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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 3  |  Issue : 2  |  Page : 107-111

Immediate effect of mulligan's mobilization with movement on forward head posture and postural sway in temporomandibular joint dysfunction: An experimental study


Department of Orthopedic Manual Therapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission16-Jul-2019
Date of Decision02-Nov-2021
Date of Acceptance11-Nov-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Dr. Anand Heggannavar
Departmnet of Orthopaedic Manual Therapy, KAHER Institute of Physiotherapy, Belagavi, Karntaka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_57_19

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  Abstract 


Context: Temporomandibular joint dysfunction (TMJD) is defined as orofacial disorders including pain, clicking in the temporomandibular joint (TMJ), fatigue of the masticatory muscles, and limitation of mandibular movements. TMJD is responsible for forward head posture (FHP) and postural sway leading to neck pain, headache, and absenteeism from work affecting their quality of life. Management of the dysfunction can alleviate pain and improve work efficiency.
Aim: The aim of this study is to evaluate the immediate effect of Mulligan's mobilization with movement (MWM) on numeric pain rating scale (NPRS), maximum mouth opening (MMO), FHP, and postural sway in participants with TMJD.
Settings and Design: Pre-and postexperimental study conducted in tertiary care hospital in Belagavi, Karnataka, India.
Methodology: Of 59 screened, 39 participants between the age group of 20–40 years of both genders were screened based on the scores obtained from Fonseca's Questionnaire and those eligible were recruited. One session of TMJ MWM was administered and outcome measures were assessed preintervention and immediately postintervention using NPRS, MMO, postural sway, and craniovertebral angle.
Statistical Analysis Used: Wilcoxon matched-pairs test and paired t-test were used for pre-and posttest scores of variable.
Results: After data analysis, the severity of pain, MMO, postural sway, and FHP showed significant improvement postintervention (P < 0.0001).
Conclusion: One session of MWM for TMJ was effective in alleviating pain, improving mouth opening, postural sway, and FHP immediately posttreatment in participants with TMJD.

Keywords: Forward head posture, Maximum mouth opening, Numeric pain rating scale, Postural sway, Temporomandibular dysfunction


How to cite this article:
Sawant R, Heggannavar A, Metgud S, D'Silva P. Immediate effect of mulligan's mobilization with movement on forward head posture and postural sway in temporomandibular joint dysfunction: An experimental study. Indian J Phys Ther Res 2021;3:107-11

How to cite this URL:
Sawant R, Heggannavar A, Metgud S, D'Silva P. Immediate effect of mulligan's mobilization with movement on forward head posture and postural sway in temporomandibular joint dysfunction: An experimental study. Indian J Phys Ther Res [serial online] 2021 [cited 2022 Jul 5];3:107-11. Available from: https://www.ijptr.org/text.asp?2021/3/2/107/335668




  Introduction Top


Temporomandibular joint dysfunction (TMJD) is a term used to characterize orofacial disorders that include a painful temporomandibular joint (TMJ), clicking on joint movements, masticatory muscle fatigue, and mandibular movement limitation.[1] Temporomandibular disorder (TMD) is defined by the American Association of Orofacial Pain as a term that encompasses a variety of issues involving the masticatory muscles, the TMJ itself, and its immediate surroundings, or both.[2] According to a study on the prevalence of TMD in the Chennai population, 53.7% of the population has at least one clinical sign and symptom of TMD, with 42.1% having mandibular deviation on mouth opening and 38.6% having a clicking sound.[3]

TMD was linked to neck pain and postural abnormalities, leading to the conclusion that TMJ problem is caused by a change in posture in the cervical area, which affects the stomatognathic system.[4] The forward head posture (FHP) is caused by a lack of strength in the cervical flexor muscles, resulting in sternocleidomastoid muscular tightness. Abnormalities in the structures of the upper quarter of the body can lead to the development of TMD. Poor cervical posture has been shown to alter mandibular position and the functions of the stomatognathic system in earlier studies. Due to the inefficient use of the muscles of the stomatognathic system, they undergo strain and spasm. Hence, the muscular connections between the head, neck, and jaw lead to the development of TMJ dysfunction.[5]

The Research Diagnostic Criteria (RDC) for TMDs have given criteria for the investigation of TMD. The symptoms of TMD include painful TMJ and muscles of mastication, in which the pain can radiate and refer, locking (inability to open fully and dislocation), clicking/crepitus during the jaw movements, headache, tightness around the face in the morning, and referred pain to the ear.[3]

Manual therapy procedures have been shown to be equally successful in treating the symptoms of TMJ dysfunction. A systematic review was conducted to see the efficiency of manual approach in curing TMD. In this review, it was found that musculoskeletal manipulative approaches are feasible in treating TMD. Furthermore, the results showed that manual approaches are more effective in curing TMD in contrast to conservative treatment.[6]

The study reveals the relationship between TMD and associated FHP and postural sway.[5] Studies have been done to see the effect of Mulligan's mobilization with movement (MWM) on TMD in relation to pain and maximum mouth opening (MMO).[6] However, there is a lacuna in literature where MWM is used to treat FHP and postural sway associated with TMD. Hence, this study aims to evaluate the immediate effect of MWM on FHP and postural sway in TMD.


  Subjects and Methods Top


This pre-and post-experimental study was conducted in a Tertiary care Hospital, on patients with TMJD of Belagavi, Karnataka, India, from April 2018 to March 2019. The study was approved by the Institutional Research and Ethics Committee (KIPT/182/14/05/18). Written informed consent was obtained from all the participants. The trial was registered under the clinical trial registry of India with trial number CTRI/2018/08/015196.

Participants with TMJ dysfunction, FHP (craniovertebral angle less than 53°) and postural sway in the age group of 20–40 years, a mouth opening of less than 39 mm for males and 36mm for females, a click, and at least a score of 5 of 10 on numeric pain rating scale (NPRS) during TMJ movements, and 45–100 points on Fonseca's questionnaire were included in the study. Bell's palsy, trigeminal neuralgia, wearing any form of dental prosthesis, having any neurological disorder that affects balance, having had any form of surgery in or around, patients with oral cancer and TMJ discomfort who were undergoing chemotherapy, as well as those with a history of trauma or fracture in and around the TMJ were excluded from the study.

A total of 59 individuals were screened for participation. Twenty participants were eliminated because they did not meet the inclusion requirements [Figure 1]. The study involved a total of 39 participants. The participants were informed about the trial and were offered treatment after obtaining the informed consent. Pretreatment assessment of all outcome measures was done.
Figure 1: CONSORT flow diagram

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The severity of pain was assessed by NPRS.[7] MMO was measured by a ruler, as the distance between the upper and lower incisors, when the mouth is opened as wide as possible painlessly.[8],[9]

The Libra Balance Board (Easytech, Italy) was used to measure postural sway. For one minute, the participant was asked to stand on the libra balance board with his eyes open. The participant was made to stand on the board facing the computer screen for medial-lateral and anterior-posterior sway. The board was rotated for anterior-posterior sway, so that the pivot could shift the board anteriorly and posteriorly. The participant received visual input in the form of a graph on the computer screen. The participant was instructed to keep his or her equilibrium between the graphs. For medial-lateral sway, values of the right and left sway were noted down.[10]

Forward head position was measured from photographs taken with a plumb line drawn from the ceiling to the lateral malleolus of the ankle and with a horizontal plane that was perpendicular to the plumb line and that passed through the spinous process of the seventh cervical vertebra. The distances from the plumb line to the ear, to the seventh vertebra, and to the shoulder were measured. Two angles were also measured: (1) ear-seventh cervical vertebra-horizontal plane and (2) eye-ear-seventh cervical vertebra.[11]

TMJ MWM was administered by a certified therapist in the following way. The therapist stood behind the seated patient, placing their palms on both sides of the patient's head, with the thumbs over the zygomatic arches, to stabilize the head. The index fingers were placed parallel and immediately anterior to the posterior border of the mandible, passing over the TMJ. The third and fourth fingers of each hand were positioned behind the posterior border of the ramus of the mandible, just above the mandibular angle. This hand placement allowed the therapist to apply transverse force across the mandible as necessary, while at the same time allowing an anterior-inferior gliding force to the mandible on the side of restriction, while also controlling the unrestricted side inhibiting any excessive mandibular forward gliding with the other hand. The combination of these manual forces allowed the mandible to maintain a midline position during mouth opening and enabling a larger range of jaw motion. The therapist could select one or several different glide directions, depending on offending or the painful movement. In case of a pain-free movement, the glide was performed three times with 6–8 repetitions. The patient applied the overpressure with his fingers on the chin when the patient opened the mouth, supporting the force for 3 s[12] [Figure 2]. TMJ MWM dosage included 3 sets of 6–8 repetitions immediately, after which the outcome measures were recorded (posttreatment).
Figure 2: Mulligan's mobilization with movement

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The Statistical package for the social sciences version 21 (SPSS for windows Armonk NY: IBGM Corp, USA) was used for statistical analysis of the study. Normality test for was done by Kolmogorov–Smirnov test. For all outcome variables of the study, to compare the pre-and posttest scores, Wilcoxon matched-pairs test/paired t-test were used.

The therapist stood behind the seated patient, placing their palms on both sides of the patient's head, with the thumbs over the zygomatic arches, to stabilize the head. The index fingers were placed parallel and immediately anterior to the posterior border of the mandible, passing over the TMJ. The third and fourth fingers of each hand were positioned behind the posterior border of the ramus of the mandible, just above the mandibular angle. This hand placement allowed the therapist to apply transverse force across the mandible as necessary, while at the same time allowing an anterior-inferior gliding force to the mandible on the side of restriction, while also controlling the unrestricted side, inhibiting any excessive mandibular forward gliding with the other hand shown in [Figure 1]. The combination of these manual forces allowed the mandible to maintain a midline position. The therapist stood behind the seated patient, placing their palms on both sides of the patient's head, with the thumbs over the zygomatic arches, to stabilize the head. The index fingers were placed parallel and immediately anterior to the posterior border of the mandible, passing over the TMJ. The third and fourth fingers of each hand were positioned behind the posterior border of the ramus of the mandible, just above the mandibular angle. This hand placement allowed the therapist to apply transverse force across the mandible as necessary, while at the same time allowing an anterior-inferior gliding force to the mandible on the side of restriction, while also controlling the unrestricted side, inhibiting any excessive mandibular forward gliding with the other hand shown in [Figure 1]. The combination of these manual forces allowed the mandible to maintain a midline position.


  Results Top


Thirty-nine participants were recruited in the study, 12 were males and 27 were females accounting to 30.77% of males and 69.23% of females in the study. The mean age of the participant was 27.97 ± 6.41 years, having the mean height of 156 ± 6.66 cms while mean weight was 53.82 ± 8.22 kg, and body mass index was 22.00 ± 2.40 kg/m2 [Table 1].
Table 1: Demographic data of all participants in the study

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The mean difference of NPRS sand MMO score was 1.77 ± 0.77 cm and 2.70 ± 1.26 cms with a P < 0.0001, respectively, which is highly significant. Ear-vertical plumb line length and shoulder-vertical plumb line length mean difference scores were 0.23 ± 0.05 cm and 0.21 ± 0.08 cm, respectively, with a P < 0.0001 significance [Table 2].
Table 2: Comparison of pretest and posttest values of Numeric Pain Rating Scale, maximum mouth opening scores, ear-vertical plumb line, and shoulder-vertical plumb line lengths

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The mean difference in medial-lateral sway and anterior-posterior sway was 12.07 ± 3.71 deg and 12.27 ± 2.15 deg, respectively, having statistical significance with a P < 0.0001 while the mean angle difference between eye-ear-C7 and ear-C7-horizontal plumb line was 1.73 ± 1.05 deg and 2.77 ± 0.90 deg, respectively, which is highly significant with a P < 0.0001. [Table 3].
Table 3: Comparison of pretest and posttest medial-lateral, anterior-posterior sway scores, eye-ear-C7, and ear-C7-horizontal plumb line angle

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  Discussion Top


The purpose of this study was to assess the immediate effect of MWM on forward head position and postural sway in persons with TMJD. Thirty-nine patients were administered MWM directed at the TMJ. The results confirmed the alternative hypothesis that there will be a change in the immediate effect of MWM on postural sway and forward head position in TMD.

A prospective case series using mobilization with movement, thoracic thrust, and dry needling for the treatment of TMD revealed improvements in pain, dysfunction, and range of motion of the mouth. MWM's mechanism of action is the correction of a flaw in the joint position with the MWM glide.[12] TMJ articular disc displacement can occur in either direction; however, it most usually occurs anteriorly during mouth opening. The rectification of this positional problem at the joint might be the cause of this pain reduction.[13]

There was a considerable improvement in the individuals' maximal mouth opening. This is because of motor control regulation. Information from the muscle spindle is essential to maintain the normal posture of the mandible and movements. To summarize, neurons in the brainstem must work to assist maintain the posture of the jaw and the muscular actions. During normal jaw movements, there is a strong link between the temporomandibular and craniocervical motor systems, as well as the brainstem, subcortical, and cortical centers.[14]

Postural control is related to trigeminal nerve impulses to the CNS, which rely on information from the organ with stomatognathic complex nerve ends. TMD is responsible for changes in muscle activity and the positioning of stomatognathic system components. As a result, the information given for postural control is muddled. As a result, the information given for postural control is interfered with. As a consequence of the masticatory muscles' composure during MWM and the alignment of joint structures, postural sway improves.[4]

The mandibular rest position is affected by the posture of the head and neck. In summary, improving the condylar fossa connection in the TMJ improves head posture in relation to the body. In increased cervical lordosis, the cranium is present in front of the  Atlas More Details, and the maxilla shifts forward relative to the mandible. The increased depth in the posterior joint space as a result of improved condyle fossa connection may result in an improvement in forward head position.[15]

Limitation of the study includes the postural sway due to malaise or any other problems of the stomatognathic system were not excluded, and the participants were not followed up to understand carryover the effect of MWM. A prospective research can be carried out to investigate the long-term benefits of the current study.


  Conclusion Top


A single session of MWM for TMJ was effective in improving pain, MMO, postural sway, and FHP in participants with TMD.

Acknowledgment

We are grateful to the Head of the institution for granting us permission to conduct the study and use the research-related infrastructure. We are thankful to all the individuals for participating in the study, without whom the study would not have been possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Muthukrishnan A, Sekar GS. Prevalence of temporomandibular disorders in Chennai population. J Indian Acad Oral Med Radiol 2015;27:508.  Back to cited text no. 3
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Amaral AP, Politti F, Hage YE, Arruda EE, Amorin CF, Biasotto-Gonzalez DA. Immediate effect of nonspecific mandibular mobilization on postural control in subjects with temporomandibular disorder: A single-blind, randomized, controlled clinical trial. Braz J Phys Ther 2013;17:121-7.  Back to cited text no. 4
    
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Evcik D, Aksoy O. Correlation of temporomandibular joint pathologies, neck pain and postural differences. J Phys Ther Sci 2000;12:97-100.  Back to cited text no. 5
    
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Martins WR, Blasczyk JC, Aparecida Furlan de Oliveira M, Lagôa Gonçalves KF, Bonini-Rocha AC, Dugailly PM, et al. Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis. Man Ther 2016;21:10-7.  Back to cited text no. 6
    
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Bijur PE, Latimer CT, Gallagher EJ. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad Emerg Med 2003;10:390-2.  Back to cited text no. 7
    
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Zawawi KH, Al-Badawi EA, Lobo SL, Melis M, Mehta NR. An index for the measurement of normal maximum mouth opening. J Can Dent Assoc 2003;69:737-41.  Back to cited text no. 8
    
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Walker N, Bohannon RW, Cameron D. Discriminant validity of temporomandibular joint range of motion measurements obtained with a ruler. J Orthop Sports Phys Ther 2000;30:484-92.  Back to cited text no. 9
    
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Liston RA, Brouwer BJ. Reliability and validity of measures obtained from stroke patients using the Balance Master. Arch Phys Med Rehabil 1996;77:425-30.  Back to cited text no. 10
    
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Lee WY, Okeson JP, Lindroth J. The relationship between forward head posture and temporomandibular disorders. J Orofac Pain 1995;9:161-7.  Back to cited text no. 11
    
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González-Iglesias J, Cleland JA, Neto F, Hall T, Fernández-de-las-Peñas C. Mobilization with movement, thoracic spine manipulation, and dry needling for the management of temporomandibular disorder: A prospective case series. Physiother Theory Pract 2013;29:586-95.  Back to cited text no. 12
    
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Vicenzino B, Paungmali A, Teys P. Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature. Man Ther 2007;12:98-108.  Back to cited text no. 13
    
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Calixtre LB, Moreira RF, Franchini GH, Alburquerque-Sendín F, Oliveira AB. 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 2015;42:847-61.  Back to cited text no. 14
    
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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