Getting to Know CRAFTA®
Over the years, physiotherapists, manual therapists, speech therapists, and dentists have shown an increasing clinical interest in the temporomandibular and craniofacial region.
CRAFTA® takes a unique approach to the craniocervical-facial region. First, the view of a CRAFTA® therapist is not limited to the TMJ. Regions that are all considered as potential causes of the head, face, or neck dysfunctions include:
Using a sound clinical reasoning process, a CRAFTA® therapist assesses all areas to form a complete well-informed treatment plan for the patient. Decisions are based on the best available evidence wherever possible. Modern pain mechanism models are integrated into the management. Management consists of a functional and very active rehabilitation approach, as the patient should be empowered as much as possible to take control of their situation – self-efficacy is the key.
A substantial part of the work is seeking the support of an interdisciplinary team when needed. Close cooperation with dentists, orthodontists, maxillo-facial surgeons, medical doctors of different disciplines (e.g., orthopedic specialists, ENTs), speech and language therapists, and many others is crucial to optimal patient treatment.
It is essential to point out that a patient’s age may range from a newborn to advanced in years. Patients often present:
- TMJ pain or dysfunctions
- Facial pain
- Neck pain
- Myofunctional dysfunctions
- Breathing difficulties
- Post-concussion symptoms
- Ongoing orthodontic treatment
- Shoulder dysfunctions
- The need for post-surgical treatment
- Post-cancer treatment
A Structured Subjective and Physical Examination Is the Key
During a thorough examination, a CRAFTA® therapist gains a deep insight into the four following regions:
1. Temporomandibular Region
There is increasing evidence supporting specialized physical therapy for TMD. There has been a 70% increase in RCT and systematic reviews supporting physical therapy as a profession, specializing in treating TMD in the last ten years. Most studies are still based on a recipe treatment. Because of the complexity of TMD and the often associated comorbidities, a CRAFTA® specialized therapist intends to treat and manage the patient on an individual level using the best available clinical and external evidence.
Some references which support this:
- Systematic review and meta-analysis from Harrera-Valencia (2020)
- Systematic review and meta-analysis from Armijo-Olivo et al. (2016)
- Systematic review and meta-analysis from Dickerson et al. (2017)
- Systematic review and meta-analysis from La Touche et al. (2018)
- Headaches and TMD; Conti et al. (2016)
- Cross-sectional study, von Piekartz et al (2016)
2. Craniofacial Region
In the CRAFTA® education program, cranial manual therapy means assessing and treating the cranium (head) and the face with passive movements (movements executed by the therapist), as these areas can be the source of many symptoms. During the examination, the therapist examines three parameters: resistance, rebound, and sensory response. Examining these parameters is relatively new thinking; therefore, the base of evidence is growing.
Gabutti and Draper (2014) suggest that the stress and strain function of cranial bones may be influenced by craniofacial (dys-) functions. Further, Schueler (2014) states that pericranial tissues can directly influence meningeal nociception associated with symptoms like headaches. However, a systematic effect study based on this background is lacking. In a systematic review by Krützkamp et al. (2014) about the outcomes of the treatment of the craniofacial tissue by passive movements, 37 studies were identified related to orthodontic splint therapy, craniosacral or manual therapy as passive interventions. All had poor methodological quality and small groups and could identify only very little evidence concerning the outcome of all therapy approaches on headaches and psychogenic problems.
In 2018 Hanskamp finished an inter-reliability study of the six standard cranial manual therapy tests taught in the CRAFTA® approach (Hanskamp et al. 2019).
3. Craniocervical Region
There is a large body of evidence supporting a close connection between cervical and TMD dysfunctions. Assessment of both areas is critical in most cases. Through differentiation tests and a thorough musculoskeletal examination of the cervical region, potential sources for the patient’s complaints can be identified (von Piekartz et al., 2016).
The focus of assessing the Cranioneural area is to detect clinical patterns of cranial nerve dysfunctions and neuropathies. Conduction tests, neurodynamic tests, and palpation of the relevant cranial nerves allow the clinician to assess if one or more cranial nerves play a role in the patient’s complaints.
CRAFTA® therapists try to classify head-face and neck pain according to the standard guidelines and taxonomies (e.g., DC/TMD). However, they also try to manage a proposed clinical classification of cranio-neuropathic pain described by von Piekartz and Hall (2018).
The examination results, along with a sound and comprehensive clinical reasoning process, will allow a CRAFTA® therapist to define the optimal treatment and self-management for head-/ neck and face pain patients. To learn more about CRAFTA® and other methods of treating head, face, and neck pain in patients, we have several other Myopain Seminars blogs from our CRAFTA® team, such as
Armijo-Olivo, S., Pitance, L., Singh, V., Neto, F., Thie, N., & Michelotti, A. (2016). Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis. Physical therapy, 96(1), 9-25.
Conti, P.C.R., Costa, Y.M., Gonḉalves, D.A., Svensson, P. (2016). Headaches and myofascial temporomandibular disorders: overlapping entities, separate managements? Journal of oral rehabilitation, 43, 702-715.
Dickerson, S. M., Weaver, J. M., Boyson, A. N., Thacker, J. A., Junak, A. A., Ritzline, P. D., & Donaldson, M. B. (2017). The effectiveness of exercise therapy for temporomandibular dysfunction: a systematic review and meta-analysis. Clinical rehabilitation, 31(8), 1039-1048.
Gabutti, M, Draper-Rodi J. Osteopathic decapitation: Why do we consider the head differently from the rest of the body? New perspectives for an evidence-informed osteopathic approach to the head International Journal of Osteopathic Medicine (2014) 17-23.
Hanskamp M, Armijo-Olivo S, von Piekartz H. Is there a difference in response to manual cranial bone tissue assessment techniques between participants with cervical and/or temporomandibular complaints versus a control group? J Bodyw Mov Ther. 2019 Apr;23(2):334-343. doi: 10.1016/j.jbmt.2019.02.001. Epub 2019 Feb 7. PMID: 31103117.
Krützkamp L, D Möller, von Piekartz H. Influence of Passive Movements to the Cranium systematic Literature review. Manuelle Therapie 2014; 18: 183–192
La Touche, R., Paris‐Alemany, A., Hidalgo‐Pérez, A., López‐de‐Uralde‐Villanueva, I., Angulo‐Diaz‐Parreño, S., & Muñoz‐García, D. (2018). Evidence for Central Sensitization in Patients with Temporomandibular Disorders: A Systematic Review and Meta‐analysis of Observational Studies. Pain Practice, 18(3), 388-409
Herrera-Valencia A, Ruiz-Muñoz M, Martin-Martin J, Cuesta-Vargas A, González- Sánchez M. Effcacy of Manual Therapy in TemporomandibularJoint Disorders and Its Medium-and Long-TermEffects on Pain and Maximum Mouth Opening:A Systematic Review and Meta-Analysis. J Clin Med. 2020 Oct 23;9(11):E3404. doi: 10.3390/jcm9113404. PMID: 33114236.
Schueler M, Messlinger K, Dux M, Neuhuber WL, De Col R. Extracranial projections of meningeal afferents and their impact on meningeal nociception and headache 2013, Sep;154(9):1622-31
Von Piekartz, H., Pudelko, A., Danzeisen, M., Hall, T., Ballenberger, N., (2016). Do subjects with acute/subacute temporomandibular disorder have associated cervical impairments: A cross-sectional study. Manual therapy, 26(2016), 208-215
Von Piekartz J, Hall T, Clinical classification of cranial neuropathies, in Temporomandibular Disorders. Manual Therapy, exercise and needling, Fernandez-de-las-Penas C, Mesa Jimenez J , Handspring Publishing, chapter 14;205-271