Fernández-de-Las-Peñas César, Von Piekartz Harry
Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Alcorcón, 28922 Madrid, Spain.
Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, 28922 Madrid, Spain.
J Clin Med. 2020 Nov 17;9(11):3686. doi: 10.3390/jcm9113686.
The current narrative literature review aims to discuss clinical reasoning based on nociceptive pain mechanisms for determining the most appropriate assessment and therapeutic strategy and to identify/map the most updated scientific evidence in relation to physical therapy interventions for patients with temporomandibular disorders (TMDs). We will also propose an algorithm for clinical examination and treatment decisions and a pain model integrating current knowledge of pain neuroscience. The clinical examination of patients with TMDs should be based on nociceptive mechanisms and include the potential identification of the dominant, central, or peripheral sensitization driver. Additionally, the musculoskeletal drivers of these sensitization processes should be assessed with the aim of reproducing symptoms. Therapeutic strategies applied for managing TMDs can be grouped into tissue-based impairment treatments (bottom-up interventions) and strategies targeting the central nervous system (top-down interventions). Bottom-up strategies include joint-, soft tissue-, and nerve-targeting interventions, as well as needling therapies, whereas top-down strategies include exercises, grade motor imagery, and also pain neuroscience education. Evidence shows that the effectiveness of these interventions depends on the clinical reasoning applied, since not all strategies are equally effective for the different TMD subgroups. In fact, the presence or absence of a central sensitization driver could lead to different treatment outcomes. It seems that multimodal approaches are more effective and should be applied in patients with TMDs. The current paper also proposes a clinical decision algorithm integrating clinical diagnosis with nociceptive mechanisms for the application of the most appropriate treatment approach.
当前的叙述性文献综述旨在讨论基于伤害性疼痛机制的临床推理，以确定最合适的评估和治疗策略，并识别/梳理与颞下颌关节紊乱病（TMD）患者物理治疗干预相关的最新科学证据。我们还将提出一种用于临床检查和治疗决策的算法，以及一个整合当前疼痛神经科学知识的疼痛模型。TMD患者的临床检查应基于伤害性机制，包括潜在地识别主要的、中枢性或外周性敏化驱动因素。此外，应评估这些敏化过程的肌肉骨骼驱动因素，以再现症状。用于管理TMD的治疗策略可分为基于组织损伤的治疗（自下而上的干预）和针对中枢神经系统的策略（自上而下的干预）。自下而上的策略包括针对关节、软组织和神经的干预以及针刺疗法，而自上而下的策略包括运动疗法、分级运动想象，还有疼痛神经科学教育。证据表明，这些干预措施的有效性取决于所应用的临床推理，因为并非所有策略对不同的TMD亚组都同样有效。事实上，中枢敏化驱动因素的存在与否可能导致不同的治疗结果。似乎多模式方法更有效，应应用于TMD患者。本文还提出了一种临床决策算法，将临床诊断与伤害性机制相结合，以应用最合适的治疗方法。
