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A Systematic Review of theEffectiveness of Exercise, ManualTherapy, Electrotherapy, RelaxationTraining, and Biofeedback in theManagement of TemporomandihularDisorder

Background and Purpose. This systematic review analyzed studies exam-ining the effectiveness of various physical therapy interventions fortemporomandihular disorder. Methods. Studies met 4 cnteria: (1) suh-jecLs were from 1 of $ 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 primar)' presenting symptoms. Thirty studies were evaluatedusing Sackett's rules of evidence and 10 scientific rigor criteria. Fourrandomly selected articles were classified independently hy 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 propdocep-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. Phy.s Ther. 2006;86:955-973.]

Key Words: facial pain, Physical therapy, Rehabilitation, Temporomandihular disorder, Temporoman-

dibular joint syndrome. Therapy. :

Morega S Medlicott^ Susan H Harris

Physical Therapy . Volume 86 . Number 7 , July 2006 955

T emporomandibular disorder (TMD) includes avariety of conditions associated with pain anddysfunction of the temporomandibular joint(TMJ) and the masticatory muscles.' An esti-

mated 20% of the population is affected, with 10% to20% of those seeking treatment.^-^ These disorders alsoare referred to as "temporomandibular dysfunction," "cra-niomandibular disorders," and "mandibular dysfunction.'"^

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.'' A variety of other symptoms, such as tinnitus,abnormal swallowing, and hyoid bone tenderness, alsomay occur.' Quality of life may be affected, with anegative effect on social function, emotional health, andenergy level.''

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.' The ResearchDiagnostic Criteria for Temporomandihular Disorders(RDC/TMD) applies a dual-axis system to diagnose andclassify patients with TMD.''"-'" The first axis is dividediiiio 3 groups of commonly occurring TMDs:

1. Muscle disorders, Including myofascial pain with andwitliout limited mandibular opening.

2. Disk displacement with or without reduction or lim-ited mandibuiar 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). • ••*'

Noninvasive, conservative treatments generally provideimprovement or relief of symptoms and are recom-mended in the initial management of TMD. ^ Physicaltlierapists are frequently involved in the management of

TMD, often in collahoration with dental professionals.In a survey of memhers of the American Dental Associ-ation, physical therapy was listed among tin- 10 mostcommon treatments used, involving 10% to 17% ofpatients.'''' A wide variet\- 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.''"''^

Research evaluating the effects of physical therapy in themanagement of TMD has been criticized for its lack ofmethodologiccil rigor.''*''^ However, recent studies haveattempted to address some pre\'iously 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), disahility and function, joint noise,tenderness, and psychological factors. Based on durationof the disorder, TMD was defined as acute (<6 months)or chronic (>6 months). Sackctt'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."'''Based on 5 hierarchical levels of evidence, which haveheen used in previous systematic reviews of physicaltherapist practice, recommendations can he maderegarding treatment options.'"'"

MethodThe literature search was restricted to English-languagepublications from 1966 through [anuar\' 2005. IndexMedicus (MEDLINE), the CAimulative Index to Nursingand Allied Health Literature (CINAHL), and theCochrane Central Register of (Controlled Trials weresearched using the text words "facial pain," "physicaltherapy," "rehahilitation," "temporomandihular disor-der (TMD)." "temporomandihnlar joint (TMJ)," "tem-poromandibular joint syndrome," and "dierapy."

MS Medlicott. BScPT, is Physical Therapist, Lion's Gate Hospital, Norlh Vancouver, British Columbia, Canada. Addres.s all correspondence lo MsMedlicolt at 2759 Webster Rd, Nanaimo. British Columbia. Canada. V9R 6W7 {mmedlicott@hotinail.com).

SR Han is, PT, PhD, F.\PTA, is Professor, School of Rehabilitation Scicnct-s-Faculty of Medicine, LFniversity of British Columbia. Vancouver, Britishia, Canada.

Ms Medlicott provided concept/idea/research design. Both authors pro\'ided WTiting and data cotloction and analysis. Dr Harris providedconsultation (including review of manuscript before submission).

This article was received fune 6, 2(X)5, and was accepted JanuaTy 31, 2006.

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

Study Selection CriteriaTo lie included in the systematic review, studies bad tonit'L't the following criteria: (1) subjects were from 1 ofthe 3 groups identified in the first axis of the RMC/TMD,'' (2) the inteivention was within the realm ofphysical therapist practice, (3) an experimental designwa.s used (eg, an RCT or nonrandomized controlleduiai). and (4) the outcome measures asse.ssed one ormore of ihc primaty presenting symptoms (eg, pain,ROM, disability or function).

Studies with any of the following exclusion criteria werenot included in the review: (1) interventions post-TMJsurger\. (2) physical therapy interventions in combi-nation with other non-pbysical therapy inteiventions,(3) acupuncture as an intervention, (4) interventionsinvolving passive ROM devices. Studies tbat assessed onlyelectromyogiaphic (EMG) results were not included.

Review CriteriaStudies were evaluated according to Sackett's initial rulesof evidence," as described by Barry."^ These levels (1-V)arc hierarchical and represent the confidence generatedby the results produced in the studies.

Level I: (a) systematic re\'iew (witb homogeneity) ofRCTs

(b) individual RCT (with narrow confidence

(c) all or none

Level II: (a) systematic review (with homogeneity) ofcohort studies

(b) indi\idual cohort study, including low-qualitv- RC:TS (eg, <80% follow-up)

(c) "outcomes" research

Level III: (a) systematic review (with homogeneity) ofcase-control studies

(b) indi\idual case-control studies

Level IV: case series (and poor-quality cohort and case-control studies)

Level V: expert opinion witliout explicit critical appraisal,or based ou physiology, bench research, or "firstprinciples"

Methodological Quality of Reviewed StudiesMethodological rigor of the studies was evaluated usingthe following criteria, adapted from Megens and Har-ris'**'" and the McMaster Occupational TherapyEvidence-Based Practice Research Group^":

(1) randomization,

(2) inclusion and exclusion criteria were listed for thesubjects (and were subsequently grouped, by theprimary author of tliis review, into 1 the categorieson tbe 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 sufiiciently described tobe replicablc,

(5) reliability of data obtained witli the outcome mea-sures was investigated,

(6) validity data obtained witb 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 metliodological 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 ofevidence''^ 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 tbe exclusion of all except 30studies was the incorporation of non-physical therapymanagement, such as medication or surgery. Onere\'iewer 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, tising theMcMaster University Critical Review Form for Quantita-tive Sttidies^" to assess methodological rigor, was 73.5%.

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

The 30 studies included in this re\'iew were divided intogroups based on the primary intervention used. Four-teen studies' - - i- "* investigated tbe use of exercise ormanual therapy, 8 studies'"- ''- ' investigated the use ofelectrotherapy, 7 studies' *'*^ investigated the use ofrelaxation training or biofeedback, and 1 study' " 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 SizeEfiect size rwas calculated using Meta-.\nalysis Programsby Schwarzer.''' If means and standard deviations wereavailable, these data were used lo 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.' ^ Effect size measurements can indi-cate the relative magnitude of the expeiimental treat-ment and can allow comparison of the magnitude ofexperimental treatments between experiments. The sug-gestion by Cohen'"'- tbat 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 rawdat;O, 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 lib due to low .study quaiih. Fourstudies" '' **™-*' had a single-group pietest-posttest designwitb a nontreatment control period, 2 studies - fi had acase series design, 1 study^ bad a single-group random-ized (treatment or placebo) crossover design, and 1study-*" involved 1 group witb a randomized order oftreatments (treatment or placebo) within sessions (witbsession 1 before session 2); these 8 studies were ideiui-ticd as level IV due to the lack of a control group.

Scientific Rigor of fhe StudiesThe methodological rigor of the studies was evaluatedusing the 10 criteria shown in Table 4 (see page 971).Tbe 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 studies22-24,25.34.4ycould be jtidged a.s "moderate" ("yes" score of 6 or 7), andthe remaining 25 studies''-'- -2'- -26-28,;i

wotild be considered "weak" ("yes" score or <5).

RandomizationSubjects were randomly assigned to 2 or more groups in24 studies,-i" '-'-'.2>-22.2-.,25.;i2.34-43,4.w.o including the 2 stud-ies that involved cross-over designs. The 6 studies inwhich subjects were not randomly assigned to groupswere all single-grotip

Subject Inclusion and Exclusion CriteriaInclusion and exclusion criteria varied among the stud-ies and in relation to the subgroup of TMD diagnosis oftbe sample studied. Subjects were classified into sub-groups identified in the RDC/TMD. Seventeen stud-ies4.2i.- 2.a4,25,27,34,38.4i-5o hivoived subjects with myofascialTMD, and 6 sttidies923,2<;,.i().:n.:w involved subjects wiihdisk displacement (1 study with subjects with reduc-tion,^' 3 studies witb svibjects without reduction,2*-2**-3and 2 studies with subjects with unspecified status as toreduction^-3«). One other study-'' involved subjects withmyofascial TMD (50%) and subjects with arthritis(50%). Six sttidies -28.25'--'2.M.ri.'-..:ifi.4o involved people witharthritis (2 studies with subjects with disk displacetncntwithout reduction, 1 study with 89% of the subjectshaving rheumatoid anhritis, I study with 56% of thestibjfcts having rheumatoid arthritis, 1 study with 64% oftbe subjects having ankylosing spondylitis, and 1 studyunspecified).

Studies involving subjects from all subgroups of TMDwere incltidcd in the systt-matic review, despite differ-ences among subgroups. Inclusion criteria were notidentified in 7 of the 30 studies. In 3 studies, '• •«^ areference source was provided, but criteria were nototherwise defined. In the other 4 studies,-'-*'- '*"^ 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 in

7-iy.. i,.s4,4i.42,47..w T h e o ther U stud-required self-reported symptoms of an

unspecified length of time. Five of the studies involvingsubjects with arthritic TMD "'' " -'- * "' required radiolog-ical evidence of osteoarthritis among the inclusion cri-teria. One sttidy invohing di.sk displacement'" requiredmagnetic resonance imaging (MRl) evidence. Sixstudies'*' ' -^ ' ' ^ required that subjects have limitedmandibular m(jvement. Evidence of "postural dysfunc-tion" was required in 3 studies,^'-'''-^i although posturaldysfunction was not defined in detail. Five of the studiesinvolving subjects with myofascial TMD'*22.:i;t,4-j.. ..irequired tlie presence of tenderness on palpation ofmasticatory muscles. Four studies- - ' - * also directlyreferenced the source of the inclusion criteria. Exclu-sion criteria tended to rule out a histoiy of trauma ormalocclusion, prior or concurrent treatment for TMD,

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

and specific contraindications relating to electrotherapymodalities.

Similarity of Graups at BaselineF o u r t e e n studies^'••'^^'^'•^•'•'^•-''-'^•'•^-'•••''

(he similarity of groups at baseline.'-'• " reported on

Repeatability of the Treatment ProtocolOf llif 14 studies involving exercise or manual therapy,9 studies'*•'••2'-23-25,2s.32,.'i4 provided sufficient description10 allow replication of the interventiiin. hi the remaining6 studies,-^-'-"" 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-\enlion described the intei-vention in sufficient detail toallow for replication/''^''-'- Of the 8 studies involvingbiofeedback or education, 6 studies'*''-^^*^ provided ade-quate information to allow replication of the interven-tion. Two studies'-^'' failed to provide sufficient detailon the interventions utilized, preventing replication,altbougli 1 study'^ referred to a manual for the descrip-tion of tlie intervention involved.

Outcome Measure ReliabilityReliability of dat;i obtained with the outcome measureswas reported in only 8 studies. Camieli and colleagues''reported intrarater reliahility for the measurement ofactive ROM of the TM], whereas Taylor et ah reportedinterrater reliability for maximal mandihular openingand lateral movement. Carlson and colleagues'-reportfd the internal consistency and intrarater reliabil-ity for subscales from the Multidimensional Pain Inven-tory (MPl) measuring pain severity, life interferencefrom pain, and perception of life control. This group ofresearchers also reported the internal consistency andintrarater reliability for ihe somatization, depression,anxiety, and obsessive-compulsive scales of the RevisedSymptom Checklist {SCL-90-R).-*'- Internal consistencyand intrarater retiabilit)- for the affective distress scalefrom the MPl, as well the internal consistency and theintrarater reliability for the sleep dysfunction scale, alsowere reported.'^

Internal consistency and interrater reliability for themuscle palpation pain index (PPl) and internal consis-tency for credibility ratings were reported by Turk andcolleagues.*-' Okeson and colleagues'*** reported on theinternal consistency for muscle and TMj palpation. Oneof the studies by Nicolakis and colleagues-' referencedthe reliahility of scores for the visual analog scale(VAS).'"'-' Wright et al-''' referenced previously reportedintrarater and interrater reliability of data for the mod-ified symptom severity index (SSI-5 VAS), maximumpain-free opening, and muscle pain thresh old.•"'• ''• -' De

Laat and colleagues^^ referenced the reliability of datafor the VAS, pressure pain threshold (PPT), and theMandihular Functional Impairment Questionnaire(MFIQ).^'^" Of the 8 studies that reported reliability ofdata ibr outcome measures, only 2 studies^-'^' reportedreliability for all of the outcome measures used.

Outcome Measure Validity\';\lidity of data ibr outcome measures was reported in 3studies.= ' - *- -' Wright and colleagues'*' indicated that thevalidity of data lor their outcome measures had beenreported previously." - ''"' Al-Badawi and coUeagues^^indicated that the 10-point Numerical Pain Scale hadbeen reported to be statistically sensitive when measur-ing pain and discomfort. ' De Laat and colleagues^^referenced the smallest detectable difference on a VASto be considered clinically relevant in TMD secondary todisk displacement witbout reduction''^ in subjects withmyofascial TMD. None of the other studies presentedany information on the validity for outcome measuresused.

In tbe 30 studies reviewed, over 75 different outcomemeasures were utilized. The outcomes of interest wereself-reported pain, pain on palpation, active ROM, EMGlevels, questionnaires regarding selfreported symptomseverity and frequency, dysfunction indexes related toimpairment, and psychological status scales. A largevariety of tools and other assessment methods were itsedto meastire the outcomes of interest with differentstudies using different tools or methods to evaluate thesame outcome.

Blind AssessmentBlinded treatment providers and outcome measurea.ssessors were used in 11 of the 30 " ' ^

Account for AttritionSubjecl attrition was reported in 15 of tbe 30studies.'''"^2.24.25.27.28.3o..si.34.36.39.4i,42.4o.r.(i [ „ t h e s t u d y by

Moystad et al,*" 6 stibjects were inexplicably unac-counted for during tbe second pliase of treatment. Inthe remaining 15 studies, subject attrition was not explic-itly described.

Lang-Term Follaw-upLong term-follow-up (6 months or greater) was reportedin 10 of the 30 studies reviewed,-''-^^'•^••^•''^'»'•'•' with the"long-term" assessment occurring from 6 months to 4years after treatment.

Adherence to Home ProgramsAlthough liome intei-vention programs were explicitlyidentified in 20 of the 30 studies reviewed, the rateof adherence was not reported in 17 of those

2'22-27ii«:w-3y-3"-*- -t:*-'- '-'''" Only 3 studies identi-

Physical Therapy . Volume 86 . Number 7 - July 2006 Medlicott and Harris . 959

fled the rate of adherence (via self-report). Magniissonand Syren'-* reported adherence at long-term follow upa.s less than 50%. Wright and colleagues'^' reported amean adherence of 75% after treatment, and Michelottiand colleagues'-^^ reported adherence to the home phys-ical therapy regimen as poor C27%) or medium (46%).

Discussion and ConclusionsTlic 22 RCTs included in ilie systematic review wereranked level II, using Sackett's rules of evidence,'^ due tolow study quality. The remaining 8 studies were rankedlevel I\' due to decreased rigor of the research designs.

Feine and Lund""' performed an analysis of re\icw arti-cles and contiolled 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 asalnuisi always hetter than no treatment, with efficacyincreasing in direct proportion to the amount of treat-ment received. In addition, those subjects who receivednioie treatment modalities seemed to do better thanthose who received fewer modalities.*^

With respect to specific interventions, 4 systematicreviews were located, none of which were included in theanalysis performed by Feine and Lund.'"' A 1996 system-atic review '-' stated that there was insufficient evidence torefute or support either manipulation or mobilization intreatment of the TMJ. A more recent systematic rexiew oflow-level laser therapy"" showed a redtiction in pain andimprovement in health status in chronic joint disorders,fiowever, a systematic review of ultrasound in the man-agement oi chionic muscukjskeletal disorders'" showedlitde evidence to support its use. A meta-analysis"^ con-cluded that, although limited in extent, the availabledata support the efficacy of EMG biofeedback treat-lnenLs 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 studies.selected. The majority of patients who sought tieatnientfor TMD and were subsequently involved in the studieswere women.''-* This finding may relate to a difference intt eatment-seeking behavior between men and women, aswell as the greater likelihood for women to have soma-tization disorders.*'"' The external validit)- of the recom-mendations is limited, dne, 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* "* showed thatthe patients who refused to participate had more painand more condition-related interference in daily lifewhen compared whh those who participated.

Temporomandibular disorder-related paiti of >6months may represent a shift from acute to chronicTMD. Five of the studies in this re\iew required aduration of pain for >6 months.' '-''•"''•'•*''•" The secondaxis of the RDC/TMD inchides the more psychosocialaspects of TMD.''-' 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.'"'•'"

Within our systematic re\aew, a variety of inten'entionswere used to treat the 3 TMD subgroups in die first axis.Interventions were grouped into I of 3 areas: exercise,electrotherapy, and biofeedback. Within the 3 areas, theinteiTentions were often heterogeneous, making com-parisons difficult. The use of multiple interventions in animiber of studies resulted in recommendations basedon a multi-intervention program because the eflective-ness of a single intervention alone was not examined.

A spectrum of different (jutcome measures was used inthe studies reviewed. Most of the studies includedbetween 2 and 5 ontcome 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,'••'--•^'•^'•'-•"^'•' withonly 2 sttidies22.34 reporting reliability on all of theoutcome measures involved. Validity was reported in 3studies,'' -^""- ''' with only 1 study'" reporting on all of theoutcome measures involved. Only 3 studies '' ' -'* ^reported whether oiucomes were clinically iinportimt.The lack of deinonstrated reliability or validity for theoutcome measures used limits the confidence withwhich the results may be interpreted.

Five studies22.24.2r,.3-!.iv. fulFilled (i 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 le.ssconfidence in the study results. The impcjrtance 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 availablee\idence. The re\iew was limited to pnblished articlesand thus may have missed those ihat were not submitted

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

or accepted for publication, presenting a possible pub-lication bias. As only the first author preformed tbeliterature search and the subsequent selection of thestudies to be considered in this review, a selection biasmay be present. Additionally, tbe first author performedtlie data abstraction, as well as a siguificaui proportion oftbe rating and classification of the studies, which maypresent a data abstraction and evaluation bias.

Implications for Clinical PracticeDespite lepoiled limitations of this systematic review ofthe scientific evidence for physical therapy interventionsibr TMD, the following clinical recommendations aresuggested:

(1) Active exercises and mantial mobilizations, alone orin combinatit)U, may be effective in the short tenuin increasing total vertical opening {TV'O) 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 witbother treatment techniques because ihe effects,independent of other treatments, are not known(eg, postural training c(jnil)int'd with a home exer-cise program may decrease pain and increase T\'Oin people with myofascial TMD).

(3) Mid-laser therapy may decrease pain and improveT\'O 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 invohing relaxation techniques andbiofeedback, EMCl 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 tbe short term andthe long term.

(5) Programs invoKing combinations of active exer-cises, manual tberapy, postural correction, andrelaxation techniques may decrease pain andimpairment and increase TVO in the short term inpeople witb 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 tbe separate elements of ihe program as individ-ual treatment techniqties.

Implications for Future ResearchTbe foregoing clinical implications should be consid-ered witb caution because none were supported bynunieious, decisive studies. C^onscnsiis on tbe definitionof TMD, and subsequent inclusion and exclusion crite-ria, wotild allow further comparison across groupsstudied. In addition, agieenicni on tise of valid andreliable outcome measures would yield more rigorousresearch.

Physical Therapy . Volume 86 . Number 7 . July 2006 Medlicott and Harris . 961

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2 IVdnuii CR, Dc Oliveint .AS, (liiaratini Ml. Prcvulencc stiirly of signsand s\inptoiii.s of tciiiporomandibiilar disorders in university students./ OmI RehabiL 2003;30:2a3-289.

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