
has recently emerged as a practical, accessible modality for these patients and their providers. The ability to assess
for clinical assessment in rehabilitation. While magnetic muscle behavior with RTUS will improve treatment
resonance imaging (MRI) is the gold standard technique for planning and adaptation for this group of disorders that has
diagnosing TMJ disc displacement and degeneration (14), been previously difficult to quantify.
MRI has been shown to identify nearly one-third of An emerging ultrasound-based modality with additional

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Frontiers of Oral and Maxillofacial Medicine, 2022 Page 5 of 13

clinical applications is shear wave elastography (SWE) properties and muscle force and activation information as
which yields information regarding musculoskeletal inputs (48). Modeling allows for assessment of effects due
tissue properties. By measuring the speed of shear-wave to variations that would be difficult to measure in real-
propagation through muscle and tendon, SWE can quantify life such as changing anatomical conditions and testing
tissue stiffness and integrity (43,44) which has implications small differences in movement. In a recent finite element
for myogenous forms of TMD. This modality has shown modeling study, Dixit et al. used musculoskeletal modeling
good repeatability and accuracy in shoulder muscle and to demonstrate long term glenohumeral joint and muscular
tendon (43) and has been used to examine changes in muscle changes in the presence of simulated injury conditions (49).
stiffness in individuals with and without chronic neck pain In combination with other in-vivo measures, a similar
(45,46). RTUS and SWE has good potential with future approach to modeling the TMJ could predict disc and
refinements to facilitate diagnosis of myofascial syndromes joint behavior over time for use in determining TMD
and tendonitis, and their use will allow therapists to monitor rehabilitation strategies.
tissue healing after surgical intervention throughout the Correctly classifying the kinetics and kinematics of
course of rehabilitation. movement is essential to provide good clinical care, and
One specific clinical use of RTUS and SWE is modeling has potential to advance knowledge in this area.
identification of myofascial trigger points (MTrPs). In In the shoulder, etiology of subacromial impingement has
a 2018 narrative review, Do and colleagues reported been studied via 3D bone modeling created from subject-
ultrasound as having potential to diagnose MTrPs in specific fluoroscopic and MRI data (50,51). Modeling
subjects with migraine and tension-type headache (47). revealed that traditional beliefs regarding shoulder
Turo et al. (44) studied MTrPs in the upper trapezii of impingement throughout shoulder elevation were not
patients with chronic neck pain and found that the trigger replicated anatomically, and that pain is likely due to
points were identifiable as focal dark areas on ultrasound other mechanisms or structures (50,51). A 2015 knee
images. Using SWE, Turo et al. demonstrated that trigger modeling study used a subject-specific musculoskeletal
point areas were stiffer, allowing for physical localization of model informed by data from an implant placed during
the trigger point. In orofacial pain conditions, correlating an instrumented total knee arthroplasty (52). The study
MTrPs with subjective symptom report will help quantify demonstrated that modeling produced accurate estimations
and differentiate between myofascial conditions such as of knee kinematics which could aid future implant design
myalgia and muscle spasm. Localizing trigger points will and inform individualized surgical protocols (52). In
improve treatment efficacy, allowing for direct application the TMJ and articular disc, such modeling would allow
of manual release work or dry needling. Overall, real time for detailed study of movement and injury processes to
ultrasound is an accessible, reliable, non-invasive diagnostic inform diagnostic and treatment protocols. Varying muscle
tool with potential for future widespread clinical use in the activation inputs, disc position, and anatomical details such
assessment and management of TMD. as joint surface characteristics and forces will yield detailed
and accurate functional information that can guide surgical
and rehabilitation decision-making.
In-vivo modeling of TMJ biomechanics
One such musculoskeletal model of the TMJ has been
In the TMJ, knowledge regarding the development and created by Tuijt and colleagues for the purpose of assessing
progression of disc disorders has continued to evolve. anatomical conditions that cause open locking (7). The model
Schiffman et al. (6) recently assessed the longitudinal included twenty-four jaw muscles with muscle moments
stability of disc disorders and degenerative joint disease and force capacity estimates as inputs to the model (8).
with advanced imaging after 8 years and found that the By varying the angle of the articular eminence in the
majority of subjects showed no change over time, with the model, Tuijt and colleagues were able to assess the efficacy
remainder divided between progression and reversal of of different muscular strategies to reduce open locking in
their conditions. These types of studies are important for different anatomical conditions (8). These modeling studies
improved understanding of long-term joint behavior yet provide clinical support for rehabilitation interventions such
difficult to execute due to the time and resources required as training muscle control during movement and teaching
for completion. Musculoskeletal modeling consists of lock reduction strategies. They also suggest that pre-
building a 3D biomechanical model with tissue material surgical subject-specific modeling could also help determine

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Page 6 of 13 Frontiers of Oral and Maxillofacial Medicine, 2022

the ideal articular eminectomy approach for a patient Addressing central sensitization in TMD
with respect to their existing anatomy and muscle control
Pain has a multidimensional nature that includes
(7,8). In the future, this same approach can be applied to
physiological, sensory, affective, cognitive, behavioral, and
other disc displacement and masticatory muscle disorders,
social/cultural/spiritual/political aspects (59). Activation
and the results of modeling studies may be useful when
of pain pathways in the central nervous system is expected
making informed decisions regarding TMJ surgery and
when a noxious input is applied at the periphery (60). In the
rehabilitation protocols.
case of TMD, peripheral input is expected to come from
masticatory muscles or TMJ structures. However, this pain
Pre- and post-surgical rehabilitation and model does not explain the persistence or magnitude of pain
management in individuals with chronic TMD. Individuals with different
forms of TMD may be more likely to have persistent pain.
When considering TMJ surgery, a conservative approach
For example, 31% of individuals with a myalgic form of
consisting of pain management and rehabilitation is the first
TMD at baseline continued to have their disorder over a
line recommended treatment for individuals with TMD
(53,54). For individuals who fail a conservative approach 5-year period (61).
or who are appropriate for direct surgical intervention, There is evidence to support sensitization of the central
post-surgical management is typically more defined in nervous system as an underlying mechanism explaining
its interprofessional approach with a team led by the oral the persistence of pain in some individuals with chronic
surgeon and including physical therapists, physicians and TMD (62). The International Association for the
pharmacists. However, effective collaborative practice Study of Pain recommends distinguishing between
for post-surgical patients often relies on the oral surgeon different types of pain (i.e., nociceptive, nociplastic, and
to have developed interprofessional collaborations and neuropathic), since the classification impacts assessment and
communication with other team members. Given the varied management (59) and TMD can be associated with
level of entry level training among physical therapists alone neuropathic pain syndromes distinguished by both
on post-surgical management of individuals with TMD (22), central and peripheral changes (63). Current models of
it can be challenging for the oral surgeon to find an TMD diagnostic classification such as the internationally
appropriately trained physical therapist for collaboration. recognized DC/TMD (14) do not include a clinical
There is strong evidential support for the use of assessment of central sensitization as part of the physical
physical therapy after open TMJ surgery to achieve examination necessary for the diagnosis of TMD beyond
good postoperative outcomes (9). Additionally, there is pain referral with applied pressure. However, the presence
evidence to support better functional patient outcomes of allodynia (pain triggered by innocuous stimuli),
in patients’ status post condylar discopexy with early hyperalgesia, or secondary hyperalgesia (spreading of
supervised physical therapy compared to self-directed home pain beyond the face) (64) has important implications for
exercise (10). Consultation with a specialized pain clinic has management of individuals with TMD. Refinements of
also been shown to reduce pain after oral and maxillofacial diagnostic classification schemes in the future may look
surgery (55). Additionally, preoperative physical therapy, to include identification of individuals likely to develop
or prehabilitation, has been shown to lead to improved persistent pain to provide a complete clinical picture for
physical and functional recovery immediately post- management of individuals with chronic TMD. Expecting
operatively in some orthopedic surgeries including total such patients to achieve good outcomes by considering
knee arthroplasty (56) and hip fracture (57). However, only the joint and muscle influences using oral appliance
preoperative physical therapy may not affect longer or standard physical therapy exercises alone is unrealistic.
term outcomes following joint replacement surgery (58). Additional examination methods may include assessment
Investigation of the effects of preoperative physical therapy of pressure pain threshold, thermal sensation, mechanical
in modifying outcomes following TMD surgery has not yet detection threshold, vibration detection threshold, or two-
been undertaken. Looking to the future, a healthcare system point discrimination (63). Use of these assessments for
that embraces and rewards interprofessional practice both documenting progress and outcomes over time should also
conservatively and post surgically to promote excellence in be considered in the management of these patients and in
patient outcomes would be a goal to best serve all patients. guiding decision making regarding surgical intervention.

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Frontiers of Oral and Maxillofacial Medicine, 2022 Page 7 of 13

Addressing kinesiophobia approach includes decreasing threatening input to the system

where input may be both nociceptive (e.g., inflammation)
In addition to clarifying the clinical picture, identification
and non-nociceptive (e.g., fear of movement) (72).
of biopsychosocial factors underlying chronic pain can
Patient education is a central part of this PNE approach for
suggest new avenues of treatment. Lira et al. (65) found that
the management of chronic persistent pain with promise for
patients with TMD and higher levels of kinesiophobia (i.e.,
individuals with persistent TMD.
fear of movement) showed a more complex clinical TMD
The goal of PNE is to reduce the perceived threat of pain
presentation with high psychosocial distress, widespread
by increasing a patient’s understanding of how the nervous
mechanical pain sensitivity, and a more complex presentation
system and body work (82). An example of this is education
of myalgia, disc displacement, and arthralgia (65).
that the central nervous system has become sensitized,
Specifically, they found a 13 times greater chance of a
and that while pain itself is normal, the processes behind
complex presentation in individuals with high-kinesiophobia
it can become modified (83). There is strong evidence to
compared to those with moderate-kinesiophobia (65).
support the use of PNE with chronic musculoskeletal pain
Fear of movement in the orofacial region can manifest as to reduce pain intensity and disability and to improve pain
alterations in functions such as eating, talking or yawning, catastrophization, fear-avoidance, and abnormal pain related
and there is evidence to support kinesiophobia in chronic behaviors (84). Individuals with chronic pain perceive
TMD (66-69). movement as difficult because the motor cortex is being
Fear of movement and pain-related fear are recognized utilized as part of the pain neuromatrix, thus perpetuating
phenomena in individuals with other forms of persistent the cycle of pain catastrophization, fear-avoidance, and
musculoskeletal pain including low back pain, where abnormal pain related behavior unless intervention occurs
chronicity of pain may be predicted by movement- to break the cycle (85).
related fear (70-73) and neck pain (74,75). An improved Entry level training of physical therapists in the US
understanding of factors which can influence the includes the neuroscience of pain and PNE principles,
development of persistent pain has led to new approaches in and PNE delivered by physical therapists has been shown
management of chronic musculoskeletal pain such as virtual to be effective in the management of individuals with
reality and externally focused rehabilitation approaches to chronic pain (86-88). Adding a single PNE session prior to
improve function and reduce movement related fear (76-80). surgery for lumbar radiculopathy has resulted in significant
For example, virtual reality activities such as dodgeball or healthcare savings over 3 years (89). Pre-surgical education
virtual walking have been used to engage individuals with for TMD using PNE principles may work to reduce fear
chronic low back to improve spinal mobility (77) and to and anxiety before surgery and assist in developing realistic
reduce pain and kinesiophobia (81). Such novel approaches expectations regarding pain after surgery as has been shown
have yet to be investigated in individuals with chronic following spinal surgery (90-93). A recent systematic review
orofacial pain. supported the use of PNE in the management of chronic
musculoskeletal disorders by reducing pain, improving
function and lowering disability, reducing psychosocial
Therapeutic PNE
factors, enhancing movement, and minimizing healthcare
In Melzack’s neuromatrix theory explaining chronic pain, utilization (84).
pain is multidimensional and not simply a response to a The use of PNE is an avenue that should be explored
noxious input to prevent further injury but a disease itself, in individuals with persistent orofacial pain. A recent case
“—the result of neural mechanisms gone awry” (71). While report of an individual with a 5-year history of bilateral
activation of the neuromatrix may be triggered by a sensory chronic myofascial TMD and comorbid neck/right arm
input as in the case of acute TMD or post-surgical pain, pain described the successful use of manual physical therapy
impulses may also be generated independent of any sensory together with graded motor imagery, a PNE technique, to
input. In a chronic pain situation, it has been proposed that reduce kinesiophobia and improve function (94). There is
the pain neuromatrix becomes progressively strengthened growing evidence related to the use of preoperative PNE
via both nociceptive and non-nociceptive inputs (82). Based programs for improving long term outcomes following
on the pain neuromatrix concept, Moseley proposed a some surgeries, but not TMD surgery. While the immediate
rehabilitative approach to treating persistent pain (82). This post-operative outcomes have not been shown to change

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Page 8 of 13 Frontiers of Oral and Maxillofacial Medicine, 2022

following a single pre-operative education session (95), long in orofacial pain disorders makes TMD rehabilitation an
term outcomes have been shown to change. A 30-minute especially appropriate area for adapting future epigenetic
preoperative PNE program delivered by a physical therapist mechanisms to help manage neuropathic pain and improve
significantly impacted health care costs at 1 year in patients the efficacy of exercise programs.
who underwent spinal surgery with a reduction of health care
expenditure by 45% compared to a control group (86), and
Conclusions
these savings were shown to be maintained at 3 years (89).
Use of pre-operative physical therapy for changing patient This review has discussed a range of topics regarding novel
outcomes and cost of care is an area that needs to be evidence-based improvements to physical therapy diagnosis
explored for TMJ surgery. and management of individuals with TMDs. Strengthening
interdisciplinary collaboration and education will allow
physical therapists to play a vital role in biopsychosocial
Epigenetics and TMD
multidisciplinary care including pre- and post-surgical
Epigenetic mechanisms are biological processes that change management. The importance of a correct diagnosis and
gene expression, and are involved in the complex interaction the prevalence of overlapping conditions in orofacial pain (5)
between genetics and environment behind most chronic highlights the need for expanded physical therapy
conditions (96). While epigenetic processes are required diagnostic criteria to address the cervical spine and central
for some normal cell function, there are three site-specific nervous system. Similarly, using tools such as RTUS to
mechanisms of interest for chronic pain: modifications to further identify muscle disorders and applying knowledge
the histones in DNA structure, DNA methylation, and of TMJ biomechanics gained from modeling studies could
RNA transcription interference (97). All three of these improve treatment efficacy and post-surgical rehabilitation
mechanisms result in genetic modifications that can increase outcomes. Central nervous system changes that can
an individual’s susceptibility to experiencing the synaptic occur in some individuals with TMD can be successfully
potentiation associated with plasticity, associative learning addressed by physical therapists through novel applications
and memory, which will change pain thresholds and of therapeutic PNE, virtual reality applications, and
contribute to neuropathic pain (96). Maladaptive plasticity epigenetic advancements. Without these strategies, barriers
can create phenomena such as central sensitization, such as central sensitization and kinesiophobia threaten
hyperalgesia and allodynia. The connection between TMD to undermine successful pain management and restrict
and central sensitization is well-documented, and frequently restoration of normal function for some individuals with
surfaces as a barrier to rehabilitation (62). Therefore, persistent pain. The strategies discussed in the review are
studying epigenetics has potential to contribute new consistent with the recommendations of the 2020 TMD
knowledge regarding the biological mechanisms behind consensus study report which called for additional research,
chronic pain and management strategies for individuals with training, and interdisciplinary collaboration to improve
chronic orofacial pain. clinical care practices for this population (5). While far
Epigenetic processes are central to PNE and future from exhaustive, the list of subjects covered reveals the
research on their application to rehabilitation will guide vast potential that exists for enhanced rehabilitative care
clinicians as technology evolves. Much of the existing in this area. Innovative, coordinated, evidence-based
epigenetic research in rehabilitation has focused on rat physical therapy provided alongside colleagues from
models, with demonstrated results ranging from exercise- multiple disciplines will visualize the future of successful
induced hypoalgesia to decreased neuronal excitability rehabilitation for individuals with TMD.
and modulation of neuropathic pain (96). Extending this
research for use with PNE in human subjects will allow
Acknowledgments
therapists to maximize the capacity for motor learning
within the context of patient-specific rehabilitation needs. Funding: None.
By combining epigenetic markers with clinical assessment,
prediction of vulnerability to chronic pain after procedures
Footnote
and/or overreaction of the immune system to exercise
becomes possible (96). The predominance of chronic pain Provenance and Peer Review: This article was commissioned

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Frontiers of Oral and Maxillofacial Medicine, 2022 Page 9 of 13

by the Guest Editors (Stephen Feinberg and Louis Mercuri) interventions for temporomandibular disorders. Phys
for the series “Temporomandibular Joint Disorders Ther 2006;86:710-25.
Diagnosis and Management – What Does the Future 4. American Academy of Orofacial Pain, de Leeuw R, Klasser
Hold?” published in Frontiers of Oral and Maxillofacial GD, editors. Orofacial Pain Guidelines for assessment,
Medicine. The article has undergone external peer review. diagnosis, and management. 6th edition. Hanover Park,
IL: Quintessence Publishing Co, Inc.; 2018.
Conflicts of Interest: The authors have completed the 5. Bond EC, Mackey S, English R, et al. The National
ICMJE uniform disclosure form (available at https:// Academies Collection: Reports funded by National
fomm.amegroups.com/article/view/10.21037/fomm-20- Institutes of Health. Temporomandibular Disorders:
44/coif). The series “Temporomandibular Joint Disorders Priorities for Research and Care. Washington (DC):
Diagnosis and Management – What Does the Future National Academies Press (US); 2020:380.
Hold?” was commissioned by the editorial office without 6. Schiffman EL, Ahmad M, Hollender L, et al. Longitudinal
any funding or sponsorship. JP was a member of the Board Stability of Common TMJ Structural Disorders. J Dent
of Directors of the Illinois Physical Therapy Foundation Res 2017;96:270-6.
(unpaid), is a consultant for Myopain Seminars (paid), and 7. Tuijt M, Koolstra JH, Lobbezoo F, et al. Biomechanical
receives conference and travel funding though Midwestern modeling of open locks of the human temporomandibular
University. EK was a paid speaker at a conference, and joint. Clin Biomech (Bristol, Avon) 2012;27:749-53.
receives conference and travel funding through the 8. Tuijt M, Koolstra JH, Lobbezoo F, et al. How muscle
University of Minnesota. The authors have no other relaxation and laterotrusion resolve open locks of
conflicts of interest to declare. the temporomandibular joint. Forward dynamic
3D-modeling of the human masticatory system. J
Ethical Statement: The authors are accountable for all Biomech 2016;49:276-83.
aspects of the work in ensuring that questions related 9. De Meurechy NKG, Loos PJ, Mommaerts
to the accuracy or integrity of any part of the work are MY. Postoperative Physiotherapy After Open
appropriately investigated and resolved. Temporomandibular Joint Surgery: A 3-Step Program. J
Oral Maxillofac Surg 2019;77:932-50.
Open Access Statement: This is an Open Access article 10. Capan N, Esmaeilzadeh S, Karan A, et al. Effect of an
distributed in accordance with the Creative Commons early supervised rehabilitation programme compared
Attribution-NonCommercial-NoDerivs 4.0 International with home-based exercise after temporomandibular joint
License (CC BY-NC-ND 4.0), which permits the non- condylar discopexy: a randomized controlled trial. Int J
commercial replication and distribution of the article with Oral Maxillofac Surg 2017;46:314-21.
the strict proviso that no changes or edits are made and the 11. Garrigós-Pedrón M, Elizagaray-García I, Domínguez-
original work is properly cited (including links to both the Gordillo AA, et al. Temporomandibular disorders:
formal publication through the relevant DOI and the license). improving outcomes using a multidisciplinary approach. J
See: https://creativecommons.org/licenses/by-nc-nd/4.0/. Multidiscip Healthc 2019;12:733-47.
12. Gil-Martínez A, Paris-Alemany A, López-de-Uralde-
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doi: 10.21037/fomm-20-44
Cite this article as: Prodoehl J, Kahnert E. Physical therapy for
temporomandibular disorders: evidence-based improvements
and enhancements for diagnosis and management. Front Oral
Maxillofac Med 2022;4:16.

© Frontiers of Oral and Maxillofacial Medicine. All rights reserved. Front Oral Maxillofac Med 2022;4:16 | http://dx.doi.org/10.21037/fomm-20-44