n PHYSICAL THERAPY

Manual Physical Therapy Interventions and Exercise

for Patients with Temporomandibular Disorders
Eric S. Furto, P.T.; Joshua A. Cleland, D.P.T., Ph.D.; Julie M. Whitman, P.T., D.Sc.;
Kenneth A. Olson, P.T., D.H.Sc.

0886-9634/2404000$05.00/0, THE
JOURNAL OF
CRANIOMANDIBULAR
PRACTICE,
Copyright 2006
by CHROMA, Inc.

Manuscript received
March 16, 2006; revised
manuscript received
July 10, 2006; accepted
August 1, 2006
Address for reprint requests:
Eric S. Furto, P.T.
Newsome Rehabilitation, Inc.
920 Essington Rd.
Joliet, IL 60544
E-mail: niupt2k@yahoo.com

ABSTRACT: The purpose of this study was to investigate the outcome of a series of consecutive
patients with temporomandibular disorder (TMD) who were treated with manual physical therapy interventions and exercise. Consecutive patients with the clinical presentation of TMD completed several
self-report measures and underwent a standardized historical and physical examination. Following the
examination, patients received a multimodal treatment approach incorporating manual physical therapy
and exercise. All self-report questionnaires were completed at a 2-week follow-up. Paired t-tests were
performed between the baseline and 2-week follow-up scores. The mean TMD Disability Index scores
were 32.1% (15.4%) at baseline and 18.3% (12.5%) at the 2-week follow-up, representing an improvement of 13.9% (CI: 8.2%, 19.5%) (p<0.05). Patient Specific Functional Scale (PSFS) scores improved
3.1 points (CI: 2.3, 3.9) (p<0.05). These results suggest that patients with TMD who are treated with a
rehabilitation program including manual physical therapy interventions plus exercise, with or without
iontophoresis with dexamethasone, can demonstrate clinically meaningful improvements in disability
and overall perceived change in a relatively short period of time.

ver ten million people in the United States suffer

from temporomandibular disorders (TMD). 1
Temporomandibular disorders are classified as a
musculoskeletal condition resulting in craniofacial pain,
functional limitations and disability.2 Symptoms associated with TMD can include temporomandibular joint
(TMJ) pain, decreased jaw mobility, joint clicking,
headaches, neck pain, tinnitus, and pain of the intraoral
structures.3 Temporomandibular disorders may be the
result of osteoarthritic degeneration, disk dislocation, or
involuntary guarding of the muscles of mastication.3
The debate surrounding the effectiveness of surgical
intervention for TMD has led many patients to seek conservative care for the management of their pain and associated loss of function.4,5 A retrospective cohort study by
Godden, et al.5 revealed that only 50% of patients who
underwent a TMJ arthroplasty viewed their outcomes as
favorable. These outcomes were obtained through a six
year follow-up survey and demonstrated that patients
experienced a reduction in pain, as measured with the
visual analog scale, to within 75% of normal; however,
the majority of patients still reported their jaw opening
was restricted (66%).5 These outcomes were determined

Eric Furto is a physical therapist in the

Newsome Physical Therapy Center in
Plainfield, Illinois and is on faculty at the
University of St. Augustine for Health
Sciences in St. Augustine, Florida. He
obtained his bachelor of physical therapy
degree in 2000 from Northern Illinois
University. Additionally, Mr. Furto serves
as a continuing education instructor on
spinal manipulation for the University of
St. Augustine.

PT INTERVENTIONS FOR TMD PATIENTS

based on subjective interpretations when they were asked

if they were prepared to undergo a further arthroscopy.
Conservative treatment options for TMD include
occlusion correction with the use of intraoral appliances,
orthodontics, cortisone injections, and joint manipulation.3,5,6 Theoretically, intraoral appliances are used to
create a natural resting position of the mandible, which in
turn should inhibit excessive tension in the muscles of
mastication and relieve pain and improve function. 6
However, a decrease in pain does not necessarily correlate with an increase in range of motion (ROM) or
improvements in jaw function.5
Manual therapy directed at the TMJ combined with
exercise has been shown to be superior to treatment with
soft repositioning splint therapy in the management of
patients with radiographically confirmed anterior displaced temporomandibular disk syndrome (ADTMD).7
In this study, the manual therapy combined with active
exercise group demonstrated significant reductions in
pain and increases in ROM, while the soft repositioning
splint group failed to show significant changes in either
dependent measure.7
Physical therapy management of TMD often consists
of manual therapy including TMJ and cervical/thoracic
spine mobilization/manipulation, soft tissue mobilization, postural education/ergonomics, therapeutic exercises for neuromuscular stabilization of the TMJ, and
physical modalities, such as iontophoresis, electrical
stimulation, or ultrasound. 6 Rocabado 6 has described
techniques to facilitate neuromuscular stabilization
through the use of repetitive lateral deviation motions
purportedly used to assist with mobility. Theoretically,
the muscles of mastication are then recruited to apply a
compressive force to the disk, thereby improving the
condylar-disk-eminence congruency and ultimately
improving function.6 These techniques can also be used
as a proprioceptive exercise to increase functional mobility with lowered pain response.6 However, limited evidence exists to support such a treatment approach.
Only preliminary evidence exists to support the use of
manual physical therapy in the treatment of TMD.8-10 In a
single case design, Cleland, et al.9 described the outcome
of a patient with anterior bilateral disk displacement who
was treated with a combination of manual physical therapy, exercise, and patient education.9 Over eight visits,
the patient achieved a reduction in pain of 48.8 mm on the
visual analog scale, an increase in mandibular depression
of 17.5 mm, and marked improvements in all three scales
of the Steigerwald/Maher TMD disability questionnaire.9,11 In a case series of 20 patients with TMD who
received TMJ exercises, postural education, and relaxation techniques, 16 participants experienced a complete

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

FURTO ET AL.

resolution of pain, 13 a full return to function, and only

three patients had continued ROM limitations at a six
month follow-up.8,10 Furthermore, data collected on these
patients at a 12-month follow-up visit continued to suggest favorable results for the use of exercise and manual
therapy in the management of TMD.
The evidence available regarding noninvasive care for
patients with TMD is sparse, and the literature is limited
by methodological shortcomings. Future studies should
ultimately examine clinical outcomes for patients prospectively, including detailed descriptions of interventions
provided, use of well-defined self-report instruments to
capture levels of disability, and including a comparison
group. The current study is the first step in this process.
The purpose of this pilot study is to report clinical outcomes (pain, disability, and function) for a series of
patients with TMD treated with manual physical therapy,
therapeutic exercise, and iontophoresis. The results of
this pilot work will facilitate the design of future randomized controlled trials, as well as develop further hypothesis formation.
Materials and Methods
During a six month period, fifteen participants were
recruited for participation in this case series (14 females).
Consecutive subjects referred to Northern Rehabilitation
and Sports Medicine Associates in DeKalb, IL with nonspecific orofacial pain were examined for eligibility criteria over a 6-month period. All patients were referred from
local dentists, ear-eye-nose-throat physicians, and/or
general practitioners with a diagnosis of TMD or orofacial pain. Eligible patients had to present with a primary
report of pain in the temporomandibular region. Eligible
patients could also exhibit cervical or thoracic spine pain,
headaches, radicular pain, and/or shoulder pain; however,
their most bothersome area had to be the TMJ. Exclusion
criteria included post surgical conditions involving the
neck or temporomandibular region. All examination and
treatment procedures in this case series were performed
by two physical therapists. Both therapists were trained in
the examination and treatment of TMD as a requirement
of an American Physical Therapy Association credentialed and American Acad-emy of Orthopaedic Manual
Physical Therapists recognized Manual Therapy
Fellowship Program. All participants signed an informed
consent approved by the Institutional Review Board at
Franklin Pierce College, Concord, NH prior to the initial
evaluation.
Data Collection
Prior to the initial examination, all participants completed a number of self-report questionnaires including:

OCTOBER 2006, VOL. 24, NO. 4

FURTO ET AL.

the TMD Disability Index, two pain diagrams and the

Numeric Pain Rating Scale (NPRS). The TMD Disability
Index consists of ten questions regarding disability associated with TMD, and each question is scored from 0-4.
Higher scores represent greater levels of disability. The
psychometric properties of this questionnaire have not
been reported. The NPRS was used to capture the patients
level of pain. Patients were asked to indicate the intensity
of current, best, and worst levels of pain over the past 24
hours using an 11-point scale ranging from 0 (no pain) to
10 (worst pain imaginable).12-14 The average of the three
ratings was used to represent the patients level of pain
over the previous 24 hours. In addition, all patients completed the Patient Specific Functional Scale (PSFS).15
The PSFS is a patient-specific outcome measure, which
investigates functional status by asking the patient to
nominate activities that are difficult to perform based on
their condition, and rate the level of limitation with each
activity. The patient rates each activity on a 0-10 scale,
with 0 representing the inability to perform the activity,
and 10 representing the ability to perform the activity
as well as they could prior to the onset of symptoms.16
The PSFS has been shown to identify changes in status
and to be valid and responsive to change for patients with
various clinical conditions, including neck pain,16 cervical radiculopathy, 17 knee pain, 18 and low back pain, 15
however, the PSFS has not been used to study patients
with TMD.
Following the completion of the self-report measures,
the patients therapist performed a standardized historical
and physical examination. The historical examination
consisted of recording the patients age, gender, past
medical history, symptom location (with the use of
a body diagram), duration and nature of symptoms,
relieving/aggravating activities, and prior episodes of
TMJ pain.
The physical examination consisted of a comprehensive evaluation of the TMJ and the upper quarter. Quantity
and quality of the bilateral active and passive TMJ, cervical, and thoracic mobility were assessed as described by
Paris.19,20 Active range of motion was assessed visually
by asking the patient to initially maneuver his/her cervical spine throughout the cardinal planes, followed by an
assessment of the thoracic spine.19,20 Passive mobility of
the cervical spine was assessed by applying overpressure
in the direction of the ROM being tested actively.19,20
Temporomandibular joint active range of motion was
assessed by asking the patient to actively depress the
mandible, laterally deviate the mandible bilaterally, and
protrude the mandible.6,22 The motion was quantified in
millimeters utilizing a millimeter ruler between the central incisors of the mandibular and maxillary row. 6,22

OCTOBER 2006, VOL. 24, NO. 4

PT INTERVENTIONS FOR TMD PATIENTS

Passive overpressure was not applied for the TMJ. The

quality of the motion was also assessed for compensatory
motions, visible through lateral condylar motion, throughout the range. Accessory motion and joint play of the
TMJ, cervical spine and thoracic spine were also assessed
in combination with the patients pain response (either
increased symptoms, no change, or decreased symptoms).19,20 Each cervical and thoracic vertebral segment
was assessed for passive intervertebral mobility. 19,20
Capsular mobility of the temporomandibular joint was
assessed by applying a long axis distraction through the
mandible for six repetitions.6,22
Other assessments applied included an anterior
mandibular glide, a medial mandibular glide, and a lateral
mandibular glide.6,22 Mobility was graded on a 0 to 6
scale with three indicating normal capsular mobility, six
being unstable, and zero being ankylosed. 19,20 Tissue
tension and flexibility were assessed for the cervical
musculature, posterior subcranial musculature, and the
lateral pterygoid muscles.21,22 Occlusion was also assessed
by the evaluating physical therapist using maximal intercuspation (MIC). MIC assesses the closed pack position
of the TMJ after swallowing. The patient is asked to bring
his/her teeth together with maximal force through biting.
The physical therapist can then assess the role the
neuromusculoskeletal system will have with maximal
muscle contraction (i.e., biting into food).6 Similar to that
of a patient with rotator cuff pathology, the neuromuscular control of the musculature surrounding the TMJ can
have an effect on the biomechanics of the mandible and
directly affect MIC. The MIC can be compared to the
loose pack position of the mandible, or freeway space,
where the teeth rest together without biting.6,22 If there
is a shift with biting during MIC, the neuromuscular control of the muscles of the TMJ are likely participating in
the pathology.6,22
Interventions
The patients therapist used an impairment-based
manual physical therapy approach for the treatment of the
TMJ, cervical spine, thoracic spine, posture, and the use
of iontophoresis as indicated. In an impairment-based
model of care, the therapist prioritizes identified physical
impairments in the order of hypothesized importance or
contribution to the patients disorder. The therapist then
provides treatment, or interventions, targeting these identified physical impairments, such as joint mobility restrictions, muscle length limitations, postural limitations and
neuromuscular deficits.
Manual physical therapy directed at identified impairments of the cervical spine consisted of nonthrust manipulations for facet upglides and downglides to facilitate

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

PT INTERVENTIONS FOR TMD PATIENTS

normal facet joint motion, subcranial forward bending

and sidebending non-thrust manipulations, and subcranial myofascial distraction.19,20 Stretches to the surrounding cervical musculature were also applied as described
by Kendal.21 Non-thrust temporomandibular joint manipulations consisted of long axis distraction, medial glide,
and lateral glide as described by Rocabado.22 Acupressure
techniques were also applied to the lateral pterygoid musculature.22 All treatment applications are described in
Table 1.
Each patient was instructed in a condylar remodeling
exercise program as described by Rocabado.22 Phase one
of this program consists of painfree lateral deviation
away from the side of pain or hypermobility as determined with accessory motion testing with a 0.5 inch piece
of surgical tubing resting between the mandibular and
maxillary row of teeth. If pain is bilateral, the device is
maneuvered away from the side of greatest hypermobility. If painfree, a bite is incorporated.6 The patient was

Table 1
Descriptive Characteristics of Participating
Patients at Baseline (N=15)
Number (%)
Variable
of Patients*
Age (years), mean (SD)
50.5 (15.5)
Sex - female
14 (93%)
- male
1 (7%)
Race - Caucasian
15 (100%)
Median duration of
TMD symptoms (range)
6 mos. (0.07-120)
Depression (self-report)
6 (40%)
Symptom descriptions
15 (100%)
TMJ region symptoms
3 (20%)
- bilateral
- painful
13 (87%)
- sharp
3 (20%)
- dull
2 (13%)
- aching
13 (87%)
Headache symptoms
13 (87%)
- median duration
6 mos. (0.07-60)
symptoms (range)
- dizziness associated
2 (13%)
with headache
9 (60%)
Cervical spine symptoms
- median duration
symptoms (range)
30 mos. (2-252)
- bilateral symptoms
6 (40%)
Thoracic spine symptoms
7 (47%)
5 (33%)
Upper extremity symptoms
- bilateral symptoms
2 (13%)
*n (%) provided unless otherwise noted

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

FURTO ET AL.

instructed to release the contraction before returning to

midline. The third phase consists of the same submaximal
contraction as phase two, but the contraction is maintained until the tubing returns to midline. The fourth
through sixth phases are similar to phases one through
three, but are performed for protrusion rather than lateral
deviation. Patients were instructed to perform six repetitions every two hours 3 (see Appendix). The exercise
program was reviewed at each treatment session. The
exercise program focused on ROM and stability exercises
for all patients suspected to exhibit anterolateral disk
translation during the clinical examination (n=8). The lateral deviation motion that accompanies the condylar
reeducation exercise program has been purported to
enhance mobility throughout the range of motion. This
program can be converted to a controlled neuromuscular
stabilization exercise program by incorporating and
maintaining a bite throughout the ROM.22
In addition to the aforementioned interventions, iontophoresis with dexamathasone was incorporated with
patients where ROM was restricted primarily due to pain
(less than 20 mm of mandibular opening). An aqueous
solution of 2.5 cc dexamethasone was applied superficially at 40 milliamps minutes to the affected TMJ. The
treatment was applied for fifteen minutes and then
removed.
Follow-Up
At the two-week follow-up visits, all patients again
completed the TMD Disability Index, PSFS, body diagrams, and NPRS. In addition, all patients completed the
Global Rating of Change scale.23 Patients were asked to
rate their overall perception of improvement since beginning physical therapy on a scale ranging from 7 (a very
great deal worse) to zero (about the same) to +7 (a very
great deal better). It is recommended that scores on the
GROC between 1 and 3 represent small changes,
scores between 4 and 5 represent moderate changes,
and scores of 6 or 7 convey large changes in patient
status.23
Statistical Analysis
Descriptive information including patient gender, age,
duration of symptoms, number of physical therapy visits,
and interventions provided was recorded for all patients.
The mean change score and associated 95% confidence
intervals were calculated for all outcome measures
assessed at baseline and at the 2-week follow-up. Paired
t-tests were performed between the baseline and 2-week
follow-up scores (=0.05) to evaluate if the change experienced was significant over time.

OCTOBER 2006, VOL. 24, NO. 4

FURTO ET AL.

PT INTERVENTIONS FOR TMD PATIENTS

Results
All participants were asked to complete the TMD
Disability Index, with three (20%) participants electing to
bypass the question regarding the level of sexual function
limitation. Demographics for all patients can be found in
Table 1. The median length of symptoms in the region of
the TMJ was six months (range 0.07-120 months).
Thirteen (87%) of the patients also experienced headache
symptoms with the median duration also being six months
(range 0.07 to 60 months). As recorded by the PSFS, the
following percentage of patients noted difficulty chewing, yawning, talking, and opening the jaw, respectively:
15 (100%), seven (47%), four (27%), and one (7%). At
the two-week follow-up session, the group had received a
mean of 4.3 physical therapy intervention sessions.
Specific interventions received can be found in Table 2.
The mean TMD Disability Index scores were 32.1% at
baseline and 18.3% at the 2-week follow up, representing
an improvement of 13.9% (CI: 8.2%, 19.5%) (p<0.05)
(Figure 1). Eleven patients (73%) reported they were
somewhat better to a very great deal better on the GROC
(Table 3), and Patient Specific Functional Scale (PSFS)
scores improved 3.1 points (CI: 2.3, 3.9) (p<0.05) (Figure
2).
Discussion
There currently is a lack of conclusive evidence to support the use of conservative management strategies in the
management of TMD. The purpose of this study was to
describe the outcomes of a cohort of patients undergoing
physical therapy management of their TMD. Outcomes
were favorable for all patients in this study and are similar to findings of Nicolakis, et al.8 who provided a six and
twelve month follow-up supporting the use of manual
therapy and exercise with a case series of twenty patients
with TMD.10 Interventions used in the Nicolakis, et al.8
study were similar this study and included nonthrust
manipulative therapy directed at the TMJ and an isometric exercise program aimed at maximizing stability of the
TMJ.
We have provided a detailed description of the interventions used to treat TMD in this pilot study and used
physical impairment as well as self-report outcomes to
capture the patients levels of pain and disability. Our
patients, similar to those in the Nicolakis, et al.8 case
series, demonstrated an overall reduction in pain and
improvement in function following two weeks of physical therapy management. During a six-month period, fifteen participants received intervention for their TMD
complaints.10 Of the 15 patients treated in this pilot study,

OCTOBER 2006, VOL. 24, NO. 4

Table 2
Number (Percentage) of Patients (n=15) Treated
With Various Physical Therapy Interventions
Manual technique
Cervical spine manipulation
- subcranial (occiput-C2)
- cervical spine (C2-C7)
TMJ manipulation
Thoracic spine manipulation
Postural education
Iontophoresis to the TMJ

Number (%)
of Patients
11 (73%)
6 (40%)
15 (100%)
4 (27%)
12 (80%)
5 (33%)

13 also experienced headache symptoms at the time of

the initial examination. It is hypothesized that poor posture with increased posterior rotation of the cranium on
the atlas will place undue strain on the posterior occipital
musculature.6,22 This strain may impinge upon the greater
occipital nerve and may result in referred pain into the
craniofacial region, most typically into the distribution of
the trigeminal nerve.24 In a study by Aprill, et al.25 it was
discovered that 21 of 34 participants who underwent a
nerve block to C1/C2 experienced complete resolution of
their headache symptoms. These findings are indicative
of the comorbidity between TMJ pain and headache and
may also support the possibility of referred pain to the
TMJ from the subcranial spine. Therefore, it is possible
that participants in the study may have not experienced
symptoms related to the TMJ, but they could also have
been experiencing symptoms referred from the cervical
spine.
The exercise program used in this pilot study was
aimed at neuromuscular reeducation of the musculature
surrounding the temporomandibular joint (Appendix).
The exercises prescribed to each patient used a piece of
tubing in a similar fashion to that of an anterior loading
splint. 6 The piece of tubing was placed between the
incisors and a series of motions were performed and combined with biting. Once the patient was able to perform
painfree lateral deviation with the exercise program, they
were instructed to perform protrusion. Lateral deviation
is typically performed initially to ensure appropriate
ROM of the affected TMJ before recruiting the opposite
joint during protrusion. The patients were instructed to
perform the exercises in a pain free fashion, every two
hours to enhance functional joint stability.6
Exercise has been shown to be effective in the management of TMD. In a randomized clinical trial, Yoda, et

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

PT INTERVENTIONS FOR TMD PATIENTS

FURTO ET AL.

Figure 1
TMD Disability Index scores at baseline
and at 2-week follow-up.

al.26 compared an exercise program to education on the

condition for patients with anterior disk displacement
with reduction (ADDWR). The results demonstrated that
the exercise group had statistically significant better outcomes for decreased pain and increased ROM (p=0.0001).
Forty-two patients participated in the study, of which
61.9% of the exercise group had favorable outcomes
(13/21 patients), while 0% of the control group had favorable results.26 Success was measured on the severity of

joint sounds and/or pain with maximal mouth opening.

Of the 13 patients that experienced a successful outcome,
only 23.1% (three) of the patients TMJ disks were actually recaptured when reexamined on MRI. The authors
reported that the 61.9% success rate experienced by the
exercise group is similar to that of splint therapy but is a
more cost effective option.26
The exercises proposed by Yoda, et al.26 differ from
those proposed by Rocabado22 in that maximal ROM is

Figure 2
Patient Specific Functional Scale scores at
baseline and at 2-week follow-up.

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

OCTOBER 2006, VOL. 24, NO. 4

FURTO ET AL.

required in the Yoda approach from the initiation of the

exercise program. In many cases, painful ROM is the
reason for consultation by a physical therapist, thus
making maximal ROM to the point of reduction a difficult starting point for the initiation of exercises. The program described by Rocabado22 and used in the current
study encourages small ranges of motion into lateral
deviation, which may accomplish the same objective:
reduced pain and improved function. While research
exists to support the use of exercise in the management of
TMD, limited evidence exists to support the specific
exercise regimen used in this study.6,26,27
Additionally, we included the use of iontophoresis
with dexamethasone in the treatment of patients within
this pilot study. While dexemethasone has been demonstrated to be effective in reducing pain and inflammation,
the delivery method of iontophoresis has been questioned. In a study by Majwer, et al.,28 27 of 32 cases of
post-traumatic TMD benefited with decreased pain from
the application of dexamethasone (n=8) or xylocane
(n=24) through iontophoresis. Since different medications were used, it is possible that the patients benefited
most from the electrical stimulation of the iontophoresis
rather than the medication itself.
The present study allows for hypothesis formulation
and the development of a future randomized clinical trial.
Follow-up studies should include examining the effectiveness of exercise and manual physical therapy when
compared to other conservative treatment approaches.
The patients in this study exhibited positive outcomes
after receiving only two weeks of the above described
multimodal physical therapy treatment regimen.
Limitations of the current study include the lack of a
control or comparison group which precludes the ability to infer a cause and effect relationship between the
treatment and outcomes, as well as, only short-term outcomes are provided in this report. It is the aim of the
authors to identify the long-term effects of the treatment
interventions used in this pilot study and determine if a
specific subgroup of patients with TMD exists that would
be most likely to benefit from exercise and manual physical therapy.

PT INTERVENTIONS FOR TMD PATIENTS

Clinical decision making rules may also be established to

enhance the identification of particular patients that are
likely to respond rapidly and dramatically to specific
interventions.
References
1.
2.
3.
4.
5.
6.
7.

8.

9.

10.

11.
12.
13.
14.

15.

16.

17.

18.

19.
20.
21.
22.
23.

Conclusion
24.

The results of this study demonstrate that physical

therapy intervention consisting of manual therapy, a
specific exercise program, and iontophoresis with
dexamethasone can be beneficial to patients presenting
with symptoms similar to that of TMD. Future research
should focus on the specific interventions as described
above to determine the most beneficial form of treatment.

OCTOBER 2006, VOL. 24, NO. 4

25.
26.

27.
28.

TMJ Diseases & Disorders - Basics - Overview. www.tmj.org/basics.asp.

Merskey H, Bogduk N: Classification of chronic pain. Seattle, WA: IASP
Press, 1994.
Kraus S: Clinics in Physical Therapy: temporomandibular joint disorders.
New York: Churchill Livingstone, 1994.
Dolwick MF, Dimitroulis G: Is there a role for temporomandibular joint
surgery? Br J Oral 1994; 32:307-313.
Godden DRP, Robertson JM: The value of patient feedback in the audit of
TMJ arthroscopy. Br Dent J 2000; 188:125.
Rocabado M: Intermediate craniofacial. Chicago; 2003.
Carmeli E, Sheklow S, Bloomenfeld I: Comparative study of repositioning
splint therapy and passive manual range of motion techniques for anterior
displaced temporomandibular disks with unstable excursive reduction.
Physiother 2001; 87:26-36.
Nicolakis P, Burak EC, Kollmitzer J, Kopf A, Piehslinger E, Wiesinger GF,
Fialka-Moser V: An investigation of the effectiveness of exercise and
manual therapy in treating symptoms of TMJ osteoarthritis. J Craniomandib
Pract 2001; 19:26-32.
Cleland J ,Palmer J: Effectiveness of manual physical therapy, therapeutic
exercise, and patient education on bilateral disk displacement without
reduction of the temporomandibular joint: a single-case design. J Orthop
Sports Phys Ther 2004; 34:535-548.
Nicolakis P, Erdogmus B, Kopf A, Ebenbichler G, Kollmitzer J, Piehslinger
E, Fialka-Moser V: Effectiveness of exercise therapy in patients with internal derangement of the temporomandibular joint. J Oral Rehabil 2002;
29:362-368.
Steigerwald DP, Maher JH: The Steigerwald/Maher TMD disability questionnaire. Todays Chiropractic 1997; July-August:86-91.
Jensen MP, Karoly P, Braver S: The measurement of clinical pain intensity: a
comparison of six methods. Pain 1986; 27:117-126.
Childs JD, Piva S, Fritz JM: Responsiveness of the numeric pain rating scale
in patients with low back pain. Spine 2004:
Pengel HM, Refshauge K, Maher C: Responsiveness of pain, disability, and
physical impairment outcomes in patients with low back pain. Spine 2004;
29:879-883.
Stratford P, Gill C, Westaway M, Binkley J: Assessing disability and change
of individual patients: a report of a patient-specific measure. Physiother
Can 1995; 47:258-263.
Westaway M, Stratford P, Binkley J: The Patient Specific Functional Scale:
validation of its use in persons with neck dysfunction. J Orthop Sports Phys
Ther 1998; 27:331-338.
Cleland JA, Fritz JM, Whitman JM, Palmer J: Construct validity of the Neck
Disability Index and Patient Specific Functional Scale in a patient population with cervical radiculopathy. Spine In Press
Chatman A, Neel J, Hyams S: The Patient Specific Functional Scale: measurement properties in patients with knee dysfunction. Phys Ther 1997;
77:820-829.
Paris SV: Intro to spinal manipulation. 2000; S1.
Paris SV: Advanced manipulation of the cervical spine. 2000; S3.
Peterson-Kendall F, Kendall-McCreary E, Provance PG: Muscle testing and
function. Baltimore: Williams and Wilkins, 1993.
Rocabado M, Iglarsh Z: Musculoskeletal approach to maxillofacial pain.
New York: JB Lippincott Co., 1991.
Jaeschke R, Singer J, Guyatt G: Measurement of health status. Ascertaining
the minimal clinically important difference. Controlled Clinical Trials
1989; 10:407-415.
Packard RC: The relationship of neck injury and post-traumatic headache.
Curr Pain Headache Rep 2002; 6:1-7.
Aprill C, Axinn M, Bogduk N: Occipital headaches stemming from the lateral
atlanto-axial (C1-C2) joint. Cephal 2002; 22:15-22.
Yoda T, et al.: A randomized controlled trial of therapeutic exercise for clicking due to disk anterior displacement with reduction in the temporomandibular joint. J Craniomandib Pract 2003; 21:10-16.
Deodato F, Cristiano S, Trusendi R, Giorgetti R: A functional approach to the
TMJ disorders. Prog Orthod 2003; 4:20-37.
Majwer K, Swider M: Results of treatment with iontophoresis of posttraumatic changes of temporomandibular joints with an apparatus of own
design. Prothet Stomatol 1989; 39:172-176.

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

PT INTERVENTIONS FOR TMD PATIENTS

FURTO ET AL.

Appendix

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

OCTOBER 2006, VOL. 24, NO. 4

FURTO ET AL.

Dr. Joshua A. Cleland is currently an assistant professor at Frankline

Pierce College and is the research coordinator at Rehabilitation Services
of Concord Hospital. He recently completed a fellowship in the manual
therapy program through Regis University in Denver, Colorado. Dr.
Clelands research interest includes investigating the effectiveness of
manual therapy and exercise in patients with extremity and spinal disorders. He recently authored a text on the orthopedic clinical examination
and has published numerous articles in peer reviewed journals.

PT INTERVENTIONS FOR TMD PATIENTS

Dr. Kenneth A. Olson is president of the physical therapy private

practice, Northern Rehabilitation and Sports Medicine Associates in
DeKalb, Illinois. Dr. Olson is also a guest lecturer at Marquette
University and serves as a mentor for the University of St. Augustine
Manual Therapy Fellowship program. He graduated with a B.S.P.T.
from Northern Illinois University, a Master of Science in orthopedic
physical therapy from the University of St. Augustine, and a Doctor of
Health Science USA. He is also a graduate of the USA Manual Therapy
Fellowship Program.

Dr. Julie M. Whitman is an assistant professor in the Department of

Physical Therapy at Regis University in Denver, Colorado. She received
an M.P.T. degree from the U.S. Army-Baylor University Graduate
Program in Physical Therapy from Baylor University in 2001. She
completed a manual physical therapy residency program in 2000 and has
over 12 years of primary care physical therapy experience in the civilian
and military environments. Dr. Whitman is actively involved in clinical
research relating to orthopedic/manual physical therapies for musculoskeletal disorders and has over 20 publications in these areas.

OCTOBER 2006, VOL. 24, NO. 4

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE