Management and Treatment of Temporomandibular Disorders: A Clinical Perspective

A temporomandibular disorder (TMD) is a very common problem affecting up to 33% of individuals within their lifetime. TMD is often viewed as a repetitive motion disorder of the masticatory structures and has many similarities to musculoskeletal disorders of other parts of the body. Treatment often involves similar principles as other regions as well. However, patients with TMD and concurrent cervical pain exhibit a complex symptomatic behavior that is more challenging than isolated TMD symptoms. Although routinely managed by medical and dental practitioners, TMD may be more effectively cared for when physical therapists are involved in the treatment process. Hence, a listing of situations when practitioners should consider referring TMD patients to a physical therapist can be provided to the practitioners in each physical therapist''s region. This paper should assist physical therapists with evaluating, treating, insurance billing, and obtaining referrals for TMD patients.KEYWORDS: Dentistry, Physical Therapy, Temporomandibular Disorders, Temporomandibular JointAtemporomandibular disorder (TMD) is a musculoskeletal disorder within the masticatory system. Many practitioners refer to TMD as a single disorder in spite of the fact that patients have various sub-diagnoses (e.g., myofascial pain, temporomandibular joint (TMJ) inflammation)^1,2. TMD is a prevalent disorder most commonly observed in individuals between the ages of 20 and 40. Approximately 33% of the population has at least one TMD symptom and 3.6% to 7% of the population has TMD with sufficient severity to cause them to seek treatment^1–3.TMD is often viewed as a repetitive motion disorder of the masticatory structures. It has many similarities to musculoskeletal disorders of other parts of the body, and therapeutic approaches for other musculoskeletal disorders generally apply to this disorder as well^1,2,4. Similar to other repetitive motion disorders, TMD self-management instructions routinely encourage patients to rest their masticatory muscles by voluntarily limiting their use, i.e., avoiding hard or chewy foods and restraining from activities that overuse the masticatory muscles (e.g., oral habits, clenching teeth, holding tension in the masticatory muscles, chewing gum, and yawning wide)^1,2,5. The self-management instructions also encourage awareness and elimination of parafunctional habits (e.g., changing teeth clenching habit to lightly resting the tongue on top of the mouth or wherever the tongue is most comfortable) and keeping the teeth apart and masticatory muscles relaxed^1,2,5.As with other musculoskeletal disorders, pain during function and/or at rest is the primary reason patients seek treatment, and reduction in pain is generally the primary goal of therapy^1,2. Less commonly, individuals seek TMD therapy for TMJ catching or locking, masticatory stiffness, limited mandibular range of motion, TMJ dislocation, and unexplained change in their occlusion (anterior or posterior open bite, or shift in their mandibular midline). However, TMJ noises are common among the general population, are generally not a concern for individuals or practitioners, are not commonly treated, and do not generally respond as well to therapy as pain^1,2,6–9. The purpose of this clinical perspective is to describe the examination and treatment of TMD from both a dentist''s and a physical therapist''s perspective.     

Characteristics of TMD headache – a systematic review

Abstract

Objective: This systematic review critically evaluated the literature on the subjective and physical characteristics of TMD-related headache, a symptom secondary to the syndrome temporomandibular disorders (TMD). The specific research question is: 'what are the diagnostic criteria that confirm temporomandibular involvement in headache presentations?'

Method: Electronic searches were conducted for MEDLINE, PubMed, and CINAHL from 1966 to September 2007. Hand searches for retrieved articles were also conducted to collect the data for this review. After applying inclusion criteria, 15 articles on TMD-related headache were found.

Results: The symptoms of TMD-related headache are frequently unilateral and often present in the pre-auricular, temple and retro-orbital regions of the head. The principal physical characteristics include tenderness of the ipsilateral masticatory muscles and reduced jaw opening, often with mandibular deviation.

Conclusion: Despite methodological problems such as low subject numbers and poorly documented sampling methods and inclusion criteria, the literature showed that TMD-related headache has identifiable diagnostic characteristics. This information could be used to develop guidelines to assist the identification of headaches which emanate from the temporomandibular structures.     

The Chiropractic Subluxation: Implications for Manual Medicine

Abstract

Objectives: Studies investigating the efficacy of intra-oral myofascial therapies (IMT) for chronic temporomandibular disorder (TMD) are rare. The objective of this randomized, controlled pilot study was to compare the effects of IMT and the addition of self-care and education over 6 months on four common TMD outcome measures: inter-incisal opening range, jaw pain at rest, jaw pain upon opening, and jaw pain upon clenching.

Participants: Thirty myogenous TMD participants between the ages of 18 and 50 years, experiencing chronic jaw pain of longer than 3-month duration, were recruited for the present study.

Intervention: Included patients were randomized into one of three groups: (1) IMT consisting of two treatment interventions per week for 5 weeks; (2) IMT plus 'self-care' involving education and exercises; and (3) wait list control.

Main outcome measures: Range of motion findings were measured in millimetres by vernier callipers and pain scores were quantified using an 11-point self-reported graded chronic pain scale. Measurements were taken at baseline, 6 weeks post-treatment, and 6 months post-treatment.

Results: The results showed statistically significant differences in resting, opening, and clenching pain and opening range scores (P<0.05) in both treatment groups compared to control at 6 months. No significant differences were observed between the two treatment groups during the course of the trial.

Conclusions: This study suggests that IMT alone or with the addition of self-care may be of some benefit in the management of chronic TMD over the short-medium term. A larger scale study over a longer term (1–2 years) may be of further value.     

Temporomandibular disorders. Part 2: conservative management

Appropriate management of temporomandibular disorders (TMD) requires an understanding of the underlying dysfunction associated with the temporomandibular joint (TMJ) and surrounding structures. A comprehensive examination process, as described in part 1 of this series, can reveal underlying clinical findings that assist in the delivery of comprehensive physical therapy services for patients with TMD. Part 2 of this series focuses on management strategies for TMD. Physical therapy is the preferred conservative management approach for TMD. Physical therapists are professionally well-positioned to step into the void and provide clinical services for patients with TMD. Clinicians should utilize examination findings to design rehabilitation programs that focus on addressing patient-specific impairments. Potentially appropriate plan of care components include joint and soft tissue mobilization, trigger point dry needling, friction massage, therapeutic exercise, patient education, modalities, and outside referral. Management options should address both symptom reduction and oral function. Satisfactory results can often be achieved when management focuses on patient-specific clinical variables.     

Inter-professional agreement of ultrasound-based diagnoses in patients with shoulder pain between physical therapists and radiologists in the Netherlands

Study designReliability study.ObjectivesThe aim of this study was to evaluate the interrater-reliability of the interpretation of diagnostic ultrasound in patients with shoulder pain between physical therapists and radiologists.BackgroundAlthough physical therapists in The Netherlands increasingly use diagnostic ultrasound in clinical practice, there is no evidence available on its reliability.MethodsA cohort study included patients with shoulder pain from primary care physiotherapy. Patients followed the usual diagnostic pathway of which diagnostic ultrasound could be a part. Patients that received diagnostic ultrasound also visited a radiologist within one week for a second one. Patients and radiologists were blinded for the diagnostic ultrasound diagnosis of the physical therapists. Agreement was assessed using Cohen's kappa statistics. Subgroup analysis was performed on education and experience.ResultsA total of 65 patients were enrolled and 13 physical therapists and 9 radiologists performed diagnostic ultrasound. We found substantial agreement (0.63 K) between physical therapists and radiologists on the assessment of full thickness tears. The overall kappa of all four diagnostic categories was 0.36, indicating fair agreement. The more experienced and highly trained physical therapists showed moderate agreement (0.43 K) compared to only slight agreement (0.17 and 0.09 K) from the less experienced and trained physical therapists with radiologists.ConclusionThe reliability between physical therapists and radiologist on diagnostic ultrasound of shoulder patients in primary care is borderline substantial (Kappa = 0.63) for full thickness tears only. This level of reliability is relatively low when compared with the high reliability between radiologists. More experience and training of physical therapists may increase the reliability of diagnostic ultrasound.     

Accuracy of rib palpation for dry needling of deep periscapular musculature,measured with ultrasound

IntroductionDry needling of the periscapular musculature is a procedure commonly performed by physical therapists. Needling of the deep musculature may be challenging, and use of a thoracic rib as a “backstop” is often applied to prevent inadvertent puncture of the pleura. The aim of this study was to: 1) To examine the accuracy rate of experienced physical therapists in identifying a mid-scapular thoracic rib using palpation, 2) to understand patient characteristics that affect the accuracy rate, and 3) to examine if therapist confidence levels were associated with palpatory accuracy.MethodsTwo experienced physical therapists attempted to palpate a thoracic rib in the mid-scapular region of healthy participants (n = 101 subjects, 202 ribs), and self-reported their level of confidence in an accurate palpation. Their accuracy was verified with ultrasonography.ResultsThe two physical therapists were accurate on 73.3% of palpations and did not differ in accuracy (72.0% vs. 75.0%, p = 0.747). The only ultrasonographic or subject characteristic measurement that correlated with improved accuracy was a reduced muscle thickness (p = 0.032). Therapists’ self-reported confidence levels did not correlate to actual accuracy (p = 0.153).DiscussionPhysical therapists should be aware that palpation of a thoracic rib may not be as accurate as it may seem. The greater thickness of muscle in the area reduces the accuracy of accurate palpation.ConclusionDry needling of the periscapular muscles should be done with caution if using a rib as a “blocking” technique.     

Clinician’s ability to identify neck and low back interventions: an inter-rater chance-corrected agreement pilot study

Abstract

Objective: To estimate inter-rater agreement of physical therapists trained in MDT approach and participating in practice-based evidence (PBE) research to identify 72 physical therapy interventions in video demonstrations on a single model and clinical vignettes. PBE is a well designed observational study and demonstrating clinician observational consistency is an important step in conducting PBE research design.

Methods: Two physical therapists volunteered to participate in pilot reliability testing and seven other physical therapists trained in McKenzie Mechanical Diagnosis and Therapy (MDT) methods volunteered for the inter-rater chance-corrected agreement study. All therapists identified interventions presented within 52 videos and 5 written clinical vignettes describing 20 more intervention techniques. Therapists independently identified all interventions. We assessed inter-rater chance-corrected agreement of therapists’ ability to identify intervention techniques using Kappa coefficients with associated 95% confidence intervals and indices for bias and prevalence.

Results: Of the 147 kappa coefficients estimated, 7% were ?0·6, 10% were >0·6 and ?0·8, and 83% were >0·8. Agreement was lowest for identifying cognitive behavioral techniques (median kappa?=?0·79). The minimum and maximum prevalence and bias indices were 0·33 and 0·85 and 0 and 0·33, respectively suggesting kappa coefficient estimates were strong. Generalized kappa coefficients ranged from 0·73 to 1·00.

Discussion: Results provide evidence that substantial to almost perfect inter-rater agreement could be expected when trained therapists identify physical therapy interventions used for patients with spinal impairments from staged videos and vignettes. This may be helpful to reassure clinicians of the quality of the reporting of intervention(s) performed when conducting multivariable analyses in future pragmatic PBE studies. Additional studies are needed to test whether these results can be validated using larger groups of therapists, trained and not trained in MDT methods, as well as examining different methods to examine inter-rater agreement for identifying diverse interventions commonly used for managing patients during routine practice.     

A History of Manipulative Therapy Through the Ages and Up to the Current Controversy in the United States

Abstract

Joint manipulation is an ancient art and science that can trace its origins to the earliest medical and lay practitioners. Today, it is practiced principally by physical therapists and chiropractors and to a lesser degree, by osteopathic and medical physicians. Self-manipulation of both joint and soft tissues is also a common practice in those who “crack” their own knuckles and spines. This article traces the history and development of manipulation from its origins to the present with a special emphasis on developments in the United States as a background for understanding current licensure and practice issues.

Since the beginning of this century, physical therapy has enjoyed a close relationship with medicine and has developed its knowledge base and practice in spinal and extremity manipulation from the medical profession. Manipulation in physical therapy has become a significant part of its rehabilitation practice, often encompassed in the terms therapeutic exercise, active and passive movement, or manual therapy. Instruction in manipulation begins with pre-professional education; for those who wish to specialize in this field, instruction continues at the post-professional level, following the medical model of specialization. Since the 1960's, physical therapists have developed their own body of knowledge in manipulation, emphasizing pain relief and enhanced physical function.

By contrast, since its independent origins in the late 19th century, chiropractic has practiced manipulation for most of its history as a primary therapeutic tool to correct spinal subluxation. It provides spinal adjustments to facilitate the free flow of nerve energy, which, in turn, relieves many human ailments. Unlike physical therapy, chiropractic has not been practiced in cooperation with medicine but has existed as an alternative during most of its history. In recent years, the chiropractic profession has divided along philosophical lines: those who strongly defend the subluxation theory (straights) to those who do not (mixers), with the later group now holding sway. This change in chiropractic philosophy and practice has brought practitioners into a practice model more closely aligned with the comprehensive model of rehabilitation therapy modeled by physical therapists. Consequently, many chiropractors now use physical therapy procedures even though they are prohibited from calling themselves physical therapists. As a result, competition in the market place has heightened, with concomitant licensure and political challenges.

This article discusses the history and evolution of the practice of manipulation against a background of other key developments in health care; as such, it should provide understanding for today's current practice scene.     

The opinion and experiences of Dutch orthopedic surgeons and radiologists about diagnostic musculoskeletal ultrasound imaging in primary care: A survey

Introduction and aimThe use of diagnostic musculoskeletal ultrasound (DMUS) in primary health care has increased in the recent years. Nevertheless, there are hardly any data concerning the reliability, accuracy and treatment consequences of DMUS used by physical therapists or general practitioners. Moreover, there are no papers published about how orthopedic surgeons or radiologists deal with the results of DMUS performed in primary care. Therefore, our aim is to evaluate the opinion, possible advantages or disadvantages and experiences of Dutch orthopedic surgeons and radiologists about DMUS in primary care.MethodsA cross-sectional survey in which respondents completed a self-developed questionnaire to determine their opinion, experiences, advantages, disadvantages of performing DMUS in primary care.ResultsQuestionnaires were sent to 838 Dutch orthopedic surgeons and radiologists of which 213 were returned (response rate 25.4%). Our respondents saw no additional value for health care for diagnostic DMUS in primary care. DMUSs were generally repeated in secondary care. They perceived more disadvantages than advantages of performing DMUS in primary care. Mentioned disadvantages were: ‘false positive results’ (71.4%), ‘lack of experience’ (70%), ‘insufficient education’ (69.5%), not able to relate the outcomes of DMUS with other forms of diagnostic imaging’ (65.7%), and ‘false negative results’ (65.3%).ConclusionRadiologists and orthopedic surgeons sampled in the Netherlands show low trust in DMUS knowledge of physical therapists and general practitioners. The results should be interpreted with caution because of the small response rate and the lack of representativeness to other countries.     

Combining psychotherapy with craniosacral therapy for severe traumatized patients: A qualitative study from an outpatient clinic in Norway

BackgroundCraniosacral therapy (CST) is an established complementary modality for several health complaints. A clinic for psychosomatics in Norway has included CST into a multimodal treatment approach for severely traumatized patients. The aim of this study was to investigate and describe the indications for the use of craniosacral therapy within trauma therapy. Specifically, to explore treatment philosophy, criteria for improvement, treatment aims, and the evaluation of the risk profile of the multimodal treatment approach.MethodsSemi-structured individual interviews (n = 8) and one focus group interview were conducted with the therapists at the Clinic for Psychosomatics, Hospital of Southern Norway, Kristiansand, Norway. The text data were transcribed verbatim, and the analysis of the material was conducted according to conventional and direct content analysis.ResultsThe therapists at the clinic applied a holistic treatment approach, based on their understanding of mind and body as one entity. To access emotions and traumata, they used a mixture of different treatment techniques. The therapists experienced patients with severe bodily symptoms as being less cognitively present and attributed this to the symptoms craving most mental resources. The craniosacral therapists’ specific aims and task within the multimodal trauma therapy was to ease these physical complaints, so that cognitive and emotional resources could be utilized for therapy. The psychotherapists found that emotions and traumata were more accessible after CST. The general treatment goals were to increase symptom tolerance levels and to enable better self-care. Furthermore, the ability to transform negative behaviors and develop positive alternatives were considered to be signs of improvement.ConclusionThe study participants considered that patients with complex traumas, including post‐traumatic stress disorder, seemed to benefit from this multimodal treatment approach and appreciated its’ holistic treatment philosophy, including craniosacral therapy. With regard to patient safety, the study participants recommended that craniosacral therapy for severely traumatized patients should only be provided in cooperation with psychotherapists, or other highly qualified health personnel working in specialized institutions.     

Current physical therapy care of patients undergoing breast reconstruction for breast cancer: a survey of practice in the United Kingdom and Brazil

BackgroundIn both the United Kingdom (UK) and Brazil, women undergoing mastectomy should be offered breast reconstruction. Patients may benefit from physical therapy to prevent and treat muscular deficits. However, there are uncertainties regarding which physical therapy program to recommend.ObjectiveThe aim was to investigate the clinical practice of physical therapists for patients undergoing breast reconstruction for breast cancer. A secondary aim was to compare physical therapy practice between UK and Brazil.MethodsOnline survey with physical therapists in both countries. We asked about physical therapists’ clinical practice.Results181 physical therapists completed the survey, the majority were from Brazil (77%). Respondents reported that only half of women having breast reconstruction were routinely referred to physical therapy postoperatively. Contact with patients varied widely between countries, the mean number of postoperative sessions was 5.7 in the UK and 15.1 in Brazil. The exercise programs were similar for different reconstruction operations. Therapists described a progressive loading structure over time: range of motion (ROM) was restricted to 90° of arm elevation in the first two postoperative weeks; by 2–4 weeks ROM was unrestricted; at 1–3 months muscle strengthening was initiated, and after three months the focus was on sports-specific activities.ConclusionOnly half of patients having a breast reconstruction are routinely referred to physical therapy. Patients in Brazil have more intensive follow-up, with up to three times more face-to-face contact with a physical therapist than in the UK. Current practice broadly follows programs for mastectomy care rather than being specific to reconstruction surgery.     

Functioning of women in the postpartum period: an International Classification of Functioning,Disability and Health-based consensus of physical therapists

BackgroundPhysical therapists provide treatment for pain and other common complaints for women in the postpartum period, thereby contributing to the improvement of their functioning. However, before applying any interventions, physical therapists should assess their patients to identify the desired therapeutic goals. In this context, the International Classification of Functioning, Disability and Health (ICF) may be a useful tool for documenting functioning data and operationalizing collaborative goal setting.ObjectiveTo identify ICF categories and the respective domains that should be considered in the evaluation of women postpartum.MethodsA consensus-building, three-round e-mail survey was conducted using the Delphi method. The sample included Brazilian physical therapists with expertise in women’s health. Meaningful content was analyzed in accordance to the ICF linking rules. The kappa coefficient and content validity index (CVI) were calculated.ResultsThe panel consisted of 45 participants with a median age of 33 years and more than 10 years of experience in women’s health. A total of 1261 meaningful contents were identified from the responses in the first round. After consensus was achieved, a final list of 62 items was prepared, including 53 categories (11 were on structures; 15 on body functions; 12 on activities and participation; 15 on environmental factors) and nine personal factors (CVI = 0.89).ConclusionFrom the perception of physical therapists, an ICF-based postpartum assessment to describe functioning and disability must comprise 53 ICF categories and nine personal factors.     

Incentive spirometer: Aspects of the clinical practice of physical therapists from Minas Gerais working with patients with respiratory dysfunction

BackgroundIncentive spirometers (ISs) are clinical devices used in respiratory physical therapy to increase alveolar ventilation and functional residual capacity.ObjectivesTo investigate factors that influence physical therapists from Minas Gerais in selecting a type of IS and the scientific background behind the use of ISs by physical therapists who work with patients with respiratory dysfunctions.MethodsPhysical therapists from 13 hospital and non-hospital institutions (public/private) completed a self-administered questionnaire based on the current evidence on ISs.ResultsIndications and contraindications of ISs are not fully understood by most of the 168 physical therapists who completed the questionnaire. Volume-oriented IS was preferred over flow-oriented IS. However, only half of the physical therapists have a scientific background to justify the choice of one IS type rather than the other.ConclusionsMost physical therapists from Minas Gerais do not fully understand the indications and contraindications for ISs. Despite physical therapists stating their preference for volume-oriented IS, this choice is not necessarily based on current scientific evidence. The development of strategies to bring physical therapists closer to evidence-based practice is necessary to ensure best patient care.     

Sedentary behavior: barriers and facilitators among older adults after hip fracture surgery. A qualitative study

ObjectivesUnderstand the experience of older adults after hip fracture surgery considering barriers and facilitators related to sedentary behavior.MethodsA qualitative study using a semi-structured interview with three men and eight women aged 60 years or older after hip fracture surgery.ResultsFive barriers emerged: physical complaints, lack of accessibility, fear of falling, demotivation and negative social representation of old age, and two facilitators: overcoming dependency and having a caregiver.ConclusionOur results highlight that physical complaints commonly addressed by physical therapists on their interventions are not the only impediments to reduce sedentary behavior. Important individual and social barriers should not be neglected when physical therapists conduct interventions to reduce sedentary behavior to maximize functional recovery in older adults after hip fracture surgery. Future clinical trials are required to investigate the effectiveness of more comprehensive interventions to reduce sedentary behavior in this population.     

Psychosocial diagnoses occurring after patients present with fatigue

ObjectiveTo discover the frequency of psychosocial and other diagnoses occurring at the end of a visit when patients present to their FPs with concerns about fatigue.DesignCross-sectional study of patient-FP encounters for fatigue.SettingTen FP practices in southwestern Ontario.ParticipantsA total of 259 encounters involving 167 patients presenting to their FPs between March 1, 2006, and June 30, 2010, with concerns about fatigue.ResultsPsychosocial diagnoses were made 23.9% of the time. Among psychosocial diagnoses made, depressive disorder and anxiety disorder or anxiety state were diagnosed more often in women (P = .048). Slightly less than 30% of the time, the cause of patients’ fatigue remained undiagnosed at the end of the encounter. A diagnosis was made more often in men.ConclusionCauses of fatigue frequently remain undiagnosed; however, when there is a diagnosis, psychosocial diagnoses are common. Therefore, it would be appropriate for FPs to screen for psychosocial issues when their patients present with fatigue, unless some other diagnosis is evident. Depression and anxiety could be considered particularly among female patients with fatigue.     

How physical therapists instruct patients with stroke: an observational study on attentional focus during gait rehabilitation after stroke

Purpose: People without neurological impairments show superior motor learning when they focus on movement effects (external focus) rather than on movement execution itself (internal focus). Despite its potential for neurorehabilitation, it remains unclear to what extent external focus strategies are currently incorporated in rehabilitation post-stroke. Therefore, we observed how physical therapists use attentional focus when treating gait of rehabilitating patients with stroke.

Methods: Twenty physical therapist-patient couples from six rehabilitation centers participated. Per couple, one regular gait-training session was video-recorded. Therapists’ statements were classified using a standardized scoring method to determine the relative proportion of internally and externally focused instructions/feedback. Also, we explored associations between therapists’ use of external/internal focus strategies and patients’ focus preference, length of stay, mobility, and cognition.

Results: Therapists’ instructions were generally more external while feedback was more internal. Therapists used relatively more externally focused statements for patients with a longer length of stay (B?=??0.239, p?=?0.013) and for patients who had a stronger internal focus preference (B?=??0.930, p?=?0.035).

Conclusions: Physical therapists used more external focus instructions, but more internally focused feedback. Also, they seem to adapt their attentional focus use to patients’ focus preference and rehabilitation phase. Future research may determine how these factors influence the effectiveness of different attentional foci for motor learning post-stroke.

• IMPLICATIONS FOR REHABILITATION

• Physical therapists use a balanced mix of internal focus and external focus instructions and feedback when treating gait of stroke patients.

• Therapists predominantly used an external focus for patients in later rehabilitation phases, and for patients with stronger internal focus preferences, possibly in an attempt to stimulate more automatic control of movement in these patients.

• Future research should further explore how a patients’ focus preference and rehabilitation phase influence the effectiveness of different focus strategies.

• Awaiting further research, we recommend that therapists use both attentional focus strategies, and explore per patient which focus works best on a trial-and-error basis.

     

Association between temporomandibular symptoms,anxiety and quality of life among nursing students

BackgroundAnxiety is inherent in the everyday life of a nursing student. One of the physiological disorders associated with anxiety is temporomandibular disorder (TMD). Although the relationship between TMD and anxiety is well established, temporomandibular-related symptoms in nursing students has yet to be examined.AimTo investigate the association between anxiety and temporomandibular-related symptoms in nursing students, and the effect on quality of life.Methods281 nursing students completed an online survey that included the Oral Health Impact Profile-TMD (OHIP-TMD) questionnaire and the Patient-Reported Outcome Measurement Information System (PROMIS) short form questionnaire. The OHIP-TMD psychometric properties were assessed using principal component analysis. Linear regression models were used to examine demographic predictors for anxiety and TMD, and a general linear model was used to assess the association between anxiety and the psychosocial and function scales.FindingsThe mean value for the OHIP-TMD and the PROMIS short form was respectively 1.6 (SD = 0.7) and 10.8 (SD = 4.1). Linear regression demonstrated that there was an inverse association between oral related quality of life and year of study; nursing students in higher course years reported lower levels of oral related quality of life. The general linear model analysis revealed that increased anxiety was significantly associated with high levels of oral physical function impairment and elevated psychosocial distress.DiscussionWith TMD reported as frequent among qualified nurses these findings are relevant and pave the way for further investigation of temporomandibular-related symptoms in nursing students.ConclusionStrategies to mitigate students’ anxiety levels should be implemented throughout the nursing course.     

Has physical therapists’ management of musculoskeletal conditions improved over time?

BackgroundOur 2019 systematic review found that up to 63% of physical therapists provided recommended care for musculoskeletal conditions, up to 43% provided non-recommended care, and up to 81% provided care of unknown value. We included studies published as early as 1993 and as recent as 2017.ObjectiveTo determine whether physical therapists’ treatment choices for musculoskeletal conditions have improved over time.MethodsFor the original review, we included studies (until April 2018) that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes, and other methods (e.g. clinical observation). Using medians and interquartile ranges, we summarised the percentage of physical therapists who provided treatments that were recommended, not recommended, and of unknown value. For this analysis, we stratified the findings from the above systematic review by decade (1990–1999, 2000–2009, 2010–2018).ResultsThe median percentage of physical therapists who provided recommended treatments (40% from 1990 to 1999, 50% from 2000 to 2009, and 35% from 2010 to 2018) and non-recommended treatments (41%, 28%, and 39% respectively) has not changed over time. However, more physical therapists seem to be providing treatments of unknown value (41% from 1990 to 1999, 55% from 2000 to 2009, and 70% from 2010 to 2018).ConclusionPossible explanations for this trend include the growing need for clinical innovation, challenge of keeping up to date with evidence, increased exposure to treatments of unknown value, belief that evidence is not relevant to practice, and possible limitations of the data. Strategies to help physical therapists replace non-recommended care with recommended care are discussed.