Background
Temporomandibular disorders (TMDs) are characterised by pain and restricted jaw mobility, often associated with comorbidities like neck or low back pain. Physical therapy, particularly manual therapy (MT), is widely used to address TMD symptoms, showing positive effects in reducing pain and improving joint mobility. However, past systematic reviews on physical therapy investigated combined approaches, limiting specific insights into individual MT effectiveness targeted to specific areas. Although MT generally includes different approaches in different body regions, the effectiveness of techniques targeted on specific regions (e.g., neck, trunk, TMJ) is essential information for manual therapists planning TMD treatments. To date, there has not been a systematic review investigating the effects on pain and TMJ range of motion following MT applied specifically to the craniomandibular structures (Cranio-Mandibular Manual Therapy (CMMT)).

Purpose
This systematic review aims to evaluate the effectiveness of CMMT on pain and TMJ range of motion in people with TMD.

Methods
This systematic review adhered to a pre-determined published protocol, registered with PROSPERO (CRD42019160213). A comprehensive search of databases, including MEDLINE, Embase, CINAHL, ZETOC, Web of Science, SCOPUS, PEDro, PubMed, Cochrane Library, Best Evidence, EBM reviews–Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature ChiroAccess, and Google Scholar, was conducted from inception until October 2020. Only randomized controlled trials comparing the effects of CMMT on pain and maximum mouth opening to other types of treatments for TMDs were included. Two independent reviewers screened articles, extracted data, assessed risk of bias using the revised Cochrane risk of bias tool for randomized trials, and evaluated the overall quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations.

Results
Among the 2720 records screened, only six studies (involving 293 participants) met the inclusion criteria. All included studies demonstrated a significant improvement in pain and maximum mouth opening after CMMT compared to baseline in the mid-term. However, only two studies indicated CMMT's superiority over other interventions. Several studies exhibited concerns regarding the risk of bias, with one study being deemed high risk. The overall quality of evidence was rated as very low for all outcomes due to high heterogeneity and small sample sizes. For the same reasons, a quantitative synthesis could not be performed.

Conclusion
The findings of this systematic review shed light on the potential benefits of CMMT for managing pain and improving maximum mouth opening in individuals with TMDs. However, the limited number of high-quality studies and the presence of heterogeneity highlight the need for further research to establish more robust evidence. Future research endeavors should prioritize large-scale, well-designed randomized controlled trials to enhance the evidence base and provide more conclusive recommendations for clinical practice. Moreover, exploring the long-term effects of CMMT on TMD outcomes would be crucial in optimizing treatment strategies and ensuring lasting benefits for patients.

Implications
Physiotherapists planning treatment of patients with TMD may consider CMMT, in addition to other treatment modalities, as one effective, low-cost, conservative option to manage pain and improve TMJ range of motion in the mid-term.

Background: Neck pain is one of the most common musculoskeletal disorders, with a prevalence rate (age-standardized) of 27.0 per 1000 population in 2019. Approximately 50%–85% of individuals with acute neck pain do not experience complete resolution of symptoms and some may go on to experience chronic pain. Manual therapy is a widely employed treatment approach for non-specific neck pain (NP), cervical radiculopathy (CR) and cervicogenic headaches (CGH). The existing body of evidence supporting manual therapies for individuals with neck disorders consists of an array of randomized clinical trials, systematic reviews and clinical practice guidelines. Purpose: The purpose of this umbrella review was to provide an updated synthesis of manual therapy (MT) interventions for individuals with cervical disorders. Methods:We followed the preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in Prospero (CRD42022327434). PubMed, CINAHL, and EMBASE databases were searched from August 2016 to May 2023 for systematic reviews with or without meta-analysis on manual therapy for individuals with NP. We included acute, subacute, and chronic stages of non-specific NP, CGH and CR. Interventions included any manual therapy of the cervical or thoracic spine and could include joint mobilization/manipulation or soft tissue mobilization. We also included neuromobilization/neurodynamics of the upper quarter. Outcomes included any measurement of pain, and/or disability/function. Two authors independently reviewed the title and abstract for eligibility. A third reviewer settled disagreements. The full-text screening was handled in the same manner. Two review authors independently extracted data from the included studies. Data were summarized as reported in the included studies. Discrepancies in data reporting were handled through discussion. Two reviewers independently assessed the methodological quality using the Assessment of Multiple Systematic Reviews (AMSTAR 2) tool. A third reviewer settled disagreements. Quality of evidence was rated with the Grading of Recommendations Assessment, Development and Evaluation approach. Results: A total of 41 systematic reviews containing 561 trials were included. Manual therapy + exercise (4 reviews), manual therapy broadly (8 reviews), cervical mobilization (6 reviews), cervical manipulation (10 reviews), thoracic spine mobilization/manipulation (2 reviews), neuromobilization (2 reviews), and other types of manual therapy (6 reviews) were supported as being effective in the management of pain and disability for individuals nonspecific neck pain, cervicogenic headache, or cervical radiculopathy. Two reviews had AMSTAR-2 quality ratings of low confidence, while all others were moderate to high quality. Conclusion(s): Manual therapy is recommended to decrease pain and disability in individuals with NP, CGH and CR in the short term. Implications: The results of this umbrella review will be utilized to inform an update to the 2017 Clinical Practice Guidelines for Neck Pain Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association.

Background: Concussions are prevalent in pediatric populations, often leading to post-concussion symptoms (PCS) including dizziness, one of the most reported PCS. Initial vestibular/ocular and neck-related impairments are known to be related to the future development of PCS. However, it is unclear if neck-related impairments are associated to vestibular/ocular impairments.
Purpose: This prospective cohort study aimed to identify recovery trajectories of vestibular/ocular impairments as measured by the Vestibular/Ocular Motor Screening (VOMS) assessment tool in pediatric concussion and assess baseline clinical markers including neck physical impairments findings that would predict trajectories.
Methods: Seventy-three children (8 to 17 yo) with a diagnosis of acute ( < 21 days) concussion were recruited. Participants took part in 3 evaluation sessions over 6 months (initial post-injury, 3-month, and 6-month). Sociodemographic data were recorded. All evaluation sessions included the primary outcome, the VOMS. Independent variables included symptom severity [Post-Concussion Symptoms Index (PCSI)], and quality of life [Pediatric Quality of Life Inventory (PedsQL)] as well as the flexion rotation test (FRT), neck pain, headache, global range of motion of the neck including pain at movement. A group-based multi-trajectory modelling analysis was performed. Each of the independent variables was compared between the trajectories.
Results: A Low Score on the VOMS (LSV) trajectory (n=53, 73%), and a High Score on the VOMS (HSV) trajectory (n=20, 27%) were identified. The PCSI (Odds Ratio (OR):82.91, 95% Confidence Interval (CI): 2.05 – –), neck pain at movement (OR:7.73, 95%CI: 2.01 – 29.75), positive FRT (OR: 5.11, 95%CI: 1.37 – 19.06), and having at least one cervical findings (OR:7.98, 95%CI: 0.93 – 68.29) were the strongest predictors of belonging to the HSV group (P < 0.05).
Conclusions: Following a concussion, 27% of children had a HSV trajectory over a 6-month period with general symptoms intensity, and cervical findings including pain at movement, and the FRT being the strongest predictors. Having at least one cervical finding was also a strong predictor of having a high score on the VOMS. Further research is needed to refine predictions and enhance personalized treatment strategies for pediatric concussions.
Implications: The study's implications for clinical practice in managing pediatric concussions and PCS highlight the importance of early identification and assessment of the vestibular/ocular impairments using tools like the VOMS. The study underlines the significance of incorporating neck evaluations in concussion assessments, given the strong link between neck impairments and vestibular/ocular impairments. Tailoring treatment plans to individual recovery trajectories, with a particular focus on evaluation of the neck and vestibular/ocular impairment, is recommended. The study also calls for further research to validate findings and explore additional factors affecting recovery trajectories. By implementing these recommendations, healthcare providers can enhance the management of pediatric concussions, particularly regarding vestibular/ocular and neck impairments, to improve patient outcomes.

Background:
Impaired balance and dizziness have been reported in migraine and causes of these may be central vestibular or cervicogenic. Neck pain is common in migraine and cervical musculoskeletal dysfunction has been identified in some individuals with migraine. However, it is unknown if balance performance is associated with dizziness, neck pain, and presence of cervical musculoskeletal dysfunction. Identifying any associations may help elucidate underlying mechanisms of impaired balance to direct management.

Purpose:
To identify i) impaired balance in participants with migraine as compared to pain-free participants, and ii) any associations between impaired balance and frequency of dizziness during migraine attacks, neck pain features, and presence of cervical musculoskeletal dysfunction.

Methods:
This is a secondary analysis of a previous study investigating cervical musculoskeletal dysfunction which identified dysfunction akin to mechanical neck pain in 39% of individuals with migraine. This present study included unpublished data on balance performance in pain-free participants (n=32) and participants with migraine (n=110 with, n=14 without neck pain). Balance in comfortable stance with eyes closed was measured by total root mean square (rms) amplitude of centre of pressure displacement. Neck pain intensity, frequency, history and disability (Neck Disability Index), as well as frequency of dizziness during migraine attacks, were surveyed. Frequency of dizziness during migraine attacks was rated by participants as “never”, “sometimes”, “often” or “always”. Balance was categorised as impaired when values exceeded the upper limit of 95% confidence intervals of total rms amplitude in pain-free participants. Associations between presence of impaired balance and frequency of dizziness, presence of cervical musculoskeletal dysfunction and neck pain features were individually explored using logistic regression with age and height as covariates.

Results:
Neck pain was reported in 89% of migraine participants, the majority (75%) of whom experienced neck pain at least weekly, for a duration of 10 years (median) interquartile range (IQR) [14], with average neck pain intensity of 4/10 (median) IQR[3/10], and Neck Disability Index Score of 24% (median) IQR[17]. The majority (44%) did not experience dizziness during migraine attacks, but dizziness “always” accompanied attacks in 9% of participants with migraine. Impaired balance was identified in 42% of participants with migraine and was not significantly associated with frequency of dizziness, presence of cervical musculoskeletal dysfunction nor any neck pain features (all p>0.05).

Conclusions:
Not all individuals with migraine in this study had impaired standing balance. Balance performance does not necessarily relate to dizziness, cervical musculoskeletal dysfunction or neck pain. Therefore, causes of impaired balance may be different within individuals. Findings may be different in the subgroups poorly represented in this study such as those with vestibular migraine.

Implications:
Specific assessments are needed to identify individuals with migraine who require intervention to improve balance. Clinicians should look beyond neck pain and cervicogenic proprioceptive dizziness as the potential cause to also consider central mechanisms when assessing for and addressing balance impairments in migraine.

Background
Neck pain is common in tension type headache (TTH). However, the origin of this neck pain is still ambiguous. Neck pain may be associated with cervical musculoskeletal (MSK) impairments and individual cervical MSK impairments have been demonstrated in TTH. However isolated impairments may not reflect a true cervical MSK disorder which typically presents with patterns or multiple cervical MSK impairments as demonstrated in patients with neck pain. Alternatively, neck pain may be a feature of pain hypersensitivity. Further study is needed to delineate the origin of neck pain in TTH to further inform clinical reasoning in the differential diagnosis of neck pain accompanying TTH.

Purpose
This study aimed to determine i) whether patterns of cervical MSK impairments are present in individuals with TTH which align with mechanical neck pain and, ii) the relationship between pain hypersensitivity and the presence or absence or frequency of MSK impairments.

Methods
This is a single-blind cross-sectional study. Participants included individuals with TTH (n=22), neck pain (n=11) and pain-free controls (n=16). Tests of pressure pain threshold (PPT), cold pain threshold (CPT) and temporal summation (wind-up ratio, WUR) were performed at the cervical spine to assess pain hypersensitivity. Assessments of cervical musculoskeletal impairments included range of motion (ROM), movement velocity and accuracy, joint position sense error (JPE), manual segmental examination, and neck flexor and extensor endurance. Shapiro-Wilk test was used to determine normality of data. Cluster analysis was used to determine how participants grouped based on cervical MSK impairments across all measures. Nonparametric tests were used to illustrate differences in cervical MSK impairments and pain hypersensitivity between clusters.

Results
Two clusters were found. Cluster 1 (n=33) included all pain-free controls and was characterised by no or isolated cervical MSK impairments. Cluster 2 (n=16) included the majority of individuals with mechanical neck pain and was characterised by multiple impairments across all measures. Participants with TTH (64%) were allocated to cluster 1 and 36% were in cluster 2. Participants in cluster 1 demonstrated greater cervical ROM in extension and right rotation (p < 0.05) and better neck extensor endurance (p < 0.001) than participants in cluster 2. Participants in cluster 1 had fewer positive cervical joint signs (p < 0.001) than in cluster 2. WUR was higher in participants of cluster 1 (p < 0.05) but PPT and CPT measures were similar between clusters.

Conclusions
The majority of participants with TTH had normal cervical function, however 36% presented with a collection of cervical MSK impairments across multiple measures that supports a cervical origin/contribution to neck pain. Higher WUR may reflect pain hypersensitivity underlying neck pain in participants with normal cervical function.

Implications
These findings demonstrate heterogeneity in neck pain mechanisms in TTH. A MSK cause/contributor to the neck pain can be confirmed by a group of cervical MSK impairments. Neck pain may also reflect pain hypersensitivity associated with headache. Local treatment to the cervical spine may not be indicated for all TTH with the complaint of neck pain.

Background: Temporomandibular disorders (TMD) are a group of conditions affecting the stomatognathic system, in addition, TMD is also commonly associated with other symptoms affecting the head and neck. Different neck exercises, especially endurance training of the deep neck muscles, have been used to reduce pain and improve neck motor control in patients with neck pain-related disorders, cervicogenic headaches, and whiplash, among others. However, to our knowledge, none of the previous studies have evaluated in isolation the effectiveness of motor control exercises or manual therapy targeted to neck muscles in improving pain, orofacial function, and quality of life in patients with TMD.
Purpose: To test the effectiveness of an 8-week exercise program targeted to the neck muscles compared to manual therapy, and placebo treatments on orofacial pain intensity, jaw function, and oral health-related quality of life (OHRQoL), and in women with TMD.
Methods: In this RCT, fifty-four women (between 18-45 years old) with a diagnosis of myofascial or mixed TMD according to the Research Diagnostic Criteria for TMD (RDC/TMD) were randomized into three groups: Neck motor control training (NTG), Manual Therapy Group (MTG), and Placebo Group (PG). All patients were evaluated with the Visual Analog Scale, Mandibular Function Impairment Questionnaire, and Oral Health Impact Profile – 14 at baseline, immediately after treatment (after 8 weeks of treatment), one month, and three-month follow-up. For all outcomes, a mixed ANOVA with repeated measures was conducted with a Bonferroni post hoc test, following the intention-to-treat (ITT) principles with imputation of missing data.
Results: NTG was significantly better than the PG group on pain and jaw function at the end of the treatment (Effect Size (ES) 0.9 [95%CI= 0.2, 1.6]), one-month follow-up (ES 0.8 [95%CI= 0.1, 1.5]) and three-months follow-up (ES 0.7 [95%CI= 0.1, 1.4]). For jaw function, NTG presented better results than PG at the end of treatment, one-month follow-up, and three-months follow-up with a large ES (>0.8). And between NTG and MTG after three-months follow-up (ES 1 [95%CI= 0.3, 1.7]), favoring the NTG group. No difference was verified between MTG and PG. For OHRQoL, NTG was significantly better than MTG and PG at the end of treatment, one-month, and three-month follow-up, with a large ES (>0.7). None of the participants received any co-intervention and did not report any type of adverse event. On average the patients attended 95.8%, 88.2%, and 91% of the sessions, in the NTG, MTG, and PG respectively.
Conclusion(s): The results of this project are encouraging, and they could be used to guide clinical practice in this field. Exercises targeted to the neck (which require low therapeutic supervision) could be a simple and conservative way to improve pain and disability for women with TMD with neck involvement.
Implications: To our knowledge, this is the first study that tested a specific neck motor control exercise protocol alone in a group of patients with TMD. This study showed that exercises directed to the neck (which requires low therapeutic supervision) could be useful in the management of patients with chronic TMD.

Background: Migraine is a common disabling primary headache disorder with high prevalence and enormous personal and socio-economic impacts.
Recent advancements in pharmacotherapy have enabled successful treatment and shown a reduction of the burden of migraine. Nonetheless, a (substantial) proportion of individuals experience migraine that is unmanageable by pharmacological treatments alone. Current non-pharmacological treatments for migraine include biobehavioural therapy, physiotherapy, aerobic exercise, acupuncture, and educational interventions. A combination of medication and behavioural therapies is considered the best treatment for migraine attacks and/or prevention of attacks.

Purpose: The concept of multidisciplinary headache therapy in outpatient settings has not yet been well established in Switzerland. Therefore, this study aimed to assess the effects of the Headache Management Program, as developed at Inselspital, Bern University Hospital, on people suffering from migraine.

Methods: This was an open-label, single-arm interventional study designed to assess the effectiveness of the Headache Management Program at Inselspital, Bern University Hospital, on patient reported outcomes in people with migraine. Participants were aged 18 years or older and seen in the outpatient headache centre before the start of the program. Diagnosis was made by a headache specialist according to the International Classification of Headache Disorders 3. Participants followed a program consisting of seven lectures once a week. The primary outcome was headache-related quality of life measured by Headache Impact Test 6 (HIT-6) and Migraine Disability Assessment (MIDAS). Descriptive statistics were mean, median and standard deviation. Data before and after the program were compared using paired t test and Wilcoxon signed rank test as appropriate.

Results: There was significant improvement in HIT-6 (p= .012 d= 0.62, paired t test) from before to after the program and scores decreased by 3.3 points, 95% CI [0.14, 1.10]. Similarly, median MIDAS post-program (Mdn= 27) was significantly lower than the median (Mdn= 38) pre-program (z= -2.53, p= .011, r= 0.40, Wilcoxon signed rank test).

Conclusion(s): This study suggests that the Headache Management Program has clinically significant patient reported outcomes and would be a good addition to standard headache care. Avenues for further research should include a randomised controlled trial with a bigger heterogenic sample size and control groups.

Implications: So far, the physiotherapists involved in the program only perform progressive muscle relaxation (PMR) at the beginning of the lectures. However, in future groups, they could also be involved in the physical activity lecture and/or design an additional lecture in which they guide program participants on exercises they can do at home or at work. This could include mobility and stretching exercises. If this goes well, a further step could be to offer a course for physiotherapists in private practice and introduce them to the program so that they can implement their own program in their own work environment. This should be tailored to physiotherapy issues related to migraine and also include basic information on drug treatment in consultation with the medical profession.

Background
Further than headache, patients with migraine frequently present musculoskeletal comorbidities. To the best of our knowledge, assessment of musculoskeletal alterations in migraine rarely stratifies patients according to neck dysfunction, verified through manual palpation of the upper cervical spine.
Purpose
We aimed to investigate the cervical joint position sense (JPS) and the neck muscle endurance among migraineurs and controls following stratification according to pain response during manual palpation of the upper cervical spine.
Methods
Thirty-two headache-free subjects and 57 migraine patients were included. The sample was stratified according to the presence of pain during the manual palpation of the upper cervical spine as follows: no neck pain (P0, n=23), local neck pain (P1, n=37) and pain referred to the head (P2, n=29). Demographic data, headache features and neck disability (NDI) were collected. All subjects were performed the JPS test after active extension, right and left rotation. The mean error (cm) between the initial and final position of three trials was considered. They also underwent the muscle endurance test of the neck flexors and extensors and the time in seconds of three trials was recorded. The test order was randomized, and data was analyzed using MANOVA tests with diagnosis and neck dysfunction as independent variables, on SPSS version 26.0 with α=5%.
Results
Eleven migraine patients were stratified in the P0 group (mean age 37.3, SD 14.3), 21 in the P1 group (mean age 34.8, SD 13.5) and 25 in the P2 group (mean age 33.1, SD 14.1). A significant effect of neck dysfunction for the joint position sense error after maximum extension was found (P0 versus P2 mean difference=1.93 cm, F2=4.85, p=0.008). No diagnosis effect was verified for all movement directions (p > 0.39), and no neck dysfunction effect was verified for the remaining right (p > 0.83) and left (p > 0.46) directions. For the muscle endurance test, a significant effect was found for diagnosis (migraine vs no migraine) and neck dysfunction. Compared to migraineurs, controls exhibited greater muscle endurance of neck flexors (mean difference 15 sec, F1=10.54, p=0.001) and extensors (mean difference 48 sec, F1=4.93, p=0.02). According to the stratification, subjects of the P0 group exhibited greater muscle endurance compared to P1 for neck flexors (mean difference 27 sec, F2=16.21, p < 0.001) and extensors (mean difference 46 sec, F2=3.20, p=0.04). The P0 group also was different from the P2 group regarding flexion (mean difference 29 sec, F2=16.21, p < 0.001) and extension (mean difference 68.4 sec, F2=3.20, p=0.04) endurance. No differences between P1 and P2 groups were found.
Conclusions
The presence of neck pain referred to the head is related to a greater joint position sense error for neck extension. The presence of migraine and/or any neck dysfunction is related to reduced endurance of neck flexor and extensor muscles.
Implications
Since the presence of neck pain delays migraine treatment and it is related to migraine chronification, the identification of differences among patients’ presentation is out of importance due its potential influence on the assessment, treatment plan and prognosis.