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Three Part Question

In [young adults with TMJ pain] do [physiotherapy techniques other than electrotherapy] improve [pain and function]

Clinical Scenario

A 23 year old female has been referred to physiotherapy with a 6 month history of temporomandibular joint (TMJ) pain without disk displacement. Based on some published evidence, the referrers commonly request electrotherapy, but you want to investigate if other forms of physiotherapy may be more beneficial.

Search Strategy

MEDLINE 1966-01/05, CINAHL 1982 –01/05, AMED 1985-01/05, SPORTDiscus 1830-01/05, EMBASE 1996-01/05, via the OVID interface and the Cochrane database In addition the PEDro database was also searched.
Medline, CINAHL, AMED, SPORTDiscus, EMBASE, Cochrane database for systematic reviews: (exp temporomandibular joint disorder OR temporomandibular joint dysfunction OR temporomandibular pain OR TMJ) AND (acupuncture OR massage OR relaxation techniques) AND (Physiotherapy.mp OR exp physical therapy techniques OR manual therapy) AND Electrotherapy AND (Physiotherapy OR physical therapy OR manual therapy). LIMITS human AND English Language.
PEDro: (temporomandibular joint)

Search Outcome

14 papers were retrieved. One was a Cochrane review of stabilisation splintage. 1 was a systematic review of a number of physiotherapy techniques and 1 was a systematic review of acupuncture. One was a meta-analysis of biofeedback treatment. All the other papers were included in one or more of the reviews.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Al-Ani et al. 2004 UK	12 RCTs on splint stabilisation for the TMJN = 496	Cochrane review. Level 1	TMJ pain	NSS comparing TMJ splintage to other treatments. Weak evidence that splintage is better than 'no treatment'.	Variety of pain outcomes between RCTs.All RCTs failed to report randomisation and allocation concealment techniques.Blinded outcome in 2 RCTs only. Small sample sizes in all RCTs.Also possible that TMJ with and without disk displacement were combined
			RoM	NSS comparing TMJ splintage to other treatments
			Muscle pain	NSS comparing TMJ splintage to other treatments
			Depression	NSS comparing TMJ splintage to other treatments
			Dysfunction	NSS comparing TMJ splintage to other treatments
			Quality of Life	NSS comparing TMJ splintage to other treatments
Ernst & White 1999 UK	6 reports of 3 Trials N = 205	Systematic review	Subjective: e.g. VAS, Anamnestic index, Pain frequency, Use of medication.	Within group efficacy but NSS between groups. In 1 trial 53% improved with acupuncture & 63% improved with occlusal splints.Acupuncture significantly (P<.01) superior to no treatment or waiting list controls and sustained for 1 year.1 trial acupuncture better (p<.001) occlusal splints & no treatment	No placebo control in any trial. Randomisation & Blinding not described. 3 trials suggest efficacy of acupuncture
			TMJ dysfunction e.g.Dysfunction index. Mouth opening. ADL. MuscleAlgometry	Within group benefits (p<.001 in 1 trial) but NSS between active groups. In 1 trial splints better (P<.04) than acupuncture at 4 wks, NSS at 12wks.
Medlicott & Harris, 2006, Canada	30 studies in total (N=1095) 17 myofascial TMJD studies (N=702) 15 level 2 2 level 4 Quality: 6 moderate 11 weak	Systematic review Level 1a	>75 methods to assess outcome	No pooled data for meta-analysis Physio almost always better than placebo. More treatments = increased short term efficacy. Inconclusive on combined treatment versus individual treatments.	Review is limited due to: a. English language studies only b. publication bias c. selection bias d. none of 17 studies judged as 'strong'
Crider & Glaros, 1999, USA	6 RCTs (N=201)	Meta-analysis Level 1	reported pain (effect size)	0.47 ES	No details given of studies qualities e.g. randomisation, blinding
			examination (effect size)	0.26 ES
			% improvement	34.7%

Comment(s)

There is some weak evidence that any of the physiotherapy modalities available are better than no treatment for TMJD and combinations of treatment may be better than single treatments. Within group benefits are usually not supported by between group benefits. All the reviews appraised comment on the lack of scientific rigour and decisive studies.

Clinical Bottom Line

In the absence of any outstandingly robust evidence, any of the numerous treatment modalities for myogenic TMJD seem to have a beneficial effect.

References

1. Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002778. DOI: 10.1002/14651858.CD002778.pub2.
2. Ernst E. White AR. Acupuncture as a treatment for Temporomandibular Joint dysfunction. A systematic review of randomized trials. Arch Otolaryngol Head Neck Surg 1999;125:269-272
3. Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy relaxation training and biofeedback in the management of temporomandibular disorder. Physical Therapy 2006;86(7):955-973.
4. Crider AB, Glaros AG. A meta-analysis of EMG biofeedback treatment of temporomandibular disorders. J.Orofac. Pain. 1999;13: 29-37.