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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) subjects were from 1 of 3 groups identified in the first axis of the Research

Diagnostic 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 Sacketts 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 may be effective; (2) postural training may be used in combination withother interventions, as independent effects of postural training are

unknown; (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 be viewed cautiously. Consensus on defining temporomandibular joint disorder, 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, manual

therapy, electrotherapy, relaxation training, and biofeedback in themanagement of temporomandibular disorder. Phys Ther . 2006;86:955973.]

Key Words: Facial pain, Physical therapy, Rehabilitation, Temporomandibular disorder, Temporoman-

dibular joint syndrome, Therapy.

Marega S Medlicott, Susan R Harris

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Temporomandibular disorder (TMD) includes a variety 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. 25 These disorders alsoare referred to as temporomandibular dysfunction, cra-

niomandibular disorders, and mandibular dysfunction.5

The presenting symptoms of TMD are: (1) intermittent or 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 of this 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. 6,810 The first axis is dividedinto 3 groups of commonly occurring TMDs:

1. Muscle disorders, including myofascial pain with and without 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 Physical

therapists 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 most common treatments used, involving 10% to 17% of patients. 12 A wide variety of physical therapy techniques,including joint mobilization, exercise prescription, elec-trotherapy, education, biofeedback and relaxation, and

postural correction, have been used in the management of this disorder. 1,6,13

Research evaluating the effects of physical therapy in themanagement of TMD has been criticized for its lack of methodological 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). Sacketts levels of evidencefacilitate the categorization of studies according to thestrength of the research design and the degree of control for potential threats to internal validity. 16,17Based on 5 hierarchical levels of evidence, which havebeen used in previous systematic reviews of physical

therapist 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, Lions 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 SciencesFaculty 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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The 30 studies included in this review were divided intogroups based on the primary intervention used. Four-teen studies 4,9,2134 investigated the use of exercise ormanual therapy, 8 studies 5,3541 investigated the use of electrotherapy, 7 studies 4249 investigated the use of relaxation training or biofeedback, and 1 study 50 inves-tigated the use of exercise and electrotherapy. The study

characteristics are summarized in Tables 1 through 3(see pages 962970), organized according to primary type of intervention.

Effect Size Effect 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 F values 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 of experimental treatments between experiments. The sug-gestion by Cohen 52 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 of statistical significance with P .05.

Levels of Evidence Of the 30 studies reviewed, 22 were RCTs and wereidentified as level IIb due to low study quality. Fourstudies 27,28,30,31 had a single-group pretest-posttest design with a nontreatment control period, 2 studies 23,26 had acase series design, 1 study 4 had a single-group random-ized (treatment or placebo) crossover design, and 1study 40 involved 1 group with a randomized order of treatments (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 810), 5 studies 22,24,25,34,49could be judged as moderate (yes score of 6 or 7), andthe remaining 25 studies 4,5,9,21,23,2628,30 32,3543,45 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 43,4550 including the 2 stud-ies that involved cross-over designs. The 6 studies in which subjects were not randomly assigned to groups were all single-group designs. 23,2628,30,31

Subject Inclusion and Exclusion Criteria Inclusion and exclusion criteria varied among the stud-ies and in relation to the subgroup of TMD diagnosis of the sample studied. Subjects were classified into sub-groups identified in the RDC/TMD. Seventeen stud-ies4,21,22,24,25,27,34,38,4150 involved subjects with myofascialTMD, and 6 studies 9,23,26,30,31,39 involved subjects withdisk displacement (1 study with subjects with reduc-tion, 31 3 studies with subjects without reduction, 23,26,30and 2 studies with subjects with unspecified status as toreduction 9,39 ). One other study 37 involved subjects withmyofascial TMD (50%) and subjects with arthritis(50%). Six studies 5,28,29,32,33,35,36,40 involved people witharthritis (2 studies with subjects with disk displacement without reduction, 1 study with 89% of the subjectshaving rheumatoid arthritis, 1 study with 56% of thesubjects having rheumatoid arthritis, 1 study with 64% of the subjects having ankylosing spondylitis, and 1 study unspecified).

Studies involving subjects from all subgroups of TMD were included in the systematic review, despite differ-ences among subgroups. Inclusion criteria were not identified in 7 of the 30 studies. In 3 studies, 21,32,46 areference source was provided, but criteria were not

otherwise 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, most commonly pain (ranging from 1 month to 1 year induration). 22,24,25,2729,31,34,41,42,47,50 The other 11 stud-ies4,5,23,30,3539,45,49 required self-reported symptoms of anunspecified length of time. Five of the studies involvingsubjects with arthritic TMD 23,28,29,36,40 required radiolog-ical evidence of osteoarthritis among the inclusion cri-teria. One study involving disk displacement 30 required

magnetic resonance imaging (MRI) evidence. Sixstudies 5,30,36,39,49,50 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 TMD 4,22,39,42,50required the presence of tenderness on palpation of masticatory muscles. Four studies 25,27,31,42 also directly referenced 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 electrotherapy modalities.

Similarity of Groups at Baseline Fourteen studies 21,22,24,25,35,3739,43,4547,49,50 reported onthe similarity of groups at baseline.

Repeatability of the Treatment Protocol Of the 14 studies involving exercise or manual therapy,9 studies 4,9,2123,25,26,32,34 provided sufficient descriptionto allow replication of the intervention. In the remaining6 studies, 24,2731 5 of which were by Nicolakis and col-leagues, exercises were not described in detail sufficient to replicate the treatments.

All studies involving electrotherapy as the primary intervention described the intervention in sufficient detail toallow for replication. 5,3642 Of the 8 studies involvingbiofeedback or education, 6 studies 43,4549 provided ade-quate information to allow replication of the interven-tion. Two studies 42,43 failed to provide sufficient detailon the interventions utilized, preventing replication,although 1 study 42 referred to a manual for the descrip-tion of the intervention involved.

Outcome Measure Reliability Reliability of data obtained with the outcome measures was reported in only 8 studies. Carmeli and colleagues 9reported intrarater reliability for the measurement of active ROM of the TMJ, whereas Taylor et al 4 reportedinterrater reliability for maximal mandibular openingand lateral movement. Carlson and colleagues 42

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 of researchers 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 consistency and intrarater reliability for the affective distress scalefrom the MPI, as well the internal consistency and theintrarater reliability for the sleep dysfunction scale, also were 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 colleagues 48 reported on theinternal consistency for muscle and TMJ palpation. Oneof the studies by Nicolakis and colleagues 27 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 colleagues 22 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 of data for outcome measures, only 2 studies 22,34 reportedreliability for all of the outcome measures used.

Outcome Measure Validity Validity of data for outcome measures was reported in 3studies. 22,34,35 Wright and colleagues 34 indicated that the validity of data for their outcome measures had beenreported previously. 48,53,54 Al-Badawi and colleagues35indicated that the 10-point Numerical Pain Scale hadbeen reported to be statistically sensitive when measur-ing pain and discomfort. 53 De Laat and colleagues 22referenced the smallest detectable difference on a VASto be considered clinically relevant in TMD secondary todisk displacement without reduction 58 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 large variety of tools and other assessment methods were usedto measure the outcomes of interest with different studies using different tools or methods to evaluate thesame outcome.

Blind Assessment Blinded treatment providers and outcome measureassessors were used in 11 of the 30 studies. 9,22,25,3438,40 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 by Moystad 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-up Long term-follow-up (6 months or greater) was reportedin 10 of the 30 studies reviewed, 24,2733,42,45,46,49 with thelong-term assessment occurring from 6 months to 4 years after treatment.

Adherence to Home Programs Although home intervention programs were explicitly identified in 20 of the 30 studies reviewed, the rateof adherence was not reported in 17 of thosestudies. 9,21,22,27,28,3032,39,42,43,4550 Only 3 studies identi-

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fied the rate of adherence (via self-report). Magnussonand Syren 24 reported adherence at long-term follow upas less than 50%, Wright and colleagues 34 reported amean adherence of 75% after treatment, and Michelottiand colleagues 25 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 Sacketts 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 Lund 15 performed an analysis of review arti-cles and controlled clinical trials to assess the efficacy of physical 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 efficacy increasing 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 of

low-level laser therapy 60 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 disorders 61 showedlittle evidence to support its use. A meta-analysis 62 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 criteria

is 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 treatment for TMD and were subsequently involved in the studies were women. 63 This finding may relate to a difference intreatment-seeking behavior between men and women, as well 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 study 64 showed that the patients who refused to participate had more painand more condition-related interference in daily life when compared with those who participated.

Temporomandibular disorder-related pain of 6months may represent a shift from acute to chronic

TMD. 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 of chronicity are TMD of the myofascial type and beingfemale. 64,65

Within our systematic review, a variety of interventions were 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 studies 22,34 reporting reliability on all of theoutcome measures involved. Validity was reported in 3studies, 22,34,35 with only 1 study 34 reporting on all of theoutcome measures involved. Only 3 studies 22,25,42reported whether outcomes were clinically important.The lack of demonstrated reliability or validity for theoutcome measures used limits the confidence with which 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 the

remaining studies failed to report either reliability or validity for the outcome measures used, creating lessconfidence in the study results. The importance of long-term follow-up to assess the retention of short-termtreatment effects is critical to examining the efficacy of the 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 of the rating and classification of the studies, which may

present a data abstraction and evaluation bias.Implications for Clinical Practice Despite reported limitations of this systematic review of the 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 people with 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 by numerous, 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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T a b l e 1 .

S t u d i e s o n E x e r c i s e a n d M a n u a l T h e r a p y a

A u t h o r s

D e s

i g n a n

d

L e v e

l o f

E v i d e n c e

S u b j e c t s

I n t e r v e n t i o n

O u t c o m e M e a s u r e s a n

d R e s u

l t s b

F o l l o w - u p R e s u

l t s b

B u r g r e s s e t a l , 2 1

1 9 9 8

R C T

L e v e l I I

N

2 9 M y , F 7 4 %

,

m e a n a g e 3 4

. 8 y ,

A / R n / a

A : m a s t i c a t o r y a n d n e c k

m u s c u l a t u r e c h i l l i n g ,

s t r e t c h e s , H P

B : m a x i m a l m

o u t h o p e n i n g

a g a i n s t r e s i s t a n c e , H P

C : n o r x ( 2 r x o v e r

3 w k )

M c G i l l P R I s c o r e s : p o s t - r x

A B : E S

0 . 3 8 ( 0 . 0 6 0 . 7

0 )

A C : E S

0 . 7 2 ( 0

. 3 8 0 . 8 9 )

B C : E S

0 . 1 6 ( 0 . 3 2 0 . 5

7 )

S e l f - r e p o r t e d p a i n c h a n g e ( P R I ) f r o m p r e - r x 1 t o

p r e - r x 2

A B : E S

0 . 2 2 ( 0 . 2 6 0 . 6

1 )

A C : E S

0 . 5 0 ( 0

. 0 0 0 . 8 0 )

B C : E S

0 . 4 0 ( 0 . 1 4 0 . 7

6 )

T V O : p r e - r x

2

A B : E S

0 . 0 8 ( 0 . 3 8 0 . 5

0 )

A C : E S

0 . 3 0 ( 0 . 1 5 0 . 6

5 )

B C : E S

0 . 3 6 ( 0 . 1 4 0 . 7

0 )

N o n e

C a r m e l i e t a l , 9

2 0 0 1

R C T

L e v e l I I

N

3 6 D D

, F

7 2 %

,

m e a n a g e 3 0

. 3 y ,

A / R n / a

A : o c c l u s a l s p l i n t

B : m a n u a l m o b i l i z a t i o n s a n d

a c t i v e e x e r c i s e s , H P ( 1 5

r x o v e r 5 w k )

P a i n l e v e l s : E S

0 . 4 4

( 0 . 1

3 - . 6

7 )

T V O : E S 0 . 1 9 ( 0 . 1 5 0 . 4

9 )

N o n e

D e L a a t e t a l , 2 2

2 0 0 3

R C T

L e v e l I I

N

2 6 M y , F 8 5 %

,

m e a n a g e 4 2

. 5 y ,

A / R 2 2 / 2 6

A : e d u c a t i o n , P

T m a s s a g e ,

u l t r a s o u n d ; c o n t i n u o u s , 5

m i n

, m u s c l e s t r e t c h i n g ,

w a r m p a d , H

P ( 1 8 r x o v e r

6 w k )

B : e d u c a t i o n w i t h P T ( a s p e r

A ) i n i t i a t e d

a f t e r 2 w k

( 1 2 r x o v e r 6 w k )

P a i n

V A S , % o f p a i n r e l i e f , j a w f u n c t i o n M F I Q

,

P P T

D e c r e a s e i n p a i n i n A a n d B

I n c r e a s e i n j a w f u n c t i o n a n d P P T i n A a n d B

N o s i g n i f i c a n t d i f f e r e n c e s b e t w e e n A a n d B

N o n e

J a g g e r , 2 3

1 9 9 1

P r e t e s t - p o s t t e s t ,

c a s e s e r i e s

L e v e l I V

N

1 2 D D w i t h o u t

r e d u c t i o n , F

6 7 %

,

m e a n a g e 2 1

. 8 y ,

A / R n / a

M a n u a l m o b i l i z a t i o n ( 1 r x )

T V O : E S 0 . 5 1 ( 0 . 1 3 0 . 7

6 )

N o n e

M a g n u s s o n a n d

S y r e n , 2 4

1 9 9 9

R C T

L e v e l I I

N

2 6 c h r o n i c M y ,

F n / a , m e a n

a g e 3 5 y ,

A / R 2 3 / 2 6

A : o c c l u s a l n i g h t s p l i n t

B : a c t i v e e x e r c i s e s , H P

( m e a n 4 . 9 r x o v e r 6 m o )

C : c o m b i n a t i o n r x a f t e r 3 m o

( n

5 ) ( m e a n

9 . 4 r x o v e r

9 m o )

C l i n i c a l a n d a n a m n e s t i c d y s f u n c t i o n i n d e x e s ,

b e h a v i o r r a t i n g s c a l e

G r e a t e r i m p r o v e m e n t i n c l i n i c a l p a r a m e t e r s a n d

s e l f - r e p o r t e d s y m p t o m s i n A a n d B

I n c r e a s e i n T V O i n B ( n o s t a t i s t i c a l a n a l y s i s )

6 m o a n d 1 4 y r : m a i n t e n a n c e

o f i m p r o v e m e n t s i n A a n d B

( n o s t a t i s t i c a l a n a l y s i s )

M i c h e l o t t i

e t a l , 2 5

2 0 0 4

R C T , c o n t r o l

L e v e l I I

N

7 0 M y , F 8 8 %

,

m e a n a g e 3 0 y ,

A / R 4 9 / 7 0

A : e d u c a t i o n , r

e l a x a t i o n

t e c h n i q u e s , m

o i s t h e a t

p a d s

, s t r e t c h i n g ,

c o o r d i n a t i o n e x e r c i s e s , H P

B : e d u c a t i o n ( 4 r x o v e r 3 m o )

N o . o f s i t e s t e n d e r t o p a l p a t i o n : E S

0 . 0 5

( 0 . 2 3 0 . 3

3 )

P a i n i n t e n s i t y ( V A S ) : E S

0 . 1 0 ( 0 . 1 9 0 . 3

7 )

P a i n - f r e e T V O : E S 0

. 2 9 ( 0 . 0 1 0 . 5

3 )

P a i n o n c h e w i n g ( V A S ) : E S 0 . 1 6 ( 0 . 1 3 0 . 4

2 )

N o n e

( c o n t i n u e d )



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T a b l e 1 .

C o n t i n u e d

A u t h o r s

D e s

i g n a n

d

L e v e

l o f

E v i d e n c e

S u b j e c t s



d R e s u

l t s b


l t s b

H e a d a c h e ( V A S ) : E S

0 . 0 3 ( 0 . 2 6 0 . 3

1 )

P P T

M a s s e t e r : E S

0 . 0 1 ( 0 . 2 8 0 . 2

9 )

T e m p o r a l i s : E S 0

. 0 7 ( 0 . 2 2 0 . 3

4 )

P a t i e n t - b a s e d t r e a t m e n t c o n t r a s t : E S

0 . 1 9

( 0 . 1 0 0 . 4

5 )

C l i n i c i a n - b a s e d t r e a t m e n t c o n t r a s t : E S

0 . 0 9

( 0 . 2 0 0 . 3

6 )

T o t a l t r e a t m e n t c o n t r a s t : E S

0 . 1 9 ( 0 . 1 0 0 . 4

4 )

M i n a g i e t a l , 2 6

1 9 9 1


c a s e s e r i e s

L e v e l I V

N



9 4 %

m e a n a g e 3 6

. 4 y ,

A / R n / a

M a n u a l m o b i l i z a t i o n , 1 r x

T V O : E S 0 . 5 8 ( 0 . 3 3 0 . 7

6 )

N o n e

N i c o l a k i s

e t a l , 2 7

2 0 0 2


p r e t r e a t m e n t

c o n t r o l p e r i o d ,

c a s e s e r i e s

L e v e l I V

N

2 0 M y , F 8 0 %

,

m e a n a g e 3 4

. 5 y ,

A / R 2 0 / 2 0 , 6 m o

A / R 1 9 / 2 0

A c t i v e e x e r c i s e s , m a n u a l

t h e r a p y , p o s t u r a l

c o r r e c t i o n , r

e l a x a t i o n

t e c h n i q u e s , H

P

( m e a n 1 0

. 8 r x o v e r m e a n

o f 5 1

. 2 d )

P a i n a t r e s t : E S

0 . 1 9 ( 0 . 1 3 0 . 4

7 )

P a i n a t s t r e s s : E S

0 . 4 1 ( 0

. 1 2 0 . 6 4 )

I m p a i r m e n t : E S

0 . 5 7 ( 0 . 3 2 0 . 7

5 )

T V O : E S 0 . 4 0 ( 0

. 1 0 0 . 6 3 )

N o . o f p a t i e n t s e x p e r i e n c i n g n o p a i n a t s t r e s s :

E S

0 . 5 8 ( 0 . 1 7 0 . 8 2 )

N o . o f p a t i e n t s e x p e r i e n c i n g i m p a i r e d T V O :

E S

0 . 6 0 ( 0 . 2 1 0 . 8 2 )

P e r c e i v e d i m p r o v e m e n t o f j a w p a i n : E S 0 . 7 5

( 0 . 4

6 0 . 9 0 )

P e r c e i v e d i m p r o v e m e n t o f j a w f u n c t i o n : E S

0 . 7 5

( 0 . 4 6 0 . 9

0 )

6 m o

D i f f e r e n c e b e t w e e n t r e a t m e n t

p e r i o d a n d f o l l o w - u p :

E S 0 . 0

0 ( 0 . 4 5 0 . 4

5 )

N i c o l a k i s

e t a l , 2 8

2 0 0 1

N i c o l a k i s

e t a l , 2 9

2 0 0 2

( 3 - y

f o l l o w - u p

)




c a s e s e r i e s

L e v e l I V

N

2 0 A r

, F

9 0 %

,

m e a n a g e 4 8

. 8 y ,

A / R 2 0 / 2 0 , 6 m o

A / R 1 9 / 2 0 , 3 y

A / R 1 7 / 2 0




e l a x a t i o n


P

( m e a n 1 0

. 8 r x o v e r m e a n

o f 4 6

. 5 d )


E S

0 . 4 5 ( 0 . 0 1 0 . 7 5 )

N o . o f p a t i e n t s e x p e r i e n c i n g n o i m p a i r m e n t :

E S

0 . 4 2 ( 0 . 0 5 0 . 7 3 )


( 0 . 4

7 0 . 9 0 )


0 . 7 7

( 0 . 5

0 0 . 9 1 )

6 m o a n d 3 y

6 m o :

P e r c e i v e d i m p r o v e m e n t o f j a w

p a i n : E S

0 . 0 2

( 0 . 4 4 0 . 4 7 )


f u n c t i o n : E S 0 . 0 2 ( 0 . 4 4

0 . 4 7 )

N i c o l a k i s

e t a l , 3 0

2 0 0 1




c a s e s e r i e s

L e v e l I V

N



7 5 %

,

m e a n a g e 3 7

. 3 y ,

A / R 2 0 / 2 0 , 6 m o

A / F 1 8 / 2 0




e l a x a t i o n


P ( m e a n 1 1

r x o v e r 5 1

. 2 d )


0 . 3 4 ( 0

. 0 3 0 . 5 9 )


0 . 4 7 ( 0

. 1 9 0 . 6 8 )


0 . 4 7 ( 0

. 1 9 0 . 6 8 )

T V O : E S 0 . 3 6 ( 0 . 0 5 0 . 6

0 )


E S

0 . 4 2 ( 0 . 0 2 0 . 7 3 )

N o . o f p a t i e n t s e x p e r i e n c i n g i m p a i r e d T V O :

E S

0 . 6 6 ( 0

. 3 1 0

. 8 6 )

6 m o :


p a i n : E S

0 . 0 5 ( 0 . 4 3 0 . 5

0 )


f u n c t i o n : E S 0 . 2 5 ( 0 . 2 5

0 . 6 4 )




10/19

T a b l e 1 .

C o n t i n u e d

A u t h o r s

D e s

i g n a n

d

L e v e

l o f

E v i d e n c e

S u b j e c t s



d R e s u

l t s b


l t s b


( 0 . 3

1 0 . 8 5 )


0 . 7 2

( 0 . 4

0 0 . 8 8 )

N i c o l a k i s

e t a l , 3 1

2 0 0 0




c a s e s e r i e s

L e v e l I V

N

3 0 D D w i t h


9 3 %

,

m e a n a g e 3 3

. 1 y ,

A / R 3 0 / 3 0 ,

6 m o A / R 2 6 / 3 0




e l a x a t i o n


P ( m e a n

9 . 9 r x o v e r 3 0 d )


0 . 5 2 ( 0

. 3 1 0 . 6 9 )


0 . 7 0 ( 0

. 5 4 0 . 8 1 )


0 . 6 5 ( 0

. 4 8 0 . 7 8 )

T V O : E S 0 . 1 5 ( 0 . 1 1 0 . 3

9 )

N o . o f p a t i e n t s e x p e r i e n c i n g n o p a i n a t a l l :

E S

0 . 4 2 ( 0

. 0 7 0

. 6 8 )

N o . o f p a t i e n t s e x p e r i e n c i n g n o p a i n a t r e s t :

E S

0 . 3 2 ( 0 . 0 5 0 . 6 1 )

N o . o f p a t i e n t s w i t h a T V O 4 0 m m : E S 0 . 4 9

( 0 . 1

5 0 . 7 2 )


( 0 . 5 6 0 . 8

8 )


0 . 7 4

( 0 . 5

3 0 . 8 7 )

P e r c e i v e d i m p r o v e m e n t o f j a w c l i c k i n g : E S

0 . 4 8

( 0 . 1

5 0 . 7 2 )

6 m o :

N o . o f p a t i e n t s e x p e r i e n c i n g

n o p a i n a t a l l : E S

0 . 3 3

( 0 . 0 7 0 . 6 4 )

N o . o f p a t i e n t s e x p e r i e n c i n g

n o p a i n a t r e s t : E S

0 . 2 0

( 0 . 2 0 0 . 5 5 )

N o . o f p a t i e n t s w i t h a T V O

4 0 m m : E S 0 . 0 6 ( 0 . 3 3

0 . 4 4 )


p a i n : E S

0 . 1 8

( 0 . 2 2 0 . 5 3 )


f u n c t i o n : E S 0 . 2 9 ( 0 . 1 2

0 . 6 1 )


c l i c k i n g : E S

0 . 2 1 ( 0 . 1 9

0 . 5 5 )

T a y l o r e t a l , 4

1 9 9 4

R a n d o m i z e d ,

p l a c e b o ,

c r o s s o v e r

L e v e l I V

N

1 5 c h r o n i c M y ,

F 9 3 %

, a g e

r a n g e 2 0 3

5 y ,

A / R n / a

A : m a n u a l m o b i l i z a t i o n s

B : s h a m r x ( 2 r x o v e r

1 d )

E M G a c t i v i t y :

R e s t i n g : E S 0 . 4 0 ( 0

. 0 5 0 . 6 7 )

O p e n / c l o s e : E S 0

. 3 3 ( 0 . 0 3 0 . 6

2 )

L T : E S 0 . 2 6 ( 0 . 1 1 0 . 5

7 )

C l e n c h i n g : E S

0 . 4 2 ( 0

. 0 8 0 . 6 8 )

T V O : E S 0 . 5 9 ( 0 . 2 9 0 . 7

8 )

L T : E S 0 . 4 7 ( 0

. 1 4 0

. 7 1 )

N o n e

T e g e l b e r g a n d

K o p p , 3 2

1 9 8 8

T e g e l b e r g a n d

K o p p , 3 3

1 9 9 6 ( 3 y

f o l l o w - u p

)


L e v e l I I

N

5 0 A r ( 5 6 % R A

,

6 4 % A S ) , F 6 4 %

,

m e a n a g e 4 8

. 1 y ,

A / R n / a

A : a c t i v e R O M e x e r c i s e s , H P

( 1 r x o v e r 3 w k )

B : n o r x

E S R , C R P , s e v e r i t y o f s y m p t o m s ( 5 - p o i n t s c a l e ) ,

H e l k i m o D y s f u n c t i o n I n d e x , C D S , T V O

D e c r e a s e i n s e v e r i t y o f s y m p t o m s i n A a n d B

( g r e a t e r i n A [ R A ] )

R e d u c t i o n i n C D S ( R A ) a n d i n c r e a s e i n T V O

g r e a t e r i n A

N o c h a n g e i n E S R a n d C R P i n A o r B

3 y ( n 3 5 ) :

R e d u c t i o n i n C D S m a i n t a i n e d

c l i n i c a l ( R A ) i n A

I n c r e a s e i n T V O m a i n t a i n e d

i n A

I n c r e a s e i n E S R i n R A ( c

o n t i n u e d )



11/19

T a b l e 1 .

C o n t i n u e d

A u t h o r s

D e s

i g n a n

d

L e v e

l o f

E v i d e n c e

S u b j e c t s



d R e s u

l t s b


l t s b

W r i g h t e t a l , 3 4

2 0 0 0


L e v e l I I

N

6 0 c h r o n i c M y ,

F 8 5 %

, m e a n

a g e 3 1

. 8 y ,

A / R 6 0 / 6 1

A : p o s t u r a l c o r r e c t i o n , H

P

( 2 r x o v e r 2 w k )

B : n o r x

M M S I

T M D : E S

0 . 5 5 ( 0

. 3 5 0 . 7 1 )

N e c k : E S

0 . 5 0 ( 0

. 2 8 0 . 6 7 )

T V O : E S 0 . 2 7 ( 0 . 0 2 0 . 4

9 )

P r e s s u r e a l g o m e t e r p a i n t h r e s h o l d :

M a s s e t e r : E S

0 . 3 1 ( 0

. 0 6 0 . 5 3 )

T r a p e z i u s : E S

0 . 3 6 ( 0

. 1 1 0 . 5 6 )

P e r c e i v e d s y m p t o m i m p r o v e m e n t

T M D : E S

0 . 4 8 ( 0

. 2 6 0 . 6 6 )

N e c k : E S

0 . 4 4 ( 0

. 2 1 0 . 6 2 )

N o n e

a A g r o u p I , A r a r t h r i t i s , A

/ R a n a l y z e d / r a n d o m i z e d , A

S a n k y l o s i n g s p o n d y l i t i s , B g r o u p I I

, C g r o u p I I I , C D S c l i n i c a l d y s f u n c t i o n s c o r e , C R P

C - r e a c t i v e p r o t e i n , D D

d i s k d i s p l a c e m e n t ( s ) ,

E M G e l e c t r o m y o g r a p h y

, E S e f f e c t s i z e ( 9 5 %

c o n f i d e n c e i n t e r v a l ) , E S R e r t h r o c y t e s e d i m e n t i o n r a t e , F

f e m a l e , H P

h o m e p r o g r a m , L

T l a t e r a l e x c u r s i o n ( l e f t a n d r i g h t ) , M

F I Q

M a n d i b u l a r F u n c t i o n I m p a i r m e n t

Q u e s t i o n n a i r e , M

M S I m o d i f i e d s y m p t o m s e v e r i t y i n d e x , M y m y o f a s c i a l / m u s c u l a r , n / a

d a t a

n o t a v a i l a b l e , P P T p r e s s u r e p a i n t h r e s h o l d , P R I p a i n r a t i n g i n t e n s i t y

, P T p h y s i c a l t h e r a p y , R

A r h e u m a t o i d a r t h r i t i s ,

R C T r a n d o m i z e d c o n t r o l l e d t r i a l , R O M r a n g e o f m o t i o n , r x t r e a t m e n t , T M D t e m p o r o m a n d i b u l a r d i s o r d e r , T

V O t o t a l v e r t i c a l o p e n i n g , V A S v i s u a l a n a l o g s c a l e .

b S t a t i s t i c a l l y s i g n i f i c a n t u n l e s s n o t e d .



12/19

T a b l e 2 .

S t u d i e s o n E l e c t r o t h e r a p y a

A u t h o r s

D e s

i g n a n

d

L e v e

l o f

E v i d e n c e

S u b j e c t s



d

R e s u

l t s b

F o l l o w - u p

R e s u

l t s b

A l - B a d a w i e t a l , 3 5

2 0 0 4

R C T , p l a c e b o

L e v e l I I

N

4 0 A r

, F

7 8 %

, a g e

r a n g e 2 2 5

5 y ,

A / R n / a

A : P R F E , 2 5 0 k H z , p u l s e d 6 0 0 H z

,

6

1 5 s , 7 - s r e s t i n t e r v a l s

B : s h a m P R F E

, ( 6 r x o v e r 2 w k )

T M J p a i n : E S 0 . 6 6 ( 0

. 4 5 0 . 8 1 )

T V O : E S 0 . 1 4 ( 0 . 1 8 0 . 4

3 )

R i g h t L T : E S

0 . 8 8 ( 0

. 7 8 0 . 9 4 )

L e f t L T : E S 0 . 8 8 ( 0

. 7 8 0 . 9 4 )

N o n e

B e r t o l u c c i a n d G r a y , 5

1 9 9 5


L e v e l I I

N

3 2 A r ( w i t h D D w i t h o u t

r e d u c t i o n ) , F n / a , m e a n

a g e n / a , A / R 3 2 / 3 3

A : m i d - l a s e r , 9 0 4 n m , 7

0 0 H z

, 2 7 W

,

1 0 0 % p o w e r o u t p u t , 9

m i n

B : p l a c e b o m i d - l a s e r ( 9 r x o v e r 3 w k )

P a i n i n d e x : E S

0 . 8 2 ( 0

. 6 7

0 . 9 1 )

T V O : E S 0 . 7 3 ( 0

. 5 1 0 . 8 6 )

L T : E S 0 . 8 4 ( 0

. 7 0 0 . 9 2 )

N o n e

B e r t o l u c c i a n d G r a y , 3 6

1 9 9 5


L e v e l I I

N

4 8 A r ( w i t h D D w i t h o u t

r e d u c t i o n ) , F n / a , m e a n

a g e n / a , A / R 4 7 / 4 8

A : m i c r o c u r r e n t e l e c t r i c a l n e u r o m u s c u l a r

s t i m u l a t i o n ; 1 0 0

A , 0 . 3 H z

, 1 0 m i n

B : m i d - l a s e r , 9 0 4 n m , 7

0 0 H z

, 2 7 W

,

1 0 0 % p o w e r o u t p u t , 9

m i n

C : m i d - l a s e r p l a c e b o ( 9 r x o v e r 3 w k )

P a i n i n d e x

A B : E S

0 . 4 0 ( 0

. 0 6 0 . 6 6 )

A C : E S

0 . 7 4 ( 0

. 5 7 0 . 8 5 )

B C : E S

0 . 8 3 ( 0

. 6 7 0 . 9 1 )

T V O A B : E S

0 . 4 0 ( 0

. 0 6 0 . 6 6 )

A C : E S

0 . 5 2 ( 0

. 2 1 0 . 7 4 )

B C : E S

0 . 7 3 ( 0

. 5 1 0 . 8 6 )

L T A B : E S

0 . 0 9 ( 0 . 2 7 0 . 4

3 )

A C : E S

0 . 8 3 ( 0

. 6 8 0 . 9 2 )

B C : E S

0 . 8 0 ( 0

. 6 3 0 . 9 0 )

N o n e

C o n t i , 3 7

1 9 9 7


L e v e l I I

N

2 0 5 0 % A r a n d 5 0 %

M y , F 9 0 %

, m e a n

a g e 3 9

. 9 y , A / R n / a

A : l o w - l e v e l l a s e r , 8

3 0 n m , 1

0 0 m W

,

4 J , 4 0 s

B : p l a c e b o l a s e r ( 3 r x o v e r 3 w k )

P a i n

V A S , T V O

, L T , P R : n o

d i f f e r e n c e s i n i m p r o v e m e n t s

b e t w e e n A a n d B

N o n e

G r a y e t a l , 3 8

1 9 9 5


L e v e l I I

N

1 3 9 M y , F 8 6 %

, a g e

r a n g e 1 5 3

0 y ,

A / R 1 3 9 / 1 7 6

A : s h o r t - w a v e d i a t h e r m y , m i l d t h e r m a l

s e t t i n g , 1

0 m i n

B : m e g a p u l s e , 6

0 - m s p u l s e

, 1 0 0 p p s ,

2 0

m i n

C : u l t r a s o u n d , 0 . 2

5 W / c m 2 , 3

M H z

,

p u l s e d a t 2 : 1 , 2 m i n

D : l a s e r , 9 0 4 n m , 4

J / c m

2 , 3

m i n

E : p l a c e b o ( 1 2 r x o v e r 4 w k )

I m p r o v e r s a n d n o n i m p r o v e r s

A : E S

0 . 1 0 ( 0 . 3 7 0 . 5

3 )

B : E S

0 . 1 0 ( 0 . 3 6 0 . 5

2 )

C : E S 0 . 1 0 ( 0 . 3 5 0 . 5

1 )

D : E S

0 . 1 0 ( 0 . 3 5 0 . 5

2 )

E : E S

0 . 3 6 ( 0 . 2 1 0 . 7

5 )

T V O , o

v e r a l l s t a t e ( 5 - p o i n t

s c a l e ) , j

o i n t a n d m u s c l e

t e n d e r n e s s a n d s o u n d s o n

p a l p a t i o n

3 m o , i m p r o v e r s a n d n o n i m p r o v e r s

A : E S

0 . 1

5 ( 0 . 3 2 0 . 5

7 )

B : E S

0 . 1 4 ( 0 . 3 1 0 . 5

4 )

C : E S

0 . 1

4 ( 0 . 3 0 0 . 5

3 )

D : E S

0 . 1

4 ( 0 . 1 4 0 . 2

8 )

E : E S

0 . 9 1 ( 0 . 7 1 0 . 9

9 )

L i n d e e t a l , 3 9

1 9 9 5

R C T

L e v e l I I

N

3 1 D D

, F

8 4 %

, m e a n

a g e 3 7 y , A / R n / a

A : T E N S , 9 0 H z

, 3 0 m i n

, j u s t b e l o w

p a i n t h r e s h o l d , 3 p e r d a y , H

P

B : o c c l u s a l s p l i n t ( 6 r x i n 6 w k )

T V O : E S 0 . 0 1 ( 0 . 3 4 0 . 3

7 )

L T : E S 0 . 1 1 ( 0 . 2 6 0 . 4

4 )

P R : E S 0 . 2 8 ( 0 . 0 8 0 . 5

8 )

S y m p t o m s ( 5 - a n d 6 - s t e p s c a l e s ) ,

p a i n

V A S , p a i n t r a c k d e v i c e ,

T V O

, t e n d e r n e s s a n d j o i n t

s o u n d s o n p a l p a t i o n

G r e a t e r d e c r e a s e i n p a i n i n B

N o n e




13/19

T a b l e 2 .

C o n t i n u e d

A u t h o r s

D e s

i g n a n

d

L e v e

l o f

E v i d e n c e

S u b j e c t s



d

R e s u

l t s b

F o l l o w - u p

R e s u

l t s b

M o y s t a d e t a l , 4 0

1 9 9 0

R a n d o m i z e d o r d e r

o f t r e a t m e n t s

w i t h i n s e s s i o n s

( t r e a t m e n t

s e s s i o n 1 b e f o r e

2 ) , p

l a c e b o

L e v e l I V

N

1 9 , A

r ( 8 9 % R A )

F 8 9 %

, m e a n a g e

3 3 y , A / R n / a

1 a : T E N S , 1 0 0 H z

, p u l s e w i d t h

0 . 1 5 m s , c o n s t a n t s e n s a t i o n T M J a r e a

1 b : p l a c e b o , 3 0 m i n ( 2 r x o v e r 2 w k )

2 a : T E N S , 2 H z

, p u l s e w i d t h 0 . 2 m s ,

a c u p u n c t u r e p o i n t o n h a n d

2 b : p l a c e b o , 3 0 m i n ( 2 r x o v e r 2 w k )

P a i n

V A S , T M J a n d m u s c l e

t e n d e r n e s s o n p a l p a t i o n ( 3 -

p o i n t s c a l e ) , T V O

, L T , a n d P R

G r e a t e r d e c r e a s e i n 1 a

N o d i f f e r e n c e i n i m p r o v e m e n t s

i n a l l o t h e r a r e a s b e t w e e n

g r o u p s

N o n e

T a u b e e t a l , 4 1

1 9 9 8


L e v e l I I

N

4 9 M y , F 9 0 %

, m e a n

a g e

4 6 . 7

y ,

A / R 4 9 / 4 9

A : u l t r a s o u n d , 0 . 0

8 W / c m 2 , p

u l s e d

B : u l t r a s o u n d , 0 . 5

W / c m

2 , p

u l s e d

C : p l a c e b o

, 5 m i n p e r T M J

( m e a n 8 . 9 r x )

T V O , m

u s c l e t e n d e r n e s s o n

p a l p a t i o n ( 3 - p o i n t s c a l e )

N o d i f f e r e n c e i n i m p r o v e m e n t s

b e t w e e n g r o u p s

N o n e

a A g r o u p I , A r a r t h r i t i s , A

/ R a n a l y z e d / r a n d o m i z e d , B

g r o u p I I

, C g r o u p I I I , D g r o u p I V

, D D

d i s k d i s p l a c e m e n t ( s ) , E

g r o u p V , E S e f f e c t s i z e ( 9 5 % c o n f i d e n c e i n t e r v a l ) , F

f e m a l e , H

P

h o m e p r o g r a m ,

L T

l a t e r a l e x c u r s i o n ( l e f t a n d r i g h t ) , M

y m y o f a s c i a l / m u s c u l a r , n / a d a t a n o t a v a i l a b l e , p p s p u l s e s p e r s e c o n d , P

R p r o t r u s i v e e x c u r s i o n , P R F E p u l s e d r a d i o f r e q u e n c y e n e r g y , P

T p h y s i c a l t h e r a p y , R

A r h e u m a t o i d

a r t h r i t i s , R

C T r a n d o m i z e d c o n t r o l l e d t r i a l , r x t r e a t m e n t , T E N S t r a n s c u t a n e o u s e l e c t r i c a l n e r v e s t i m u l a t i o n , T M J t e m p o r o m a n d i b u l a r j o i n t , T V O t o t a l v e r t i c a l o p e n i n g , V A S v i s u a l a n a l o g s c a l e .

b S t a t i s t i c a l l y s i g n i f i c a n t u n l e s s n o t e d .



14/19

T a b l e 3 .

S t u d i e s o n R e l a x a t i o n T r a i n i n g a n d E d u c a t i o n a

A u t h o r s

D e s

i g n a n

d

L e v e

l o f

E v i d e n c e

S u

b j e c t s


O u t c o m e s M e a s u r e s a n

d R e s u

l t s b


l t s b

C a r l s o n e t a l , 4 2

2 0 0 1

R C T

L e v e l I I

N

4 4 M y , F 7 7 %

,

m e a n a g e 3 4

. 6 y ,

A / R 4 4 / 4 4 ,

2 6 w k A / R 3 2 / 4 4

A : b r e a t h i n g a n d p o s t u r a l r e l a x a t i o n

t e c h n i q u e s , p

r o p r i o c e p t i v e

r e - e d u c a t i o n , H P

B : o c c l u s a l s p l i n t , e d u c a t i o n

( 2 r x o v e r 3 w k )

P a i n m e a s u r e s

D a i l y s e l f - m o n i t o r i n g : E S

0 . 5 7 ( 0

. 3 3 0 . 7 4 )

P a i n s e v e r i t y : E S

0 . 6 7 ( 0

. 4 7 0 . 8 1 )

L i f e i n t e r f e r e n c e : E S

0 . 5 7 ( 0

. 3 3 0 . 7 4 )

L i f e c o n t r o l : E S

0 . 4 3 ( 0

. 1 5 0 . 6 5 )

P h y s i c a l e x a m i n a t i o n

O p e n i n g w i t h o u t p a i n : E S 0 . 4 5 ( 0

. 1 8 0 . 6 6 )

O p e n i n g w i t h p a i n : E S 0 . 3 3 ( 0

. 0 4 0 . 5 7 )

M u s c l e p a i n i n d e x : E S

0 . 4 4 ( 0

. 1 7 0 . 6 5 )

A w a r e n e s s o f t o o t h c o n t a c t : E S

0 . 7 2 ( 0

. 5 4 0 . 8 4 )

P s y c h o l o g i c v a r i a b l e s

A f f e c t i v e d i s t r e s s : E S

0 . 3 9 ( 0

. 1 1 - 0 . 6

2 )

S o m a t i z a t i o n : E S

0 . 3 3 ( 0

. 0 4 0 . 5 7 )

D e p r e s s i o n : E S

0 . 2 8 ( 0 . 0 2 0 . 5

3 )

A n x i e t y : E S

0 . 2 8 ( 0 . 0 2 0 . 5

3 )

O b s e s s i v e / c o m p u l s i v e : E S

0 . 3 7 ( 0

. 0 8 0 . 6 0 ) ;

F a t i g u e : E S 0 . 1 2 ( 0 . 1 8 0 . 4

0 )

O v e r a l l s l e e p d y s f u n c t i o n : E S

0 . 3 2 ( 0

. 0 3 0 . 5 6 )

2 6 w k : l e s s p a i n a n d g r e a t e r

T V O

i n A

C r o c k e t t e t a l , 5 0

1 9 8 6


L e v e l I I

N

2 1 c h r o n i c M y ,

F 1 0 0 %

, a g e 1 9 y ,

m e a n a g e n / a ,

A / R 2 1 / 2 8

A : o c c l u s a l s p l i n t , h o t / c o l d

a p p l i c a t i o n , p o s t u r a l c o r r e c t i o n ,

a c t i v e e x e r c i s e s , H

P

B : m u s c l e r e l a x a t i o n t r a i n i n g , E M G

b i o f e e d b a c k , H P

C : m i n i m a l r x , T E N S , 1 0 0 H z

,

5 0

A , m i n i m a l s e n s a t i o n ,

3 0 m i n

, H P ( 8

r x o v e r 8 w k )

P a i n t o p a l p a t i o n

A B : E S

0 . 0 6 (

0 . 4 8 0 . 5

8 )

A C : E S

0 . 2 5 ( 0 . 3 2 0 . 6

9 )

B C : E S

0 . 1 9 (

0 . 3 8 0 . 6

5 )

T V O

A B : E S

0 . 1 7 (

0 . 4 0 0 . 6

4 )

A C : E S

0 . 0 1 ( 0 . 5 3 0 . 5

4 )

B C : E S

0 . 1 5 (

0 . 4 2 0 . 6

3 )

W o r s t p a i n r a t i n g

A B : E S

0 . 2 5 (

0 . 3 2 0 . 6

9 )

A C : E S

0 . 1 7 ( 0 . 4 0 0 . 6

4 )

B C : E S

0 . 1 0 (

0 . 4 6 0 . 6

0 )

A d j e c t i v a l p a i n r a t i n g

A B : E S

0 . 1 0 (

0 . 4 6 0 . 6

0 )

A C : E S

0 . 0 8 ( 0 . 4 7 0 . 5

8 )

B C : E S

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