Does the IFOMPT Neglect Orofacial Musculoskeletal Therapy?

As musculoskeletal physical therapy professionals from around the globe gather in Basel (Switzerland) for the International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Conference 2024, there is an air of anticipation about the latest advancements in musculoskeletal therapy. Unfortunately, physical therapists interested in the cranio-orofacial region will have few options, as this area has been overlooked since the Rotterdam 2008 IFOMPT conference.

Despite mounting evidence supporting musculoskeletal therapy’s effectiveness in treating persistent orofacial dysfunction and pain, the IFOMPT and leaders in musculoskeletal therapy seem to pay insufficient attention to this significant manual therapy specialty area. This persistent oversight calls for a closer examination, especially given the increasing number of studies advocating for integrating orofacial considerations into general musculoskeletal practice.

Why is the orofacial area not getting the attention it deserves within the musculoskeletal IFOMPT community?

Orofacial pain, encompassing discomfort in the face and mouth region and related structures like the neck and shoulders, can profoundly affect an individual’s quality of life (Oghli et al., 2020). It may manifest as headaches, jaw pain, and even disturbances in neck function, including mobility and (muscular) stability. The causes vary from dental issues to nociceptive or nociplastic conditions to a lack of motor control like parafunctional activity (e.g., bruxism) or postural imbalances linked by various psycho-emotional risk factors. The multifactorial etiology complicates assessing and treating patients with complex orofacial pain. Based on internal and external evidence, the integration of musculoskeletal orofacial therapy into treatment plans has shown promising results, offering relief where traditional methods may fall short.

The evidence is clear. Several recent systematic reviews have highlighted significant improvements in patients with chronic jaw and facial pain following targeted musculoskeletal interventions (van der Meer et al. 2017; von Piekartz et al. 2023). Treatments, including manual therapy, exercise, and patient education, provide a holistic approach that addresses the symptoms and underlying causes of orofacial pain with good or excellent outcomes.

What may be the reason?

However, despite this growing body of evidence, sessions dedicated to orofacial musculoskeletal therapy were notably sparse at recent IFOMPT conferences (Table 1). The 2024 IFOMPT congress features only two oral presentations on orofacial pain.  This gap reflects a missed opportunity and a disservice to the countless patients who could benefit from these therapeutic approaches. The question then arises: Why is the orofacial area not getting the attention it deserves within the musculoskeletal IFOMPT community?

 

Table 1 – Number of orofacial presentations compared to other presentations at the last four IFOMPT conferences

1.  One possible reason is the traditional segmentation of medical specialties. Orofacial pain is often seen as the domain of dentists and maxillofacial specialists, thus creating a barrier to interdisciplinary collaboration. Furthermore, physical therapists need specialized training and education to handle these complex cases effectively.

2.  Another reason may be a lack of training in the IFOMPT curriculum in this area. Schaffer et al.’s survey (2018) on IFOMPT education concerning temporomandibular dysfunction (TMD) and upper cervical assessment and treatment reveals inconsistencies in the duration and content of how post-professional orthopedic manual physical therapy (OMPT) programs address TMD education. Most programs, however, consistently offer more training in cervical spine disorders than in TMD. These results indicate the need for further research to evaluate whether TMD education in these programs is still insufficient.

Based on my personal experience, musculoskeletal therapists, including those who teach in the IFOMPT domain, often face challenges with average topics such as:

• Understanding the innervation of the temporomandibular joint (TMJ)
• The functions and interactions between the trigeminal and facial nerves
• The dual compartments of the TMJ and their specific functions
• How dental occlusion affects TMJ and neck function
• Distinguishing between myogenic TMD and bruxism
• Identifying types of perception changes during craniofacial-orofacial headaches.

It seems reasonable to expect that an IFOMPT-specialized musculoskeletal therapist would possess this fundamental knowledge, even if not intensively involved in clinical work with patients suffering from orofacial dysfunction and pain.

3.  Another reason may be the paradigm shift in rehabilitation. From 2018 to 2019, IFOMPT mandated the integration of “communication” more prominently into training programs. As a result, Pain Science and Pain Neuroscience Education received higher priority in the curriculum.

4.  Another factor could be the paradigm shift towards “research.” It is concerning that many PhD students in physiotherapy without an IFOMPT diploma, who have not gone through an IFOMPT curriculum and, therefore, have no clinical experience, are conducting research in musculoskeletal therapy to complete their PhDs. While more research in musculoskeletal therapy is beneficial, research questions are not always posed from a clinical or pragmatic perspective. In my opinion, clinical questions, particularly those concerning facial and TMD issues, are significantly underrepresented. This shortfall occurs because PhD students often lack training in this area. Sometimes, their supervisors have specialized expertise and they may be able to assist the PhD student. However, it is worth noting that few musculoskeletal physical therapists with an IFOMPT diploma and a PhD are engaged in research.

The medical world recognizes orofacial dysfunction and pain, but it does not recognize cervical headaches

 

Manual therapists may not want to acknowledge the reality, but the medical community still does not recognize ‘cervical’ headaches as a distinct entity. Despite the significant efforts of experts like Gwenn Jull, Toby Hall, and Dean Watson during the 1990s and early 2000s, who began substantiating their clinical experiences with foundational research published in well-regarded journals, there has been little change in this area. As a side note (by Jan Dommerholt), the International Headache Society’s (IHS) International Classification of Headache Disorders maintains that out of more than 300 specific types of headaches, only two are directly attributed to the musculoskeletal system, namely cervicogenic headache and headaches attributed to temporomandibular disorders (Oleson, 2018).

Additionally, most IFOMPT musculoskeletal therapists are not familiar with the diagnostic criteria for TMD as outlined by the International Consortium for Myofascial Pain Diagnostics and the International Classification of Orofacial Pain (ICOP 2020). These frameworks offer significant insights for the assessment, management, and research in musculoskeletal therapy and provide excellent opportunities for integration with other evidence-based disciplines such as dentistry, orofacial surgery, neurology, and psychology.

Driven by this knowledge, the Craniofacial Therapy Academy (CRAFTA) organized a successful hybrid conference in June 2024 titled “TMD AND OROFACIAL PAIN PHYSICAL THERAPY MEETS DENTISTRY.”  The conference concluded that there are clear overlaps between dentistry and musculoskeletal therapy. Functionally-minded dentists have shown a readiness to cooperate and reach consensus, but they observe a lack of specialized craniofacial therapy with robust skills grounded in evidence-based practice. Consequently, they are welcoming physiotherapists with open arms to the American Academy of Orofacial Pain (AAOP) in the US and the Deutsche Gesellschaft für Funktionsdiagnostik (DGFDT) in Germany, both as participants and speakers. Interestingly, while 80% of the attendees of the CRAFTA congress were physical therapists, less than 15% were registered with an IFOMPT diploma.

Crossing Bridges

Can we blame IFOMPT teaching organizations? Maybe at least partially because they must function within the parameters of the IFOMPT curriculum, which prescribes specific objectives and competencies. If IFOMPT does not recognize orofacial pain, the curricula of international musculoskeletal education organizations may follow in its footsteps. The IFOMPT conference in Basel reflects this dilemma. The conference’s theme is “Crossing Bridges,” which suggests a desire to connect and challenge new and different ideas and areas of interest, which sounds promising, except for the face and head regions. Most submitted symposiums on facial pain were rejected by the scientific IFOMPT commission. From the nearly 60 keynote lectures and short research presentations, only two 90-minute sessions focus on craniocervical, neck, and orofacial headache themes. Thus, we can conclude that the IFOMPT musculoskeletal therapists are specialists in musculoskeletal therapy but have limited expertise regarding the face!

Which physical therapist will be competent to manage

• Patients with neck pain whose source of pain is not in the neck
• Patients with facial pain following facial trauma and concussions
• Complex cases of vertigo and tinnitus not originating from the vestibular organ
• Young patients experiencing facial and head pain after orthodontic treatments
• Patients with Symptoms related to facial neuropathies, among others?

An IFOMPT musculoskeletal therapist should be able to address these issues, but perhaps we must accept that this is not the case.

The face is our vital instrument for communication, using many muscles to express emotions ranging from smiles to frowns. The face shows beauty and is also key for sensing the world: our eyes see beauty and chaos, our noses detect scents, and our lips and tongues taste and speak. The physical therapist specializing in orofacial manual therapy gets credits from the medical world but is not really supported by the IFOMPT.

Harry von Piekartz, PhD, MSc, BSc.PT, MT (OMPT)

References

• Oghli, I., List, T., Su, N., & Häggman-Henrikson, B. (2020). The impact of oro-facial pain conditions on oral health-related quality of life: A systematic review. Journal of Oral Rehabilitation, 47(8), 1052–1064. https://doi.org/10.1111/joor.12994
• Olesen J. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. (2018) 38:1–211. http://doi:10.1177/0333102417738202
• van der Meer, H. A., Calixtre, L. B., Engelbert, R. H. H., Visscher, C. M., Nijhuis-van der Sanden, M. W., & Speksnijder, C. M. (2020). Effects of physical therapy for temporomandibular disorders on headache pain intensity: A systematic review. Musculoskeletal Science & Practice, 50, 102277. https://doi.org/10.1016/j.msksp.2020.102277
• Piekartz, H. V., van der Meer, H., & Olivo, S. A. (2023). Craniofacial disorders and headaches. A narrative review. Musculoskeletal Science & Practice, 66, 102815. https://doi.org/10.1016/j.msksp.2023.102815
• Shaffer, S. M., Stuhr, S. H., Sizer, P. S., Courtney, C. A., & Brismée, J. M. (2018). The status of temporomandibular and cervical spine education in post-professional physical therapy training programs recognized by Member Organizations of IFOMPT: an investigation of didactic and clinical education. The Journal of Manual & Manipulative Therapy, 26(2), 102–108. https://doi.org/10.1080/10669817.2017.1422614

Slightly modified from the original by Jan Dommerholt | Photo by Mika Ruusunen on Unsplash