Physical Self-Regulation Training for the Management of Temporomandibular Disorders

Aims: To evaluate the long-term effectiveness of a brief skills training program for the management of chronic facial muscle pain. This program of physical self-regulation (PSR) involved primarily training in breathing, postural relaxation, and proprioceptive re-education. Methods: Physical self-regulation training was presented by a dentist during two 50-minute sessions spaced at 3-week intervals and was compared to a standard dental care (SDC) program that included a flat-plane intraoral appliance and selfcare instructions provided by a dentist. Participants (n = 44) were initially evaluated by a dentist experienced in the diagnosis and management of orofacial pain and were determined to have myofascial pain (Type 1a and 1b diagnoses per the Research Diagnostic Criteria) prior to random assignment to either the PSR or SDC conditions. Posttreatment evaluations 6 weeks and 26 weeks after treatment had begun were conducted by a dentist who was not aware of which treatment the participants received. Results: Initial results indicated that pain severity and life interference from pain were reduced in both groups (P < 0.001), while perception of control was increased (P < 0.001), as was incisal opening without pain (P < 0.05). At the 26-week follow-up, the PSR group reported less pain (P < 0.04) and greater incisal opening, both with (P < 0.04) and without (P < 0.01) pain, than the SDC group. There were also significant decreases (P < 0.05) in affective distress, somatization, obsessive-compulsive symptoms, tender point sensitivity, awareness of tooth contact, and sleep dysfunction for both groups over time. Conclusion: The findings support the use of PSR for the short- and long-term management of muscle pain in the facial region. These results are discussed in terms of the potential mechanisms by which self-regulation treatment strategies are effective for the management of these pain disorders.

pain; myofascial pain; self-regulation; removable orthodontic appliance; relaxation techniques

1. Von Korff M, Dworkin SF, LeResche L, Kruger A. An epidemiologic comparison of pain complaints. Pain 1988;32:173–183.

2. Dworkin SF. Perspectives on the interaction of biological, psychological, and social factors in TMD. J Am Dent Assoc 1994;125:856–863.

3. Carlson CR, Reid KI, Curran SL, Studts J, Okeson JP, Falace D, et al. Psychological and physiological parameters of masticatory muscle pain. Pain 1998;76:297–307.

4. Korszun A, Hinderstein B, Wong M. Comorbidity of depression with chronic facial pain and temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:496–500.

5. Curran S, Carlson C, Okeson J. Emotional and physiologic responses to laboratory challenges: Patients with temporomandibular disorders versus matched control subjects. J Orofac Pain 1996;10:141–150.

6. Moody PM, Calhoun TC, Okeson JP, Kemper JT. Stress-pain relationship in MPD syndrome patients and non-MPD syndrome patients. J Prosthet Dent 1981;45:84–88.

7. Boscarino JA. Posttraumatic stress disorder, exposure to combat and lower plasma cortisol among Vietnam veterans: Findings and clinical implications. J Consult Clin Psychol 1996;64:191–201.

8. McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med 1998;338:171–179.

9. Guyton AC, Hall JE. Textbook of Medical Physiology, ed

9. Philadelphia, PA: Saunders, 1996:612–613.

10. Devor M, Wall PD. Cross-excitation in dorsal root ganglia of nerve-injured and intact rats. J Neurophysiol 1990;64:1733–1746.

11. Lisney SJ, Devor M. Afterdischarge and interactions among fibers in damaged peripheral nerve in the rat. Brain Res 1987;415:122–136.

12. Macefield G, Burke D. Paraesthesiae and tetany induced by voluntary hyperventilation. Increased excitability of human cutaneous and motor axons. Brain 1991;114:527–540.

13. Dubner R, Ruda MA. Activity-dependent neuronal plasticity following tissue injury and inflammation. Trends Neurosci 1992;15:96–103.

14. Sessle BJ, Hu WJ. Mechanisms of pain arising from articular tissues. Can J Physiol Pharmacol 1991;69:617–626.

15. Maixner W, Fillingim R, Booker D, Sigurdsson A. Sensitivity of patients with painful temporomandibular disorders to experimentally evoked pain. Pain 1995;63: 341–351.

16. Dworkin SF, Turner JA, Wilson L, Massoth D, Whitney C, Huggins KH, et al. Brief group cognitive-behavioral intervention for temporomandibular disorders. Pain 1994;59:175–187.

17. Turk DC, Rudy TE, Kubinski JA, Zaki HS, Greco CM. Dysfunctional patients with temporomandibular disorders: Evaluating the efficacy of a tailored treatment protocol. J Consult Clin Psychol 1996;64:139–146.

18. Rugh JD, Dahlstrom L. Psychological management of the orofacial pain patient. In: Stohler CS, Carlson DS (eds). Biological and Psychological Aspects of Orofacial Pain. Ann Arbor, MI: University of Michigan Press, 1994.

19. Dao TTT, Lavigne GJ, Charbonneau A, Feine JS, Lund JP. The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: A controlled clinical trial. Pain 1994;56:85–94.

20. Whitney CW, Von Korff M. Regression to the mean in treated versus untreated chronic pain. Pain 1992; 50:281–285.

21. Dworkin SF, LeResche L. Research Diagnostic Criteria for Temporomandibular Disorders: Review, Criteria, Examinations andSpecifications, Critique. J Craniomandib Disord Facial Oral Pain 1992;6:301–355.

22. Okeson J. Management of Temporomandibular Disorders and Occlusion, ed 4. St Louis: Mosby, 1998.

23. Clark GT, Seligman DA, Solberg WK, Pullinger AG. Guidelines for the treatment of temporomandibular disorders. J Craniomandib Disord Facial Oral Pain 1990; 4:80–88.

24. Carlson CR, Bertrand PM. Self-Regulation Training Manual. Lexington, KY, 1995.

25. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23:345–356.

26. Derogatis LR. SCL-90R Manual: Administration, Scoring, and Procedures. Towson, MD: Clinical Psychometric Research, 1992.

27. Piper BF. Piper Fatigue Scale. Oncol Nursing Forum 1990;17:661–662.

28. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193–213.

29. Simons DG, Travell JG, Simons LS. Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, ed 2. Baltimore: Williams & Wilkins, 1999.

30. Bandura A. Self-Efficacy: The Exercise of Control. New York: Freeman, 1997.

31. Crow R, Gage H, Hampson S, Hart J, Kimber A, Thomas H. The role of expectancies in the placebo effect and their use in the delivery of health care: A systematic review. Health Technol Assess 1999;3:1–96.

32. Jacobson NS, Truax P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991;59:12–19.

33. Kroon GW, Naeije M. Electromyographic evidence of local muscle fatigue in a subgroup of patients with myogenous craniomandibular disorders. Arch Oral Biol 1992;37:215–218.

34. Mao J, Stein RB, Osborn JW. Fatigue in human jaw muscles: A review. J Orofac Pain 1993;7:135–142.

35. Studts J, Carlson C. Psychological factors distinguishing neuropathic and myofascial pain patients [abstract]. J Dent Res 1999;78:555.