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2006; 86:955-973.PHYS THER. Marega S Medlicott and Susan R HarrisTemporomandibular DisorderTraining, and Biofeedback in the Management of
RelaxationExercise, Manual Therapy, Electrotherapy, A Systematic Review of the Effectiveness of
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A Systematic Review of theEffectiveness of Exercise, ManualTherapy, Electrotherapy, RelaxationTraining, and Biofeedback in theManagement of TemporomandibularDisorder
Background and Purpose. This systematic review analyzed studies exam-ining the effectiveness of various physical therapy interventions fortemporomandibular disorder. Methods. Studies met 4 criteria: (1) sub-jects were from 1 of 3 groups identified in the first axis of the ResearchDiagnostic Criteria for Temporomandibular Disorders, (2) the interven-tion was within the realm of physical therapist practice, (3) an experi-mental design was used, and (4) outcome measures assessed one ormore primary presenting symptoms. Thirty studies were evaluatedusing Sackett’s rules of evidence and 10 scientific rigor criteria. Fourrandomly selected articles were classified independently by 2 raters(interrater agreement of 100% for levels of evidence and 73.5% formethodological rigor). Results. The following recommendations arosefrom the 30 studies: (1) active exercises and manual mobilizations maybe effective; (2) postural training may be used in combination withother interventions, as independent effects of postural training areunknown; (3) mid-laser therapy may be more effective than otherelectrotherapy modalities; (4) programs involving relaxation tech-niques and biofeedback, electromyography training, and propriocep-tive re-education may be more effective than placebo treatment orocclusal splints; and (5) combinations of active exercises, manualtherapy, postural correction, and relaxation techniques may be effec-tive. Discussion and Conclusion. These recommendations should beviewed cautiously. Consensus on defining temporomandibular jointdisorder, inclusion and exclusion criteria, and use of reliable and validoutcome measures would yield more rigorous research. [Medlicott MS,Harris SR. A systematic review of the effectiveness of exercise, manualtherapy, electrotherapy, relaxation training, and biofeedback in themanagement of temporomandibular disorder. Phys Ther. 2006;86:955–973.]
Key Words: Facial pain, Physical therapy, Rehabilitation, Temporomandibular disorder, Temporoman-
dibular joint syndrome, Therapy.
Marega S Medlicott, Susan R Harris
Physical Therapy . Volume 86 . Number 7 . July 2006 955
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Temporomandibular disorder (TMD) includes avariety of conditions associated with pain anddysfunction of the temporomandibular joint(TMJ) and the masticatory muscles.1 An esti-
mated 20% of the population is affected, with 10% to20% of those seeking treatment.2–5 These disorders alsoare referred to as “temporomandibular dysfunction,” “cra-niomandibular disorders,” and “mandibular dysfunction.”5
The presenting symptoms of TMD are: (1) intermittentor persistent pain in the masticatory muscles or the TMJ,and less frequently in adjacent structures; (2) limitationsor deviations of mandibular movement; and (3) TMJsounds.6 A variety of other symptoms, such as tinnitus,abnormal swallowing, and hyoid bone tenderness, alsomay occur.7 Quality of life may be affected, with anegative effect on social function, emotional health, andenergy level.6
Currently, there is lack of consensus among researchersregarding the etiology, diagnosis, and management ofthis disorder. The diagnosis of TMD is commonly basedon the presenting signs and symptoms.8 The ResearchDiagnostic Criteria for Temporomandibular Disorders(RDC/TMD) applies a dual-axis system to diagnose andclassify patients with TMD.6,8–10 The first axis is dividedinto 3 groups of commonly occurring TMDs:
1. Muscle disorders, including myofascial pain with andwithout limited mandibular opening.
2. Disk displacement with or without reduction or lim-ited mandibular opening.
3. Arthralgia, arthritis, and arthrosis.
The second axis includes a 31-item questionnaire, usedto evaluate relevant behavioral, psychological, and psy-chosocial factors (eg, pain status variables, depression,nonspecific physical symptoms, disability levels).6,8,10
Noninvasive, conservative treatments generally provideimprovement or relief of symptoms and are recom-mended in the initial management of TMD.11 Physicaltherapists are frequently involved in the management of
TMD, often in collaboration with dental professionals.In a survey of members of the American Dental Associ-ation, physical therapy was listed among the 10 mostcommon treatments used, involving 10% to 17% ofpatients.12 A wide variety of physical therapy techniques,including joint mobilization, exercise prescription, elec-trotherapy, education, biofeedback and relaxation, andpostural correction, have been used in the managementof this disorder.1,6,13
Research evaluating the effects of physical therapy in themanagement of TMD has been criticized for its lack ofmethodological rigor.14,15 However, recent studies haveattempted to address some previously identified limita-tions. Because much of the research examining theeffects of physical therapy on TMD has not been pub-lished in physical therapy journals, developing an evi-dence base for managing TMD is not easy.
This systematic review of randomized controlled trials(RCTs) and nonrandomized controlled trials assessedthe physical therapy management of acute and chronicTMD on clinically relevant outcomes such as pain, rangeof motion (ROM), disability and function, joint noise,tenderness, and psychological factors. Based on durationof the disorder, TMD was defined as acute (�6 months)or chronic (�6 months). Sackett’s levels of evidencefacilitate the categorization of studies according to thestrength of the research design and the degree ofcontrol for potential threats to internal validity.16,17
Based on 5 hierarchical levels of evidence, which havebeen used in previous systematic reviews of physicaltherapist practice, recommendations can be maderegarding treatment options.17,18
MethodThe literature search was restricted to English-languagepublications from 1966 through January 2005. IndexMedicus (MEDLINE), the Cumulative Index to Nursingand Allied Health Literature (CINAHL), and theCochrane Central Register of Controlled Trials weresearched using the text words “facial pain,” “physicaltherapy,” “rehabilitation,” “temporomandibular disor-der (TMD),” “temporomandibular joint (TMJ),” “tem-poromandibular joint syndrome,” and “therapy.”
MS Medlicott, BScPT, is Physical Therapist, Lion’s Gate Hospital, North Vancouver, British Columbia, Canada. Address all correspondence to MsMedlicott at 2759 Webster Rd, Nanaimo, British Columbia, Canada, V9R 6W7 (mmedlicott@hotmail.com).
SR Harris, PT, PhD, FAPTA, is Professor, School of Rehabilitation Sciences–Faculty of Medicine, University of British Columbia, Vancouver, BritishColumbia, Canada.
Ms Medlicott provided concept/idea/research design. Both authors provided writing and data collection and analysis. Dr Harris providedconsultation (including review of manuscript before submission).
This article was received June 6, 2005, and was accepted January 31, 2006.
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Study Selection CriteriaTo be included in the systematic review, studies had tomeet the following criteria: (1) subjects were from 1 ofthe 3 groups identified in the first axis of the RMC/TMD,6 (2) the intervention was within the realm ofphysical therapist practice, (3) an experimental designwas used (eg, an RCT or nonrandomized controlledtrial), and (4) the outcome measures assessed one ormore of the primary presenting symptoms (eg, pain,ROM, disability or function).
Studies with any of the following exclusion criteria werenot included in the review: (1) interventions post–TMJsurgery, (2) physical therapy interventions in combi-nation with other non–physical therapy interventions,(3) acupuncture as an intervention, (4) interventionsinvolving passive ROM devices. Studies that assessed onlyelectromyographic (EMG) results were not included.
Review CriteriaStudies were evaluated according to Sackett’s initial rulesof evidence,17 as described by Barry.16 These levels (I–V)are hierarchical and represent the confidence generatedby the results produced in the studies.
Level I: (a) systematic review (with homogeneity) ofRCTs
(b) individual RCT (with narrow confidenceinterval)
(c) all or none
Level II: (a) systematic review (with homogeneity) ofcohort studies
(b) individual cohort study, including low-quality RCTs (eg, �80% follow-up)
(c) “outcomes” research
Level III: (a) systematic review (with homogeneity) ofcase-control studies
(b) individual case-control studies
Level IV: case series (and poor-quality cohort and case-control studies)
Level V: expert opinion without explicit critical appraisal,or based on physiology, bench research, or “firstprinciples”
Methodological Quality of Reviewed StudiesMethodological rigor of the studies was evaluated usingthe following criteria, adapted from Megens and Har-ris18,19 and the McMaster Occupational TherapyEvidence-Based Practice Research Group20:
(1) randomization,
(2) inclusion and exclusion criteria were listed for thesubjects (and were subsequently grouped, by theprimary author of this review, into 1 the categorieson the first axis of the RMC/TMD),
(3) similarity of groups at baseline (if the study designused 2 or more groups),
(4) the treatment protocol was sufficiently described tobe replicable,
(5) reliability of data obtained with the outcome mea-sures was investigated,
(6) validity data obtained with the outcome measureswas addressed,
(7) blinding of patient, treatment provider, and assessor,
(8) dropouts were reported,
(9) long-term (6 months or greater) results wereassessed via follow-up, and
(10) adherence to home programs was investigated (ifincluded in the intervention).
We rated the methodological rigor of the study as“strong” (“yes” score of 8–10), “moderate” (“yes” scoreof 6 or 7), or “weak” (“yes” score of �5). To assess thereliability of different raters’ judgments in classifyingstudies, 4 randomly selected articles were independentlyreviewed and classified according to Sackett’s levels ofevidence17 and methodological rigor criteria by 2 differ-ent raters.
ResultsA large number of articles were identified that includedphysical therapy management of TMD. Many articleswere general reviews or were descriptive in nature. Ofthe 108 articles that reported experimental studies, 30articles met the inclusion criteria. No studies could belocated that solely assessed disability related to TMD.The primary reason for the exclusion of all except 30studies was the incorporation of non–physical therapymanagement, such as medication or surgery. Onereviewer completed the study literature search and thestudy selection and data abstraction.
Interrater agreement (percentage of agreement) on thelevels of evidence for each of the 4 studies independentlyreviewed was 100%. Interrater agreement, using theMcMaster University Critical Review Form for Quantita-tive Studies20 to assess methodological rigor, was 73.5%.
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The 30 studies included in this review were divided intogroups based on the primary intervention used. Four-teen studies4,9,21–34 investigated the use of exercise ormanual therapy, 8 studies5,35–41 investigated the use ofelectrotherapy, 7 studies42–49 investigated the use ofrelaxation training or biofeedback, and 1 study50 inves-tigated the use of exercise and electrotherapy. The studycharacteristics are summarized in Tables 1 through 3(see pages 962–970), organized according to primarytype of intervention.
Effect SizeEffect size r was calculated using Meta-Analysis Programsby Schwarzer.51 If means and standard deviations wereavailable, these data were used to calculate effect size r.In some cases, other statistics were reported, such as Fvalues or chi-square values, which were transformed intoan effect size r. A 95% confidence interval was subse-quently calculated.51 Effect size measurements can indi-cate the relative magnitude of the experimental treat-ment and can allow comparison of the magnitude ofexperimental treatments between experiments. The sug-gestion by Cohen52 that effect sizes of 0.20 are small, 0.50are medium, and 0.80 are large facilitates the compari-son of the effect size results of an experiment withknown benchmarks. Effect size was calculated for 24studies; however, due to lack of data, it was not alwayspossible to calculate effect sizes for all of the outcomemeasures utilized (ie, the remaining 6 studies lacked rawdata), although the results were reported in terms ofstatistical significance with P�.05.
Levels of EvidenceOf the 30 studies reviewed, 22 were RCTs and wereidentified as level IIb due to low study quality. Fourstudies27,28,30,31 had a single-group pretest-posttest designwith a nontreatment control period, 2 studies23,26 had acase series design, 1 study4 had a single-group random-ized (treatment or placebo) crossover design, and 1study40 involved 1 group with a randomized order oftreatments (treatment or placebo) within sessions (withsession 1 before session 2); these 8 studies were identi-fied as level IV due to the lack of a control group.
Scientific Rigor of the StudiesThe methodological rigor of the studies was evaluatedusing the 10 criteria shown in Table 4 (see page 971).The studies were organized in Table 4 according to scoreon the methodological criteria. The study quality scoresranged from 1 to 7.3, with a median score of 4.0 and amean score of 4.15. None of the studies could be judgedas “strong” (“yes” score of 8–10), 5 studies22,24,25,34,49
could be judged as “moderate” (“yes” score of 6 or 7), andthe remaining 25 studies4,5,9,21,23,26–28,30–32,35–43,45–48,50
would be considered “weak” (“yes” score or �5).
RandomizationSubjects were randomly assigned to 2 or more groups in24 studies,4,5,9,21,22,24,25,32,34–43,45–50 including the 2 stud-ies that involved cross-over designs. The 6 studies inwhich subjects were not randomly assigned to groupswere all single-group designs.23,26–28,30,31
Subject Inclusion and Exclusion CriteriaInclusion and exclusion criteria varied among the stud-ies and in relation to the subgroup of TMD diagnosis ofthe sample studied. Subjects were classified into sub-groups identified in the RDC/TMD. Seventeen stud-ies4,21,22,24,25,27,34,38,41–50 involved subjects with myofascialTMD, and 6 studies9,23,26,30,31,39 involved subjects withdisk displacement (1 study with subjects with reduc-tion,31 3 studies with subjects without reduction,23,26,30
and 2 studies with subjects with unspecified status as toreduction9,39). One other study37 involved subjects withmyofascial TMD (50%) and subjects with arthritis(50%). Six studies5,28,29,32,33,35,36,40 involved people witharthritis (2 studies with subjects with disk displacementwithout reduction, 1 study with 89% of the subjectshaving rheumatoid arthritis, 1 study with 56% of thesubjects having rheumatoid arthritis, 1 study with 64% ofthe subjects having ankylosing spondylitis, and 1 studyunspecified).
Studies involving subjects from all subgroups of TMDwere included in the systematic review, despite differ-ences among subgroups. Inclusion criteria were notidentified in 7 of the 30 studies. In 3 studies,21,32,46 areference source was provided, but criteria were nototherwise defined. In the other 4 studies,9,26,43,48 inclu-sion criteria were unclear.
For the 23 studies that described inclusion (and exclu-sion) criteria, 12 required self-reported symptoms, mostcommonly pain (ranging from 1 month to 1 year induration).22,24,25,27–29,31,34,41,42,47,50 The other 11 stud-ies4,5,23,30,35–39,45,49 required self-reported symptoms of anunspecified length of time. Five of the studies involvingsubjects with arthritic TMD23,28,29,36,40 required radiolog-ical evidence of osteoarthritis among the inclusion cri-teria. One study involving disk displacement30 requiredmagnetic resonance imaging (MRI) evidence. Sixstudies5,30,36,39,49,50 required that subjects have limitedmandibular movement. Evidence of “postural dysfunc-tion” was required in 3 studies,27,30,31 although posturaldysfunction was not defined in detail. Five of the studiesinvolving subjects with myofascial TMD4,22,39,42,50
required the presence of tenderness on palpation ofmasticatory muscles. Four studies25,27,31,42 also directlyreferenced the source of the inclusion criteria. Exclu-sion criteria tended to rule out a history of trauma ormalocclusion, prior or concurrent treatment for TMD,
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and specific contraindications relating to electrotherapymodalities.
Similarity of Groups at BaselineFourteen studies21,22,24,25,35,37–39,43,45–47,49,50 reported onthe similarity of groups at baseline.
Repeatability of the Treatment ProtocolOf the 14 studies involving exercise or manual therapy,9 studies4,9,21–23,25,26,32,34 provided sufficient descriptionto allow replication of the intervention. In the remaining6 studies,24,27–31 5 of which were by Nicolakis and col-leagues, exercises were not described in detail sufficientto replicate the treatments.
All studies involving electrotherapy as the primary inter-vention described the intervention in sufficient detail toallow for replication.5,36–42 Of the 8 studies involvingbiofeedback or education, 6 studies43,45–49 provided ade-quate information to allow replication of the interven-tion. Two studies42,43 failed to provide sufficient detailon the interventions utilized, preventing replication,although 1 study42 referred to a manual for the descrip-tion of the intervention involved.
Outcome Measure ReliabilityReliability of data obtained with the outcome measureswas reported in only 8 studies. Carmeli and colleagues9
reported intrarater reliability for the measurement ofactive ROM of the TMJ, whereas Taylor et al4 reportedinterrater reliability for maximal mandibular openingand lateral movement. Carlson and colleagues42
reported the internal consistency and intrarater reliabil-ity for subscales from the Multidimensional Pain Inven-tory (MPI) measuring pain severity, life interferencefrom pain, and perception of life control. This group ofresearchers also reported the internal consistency andintrarater reliability for the somatization, depression,anxiety, and obsessive-compulsive scales of the RevisedSymptom Checklist (SCL-90-R).42 Internal consistencyand intrarater reliability for the affective distress scalefrom the MPI, as well the internal consistency and theintrarater reliability for the sleep dysfunction scale, alsowere reported.42
Internal consistency and interrater reliability for themuscle palpation pain index (PPI) and internal consis-tency for credibility ratings were reported by Turk andcolleagues.49 Okeson and colleagues48 reported on theinternal consistency for muscle and TMJ palpation. Oneof the studies by Nicolakis and colleagues27 referencedthe reliability of scores for the visual analog scale(VAS).53 Wright et al34 referenced previously reportedintrarater and interrater reliability of data for the mod-ified symptom severity index (SSI-5 VAS), maximumpain-free opening, and muscle pain threshold.46,54,55 De
Laat and colleagues22 referenced the reliability of datafor the VAS, pressure pain threshold (PPT), and theMandibular Functional Impairment Questionnaire(MFIQ).56,57 Of the 8 studies that reported reliability ofdata for outcome measures, only 2 studies22,34 reportedreliability for all of the outcome measures used.
Outcome Measure ValidityValidity of data for outcome measures was reported in 3studies.22,34,35 Wright and colleagues34 indicated that thevalidity of data for their outcome measures had beenreported previously.48,53,54 Al-Badawi and colleagues35
indicated that the 10-point Numerical Pain Scale hadbeen reported to be statistically sensitive when measur-ing pain and discomfort.53 De Laat and colleagues22
referenced the smallest detectable difference on a VASto be considered clinically relevant in TMD secondary todisk displacement without reduction58 in subjects withmyofascial TMD. None of the other studies presentedany information on the validity for outcome measuresused.
In the 30 studies reviewed, over 75 different outcomemeasures were utilized. The outcomes of interest wereself-reported pain, pain on palpation, active ROM, EMGlevels, questionnaires regarding self-reported symptomseverity and frequency, dysfunction indexes related toimpairment, and psychological status scales. A largevariety of tools and other assessment methods were usedto measure the outcomes of interest with differentstudies using different tools or methods to evaluate thesame outcome.
Blind AssessmentBlinded treatment providers and outcome measureassessors were used in 11 of the 30 studies.9,22,25,34–38,40–42
Account for AttritionSubject attrition was reported in 15 of the 30studies.5,22,24,25,27,28,30,31,34,36,39,41,42,49,50 In the study byMoystad et al,40 6 subjects were inexplicably unac-counted for during the second phase of treatment. Inthe remaining 15 studies, subject attrition was not explic-itly described.
Long-Term Follow-upLong term-follow-up (6 months or greater) was reportedin 10 of the 30 studies reviewed,24,27–33,42,45,46,49 with the“long-term” assessment occurring from 6 months to 4years after treatment.
Adherence to Home ProgramsAlthough home intervention programs were explicitlyidentified in 20 of the 30 studies reviewed, the rateof adherence was not reported in 17 of thosestudies.9,21,22,27,28,30–32,39,42,43,45–50 Only 3 studies identi-
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fied the rate of adherence (via self-report). Magnussonand Syren24 reported adherence at long-term follow upas less than 50%, Wright and colleagues34 reported amean adherence of 75% after treatment, and Michelottiand colleagues25 reported adherence to the home phys-ical therapy regimen as poor (27%) or medium (46%).
Discussion and ConclusionsThe 22 RCTs included in the systematic review wereranked level II, using Sackett’s rules of evidence,17 due tolow study quality. The remaining 8 studies were rankedlevel IV due to decreased rigor of the research designs.
Feine and Lund15 performed an analysis of review arti-cles and controlled clinical trials to assess the efficacy ofphysical therapy and physical modalities for the controlof chronic musculoskeletal pain disorders, whichincluded TMD; they reported that symptoms improvedduring treatment with most forms of physical therapy,including placebo. Physical therapy was reported asalmost always better than no treatment, with efficacyincreasing in direct proportion to the amount of treat-ment received. In addition, those subjects who receivedmore treatment modalities seemed to do better thanthose who received fewer modalities.15
With respect to specific interventions, 4 systematicreviews were located, none of which were included in theanalysis performed by Feine and Lund.15 A 1996 system-atic review59 stated that there was insufficient evidence torefute or support either manipulation or mobilization intreatment of the TMJ. A more recent systematic review oflow-level laser therapy60 showed a reduction in pain andimprovement in health status in chronic joint disorders.However, a systematic review of ultrasound in the man-agement of chronic musculoskeletal disorders61 showedlittle evidence to support its use. A meta-analysis62 con-cluded that, although limited in extent, the availabledata support the efficacy of EMG biofeedback treat-ments for TMD.
Inclusion criteria varied among the studies we reviewed,likely due to the lack of consensus regarding the diag-nosis of TMD. The lack of standardized inclusion criteriais a limitation when comparing studies, as well as withrespect to the recommendations made. Subjects withmyofascial TMD were included in 60% of the studiesselected. The majority of patients who sought treatmentfor TMD and were subsequently involved in the studieswere women.63 This finding may relate to a difference intreatment-seeking behavior between men and women, aswell as the greater likelihood for women to have soma-tization disorders.63 The external validity of the recom-mendations is limited, due, in part, to the differences inthe groups studied. There also may be differencesbetween those who agree to participate in an RCT and
those who do not. For example, one study64 showed thatthe patients who refused to participate had more painand more condition-related interference in daily lifewhen compared with those who participated.
Temporomandibular disorder-related pain of �6months may represent a shift from acute to chronicTMD. Five of the studies in this review required aduration of pain for �6 months.4,24,34,49,50 The secondaxis of the RDC/TMD includes the more psychosocialaspects of TMD.6,8 Women and men who developchronic TMD display more psychosocial distress thanthose whose acute TMD resolves. Other predictors ofchronicity are TMD of the myofascial type and beingfemale.64,65
Within our systematic review, a variety of interventionswere used to treat the 3 TMD subgroups in the first axis.Interventions were grouped into 1 of 3 areas: exercise,electrotherapy, and biofeedback. Within the 3 areas, theinterventions were often heterogeneous, making com-parisons difficult. The use of multiple interventions in anumber of studies resulted in recommendations basedon a multi-intervention program because the effective-ness of a single intervention alone was not examined.
A spectrum of different outcome measures was used inthe studies reviewed. Most of the studies includedbetween 2 and 5 outcome measures. Although there wassome continuity in the outcome areas assessed, theactual measures differed among the studies, with over 75different methods used to assess the outcomes. Reliabil-ity was reported in only 8 studies,4,9,22,27,34,42,48,49 withonly 2 studies22,34 reporting reliability on all of theoutcome measures involved. Validity was reported in 3studies,22,34,35 with only 1 study34 reporting on all of theoutcome measures involved. Only 3 studies22,25,42
reported whether outcomes were clinically important.The lack of demonstrated reliability or validity for theoutcome measures used limits the confidence withwhich the results may be interpreted.
Five studies22,24,25,34,49 fulfilled 6 or more (of 10) criteriafor methodological rigor (Tab. 4). The majority of theremaining studies failed to report either reliability orvalidity for the outcome measures used, creating lessconfidence in the study results. The importance oflong-term follow-up to assess the retention of short-termtreatment effects is critical to examining the efficacy ofthe interventions involved.
This review has several limitations. Because only English-language articles were included, it is possible that thisreview is a not complete representation of the availableevidence. The review was limited to published articlesand thus may have missed those that were not submitted
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or accepted for publication, presenting a possible pub-lication bias. As only the first author preformed theliterature search and the subsequent selection of thestudies to be considered in this review, a selection biasmay be present. Additionally, the first author performedthe data abstraction, as well as a significant proportion ofthe rating and classification of the studies, which maypresent a data abstraction and evaluation bias.
Implications for Clinical PracticeDespite reported limitations of this systematic review ofthe scientific evidence for physical therapy interventionsfor TMD, the following clinical recommendations aresuggested:
(1) Active exercises and manual mobilizations, alone orin combination, may be effective in the short termin increasing total vertical opening (TVO) in peoplewith TMD resulting from acute disk displacement,acute arthritis, or acute or chronic myofascial TMD.A home exercise program was often included in thetreatment protocol.
(2) Postural training may be used in combination withother treatment techniques because the effects,independent of other treatments, are not known(eg, postural training combined with a home exer-cise program may decrease pain and increase TVOin people with myofascial TMD).
(3) Mid-laser therapy may decrease pain and improveTVO and lateral excursion in people with TMD
secondary to acute disk displacement and may bemore effective than other electrotherapy modalitiesin the short term, although comparison is difficult.
(4) Programs involving relaxation techniques andbiofeedback, EMG training, proprioceptive re-education may be more effective than placebo treat-ment or occlusal splints in decreasing pain andincreasing TVO in people with acute or chronicmyofascial or muscular TMD in the short term andthe long term.
(5) Programs involving combinations of active exer-cises, manual therapy, postural correction, andrelaxation techniques may decrease pain andimpairment and increase TVO in the short term inpeople with TMD resulting from acute disk displace-ment, acute arthritis, or acute myofascial TMD.However, it is impossible to discern whether acombination program is more effective than provid-ing the separate elements of the program as individ-ual treatment techniques.
Implications for Future ResearchThe foregoing clinical implications should be consid-ered with caution because none were supported bynumerous, decisive studies. Consensus on the definitionof TMD, and subsequent inclusion and exclusion crite-ria, would allow further comparison across groupsstudied. In addition, agreement on use of valid andreliable outcome measures would yield more rigorousresearch.
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Table
1.
Stud
ies
onEx
erci
sean
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lThe
rapy
a
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ors
Des
ign
and
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lof
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ence
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cts
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rven
tion
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om
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easu
res
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ultsb
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ultsb
Burg
ress
etal
,21
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lII
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,m
ean
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/R�
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astic
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imal
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thop
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ains
tres
ista
nce,
HP
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over
�3
wk)
McG
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res:
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A�
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�0.
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0.06
–0.7
0)—
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0.89
)—
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0.16
(�0.
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rted
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ge(P
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rom
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ES�
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Non
e
Car
mel
ieta
l,920
01RC
TLe
velI
IN
�36
DD
,F�
72%
,m
ean
age�
30.3
y,A
/R�
n/a
A:o
cclu
sals
plin
tB:
man
ualm
obili
zatio
nsan
dac
tive
exer
cise
s,H
P(�
15rx
over
5w
k)
Pain
leve
ls:ES
�0.
44(0
.13–
-.67)
TVO
:ES�
0.19
(�0.
15–0
.49)
Non
e
De
Laat
etal
,22
2003
RCT
Leve
lII
N�
26M
y,F�
85%
,m
ean
age�
42.5
y,A
/R�
22/2
6
A:e
duca
tion,
PT—
mas
sage
,ul
traso
und;
cont
inuo
us,5
min
,mus
cle
stret
chin
g,w
arm
pad,
HP
(18
rxov
er6
wk)
B:ed
ucat
ion
with
PT(a
spe
rA
)ini
tiate
daf
ter
2w
k(1
2rx
over
6w
k)
Pain
—VA
S,%
ofpa
inre
lief,
jaw
func
tion—
MFI
Q,
PPT
—D
ecre
ase
inpa
inin
Aan
dB
—In
crea
sein
jaw
func
tion
and
PPT
inA
and
B—
No
sign
ifica
ntdi
ffere
nces
betw
een
Aan
dB
Non
e
Jagg
er,2
319
91Pr
etes
t-pos
ttest,
case
serie
sLe
velI
V
N�
12D
Dw
ithou
tre
duct
ion,
F�67
%,
mea
nag
e�21
.8y,
A/R
�n/
a
Man
ualm
obili
zatio
n(1
rx)
TVO
:ES�
0.51
(0.1
3–0.
76)
Non
e
Mag
nuss
onan
dSy
ren,
24
1999
RCT
Leve
lII
N�
26ch
roni
cM
y,F�
n/a,
mea
nag
e�35
y,A
/R�
23/2
6
A:o
cclu
saln
ight
splin
tB:
activ
eex
erci
ses,
HP
(mea
n�4.
9rx
over
6m
o)C
:com
bina
tion
rxaf
ter
3m
o(n
�5)
(mea
n�9.
4rx
over
9m
o)
Clin
ical
and
anam
nesti
cdy
sfun
ctio
nin
dexe
s,be
havi
orra
ting
scal
e—
Gre
ater
impr
ovem
enti
ncl
inic
alpa
ram
eter
san
dse
lf-re
porte
dsy
mpt
oms
inA
and
B—
Incr
ease
inTV
Oin
B(n
osta
tistic
alan
alys
is)
6m
oan
d1–
4yr
:mai
nten
ance
ofim
prov
emen
tsin
Aan
dB
(no
statis
tical
anal
ysis
)
Mic
helo
ttiet
al,2
5
2004
RCT,
cont
rol
Leve
lII
N�
70M
y,F�
88%
,m
ean
age�
30y,
A/R
�49
/70
A:e
duca
tion,
rela
xatio
nte
chni
ques
,moi
sthe
atpa
ds,s
tretc
hing
,co
ordi
natio
nex
erci
ses,
HP
B:ed
ucat
ion
(4rx
over
3m
o)
No.
ofsi
tes
tend
erto
palp
atio
n:ES
�0.
05(�
0.23
–0.3
3)Pa
inin
tens
ity(V
AS)
:ES�
0.10
(�0.
19–0
.37)
Pain
-free
TVO
:ES�
0.29
(�0.
01–0
.53)
Pain
onch
ewin
g(V
AS)
:ES�
0.16
(�0.
13–0
.42)
Non
e
(con
tinue
d)
962 . Medlicott and Harris Physical Therapy . Volume 86 . Number 7 . July 2006 by guest on March 21, 2015http://ptjournal.apta.org/Downloaded from
Table
1.
Con
tinue
d
Auth
ors
Des
ign
and
Leve
lof
Evid
ence
Subje
cts
Inte
rven
tion
Outc
om
eM
easu
res
and
Res
ultsb
Follo
w-u
pRes
ultsb
Hea
dach
e(V
AS)
:ES�
0.03
(�0.
26–0
.31)
PPT
—M
asse
ter:
ES�
0.01
(�0.
28–0
.29)
—Te
mpo
ralis
:ES�
0.07
(�0.
22–0
.34)
Patie
nt-b
ased
treat
men
tcon
trast:
ES�
0.19
(�0.
10–0
.45)
Clin
icia
n-ba
sed
treat
men
tcon
trast:
ES�
0.09
(�0.
20–0
.36)
Tota
ltre
atm
entc
ontra
st:ES
�0.
19(�
0.10
–0.4
4)
Min
agie
tal,2
6
1991
Pret
est-p
ostte
st,ca
sese
ries
Leve
lIV
N�
35D
Dw
ithou
tre
duct
ion,
F�94
%m
ean
age�
36.4
y,A
/R�
n/a
Man
ualm
obili
zatio
n,1
rxTV
O:E
S�0.
58(0
.33–
0.76
)N
one
Nic
olak
iset
al,2
7
2002
Pret
est-p
ostte
st,pr
etre
atm
ent
cont
rolp
erio
d,ca
sese
ries
Leve
lIV
N�
20M
y,F�
80%
,m
ean
age�
34.5
y,A
/R�
20/2
0,6
mo
A/R
�19
/20
Act
ive
exer
cise
s,m
anua
lth
erap
y,po
stura
lco
rrec
tion,
rela
xatio
nte
chni
ques
,HP
(mea
n�10
.8rx
over
mea
nof
51.2
d)
Pain
atre
st:ES
�0.
19(�
0.13
–0.4
7)Pa
inat
stres
s:ES
�0.
41(0
.12–
0.64
)Im
pairm
ent:
ES�
0.57
(�0.
32–0
.75)
TVO
:ES�
0.40
(0.1
0–0.
63)
No.
ofpa
tient
sex
perie
ncin
gno
pain
atstr
ess:
ES�
0.58
(�0.
17–0
.82)
No.
ofpa
tient
sex
perie
ncin
gim
paire
dTV
O:
ES�
0.60
(�0.
21–0
.82)
Perc
eive
dim
prov
emen
tofj
awpa
in:E
S�0.
75(0
.46–
0.90
)Pe
rcei
ved
impr
ovem
ento
fjaw
func
tion:
ES�
0.75
(�0.
46–0
.90)
6m
oD
iffer
ence
betw
een
treat
men
tpe
riod
and
follo
w-u
p:ES
�0.
00(�
0.45
–0.4
5)
Nic
olak
iset
al,2
8
2001
Nic
olak
iset
al,2
9
2002
(3-y
follo
w-u
p)
Pret
est-p
ostte
st,pr
etre
atm
ent
cont
rolp
erio
d,ca
sese
ries
Leve
lIV
N�
20A
r,F�
90%
,m
ean
age�
48.8
y,A
/R�
20/2
0,6
mo
A/R
�19
/20,
3y
A/R
�17
/20
Act
ive
exer
cise
s,m
anua
lth
erap
y,po
stura
lco
rrec
tion,
rela
xatio
nte
chni
ques
,HP
(mea
n�10
.8rx
over
mea
nof
46.5
d)
No.
ofpa
tient
sex
perie
ncin
gno
pain
atstr
ess:
ES�
0.45
(�0.
01–0
.75)
No.
ofpa
tient
sex
perie
ncin
gno
impa
irmen
t:ES
�0.
42(�
0.05
–0.7
3)Pe
rcei
ved
impr
ovem
ento
fjaw
pain
:ES�
0.76
(0.4
7–0.
90)
Perc
eive
dim
prov
emen
tofj
awfu
nctio
n:ES
�0.
77(0
.50–
0.91
)
6m
oan
d3
y6
mo:
Perc
eive
dim
prov
emen
tofj
awpa
in:E
S�0.
02(�
0.44
–0.4
7)Pe
rcei
ved
impr
ovem
ento
fjaw
func
tion:
ES�
0.02
(�0.
44–
0.47
)
Nic
olak
iset
al,3
0
2001
Pret
est-p
ostte
st,pr
etre
atm
ent
cont
rolp
erio
d,ca
sese
ries
Leve
lIV
N�
20D
Dw
ithou
tre
duct
ion,
F�75
%,
mea
nag
e�37
.3y,
A/R
�20
/20,
6m
oA
/F�
18/2
0
Act
ive
exer
cise
s,m
anua
lth
erap
y,po
stura
lco
rrec
tion,
rela
xatio
nte
chni
ques
,HP
(mea
n�11
rxov
er51
.2d)
Pain
atre
st:ES
�0.
34(0
.03–
0.59
)Pa
inat
stres
s:ES
�0.
47(0
.19–
0.68
)Im
pairm
ent:
ES�
0.47
(0.1
9–0.
68)
TVO
:ES�
0.36
(0.0
5–0.
60)
No.
ofpa
tient
sex
perie
ncin
gno
pain
atstr
ess:
ES�
0.42
(�0.
02–0
.73)
No.
ofpa
tient
sex
perie
ncin
gim
paire
dTV
O:
ES�
0.66
(0.3
1–0.
86)
6m
o:Pe
rcei
ved
impr
ovem
ento
fjaw
pain
:ES�
0.05
(�0.
43–0
.50)
Perc
eive
dim
prov
emen
tofj
awfu
nctio
n:ES
�0.
25(�
0.25
–0.
64)
(con
tinue
d)
Physical Therapy . Volume 86 . Number 7 . July 2006 Medlicott and Harris . 963
������
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by guest on March 21, 2015http://ptjournal.apta.org/Downloaded from
Table
1.
Con
tinue
d
Auth
ors
Des
ign
and
Leve
lof
Evid
ence
Subje
cts
Inte
rven
tion
Outc
om
eM
easu
res
and
Res
ultsb
Follo
w-u
pRes
ultsb
Perc
eive
dim
prov
emen
tofj
awpa
in:E
S�0.
66(0
.31–
0.85
)Pe
rcei
ved
impr
ovem
ento
fjaw
func
tion:
ES�
0.72
(0.4
0–0.
88)
Nic
olak
iset
al,3
1
2000
Pret
est-p
ostte
st,pr
etre
atm
ent
cont
rolp
erio
d,ca
sese
ries
Leve
lIV
N�
30D
Dw
ithre
duct
ion,
F�93
%,
mea
nag
e�33
.1y,
A/R
�30
/30,
6m
oA
/R�
26/3
0
Act
ive
exer
cise
s,m
anua
lth
erap
y,po
stura
lco
rrec
tion,
rela
xatio
nte
chni
ques
,HP
(mea
n9.
9rx
over
30d)
Pain
atre
st:ES
�0.
52(0
.31–
0.69
)Pa
inat
stres
s:ES
�0.
70(0
.54–
0.81
)Im
pairm
ent:
ES�
0.65
(0.4
8–0.
78)
TVO
:ES�
0.15
(�0.
11–0
.39)
No.
ofpa
tient
sex
perie
ncin
gno
pain
atal
l:ES
�0.
42(0
.07–
0.68
)N
o.of
patie
nts
expe
rienc
ing
nopa
inat
rest:
ES�
0.32
(�0.
05–0
.61)
No.
ofpa
tient
sw
itha
TVO
�40
mm
:ES�
0.49
(0.1
5–0.
72)
Perc
eive
dim
prov
emen
tofj
awpa
in:E
S�0.
76(�
0.56
–0.8
8)Pe
rcei
ved
impr
ovem
ento
fjaw
func
tion:
ES�
0.74
(0.5
3–0.
87)
Perc
eive
dim
prov
emen
tofj
awcl
icki
ng:E
S�0.
48(0
.15–
0.72
)
6m
o:N
o.of
patie
nts
expe
rienc
ing
nopa
inat
all:
ES�
0.33
(�0.
07–0
.64)
No.
ofpa
tient
sex
perie
ncin
gno
pain
atre
st:ES
�0.
20(�
0.20
–0.5
5)N
o.of
patie
nts
with
aTV
O�
40m
m:E
S�0.
06(�
0.33
–0.
44)
Perc
eive
dim
prov
emen
tofj
awpa
in:E
S�0.
18(�
0.22
–0.5
3)Pe
rcei
ved
impr
ovem
ento
fjaw
func
tion:
ES�
0.29
(�0.
12–
0.61
)Pe
rcei
ved
impr
ovem
ento
fjaw
clic
king
:ES�
0.21
(�0.
19–
0.55
)
Tayl
oret
al,4
1994
Rand
omiz
ed,
plac
ebo,
cros
sove
rLe
velI
V
N�
15ch
roni
cM
y,F�
93%
,age
rang
e�20
–35
y,A
/R�
n/a
A:m
anua
lmob
iliza
tions
B:sh
amrx
(2rx
over
1d)
EMG
activ
ity:
—Re
sting
:ES�
0.40
(0.0
5–0.
67)
—O
pen/
clos
e:ES
�0.
33(�
0.03
–0.6
2)—
LT:E
S�0.
26(�
0.11
–0.5
7)—
Cle
nchi
ng:E
S�0.
42(0
.08–
0.68
)TV
O:E
S�0.
59(0
.29–
0.78
)LT
:ES�
0.47
(0.1
4–0.
71)
Non
e
Tege
lber
gan
dKo
pp,3
2
1988
Tege
lber
gan
dKo
pp,3
3
1996
(3y
follo
w-u
p)
RCT,
cont
rol
Leve
lII
N�
50A
r(5
6%RA
,64
%A
S),F
�64
%,
mea
nag
e�48
.1y,
A/R
�n/
a
A:a
ctiv
eRO
Mex
erci
ses,
HP
(1rx
over
3w
k)B:
norx
ESR,
CRP
,sev
erity
ofsy
mpt
oms
(5-p
oint
scal
e),
Hel
kim
oD
ysfu
nctio
nIn
dex,
CD
S,TV
O—
Dec
reas
ein
seve
rity
ofsy
mpt
oms
inA
and
B(g
reat
erin
A[R
A])
—Re
duct
ion
inC
DS
(RA
)and
incr
ease
inTV
Ogr
eate
rin
A—
No
chan
gein
ESR
and
CRP
inA
orB
3y
(n�
35):
—Re
duct
ion
inC
DS
mai
ntai
ned
clin
ical
(RA
)in
A—
Incr
ease
inTV
Om
aint
aine
din
A—
Incr
ease
inES
Rin
RA (con
tinue
d)
964 . Medlicott and Harris Physical Therapy . Volume 86 . Number 7 . July 2006 by guest on March 21, 2015http://ptjournal.apta.org/Downloaded from
Table
1.
Con
tinue
d
Auth
ors
Des
ign
and
Leve
lof
Evid
ence
Subje
cts
Inte
rven
tion
Outc
om
eM
easu
res
and
Res
ultsb
Follo
w-u
pRes
ultsb
Wrig
htet
al,3
4
2000
RCT,
cont
rol
Leve
lII
N�
60ch
roni
cM
y,F�
85%
,mea
nag
e�31
.8y,
A/R
�60
/61
A:p
ostu
ralc
orre
ctio
n,H
P(2
rxov
er2
wk)
B:no
rx
MM
SI—
TMD
:ES�
0.55
(0.3
5–0.
71)
—N
eck:
ES�
0.50
(0.2
8–0.
67)
TVO
:ES�
0.27
(0.0
2–0.
49)
Pres
sure
algo
met
erpa
inth
resh
old:
—M
asse
ter:
ES�
0.31
(0.0
6–0.
53)
—Tr
apez
ius:
ES�
0.36
(0.1
1–0.
56)
Perc
eive
dsy
mpt
omim
prov
emen
t—
TMD
:ES�
0.48
(0.2
6–0.
66)
—N
eck:
ES�
0.44
(0.2
1–0.
62)
Non
e
aA
�gr
oup
I,A
r�ar
thri
tis,
A/R
�an
alyz
ed/r
ando
miz
ed,
AS�
anky
losi
ng
spon
dylit
is,
B�
grou
pII
,C
�gr
oup
III,
CD
S�cl
inic
aldy
sfun
ctio
nsc
ore,
CR
P�C
-rea
ctiv
epr
otei
n,
DD
�di
skdi
spla
cem
ent(
s),
EM
G�
elec
trom
yogr
aph
y,E
S�ef
fect
size
(95%
con
fide
nce
inte
rval
),E
SR�
erth
rocy
tese
dim
enti
onra
te,
F�fe
mal
e,H
P�h
ome
prog
ram
,L
T�
late
ral
excu
rsio
n(l
eft
and
righ
t),
MFI
Q�
Man
dibu
lar
Fun
ctio
nIm
pair
men
tQ
uest
ion
nai
re,
MM
SI�
mod
ifie
dsy
mpt
omse
veri
tyin
dex,
My�
myo
fasc
ial/
mus
cula
r,n
/a�
data
not
avai
labl
e,PP
T�
pres
sure
pain
thre
shol
d,PR
I�pa
inra
tin
gin
ten
sity
,PT
�ph
ysic
alth
erap
y,R
A�
rheu
mat
oid
arth
riti
s,R
CT
�ra
ndo
miz
edco
ntr
olle
dtr
ial,
RO
M�
ran
geof
mot
ion
,rx
�tr
eatm
ent,
TM
D�
tem
poro
man
dibu
lar
diso
rder
,T
VO
�to
tal
vert
ical
open
ing,
VA
S�vi
sual
anal
ogsc
ale.
bSt
atis
tica
llysi
gnif
ican
tun
less
not
ed.
Physical Therapy . Volume 86 . Number 7 . July 2006 Medlicott and Harris . 965
������
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by guest on March 21, 2015http://ptjournal.apta.org/Downloaded from
Table
2.
Stud
ies
onEl
ectro
ther
apya
Auth
ors
Des
ign
and
Leve
lof
Evid
ence
Subje
cts
Inte
rven
tion
Outc
om
eM
easu
res
and
Res
ultsb
Follo
w-u
pRes
ultsb
Al-B
adaw
ieta
l,35
2004
RCT,
plac
ebo
Leve
lII
N�
40A
r,F�
78%
,age
rang
e�22
–55
y,A
/R�
n/a
A:P
RFE,
250
kHz,
pulse
d60
0H
z,6
�15
s,7-
sre
stin
terv
als
B:sh
amPR
FE,(
6rx
over
2w
k)
TMJp
ain:
ES�
0.66
(0.4
5–0.
81)
TVO
:ES�
0.14
(�0.
18–0
.43)
Righ
tLT:
ES�
0.88
(0.7
8–0.
94)
Left
LT:E
S�0.
88(0
.78–
0.94
)
Non
e
Berto
lucc
iand
Gra
y,5
1995
RCT,
plac
ebo
Leve
lII
N�
32A
r(w
ithD
Dw
ithou
tre
duct
ion)
,F�
n/a,
mea
nag
e�n/
a,A
/R�
32/3
3
A:m
id-la
ser,
904
nm,7
00H
z,27
W,
100%
pow
erou
tput
,9m
inB:
plac
ebo
mid
-lase
r(9
rxov
er3
wk)
Pain
inde
x:ES
�0.
82(0
.67–
0.91
)TV
O:E
S�0.
73(0
.51–
0.86
)LT
:ES�
0.84
(0.7
0–0.
92)
Non
e
Berto
lucc
iand
Gra
y,3
6
1995
RCT,
plac
ebo
Leve
lII
N�
48A
r(w
ithD
Dw
ithou
tre
duct
ion)
,F�
n/a,
mea
nag
e�n/
a,A
/R�
47/4
8
A:m
icro
curr
ente
lect
rical
neur
omus
cula
rsti
mul
atio
n;10
0�
A,0
.3H
z,10
min
B:m
id-la
ser,
904
nm,7
00H
z,27
W,
100%
pow
erou
tput
,9m
inC
:mid
-lase
rpl
aceb
o(9
rxov
er3
wk)
Pain
inde
x—
A�
B:ES
�0.
40(0
.06–
0.66
)—
A�
C:E
S�0.
74(0
.57–
0.85
)—
B�C
:ES�
0.83
(0.6
7–0.
91)
TVO
—A
�B:
ES�
0.40
(0.0
6–0.
66)
—A
�C
:ES�
0.52
(0.2
1–0.
74)
—B�
C:E
S�0.
73(0
.51–
0.86
)LT —
A�
B:ES
�0.
09(�
0.27
–0.4
3)—
A�
C:E
S�0.
83(0
.68–
0.92
)—
B�C
:ES�
0.80
(0.6
3–0.
90)
Non
e
Con
ti,3
719
97RC
T,pl
aceb
oLe
velI
IN
�20
50%
Ar
and
50%
My,
F�90
%,m
ean
age�
39.9
y,A
/R�
n/a
A:l
ow-le
vell
aser
,830
nm,1
00m
W,
4J,
40s
B:pl
aceb
ola
ser
(3rx
over
3w
k)
Pain
—VA
S,TV
O,L
T,PR
:no
diffe
renc
esin
impr
ovem
ents
betw
een
Aan
dB
Non
e
Gra
yet
al,3
819
95RC
T,pl
aceb
oLe
velI
IN
�13
9M
y,F�
86%
,age
rang
e�15
–30
y,A
/R�
139/
176
A:s
hort-
wav
edi
athe
rmy,
mild
ther
mal
setti
ng,1
0m
inB:
meg
apul
se,6
0-m
spu
lse,1
00pp
s,20
min
C:u
ltras
ound
,0.2
5W
/cm
2,3
MH
z,pu
lsed
at2:
1,2
min
D:l
aser
,904
nm,4
J/cm
2,3
min
E:pl
aceb
o(1
2rx
over
4w
k)
Impr
over
san
dno
nim
prov
ers
—A
:ES�
0.10
(�0.
37–0
.53)
—B:
ES�
0.10
(�0.
36–0
.52)
—C
:ES�
0.10
(�0.
35–0
.51)
—D
:ES�
0.10
(�0.
35–0
.52)
—E:
ES�
0.36
(�0.
21–0
.75)
TVO
,ove
rall
state
(5-p
oint
scal
e),j
oint
and
mus
cle
tend
erne
ssan
dso
unds
onpa
lpat
ion
3m
o,im
prov
ers
and
noni
mpr
over
s—
A:E
S�0.
15(�
0.32
–0.5
7)—
B:ES
�0.
14(�
0.31
–0.5
4)—
C:E
S�0.
14(�
0.30
–0.5
3)—
D:E
S�0.
14(�
0.14
–0.2
8)—
E:ES
�0.
91(�
0.71
–0.9
9)
Linde
etal
,39
1995
RCT
Leve
lII
N�
31D
D,F
�84
%,m
ean
age�
37y,
A/R
�n/
aA
:TEN
S,90
Hz,
30m
in,j
ustb
elow
pain
thre
shol
d,3�
per
day,
HP
B:oc
clus
alsp
lint(
6rx
in6
wk)
TVO
:ES�
0.01
(�0.
34–0
.37)
LT:E
S�0.
11(�
0.26
–0.4
4)PR
:ES�
0.28
(�0.
08–0
.58)
Sym
ptom
s(5
-and
6-ste
psc
ales
),pa
in—
VAS,
pain
track
devi
ce,
TVO
,ten
dern
ess
and
join
tso
unds
onpa
lpat
ion
—G
reat
erde
crea
sein
pain
inB
Non
e
(con
tinue
d)
966 . Medlicott and Harris Physical Therapy . Volume 86 . Number 7 . July 2006 by guest on March 21, 2015http://ptjournal.apta.org/Downloaded from
Table
2.
Con
tinue
d
Auth
ors
Des
ign
and
Leve
lof
Evid
ence
Subje
cts
Inte
rven
tion
Outc
om
eM
easu
res
and
Res
ultsb
Follo
w-u
pRes
ultsb
Moy
stad
etal
,40
1990
Rand
omiz
edor
der
oftre
atm
ents
with
inse
ssio
ns(tr
eatm
ent
sess
ion
1be
fore
2),p
lace
boLe
velI
V
N�
19,A
r(8
9%RA
)F�
89%
,mea
nag
e�33
y,A
/R�
n/a
1a:T
ENS,
100
Hz,
pulse
wid
th0.
15m
s,co
nsta
ntse
nsat
ion
TMJa
rea
1b:p
lace
bo,3
0m
in(2
rxov
er2
wk)
2a:T
ENS,
2H
z,pu
lsew
idth
0.2
ms,
acup
unct
ure
poin
ton
hand
2b:p
lace
bo,3
0m
in(2
rxov
er2
wk)
Pain
—VA
S,TM
Jand
mus
cle
tend
erne
sson
palp
atio
n(3
-po
ints
cale
),TV
O,L
T,an
dPR
—G
reat
erde
crea
sein
1a—
No
diffe
renc
ein
impr
ovem
ents
inal
loth
erar
eas
betw
een
grou
ps
Non
e
Taub
eet
al,4
119
98RC
T,pl
aceb
oLe
velI
IN
�49
My,
F�90
%,m
ean
age�
�46
.7y,
A/R
�49
/49
A:u
ltras
ound
,0.0
8W
/cm
2,p
ulse
dB:
ultra
soun
d,0.
5W
/cm
2,p
ulse
dC
:pla
cebo
,5m
inpe
rTM
J(m
ean�
8.9
rx)
TVO
,mus
cle
tend
erne
sson
palp
atio
n(3
-poi
ntsc
ale)
—N
odi
ffere
nce
inim
prov
emen
tsbe
twee
ngr
oups
Non
e
aA
�gr
oup
I,A
r�ar
thri
tis,
A/R
�an
alyz
ed/r
ando
miz
ed,
B�
grou
pII
,C
�gr
oup
III,
D�
grou
pIV
,D
D�
disk
disp
lace
men
t(s)
,E
�gr
oup
V,
ES�
effe
ctsi
ze(9
5%co
nfi
den
cein
terv
al),
F�fe
mal
e,H
P�h
ome
prog
ram
,L
T�
late
ral
excu
rsio
n(l
eft
and
righ
t),
My�
myo
fasc
ial/
mus
cula
r,n
/a�
data
not
avai
labl
e,pp
s�pu
lses
per
seco
nd,
PR�
prot
rusi
veex
curs
ion
,PR
FE�
puls
edra
dio
freq
uen
cyen
ergy
,PT
�ph
ysic
alth
erap
y,R
A�
rheu
mat
oid
arth
riti
s,R
CT
�ra
ndo
miz
edco
ntr
olle
dtr
ial,
rx�
trea
tmen
t,T
EN
S�tr
ansc
utan
eous
elec
tric
aln
erve
stim
ulat
ion
,T
MJ�
tem
poro
man
dibu
lar
join
t,T
VO
�to
tal
vert
ical
open
ing,
VA
S�vi
sual
anal
ogsc
ale.
bSt
atis
tica
llysi
gnif
ican
tun
less
not
ed.
Physical Therapy . Volume 86 . Number 7 . July 2006 Medlicott and Harris . 967
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by guest on March 21, 2015http://ptjournal.apta.org/Downloaded from
Table
3.
Stud
ies
onRe
laxa
tion
Trai
ning
and
Educ
atio
na
Auth
ors
Des
ign
and
Leve
lof
Evid
ence
Subje
cts
Inte
rven
tion
Outc
om
esM
easu
res
and
Res
ultsb
Follo
w-u
pRes
ultsb
Car
lson
etal
,42
2001
RCT
Leve
lII
N�
44M
y,F�
77%
,m
ean
age�
34.6
y,A
/R�
44/4
4,26
wk
A/R
�32
/44
A:b
reat
hing
and
postu
ralr
elax
atio
nte
chni
ques
,pro
prio
cept
ive
re-e
duca
tion,
HP
B:oc
clus
alsp
lint,
educ
atio
n(2
rxov
er3
wk)
Pain
mea
sure
s—
Dai
lyse
lf-m
onito
ring:
ES�
0.57
(0.3
3–0.
74)
—Pa
inse
verit
y:ES
�0.
67(0
.47–
0.81
)—
Life
inte
rfere
nce:
ES�
0.57
(0.3
3–0.
74)
—Lif
eco
ntro
l:ES
�0.
43(0
.15–
0.65
)Ph
ysic
alex
amin
atio
n—
Ope
ning
with
outp
ain:
ES�
0.45
(0.1
8–0.
66)
—O
peni
ngw
ithpa
in:E
S�0.
33(0
.04–
0.57
)—
Mus
cle
pain
inde
x:ES
�0.
44(0
.17–
0.65
)—
Aw
aren
ess
ofto
oth
cont
act:
ES�
0.72
(0.5
4–0.
84)
Psyc
holo
gic
varia
bles
—A
ffect
ive
distr
ess:
ES�
0.39
(0.1
1–-0
.62)
—So
mat
izat
ion:
ES�
0.33
(0.0
4–0.
57)
—D
epre
ssio
n:ES
�0.
28(�
0.02
–0.5
3)—
Anx
iety
:ES�
0.28
(�0.
02–0
.53)
—O
bses
sive
/com
pulsi
ve:E
S�0.
37(0
.08–
0.60
);—
Fatig
ue:E
S�0.
12(�
0.18
–0.4
0)O
vera
llsle
epdy
sfun
ctio
n:ES
�0.
32(0
.03–
0.56
)
26w
k:le
sspa
inan
dgr
eate
rTV
Oin
A
Cro
cket
teta
l,50
1986
RCT,
plac
ebo
Leve
lII
N�
21ch
roni
cM
y,F�
100%
,age
�19
y,m
ean
age�
n/a,
A/R
�21
/28
A:o
cclu
sals
plin
t,ho
t/co
ldap
plic
atio
n,po
stura
lcor
rect
ion,
activ
eex
erci
ses,
HP
B:m
uscl
ere
laxa
tion
train
ing,
EMG
biof
eedb
ack,
HP
C:m
inim
alrx
,TEN
S,10
0H
z,50
�A
,min
imal
sens
atio
n,30
min
,HP
(8rx
over
8w
k)
Pain
topa
lpat
ion
—A
�B:
ES�
0.06
(�0.
48–0
.58)
—A
�C
:ES�
0.25
(�0.
32–0
.69)
—B�
C:E
S�0.
19(�
0.38
–0.6
5)TV
O—
A�
B:ES
�0.
17(�
0.40
–0.6
4)—
A�
C:E
S�0.
01(�
0.53
–0.5
4)—
B�C
:ES�
0.15
(�0.
42–0
.63)
Wor
stpa
inra
ting
—A
�B:
ES�
0.25
(�0.
32–0
.69)
—A
�C
:ES�
0.17
(�0.
40–0
.64)
—B�
C:E
S�0.
10(�
0.46
–0.6
0)A
djec
tival
pain
ratin
g—
A�
B:ES
�0.
10(�
0.46
–0.6
0)—
A�
C:E
S�0.
08(�
0.47
–0.5
8)—
B�C
:ES�
0.16
(�0.
41–0
.64)
Ave
rage
wee
kly
frequ
ency
ofpa
in—
A�
B:ES
�0.
02(�
0.52
–0.5
5)—
A�
C:E
S�0.
75(0
.36–
0.92
)—
B�C
:ES�
0.58
(0.0
7–0.
85)
Ave
rage
wee
kly
pain
inte
nsity
—A
�B:
ES�
0.50
(�0.
05–0
.81)
—A
�C
:ES�
0.01
(�0.
53–0
.53)
—B�
C:E
S�0.
44(�
0.11
–0.7
9)
Non
e
(con
tinue
d)
968 . Medlicott and Harris Physical Therapy . Volume 86 . Number 7 . July 2006 by guest on March 21, 2015http://ptjournal.apta.org/Downloaded from
Table
3.
Con
tinue
d
Auth
ors
Des
ign
and
Leve
lof
Evid
ence
Subje
cts
Inte
rven
tion
Outc
om
esM
easu
res
and
Res
ultsb
Follo
w-u
pRes
ultsb
Dah
lstro
met
al,4
3
1982
Dah
lstro
man
dC
arlss
on,4
4
1984
RCT
Leve
lII
N�
30M
y,F�
100%
,m
ean
age�
28.6
y,A
/R�
n/a
A:o
cclu
sals
plin
t(2
rxov
er6
wk)
B:EM
Gbi
ofee
dbac
k,H
P(m
ean�
5.3
rxov
er6
wk)
Self-
repo
rted
sym
ptom
ratin
g:ES
�0.
15(�
0.23
–0.4
8)Se
lf-re
porte
dsy
mpt
oms—
5-po
ints
cale
,clin
ical
dysf
unct
ion
(Hel
kim
oIn
dex)
,TVO
—in
crea
sein
TVO
inB
12m
o:no
furth
ersi
gnifi
cant
chan
ges
Dal
enet
al,4
5
1986
RCT,
cont
rol
Leve
lII
N�
19M
y,F�
95%
,m
ean
age�
n/a,
A/R
�n/
a
A:E
MG
biof
eedb
ack,
HP
B:co
ntro
l(8
rxov
er4
wk)
EMG
—M
asse
ter:
ES�
0.39
(�0.
08–0
.72)
—Fr
onta
lis:E
S�0.
48(0
.04–
0.76
)EM
G1
wk
postt
reat
men
t(fro
ntal
is):
ES�
0.63
(0.2
6–0.
85)
EMG
8w
kpo
sttre
atm
ent(
front
alis
):ES
�0.
52(0
.08–
0.79
)Pa
indu
ratio
n:ES
�0.
85(�
0.65
–0.9
4)Pa
inin
tens
ityva
riabl
e:ES
�0.
76(0
.47–
0.90
)
6m
o—
EMG
12w
kpo
sttre
atm
ent
(fron
talis
):ES
�0.
63(0
.25–
0.84
)
Doh
rman
nan
dLa
skin
,46
1978
RCT,
plac
ebo
Leve
lII
N�
24M
y,F�
88%
,m
ean
age�
37y,
A/R
�n/
a
A:P
biof
eedb
ack,
HP
B:sh
ambi
ofee
dbac
k,H
P(1
2rx
over
6w
k)
EMG
:ES�
0.39
(�0.
01–0
.69)
Pain
(3-p
oint
scal
e),T
VO,p
ain-
free
TVO
,pai
non
mus
cle
palp
atio
n,se
lf-re
port
onjo
ints
ound
s,ov
eral
ltre
atm
ents
ucce
ss(p
atie
ntan
dex
amin
er),
EMG
leve
ls:—
Gre
ater
redu
ctio
nin
pain
and
tend
eron
palp
atio
nin
A—
Incr
ease
inTV
Oin
A(n
osta
tistic
alan
alys
is)
6an
d12
mo:
furth
errx
requ
ired
in25
%of
A(n
osta
tistic
alan
alys
is)
Hijz
enet
al,4
7
1986
RCT,
cont
rol
Leve
lII
N�
48M
y,F�
94%
,m
ean
age�
n/a,
A/R
�n/
a
A:o
cclu
saln
ight
splin
tB:
biof
eedb
ack
(10
rxov
er5
wk)
C:c
ontro
l(sp
lintt
hera
pyde
laye
d)
TVO
:ES�
0.89
(0.8
1–0.
94)
Join
tsou
nds:
ES�
0.88
(0.7
9–0.
93)
Grin
ding
:ES�
0.58
(0.3
5–0.
74)
Stuf
fed
ordu
llfe
elin
gin
ears
:ES�
0.53
(0.2
0–0.
71)
Jaw
mus
cle
stiffn
ess
onaw
aken
ing:
ES�
0.76
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nsity
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(0.8
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96)
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uenc
yof
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ds:E
S�0.
92(0
.85–
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)C
ontro
love
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wm
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S�0.
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)A
ttent
ion
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)H
elki
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)
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RCT
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,m
ean
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a
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P(4
–6rx
over
4–6
wk)
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erva
ble
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.69–
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)M
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)M
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tinue
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Table
3.
Con
tinue
d
Auth
ors
Des
ign
and
Leve
lof
Evid
ence
Subje
cts
Inte
rven
tion
Outc
om
esM
easu
res
and
Res
ultsb
Follo
w-u
pRes
ultsb
Turk
etal
,49
1993
RCT
cont
rol
Leve
lII
N�
58ch
roni
cM
y,F�
82%
mea
nag
e�34
.1y,
A/R
�78
/80
A:o
cclu
sals
plin
tB:
biof
eedb
ack,
stres
sm
anag
emen
ted
ucat
ion
C:w
aitin
glis
tcon
trolg
roup
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k)
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-D—
A�
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01(�
0.25
–0.2
7)—
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0.41
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62)
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0.24
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0.23
(�0.
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Table
4.
Eval
uativ
eC
riter
iafo
rSt
udie
sRe
view
ed
Aut
hor
Rand
omiz
atio
n
Incl
usio
nand
Excl
usio
nCr
iteri
a
Sim
ilari
tyof
Gro
ups
atBase
line
Rep
licabili
tyRel
iabili
tyV
alid
ity
Blin
din
g(a
�Pa
tient
,b
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ovid
er,
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sses
sor)
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pou
ts
Long
-Te
rmRes
ults
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renc
eTo
tal
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eLe
velo
fEv
iden
ce
Wrig
htet
al,3
420
00Y
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(c)
YN
Y7.
3/10
IIbD
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atet
al,2
220
03Y
YY
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Y(1
/3)
N(2
/3)
Y(c
)Y
NN
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10IIb
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helo
ttiet
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520
04Y
YY
YN
NY
(c)
YN
Y6.
3/10
IIbTu
rket
al,4
919
93Y
YY
YY
(1/4
)N
(3/4
)N
NY
YN
6.25
/10
IIb
Al-B
adaw
ieta
l,35
2004
YY
YY
NY
(1/2
)aY
(a,b
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NN
N/A
5.5/
9IIb
Mag
nuss
onan
dSy
ren,
24
1999
YY
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NN
NY
YY
6/10
IIb
Car
lson
etal
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2001
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/6)
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ti,37
1997
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lucc
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1995
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/A4.
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rtolu
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rman
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etal
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1995
YY
YY
NN
NN
NN
4/10
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019
90Yb
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6/9
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(1/2
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NN
NN
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01Y
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icol
akis
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2002
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/5)
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ess
etal
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1998
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lstro
man
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,198
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gan
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1988
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120
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8,2
9
2001
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NN
NN
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9IV
Nic
olak
iset
al,3
020
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N/A
NN
NN
YY
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9IV
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son
etal
,48
1983
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NY
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NN
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N2.
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IIb
Jagg
er,2
319
91N
eY
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1991
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ent
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od.
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ttes
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Physical Therapy . Volume 86 . Number 7 . July 2006 Medlicott and Harris . 973
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2006; 86:955-973.PHYS THER. Marega S Medlicott and Susan R HarrisTemporomandibular DisorderTraining, and Biofeedback in the Management of
RelaxationExercise, Manual Therapy, Electrotherapy, A Systematic Review of the Effectiveness of
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