Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2015 42; 847–861
Review
Manual therapy for the management of pain and limited
range of motion in subjects with signs and symptoms of
temporomandibular disorder: a systematic review of
randomised controlled trials
L. B. CALIXTRE*, R. F. C. MOREIRA*, G. H. FRANCHINI*, F. ALBURQUERQUE-
S E N D
IN † & A . B . O L I V E I R A * *Department of Physiotherapy, Federal University of S~ao Carlos (UFSCar), S~ao Carlos,
Brazil and †Department of Nursing and Physiotherapy, Salamanca University, Salamanca, Spain
SUMMARY There is a lack of knowledge about the
effectiveness of manual therapy (MT) on subjects
with temporomandibular disorders (TMD). The aim
of this systematic review is to synthetise evidence
regarding the isolated effect of MT in improving
maximum mouth opening (MMO) and pain in
subjects with signs and symptoms of TMD.
MEDLINEâ, Cochrane, Web of Science, SciELO and
EMBASETM electronic databases were consulted,
searching for randomised controlled trials applying
MT for TMD compared to other intervention, no
intervention or placebo. Two authors
independently extracted data, PEDro scale was
used to assess risk of bias, and GRADE (Grading of
Recommendations Assessment, Development and
Evaluation) was applied to synthetise overall
quality of the body of evidence. Treatment effect
size was calculated for pain, MMO and pressure
pain threshold (PPT). Eight trials were included,
seven of high methodological quality. Myofascial
release and massage techniques applied on the
masticatory muscles are more effective than control
Background
Temporomandibular disorder (TMD) is a general term
that refers to disorders associated with the temporo-
mandibular joint (TMJ) and masticatory muscles (1).
The main signs in patients with TMD are noise and
limitations or deviations during mouth opening, and
© 2015 John Wiley & Sons Ltd
(low to moderate evidence) but as effective as toxin
botulinum injections (moderate evidence). Upper
cervical spine thrust manipulation or mobilisation
techniques are more effective than control (low to
high evidence), while thoracic manipulations are
not. There is moderate-to-high evidence that MT
techniques protocols are effective. The
methodological heterogeneity across trials protocols
frequently contributed to decrease quality of
evidence. In conclusion, there is widely varying
evidence that MT improves pain, MMO and PPT in
subjects with TMD signs and symptoms, depending
on the technique. Further studies should consider
using standardised evaluations and better study
designs to strengthen clinical relevance.
KEYWORDS: musculoskeletal manipulations, physical
therapy modalities, temporomandibular joint
disorders, craniomandibular disorders, facial pain,
articular range of motion
Accepted for publication 17 May 2015
mandibular dysfunction. The main symptoms are
pain in the region of the TMJ, the masticatory mus-
cles or both (2). Thirty-nine per cent of the general
population presents at least one sign or symptom of
TMD (3).
There is evidence that occlusal appliances, acupunc-
ture, behavioural therapy, jaw exercises, postural
doi: 10.1111/joor.12321
848 L . B . C A L I X T R E et al.
training and some pharmacological treatments can be
effective in alleviating those signs and symptoms (4).
Physiotherapy usually applies different therapy
modalities, such as electrical stimulation, low-level
laser therapy, ultrasound, acupuncture and relaxation
exercises using biofeedback, as well as active exercises
and MT (5). These modalities are often combined in
rehabilitation protocols.
According to the American Academy of Orthopae-
dic Manual Physical Therapists, MT, also called ortho-
paedic manual physical therapy, comprises ‘any
hands-on treatment provided by the physical thera-
pist’. Treatment may include moving joints in specific
directions and at different speeds to regain movement
(joint mobilisation and manipulation), muscle stretch-
ing, passive movements of the affected body part or
having the patient move the body part against the
therapist’s resistance to improve muscle activation
and timing. Selected specific soft tissue techniques
may also be used to improve the mobility and func-
tion of tissue and muscles (6).
Generally, MT improves circulation, decreases mus-
cle spasm, relaxes muscles around the joint, realigns
soft tissue, breaks adhesions, increases range of
motion and decreases pain (7). In patients with signs
and symptoms of TMD, MT (by itself or in combina-
tion with other techniques) has been applied directly
to the TMJ and masticatory musculature (8–10), to
the cervical spine and neck muscles (11–14) or to
both regions or structures (15–18).
Two systematic reviews (5, 19) on the effective-
ness of physical therapy treatment of patients with
TMD were identified in the literature. Both were
published in 2006 and synthetised limited evidence
regarding the effectiveness of MT techniques to treat
those subjects. McNeely et al. (5) found only one pri-
mary study using MT in association with exercises,
and they highlight the need for better designed stud-
ies giving more attention to methodological issues
and clinical relevance. Medlicot et al. (19) included
nine studies applying MT for TMD. However, most
of them were case series, and only three studies
were randomised controlled trials (RCT). Further-
more, the authors investigated the effects of MT
associated with other therapeutic modalities, leading
to a biased evidence synthesis regarding the effec-
tiveness of MT itself.
Although physical therapy treatment, in general,
presents itself as a multidisciplinary and multimodal
approach, the knowledge about the effectiveness of
each technique to improve symptoms is essential for
planning an efficient treatment protocol. The use of
non-effective techniques may compromise a patient’s
adherence to treatment. Therefore, it is important to
emphasise that the evaluation of combined tech-
niques jeopardises the identification of which modal-
ity is actually effective in the improvement of
symptoms. Therefore, the aim of this study is to syn-
thetise evidence regarding the isolated effect of MT in
improving TMJ function, considering maximum
mouth opening (MMO) and pain as main outcomes.
The review followed the Cochrane Collaboration rec-
ommendations for systematic reviews (20) and applied
the GRADE (Grading of Recommendations Assessment,
Development and Evaluation) approach (21).
Methods
Data sources and searches
Electronic searches were carried out in MEDLINE,
Cochrane, Web of Science, SciELO and EMBASE data-
bases, using the following combination of keywords:
(Musculoskeletal Manipulations[MeSH Terms] OR
massage[MeSH Terms] OR manipulation, chiropractic
[MeSH Terms] OR physical therapy modalities[MeSH
Terms]) AND (craniomandibular disorders[MeSH
Terms] OR temporomandibular joint disorders
[MeSH Terms] OR facial pain[MeSH Terms]). The
search strategy focused on publications from the last
21 years (1993–2014). There was no restriction regard-
ing the publication language. Grey literature was not
accessed; therefore, such publications as reports, con-
ference proceedings, and theses or dissertations were
not considered for analysis (22).
The reference lists of the selected papers were also
checked to identify potentially relevant studies not
retrieved in the electronic search.
Trial selection
Two independent reviewers screened titles and
abstracts of the retrieved publications to exclude those
not related to the topic of the review. Full texts of
potentially relevant articles were retrieved for final
evaluation. The whole selection process was con-
ducted by consensus. When consensus was not
achieved, a third reviewer was consulted for final
© 2015 John Wiley & Sons Ltd
 MANUAL THERAPY FOR TEMPOROMANDIBULAR JOINT TREATMENT
judgment. START (State of the Art through System-
atic Review*), a reference manager software, was
used during the selection of papers.
Eligibility criteria for initial study selection
Type of study. Studies were considered eligible for
inclusion if they were RCTs comparing an MT physi-
cal therapy intervention to a reference group (placebo
intervention, controlled comparison intervention,
standard treatment or other treatment).
Participants. Trials with adult participants presenting
signs and symptoms of temporomandibular disorders
were included. Studies that applied manual therapy
in non-symptomatic subjects were excluded.
Type of intervention. Primary studies addressing the
treatment of TMJ impairments through MT protocols
with emphasis on joint, ligaments, fascia, muscles or a
combination of these techniques were included. At
least one of the intervention groups must have exclu-
sively received some modality of MT. Temporomandib-
ular joint treatments after surgery, fracture, dislocation
or trauma were not included in the review, and hyper-
plasia, ankylosis, synovitis, Eagle’s syndrome and treat-
ments for rheumatic diseases were excluded.
Outcome measures. Studies reporting outcomes related to
pain, MMO or pressure pain threshold (PPT) of the mas-
ticatory muscles were included. These outcomes were
selected because they represent the main complaints of
subjects with TMD. The methods applied to evaluate
outcome measures had to be valid and reliable.
Quality assessment and clinical relevance
The PEDro (Physiotherapy Evidence-Based Database)
scale was used to assess the methodological quality of
the studies included in this review. The reliability of
this tool is fair to good (23).
Although this scale has 11 items, specification of
eligibility criteria was not accounted in the final score,
so the total score ranges from zero to ten. Each satis-
fied item scored one point, and the final score was
obtained by the sum of all positive answers. The stud-
*Laboratory of Research on Software Engineering from Federal Uni-
versity of Sćo Carlos, Sćo Carlos, Brazil.
© 2015 John Wiley & Sons Ltd
849
ies indexed in the PEDro database already had a rat-
ing, which was maintained. The non-indexed studies
were independently evaluated by two reviewers
(L.B.C., G.H.F.). In case of disagreement, a third
reviewer (R.F.C.M.) was consulted.
The literature suggests that high-quality studies
should achieve a total score higher than 50% of the
possible maximum (24, 25). Thus, for this review,
RCTs with a PEDro score higher than or equal to 5
0
were classified as high methodological quality studies.
Recommended criteria proposed by Higgins and
Green (20) were used to evaluate clinical relevance.
Data extraction
After the final consensus and selection of the pri-
mary studies, the reviewers (L.B.C., G.H.F.) worked
independently. A standardised form, adapted to the
model proposed by the Cochrane Collaboration, was
used for data extraction including information
regarding study design, follow-up, sample characteris-
tics, intervention characteristics (type, duration and
number of sessions), comparison groups and out-
comes.
Data synthesis and analysis
Because of the heterogeneity of the primary studies,
it was not possible to perform a meta-analysis. To
compare the effect size (ES) of each MT technique,
standardised mean difference (26) was calculated for
each comparison group separately, considering the
values before and after intervention. These were fur-
ther classified as small (<0
20), moderate (around
0
50) or large (>0
80), according to Cohen’s criteria
(27).
The quality of the body of evidence was determined
using the GRADE approach, which analyses the fol-
lowing domains: trial design limitations due to risk of
bias, inconsistency of results, indirectness, imprecision
of results and publication bias. The details of this
method have been reported previously (21, 28, 29); a
detailed description is presented in Data S1.
The studies were primarily divided according to the
body structure that received MT: masticatory muscu-
lature, cervical or thoracic spine, or a combination of
several techniques in an MT protocol. Subsequently,
distinctions were made according to the outcomes
(pain, MMO and PPT) and comparison groups.
850 L . B . C A L I X T R E et al.
Results
Trial selection
The electronic search returned 6581 published refer-
ences. The final selection process resulted in eight
included studies for evidence synthesis (13, 16, 17,
30–34). The main reasons for exclusion are specified
in Data S2. Most of them were excluded because of
the trial design (non-randomised and controlled stud-
ies), and the combination of therapies.
Details of the selection process are presented in Fig. 1.
Quality assessment and clinical relevance
Seven studies presented high methodological quality.
The mean PEDro total score obtained for the studies
was 6
62 (Table 1). Only one study (13) was classified
as low methodological quality. Only one study (30)
was not indexed by the PEDro database. Therefore,
the reviewers assessed its methodological quality.
The most critical criteria to be satisfied were blinding
subjects (25%), intention-to-treat analysis (37
5%)
and concealed allocation (62
5%).
The studies presented a mean score of 2
9 on the
clinical relevance scale. Only one study (32) achieved
the highest score (five points). The least satisfied crite-
rion was related to the clinical importance of the
effect size, achieved by two primary studies (17, 32).
Only three studies (13, 32, 34) provided confidence
intervals. Sample size calculation was reported by five
studies (30, 32–35) and the ES by three studies (13,
33, 34). Finally, none of the studies tested the reliabil-
ity of the assessment tool.
Trial characteristics
The characteristics of the eight included papers are
listed in Table 2.
Although all included studies were RCT, there was a
variation in the applied protocols regarding the number
of sessions and the frequency of therapy application.
Fig. 1. Trial flow of the selection
process.
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 MANUAL THERAPY FOR TEMPOROMANDIBULAR JOINT TREATMENT 851

Table 1. Methodological quality evaluated according to PEDro scale and clinical relevance criteria

Risk of bias (PEDro scale) Clinical relevance

Total Total
Study 1 2 3 4 5 6 7 8 9 10 11 score 12 13 14 15 16 Score

Kalamir + + + + + + + + + 8 + + + + 4
et al. 2012 (31)
Guarda Nardini + + + + + + 5 + + + 3
et al. 2012 (30)
Gomes et al. 2014 (33) + + + + + + + + 7 + + 2
Mansilla-Ferragut + + + + + 4 + + + + 4
et al. 2008 (13)
La Touche + + + + + + + + + 8 + + + + + 5
et al. 2013 (32)
Packer et al. 2014 (34) + + + + + + + + + + 9 + + + 3
Cuccia et al. 2010 (16) + + + + + + + 6 + + + + 4
Piekartz + + + + + + + 6 + + + + 4
et al. 2011 (17)
Percentage of studies 100 100 62
5 75 25 0 87
5 75 37
5 100 100 87
5 62
5 97
5 37
5 97
5
which satisfied
the criteria

1. Eligibility criteria; 2. Random allocation; 3. Concealed allocation; 4. Baseline comparability; 5. Blind subjects; 6. Blind therapists; 7.
Blind assessors; 8. Adequate follow-up; 9. Intention-to-treat analysis; 10. Between-group comparisons; 11. Point estimates and vari-
ability; 12. Are the patients described in detail so that you can decide whether they are comparable to those that you see in your prac-
tice? 13. Are the interventions and treatment settings described well enough so that you can provide the same for your patients? 14.
Were all clinically relevant outcomes measured and reported? 15. Is the size of the effect clinically important? 16. Are the likely treat-
ment benefits worth the potential harms?
Eligibility criteria item is not accounted in the total score.

Two of these studies (13, 36) analysed the immediate
effect of MT. The six remaining studies performed a
longer follow-up evaluation after the treatment. Two
of them (30, 32) applied a protocol of three sessions,
while the other three studies (17, 31, 33) used longer
protocols (more than three sessions). One study (16)
did not specify the number of sessions applied.
Outcome measurement tools
Pain intensity at rest was evaluated through the visual
analogue scale in five studies (16, 30–32, 34). The col-
oured analogue scale was also applied (17) both at rest
and at MMO. MMO measurements were taken in all
studies except for 2 (32, 34), while PPT was assessed in
three of eight included studies (13, 32, 34).
Characteristics of subjects included in the primary studies
The total number of participants in the studies ranged
from 30 to 93, and the mean number of subjects was
45
6  18
2. All evaluated subjects were adults, based
on a minimum age of 18 years and a maximum age of
50 to 65 years. Females predominated (62
6% of the
sample) in most of the studies, and in one study (34),
the sample was composed exclusively of women.
Four studies (30–32, 34) used the standardised eval-
uation protocol Research Diagnostic Criteria for Tem-
poromandibular Disorders (RDC/TMD) (37): All of
them included patients with myogenic dysfunction.
The remaining studies adopted non-standard evalua-
tion protocols. In general, the presence of signs and
symptoms of TMD (13, 16, 17, 33) was required for
subject inclusion, and some studies (13, 17, 32, 34)
also included subjects with TMD and associated neck
pain symptoms.
Most of these studies have clearly reported their
exclusion criteria (16, 30–34). The most frequent
criteria adopted were subjects who suffer from malig-
nancy, fibromyalgia, TMJ inflammatory arthritis, or
from metabolic, connective tissue, rheumatic, or hae-
matological diseases. Subjects with previous oral or
cervical surgery, history of neck trauma or whiplash
were also excluded. Studies involving manipulative

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Table 2. Characteristics of primary studies considering study design, subjects, intervention and outcomes

Trial Subjects’ characteristics Intervention group(s) Comparison Group Outcomes and tools Follow-up

Kalamir et al. (31) Patients with TMD (RDC/TMD) and
daily history of periauricular pain
with or without joint sounds
>3 months in duration and
(a) 10 sessions of intra-oral
temporalis release, intra-oral
medial and lateral pterygoid
(origin) technique, intra-oral
(c) control group MMO (calliper) After five weeks of
intervention, six months
and a year follow-up
L . B . C A L I X T R E et al.

minimum baseline graded chronic sphenopalatine ganglion technique

pain score of 3
Risk of Bias: 8 Age: 18–50 years (b) group A +instructions + home Jaw pain at rest,
Clin. Relevance: N: 93 (52 W and 41 M) exercise (not considered in maximal active
4 analysis) opening and
clenching (VAS)
Guarda Nardini Patients with myofascial TMD (a) 3(1) sessions based on fascial (b) 1 session of MMO (NE tool) Immediately after
et al. (30) according to RDC/TMD and manipulation guidelines multiple botulin toxin intervention, and
bilateral pain >6 months injections in 2 months follow-up
Risk of Bias: 5 Age: 23–69 years temporalis and
Clin. Relevance: 3 N: 30 (22 W and 8 M) masseters muscles Pain (VAS)
Gomes et al. (33) Group (a) and (c): presence of TMD (a) Massage therapy involving (c) treatment with MMO (calliper) After 4 weeks of
signs and symptoms according to sliding and kneading manoeuvres occlusal splint for intervention
FAI on the masseters and temporalis 4 weeks
Group (b): absence of TMD signs muscles
and symptoms according to FAI
Risk of Bias:7 Age: 18–40 years (b) Asymptomatic comparison group
Clin. Relevance: 2 N:42 (30 W and 12 M) was not submitted to any form of
intervention (not considered in
analysis)
Mansilla-Ferragut Subjects with <40 mm of mouth (a) 1 session of atlanto-occipital (b) control group MMO (calliper) Immediately after
et al. (13) opening, with or without TMD joint thrust manipulation intervention
symptoms. Headache >1 month,
not received any osteopathic
treatment <2 months before the
study and not received any
medical treatment <2 weeks
Risk of Bias: 4 Age: 21–50 years PPT of temporalis
Clin. Relevance: 4 N: 52 (40 W and 12 M) muscles
(algometer)

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 Table 2. (continued)

Trial Subjects’ characteristics Intervention group(s) Comparison Group Outcomes and tools Follow-up

© 2015 John Wiley & Sons Ltd

La Touche et al. Subjects with myofascial pain (RDC/ (a) Anterior–posterior upper cervical (b) Placebo technique: Pain (VAS) After 3 sessions of
(32) TMD), for at least 3 months, mobilisation on the 3 upper same hand position of intervention
bilateral pain and presence of TrPs cervical segments (C0-C3). The the therapist.
in masseters, temporalis, upper mobilisation was applied at a rate However,
trapezius and suboccipital muscles; of 1 oscillation per 2 s (0
5 Hz) mobilisation was not
>3 mm on VAS scale; neck and/or applied to the cervical
shoulder pain; NDI ≥ 15 spine
Risk of Bias: 8 Age: 33
19  9
49 and PPT in masseters
Clin. Relevance: 5 34
56  7
84 years and temporalis (2
32 (21 W and 11 M) points each
muscle)
Packer et al. (34) Myofascial pain or mixed TMD (a) Upper thoracic manipulation (b) placebo technique: Pain (VAS) Immediately, 48 and
according to the RDC/TMD, technique applied to the T1 same position of the 72 h after the procedure
complaints of pain or fatigue in the vertebral segment. Therapist hand subject; however,
masticatory muscles during in pistol grip. therapist hand was
functional activities >6 months, open and not in
diagnosis of neck pain (NDI) and pistol grip.
body mass index <25 kg m 2
Risk of Bias: 9 Age: 18–40 years PPT in masseters
Clin. Relevance: 3 N: 32 (32 W) and temporalis
Cuccia et al. (16) Subjects with TMI reference value (a) OMT: myofascial release, (b) conventional MMO (calliper) After intervention and
of ≥0
08  0
10, and minimum balanced membranous tension, treatment: oral 2 months follow-up
pain intensity of 40 mm on a muscle energy, myofascial release, appliance, muscle
visual analogue scale joint articulation, high-velocity, stretching and
Risk of Bias: 6 Age: 18–50 years low-amplitude thrust and cranial- relaxing exercises, Pain (VAS)
Clin. Relevance: 4 N: 50 (28 W and 22 M) sacral therapy hot and/or cold
packs, TENS
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854 L . B . C A L I X T R E et al.

Temporomandibular disorder; VAS, Visual analogue scale; CAS, Coloured analogue scale; PPT, Pressure pain threshold; TMI, Temporomandibular index; RDC/TMD, Research
N, Number of subjects; Clin, Clinical, MMO; Maximum mouth opening; NE, Not specified; W, Women; M, Men; TrPs, Trigger points; TMJ, Temporomandibular joint; TMD,

Diagnostic Criteria for Temporomandibular Disorders; OMT, Osteopathic manual therapy; NDI, Neck Disability Index; ICDCH, International Classification of Diagnostic Criteria
techniques to the cervical spine (13, 16) have applied
other specific exclusion criteria.

6 months follow-up
intervention and
After 6 weeks of
Manual therapy techniques
Follow-up

Some studies applied intra-oral (31) myofascial release

techniques as well as massage therapy (33) on mastica-
tory muscles. One study (13) applied an atlanto-occipi-
Outcomes and tools

tal joint thrust manipulation, another (34) applied a

thoracic manipulation, and another applied a mobilisa-
MMO (ruler)

tion for the upper cervical spine (32). Finally, two stud-
Pain (CAS) ies (16, 17) applied many MT techniques to treat
patients with signs and symptoms of TMD.

Effect of manual therapy techniques

craniocervical region
(b) usual care group:
Comparison Group

treatment of the
continued their

The quality of evidence for each MT technique

according to GRADE approach is presented in
Tables 3–5. Reasons for downgrading the quality of
the body of evidence are cited in the legends below
each table.
The evidence synthesis showed moderate and low
optimal function of cranial nerve

evidence that myofascial release and massage tech-

therapists’ clinical decisions. The
TMJ and/or masticatory muscle
techniques (TrPs treatment and
(a) translator movements of the

passive movements facilitating

tissue, coordination and home

muscle stretching), active and

niques are more effective than placebo or no inter-

necessary, opt for additional
exercises, depending on the

therapist could also, when

vention for MMO and pain outcomes respectively.

There is also moderate evidence that no significant
treatment of the neck
Intervention group(s)

difference exists between myofascial release and toxin

botulinum for improvement on the same outcomes.
of Headaches; C1, First cervical vertebrae; FAI, Fonseca Anamnestic
Index.

There is moderate evidence that atlanto-occipital

joint thrust manipulation is more effective than pla-
cebo in improving MMO in individuals with TMD.
However, there is low evidence that C7-T1 thrust
manipulation does not improve PPT in subjects with
Subjects with 4 of following signals:

muscle pain at a minimum of two

headache according to the ICDCH

during passive MO + cervicogenic
tender points in the masseters or

lasting more than 3 months and

TMD when compared to placebo manipulation.

joint sounds, deviation during
MMO, extra oral muscle pain

In addition, an upper cervical mobilisation proposed by

temporalis muscles and pain

La Touche et al. (32) showed high evidence on reducing

N: 43 (27 W and 16 M)
Subjects’ characteristics

pain and increasing PPT comparing to placebo.

Finally, MT osteopathic technique protocols showed
Age: 18–65 years

greater MMO, pain and PPT improvement when com-

pared to a usual care group (revealing high evidence
NDI > 15

for MMO and moderate evidence for pain and PPT).

Only two studies (30, 31) reported absence of
adverse effects as a consequence of the applied tech-
Table 2. (continued)

niques; the remaining did not report.

Clin. Relevance: 4
Piekartz et al. (17)

Risk of Bias: 6

Discussion
Most of the RCTs included in this review were high
Trial

methodological quality studies and presented positive

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© 2015 John Wiley & Sons Ltd
Table 3. Quality of evidence according to the GRADE approach for studies comparing 1–10 sessions of manual therapy techniques applied to the masticatory muscles to con-
trol or usual care group, as well as manual therapy compared to botulinum toxin injection

Miofascial techniques and massage on masticatory muscles

Manual Therapy Comparison

Magnitude GRADE
Outcome Limitations Inconsistency Indirectness Imprecision Publication Bias Trial n ES n ES of effect quality

Miofascial release 9 Control/usual care

Pain* No serious N/A N/A Serious 2,3 N/A Kalamir (31) 31 N/E 31 N/E No Low
MMO** No serious Serious 1 No serious Serious 2 Undetected Kalamir (31) 31 N/E 31 N/E No Moderate
Gomes (33) 14 1
35 14 1
43
Miofascial release 9 botox
Pain No serious N/A N/A Serious 3 N/A Guarda-Nardini (30) 15 2
29 15 1
31 No Moderate
MMO No serious N/A N/A Serious 3 N/A Guarda-Nardini (30) 15 0
23 15 0
13 No Moderate

Serious 1 – >75% of the sample show conflicting results.

Serious 2 – <75% of the studies present data that can be included in a meta-analysis.
Serious 3 – Only one study.
*Follow-up 1–10 sessions; measured with: VAS or VAS upon pressure; better indicated by lower values.
**Follow-up 1–10 sessions; measured with: calliper; better indicated by higher values.
N/A, not applicable.
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Table 4. Quality of evidence according to the GRADE approach for studies that applied 1–3 sessions of vertebral manipulation or mobilisation techniques applied on the upp-
er cervical or on the thoracic spine compared to control or placebo group

Vertebral manipulation or mobilisation techniques

Manual Therapy Comparison

Magnitude GRADE
Outcome Limitations Inconsistency Indirectness Imprecision Publication Bias Trial n ES n ES of effect quality

C0-C1 trust manipulation 9 control/placebo

MMO* Serious 1 N/A N/A Serious 2 N/A Mansila Ferragut (13) 26 0
79 26 0
05 Large effect Moderate
PPT** Serious 1 N/A N/A Serious 2 N/A Mansila Ferragut (13) 26 0
20 26 0
27 No Low
C7-T1 thrust manipulation 9 placebo
Pain*** No serious N/A N/A Serious 2 N/A Packer (34) 16 0
20 16 0
2 No Moderate
PPT** No serious N/A N/A Serious 2 N/A Packer (34) 16 0
00 16 0
00 No Moderate
Upper cervical mobilisation 9 placebo
Pain*** No serious N/A N/A Serious 2 N/A La Touche (32) 16 3
05 16 0
04 Very large effect High
PPT** No serious N/A N/A Serious 2 N/A La Touche (32) 16 >0
8 16 <0
2 Very large effect High

Serious 1 – <75% of the studies presented high quality (PEDro).

Serious 2 – Only one study.
*Follow-up 1–3 sessions; measured with: calliper; better indicated by higher values.
**Follow-up 1–3 sessions; measured with: algometer; better indicated by higher values.
***Follow-up 1–3 sessions; measured with: VAS; better indicated by lower values.
N/A, not applicable.

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 MANUAL THERAPY FOR TEMPOROMANDIBULAR JOINT TREATMENT 857

effects on pain, MMO and PPT in response to MT

Moderate

Moderate
GRADE
quality
techniques on subjects with signs and symptoms of

High
TMD. The results showed highly variable evidence
that MT improves signs and symptoms of TMD. In

Very large effect

fact, MT reduces pain and increases MMO and PPTs
Table 5. Quality of evidence according to the GRADE approach for studies that applied combined manual therapy techniques compared to usual care group

in TMD impairments, depending on the technique

Magnitude
of effect

No used.

No
Vertebral manipulations and mobilisation techniques
3
58
0
07
0
33
0
20
0
87
Comparison

The effectiveness of an atlanto-occipital joint thrust

ES

manipulation technique was evaluated by one low

25
21
25
21
21

methodological quality study (13), and both statistical

n

improvement and ES were favourable to the tech-

Manual Therapy

6
24
1
79
2
39
2
21
0
21/0
53

nique considering MMO. Otherwise, it was not effec-

tive on PPT improvement (Table 4).
ES

Two mechanisms are proposed to explain the use of

MT on the upper cervical spine to resolve TMD symp-
25
22
25
22
22
n

toms: the biomechanical relationship between neck

and jaw (12, 38, 39), and the neuroanatomical rela-
Piekartz (17)

Piekartz (17)
Piekartz (17)
Cuccia (16)

Cuccia (16)

tionship between those areas (40–42).

La Touche et al. (32) applied a mobilisation tech-
Trial

nique on the upper cervical spine with neurophysiolog-

ical effects similar to the ones described previously. The
Publication Bias

technique reduced pain and increased masseter and

Undetected

Undetected

temporalis PPT. Although only one study applied this

kind of mobilisation, it showed a very large effect size.
N/A

Therefore, the evidence was addressed as high accord-

ing to the criteria applied in this review (Table 4).
Imprecision

A thoracic thrust manipulation was applied by

No serious

No serious

Serious 2

Packer et al. (34) in patients with TMD and neck pain,

***Measured with: algometer; better indicated by higher values.

based on the reasoning that cervical and thoracic

*Measured with: VAS/CAS; better indicated by lower values.
**Measured with: calliper; better indicated by higher values.

spines are related in terms of anatomy, biomechanics

Serious 1 – >75% of the sample show conflicting results.

and nerve connections. Therefore, joint mobility prob-

Indirectness

No serious

No serious

lems in the thoracic region would lead to neck pain

and, consequently, to TMD. However, when compar-
N/A

ing C7-T1 thrust manipulation with sham, the results

were not statistically different, moreover effect sizes
Inconsistency

Manual therapy protocol 9 usual care

No serious

were small for PPT increasing and pain decreasing in

Serious 1

both groups. Thus, there is moderate evidence that

N/A

this technique does not increase those outcomes.

Serious 2 – Only one study.
Manual therapy protocols

Limitations

No serious

No serious

No serious

Myofascial release and massage of masticatory muscles

N/A, not applicable.

One high methodological study (31) applied myofas-

cial release techniques in MTrPs and one (33) study
MMO**

applied massage therapy on masticatory muscles.

Outcome

PPT***
Pain*

These studies are of high methodological quality, and

one of them showed a statistical trend towards

© 2015 John Wiley & Sons Ltd

858 L . B . C A L I X T R E et al.
improvement of pain and MMO. However, the evi-
dence of effectiveness is moderate because the tech-
niques varied across the studies, causing data
heterogeneity and analysis difficulties. In addition,
Gomes et al. (33) presented MMO improvement in
both comparison groups; Kalamir et al. (31) have not
provided data to allow the ES calculation, making it
difficult to compare results and failing on inconsis-
tency and imprecision criteria.
Guarda-Nardini et al. (30) used a protocol of myo-
fascial release techniques and compared its efficacy
with botulinum toxin injections in patients with
TMD. The injections caused more MMO improvement
in the group that received botulinum toxin, but pain
reduction was greater in those who underwent MT.
Considering there is only one study evaluating this
technique, the evidence was moderate.
According to a previous study (43), patients with
TMD exhibit reduced blood flow on the masticatory
muscles because of vasoconstriction stemming from
muscle hyperactivity. Consequently, the transport of
nutrients and metabolites is impeded, which can
cause the build-up of by-products, thereby triggering
pain. Massage therapy and myofascial release tech-
niques have been used to treat MTrPs in the mastica-
tory muscles, considering that they cause referred
pain, restricted motion, fatigue and other muscle dys-
functions, and it is a common alteration in patients
with TMD (44). Of these, several manual therapy
techniques are used to equalise the length of sarco-
meres in the involved MTrPs (45), causing reactive
hyperaemia in that region or a spinal reflex mecha-
nism for muscle spasm relief (46). Both mechanisms
can explain the pain relief achieved by these tech-
niques.
Combined MT protocols
To verify the efficacy of various combined MT tech-
niques, two studies evaluated protocols of osteopathic
MT techniques.
Cuccia et al. (16) and von Piekartz and L€ udtke (17)
compared their combined MT protocol (described in
Table 2) to a usual care treatment for subjects with
TMD and demonstrated a significant improvement of
MMO. In addition, the ES values were large, consti-
tuting high evidence for the effectiveness of these
techniques to improve MMO and moderate evidence
of their ability to relieve pain and improve PPT.
However, the techniques were poorly described
with respect to eligibility, frequency and dose, com-
promising both the reproducibility of the protocol and
the identification of which technique may have been
effective in each case.
Methodological considerations
The primary studies showed heterogeneity for diagno-
sis of TMD. Although a standardised evaluation proto-
col (RDC/TMD) has been available since 1992 (37), it
was applied in only four of these studies (30–32, 34).
Therefore, it was not possible to include only studies
that used RDC/TMD as a diagnostic tool. Studies that
evaluated subjects with TMD classified by other proto-
cols were also included. The use of the RDC/TMD to
diagnose TMD according to its origin could improve
external validity as well as improve the evidence syn-
thesis.
Concealment of allocation is another criterion in
need of improvement to reduce the risk of bias (47).
The lack of concealment may overestimate the effect
of the intervention, as well as contribute to mask a
possible effect.
The intention-to-treat analysis and its proper
description increase external validity. Given that
patients often either drop out of treatment or do not
realise it correctly, they may show improvement,
worsening or stagnation of symptoms. The study
design must seek to avoid dropout. Data from people
who did not complete treatment or failed to do it
properly have to be analysed, and dropouts should be
described and justified in the study (48, 49).
In order to match the blinding subject criterion,
simulations (sham) are necessary to measure the
influence of placebo effects in MT techniques. The
use of simulations in MT studies has increased in
recent years (50, 51), but the development and vali-
dation of simulation protocols is still under discussion.
Many of the components for the development of
sham protocols were reviewed by a recent study (52).
Identified in the literature were some MT studies
using simulations on different body parts (51, 53–58).
However, only two of the included studies (32, 34)
have used sham groups to compare the effect of MT
in subjects with signs and symptoms of TMD. La Tou-
che et al. (32) and Packer et al. (34) applied a techni-
que that seemed similar to the original one to
simulate therapy. The patient was in the same posi-
© 2015 John Wiley & Sons Ltd
 MANUAL THERAPY FOR TEMPOROMANDIBULAR JOINT TREATMENT
tion of the original technique but the therapist did
not make the movements necessary to cause a real
effect.
A few primary studies calculated the effect size of
their outcomes, and when those measures were calcu-
lated for the evidence synthesis, most of them showed
small effect size. That is why the criterion regarding the
effect size of the interventions was the least contem-
plated on the clinical relevance analysis. This kind of
analysis is crucial to enhance the transfer of knowledge
from research into clinical practice. Clinicians and
researchers need to be aware of the importance of the
research results and should avoid interpreting results
based only on the statistical significance. A result can
be clinically relevant, but might be neglected if statisti-
cal significance was not attained because of small sam-
ple sizes and high intersubject variability (59).
Finally, there is a clear lack of methodological rig-
our in the description of MT technique protocols.
Detailing a technique’s description and using a stan-
dardised number and frequency of sessions, as well as
a predetermined application of manual therapy,
would facilitate the reproducibility of the intervention
protocol for both clinical and research purposes.
Study limitations
The relatively low number of RCTs addressing the iso-
lated effect of MT technique impairs the synthesis of
evidence regarding the different techniques. Further-
more, the studies reveal large methodological differ-
ences in the assessment of subjects and the diagnosis
of TMD, as well as in the study design itself (treat-
ment frequency, duration and follow-up). To improve
clinical evidence on the effectiveness of MT tech-
niques, high-quality RCTs with adequate study design
and application of standardised methods to classify
and evaluate the subjects are still needed.
Conclusion
Implications for clinical practice
The results of this systematic review showed that
upper cervical manipulation or mobilisation, and pro-
tocols of mixed MT techniques, presented the strong-
est evidence for symptom control and improvement
of MMO. However, when considering mixed proto-
cols, more precise information about the isolated tech-
© 2015 John Wiley & Sons Ltd
859
niques (including criteria for application, frequency
and number of sessions) is necessary to allow replica-
tion in clinical settings.
Implications for research
The literature in this area includes some high-quality
studies. However, further studies will be required to
strengthen the clinical evidence regarding the tech-
niques applied and their effects on MMO and painful
symptoms. Investigators should first consider improv-
ing external validity using a standard protocol (RDC/
TMD, for example) to evaluate and diagnose the dys-
function and could further improve methodological
quality and internal validity by implementing con-
cealment of allocation, intention-to-treat analysis and
blinding subjects, creating MT simulation protocols
that would allow the investigation of placebo effects.
Disclosure/Acknowledgments
The authors are grateful to the Brazilian National
Council for Scientific and Technological Development
(CNPq) for funding the study. No conflict of interests
are declared.
References
1. AS of TJS (ASTJS). Guidelines for diagnosis and management
of disorders involving the temporomandibular joint and
related musculoskeletal structures. Cranio. 2003;21:68–76.
2. Dworkin SF, Huggins KH, LeResche L, Von Korff M, Howard
J, Truelove E et al. Epidemiology of signs and symptoms in
temporomandibular disorders: clinical signs in cases and
controls. J Am Dent Assoc. 1990;120:273–281.
3. Goncßalves DADG, Dal Fabbro AL, Campos JADB, Bigal ME,
Speciali JG. Symptoms of temporomandibular disorders in
the population: an epidemiological study. J Orofac Pain.
2010;24:270–278.
4. List T, Axelsson S. Management of TMD: evidence from sys-
tematic reviews and meta-analyses. J Oral Rehabil.
2010;37:430–451.
5. McNeely ML, Armijo-Olivo S, Magee DJ. A systematic
review of the effectiveness of physical therapy interventions
for temporomandibular disorders. Phys Ther. 2006;86:710–
725.
6. American Physical Therapy Association (APTA). Manipula-
tion education manual for physical therapist professional
degree programs manipulation. Available at: http://www.
apta.org/uploadedFiles/APTAorg/Educators/Curriculum_Re-
sources/APTA/Manipulation/ManipulationEducationManual.
pdf, accessed 29 May 2015.
860 L . B . C A L I X T R E et al.
7. Bialosky JE, Bishop MD, Price DD, Robinson ME, George
SZ. The mechanisms of manual therapy in the treatment of
musculoskeletal pain: a comprehensive model. Man Ther.
2009;14:531–538.
8. De Laat A, Stappaerts K, Papy S. Counseling and physical
therapy as treatment for myofascial pain of the masticatory
system. J Orofac Pain. 2003;17:42–49.
9. Ismail F, Demling A, Hessling K, Fink M, Stiesch-Scholz M.
Short-term efficacy of physical therapy compared to splint
therapy in treatment of arthrogenous TMD. J Oral Rehabil.
2007;34:807–813.
10. Nascimento M, Vasconcelos B, Porto G, Ferdinanda G,
Nogueira C, Raimundo R. Physical therapy and anesthetic
blockage for treating temporomandibular disorders: a clinical
trial. Med Oral Patol Oral Cir Bucal. 2013;18:e81–e85.
11. Ota~ no L, Legal L. Modificaciones radiol
ogicas del espacio
entre el occipucio y el cuerpo del atlas tras una manipulac-
i

on global (OAA) de Fryette. Osteopat Cient
ıfica. 2010;5:38–
46.
12. Oliveira-Campelo NM, Rubens-Rebelatto J, Mart
ı N-Vallejo
FJ, Alburquerque-Send
ın F, Fern
andez-de-Las-Pe~ nas C. The
immediate effects of atlanto-occipital joint manipulation and
suboccipital muscle inhibition technique on active mouth
opening and pressure pain sensitivity over latent myofascial
trigger points in the masticatory muscles. J Orthop Sports
Phys Ther. 2010;40:310–317.
13. Mansilla Ferragud P, Bosc
a Gandia JJ. Efecto de la manipu-
laci

on de la charnela occipito-atlo-axoidea en la apertura de
la boca. Osteopat Cient
ıfica. 2008;3:45–51.
14. La Touche R, Fern
andez-de-las-Pe~ nas C, Fern
andez-Carnero
J, Escalante K, Angulo-D
ıaz-Parre~ no S, Paris-Alemany A
et al. The effects of manual therapy and exercise directed at
the cervical spine on pain and pressure pain sensitivity in
patients with myofascial temporomandibular disorders. J
Oral Rehabil. 2009;36:644–652.
15. Furto ES, Cleland JA, Whitman JM, Olson KA. Manual
physical therapy interventions and exercise for patients with
temporomandibular disorders. Cranio. 2006;24:283–291.
16. Cuccia AM, Caradonna C, Annunziata V, Caradonna D.
Osteopathic manual therapy versus conventional conserva-
tive therapy in the treatment of temporomandibular disor-
ders: a randomized controlled trial. J Bodyw Mov Ther.
Elsevier Ltd., 2010;14:179–184.
17. Von Piekartz H, L€ udtke K. Effect of treatment of temporo-
mandibular disorders (TMD) in patients with cervicogenic
headache: a single-blind, randomized controlled study. Cra-
nio. 2011;29:43–56.
18. Oh DW, Kim KS, Lee GW. The effect of physiotherapy on
post-temporomandibular joint surgery patients. J Oral Reha-
bil. 2002;29:441–446.
19. Medlicott MS, Harris SR. A systematic review of the effec-
tiveness of exercise, manual therapy, electrotherapy, relaxa-
tion training, and biofeedback in the management of
temporomandibular disorder. Phys Ther. 2006;86:955–973.
20. Higgins J, Green S. Cochrane handbook for systematic
reviews of interventions version 5.1.0. The Cochrane Colla-
boration; updated March 2011. Available at www.cochrane-
handbook.org, accessed 30 May 2015.
21. Furlan AD, Pennick V, Bombardier C, van Tulder M. 2009
updated method guidelines for systematic reviews in the
Cochrane Back Review Group. Spine. 2009;15:34.
22. Jonathan E, Sterne AC, Egger M, Moher D, Bias C. Chapter
10: addressing reporting biases. The Cochrane Collaboration;
updated March 2011. Available at www.cochrane-handboo-
k.org, accessed 30 May 2015.
23. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins
M. Reliability of the PEDro scale for rating quality of ran-
domized controlled trials. Phys Ther. 2003;83:713–721.
24. Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M,
Bouter LM et al. The Delphi list: a criteria list for quality
assessment of randomized clinical trials for conducting sys-
tematic reviews developed by Delphi consensus. J Clin Epi-
demiol. 1998;51:1235–1241.
25. Coury HJCG, Moreira RFC. Evaluation of the effectiveness
of workplace exercise in controlling neck, shoulder and low
back pain : a systematic review. Rev Bras Fisioter.
2009;13:461–479.
26. Hedges L, Olkin I. Statistical methods for meta-analysis, 1st
ed. Orlando (FL): Academic Press; 1985.
27. Cohen J. Statistical power analysis for behavioural sciences,
2nd ed. Hillsdale (NJ): Lawrence Eribaum Associates. Inc.;
1988.
28. Atkins D, Best D, Briss P, Eccles M, Falck-Ytter Y, Flottorp
S. Grading quality of evidence and strength of recommenda-
tions. The GRADE Working Group. Br Med J (Clin Res Ed).
2004;328:1490.
29. Richards MC, Ford JJ, Slater SL, Hahne AJ, Surkitt LD,
Davidson M et al. The effectiveness of physiotherapy func-
tional restoration for post-acute low back pain: a systematic
review. Man Ther. 2013;18:4–25.
30. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredi-
ni D. Myofascial pain of the jaw muscles: comparison of
short-term effectiveness of botulinum toxin injections and
fascial manipulation technique. Cranio. 2012;30:95–102.
31. Kalamir A, Bonello R, Graham P, Vitiello AL, Pollard H. In-
traoral myofascial therapy for chronic myogenous temporo-
mandibular disorder: a randomized controlled trial. J
Manipulative Physiol Ther. 2012;35:26–37.
32. La Touche R, Par
ıs-Alemany A, Mannheimer JS, Angulo-
D
ıaz-Parre~no S, Bishop MD, Lop
ez-Valverde-Centeno A
et al. Does mobilization of the upper cervical spine affect
pain sensitivity and autonomic nervous system function in
patients with cervico-craniofacial pain? A randomized-con-
trolled trial. Clin J Pain. 2013;29:205–215.
33. Gomes CAFDP, Politti F, Andrade DV, de Sousa DFM, Herp-
ich CM, Dibai-Filho AV et al. Effects of massage therapy and
occlusal splint therapy on mandibular range of motion in
individuals with temporomandibular disorder: a randomized
clinical trial. J Manipulative Physiol Ther. 2014;37:164–169.
34. Packer AC, Pires PF, Dibai-Filho AV, Rodrigues-Bigaton D.
Effects of upper thoracic manipulation on pressure pain sen-
sitivity in women with temporomandibular disorder: a ran-
© 2015 John Wiley & Sons Ltd
 MANUAL THERAPY FOR TEMPOROMANDIBULAR JOINT TREATMENT
domized, double-blind, clinical trial. Am J Phys Med Reha-
bil. 2014;93:160–168.
35. Kalamir A, Pollard H, Vitiello AL, Bonello R. Manual ther-
apy for temporomandibular disorders: a review of the litera-
ture. J Bodyw Mov Ther. 2007;11:84–90.
36. De Laat A, Meuleman H, Stevens A, Verbeke G. Correlation
between cervical spine and temporomandibular disorders.
Clin Oral Investig. 1998;2:54–57.
37. Dworkin SF, LeResche L. Research diagnostic criteria for
temporomandibular disorders: review, criteria, examinations
and specifications, critique. J Craniomandib Disord.
1992;6:301–355.
38. Eriksson PO, Zafar H, Nordh E. Concomitant mandibular
and head-neck movements during jaw opening-closing in
man. J Oral Rehabil. 1998;25:859–870.
39. Zafar H, Nordh E, Eriksson PO. Temporal coordination between
mandibular and head-neck movements during jaw opening-
closing tasks in man. Arch Oral Biol. 2000;45:675–682.
40. Goadsby PJ, Hoskin KL. The distribution of trigeminovascular
afferents in the nonhuman primate brain Macaca nemestrina: a
c-fos immunocytochemical study. J Anat. 1997;3:367–375.
41. Bartsch T, Goadsby PJ. Increased responses in trigeminocer-
vical nociceptive neurons to cervical input after stimulation
of the dura mater. Brain. 2003;126(Pt 8):1801–1813.
42. Ro JY, Svensson P, Capra N. Effects of experimental muscle
pain on electromyographic activity of masticatory muscles
in the rat. Muscle Nerve. 2002;25:576–584.
43. Bar~ ao VA, Gallo AK, Zuim PR, Garcia AR, Assuncß~ ao WG.
Effect of occlusal splint treatment on the temperature of dif-
ferent muscles in patients with TMD. J Prosthodont Res.
2011;55:19–23.
44. Simons DG, Travell JG, Simons LS. Myofascial pain and dys-
function – the trigger point manual, Vol. 1. 2nd ed. Balti-
more: Lippincott Williams & Wilkins; 1999:103–164.
45. Simons DG. Understanding effective treatments of myofas-
cial trigger points. J Bodyw Mov Ther. 2002;6:81–88.
46. Hou C-R, Tsai L-C, Cheng K-F, Chung K-C, Hong C-Z.
Immediate effects of various physical therapeutic modalities
on cervical myofascial pain and trigger-point sensitivity.
Arch Phys Med Rehabil. 2002;83:1406–1414.
47. Kunz R, Vist G, Oxman AD. Randomisation to protect
against selection bias in healthcare trials. Cochrane Database
Syst Rev. 2007;(2):MR000012.
48. Capurro D, Gabrielli L, Letelier LM. Importancia de la inten-
ci

on de tratar y el seguimiento en la validez interna de un
estudio cl
ınico randomizado. Rev Med Chil. 2004;132:1557–
1560.
49. Herman A, Botser IB, Tenenbaum S, Chechick A. Intention-
to-treat analysis and accounting for missing data in ortho-
paedic randomized clinical trials. J Bone Joint Surg Am.
2009;91:2137–2143.
50. Vernon H, MacAdam K, Marshall V, Pion M, Sadowska M.
Validation of a sham manipulative procedure for the cervi-
cal spine for use in clinical trials. J Manipulative Physiol
Ther. 2005;28:662–666.
© 2015 John Wiley & Sons Ltd
861
51. Brose SW, Jennings DC, Kwok J, Stuart CL, O’Connell SM,
Pauli HA et al. Sham manual medicine protocol for cervical
strain-counterstrain research. PM R. 2013;5:400–407.
52. Price DD, Finniss DG, Benedetti F. A comprehensive review
of the placebo effect: recent advances and current thought.
Annu Rev Psychol. 2008;59:565–590.
53. Yu X, Wang X, Zhang J, Wang Y. Changes in pressure pain
thresholds and Basal electromyographic activity after instru-
ment-assisted spinal manipulative therapy in asymptomatic
participants: a randomized, controlled trial. J Manipulative
Physiol Ther. 2012;35:437–445.
54. Hoiriis KT, Pfleger B, McDuffie FC, Cotsonis G, Elsangak O,
Hinson R et al. A randomized clinical trial comparing
chiropractic adjustments to muscle relaxants for subacute low
back pain. J Manipulative Physiol Ther. 2004;27:388–398.
55. Vernon H, Jansz G, Goldsmith CH, McDermaid C. A ran-
domized, placebo-controlled clinical trial of chiropractic and
medical prophylactic treatment of adults with tension-type
headache: results from a stopped trial. J Manipulative Phys-
iol Ther. 2009;32:344–351.
56. L
opez-Send
ın N, Alburquerque-Send
ın F, Cleland JA,
Fern
andez-de-las-Pe~ nas C. Effects of physical therapy on
pain and mood in patients with terminal cancer: a pilot ran-
domized clinical trial. J Altern Complement Med.
2012;18:480–486.
57. Lewis C, Khan A, Souvlis T, Sterling M. A randomised con-
trolled study examining the short-term effects of Strain-
Counterstrain treatment on quantitative sensory measures
at digitally tender points in the low back. Man Ther.
2010;15:536–541.
58. Oliveira-Campelo NM, de Melo CA, Alburquerque-Send
ın
F, Machado JP. Short- and medium-term effects of manual
therapy on cervical active range of motion and pressure
pain sensitivity in latent myofascial pain of the upper trape-
zius muscle: a randomized controlled trial. J Manipulative
Physiol Ther. 2013;36:300–309.
59. Armijo-Olivo S, Warren S, Fuentes J, Magee DJ. Clinical
relevance vs. statistical significance: using neck outcomes in
patients with temporomandibular disorders as an example.
Man Ther. 2011;16:563–572.
Correspondence: Ana Beatriz Oliveira, Departamento de Fisioterapia,
Universidade Federal de S~ ao Carlos, Via Washington Luis, KM 235,
CP 676, CEP 13565-905 S~ ao Carlos, Brazil.
E-mails: biaoliveira@ufscar.br; biaoliveira@gmail.com
Supporting Information
Additional Supporting Information may be found in
the online version of this article:
Data S1. Detailing GRADE criteria.
Data S2. Reasons for excluding studies from the
systematic review after full-text reading.