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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 ([email protected]).

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.

956 . Medlicott and Harris Physical Therapy . Volume 86 . Number 7 . July 2006 by guest on March 21, 2015http://ptjournal.apta.org/Downloaded from


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%.

Physical Therapy . Volume 86 . Number 7 . July 2006 Medlicott and Harris . 957

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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,



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



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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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)



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)


��

��

��

��



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)



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.


��

��

��

��



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)



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.


��

��

��

��



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)



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

(0.6

1–0.

86)

Pain

inte

nsity

:ES�

0.93

(0.8

8–0.

96)

Freq

uenc

yof

pain

perio

ds:E

S�0.

92(0

.85–

0.95

)C

ontro

love

rja

wm

uscl

es:E

S�0.

96(0

.94–

0.98

)A

ttent

ion

toja

wm

uscl

eac

tivity

:ES�

0.67

(0.4

7–0.

80)

Jaw

mus

cle

rela

xatio

n:ES

�0.

97(0

.95–

0.98

)H

elki

mo

Dys

func

tion

Inde

x:ES

�0.

89(0

.82–

0.94

)

Non

e

Oke

son

etal

,48

1983

RCT

Leve

lII

N�

24M

y,F�

86%

,m

ean

age�

30y,

A/R

�n/

a

A:o

cclu

sals

plin

tB:

rela

xatio

nta

pe,2

0m

in,H

P(4

–6rx

over

4–6

wk)

Tota

lobs

erva

ble

pain

scor

es:E

S�0.

86(0

.69–

0.94

)M

axim

umco

mfo

rtabl

eTV

O:E

S�0.

89(0

.75–

0.95

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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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