DISCUSSIONS
Cervical pain is one of the most widespread forms of pain, with a prevalence of
between 6-22% according to research (article on prevalence at the office). It affects
millions of people, and is a major public health problem in terms of mortality and
morbidity, as it tends to become increasingly chronic.
As for temporomandibular disorders, they are constantly on the rise, with a 25.9%
increase ( Prevalence TMD bureau article ). This type of pathology is a problem
because there are so few health professionals trained to deal with it.
This is a considerable challenge for healthcare professionals, requiring a pragmatic
management strategy as well as the promotion of ongoing and additional training for
physiotherapists in the management of this type of pathology.
Physiotherapy is frequently used, and is a key component in the management of
patients with neck pain or TMD, or both, as in this presentation. It is an integral part
of the multidisciplinary management of these two types of pathology.
Improving physiotherapists' knowledge of the combined management of these two
pathologies would enable a more comprehensive, multifactorial and personalized
treatment approach, essential in patient management.
For many years, scientists have recognized the interaction between chronic neck
disorders and TMJ function. This relationship is a two-way street, affecting both TMJ
and cervical health. The coordinated action of head and neck muscles is essential for
movement and posture maintenance. Any disruption to one of these structures can
lead to imbalances, which in turn can lead to a variety of related pathologies.
In physiotherapy, specific clinical studies have demonstrated significant efficacy in
the treatment of TMJ disorders accompanied by neck pain, using a combined
approach of orofacial exercises and cervical programs. ( article dentaire suard )
5.1- Effects of physiotherapy in pain
The primary aim of this systematic review is to show whether physiotherapy is
effective on pain in patients with neck pain associated with temporomandibular
disorders.
Pain is one of the most difficult variables to assess, as it is patient-dependent. It is an
experience unique to each patient and cannot be quantified or evaluated by others
who are not subject to it.
However, scales have been developed to objectify pain and give it a value, which in
most cases can be quantified and quantified numerically.
Of the studies included in our systematic review, 5 used the Visual Analogue Scale
or VAS, 1 used the Numeric Pain Rating Scale or NPRS, and 1 used the 4-Grade
scale composed of 4 grades ranging from 0 to 3 in the order of no pain, mild pain,
moderate pain and severe pain.
The results for the articles in our selection show a significant reduction in pain for
6 of them, in both the TMJ and cervical regions. For our last selected article, the
findings did not show any significant change in the evolution of pain during the
intervention.
For all articles evaluating pain with the VAS, the results show a significant reduction
of an average of 3.0426cm after analysis and averaging of all results.
As for the article evaluating pain with the 4-grade Scale, the results show a
significant reduction of 1.75 on average after 6 weeks of treatment compared to
control group.
Finally, the last article, using the NPRS, shows a 2cm reduction which is not
considered significant according to the results after 3 months post-intervention
compared to control group.
Previous research has studied the effectiveness of physiotherapy on the pain of
patients with neck pain and Temporomandibular disorders. For example, a meta-
analysis by ROY LATOUCH et al. evaluated the effects of manual therapy (a branch
of physiotherapy) on patients with neck pain and TMD. This study shows a
significant reduction in pain in the study group compared with the control group. In
addition, a single cohort center study by In-Su LEE and Suhn-Yeop KIM
investigated the effectiveness of manual therapy on pain and disability in
temporomandibular disorders associated with headaches. Headaches were
assessed using the Numerical Rating Scale (NRS). After 10 weeks of treatment, the
results show a significant reduction in pain in the intervention group compared
with the control group.
There are several possible explanations for how physical therapy can reduce pain:
- One mechanism is the hinibition of stimuli sent via the large-caliber
pathways, which inhibits the nociceptors. This phenomenon is called GATE
control. Massage, mobilization and exercise are all part of this theory. ( kine
antalgique)
- Physiotherapy, the use and application of physical agents such as heat,
cold, electricity or water, has an effect on pain and acts as an analgesic. ( kine
antalgique )
These two methods are an integral part of physiotherapy and may therefore explain
the significant evolution of pain in the articles of this systematic review.
5.2- Effects of physiotherapy on the Range Of Motion ( ROM )
Range Of Motion (ROM) is a person's ability to have a certain degree of movement.
ROM is of paramount importance in the body's schema, as it enables freedom of
movement, without imbalance, and optimal function.
ROM limitation can be caused by a variety of factors, including pathology, accident,
fracture, surgery, muscle tension or pain. These limitations may be hard or soft, or
may be visible through active or passive movement.
In this systematic review, the ROM studied was the mouth opening of patients with
neck pain associated with temporomandibular disorders. However, 1 of the articles
assessed cervical ROM in all directions and was therefore not considered.
Of the 7 articles in this study, 4 assessed mouth opening (54, 58-60). For this
purpose, all studies used the Maximal Mouth Opening or MMO to measure aperture.
According to 3 of the 4 articles, physiotherapy significantly increased mouth
opening in patients with TMD associated with neck pain, in the intervention group
compared with the control group.
For each article, the results were as follows: 35-48mm (41.5mm) at baseline to 49-
62mm (55.5mm) at 3rd measurement (54); from 42.15mm before treatment to
48.15 after treatment (58); from 36.1mm before to 41.32mm at 3 months after
treatment (59). This gives an average increase of 8.4mm after averaging the
increases in each study.
However, one of the articles concludes that physiotherapy has no significant effect.
This article shows a mean increase of 8.04mm, ranging from 37.8mm pre-treatment
to 45.84mm post-treatment. All the articles show an increase in ROM following
treatment with physical therapy or physiotherapy, although the conclusions do not
seem significant.
Several studies have been carried out on the effectiveness of physiotherapy on
MMO. In the study by Ana-M Idañez-Robles et al., MMO was studied in patients
with TMD receiving exercise therapy. It showed a significant increase in ROM
according to the results obtained.
A second study by Kazuhiro Nagata et al. was also carried out. The aim of this study
was to demonstrate the effectiveness of mandibular manipulation on mouth opening
(MMO) in patients with TMD. The results also showed a significant increase in
ROM.
