| |

Received: 2 November 2019    Revised: 11 February 2020    Accepted: 25 February 2020

DOI: 10.1111/joor.12959

ORIGINAL ARTICLE

International consensus on the most useful assessments

used by physical therapists to evaluate patients with
temporomandibular disorders: A Delphi study

Harry von Piekartz1  | Julius Schwiddessen1 | Lukas Reineke1 | Susan Armijo-Olivio2 |

Débora Bevilaqua-Grossi3 | Daniela A. Biasotto Gonzalez4  | Gabriela Carvalho5,6 |
Eve Chaput7,8 | Erin Cox9 | Cesar Fernández-de-las-Peñas10,11 | Inae Caroline Gadotti12
 | Alfonso Gil Martínez13 | Anita Gross14 | Toby Hall15,16 | Marisa Hoffmann17 |
Elisabeth Heggem Julsvoll18 | Micheal Karegeannes19 | Roy La Touche20,21,22 |
Jeffrey Mannheimer23,24,25 | Laurent Pitance26 | Mariano Rocabado27 |
Mark Strickland28 | Wolfgang Stelzenmüller29 | Caroline Speksnijder30 |
Hedwig Aleida van der Meer31 | Kerstin Luedke32 | Nicolaus Ballenberger1
1
Department Physical Therapy and Rehabilitation science, University of Applied Science Osnabrück, Osnabrück, Germany
2
Faculty of Rehabilitation Medicine, Faculty of Medicine and Dentistry Rehabilitation Research Center, University of Alberta, Edmonton Institute of Health
Economics (IHE), Edmonton, AB, Canada
3
Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
4
University Nove de Julho of São Paulo, São Paulo, Brazil
5
Lübeck University and Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
6
University of São Paulo, São Paulo, Brazil
7
University of Montreal and Western University, Montreal, QC, Canada
8
Quebec Association of Orthopedic Manual Physiotherapy (AQPMO), Montreal, QC, Canada
9
Kinatex Sports Physio, Laval, QC, Canada
10
Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Madrid, Spain
11
Cátedra de Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico - University Rey Juan Carlos of Madrid,
Madrid, Spain
12
Department of Physical Therapy, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL, USA
13
University Autónoma of Madrid, Madrid, Spain
14
Rehabilitation Sciences - McMaster University, Hamilton, ON, Canada
15
Curtin University, Perth, WA, Australia
16
University of Western Australia, Perth, WA, Australia
17
AGILPHYSIO physical therapy, Nieder-Olm, Germany
18
Hans and Olaf physical therapy of Oslo, Oslo, Norway
19
Freedom physical therapy services, Santa Monica, CA, USA
20
Departamento de Fisioterapia, Centro Superior de Estudios - Universitarios La Salle, Universidad Autónoma de Madrid, Madrid, Spain
21
Grupo de Investigación Motion in Brains, Instituto de Neurociencia y Ciencias del Movimiento (INCIMOV), Centro Superior de Estudios, Universitarios La
Salle - Universidad Autónoma de Madrid, Madrid, Spain
22
Instituto de Neurociencia y Dolor Craneofacial (INDCRAN), Madrid, Spain
23
Delaware Valley Physical Therapy Associates, New Jersey, NJ, USA
24
Department of Regenerative and Rehabilitation Medicine, Columbia University, New York, NY, USA
25
Physical Therapy Board of Craniofacial & Cervical Therapeutics Office for physical therapy, Lawrenceville, NJ, USA
26
Faculté des Sciences de la Motricité FSM, Institut de Recherche Expetimentale et Clinique (IREC), Laboratoire de Neuro musculo squelettique (NMSK) –

The peer review history for this article is available at https://publo​ns.com/publo​n/10.1111/joor.12959

J Oral Rehabil. 2020;47:685–702. wileyonlinelibrary.com/journal/joor© 2020 John Wiley & Sons Ltd.     685 |
686      | PIEKARTZ et al.

University catholic of Louvain, Neuve, Belgium

27
Dean Faculty of Rehabilitation Science, University Andrés Bello, Santiago, Chile
28
Operations Central Texas, For Health Sciences - University of St. Augustine, St. Augustine, FL, USA
29
Office for physical therapy, Neu-Isenburg, Germany
30
Division Surgical Specialty, Oral and Maxillofacial Surgery and Special Dental Care, Head and Neck Surgical Oncology – University Medical Center Utrecht,
Utrecht, The Netherlands
31
Centre for Applied Research on Education - Amsterdam University of Applied Sciences, Amsterdam Centre for Innovative Health Practice (ACHIEVE),
Amsterdam, The Netherlands
32
Department of Physical Therapy, University Lübeck, Lübeck, Germany

Correspondence
Harry von Piekartz, Department of Physical Abstract
Therapy and Rehabilitation science, Faculty Objective: To identify assessment tools used to evaluate patients with temporoman-
of Business, Management and Social
Science University of Applied Science dibular disorders (TMD) considered to be clinically most useful by a panel of interna-
Osnabruck, Caprivistrasse 30a, 49076 tional experts in TMD physical therapy (PT).
Osnabrück, Germany.
Email [email protected] Methods: A Delphi survey method administered to a panel of international experts
in TMD PT was conducted over three rounds from October 2017 to June 2018. The
initial contact was made by email. Participation was voluntary. An e-survey, according
to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), was posted
using SurveyMonkey for each round. Percentages of responses were analysed for
each question from each round of the Delphi survey administrations.
Results: Twenty-three experts (completion rate: 23/25) completed all three rounds
of the survey for three clinical test categories: 1) questionnaires, 2) pain screening
tools and 3) physical examination tests. The following was the consensus-based deci-
sion regarding the identification of the clinically most useful assessments. (1) Four
of 9 questionnaires were identified: Jaw Functional Limitation (JFL-8), Mandibular
Function Impairment Questionnaire (MFIQ), Tampa Scale for Kinesiophobia for
Temporomandibular disorders (TSK/TMD) and the neck disability index (NDI). (2)
Three of 8 identified pain screening tests: visual analog scale (VAS), numeric pain
rating scale (NRS) and pain during mandibular movements. (3) Eight of 18 identified
physical examination tests: physiological temporomandibular joint (TMJ) movements,
trigger point (TrP) palpation of the masticatory muscles, TrP palpation away from the
masticatory system, accessory movements, articular palpation, noise detection dur-
ing movement, manual screening of the cervical spine and the Neck Flexor Muscle
Endurance Test.
Conclusion: After three rounds in this Delphi survey, the results of the most used
assessment tools by TMD PT experts were established. They proved to be founded
on test construct, test psychometric properties (reliability/validity) and expert pref-
erence for test clusters. A concordance with the screening tools of the diagnostic
criteria of TMD consortium was noted. Findings may be used to guide policymaking
purposes and future diagnostic research.

KEYWORDS

assessments, delphi study, physical therapy, TMD

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1 | I NTRO D U C TI O N 2 | M E TH O DS

The diagnosis of temporomandibular disorders (TMD) represents a A Delphi survey was designed and conducted following established
complex collection of clinical signs and symptoms in the craniofacial guidelines15 and the Checklist for Reporting Results of Internet
region, including masticatory muscles, temporomandibular joints E-Surveys (CHERRIES) and previously published Delphi surveys with
1-4
and other related structures. Several neuromuscular, neurobio- similar research questions.16-18 The survey was guided by a system-
5,6
logical, biomechanical and biopsychosocial risk factors have been atic evaluation of the literature of all clinical tools and assessments
associated with the development or perpetuation of TMD. TMD has proposed for the assessment of musculoskeletal dysfunctions of
a one-year prevalence of 19% with frequent myofascial complaints, patients with TMD. Ethical approval (wiso_BA_ELP_HP-SS-18-01—
4
a yearly incidence of 4% and a broad peak prevalence between 20 05) was granted by the local ethics authority (University of Applied
and 40 years.7 Females are affected at least twice as often as men.8,9 Science of Osnabrück). The data collection time frame was from
The estimated annual medical cost for TMD treatment in the United October 2017 to June 2018. There were three e-survey rounds sent
States alone is $4 billion.10 out through email with an automatic method of capturing responses
Due to its complexity, TMD is an umbrella term for di- using SurveyMonkey. The completion rate was considered the ratio
verse clinical symptoms,11 classified in the Diagnostic Criteria of of users who finished the survey/users who agreed to participate.
Temporomandibular Disorders (DC/TMD).12 The classification The survey was voluntary with a non-monetary incentive, that is an
consists of two subscales, the physical (Axis I) and the psychoso- offer to provide the survey results at the end of the study.
11,13
cial (Axis II) sections. The DC/TMD Axis I is divided into painful
TMD, intra-articular disorders, degenerative joint disease and joint
subluxation. The Axis II classifies chronic facial pain into pain-related 2.1 | The experts
impairment of daily activities, depression and non-specific somatic
symptoms.11 Shiffman et al12 within the DC/TMD validated the Experts were defined as physical therapists with a specialised education
assessment of TMD with questionnaires and physical tests. Their in musculoskeletal therapy in TMD, with at least 10 years of clinical ex-
results, although sometimes lacking a gold standard, led to the selec- perience or with a research background, including at least five publica-
tion of valid diagnostic criteria for differentiating the most common tions in the area. They were contacted by email or phone and invited to
pain-related TMDs, such as myofascial pain with referral (sensitivity participate in the study. For this purpose, the experts received a clear
0.86; specificity 0.98), arthralgia (sensitivity 0.89; specificity 0.98), description of the study aims and procedures before informed consent
headache attributed to TMD (sensitivity 0.89; specificity 0.87) and was sought. Thirty-one international experts from 11 different countries
disc displacement without reduction with limited opening (sensitiv- were invited (by email) to participate in the first round of the Delphi study.
ity of 0.80 and specificity of 0.97). Twenty-five experts responded and were required to state whether they
Physical therapists play an essential role in the multidisciplinary were predominantly involved in research (n = 14), clinical practice (n = 2)
team working with patients with TMD and are primarily educated or mixed (n = 9). They provided their responses anonymously to allow
within the framework of the International Classification of Function unbiased answers and to reduce the influence of potentially dominant
14
and Disability (ICF). Physical therapy outcome measurements personalities on the overall results. Experts were encouraged to revise,
often include questionnaires, clinical tests assessing pain and (neuro) improve or add additional comments during each survey round.19
musculoskeletal tests as well as collecting relevant contributing fac-
tors. These tests are the basis for physical therapy treatment and
management decisions.14 2.2 | Assessment tools
In addition to the DC/TMD examination and questions, phys-
ical therapists may include additional questionnaires and tests in The assessment tools were divided into three test categories: a)
their process of developing a diagnosis such as the Neck Disability questionnaires, b) pain screening tools and c) physical examination
Index. These tests are generally used along with the DC/TMD tests. Each test had the aim to both support TMD diagnosis and
instruments to determine the most appropriate treatment path guide treatment choice. Before the first round of the survey, a list
for patients. That being said, what are the most common tests, of assessment tools from the three categories described above was
instruments or tools used by physical therapists to evaluate pa- generated based on a systematic evaluation of the literature per-
tients with TMD? Besides, an inventory of the most common formed in the following databases: PubMed, Cinahl, EMBASE and
assessments tools, including tests and questionnaires, used by PEDro, including the following search strategy:
physical therapists to evaluate patients with TMD, has never been
published. The aim of this Delphi survey was to reach a consen- temporomandibular disorder [MeSH Terms], OR tem-
sus-based decision by a panel of international experts in TMD PT poromandibular joint disorder [MeSH Terms] OR further
regarding the identification of the most clinically useful question- synonyms. AND (physiotherapy OR manual therapy OR
naires and clinical tests that evaluate pain and dysfunction in pa- physical therapy AND assessments OR examination OR
tients with TMD. test OR measurement).
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688       PIEKARTZ et al.

Synonyms of these words were also used. Based on this strat- required to be verified as correct by the respondents, with a back
egy, 150 studies identified to be potentially relevant. After full text button available to modify responses. Before each round, the survey
screening, 36 studies were classified as relevant and formed the basis was trialed for comprehensibility such as ambiguous questions or
for the chosen assessment tools for the Round-1 in the Delphi survey wording, unclear instructions or problems with the instrument and
(Table 1). revised accordingly before widespread dissemination based on com-
ments from three clinical and research experts of the Delphi team
(HVP, KL and NB).
2.3 | Survey Round-1 Regarding the physical examination tests and the pain screen-
ing tools, experts were asked to classify the tests into the follow-
The aim of the first round (Round-1) of the survey was to rate the ing disorder subcategories: myogenic, arthrogenic, mixed or chronic
clinical importance of the assessments identified in the literature pain. Each test was evaluated for clinical usefulness on a scale from
and to collect additional suggestions of assessment tools consid- 0 (definitely not useful) to 4 (extremely useful). If the clinical use-
ered clinically useful by the experts. Experts received a survey with fulness of a test was considered “unclear,” the expert could add an
questions on three clinical test categories: 1) questionnaires, 2) pain explanation in the response document. Experts were also asked to
screening tools and 3) physical examination tests. The survey in- make further suggestions regarding additional questionnaires or as-
cluded a list of references supporting the tests used and comprised sessment tools. These would be included in the next survey iteration
thirty two questions distributed over eight pages with between or round. The survey questions used during the first and second sur-
three to seven items per page. A summary of the responses was vey round are described in Table 2.

TA B L E 1   Assessment tools included

  1. Questionnaires 2. Pain screening 3. Physical tests
for three categories in Round-1
1 PHQ-412,41,42 Detailed screening of the Physiological TMJ movements
pain in general70 41,49-51

2 PHQ-9 12,47 TMD-pain screener 12,61 Accessory movements 12,53,76

8,12,44,47 12
3 GAD-7 Pain drawing Noise registration during
movement manual palpation
48,57

4 DC/TMD demographics Graded chronic pain scale Noise registration

12
version 2 12,53,62 during movement with
stethoscope53,55,76,77
5 JFL scale 8 Item12,45,51 CAS63,64 Statistical tests 41,52,86
12,45,51 64-66
6 JFL scale 20 Item VAS Myofascial Trp of masticatory
m. 41,80-81,83
7 Oral behaviors Mouth movements Myofascial TrP outside the
checklist12,45,46 pain67-68,86 masticatory system78,82
8 PHQ-15 physical   PPT of masticatory
symptoms12,47 muscles35,53,83,84
9 MFIQ48-50   PPT of masticatory muscles
outside the masticatory
system8,53,68,85
10 CONTI   Dynamic and static load test
questionnaire52-55 of the TMJ24,54
11 Helkimo´s clinical   Laterotrusion test12,41,76,86
dysfunction index56-59
12 Fonseca anamnestic   Dental stick test69,76,81
index60
13     Neurodynamic test of the
mandibular nerve29,86
14     Screenings test cervical
spine 42,71,73-75,79

Abbreviations: CAS, color analog scale; DC/TMD, diagnostic criteria for temporomandibular
disorders; GAD-7, generalised anxiety disorder scale; JFL, jaw functional limitation; MFIQ,
mandibular function impairment questionnaire; PHQ, patient health questionnaire; PPT, pain
pressure threshold; PPT, pressure pain threshold; TMJ, temporomandibular joint; TrP, trigger point;
VAS, visual analog scale.
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TA B L E 2   Protocol used during Round-1 and Round-2

I consider this I consider this I consider this I consider this I consider this
questionnaire … for assessment… for assessment … for assessment… for assessment… for
  TMD myogenic symptoms arthrogenic symptoms mixed symptoms chronic pain state

(4) extremely useful, (3) useful, (2) don't know, (1) probably not useful, (0) definitely not useful
Questionnaires *X        
Pain screening tools   *X *X *X *X
Physical examination   *X *X *X *X
tests
I further suggest the 1)
use of the next 2)
assessment(s) 3)

*X clinical usefulness on a score from 0 to 4.

A period of 8-weeks was given for Round-1. Experts were sent as additional assessment tools suggested by the experts in Round-
email reminders to answer the survey if no response was received 1. After the evaluation of the new tests by the experts, they were
within this time frame. If they did not respond after the reminder also invited to agree or disagree with the statements made by other
within 2-weeks, they were excluded from the analyses and from fur- experts during Round-1.
ther rounds.
Results from Round-1 were presented to experts in Round-2, the
second round, through a box plot diagram for each of the clinical test 2.5 | Survey Round-3
categories: 1) questionnaires, 2) pain screening tools and 3) phys-
ical examination tests. The specific test within each category was The first two rounds were predominantly focused on the useful-
divided into three classifications: a) useful (2.5-4), b) not useful (0- ness of the assessment tools. In the third round (Round-3), experts
1.5) and c) unclear results (1.5-2.5). Tests considered “unclear” by ex- received the results from Round-2 as summarised feedback and a
perts were included in the third round (Round-3) with more specific final response document. Experts further specified the clinical use
questions to add clarity to the classification. Additional details for of each clinical test (Table 3). The authors were informed that tests
the “unclear” tests, including available literature supporting them, with a minimum rating of three (“useful”) from at least 60% (n = 15) of
were provided. A new response document was sent back to the ex- expert participants would be included in the final list of useful tests.
perts who classified the tests as “unclear” in the test description. The consensus-based decision regarding the identification of the
clinically most useful tests was formulated on this basis.41 Experts
were further asked to rate the newly suggested assessments from
2.4 | Survey Round-2 Round-2. During this round, experts also decided which test they
considered most appropriate according to the DC/TMD classifica-
The aim of the second round (Round-2) was to rate the new tests, tion. A period of 8 weeks was given to complete this round. An over-
to clarify issues on the unclear tests and to formulate a preliminary view of the questions the experts received in Round-3 is provided
consensus on the different statements from Round-1. Following in Table 3. Also, the classifications 1, 2, 3 and 4 are detailed in the
completion of Round-1, experts received the Round-1 results as well results section of this manuscript.

TA B L E 3   Questionnaire to specify
  Supporting a musculoskeletal diagnosis
the clinical use and purpose of the
assessments 1 A. Is this test sufficient as a stand-alone tool to support your diagnosis?
B. Do you use it embedded in a cluster of tests with the same purpose?
C. Can you use this test for the progress documentation or as a retest doing your
treatment?
2 Supporting a specific treatment technique/approach
3 Supporting both a musculoskeletal diagnosis and the choice of a specific treatment
technique/approach.
4 Other possible uses, like
  A. For the documentation
B. Supporting prognosis
C. Anything else, please mention in additions
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690       PIEKARTZ et al.

3 |  A N A LYS I S Among the 33 initial assessment tools, the following were rated
as “unclear” by nine (9) of the 25 experts and were clarified in detail
Only complete questionnaires were analysed. No statistical correc- in Round-2 using evidence-based literature:
tion was required as there was no difference in weighting of items.
Based on simple percentage comparisons, data were presented • Questionnaires: patient health questionnaire (Physical Symptoms,
graphically. The questionnaires with the highest rankings were in- PHQ-15), Fonseca Anamnestic Index.
cluded in the subsequent round. To be included in Round-3, the as- • Pain screening tools: Color analog Scale (CAS), DC/TMD
sessment tool had to be rated at least 3-“useful” by at least 60% demographics.
(n = 15) of all experts. In addition, for survey items with open-ended • Physical examination tests: pressure pain thresholds of other
questions, we included qualitative descriptions for analysis. body regions, dental stick test, mandibular neurodynamic test,
noise detection during movement with a stethoscope.

4 |   R E S U LT S
4.2 | Survey Round-2
Twenty-three experts completed all rounds of the Delphi survey, and
34 assessment tools were considered clinically useful after the three Twenty-five participants answered Round-2 within 8  weeks. After
rounds. Among them, nine were questionnaires, eight tests for pain Round-2, 23 experts provided a ranking of the assessments rated as
screening and 18 for physical examination. useful (see Figures 1-6). The questionnaires with the highest rank-
ings were the TSK/TMD (84%, 21/25 experts), MFIQ (76%, 19/25
experts) and the JFL-8 (76%, 19/25 experts) (Figure 1).
4.1 | Survey Round-1 For pain screening tools, clinical experts reported using pain
screening in general (88%, 22/25), pain drawings (84%, 21/25) and
Twenty-five participants responded the first round within 8-weeks. VAS (80%, 20/25) (See Figure 2). The choice of pain screening tools
Based on the literature review, 33 assessment tools were suggested used varied by TMD sub-classification (Axis I DC/TMD). Specific to
to be assessed by the experts. Among them, 12 were questionnaires, myogenic TMD, experts found pain drawings (88%, 22/25 experts),
seven (7) were pain screening tools, and 14 were physical examina- the VAS (88%, 20/25 experts) and the NRS (88%, 22/25 experts)
tion tests (Table 1). Three (3) questionnaires, one (1) assessments for to be particularly useful while for arthrogenic TMD, the VAS (92%,
the pain screening and four (4) physical examination tests were rated 23/25 experts) and the NRS (92%, 23/25 experts) were rated as
as unclear. Furthermore, 16 new assessments were suggested by the highly useful, followed by pain drawings (88%, 23/25 experts). For
experts in this round: five (5) questionnaires, four (4) pain screen- mixed TMD, experts considered the VAS (92%, 23/25 experts),
ing tools and seven (7) physical examination tests. An overview of pain drawings (88%, 22/25 experts), NDI, NRS and pain provoked
the new assessment tools suggested by at least one expert after by mandibular movements (each 84%, 21/25 experts) to be useful.
Round-1 is shown in Table 4. For chronic oro-facial pain, experts considered pain drawings, VAS

TA B L E 4   An overview of the new assessments based on consensus of the experts after Round-1

  1. Questionnaires 2. Pain screening 3. Physical tests

87 96,97
1 The central sensitisation inventory (CSI) NDI Evaluation of the mobilisation of
the hyoid bone 112
2 Pain localisation in CMD patients with modified pain TMD Disability Index 98 Articular palpation 103
questionnaire 88
3 The Brief Illness Perception Questionnaire 89 Mc Gill questionnaire 99 Intra-oral examination for signs of
parafunctional habits104,105
4 TSK/TMD90,91 Numeric Pain Rating Evaluation of the Head and neck
Scale100-102 posture106-108
5 LDF-TMDQ/JFS 92-95   Mobilisation with movement of the
TMJ 109
6     Dynamic/static tests As
Assessment of pain 110
7     Neck flexor muscle endurance
test 111

Abbreviations: CSI, central sensitisation inventory; LDF-TMDQ-JFS, limitations of daily functions in TMD questionnaire; NDI, neck disability index;
TMJ, temporomandibular joint; TSK/TMD, Tampa scale for kinesiophobia for temporomandibular disorders.
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F I G U R E 1   Distribution of answers for

the questionnaires category after Round-1
and Round-2 for all TMD [Colour figure
can be viewed at wileyonlinelibrary.com]

and NDI as relevant to evaluate the condition with 80% each (20/25 patients with modified pain questionnaire, 10) pressure pain thresh-
experts). olds of the masticatory muscles, 11) neurodynamic test of the man-
The most useful physical tests identified for 1) arthrogenic TMD dibular nerve and 12) the accessory movement of the hyoid bone.
were physiological TMJ movements (100%, 25/25 experts), and ac-
cessory movements and articular palpation (96%, 24/25 experts)
(Figures  2 and 3) myogenic TMD were physiological TMJ move- 4.3 | Survey Round-3
ments (96%, 24/25 experts), TrP palpation of the facial muscles
(92%, 23/25 experts) and TrP palpation outside the masticatory sys- In the third round (Round-3), two experts dropped out due to lack of
tem (96%, 24/25 experts) (Figure 3). In contrast, for mixed TMD, the time; therefore, 23 experts returned the responses within the time
clinical experts rated the assessment of physiological movements as frame. An overview of the results related to the use of the tests and
the most appropriate test (100%, 25/25 experts), followed by ac- assessment tools is reported in Table 3 and depicted in Table 5.
cessory movements (96%, 24/25 experts) and TrP palpation outside
the masticatory system (92%, 23/25 experts) (Figure 3). If a chronic
oro-facial pain state was associated with Axis ll, the screening of 4.3.1 | Questionnaires
physiological movements (100%, 25/25 experts), muscle/TrP as-
sessment outside the masticatory system (92%, 23/25 experts) and The TSK/TMD reached the highest rate as a stand-alone test (one
screening of the cervical spine were stated as the most appropriate test which confirms the diagnosis) (Question - Q1A) to make a muscu-
clinical tests (88%, 22/25 experts) (Figure 3). loskeletal diagnosis (Q1) with only 17.4%. When experts were asked
To be included in subsequent rounds (Round-3), the assess- which tests they would use within a cluster (a collection of tests which
ment tool should have been rated at least 3-“useful” by at least 60% increases the accuracy of the suspected diagnosis) of assessments to
(n = 15) of all experts. The following 12 tests did not reach this min- support a musculoskeletal diagnosis and for documentation (Q1B), or
imum requirement: 1) PHQ-4, 2) Helkimo's Clinical Dysfunction, 3) as a retest of a musculoskeletal treatment (Q1C), the JFL-8 and the
CAS, 4) Conti Anamnestic Questionnaire, 5) DC/TMD demographics, Oral Behavior Checklist received the highest scores with 82.6% (19/23
6) PHQ-15 physical symptoms, 7) Fonseca anamnestic index, 8) the experts) and 78.3% (18/23), respectively. The experts did not con-
Letter illness perception questionnaire, 9) pain localisation in TMD sider the GAD-7 as a stand-alone tool (Q1A) 69.6% (16/23 experts) or
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692       PIEKARTZ et al.

F I G U R E 2   Mean of pain assessment

tool in myogenic, arthrogenic, mixed TMD
or chronic oro-facial pain after Round-1
and Round-2 [Colour figure can be viewed
at wileyonlinelibrary.com]

F I G U R E 3   Distribution of answers after Round-1 and 2 in the physical tests category for arthrogenic TMD [Colour figure can be viewed
at wileyonlinelibrary.com]

imbedded (Q1B) in with other assessments (56.5%, 13/23) supporting the documentation or reassessment test (Q1C), the LDF-TMDQ/JFS
a musculoskeletal diagnosis. Also, the GAD-7 and the JFL-8 achieved (Q1B: 30.4%, 7/23) and the GAD-7 (Q1C: 30.4%, 7/23) scored the low-
only 4.3% (1/23 experts) as sufficient stand-alone assessments est. For other uses of the questionnaires (Q4), the highest values were
(Q1A). Regarding the clustering of tests (Q1B) and as assessment for achieved by the GAD-7 (69.6%, 16/23) for the documentation process
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F I G U R E 4   Distribution of the answers

after Round-1 and Round-2 in the physical
tests category for myogenic TMD [Colour
figure can be viewed at wileyonlinelibrary.
com]

F I G U R E 5   Distribution of the answers

after Round-1 and Round-2 in the physical
tests category for mixed TMD [Colour
figure can be viewed at wileyonlinelibrary.
com]

(Q4A), the JFL-20 (60.9%, 14/23) for prognosis (Q4B) and the Oral better during clustering (69.6%, 16/23). Besides, the GCPS scale
Behaviors Checklist (78.3%, 18/23) for anything else (Q4C). (version-2) achieved the lowest score to support a neuromuscu-
loskeletal diagnosis in a cluster with other tests (56.5%, 13/23,
Q1B).
4.3.2 | Pain screening Regarding the question of whether a test supports a specific
treatment technique/approach (Q2), “pain triggered by mandibular
For the assessment of pain, both VAS and TMD Disability Index movements” achieved the highest expert support (52.2%, 12/23). To
achieved the highest scores (95.7%, 22/23, Q1B). The results support both, a neuromusculoskeletal diagnosis and the choice of a
showed that 78.3% (18/23) of the experts rated the TMD Disability particular treatment technique or approach (Q3), the TMD Disability
Index and the NRS as a useful pain assessment tool for documen- Index and NDI (69.6%, 16/23) were both rated as the most useful
tation or retest (Q1C). The McGill Pain Questionnaire (8.7%, 2/23, assessment of the experts. The pain drawing (30.4%, 7/23), to-
Q1A) was rated as a sufficient independent assessment but was gether with the VAS (34.8%, 8/23), scored the lowest. When asking
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694       PIEKARTZ et al.

F I G U R E 6   Distribution of answers
after Round-1 and Round-2 in the physical
tests category for chronic oro-facial pain
state [Colour figure can be viewed at
wileyonlinelibrary.com]

whether there were any other uses for the pain assessment (Q4), TMD in the DC/TMD categories. Palpation of the masticatory
the pain drawing and the TMD disability index both reached the muscles achieved the highest value in the category "painful TMD"
highest level (73.9%,17/23) supporting the documentation process with 91.3% (21/23). In all the three categories (Q1A-C), physiolog-
(Q4A), and the TMD disability index and NDI both (73.9%, 17/23) ical TMJ movements achieved the highest score (100%, 23/23),
supported prognosis (Q4B). The McGill Pain Questionnaire reached especially in combination with other tests (Q1B). The lowest re-
the highest value in Q4C, with 21.7% (5/23) of the experts consider- sult (21.7%, 5/23) was for noise detection during movement with
ing the McGill Pain Questionnaire. a stethoscope (Q1A). In addition, pain pressure threshold (PPT)
Furthermore, the experts were asked whether the assessment of the masticatory muscles reached the lowest value (4.3%, 1/23)
tool could help to classify TMD according to the International in the two categories "intra-articular disorders" and "joint sub-
Classification of the DC/TMD in the following categories: “pain- luxation." To support a neuromusculoskeletal diagnosis (Q1B), dy-
ful TMD”; “intra-articular disorders”; “degenerative joint diseases”; namic and static load test of the TMJ achieved the highest rating
and “joint subluxation”. In the category "painful TMD," the VAS (95.7%, 22/23). The following five tests, 1) static test, 2) dynamic
and pain drawing reached 87% (20/23), and in combination with and static load test of the TMJ, 3) dental stick test, 4) articular
the examination of mandibular movements, the best results were palpation and 5) dynamic/static load tests, were all used by 91.3%
for "intra-articular disorders" (69.6%, 16/23) and "degenerative (21/23) of the experts as a cluster of tests (Q1B). Physiological
joint disease" (60.9% 14/23). The NDI scored the worst (43.5%, movements of the TMJ were rated as the most useful assessment
10/23) result in the category “painful TMD.” The NDI together for the follow-up documentation (87%, 20/23, Q1C). Evaluation of
with the CGPS-2 and the McGill Pain Questionnaire were also the head and neck posture was rated as useful by 4.3% (1/23) of
rated the least useful (21.7%, 5/23) for the assessment of pain in the experts as a stand-alone tool (Q1A).
the category “degenerative joint disease.” The CGPS-2 had the Regarding the question, if some tests supported a specific
lowest score (26.1%, 6/23) in the category “intra-articular disor- treatment approach (item 2, Table  5), extra-oral TrP palpation of
ders,” and together with the NDI also the lowest score (13%, 3/23) the masticatory system achieved the best results (78.3%, 18/23),
in the category “joint subluxation.” These results are not depicted and the stethoscope noise detection during movement test
in Table 5. reached the lowest (47.8%, 11/23). To support both, a neuromus-
culoskeletal diagnosis and a specific treatment approach (Q3),
87% (20/23) of the experts considered the screening test of the
4.3.3 | Physical examination tests cervical spine together with palpation of the masticatory system
as the most useful test battery. Articular palpation received the
The 18 clinical tests integrated into the physical examination lowest score (34.8%, 8/23). Up to 74% (17/23) of the participants
questionnaire in Round-3 achieved the following results defining agreed about the benefit of intra-oral examination as an additional
TA B L E 5   Overview of the most useful test according the clinical experts

1. Supporting neuromusculoskeletal diagnosis 3. Supporting both a 4. Other possible uses

neuromusculoskeletal
A) sufficient as B) imbedded C) Can be used 2. Supporting a diagnosis and the A) sufficient as a B) imbedded in
PIEKARTZ et al.

a stand-alone in a cluster of for the progress specific treatment choice of a specific stand-alone tool a cluster of tests C) Can be used for the
tool to support tests with the documentation or technique/ treatment technique/ to support the with the same progress documentation
  the diagnosis same purpose as a retest approach approach diagnosis purpose or as a retest

Questionnaires (%, numbers/total numbers)

1. JFLS-8 4.3 (1/23) 82.6 (19/23) 78.3 (18/23) 43.5 (10/23) 47.8 (11/23) 30.4 (7/23) 39.1 (9/23) 4.3 (1/23)
2. MFIQ 13.0 (3/23) 60.9 (14/23) 69.6 (16/23) 43.5 (10/23) 47.8 (11/23) 60.9 (14/23) 52.2 (12/23) 4.3 (1/23)
3.TSK/TMD 17.4 (4/23) 47.8 (11/23) 60.9 (14/23) 60.9 (14/23) 47.8 (11/23) 60.9 (14/23) 56.5 (13/23) 13.0 (3/23)
4. JFLS-20 8.7 (2/23) 65.2 (15/23) 78.3 (18/23) 43.5 (10/23) 43.5 (10/23) 52.2 (12/23) 60.9 (14/23) 4.3 (1/23)
5. Oral Beh. 13.0 (3/23) 78.3 (18/23) 60.9 (14/23) 52.2 (12/23) 30.4 (7/23) 65.2 (15/23) 8.7 (2/23) 78.3 (18/23)
6. LDF-TMDQ/JFS 13.0 (3/23) 30.4 (7/23) 65.2 (15/23) 43.5 (10/23) 52.2 (12/23) 69.6 (16/23) 39.1 (9/23) 4.3 (1/23)
7. PHQ 9 13.0 (3/23) 43.5 (10/23) 43.5 (10/23) 30.4 (7/23) 26.1 (6/23) 65.2 (15/23) 52.2 (12/23) 26.1 (6/23)
8. GAD 7 4.3 (1/23) 39.1 (9/23) 30.4 (7/23) 34.8 (8/23) 17.4 (4/23) 69.6 (16/23) 56.5 (13/23) 8.7 (2/23)
Pain screening (%, numbers/total numbers)
1. VAS 34.8 (8/23) 95.7 (22/23) 56.5 (13/23) 34.8 (8/23) 39.1 (9/23) 69.6 (16/23) 56.5 (13/23) 13.0 (3/23)
2. NDI 8.7 (2/23) 82.6 (19/23) 60.9 (14/23) 47.8 (11/23) 69.6 (16/23) 65.2 (15/23) 73.9 (17/23) 8.7 (2/23)
3. NPRS 17.4 (4/23) 82.6 (19/23) 78.3 (18/23) 39.1 (9/23) 39.1 (9/23) 65.2 (15/23) 52.2 (12/23) 13.0 (3/23)
4. Mouth Mvt. 21.7 (5/23) 91.3 (21/23) 60.9 (14/23) 52.2 (12/23) 60.9 (14/23) 69.6 (16/23) 52.2 (12/23) 8.7 (2/23)
5. Pain Drawing 17.4 (4/23) 78.3 (18/23) 56.5 (13/23) 30.4 (7/23) 47.8 (11/23) 73.9 (17/23) 56.5 (13/23) 8.7 (2/23)
6. TMD Dis.Ind. 13.0 (3/23) 95.7 (22/23) 78.3 (18/23) 47.8 (11/23) 69.6 (16/23) 73.9 (17/23) 73.9 (17/23) 8.7 (2/23)
7. TMD Pain S. 21.7 (5/23) 60.9 (14/23) 56.5 (13/23) 52.2 (12/23) 43.5 (10/23) 56.5 (13/23) 34.8 (8/23) 4.3 (1/23)
8. GCPS 2 17.4 (4/23) 56.5 (13/23) 65.2 (15/23) 30.4 (7/23) 43.5 (10/23) 65.2 (15/23) 56.2 (13/23) 13.0 (3/23)
9. Mc Gill Q. 8.7 (2/23) 69.6 (16/23) 47.8 (11/23) 47.8 (11/23) 52.2 (12/23) 65.2 (15/23) 69.6 (16/23) 21.7 (5/23)
Physical examination tests (%, numbers/total numbers)
1. Phys.Mvt TMJ 56.5(13/23) 100 (23/23) 87.0 (20/23) 69.6 (16/23) 78.3 (18/23) 65.2 (15/23) 69.6 (16/23) 8.7 (2/23)
2. Palp mastic. M 34.8 (8/23) 91.3 (21/23) 60.9 (14/23) 69.6 (16/23) 87.0 (20/23) 60.9 (14/23) 39.1 (9/23) 8.7 (2/23)
3. Art palp 21.7 (5/23) 91.3 (21/23) 69.6 (16/23) 65.2 (15/23) 34.8 (8/23) 74.0(17/23) 47.8 (11/23) 13.0 (3/23)
4. Screen. Cerv. 21.7 (5/23) 78.3 (18/23) 60.9 (14/23) 56.5 (13/23) 87.0 (20/23) 60.9 (14/23) 56.5 (13/23) 8.7 (2/23)
5. Acc Mvt TMJ 13.0 (3/23) 87.0 (20/23) 60.9 (14/23) 73.9 (17/23) 78.3 (18/23) 56.5 (13/23) 34.8 (8/23) 4.3 (1/23)
6. Noise Reg. 21.7 (5/23) 78.3 (18/23) 60.9 (14/23) 56.5 (13/23) 47.8 (11/23) 69.6 (16/23) 56.5 (13/23) 13.0 (3/23)
7. Load Tests 21.7 (5/23) 91.3 (21/23) 56.5 (13/23) 65.2 (15/23) 73.9 (17/23) 56.5 (13/23) 39.1 (9/23) 8.7 (2/23)
8. Trp. Outside 17.4 (4/23) 82.6 (19/23) 60.9 (14/23) 78.3 (18/23) 78.3 (18/23) 69.6 (16/23) 52.2 (12/23) 8.7 (2/23)
|

9. Lat.Test 17.4 (4/23) 87.0 (20/23) 56.5 (13/23) 60.9 (14/23) 65.2 (15/23) 65.2 (15/23) 34.8 (8/23) 4.3 (1/23)
      695

(Continues)
 |
696      

TA B L E 5   (Continued)

1. Supporting neuromusculoskeletal diagnosis 3. Supporting both a 4. Other possible uses

neuromusculoskeletal
A) sufficient as B) imbedded C) Can be used 2. Supporting a diagnosis and the A) sufficient as a B) imbedded in
a stand-alone in a cluster of for the progress specific treatment choice of a specific stand-alone tool a cluster of tests C) Can be used for the
tool to support tests with the documentation or technique/ treatment technique/ to support the with the same progress documentation
  the diagnosis same purpose as a retest approach approach diagnosis purpose or as a retest

10. statistical 17.4 (4/23) 91.3 (21/23) 56.5 (13/23) 65.2 (15/23) 78.3 (18/23) 52.2 (12/23) 34.8 (8/23) 8.7 (2/23)
11. Head and neck 4.3 (1/23) 82.6 (19/23) 52.2 (12/23) 69.6 (16/23) 60.9 (14/23) 69.6 (16/23) 30.4 (7/23) 8.7 (2/23)
posture
12. load tests 21.7 (5/23) 95.7 (22/23) 65.2 (15/23) 56.5 (13/23) 60.9 (14/23) 65.2 (15/23) 43.5 (10/23) 8.7 (2/23)
13. Intra-oral tech. 13.0 (3/23) 78.3 (18/23) 47.8 (11/23) 56.5 (13/23) 65.2 (15/23) 73.9 (17/23) 47.8 (11/23) 8.7 (2/23)
14. dentalstick 21.7 (5/23) 91.3 (21/23) 56.5 (13/23) 65.2 (15/23) 73.9 (17/23) 56.5 (13/23) 39.1 (9/23) 8.7 (2/23)
15. mob with mvt. 13.0 (3/23) 69.6 (16/23) 39.1 (9/23) 52.2 (12/23) 47.8 (11/23) 47.8 (11/23) 34.8 (8/23) 8.7 (2/23)
16. Neck flexor 30.4 (7/23) 73.9 (17/23) 56.5 (13/23) 69.6 (16/23) 82.6 (19/23) 52.2 (12/23) 43.5 (10/23) 8.7 (2/23)
17. Noise reg. with 21.7 (5/23) 73.9 (17/23) 56.5 (13/23) 47.8 (11/23) 69.6 (16/23) 60.9 (14/23) 47.8 (11/23) 13.0 (3/23)
mvt.
18. PPT mast. 13.0 (3/23) 78.3 (18/23) 43.5 (10/23) 52.2 (12/23) 65.2 (15/23) 60.9 (14/23) 73.9 (17/23) 21.7 (5/23)

Note: Numbers in bold; highest or lowest values discussed during results in Round-3.
Abbreviations: Acc Mvt TMJ, accessory movements; Art palp, articular palpation; Dentalstick, Dentalstick-Test; GAD 7, Generalisied Anxiety Disorder Scale-7; GCPS 2, Graded Chronic Pain Scale Version
2; Intra-oral, Intra-oral examination for signs of parafunction habits; JFLS-20, Jaw Function Limitations Scale 20-item,Oral Beh., Oral Behaviors Checklist; JFLS-8, Jaw Function Limitations Scale 8-item;
Lat.Test, laterotrusion Test,Statical, statical tests,Head and neck, evaluation of the Head and neck posture; LDF-TMDQ/JFS, Limitations of Daily Functions in TMD Questionnaire (LDF-TMDQ/JFS); Load
tests, dynamic/static tests; Mc Gill Q., Mc Gill questionnaire; MFIQ, Mandibular Function Impairment Questionnaire (MFIQ); Mob.with mvt., Mobilisation with movement of the TMJ; Mouth Mvt., Mouth
movements pain; NDI, Neck Disability Index; Neck flexor, neck flexor muscle endurance test; Noise Reg., noise registration during movement Load tests, Dynamic and static load test of the TMJ; Noise
stethoscope, noise registration during movement with stethoscope; NPRS, Numeric Pain Rating Scale; Pain Drawing, Pain Drawing; Palp mastic. M., triggerpoint; palpation of masticatory muscles; PHQ 9,
Patient Health Questionnaire 9; Phys.Mvt TMJ, physiological TMJ movements; PPT mast., pressure pain thresholds of masticatory muscles outside the masticatory system;Screen. Cerv., screenings Test
cervical spine; TMD Dis.Ind., TMD Disability Index; TMD Pain S., TMD-Pain Screener; Trp.outside, triggerpoint-Palpation outside the masticatory system; TSK/TMD, The Tampa Scale for Kinesiophobia
for Temporomandibular Disorders (TSK/TMD); VAS, visual analog scale.
*The physical examination tests are the sum for all subcategories of the Axis I of the DC/TMD.
PIEKARTZ et al.
PIEKARTZ et al. |
      697

procedure to confirm the clinical neuromusculoskeletal diagnosis determine whether pain is triggered by mandibular movements.
(Q4A) and 73.9% (17/23) indicated the benefit of PPT of the masti- The second, the TMD Disability Index, may give an overall as-
catory muscles to support the prognosis (Q4B). In addition, 21.7% sessment of the function, pain intensity and also regarding other
(5/23) of the participants also used PPT of the masticatory system symptoms associated with TMD, such as tinnitus and dizziness.
for other uses such as including or excluding myofascial tissue dys- However, the authors of the present study found no validation
function in the diagnosis (Q4C). studies on these two assessment tools. An explanation could be
that the TMD Disability Index has only been used in case stud-
ies with the purpose to reassess patients individually. 22 The TMD
5 | D I S CU S S I O N Disability Index was preferably clustered with pain drawings and
with the NDI, suggesting that physical therapists use this tool in
This Delphi study obtained a consensus regarding the most use- combination with other tools during their search to recognise clini-
ful tools to evaluate pain and dysfunction in patients with TMD by cal patterns, along with general measurements for pain such as the
an international group of physical therapy experts in TMD. During NRS, GCPS and the McGill Pain Questionnaire. It may be assumed
three survey rounds, 23 international clinical or research experts that during this study, the experts claimed to use pain assessments
in TMD from 11 different countries evaluated three categories of in combination with other valid measurements to support the hy-
assessment tools, including 1) questionnaires, 2) pain screening pothesis of TMD and to find an indicator for a promising treatment
tools and 3) physical examination tests. After the three rounds, nine approach.
questionnaires, eight pain screening tests and 18 physical exami-
nation tests were considered clinically useful by the international
experts. The most useful tests considered by the experts included 5.3 | Physical examination tests
the following questionnaires: JFL-8, MFIQ, TSK/TMD and the NDI.
The useful assessments for pain screening were the VAS, the NRS After Round-2, an overview of all physical tests considered as useful
and pain provoked by mandibular movements. The recommended for the evaluation of patients with suspected TMD was provided to
physical examination tests included physiological TMJ movements, the clinical experts (see Figure 7). Among the 14 tests described in
TrP palpation of the masticatory muscles, TrP palpation outside the literature, the following were not familiar to all experts, such as
the masticatory system, accessory movements, articular palpation, the dental stick test, hyoid movement, mandibular nerve test and ten
noise detection during movement, manual screening of the cervical new tests suggested by individual experts. These 13 tests are not
spine and the Neck Flexor Muscle Endurance Test. regularly imbedded in research studies and have not been reviewed
for reliability and validity. 23
Nearly, all experts perform physiological mandibular movements
5.1 | Questionnaires and rated them as important for the reassessment during the treat-
ment process and also to distinguish between intra-articular disor-
Experts agreed that from the available questionnaires, a musculo- ders, degenerative joint disease and myogenic disorders. Experts
skeletal diagnosis was best supported by the TSK/TMD, followed sometimes used them as stand-alone tests to confirm their hypothe-
by JFL-8 and MFIG. All three questionnaires are focused on oro-fa- sis. For the assessment of painful myofascial TMD, manual palpation
cial daily functions such as eating, chewing, talking and (non)verbal was the preferred assessment for almost all experts in comparison to
functions of the mandible. The TSK/TMD also measures the dimen- the use of an algometer (PPT), which was comparable with the pro-
sion of fear associated with TMD (ie related to pain, joint sounds and posal of the DC/TMD consortium published in 2014 and illustrated
limited jaw movements) and may provide information about future in Figure 7, where different clinical physical tests are applied along
management strategies. The majority of experts (96%) rated the with the clinical diagnosis as described in the DC/TMD. Interestingly,
JFL-8 as an appropriate test when used in combination with physi- most physical therapy experts did not believe in an isolated phys-
cal tests to confirm the TMD diagnosis. Interestingly, the TSK/TMD ical test to support the clinical diagnosis. They preferred “cluster
reached higher scores than the LDF-TMDQ/JFS and MFIG, suggest- of tests” including inspection for posture, myofascial examination,
ing that clinical experts are frequently confronted with patients physiological examination and mandibular movements. Recent stud-
with TMD and kinesiophobia. This is particularly frequent in chronic ies highlighted that clinicians should look at a combination of assess-
patients, such as those with TMD and often associated with psycho- ment tests and functional tests for the diagnosis of musculoskeletal
social factors, such as depression and anxiety. 20,21 conditions such as patellofemoral pain syndrome, 25 cervicogenic
headache26,39or shoulder pain. 27 This was in accordance with the lit-
erature, where combinations of symptoms and a clinical test were
5.2 | Pain assessment tools considered to have a moderate to high reliability (k-values  >0.4).
This combination of tests assisted the clinician to sub-classify the
The experts recommended two ways to screen pain in subjects patients' presentation into arthrogenic, myogenic or neurogenic
with TMD. The first was the VAS during mandibular excursions to TMD. 24,28For example, when assessing cervical impairment, experts
 |
698       PIEKARTZ et al.

F I G U R E 7   Differentiation in the
choice of physical tests in percentages
during the main clinical diagnosis after
Round-3. Axis 1 within the DC/TMD
Axis 1 consortium 2014; myogenic TMD,
atherogenic TMD, degenerative TMD and
subluxation [Colour figure can be viewed
at wileyonlinelibrary.com]

preferred the craniocervical flexion test (endurance) and cervical therapy experts in the TMD field being small in comparison with
spine screening with manual techniques. The craniocervical flexion other areas such as the lumbar spine, cervical spine and shoul-
test is a clinical test of neuromotor control of the deep flexors of der. 30 Although we tried to represent different areas of specialty
the cervical spine. This test may be strongly associated with chronic and geographical regions with our experts, our findings may have
neck pain25-26,30,31 and cervicogenic headache.32 Experts suggested limited generalisability.
it should to be used to evaluate myogenic (64%) and mixed (74%) Despite the limitations, the results of this study demonstrated that
TMD Axis 1, as well as for chronic oro-facial pain (Axis II). Screening the proposed Delphi process was a useful method for reaching con-
of the cervical spine requires the use of valid cervical physical tests sensus in the physical therapy related to TMD assessment tools. From
with the aim of finding cervical impairments. These impairments can a clinical and research perspective, our study succeeded in demon-
play a role in determining the patients’ TMD complaints. It was noted strating an agreement of about 60% within the experts. There was a
by the experts that in those with TMD, cervical manual screening large overlap of the assessment tools used by physical therapists to
in Axis I (82.6%, 19/23) and Axis II (87.0%, 20/23) was useful. Most assess the TMD. Additionally, this study may promote collaboration
physical therapist experts were familiar with the clinical patterns and research with other disciplines that use the DC/TMD consortium.
classified in the DC/TMD and the strong association of cervical im-
pairments29 and TMD.36,37
7 | CO N C LU S I O N

6 |  S TR E N G TH S A N D LI M ITATI O N S This study was an international consensus of 23 clinical physical ther-
apy TMD experts from 11 countries on questionnaires, pain screening
Our study had some limitations. A Delphi study is based on a quali- tools and physical examination tests for the evaluation of TMD. The
tative analysis and does not have the sampling requirements of chosen assessments of the Delphi panel were based on a comprehen-
a randomised design. 38,39,40 We included 23 motivated experts sive evaluation of the literature before the first survey round and on
from around the world who were known (personally or through the opinion of international experts after the second round. The most
the publications) by the Delphi team. The number of participants used questionnaires by the panel of experts were TSK/TMD followed
in comparison with other Delphi studies in the physical therapy by JFL-8 and the MFIG. For pain screening assessment, the VAS and
area was small. This was probably due to the number of physical the TMD Disability Index were considered relevant by the panel of
PIEKARTZ et al. |
      699

experts. For physical examination tests, physiological mandibular 10. Stowell AW, Gatche RJ, Wildenstein L. Cost-effectiveness of
treatments for as usual. J Am Dent Assoc. 2007;138(2):202-208.
movement assessment, muscle palpation and cervical manual screen-
11. List T, Jensen R. Temporomandibular disorders: old ideas and new
ing were the preferred tests. Most experts were familiar with the DC/ concepts. Cephalalgia. 2017;37(7):692-704.
TMD classification and believe that physical examination tests need 12. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria
to be clustered to confirm subgroups in TMD (DC/TMD). This con- for Temporomandibular Disorders (DC/TMD) for Clinical and
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RDC/TMD Consortium Network* and Orofacial Pain Special
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Interest Group†. J Oral Facial Pain Headache. 2014;28(1):6-27.
clinical research, clinical practice and could allow collaboration with 13. Dworkin SF, LeResche L. „Research diagnostic criteria for tem-
other disciplines utilising the DC/TMD. poromandibular disorders: review, criteria, examinations and spec-
ifications, critique, J Craniomandib Disord. 1992;6(4):301-355.
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I, La Touche R. Management of pain in patients with temporo-
Thanks to Dr Dijkstra and Mr F. Grondin for contributing to the mandibular disorder (TMD): challenges and solutions. J Pain Res,
study up to round two. The study was approved by the Research 2018;11:571-587.
Ethics Commission of the University of Applied Science Osnabrück 15. Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A,
Stucki G. Use of the ICF model as a clinical problem-solving
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