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The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/86/7/955
Key Words: Facial pain, Physical therapy, Rehabilitation, Temporomandibular disorder, Temporoman-
dibular joint syndrome, Therapy.
Currently, there is lack of consensus among researchers This systematic review of randomized controlled trials
regarding the etiology, diagnosis, and management of (RCTs) and nonrandomized controlled trials assessed
this disorder. The diagnosis of TMD is commonly based the physical therapy management of acute and chronic
on the presenting signs and symptoms.8 The Research TMD on clinically relevant outcomes such as pain, range
Diagnostic Criteria for Temporomandibular Disorders of motion (ROM), disability and function, joint noise,
(RDC/TMD) applies a dual-axis system to diagnose and tenderness, and psychological factors. Based on duration
classify patients with TMD.6,8 10 The first axis is divided of the disorder, TMD was defined as acute (6 months)
into 3 groups of commonly occurring TMDs: or chronic (6 months). Sacketts levels of evidence
facilitate the categorization of studies according to the
1. Muscle disorders, including myofascial pain with and strength of the research design and the degree of
without limited mandibular opening. control for potential threats to internal validity.16,17
Based on 5 hierarchical levels of evidence, which have
2. Disk displacement with or without reduction or lim- been used in previous systematic reviews of physical
ited mandibular opening. therapist practice, recommendations can be made
regarding treatment options.17,18
3. Arthralgia, arthritis, and arthrosis.
Method
The second axis includes a 31-item questionnaire, used The literature search was restricted to English-language
to evaluate relevant behavioral, psychological, and psy- publications from 1966 through January 2005. Index
chosocial factors (eg, pain status variables, depression, Medicus (MEDLINE), the Cumulative Index to Nursing
nonspecific physical symptoms, disability levels).6,8,10 and Allied Health Literature (CINAHL), and the
Cochrane Central Register of Controlled Trials were
Noninvasive, conservative treatments generally provide searched using the text words facial pain, physical
improvement or relief of symptoms and are recom- therapy, rehabilitation, temporomandibular disor-
mended in the initial management of TMD.11 Physical der (TMD), temporomandibular joint (TMJ), tem-
therapists are frequently involved in the management of poromandibular joint syndrome, and therapy.
MS Medlicott, BScPT, is Physical Therapist, Lions Gate Hospital, North Vancouver, British Columbia, Canada. Address all correspondence to Ms
Medlicott at 2759 Webster Rd, Nanaimo, British Columbia, Canada, V9R 6W7 (mmedlicott@hotmail.com).
SR Harris, PT, PhD, FAPTA, is Professor, School of Rehabilitation SciencesFaculty of Medicine, University of British Columbia, Vancouver, British
Columbia, Canada.
Ms Medlicott provided concept/idea/research design. Both authors provided writing and data collection and analysis. Dr Harris provided
consultation (including review of manuscript before submission).
This article was received June 6, 2005, and was accepted January 31, 2006.
With respect to specific interventions, 4 systematic A spectrum of different outcome measures was used in
reviews were located, none of which were included in the the studies reviewed. Most of the studies included
analysis performed by Feine and Lund.15 A 1996 system- between 2 and 5 outcome measures. Although there was
atic review59 stated that there was insufficient evidence to some continuity in the outcome areas assessed, the
refute or support either manipulation or mobilization in actual measures differed among the studies, with over 75
treatment of the TMJ. A more recent systematic review of different methods used to assess the outcomes. Reliabil-
low-level laser therapy60 showed a reduction in pain and ity was reported in only 8 studies,4,9,22,27,34,42,48,49 with
improvement in health status in chronic joint disorders. only 2 studies22,34 reporting reliability on all of the
However, a systematic review of ultrasound in the man- outcome measures involved. Validity was reported in 3
agement of chronic musculoskeletal disorders61 showed studies,22,34,35 with only 1 study34 reporting on all of the
little evidence to support its use. A meta-analysis62 con- outcome measures involved. Only 3 studies22,25,42
cluded that, although limited in extent, the available reported whether outcomes were clinically important.
data support the efficacy of EMG biofeedback treat- The lack of demonstrated reliability or validity for the
ments for TMD. outcome measures used limits the confidence with
which the results may be interpreted.
Inclusion criteria varied among the studies we reviewed,
likely due to the lack of consensus regarding the diag- Five studies22,24,25,34,49 fulfilled 6 or more (of 10) criteria
nosis of TMD. The lack of standardized inclusion criteria for methodological rigor (Tab. 4). The majority of the
is a limitation when comparing studies, as well as with remaining studies failed to report either reliability or
respect to the recommendations made. Subjects with validity for the outcome measures used, creating less
myofascial TMD were included in 60% of the studies confidence in the study results. The importance of
selected. The majority of patients who sought treatment long-term follow-up to assess the retention of short-term
for TMD and were subsequently involved in the studies treatment effects is critical to examining the efficacy of
were women.63 This finding may relate to a difference in the interventions involved.
treatment-seeking behavior between men and women, as
well as the greater likelihood for women to have soma- This review has several limitations. Because only English-
tization disorders.63 The external validity of the recom- language articles were included, it is possible that this
mendations is limited, due, in part, to the differences in review is a not complete representation of the available
the groups studied. There also may be differences evidence. The review was limited to published articles
between those who agree to participate in an RCT and and thus may have missed those that were not submitted
(2) Postural training may be used in combination with Implications for Future Research
other treatment techniques because the effects, The foregoing clinical implications should be consid-
independent of other treatments, are not known ered with caution because none were supported by
(eg, postural training combined with a home exer- numerous, decisive studies. Consensus on the definition
cise program may decrease pain and increase TVO of TMD, and subsequent inclusion and exclusion crite-
in people with myofascial TMD). ria, would allow further comparison across groups
studied. In addition, agreement on use of valid and
(3) Mid-laser therapy may decrease pain and improve reliable outcome measures would yield more rigorous
TVO and lateral excursion in people with TMD research.
Design and
Level of
Authors Evidence Subjects Intervention Outcome Measures and Resultsb Follow-up Resultsb
Burgress et al,21 RCT N29 My, F74%, A: masticatory and neck McGill PRI scores: post-rx None
1998 Level II mean age34.8 y, musculature chilling, AB: ES0.38 (0.060.70)
Physical Therapy
11, 2016
Magnusson and RCT N26 chronic My, A: occlusal night splint Clinical and anamnestic dysfunction indexes, 6 mo and 14 yr: maintenance
Syren,24 Level II Fn/a, mean B: active exercises, HP behavior rating scale of improvements in A and B
1999 age35 y, (mean4.9 rx over 6 mo) Greater improvement in clinical parameters and (no statistical analysis)
A/R23/26 C: combination rx after 3 mo self-reported symptoms in A and B
(n5) (mean9.4 rx over Increase in TVO in B (no statistical analysis)
9 mo)
Michelotti RCT, control N70 My, F88%, A: education, relaxation No. of sites tender to palpation: ES0.05 None
et al,25 Level II mean age30 y, techniques, moist heat (0.230.33)
2004 A/R49/70 pads, stretching, Pain intensity (VAS): ES0.10 (0.190.37)
coordination exercises, HP Pain-free TVO: ES0.29 (0.010.53)
B: education (4 rx over 3 mo) Pain on chewing (VAS): ES0.16 (0.130.42)
(continued)
Design and
Level of
Authors Evidence Subjects Intervention Outcome Measures and Resultsb Follow-up Resultsb
Downloaded
Minagi et al,26 Pretest-posttest, N35 DD without Manual mobilization, 1 rx TVO: ES0.58 (0.330.76) None
7 . Julyfrom
1991 case series reduction, F94%
2006
Level IV mean age36.4 y,
A/Rn/a
Nicolakis Pretest-posttest, N20 My, F80%, Active exercises, manual Pain at rest: ES0.19 (0.130.47) 6 mo
et al,27 pretreatment mean age34.5 y, therapy, postural Pain at stress: ES0.41 (0.120.64) Difference between treatment
2002 control period, A/R20/20, 6 mo correction, relaxation Impairment: ES0.57 (0.320.75) period and follow-up:
case series A/R19/20 techniques, HP TVO: ES0.40 (0.100.63) ES0.00 (0.450.45)
Level IV (mean10.8 rx over mean No. of patients experiencing no pain at stress:
of 51.2 d) ES0.58 (0.170.82)
No. of patients experiencing impaired TVO:
ES0.60 (0.210.82)
Perceived improvement of jaw pain: ES0.75
(0.460.90)
Perceived improvement of jaw function: ES0.75
(0.460.90)
Nicolakis Pretest-posttest, N20 Ar, F90%, Active exercises, manual No. of patients experiencing no pain at stress: 6 mo and 3 y
et al,28 pretreatment mean age48.8 y, therapy, postural ES0.45 (0.010.75) 6 mo:
2001 control period, A/R20/20, 6 mo correction, relaxation No. of patients experiencing no impairment: Perceived improvement of jaw
Nicolakis case series A/R19/20, 3 y techniques, HP ES0.42 (0.050.73) pain: ES0.02
et al,29 Level IV A/R17/20 (mean10.8 rx over mean Perceived improvement of jaw pain: ES0.76 (0.440.47)
Design and
Level of
Authors Evidence Subjects Intervention Outcome Measures and Resultsb Follow-up Resultsb
Physical Therapy
LT: ES0.47 (0.140.71)
11, 2016
Tegelberg and RCT, control N50 Ar (56% RA, A: active ROM exercises, HP ESR, CRP, severity of symptoms (5-point scale), 3 y (n35):
Kopp,32 Level II 64% AS), F64%, (1 rx over 3 wk) Helkimo Dysfunction Index, CDS, TVO Reduction in CDS maintained
1988 mean age48.1 y, B: no rx Decrease in severity of symptoms in A and B clinical (RA) in A
Tegelberg and A/Rn/a (greater in A [RA]) Increase in TVO maintained
Kopp,33 Reduction in CDS (RA) and increase in TVO in A
1996 (3 y greater in A Increase in ESR in RA
follow-up) No change in ESR and CRP in A or B
(continued)
Design and
Level of
Authors Evidence Subjects Intervention Outcome Measures and Resultsb Follow-up Resultsb
Wright et al,34 RCT, control N60 chronic My, A: postural correction, HP MMSI None
2000 Level II F85%, mean (2 rx over 2 wk) TMD: ES0.55 (0.350.71)
age31.8 y, B: no rx Neck: ES0.50 (0.280.67)
A/R60/61 TVO: ES0.27 (0.020.49)
Pressure algometer pain threshold:
Masseter: ES0.31 (0.060.53)
Trapezius: ES0.36 (0.110.56)
Downloaded
Neck: ES0.44 (0.210.62)
a
7 . Julyfrom
Agroup I, Ararthritis, A/Ranalyzed/randomized, ASankylosing spondylitis, Bgroup II, Cgroup III, CDSclinical dysfunction score, CRPC-reactive protein, DDdisk displacement(s),
2006
EMGelectromyography, ESeffect size (95% confidence interval), ESRerthrocyte sedimention rate, Ffemale, HPhome program, LTlateral excursion (left and right), MFIQMandibular Function Impairment
Questionnaire, MMSImodified symptom severity index, Mymyofascial/muscular, n/adata not available, PPTpressure pain threshold, PRIpain rating intensity, PTphysical therapy, RArheumatoid arthritis,
RCTrandomized controlled trial, ROMrange of motion, rxtreatment, TMDtemporomandibular disorder, TVOtotal vertical opening, VASvisual analog scale.
b
Statistically significant unless noted.
Design and
Level of Outcome Measures and
Authors Evidence Subjects Intervention Resultsb Follow-up Resultsb
Al-Badawi et al,35 RCT, placebo N40 Ar, F78%, age A: PRFE, 250 kHz, pulsed 600 Hz, TMJ pain: ES0.66 (0.450.81) None
2004 Level II range2255 y, 6 15 s, 7-s rest intervals TVO: ES0.14 (0.180.43)
Physical Therapy
D: laser, 904 nm, 4 J/cm2, 3 min TVO, overall state (5-point
11, 2016
E: placebo (12 rx over 4 wk) scale), joint and muscle
tenderness and sounds on
palpation
Linde et al,39 1995 RCT N31 DD, F84%, mean A: TENS, 90 Hz, 30 min, just below TVO: ES0.01 (0.340.37) None
Level II age37 y, A/Rn/a pain threshold, 3 per day, HP LT: ES0.11 (0.260.44)
B: occlusal splint (6 rx in 6 wk) PR: ES0.28 (0.080.58)
Symptoms (5- and 6-step scales),
painVAS, pain track device,
TVO, tenderness and joint
sounds on palpation
Greater decrease in pain in B
(continued)
Design and
Level of Outcome Measures and
Authors Evidence Subjects Intervention Resultsb Follow-up Resultsb
Moystad et al,40 1990 Randomized order N19, Ar (89% RA) 1a: TENS, 100 Hz, pulse width PainVAS, TMJ and muscle None
of treatments F89%, mean age 0.15 ms, constant sensation TMJ area tenderness on palpation (3-
within sessions 33 y, A/Rn/a 1b: placebo, 30 min (2 rx over 2 wk) point scale), TVO, LT, and PR
(treatment 2a: TENS, 2 Hz, pulse width 0.2 ms, Greater decrease in 1a
session 1 before acupuncture point on hand No difference in improvements
2), placebo 2b: placebo, 30 min (2 rx over 2 wk) in all other areas between
Level IV groups
Downloaded
A/R49/49 C: placebo, 5 min per TMJ No difference in improvements
7 . Julyfrom
(mean8.9 rx) between groups
2006
a
Agroup I, Ararthritis, A/Ranalyzed/randomized, Bgroup II, Cgroup III, Dgroup IV, DDdisk displacement(s), Egroup V, ESeffect size (95% confidence interval), Ffemale, HPhome program,
LTlateral excursion (left and right), Mymyofascial/muscular, n/adata not available, ppspulses per second, PRprotrusive excursion, PRFEpulsed radio frequency energy, PTphysical therapy, RArheumatoid
arthritis, RCTrandomized controlled trial, rxtreatment, TENStranscutaneous electrical nerve stimulation, TMJtemporomandibular joint, TVOtotal vertical opening, VASvisual analog scale.
b
Statistically significant unless noted.
Design and
Level of
Authors Evidence Subjects Intervention Outcomes Measures and Resultsb Follow-up Resultsb
Carlson et al,42 RCT N44 My, F77%, A: breathing and postural relaxation Pain measures 26 wk: less pain and greater
2001 Level II mean age34.6 y, techniques, proprioceptive Daily self-monitoring: ES0.57 (0.330.74) TVO in A
Physical Therapy
Adjectival pain rating
11, 2016
AB: ES0.10 (0.460.60)
AC: ES0.08 (0.470.58)
BC: ES0.16 (0.410.64)
Average weekly frequency of pain
AB: ES0.02 (0.520.55)
AC: ES0.75 (0.360.92)
BC: ES0.58 (0.070.85)
Average weekly pain intensity
AB: ES0.50 (0.050.81)
AC: ES0.01 (0.530.53)
BC: ES0.44 (0.110.79)
(continued)
Design and
Level of
Authors Evidence Subjects Intervention Outcomes Measures and Resultsb Follow-up Resultsb
Dahlstrom et al,43 RCT N30 My, F100%, A: occlusal splint (2 rx over 6 wk) Self-reported symptom rating: ES0.15 12 mo: no further significant
1982 Level II mean age28.6 y, B: EMG biofeedback, HP (0.230.48) changes
Dahlstrom and A/Rn/a (mean5.3 rx over 6 wk) Self-reported symptoms5-point scale, clinical
Carlsson,44 dysfunction (Helkimo Index), TVO
1984 increase in TVO in B
Dalen et al,45 RCT, control N19 My, F95%, A: EMG biofeedback, HP EMG 6 mo
Downloaded
(0.260.85)
7 . Julyfrom
EMG 8 wk posttreatment (frontalis): ES0.52
2006
(0.080.79)
Pain duration: ES0.85 (0.650.94)
Pain intensity variable: ES0.76 (0.470.90)
Dohrmann and RCT, placebo N24 My, F88%, A:P biofeedback, HP EMG: ES0.39 (0.010.69) 6 and 12 mo: further rx
Laskin,46 1978 Level II mean age37 y, B: sham biofeedback, HP (12 rx Pain (3-point scale), TVO, pain-free TVO, pain on required in 25% of A (no
A/Rn/a over 6 wk) muscle palpation, self-report on joint sounds, statistical analysis)
overall treatment success (patient and examiner),
EMG levels:
Greater reduction in pain and tender on palpation
in A
Increase in TVO in A (no statistical analysis)
Hijzen et al,47 RCT, control N48 My, F94%, A: occlusal night splint TVO: ES0.89 (0.810.94) None
1986 Level II mean agen/a, B: biofeedback (10 rx over 5 wk) Joint sounds: ES0.88 (0.790.93)
A/Rn/a C: control (splint therapy delayed) Grinding: ES0.58 (0.350.74)
Stuffed or dull feeling in ears: ES0.53 (0.200.71)
Jaw muscle stiffness on awakening: ES0.76 (0.61
0.86)
Pain intensity: ES0.93 (0.880.96)
Frequency of pain periods: ES0.92 (0.850.95)
Design and
Level of
Authors Evidence Subjects Intervention Outcomes Measures and Resultsb Follow-up Resultsb
Turk et al,49 RCT control N58 chronic My, A: occlusal splint CES-D 6 mo
1993 Level II F82% mean age B: biofeedback, stress management AB: ES0.01 (0.250.27) CES-D, A and B: ES0.34
Inclusion Blinding
and Similarity (aPatient, Long-
Exclusion of Groups bProvider, Term Total Level of
Author Randomization Criteria at Baseline Replicability Reliability Validity cAssessor) Dropouts Results Adherence Score Evidence
Downloaded
N (3/6)
Gray et al,38 1995 Y Y Y N N N Y (a,b,c) Y N N/A 5/9 IIb
7 . Julyfrom
2006
Taube et al,41 1988 Y Y N Y N N Y (a,c) Y N N/A 4.6/9 IIb
Dalen et al,45 1986 Y Y Y Y N N N N Y N 5/10 IIb
Conti,37 1997 Y Y Y Y N N Y (a,c) N N N/A 4.6/9 IIb
Bertolucci and Gray,36 1995 Y Y N Y N N Y (a) Y N N/A 4.3/9 IIb
Bertolucci and Gray,5 1995 Y Y N Y N N N Y N N/A 4/9 IIb
Crockett et al,50 1986 Y Y Y N N N N Y N N 4/10 IIb
Dohrmann and Laskin,46 Y Na Y Y N N N N Y N 4/10 IIb
1978
Hijzen et al,47 1986 Y Y Y Y N N N N N N 4/10 IIb
Linde et al,39 1995 Y Y Y Y N N N N N N 4/10 IIb
Moystad et al,40 1990 Yb Y N Y N N Y (a,c) N N N/A 3.6/9 IV
Taylor et al,4 1994 Yc Y N Y Y (1/2) N N N N N/A 3.5/9 IV
N (1/2)
Carmeli et al,9 2001 Y N N Y Y N Y (c) N N N 3.3/10 IIb
Nicolakis et al,27 2002 Nd Y N/A N Y (2/5)a N N Y Y N 3.4/9 IV
N (3/5)
Burgess et al,21 1998 Y Na Y Y N N N N N N 3/10 IIb
Dahlstrom and colleagues,43,44 Y N Y Y N N N N N N 3/10 IIb
1982, 1984
Tegelberg and Kopp,32,33 Y Na N Y N N N N Y N 3/10 IIb
1988, 1996
Nicolakis et al,31 2000 Nd Y N/A N N N N Y Y N 3/9 IV
Nicolakis et al,28,29 Nd Y N/A N N N N Y Y N 3/9 IV
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