Immediate Changes in Objective Tongue Mobility Assessment Following a Standardised Conservative Intraoral Myofascial Intervention: An Exploratory Analysis of Routine Clinical Data

1. Introduction

The tongue plays a central role in swallowing, speech, mastication and oral rest posture. Efficient tongue movement depends on coordinated activity of the intrinsic and extrinsic tongue muscles together with the mandible, suprahyoid musculature and surrounding neuromuscular structures. Reduced tongue mobility is clinically relevant to the assessment of ankyloglossia and orofacial myofunctional disorders [1,2,3,4]. Accurate assessment of tongue mobility therefore forms an important component of comprehensive functional evaluation. Objective assessment of tongue mobility has become increasingly important within contemporary orofacial myology and related disciplines. Commonly used clinical measurements include maximal mouth opening (MMO), tongue tip to incisive papilla (TTIP) and lingual–palatal suction (LPS), each providing complementary information regarding mandibular mobility as well as anterior and posterior tongue function. These measurements are frequently incorporated into the Tongue Range of Motion Ratio (TRMR), which standardises tongue mobility relative to maximal mouth opening and is increasingly used to support clinical assessment and communication among practitioners [5,6].

Among the available assessment methods, the Tongue Range of Motion Ratio (TRMR) has emerged as one of the most widely described functional measures of tongue mobility.

Published TRMR grading approaches include threshold values used to describe reduced anterior and posterior tongue mobility [5,6]. For the exploratory analysis in this study, anterior TRMR values below 50% and posterior TRMR values below 30% were classified as restricted [5,6]. Because these classifications may contribute to broader assessment of suspected ankyloglossia and subsequent treatment planning, it is clinically relevant to determine whether brief conservative intervention can alter either the underlying measurements or the resulting functional classification.

Although objective tongue mobility measurements are increasingly incorporated into diagnosis, treatment planning and, where appropriate, surgical decision-making, little evidence exists regarding whether these measurements may change immediately following a standardised conservative intraoral intervention. This is particularly relevant for ratio-based measures such as TRMR because the calculated value expresses tongue mobility relative to maximal mouth opening. Consequently, immediate changes in mandibular opening have the potential to influence ratio-based interpretation, even when absolute tongue mobility measurements improve.

Understanding whether conservative intervention can immediately influence objective tongue mobility measurements has potential implications for clinical assessment and interpretation. If immediate changes in these measurements occur, reassessment following a standardised conservative intervention may provide additional information regarding the relationship between absolute tongue mobility measurements and ratio-based indices before subsequent therapeutic or surgical decisions are made. At present, evidence addressing this question is limited.

The primary aim of this exploratory study was to investigate whether objective measurements of mandibular opening and tongue mobility changed immediately following a standardised approximately five-minute conservative intraoral intervention.

Secondary objectives were to examine changes in anterior and posterior Tongue Range of Motion Ratios (TRMR) and to explore whether participants crossed published TRMR classification thresholds. The study was designed to generate preliminary evidence to inform the design of future controlled investigations.

2. Materials and Methods

2.1. Study Design

This manuscript reports an exploratory analysis of anonymised routine clinical data collected using a pre–post repeated-measures assessment approach. Standardised objective measurements of mandibular opening and tongue mobility were obtained immediately before and immediately after a standardised approximately five-minute intraoral myofascial intervention delivered during routine clinical care. Each participant served as their own comparator. Clinical data were collected between November 2025 and May 2026 in two private Orofacial Myology and Temporomandibular Disorder practices in London, United Kingdom.

All participants received the same standardised YTM® Introductory Protocol as part of routine clinical care. The intervention was not introduced or modified for the purposes of the subsequent exploratory analysis, and all participants would have received the same protocol regardless of whether the anonymised clinical data were later analysed or published.

The protocol formed part of the routine clinical assessment pathway within the participating practices and was applied consistently irrespective of any subsequent decision to analyse anonymised clinical data.

2.2. Clinical Setting

Participants were assessed either during routine clinical appointments or during a standardised clinical assessment event in which the same assessment and intervention protocol was applied to all attendees.

2.3. Participants

Twenty consecutive participants (17 females and 3 males; aged 6–84 years) presenting to the participating practices with concerns relating to tongue mobility, orofacial function and/or temporomandibular symptoms were included.

Participants were eligible if they were able to follow verbal instructions, complete all assessment procedures and provide written informed consent. Written parental informed consent was obtained for the participant younger than 18 years of age.

All participants completed the standardised assessment and intervention protocol. No participants were excluded because of incomplete outcome measurements or protocol deviations.

2.4. Ethical Considerations

Participants received assessment and treatment as part of routine clinical care in two private Orofacial Myology and Temporomandibular Disorder practices or during a standardised clinical assessment event. All participants would have received the same standardised YTM® Introductory Protocol as part of their usual clinical care regardless of whether the anonymised clinical data were subsequently analysed or published. No additional clinical procedures were introduced solely for the purposes of the subsequent exploratory analysis.

Written informed consent for treatment and for the anonymised use of clinical data for research and publication was obtained from all participants prior to participation. Written parental informed consent was obtained for the participant younger than 18 years of age.

The subsequent analysis and reporting of anonymised clinical data were undertaken in accordance with applicable UK governance and data protection requirements.

2.5. Outcome Measures

Objective tongue mobility was assessed using four standardised measurements: maximal mouth opening (MMO), tongue tip to incisive papilla (TTIP), lingual–palatal suction (LPS), and the Tongue Range of Motion Ratio (TRMR) [5,6].

Maximal mouth opening (MMO) was measured as the maximum inter-incisal distance (mm) achieved during comfortable maximal mouth opening without pain limitation. MMO served as the reference measurement for subsequent ratio calculations.

Tongue tip to incisive papilla (TTIP) was measured as the maximum inter-incisal distance achieved while the participant elevated the tongue tip to the incisive papilla with the mouth open as widely as possible [5].

Lingual–palatal suction (LPS) was measured as the maximum inter-incisal distance achieved while maintaining complete tongue suction against the palate during maximal mouth opening. LPS provides a functional assessment of posterior tongue mobility [6].

The Tongue Range of Motion Ratio (TRMR) was calculated by expressing TTIP and LPS as a percentage of maximal mouth opening using the following equations:

Anterior TRMR (%) = (TTIP ÷ MMO) × 100

Posterior TRMR (%) = (LPS ÷ MMO) × 100

Expressing tongue mobility relative to maximal mouth opening standardises interpretation across individuals with differing mandibular opening capacities [5].

For the exploratory threshold analysis, anterior TRMR values below 50% and posterior TRMR values below 30% were classified as functionally restricted according to the published TRMR grading system [5,6].

For a subgroup of 10 participants aged 18 years or older, pain assessment formed part of routine clinical documentation. Pain was rated immediately before and immediately after the intervention using an 11-point Numerical Rating Scale ranging from 0, indicating no pain, to 10, indicating the worst possible pain [11]. Pain ratings were recorded across the eight treatment regions and analysed descriptively.

Five regions (lateral pterygoid, masseter, buccinator, zygomatic region, and digastric) were rated separately on the right and left sides, while three regions (upper lip, lower lip, and central lingual frenulum region) were rated once as midline structures; the resulting ratings were summed across all regions to generate a total pain score, with a theoretical range of 0 to 130.

2.6. Measurement Instrument

All measurements and interventions were performed using the YTM® Tool, a graduated handheld intraoral instrument incorporating engraved millimetre measurement scales, designed to standardise objective measurements and the application of conservative intraoral myofascial techniques. The tool was developed to provide consistent contact with intraoral soft tissues while facilitating standardised assessment and intervention across clinicians and participants.

The same YTM® Tool was used for all baseline and post-intervention procedures throughout the study.

The instrument was selected to facilitate consistent access to confined intraoral anatomical regions while standardising contact surface, treatment direction and pressure across participants. Standardisation using a dedicated instrument was intended to improve procedural reproducibility compared with manual application, which may vary according to clinician hand size, finger dimensions and anatomical access. The protocol itself is independent of the instrument and could be reproduced using another device with comparable design characteristics.

2.7. Intervention

Immediately following completion of the baseline assessment, each participant received a standardised approximately five-minute intraoral myofascial intervention delivered by one of three trained clinicians using the predefined YTM® Introductory Protocol.

The intervention targeted anatomical regions that contribute to mandibular movement and tongue mobility while maintaining an identical treatment sequence for all participants. Sequential intraoral treatment was applied to the following anatomical regions:

• lateral pterygoid
• masseter
• buccinator
• zygomatic region
• upper lip
• lower lip
• digastric
• central lingual frenulum region

Treatment was performed bilaterally where anatomically applicable. Three standardised treatment strokes were applied to each anatomical region before progressing to the next region in the predefined sequence. The central lingual frenulum region was treated along the midline.

All treatment strokes were delivered in the same direction, over the same anatomical distance, using identical stroke repetition and Pressure 2 as defined in the YTM® Introductory Protocol. Within the protocol, Pressure 2 was defined as gentle engagement of the superficial soft tissues while maintaining participant comfort.

The intervention required approximately five minutes to complete and was identical for all participants. The treatment sequence, duration, anatomical targets and number of treatment strokes were identical for all participants.

Immediately following completion of the intervention, all outcome measurements were repeated using the identical standardised assessment protocol.

The intervention duration reflected the routine clinical application of the standardised YTM® Introductory Protocol and was determined by the predefined treatment sequence rather than by participant characteristics or clinical response.

2.8. Measurement Standardisation

To minimise procedural and measurement variability, all three clinicians were trained in the standardised assessment and intervention protocol before commencement of the study and followed the same predefined assessment sequence, anatomical landmarks, treatment duration, number of treatment strokes and measurement procedures throughout the study.

Outcome measurements were obtained immediately before and immediately after intervention using identical participant positioning, verbal instructions and measurement techniques. No modifications to the assessment or intervention protocols were made during the study period.

Post-intervention measurements were obtained by the treating clinician using the same standardised measurement protocol.

All clinicians had prior experience in the assessment and delivery of the standardised protocol before participant recruitment commenced.

2.9. Statistical Analysis

Descriptive statistics were calculated for all outcome measures and are presented as mean ± standard deviation (SD) unless otherwise stated.

Pre- and post-intervention measurements of maximal mouth opening (MMO), tongue tip to incisive papilla (TTIP), lingual–palatal suction (LPS), and Tongue Range of Motion Ratios (TRMR) were analysed using paired t-tests. Wilcoxon signed-rank tests were performed as sensitivity analyses to assess the robustness of the findings. Statistical significance was defined as p < 0.05 (two-tailed).

As an exploratory secondary analysis, participants were classified according to the published TRMR threshold values (<50% for anterior TRMR and <30% for posterior TRMR), and changes in classification before and after intervention were summarised descriptively.

As this was an exploratory analysis of anonymised clinical data collected during routine clinical care, no formal sample size calculation was performed. The available consecutive participant dataset was analysed to generate preliminary evidence and inform the design of future controlled studies.

3. Results

3.1. Participant Characteristics

Twenty participants completed the assessment protocol and were included in the final analysis. The cohort comprised 17 females and 3 males, ranging in age from 6 to 84 years. All participants completed the baseline assessment, standardised intervention and immediate post-intervention assessment. No participants were excluded, and there were no missing outcome data.

Table 1. Participant characteristics.

Characteristic	Value
Participants (n)	20
Female	17 (85%)
Male	3 (15%)
Age range (years)	6–84
Completed study	20 (100%)
Missing data	0

Table 1. Participant characteristics.

Characteristic	Value
Participants (n)	20
Female	17 (85%)
Male	3 (15%)
Age range (years)	6–84
Completed study	20 (100%)
Missing data	0

3.2. Changes in Absolute Objective Measurements

Statistically significant immediate increases were observed in all three absolute objective measurements following the standardised intervention.

Mean maximal mouth opening increased from 35.5 ± 7.0 mm before intervention to 40.8 ± 6.5 mm after intervention, representing a mean increase of 5.3 mm (95% CI 3.54–6.96 mm; p < 0.001).

Mean tongue tip to incisive papilla distance increased from 26.2 ± 7.8 mm to 30.4 ± 8.5 mm, representing a mean increase of 4.2 mm (95% CI 2.02–6.28 mm; p < 0.001).

Mean lingual–palatal suction increased from 18.8 ± 6.6 mm to 22.1 ± 8.2 mm, representing a mean increase of 3.3 mm (95% CI 1.73–4.87 mm; p < 0.001).

Table 2. Changes in absolute objective measurements before and after intervention.

Outcome	Pre-intervention (Mean ± SD)	Post-intervention (Mean ± SD)	Mean Difference (95% CI)		p value
MMO (mm)	35.5 ± 7.0	40.8 ± 6.5	5.3 (3.54–6.96)		<0.001
TTIP (mm)	26.2 ± 7.8	30.4 ± 8.5	4.2 (2.02–6.28)		<0.001
LPS (mm)	18.8 ± 6.6	22.1 ± 8.2	3.3 (1.73–4.87)		<0.001

Table 2. Changes in absolute objective measurements before and after intervention.

Outcome	Pre-intervention (Mean ± SD)	Post-intervention (Mean ± SD)	Mean Difference (95% CI)		p value
MMO (mm)	35.5 ± 7.0	40.8 ± 6.5	5.3 (3.54–6.96)		<0.001
TTIP (mm)	26.2 ± 7.8	30.4 ± 8.5	4.2 (2.02–6.28)		<0.001
LPS (mm)	18.8 ± 6.6	22.1 ± 8.2	3.3 (1.73–4.87)		<0.001

Sensitivity analyses using the Wilcoxon signed-rank test produced results consistent with the paired t-test analyses for all absolute outcome measures (MMO, p = 0.00019; TTIP, p = 0.00189; LPS, p = 0.00106).

Effect sizes were large for all three absolute measures (Cohen's d_z = 1.45 for MMO, 0.92 for TTIP and 0.98 for LPS).

3.3. Changes in Ratio-Based Measurements

In contrast to the absolute measurements, group-level Tongue Range of Motion Ratios demonstrated minimal overall change following the intervention.

Mean anterior TRMR changed from 75.4 ± 20.9% to 75.3 ± 21.5% (mean difference −0.1%; p = 0.97).

Mean posterior TRMR changed from 54.0 ± 18.7% to 55.4 ± 22.5% (mean difference 1.5%; p = 0.46).

Table 3. Changes in Tongue Range of Motion Ratios.

Outcome	Pre-intervention	Post-intervention	Mean Difference	p value
Anterior TRMR (%)	75.4 ± 20.9	75.3 ± 21.5	−0.1	0.97
Posterior TRMR (%)	54.0 ± 18.7	55.4 ± 22.5	1.5	0.46

Table 3. Changes in Tongue Range of Motion Ratios.

Outcome	Pre-intervention	Post-intervention	Mean Difference	p value
Anterior TRMR (%)	75.4 ± 20.9	75.3 ± 21.5	−0.1	0.97
Posterior TRMR (%)	54.0 ± 18.7	55.4 ± 22.5	1.5	0.46

Sensitivity analyses using the Wilcoxon signed-rank test produced consistent findings, demonstrating no statistically significant changes in anterior TRMR (p = 0.717) or posterior TRMR (p = 0.629).

3.4. Exploratory TRMR Classification Analysis

Application of the published TRMR classification thresholds demonstrated minimal changes in functional classification following the intervention.

For anterior TRMR, one participant remained below the published threshold for functional restriction (<50%) both before and after intervention. Two participants changed from values above the threshold to below the threshold following intervention. No participants changed from restricted to non-restricted classification.

For posterior TRMR, two participants remained below the published threshold for functional restriction (<30%) before and after intervention. One participant changed from above the threshold to below the threshold following intervention. No participants changed from restricted to non-restricted classification.

Table 4. Exploratory TRMR classification changes following intervention.

Classification change	Anterior TRMR (<50%)	Posterior TRMR (<30%)
Restricted → Non-restricted	0	0
Non-restricted → Restricted	2	1
No category change	18	19

Table 4. Exploratory TRMR classification changes following intervention.

Classification change	Anterior TRMR (<50%)	Posterior TRMR (<30%)
Restricted → Non-restricted	0	0
Non-restricted → Restricted	2	1
No category change	18	19

3.5. Individual Response Analysis

Improvements in maximal mouth opening were observed in 18 of 20 participants (90%), tongue tip to incisive papilla distance (TTIP) in 17 participants (85%), and lingual–palatal suction (LPS) in 16 participants (80%). Simultaneous improvements in all three absolute measurements were observed in 13 participants (65%).

Anterior TRMR increased in 10 participants (50%), remained unchanged in one participant (5%), and decreased in nine participants (45%).

Posterior TRMR demonstrated an identical distribution, increasing in 10 participants (50%), remaining unchanged in one participant (5%), and decreasing in nine participants (45%).

3.6. Exploratory Pain Subgroup Analysis

Pain assessment formed part of routine clinical documentation for a subgroup of 10 participants aged 18 years or older and was therefore analysed descriptively. Pain was assessed using an 11-point Numerical Rating Scale (0–10) across the eight treatment regions immediately before and immediately after the intervention [11].

For each participant, pain ratings across the assessed treatment regions were summed to generate a total pain score. The mean total pain score decreased from 30.9 before intervention to 17.7 after intervention, representing a mean reduction of 13.2 points (42.7%).

As pain assessment was available only for this exploratory subgroup, no formal statistical analysis was performed and these findings should be interpreted cautiously.

4. Discussion

4.1. Principal Findings

This exploratory analysis investigated whether objective tongue mobility measurements changed immediately following a standardised approximately five-minute conservative intraoral intervention. Statistically significant immediate increases were observed in all absolute outcome measures, including maximal mouth opening (MMO), tongue tip to incisive papilla (TTIP), and lingual–palatal suction (LPS).

In contrast, group-level Tongue Range of Motion Ratios (TRMR) demonstrated little overall change despite statistically significant improvements in the underlying absolute measurements. Individual participant analysis demonstrated greater variability in ratio-based measures than in the corresponding absolute measurements, with both increases and decreases observed following intervention.

Exploratory analysis using published TRMR threshold values demonstrated that a small number of participants changed functional classification despite stable or improved absolute tongue mobility measurements.

Collectively, these findings suggest that immediately modifiable functional components may contribute to the interpretation of objective tongue mobility assessment and, consequently, the interpretation of ratio-based tongue mobility measures. Accordingly, absolute measurements and ratio-derived measures should be interpreted together rather than in isolation.

4.2. Interpretation of Findings

The immediate improvements observed in MMO, TTIP and LPS suggest that objective measures of mandibular opening and tongue mobility may be influenced by functional factors that are capable of changing over a short period following conservative intervention. As this study did not include a control or comparator group, it cannot determine whether the observed changes resulted from the intervention itself or from non-specific influences such as repeated testing, participant familiarisation, expectancy effects, or a combination of these factors. Nevertheless, the consistency of improvement across the absolute measurements suggests that immediate changes in objective tongue mobility warrant further investigation.

The findings also highlight an important distinction between absolute measurements and ratio-derived indices. TRMR expresses tongue mobility as a proportion of maximal mouth opening rather than as an absolute measure. Consequently, changes in mandibular opening may alter the calculated ratio independently of changes in tongue excursion. This may explain why group-level TRMR values remained relatively stable despite significant improvements in the underlying absolute measurements.

The exploratory threshold analysis further illustrates this concept. A small number of participants crossed published TRMR classification thresholds despite stable or improved absolute tongue mobility measurements. Although these observations should be interpreted cautiously, they raise the possibility that functional classification based solely on ratio-derived measures may be influenced by immediately modifiable changes in mandibular opening. Accordingly, ratio-derived classifications should always be interpreted alongside the underlying absolute measurements and within the broader clinical context.

4.3. Clinical Relevance

Objective tongue mobility measurements are increasingly incorporated into multidisciplinary assessment of suspected tongue mobility restriction and may contribute, alongside clinical examination and symptom presentation, to conservative management, multidisciplinary rehabilitation and, where appropriate, surgical referral.

Importantly, this study does not suggest that conservative intervention should replace established therapeutic or surgical management where clinically indicated. Rather, it raises the question of whether immediately modifiable functional components of tongue mobility restriction should be considered during assessment before concluding that an observed restriction primarily reflects a fixed structural limitation.

Accordingly, clinicians may wish to consider the potential contribution of immediately modifiable functional components as part of objective tongue mobility assessment before making definitive therapeutic or surgical decisions. When clinically appropriate, reassessment following a brief standardised conservative intervention may provide additional information to support interpretation of objective tongue mobility measurements. Whether such an approach improves diagnosis, treatment planning or patient outcomes remains unknown and requires evaluation in future controlled studies.

Although assessed in only a subgroup of participants, the observed reduction in pain following the intervention is consistent with reports of pain reduction following manual therapy for temporomandibular disorders and warrants investigation as a predefined secondary outcome in future controlled studies [7,8,9].

4.4. Comparison with Previous Literature

Previous studies have established the clinical utility of objective tongue mobility assessment and the use of TRMR as a functional measure of tongue mobility [5,6]. However, little published evidence has examined whether these measurements can change immediately following a brief conservative intraoral intervention.

The present findings therefore complement the existing literature by demonstrating that measurable immediate changes in objective tongue mobility measurements are possible following a standardised conservative intervention. While these observations do not establish causality, they highlight the importance of considering both absolute measurements and ratio-derived measures when interpreting objective tongue mobility.

Accordingly, the present findings should be regarded as hypothesis-generating and provide a rationale for future controlled investigations rather than evidence for modification of current clinical assessment pathways.

Systematic reviews of manual therapy for temporomandibular disorders have reported improvements in maximal mouth opening in some patient groups, although intervention methods, clinical populations and study quality vary considerably [7,8,9]. Proposed explanations for short-term changes following manual intervention include interacting mechanical, neurological and contextual responses; however, the present study was not designed to investigate the mechanism underlying the observed changes [10].

4.5. Strengths and Limitations

This study has several strengths. A predefined standardised intervention protocol was applied consistently across all participants using identical treatment sequencing, anatomical landmarks, intervention duration and measurement procedures. Immediate pre- and post-intervention assessments minimised the influence of longer-term confounding factors and enabled evaluation of immediate changes in objective measurements.

The study also has important limitations. The sample size was small and participants were recruited from private clinical practice, limiting generalisability. The absence of a control group means that improvements cannot be attributed solely to the intervention, and repeated measurement or participant familiarisation may have contributed to the observed changes. In addition, only immediate effects were evaluated; the persistence and clinical significance of these changes remain unknown.

The intervention was delivered by experienced clinicians trained in the standardised protocol; therefore, the findings may not be directly generalisable to clinicians without equivalent training.

Pain outcomes were available only for a subgroup of participants aged 18 years or older as part of routine clinical documentation and should therefore be interpreted as exploratory observations.

As the intervention utilised a protocol developed by the corresponding author, the potential for investigator allegiance bias should also be considered. Independent replication by researchers not involved in development of the protocol will be important to evaluate its reproducibility and generalisability.

Outcome measurements were obtained by the treating clinician immediately before and immediately after the intervention, reflecting routine clinical practice. Consequently, assessor blinding was not feasible and measurement bias cannot be excluded.

Formal assessment of inter-rater and intra-rater reliability was not undertaken and should be evaluated in future studies.

As with routine clinical measurements obtained using a graduated handheld instrument with engraved millimetre measurement scales, small measurement variability is inevitable despite standardised procedures. Accordingly, all measurements should be interpreted as clinical estimates rather than exact values.

4.6. Future Research

Larger controlled studies are required to determine whether the immediate changes observed in objective tongue mobility measurements exceed those associated with repeated assessment alone. Future investigations should determine whether incorporation of a standardised conservative pre-assessment intervention influences functional classification, clinician interpretation, multidisciplinary treatment planning or recommendations for surgical management compared with conventional assessment alone.

Future studies incorporating blinded assessors, repeated baseline measurements, comparison groups and longer-term follow-up will be important to distinguish intervention effects from repeated testing or participant familiarisation and to establish the reproducibility, durability and clinical significance of the observed findings.

Such studies should also investigate whether incorporating a brief standardised conservative intervention before objective assessment improves diagnostic consistency, inter-clinician agreement and clinical decision-making.

5. Conclusions

This exploratory study demonstrated statistically significant immediate increases in objective measures of mandibular opening and tongue mobility following a standardised approximately five-minute conservative intraoral myofascial intervention. Although group-level Tongue Range of Motion Ratios demonstrated little overall change, exploratory analysis indicated that ratio-based functional classifications may vary despite stable or improved absolute tongue mobility measurements.

These findings suggest that objective tongue mobility assessment may be influenced by immediately modifiable functional components. Consideration of these components during assessment may assist clinicians when interpreting objective tongue mobility measurements before definitive therapeutic or surgical decision-making.

As this exploratory analysis did not include a control group, the observed immediate changes cannot be attributed solely to the intervention and may also reflect repeated assessment, participant familiarisation or other non-specific factors. Larger controlled studies are warranted to determine whether incorporation of a standardised conservative pre-assessment intervention improves clinical assessment, treatment planning and recommendations for surgical management.