A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder

Study Title: A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder

Study Type: Systematic review

Level of Evidence: Level 3

Clinical Summary: The reviewers state their results as follows: Exercises and mobilizations, alone or in combination, may be effective in short term increasing total ROM in patients with TMD. Postural training is of unclear importance in treating TMD. Laser may be more effective at improving both pain and function than other electrotherapies for TMD. Programs involving relaxation, biofeedback, EMG training, and proprioceptive training may be more effective than placebo or occlusal splints in improving pain and function for patients with myofascial TMD in the short and long term. Combinations of exercises, manual therapy, postural correction, and relaxation may decrease pain and impairment short-term, but it is impossible to determine whether the combination is more effective than individual elements of the program as treatments.

Overall Quality: Moderate- Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Why: The lit search only included English studies, inclusion and exclusion criteria were broad. Most of the search, data abstraction, and rating of studies were done by one author. Many of the studies looked at different outcome measures, so meta-analysis was of limited value.

Apply This: Based on this review, treatments for the TMJ should focus on exercises, mobilization, and relaxation training with biofeedback or other training techniques. Laser therapies are likely more effective than other electrotherapies at improving pain and function. Postural correction is of uncertain value in the clinical picture, but may best be determined on a case-by-case basis.

Study Author(s): Marega S Medlicott, Susan R Harris

Publication Date: 7/1/2006

Published in: Physical Therapy

Tags: (region, condition/dx, tx, level of evidence, quality rating)TMJ, TMD, manual therapy, LLLT, exercises, proprioceptive training, Level 3, Moderate

 

A meta-analysis of Clinical Effects of Low-level Laser Therapy on Temporomandibular Joint Pain

Study Title: A meta-analysis of Clinical Effects of Low-level Laser Therapy on Temporomandibular Joint Pain

Study Type: Systematic Review with Meta-analysis

Level of Evidence: Level 1

Clinical Summary: The researchers pooled the results (n=216) from 6 high quality RCTs (peDRO score >/= 7/11), and found a moderate treatment effect size of 0.6 (95% CI 0.47 to 0.73). Outcomes looked at were primarily pain assessed by VAS. Results were both statistically and clinically significant.

Overall Quality: High- Further research very unlikely to change our confidence in the estimate of effect

Why: Inclusion criteria clearly stated, only high quality studies were included, meta-analysis included.

Apply This: Though the optimal parameters and dosage of LLLT for TMJ have not been clearly established, the 780-830 nm range seems to have the largest effect size. Effective therapeutic dosage seems to be between 6.3-105 J/cm^2. Power output of between 30-500 mW was used. In the studies reviewed, between 4 and 10 treatment sessions demonstrated a moderate to large treatment effect size.

Study Author(s): Wen-Dien Chang PhD, Chia-Lun Lee PhD, Hung-Yu Lin PhD, Yung-Chun Hsu MS, Chung-Jieh Wang PhD, Ping-Tung Lai BS

Publication Date: 2/16/2014

Published in: J. Phys. Ther. Sci Vol.26, No. 8, 2014

 

Chiropractic treatment of temporomandibular disorders using the activator adjusting instrument: a prospective case series

Study Title: Chiropractic treatment of temporomandibular disorders using the activator adjusting instrument: A prospective case series

Study Type: Case Series

Level of Evidence: Level 4

Clinical Summary: 14 adult patients with TMD symptoms were treated with Activator protocol and an additional suprahyoid muscle treatment. The average reduction in pain as rated by the patient was 6.9 points on 0-10 Verbal Numeric Pain Scale (MCID 2-3). All patients showed reduction of TMD symptoms, however the lack of specific inclusion criteria, high variability in number of patient visits, and the fact that most of the patients were already under care for TMD calls into question the validity of the results.

Overall Quality: Low- Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Why: No specific inclusion criteria, no specific time period or number of treatments established, and potential conflict of interest as one of the authors is currently and has previously been professionally affiliated with Activator Methods International.

Apply This: If treating TMD, myofascial release, trigger-point therapy, and impulses from an Activator or similar instrument applied to the suprahyoid muscles may increase the effect of treatment.

Study Author(s): Steven Pavia DC, Rebecca Fischer DC, Richard Roy DC

Publication Date: 8/19/2015

Published in: Journal of Chiropractic Medicine

 

Interventions for the management of temporomandibular joint osteoarthritis

Study Title:Interventions for the management of temporomandibular joint osteoarthritis (Review)

Study Type: Systematic Review

Level of Evidence: Level 1

Clinical Summary:Injections of hyaluronic acid or corticosteroids seem to be equally effective for pain at 6 months, VAS SMD: -17.00 (95%CI: -32.6 to -1.4) No measures of jaw movements had significant results in the first study. Night splints appear to be as effective as diclofenac sodium, but pain scores were reported as percentages and could not be extracted. Diclofenac sodium was associated with more severe side effects. Glucosamine Sulfate appeared to be as effective as ibuprofen at improving pain and function over a 90-day period: VAS SMD -6.74 (-14.70, 1.22).

Overall Quality: Moderate- Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Why:The quality of the review is excellent, however the studies themselves lack homogeneity and specifics in some cases, and there were very few that met the inclusion criteria used by the reviewers. For these reasons, the weight of the evidence is relatively minor, and further research is needed in each area.

Apply This:The glucosamine protocol used was as follows: glucosamine sulfate 500 mg PO TID for 90 days.

Study Author(s):de Souza RF, Lovato da Silva CH, Nasser M, Fedorowicz Z, Al-Muharraqi MA

Publication Date:2012

Published in:The Cochrane Library

Mandibular Manipulation for the Treatment of Temporomandibular Disorder

Study Title: Mandibular Manipulation for the Treatment of Temporomandibular Disorder         

Study Type: Systematic Review

Level of Evidence: Level 1

Clinical Summary:Only 2 studies met the inclusion criteria, and both showed no evidence for therapeutic benefit. This does not demonstrate a lack of benefit from manipulative therapy so much as a lack of quality studies on the subject. This study specifically looked at patients with confirmed disc displacement without reduction.

Overall Quality: Moderate- Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Why:Only 2 studies were included, thus total evidence reviewed is too limited to draw hard conclusions. Methodology in this review is sound, however, and both studies reviewed were of high quality and their results were in agreement. A lack of a priori power calculations in both studies reviewed raises questions about the statistical power to detect changes.

Apply This:For TMJ pain related to disc displacement without reduction, there may be some benefit to some patients from mandibular manipulation, and no adverse events were reported.

Study Author(s):Betania Mara Franco Alves, MD, Cristiane Rufino Macedo, MD, Eduardo Januzzi, MD, Eduardo Grossmann, MD, Alvaro Nagib Atallah, MD, Stella Peccin, MD

Publication Date:3/1/2013

Published in: The Journal of Craniofacial Surgery

Temporomandibular disorders part 2: conservative management

Study Title: Temporomandibular disorders part 2: conservative management

Study Type: Narrative Review (listed as Systematic Review)

Level of Evidence: Level 5

Clinical Summary:A review of the evidence for the most widely-utilized TMD therapeutic approaches. STM, while perhaps the most common treatment, has very little formal research to support its use. Therapeutic exercises, such as the Rocabado 6×6 program, though often recommended, also lack evidence. One study showed no additional benefit when the Rocabado 6×6 program was added. Pt education is considered important and effective. CBT not generally effective, but may be necessary on a case-by-case basis. Electrical modalities help with symptom management. Biofeedback shown to be effective in muscular TMD. Iontophoresis of dexamethasone may not be equally absorbed by all pts and does not improve pain, though function may be improved; not recommended due to conflicting evidence and risks of side effects. Ultrasound not recommended. Splints have insufficient evidence for or against, so a case-by-case approach is recommended. Multimodal approaches including STM, postural corrections, joint mobilization, exercises, and relaxation techniques appear to be the most helpful.

Overall Quality: Moderate- Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Why:No specific question answered, merely a summary of research with authors’ recommendations. No description of the search strategy, inclusion criteria, or quality assessment of studies included. Still, a very thorough summary and description of current therapeutic approaches.

Apply This: Useful as a starting-point for further research or for background information.

Study Author(s): Stephen M. Shaffer, Jean-Michel Brisme’e, Phillip s. Sizer, Carol A. Courtney

Publication Date:2014

Published in:JMMT

Tags: (region, condition/dx, tx, level of evidence, quality rating)TMJ, TMD, Level 5, Moderate

 

Temporomandibular Disorders Part 1: anatomy and examination/diagnosis

Study Title: Temporomandibular Disorders Part 1: anatomy and examination/diagnosis

Study Type:Narrative Review

Clinical Summary: A review of literature and practices pertaining to manual therapists and the management of TMD, encompassing a review of anatomy, history, and physical examination.

Overall Quality: Moderate- Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Why: While this is a well done and very thorough narrative review, narrative reviews in general are at high risk of reflecting the reviewers’ bias.

Apply This: This is a useful starting point for review of the background information and general information about relevant history, physical examination, and differential diagnosis.

Study Author(s): Stephen M. Shaffer, Jean-Michel Brisme’e, Phillip S Sizer, Carol A. Courtney

Publication Date: 2014

Published in: JMMT