Disfunção temporomandibular e sintomas otológicos: efeitos e relevância clínica da terapia manual e de exercícios terapêuticos

Abstract

Background: Temporomandibular disorder (TMD) is a complex musculoskeletal condition often causes orofacial pain, functional limitations, and otological symptoms. Specific cervical exercises and manual therapy are widely used strategies for managing TMD-related symptoms; however, their effects on otologic symptoms remain unclear. Aerobic exercise, despite its therapeutic potential for musculoskeletal pain, is still underexplored in this population. Objectives: This thesis investigated the effectiveness and clinical relevance of physiotherapy interventions involving manual therapy and specific cervical exercises, alone or in combination with aerobic training, on orofacial pain, neck disability, and otological symptoms in women with chronic TMD. The specific aims were: (1) to analyze the effectiveness of manual therapy and therapeutic exercises on otologic symptoms in individuals with TMD through a systematic review (Article 1); (2) to evaluate the additional effects of aerobic training to cervical exercises on orofacial pain, neck disability, and related outcomes in a randomized controlled trial (Article 2); (3) to assess whether otological symptoms secondary to TMD improve after isolated cervical exercises or combined with aerobic training (Article 3); and (4) to determine the clinical relevance of the effects of these interventions using distribution- and anchor-based methods, with a focus on the minimal important difference (MID) (Article 4). Methods: The thesis comprised a systematic review and a randomized controlled trial. The systematic review included studies that evaluated the effects of manual therapy and exercises on otological symptoms in individuals with TMD, with certainty of evidence assessed using the GRADE approach. The randomized controlled trial enrolled 58 women with chronic TMD, allocated to two groups: (1) cervical exercises (strengthening and stretching of flexors, extensors, and rotators, and spinal mobility) and (2) cervical exercises combined with aerobic treadmill training. The intervention lasted eight weeks, with two sessions per week. Outcomes included orofacial pain, neck disability, otological symptoms, mandibular function, oral health-related quality of life, self-efficacy, and pressure pain thresholds of masticatory and cervical muscles. Statistical analyses included repeated-measures models, multilevel modeling (MLM), and estimation of the MID using distribution- and anchor-based methods. Results: The systematic review found that combining exercises with manual therapy may improve otological symptoms in individuals with TMD, but the certainty of evidence was low. In the clinical trial, no statistically significant differences were found between groups. However, both groups showed significant within-group improvements in pain, neck disability, otological symptoms, mandibular function, quality of life, and self-efficacy. Effect sizes were generally larger in the group that combined cervical and aerobic exercises. Otological symptoms significantly decreased in both groups, with clinically relevant reductions, particularly for tinnitus, earache, and ear fullness. Clinical relevance analysis showed that between-group differences did not reach the MID thresholds, whereas within-group effects were moderate to large. MID values ranged from 17.05 to 31.56 mm for pain intensity, and from 1.04 to 3.41 points for neck disability. Conclusion: Combining exercises with manual therapy may improve otological symptoms in individuals with TMD, though the certainty of evidence remains low. Adding aerobic training to specific cervical exercises did not yield additional benefits in reducing orofacial pain or otological symptoms in women with TMD. This thesis provides evidence on the effectiveness of these interventions and offers clinically relevant parameters to support evidence-based practice and patient-centered decision-making.