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Cited by 14Temporomandibular Joint DisordersMyofascial pain diagnosis and treatmentMusculoskeletal pain and rehabilitation

The Effect of Upper Cervical Mobilization/Manipulation on Temporomandibular Joint Pain, Maximal Mouth Opening, and Pressure Pain Thresholds: A Systematic Review and Meta-Analysis

Open access
Lam, Alan C., Liddle, Lane J., MacLellan, Crystal L.·2023·Archives of Rehabilitation Research and Clinical Translation
DOI 10.1016/j.arrct.2022.100242PMC PMC10036235
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Abstract

To evaluate the efficacy of upper cervical joint mobilization and/or manipulation on reducing pain and improving maximal mouth opening (MMO) and pressure pain thresholds (PPTs) in adults with temporomandibular joint (TMJ) dysfunction compared with sham or other intervention. MEDLINE, CINAHL, EMBASE, and Cochrane Library from inception to June 3, 2022, were searched. Eight randomized controlled trials with 437 participants evaluating manual therapy (MT) vs sham and MT vs other intervention were included. Two reviewers independently extracted data and assessed risk of bias. Two independent reviewers extracted information about origin, number of study participants, eligibility criteria, type of intervention, and outcome measures. Manual therapy was statistically significant in reducing pain compared with sham (mean difference [MD]: -1.93 points, 95% confidence interval [CI]: -3.61 to -0.24, P=.03), and other intervention (MD: -1.03 points, 95% CI: -1.73 to -0.33, P=.004), improved MMO compared with sham (MD: 2.11 mm, 95% CI: 0.26 to 3.96, P=.03), and other intervention (MD: 2.25 mm, 95% CI: 1.01 to 3.48, P<.001), but not statistically significant in improving PPT of masseter compared with sham (MD: 0.45 kg/cm2, 95% CI: -0.21 to 1.11, P=.18), and other intervention (MD: 0.42 kg/cm2, 95% CI: -0.19 to 1.03, P=.18), or the PPT of temporalis compared with sham (MD: 0.37 kg/cm2, 95% CI: -0.03 to 0.77, P=.07), and other intervention (MD: 0.43 kg/cm2, 95% CI: -0.60 to 1.45, P=.42). There appears to be limited benefit of upper cervical spine MT on TMJ dysfunction, but definitive conclusions cannot be made because of heterogeneity and imprecision of treatment effects.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis of 8 RCTs (437 participants) found that upper cervical mobilization/manipulation produced statistically significant improvements in TMJ pain and maximal mouth opening versus sham or other interventions, but these effects generally did not reach minimal clinically important difference thresholds. Pressure pain thresholds of the masseter and temporalis did not significantly improve, and the authors conclude that upper cervical manual therapy alone may not provide clinically meaningful benefit for TMJ dysfunction.

Key findings

  • Versus sham, upper cervical MT significantly reduced pain (MD −1.93, 95% CI −3.61 to −0.24, P=.03; I²=83%) and increased maximal mouth opening (MD 2.11 mm, 95% CI 0.26 to 3.96, P=.03; I²=0%), but neither effect met the MCID (2.0 points for pain; 2.5 mm for MMO).
  • Versus other intervention, MT significantly reduced pain (MD −1.03, 95% CI −1.73 to −0.33, P=.004; I²=27%) and improved MMO (MD 2.25 mm, 95% CI 1.01 to 3.48, P<.001; I²=0%).
  • MT did not significantly increase pressure pain threshold of the masseter versus sham (MD 0.45 kg/cm², 95% CI −0.21 to 1.11, P=.18) or versus other intervention (MD 0.42 kg/cm², 95% CI −0.19 to 1.03, P=.18), nor of the temporalis versus sham (MD 0.37 kg/cm², 95% CI −0.03 to 0.77, P=.07) or versus other intervention (MD 0.43 kg/cm², 95% CI −0.60 to 1.45, P=.42).
  • Post hoc earliest-time-point analyses showed MT did not significantly improve pain versus sham (MD −1.45, 95% CI −3.97 to 1.06, P=.26) or MMO versus other intervention (MD 0.63 mm, 95% CI −1.47 to 2.72, P=.56); GRADE quality was moderate for pain and MMO and low for PPT of masseter and temporalis.

Methods

  • Systematic review and meta-analysis of RCTs; searched MEDLINE, CINAHL, EMBASE, and The Cochrane Library from inception to June 3, 2022; included adults >18 years with TMJ pain of insidious onset and trials of articular joint mobilization/manipulation to the upper cervical spine (C0/1, C1/2, or C2/3).
  • Comparisons were MT vs sham intervention and MT vs other intervention; outcomes were pain (NPRS or VAS), maximal mouth opening (mm), and pressure pain thresholds of masseter and/or temporalis (kg/cm²).
  • Two reviewers independently screened, extracted data, assessed risk of bias with the Cochrane Risk of Bias Tool, and rated evidence with GRADE; random-effects meta-analysis used mean differences in R, with the longest time point from each trial and post hoc analyses using the earliest time point when <4 weeks after treatment.

Limitations

  • Stated: five of 8 included trials demonstrated selection bias and all demonstrated similar degrees of performance bias; evidence quality was low to moderate, with low precision, high heterogeneity, wide confidence intervals, small sample sizes, and limited numbers of trials.
  • Stated: many trials did not state the type or specific joint level of mobilization/manipulation or criteria for successful manipulation; placebo response cannot be excluded, adverse events may have been missed, and conclusions about clinically meaningful benefit cannot be drawn definitively.
  • Evident from the text: several meta-analyses were based on only 2–3 trials, publication bias could not be reliably assessed because fewer than 10 trials were available, and no trial blinded participants or study personnel to group allocation.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.arrct.2022.100242

Cites

63 of 63 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

15 of 65 cited sources checked · 7 supported · 1 flagged · accuracy not yet measured

  • Premisereasoning

    Limitations with those reviews and their supporting evidence make it difficult to determine the efficacy of cervical spine joint mobilizations or manipulations.

    “However, limitations with those reviews and their supporting evidence makes it difficult to determine the efficacy of cervical spine joint mobilizations or manipulations.”
    Quote in the paperSubstantial claim2 of 4 sources checked
    • cites [5] Armijo-Olivo, 2016, Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis, Phys Ther source

      The Methodological Elements and Overall Quality of the Evidence and Limitations sections rate the evidence as low and caution that study bias and combined treatments make effects difficult to assess. This supports uncertainty about the reviewed treatments, but the review is explicitly limited to temporomandibular disorders; it does not establish the efficacy of cervical spine mobilizations or manipulations generally. Page numbers were not available in our copy. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [19] Calixtre, 2015, 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, J Oral Rehabil source
    • cites [23] La Touche, 2020, Effect of manual therapy and therapeutic exercise applied to the cervical region on pain and pressure pain sensitivity in patients with temporomandibular disorders: a systematic review and meta-analysis, Pain Med source
    • cites [24] De Castro, 2020, Effects of manual therapy in the treatment of temporomandibular dysfunction—a review of the literature, Man Ther Posturology Rehabil J source

      The Discussion and Conclusion (pages unavailable) report improved mouth opening with cervical mobilization or manipulation and conclude that the technique is effective for improving joint mobility. The Conclusion notes a lack of direct comparisons with myofascial release, but does not say that limitations make its efficacy difficult to determine. (LLM, conf=0.82)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Premisecitation

    Few systematic reviews evaluate the efficacy of physical therapy interventions.

    “Few systematic reviews evaluate the efficacy of physical therapy interventions, and a limited number of randomized controlled trials (RCTs) evaluate any particular physical therapy intervention.13,21,22”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [13] Visscher, 2002, Is there a relationship between head posture and craniomandibular pain?, J Oral Rehabil source
    • cites [21] Tseng, 2017, Retrospective study to identify trigeminal-cervical ocular referred pain as a new causative entity of ocular pain, J Pain Res source

      The Results > Treatment section reports outcomes of this paper’s retrospective ocular-pain study, and the Discussion notes its lack of a control group. Neither section addresses how many systematic reviews or randomized controlled trials evaluate physical therapy interventions; searches for those terms found no passage that does. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites [22] Häggman-Henrikson, 2013, Temporomandibular disorder pain after whiplash trauma: a systematic review, J Orofac Pain source
  • Premisecitation

    A limited number of randomized controlled trials evaluate any particular physical therapy intervention.

    “Few systematic reviews evaluate the efficacy of physical therapy interventions, and a limited number of randomized controlled trials (RCTs) evaluate any particular physical therapy intervention.13,21,22”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [13] Visscher, 2002, Is there a relationship between head posture and craniomandibular pain?, J Oral Rehabil source
    • cites [21] Tseng, 2017, Retrospective study to identify trigeminal-cervical ocular referred pain as a new causative entity of ocular pain, J Pain Res source

      The Results (Treatment) describe conservative treatments and trigger-point injections for ocular pain, while the Discussion identifies this study as retrospective and calls for future comparative studies. Neither section addresses how many randomized controlled trials evaluate particular physical therapy interventions; searches for randomized trials and physical therapy interventions found no such passage. Page numbers were not provided in our copy. (LLM, conf=0.78)

      Experimental — accuracy not yet measured
    • cites [22] Häggman-Henrikson, 2013, Temporomandibular disorder pain after whiplash trauma: a systematic review, J Orofac Pain source
  • Premisecitation

    Other systematic reviews have investigated the efficacy of various cervical manual therapy techniques on temporomandibular joint dysfunction, including myofascial release, mobilization/manipulation, and combined interventions.

    “Other systematic reviews have investigated the efficacy of various cervical MT techniques on TMJ dysfunction,5,19,23,24 such as myofascial release to the masticatory and cervical muscles, mobilization/manipulation to the cervical and thoracic spine, and interventions combining the two.5,19”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [5] Armijo-Olivo, 2016, Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis, Phys Ther source

      The sections “Manual Therapy Targeted to the Orofacial Region in Myogenous TMD” and “Manual Therapy and Mixed TMD” review intraoral myofascial therapy, cervical mobilization, and upper-thoracic manipulation. “Manual Therapy Plus Exercises for Mixed TMD” also examines combined orofacial and cervical treatment. The copy does not specifically identify myofascial release to cervical muscles or an intervention combining that release with spinal mobilization or manipulation; page numbers were not available in the indexed passages. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [19] Calixtre, 2015, 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, J Oral Rehabil source
    • cites [23] La Touche, 2020, Effect of manual therapy and therapeutic exercise applied to the cervical region on pain and pressure pain sensitivity in patients with temporomandibular disorders: a systematic review and meta-analysis, Pain Med source
  • Premisecitation

    Heterogeneity is also influenced by unique patient characteristics, treatment techniques, and variability in measured outcomes.

    “but this is also influenced by unique patient characteristics, treatment techniques, and variability in measured outcomes.58”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [58] IntHout, 2015, Small studies are more heterogeneous than large ones: a meta-meta-analysis, J Clin Epidemiol source

      The Discussion (page unavailable) suggests that differences in patient populations may contribute to heterogeneity. Another passage notes that heterogeneity may relate to intervention and outcome type, but the paper does not specifically establish effects of treatment techniques or variability in measured outcomes. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
  • Classified as probably not a substantial claim. 17
  • May combine two claims. 32
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Reporting aligned with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

    “Reporting aligned with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.34”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [34] Moher, 2009, Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement, PLoS Med source

  • May combine two claims.

    Premisecitation

    Details about specific manual therapy techniques used were not consistently provided, and manual therapy techniques were variable.

    “Details about specific MT techniques used were not consistently provided, and MT techniques were variable, including soft tissue release, joint mobilizations, and joint manipulations performed to the cervical spine and/or TMJ.5,19,23,24”
    Quote in the paperSubstantial claim2 of 4 sources checked
    • cites [5] Armijo-Olivo, 2016, Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis, Phys Ther source
    • cites [19] Calixtre, 2015, 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, J Oral Rehabil source
    • cites [23] La Touche, 2020, Effect of manual therapy and therapeutic exercise applied to the cervical region on pain and pressure pain sensitivity in patients with temporomandibular disorders: a systematic review and meta-analysis, Pain Med source
    • cites [24] De Castro, 2020, Effects of manual therapy in the treatment of temporomandibular dysfunction—a review of the literature, Man Ther Posturology Rehabil J source

  • Classified as probably not a substantial claim.

    Premisecitation

    These reviews suggest that manual therapy combined with other interventions improves outcomes for those with temporomandibular joint dysfunction.

    “These reviews suggest that MT combined with other interventions improves outcomes for those with TMJ dysfunction.5,19,23”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [5] Armijo-Olivo, 2016, Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis, Phys Ther source
    • cites [19] Calixtre, 2015, 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, J Oral Rehabil source
    • cites [23] La Touche, 2020, Effect of manual therapy and therapeutic exercise applied to the cervical region on pain and pressure pain sensitivity in patients with temporomandibular disorders: a systematic review and meta-analysis, Pain Med source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    There is currently no standardized treatment approach for temporomandibular joint dysfunction, and clinicians tend to use a multimodal approach including education, exercise, and manual therapy.

    “There is currently no standardized treatment approach for TMJ dysfunction, and clinicians tend to use a multimodal approach50, 51, 52 to care including education, exercise, and MT.”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [50] Beltran-Alacreu, 2015, Manual therapy, therapeutic patient education, and therapeutic exercise, an effective multimodal treatment of nonspecific chronic neck pain: a randomized controlled trial, Am J Phys Med Rehabil source
    • cites [51] Crossley, 2015, Exercise, education, manual-therapy and taping compared to education for patellofemoral osteoarthritis: a blinded, randomised clinical trial, Osteoarthr Cartil source

      The Randomisation and interventions section describes a multimodal programme combining education, exercise, and manual therapy. But the trial concerns patellofemoral osteoarthritis, not temporomandibular joint dysfunction; it does not establish that TMJ treatment lacks a standardized approach or that clinicians generally use this combination for TMJ care. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [52] Wand, 2004, Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise, Spine source

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The risk of bias in each randomized controlled trial was evaluated by 2 reviewers independently using the Cochrane Risk of Bias Tool.

    “The risk of bias in each RCT was evaluated by 2 reviewers independently using the Cochrane Risk of Bias Tool.35”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [35] Sterne, 2019, RoB 2: a revised tool for assessing risk of bias in randomised trials, BMJ source

  • May combine two claims.

    Premisecitation

    The numeric pain rating scale and visual analog scale demonstrate good validity and reliability.

    “Although the MCID of both the NPRS and the VAS specific to TMJ pain has not been identified in the literature, a change of 2.0 points on the NPRS26 is deemed clinically important in chronic pain studies, with both tools demonstrating good validity27 and reliability.28”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [27] Ferreira-Valente, 2011, Validity of four pain intensity rating scales, Pain source
    • cites [28] Alghadir, 2018, Test-retest reliability, validity, and minimum detectable change of visual analog, numerical rating, and verbal rating scales for measurement of osteoarthritic knee pain, J Pain Res source

  • May combine two claims.

    Premisecitation

    Maximal mouth opening using a range of motion scale demonstrates good inter-rater reliability and intra-rater reliability.

    “Maximal mouth opening using a ROM scale demonstrates good inter-rater reliability and intra-rater reliability,29,30 and the MCID for MMO is ∼2.5 mm.31”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [29] Beltran-Alacreu, 2014, Intra-rater and inter-rater reliability of mandibular range of motion measures considering a neutral craniocervical position, J Phys Ther Sci source
    • cites [30] Kropmans, 2000, Smallest detectable difference of maximal mouth opening in patients with painfully restricted temporomandibular joint function, Eur J Oral Sci source

  • May combine two claims.

    Study design and conductcitation

    Five of the eight included trials demonstrated selection bias, and all included trials demonstrated similar degrees of performance bias.

    “Five of the 8 included trials40, 41, 42,45,46 demonstrated selection bias, and all demonstrated similar degrees of performance bias.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [40] Cuccia, 2010, Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: a randomized controlled trial, J Bodyw Mov Ther source
    • cites [41] Bortolazzo, 2015, Effects of upper cervical manipulation on the electromyographic activity of the masticatory muscles and the opening range of motion of the mouth in women with temporomandibular disorder: randomized and blind clinical trial, Fisioterapia e Pesquisa

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [42] Corum, 2018, Spinal high-velocity low-amplitude manipulation with exercise in women with chronic temporomandibular disorders, Manuelle Medizin source

      The Strengths and limitations section (page unavailable) says the trial could not blind patients or the treating physician, supporting a concern about performance bias in this trial. The Study design section (page unavailable) reports computer-generated randomization but does not establish that this trial demonstrated selection bias. As a single trial, the paper also cannot substantiate the citing document’s counts across eight trials. (LLM, conf=0.83)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    For pressure pain threshold of the temporalis muscle versus sham, included trials were heterogeneous (I2=86%; P<.001), the funnel plot was visually asymmetrical, and Egger regression was not significant but may have been underpowered (P=.59).

    “For PPT of the temporalis muscle, included trials were also heterogeneous (I2=86%; P<.001), and the funnel plot was visually asymmetrical (figure 6B). The Egger regression was not significant but may have been underpowered (P=.59).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For pressure pain threshold of the masseter muscle versus sham, included trials were statistically heterogenous (I2=92%; P<.001), the funnel plot was visually asymmetrical, and Egger regression was likely underpowered to detect this asymmetry (P=.63).

    “For PPT of the masseter muscle, included trials were statistically heterogenous (I2=92%; P<.001), the funnel plot was visually asymmetrical (figure 5B), and Egger regression was likely underpowered to detect this asymmetry (P=.63).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Heterogeneity analysis for maximal mouth opening versus other intervention demonstrated small improvements consistent across trials, with no outlying effect size estimates (I2=0%, P=.60).

    “The heterogeneity analysis demonstrated that small improvements were consistent across trials, with no outlying effect size estimates (I2 = 0%, P=.60).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Upper cervical spine manual therapy significantly reduced temporomandibular joint pain.

    “While upper cervical spine MT significantly reduced TMJ pain, this effect is unlikely to be clinically important as the MCID threshold of 2.0 points26 was not achieved.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The results for maximal mouth opening versus sham appeared relatively homogenous (I2=0%; P=.55) and funnel plot symmetry (P=.19).

    “The results appeared to be relatively homogenous (I2=0%; P=.55) and visual and formal analyses of the funnel plot demonstrated relative funnel plot symmetry (figure 4B; P=.19).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    As the small number of randomized controlled trials have low to moderate quality, the benefit of cervical manual therapy for temporomandibular joint dysfunction remains unclear.

    “As the small number of RCTs have low to moderate quality, the benefit of cervical MT for TMJ dysfunction remains unclear.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Premisenone given

    The complex biomechanical, anatomic, and neurophysiological links between the upper cervical spine and trigeminal nucleus provide a clinical basis for treatment of the cervical spine.

    “The complex biomechanical, anatomic, and neurophysiological links between the upper cervical spine and trigeminal nucleus provide a clinical basis for treatment of the cervical spine.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    A recent systematic review suggested that both cervical and cervico-craniomandibular manual therapy improve pain and maximal mouth opening in individuals with temporomandibular joint dysfunction.

    “A recent systematic review23 suggested that both cervical and cervico-craniomandibular MT improve pain and maximal mouth opening (MMO) in individuals with TMJ dysfunction, and adding cervico-craniomandibular MT appears to provide greater benefit than cervical MT alone.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] La Touche, 2020, Effect of manual therapy and therapeutic exercise applied to the cervical region on pain and pressure pain sensitivity in patients with temporomandibular disorders: a systematic review and meta-analysis, Pain Med source

  • Classified as probably not a substantial claim.

    Premisecitation

    Adding cervico-craniomandibular manual therapy appears to provide greater benefit than cervical manual therapy alone.

    “A recent systematic review23 suggested that both cervical and cervico-craniomandibular MT improve pain and maximal mouth opening (MMO) in individuals with TMJ dysfunction, and adding cervico-craniomandibular MT appears to provide greater benefit than cervical MT alone.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] La Touche, 2020, Effect of manual therapy and therapeutic exercise applied to the cervical region on pain and pressure pain sensitivity in patients with temporomandibular disorders: a systematic review and meta-analysis, Pain Med source

  • May combine two claims.

    Study design and conductown data

    Using the GRADE approach, the quality of evidence was rated moderate for subjective pain and maximal mouth opening, and low for pressure pain threshold of the masseter and temporalis muscles.

    “Using the GRADE approach, the quality of evidence was rated moderate for subjective pain and MMO, and low for PPT of the masseter and temporalis muscles.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The 2 reviewers independently extracted data for pain, maximal mouth opening, and pressure pain threshold of the masseter and temporalis muscles, along with sample size, participant characteristics, and details of interventions.

    “The 2 reviewers independently extracted data for pain, MMO, and PPT of the masseter and temporalis muscles, along with sample size, participant characteristics, and details of interventions.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Study selection (r=0.99) and outcome data extraction (r=0.99) were highly consistent between reviewers.

    “Study selection (r=0.99) and outcome data extraction (r=0.99) were highly consistent between reviewers.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Four trials contained other biases including small group sizes, low baseline pain levels which may have led to floor effects, use of prescribed non-steroidal anti-inflammatory medication that differed between groups, and lack of assessment of exercise compliance during follow-up, potentially confounding results.

    “Four trials40, 41, 42,45 contained other biases including small group sizes, low baseline pain levels which may have led to floor effects, use of prescribed non-steroidal anti-inflammatory medication that differed between groups, and lack of assessment of exercise compliance during follow-up, potentially confounding results.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisereasoning

    Clinicians often consider the cervical spine as a potential source of temporomandibular joint symptoms.

    “Clinicians therefore often consider the cervical spine as a potential source of TMJ symptoms.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Of the included trials, 1 (12.5%) demonstrated low risk of bias, 5 (62.5%) demonstrated unclear risk of bias, and 2 (25%) demonstrated high risk of bias.

    “Of the included trials, 1 (12.5%) demonstrated low risk of bias,38 5 (62.5%) demonstrated unclear risk of bias,40,41,44,45,47 and 2 (25%) demonstrated high risk of bias.42,46”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Publication bias for pain versus sham was difficult to determine visually and could not be quantified using Egger regression because of the small number of trials.

    “Publication bias was difficult to determine visually (figure 3B) and could not be quantified using Egger regression because of the small number of trials.44,45”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [44] Calixtre, 2019, Effectiveness of mobilisation of the upper cervical region and craniocervical flexor training on orofacial pain, mandibular function and headache in women with TMD. A randomised, controlled trial, J Oral Rehabil source
    • cites [45] La Touche, 2013, Does mobilisation of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervico-craniofacial pain? A randomized-controlled trial, Clin J Pain source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Two independent reviewers screened titles and abstracts to identify relevant studies.

    “Two independent reviewers screened titles and abstracts to identify relevant studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Upper cervical manual therapy may not have clinically meaningful effects on subjective pain or maximal mouth opening.

    “therefore, MT may not have clinically meaningful effects on these outcomes.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The 2 reviewers independently reviewed full text articles according to predetermined eligibility and inclusion criteria.

    “The 2 reviewers independently reviewed full text articles according to predetermined eligibility and inclusion criteria.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Despite statistically significant reductions in pain, this effect did not meet the 2.0 point MCID threshold and may not be clinically important.

    “Despite statistically significant reductions in pain, this effect did not meet the 2.0 point MCID threshold26 and may not be clinically important.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [26] Farrar, 2001, Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale, Pain source
    • Rests on an assumption: The minimal clinically important difference of both the numeric pain rating scale and the visual analog scale specific to temporomandibular joint pain has not been identified in the literature.

  • May combine two claims.

    Study design and conductown data

    The funnel plot for pain versus other intervention was relatively symmetrical and Egger regression non-significant (P=.25), but conclusions about publication bias are difficult given fewer than 10 randomized controlled trials.

    “The funnel plot (figure 3D) was relatively symmetrical and the Egger regression statistic was non-significant (P=.25), but conclusions about publication bias are difficult to draw given the few randomized controlled trials (less than 10)48 that assessed pain using the VAS or the NPRS.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [48] Page, 2019, Chapter 13: assessing risk of bias due to missing results in a synthesis source

  • May combine two claims.

    Premisecitation

    The reliability of pressure algometry in the masticatory structures is high in healthy volunteers and in patients with temporomandibular joint dysfunction.

    “The MCID for PPT has been reported to be 0.2 kg/cm2 in the masticatory muscles31 and the reliability of pressure algometry in the masticatory structures is high in healthy volunteers32 and in patients with TMJ dysfunction.33”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [32] Isselée, 1997, Short-term reproducibility of pressure pain thresholds in masseter and temporalis muscles of symptom-free subjects, Eur J Oral Sci source
    • cites [33] Gomes, 2008, Palpation and pressure pain threshold: reliability and validity in patients with temporomandibular disorders, Cranio source

  • May combine two claims.

    Interpretationreasoning

    The true effect likely falls within the 95% CI and could be larger or smaller than the MCID.

    “The true effect likely falls within the 95% CI and could be larger or smaller than the MCID.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    This effect did not meet the 2.5 mm MCID for maximal mouth opening and may not be clinically important.

    “This effect did not meet the 2.5 mm MCID for MMO26 and may not be clinically important.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [26] Farrar, 2001, Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale, Pain source

  • May combine two claims.

    Study design and conductown data

    Substantial heterogeneity occurred for pressure pain threshold of the masseter and temporalis muscles, and for pain compared with sham controls, leading to an overall inconsistency grade of moderate.

    “Substantial heterogeneity occurred for PPT of the masseter and temporalis muscles, and for pain (compared with sham controls), leading us to grade the overall inconsistency as moderate.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Pooled results were based on a few trials with small sample sizes, leading to heterogeneity and imprecision of effect estimates, which affected the GRADE categories of inconsistency and imprecision.

    “Pooled results are based on a few trials with small sample sizes, leading to issues such as heterogeneity and imprecision of effect estimates, affecting the GRADE categories of inconsistency and imprecision, respectively.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Although 3 trials reported adequate random sequence generation, none blinded participants or study personnel to group allocation.

    “Although 3 trials38,44,47 reported adequate random sequence generation, none blinded participants or study personnel to group allocation.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The link between the upper cervical spine and temporomandibular joint dysfunction has led manual therapists to evaluate the principle of regional interdependence, which implies that successful outcomes can be achieved by treating areas remote from the symptomatic site.

    “The link between the upper cervical spine and TMJ dysfunction has led manual therapists to evaluate the principle of regional interdependence, implying that successful outcomes can be achieved by treating areas remote from the symptomatic site.53”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [53] McDevitt, 2015, Regional interdependence and manual therapy directed at the thoracic spine, J Man Manip Ther source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Funnel plots and Egger regression analysis for pressure pain threshold versus other intervention could not be completed because of limited degrees of freedom.

    “The funnel plots (figures 5D and 6D) and Egger regression analysis could not be completed because of the limited degrees of freedom.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    A placebo response cannot be excluded, and the possibility that adverse events were missed cannot be excluded.

    “however, a placebo response cannot be excluded, nor can we exclude the possibility that adverse events were missed.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    Even with small effect sizes and large heterogeneity, meaningful effects can sometimes be derived from a particular intervention.

    “However, even with small effect sizes and large heterogeneity, meaningful effects can sometimes be derived from a particular intervention.55”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [55] Auerbach, 2001, Depression, pain, exposure to stressful life events, and long-term outcomes in temporomandibular disorder patients, J Oral Maxillofac Surg source

  • May combine two claims.

    Interpretationreasoning

    The effect of psychological and patient-specific factors on heterogeneity may be especially true for subjective outcomes and may explain why subjective pain ratings and pressure pain thresholds of the masseter and temporalis were more heterogeneous compared with maximal mouth opening.

    “This may be especially true for subjective outcomes and may explain why subjective pain ratings and PPTs of the masseter and temporalis were more heterogeneous compared with that of MMO.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Temporomandibular dysfunction has been associated with poor quality of sleep and exposure to stressful life events, especially when pain is of muscular origin.

    “Temporomandibular dysfunction has been associated with poor quality of sleep53 and exposure to stressful life events, especially when pain is of muscular origin.54”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [53] McDevitt, 2015, Regional interdependence and manual therapy directed at the thoracic spine, J Man Manip Ther source
    • cites [54]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationreasoning

    Treatment effects of upper cervical manual therapy for temporomandibular joint dysfunction appear to be small and not likely clinically important.

    “It appears that treatment effects are small and not likely clinically important.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Psychological overlay, chronic stress, duration of pain, and patient-specific beliefs and expectations regarding care may have increased clinical heterogeneity among trials.

    “Psychological overlay, chronic stress, duration of pain, and patient-specific beliefs and expectations regarding care may have increased the clinical heterogeneity among trials.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Early transient benefits or adverse effects of upper cervical manual therapy likely did not occur.

    “and that early transient benefits or adverse effects likely did not occur.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductcitation

    Small sample sizes and a limited number of trials contributed to heterogeneity.

    “Small sample sizes and limited number of trials contributed to heterogeneity,57”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [57] Dorey, 2010, In brief: statistics in brief: confidence intervals: what is the real result in the target population?, Clin Orthop Relat Res source
45 of 45

  • The paper relies on this without support.

    Given the association between temporomandibular joint dysfunction and the upper cervical spine, manual therapy of the upper cervical spine is commonly used to treat temporomandibular joint dysfunction.

    “Given the association between TMJ and the upper cervical spine, MT of the upper cervical spine is commonly used to treat TMJ dysfunction.”

  • The paper relies on this without support.

    To date, no systematic review has evaluated the use of upper cervical manual therapy alone for temporomandibular joint dysfunction.

    “To date, no systematic review has evaluated the use of upper cervical MT alone for TMJ dysfunction.”

  • The paper relies on this without support.

    The minimal clinically important difference of both the numeric pain rating scale and the visual analog scale specific to temporomandibular joint pain has not been identified in the literature.

    “Although the MCID of both the NPRS and the VAS specific to TMJ pain has not been identified in the literature, a change of 2.0 points on the NPRS26 is deemed clinically important in chronic pain studies, with both tools demonstrating good validity27 and reliability.28”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Claimed imprecision downgrade conflicts with GRADE table

    Major

    The text says every outcome was downgraded at least one level for imprecision. The GRADE table instead lists no serious imprecision for maximal mouth opening, including a high-quality rating for one comparison.

  • A no-treatment trial is included in the sham comparison

    Major

    The pain meta-analysis is described as comparing manual therapy with sham intervention and includes trial 44. Table 1 identifies trial 44's comparator as no treatment, not sham intervention.

  • Trial 41 has conflicting TMJ pain durations

    Minor

    The results describe trial 41's TMJ pain duration as between one and five years. Its Table 1 duration entry instead gives 25.8±6.8 years-the same value listed there as participants' mean age.

3 of 3

Cites

Flagged first, then by citations

5 of the 68 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Lam, A. C., Liddle, L. J., & MacLellan, C. L.
Affiliations
  • St. John's University (US)
  • University of Alberta (CA)
Corresponding author
Lam, Alan C.
ORCID
Venue
Archives of Rehabilitation Research and Clinical Translation
Publisher
Elsevier BV
Published
2023-03
Volume
5
Issue
1
Pages
100242
ISSN
2590-1095 (ISSN-L)
DOI
10.1016/j.arrct.2022.100242
PMC
PMC10036235
OpenAlex
W4307991046
Semantic Scholar
33e63aa1b534b00b61d65ea405773082a5de6e28
Cited by
14
References
68
Citations by year
2026: 6 · 2025: 5 · 2024: 1 · 2023: 2
FWCI
0.58
Type
journal article
Language
en
Open access
Licence
Locations
  • Archives of Rehabilitation Research and Clinical Translation (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion, cc-by-nc-nd)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Health Professions › Complementary and Manual Therapy › Temporomandibular Joint Disorders
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Cell Biology › Myofascial pain diagnosis and treatment
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
Keywords
upper cervical manipulation, temporomandibular disorders, temporomandibular joint pain, maximum mouth opening, pressure pain threshold, manual therapy, sham treatment, masseter muscle, temporalis muscle, cervical manipulation, analgesia

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-12.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-12.

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