The Additional Value of a Home Physical Therapy Regimen Versus Patient Education Only for the Treatment of Myofascial Pain of the Jaw Muscles: Short-term Results of a Randomized Clinical Trial

Aims: To compare the short-term efficacy of patient education only versus the combination of patient education and home exer-cises for the treatment of myofascial pain of the jaw muscles. Materials and Methods: Seventy myogenous temporomandibular disorder patients were assigned to 2 treatment groups. One group received patient education supplemented by general information about self-care of the jaw musculature. The other group received both education and a home physical therapy program. Treatment contrast, calculated from the mean normalized relative changes in anamnestic and clinical scores, was used to determine treatment success. Clinical outcome measures included pressure pain thresh-old (PPT) of the masseter, anterior temporalis, and Achilles ten-don; pain-free maximal jaw opening; and pain on chewing, spon-taneous muscle pain, and headache as rated on visual analog scales. Results: After 3 months the success rate was 57% for the group that received education only and 77% for the group that received both education and home physical therapy (P = .157). The patients were then redivided into 2 groups: successfully treated patients and unsuccessfully treated patients. In the unsuc-cessfully treated group, pain-free maximal jaw opening increased significantly more among those who had been in the education and physical therapy group than among those who had been in the education-only group (P = .019). The change in PPT was signifi-cantly greater in successfully treated patients than in unsuccess-fully treated patients (.009 ＜ P ＜ .039), independent of the treat-ment modality, with higher PPTs among successful patients. There were no significant differences between the successfully and unsuc-cessfully treated groups or between treatment modalities for any other variable. Conclusion: Over a period of 3 months, the combi-nation of education and a home physical therapy regimen, as used in this protocol, is slightly more clinically effective than education alone for the treatment of myofascial pain of the jaw muscles.

myofascial pain; patient education; physiotherapy; pressure pain threshold; randomized clinical trial

1. Okeson JP (ed). Orofacial Pain. Guidelines for Assessment, Diagnosis and Management. Chicago: Quintessence,1996:113–184.

2. Mejersjo C, Carlsson GE. Long-term results of treatment for temporomandibular pain dysfunction. J Prosthet Dent 1983;49:809–815.

3. Dahlstrom L. Conservative treatment methods in cran-iomandibular disorder. Swed Dent J 1992;16:217–230.

4. Okeson JP (ed). Management of Temporomandibular Disorders and Occlusion. St Louis: Mosby, 1993:349–350.

5. Okeson JP, Hayes DK. Long-term results of treatment for temporomandibular disorders: An evaluation by patients. J Am Dent Assoc 1986;112:473–478.

6. Garafis P, Grigoriadou E, Zarafi A, Koidis PT. Effectiveness of conservative treatment for craniomandibular disorders: A 2-year longitudinal study. J Orofac Pain 1994;8:309–314.

7. Magnusson T, Carlsson GE, Egermark I. Changes in clinical signs of craniomandibular disorders from the age of 15 to 25 years. J Orofac Pain 1994;8:207–215.

8. Dimitroulis J, Gremillion HA, Dolwick MF, Walter JH. Temporomandibular disorders. 2. Non-surgical treatment. Aust Dent J 1995;40:372–376.

9. Stam HJ, McGrath PA, Brooke RI. The effects of a cognitive-behavioral treatment program on temporomandibular pain and dysfunction syndrome. Psychosom Med 1984;46:534–545.

10. Turk DC, Rudy TE, Zaki HS. Multiaxial assessment and classification of temporomandibular disorder pain patients. In: Fricton JR and Dubner R (eds). Advances in Pain Research and Therapy. New York: Raven Press, 1995:145–163.

11. Suvinen TI, Hanes KR, Reade PC. Outcome of therapy in the conservative management of temporomandibular pain dysfunction disorder. J Oral Rehabil 1997;24:718–724.

12. Widerstrom-Noga E, Dyrehag LE, Borglum-Jensen L, Aslund PG, Wenneberg B, Andersson SA. Pain threshold responses to two different modes of sensory stimulation in patients with orofacial muscular pain: Psychologic consid-erations. J Orofac Pain 1998;12:27–34.

13. Haldorsen EMH, Kronholm K, Skouen JS, Ursin H. Multimodal cognitive behavioral treatment of patients sicklisted for musculoskeletal pain. A randomized con-trolled study. Scand J Rheumatol 1998;27:1–25.

14. Glaros AG, Tabacchi KN, Glass EG. Effect of parafunctional clenching on TMD pain. J Orofac Pain 1998;12:145–152.

15. Glaros AG, Forbes M, Shanker J, Glass EG. Effect of parafunctional clenching on temporomandibular disorder pain and proprioceptive awareness. Cranio 2000;18:198–204.

16. Palla S. Principi di terapia delle mioartropatie. In Palla S (ed). Mioartropatie del Sistema Masticatorio e Dolori Orofacciali. Milano: RC Libri, 2001:351–387.

17. Komiyama O, Kawara M, Arai M, Asano T, Kobayashi K. Posture correction as part of behavioral therapy in treatment of myofascial pain with limited opening. J Oral Rehabil 1999;26:428–435.

18. Danzig WN, Van Dyke AR. Physical therapy as an adjunct to temporomandibular joint therapy. J Prosthet Dent 1983;46:96–99.

19. Hargreaves AS, Wordle JJM. The use of physiotherapy in the treatment of temporomandibular disorders. Br Dent J 1983;155:121–124.

20. Solberg WK. Temporomandibular disorders: Masticatory myalgia and its management. Br Dent J 1986;160:351–356.

21. Pardamec E, Genucchi R. Il trattamento fisioterapico. In: Palla S (ed). Mioartropatie del Sistema Masticatorio e Dolori Orofacciali. Milano: RC Libri, 2001:391–402.

22. Zarb GT, Carlsson GE, Rugh JD. Clinical management. In: Zarb GT, Carlsson GE, Sessle BJ, Mohl ND (eds). Temporomandibular Joint and Masticatory Muscles Disorders. Copenhagen: Munksgaard, 1994:529–546.

23. Palla S. Therapeutic approach to muscle pain in patients with myoarthropathies of the masticatory system. In: Vecchiet L, Giamberardino MA (eds). Muscle Pain, Myofascial Pain, and Fibromyalgia. New York: The Haworth Press, 1999:171–181.

24. Feine J, Lund JP. An assessment of the efficacy of physical therapy and physical modalities for the control of chronic musculoskeletal pain. Pain 1997;71:5–23.

25. Schiffman EL. Randomized clinical trials, the gold stan-dard for assessing TMD treatments. NVGPT Bulletin 1999;3:5–19.

26. Dworkin SF, Huggins KH, Wilson L, et al. A randomized clinical trial using research diagnostic criteria for temporo-mandibular disorders-Axis II to target clinical cases for a tailored self-care TMD treatment program. J Orofac Pain 2002;16:48–63.

27. Dworkin SF, Turner EA, Mancl L, et al. A randomized clinical trial of a tailored comprehensive care treatment program for temporomandibular disorders. J Orofac Pain 2002;16:259–276.

28. Lundh H, Westesson PL, Eriksson L, Brooks SL. Temporomandibular joint disk displacement without reduction. Treatment with flat occlusal splint versus no treatment. Oral Surg Oral Med Oral Pathol 1992;73:655–658.

29. Turk DC, Hussein SZ, Rudy TE. Effects of intraoral appliance and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders. J Prosthet Dent 1993;70:158–164.

30. Michelotti A, Parisini F, Farella M, Cimino R, Martina R. Muscular physiotherapy in patients with temporo-mandibular disorders. Controlled clinical trial [in Italian]. Minerva Stomatol 2000;49:541–548.

31. Dworkin SF, LeResche L. Research Diagnostic Criteria for Temporomandibular Disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord Facial Oral Pain 1992;4:301–355.

32. Dao T, Lavigne GJ, Feine JS, Tanguay R, Lund JP. Power and sample size calculations for clinical trials of myofascial pain of jaw muscles. J Dent Res 1991;70:118–122.

33. Michelotti A, Farella M, Vollaro S, Martina R. Mandibular rest position and electrical activity of the masticatory muscles. J Prosthet Dent 1997;78:48–53.

34. Van der Glas HW, Van Grootel RJ. Treatment contrast: the mean relative change in scores of pain intensity and limitation of oral functions to quantify treatment effect in TMD patients. J Oral Rehabil 2000;27:456–457.

35. Steenks MH, van der Glas HW, van Grootel RJ, et al. Short-term efficacy physiotherapy versus therapy using a stabilization splint in patient with myogenous craniomandibular disorders [abstract]. J Orofac Pain 1998;12:244.

36. Farella M, Michelotti A, Steenks MH, Cimino R, Romeo R, Bosman F. The diagnostic value of pressure algometry in myofascial pain of the jaw muscles. J Oral Rehabil 2000;27:9–14.

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

38. Turk DS. Biopsychosocial perspective on chronic pain. In: Gatchel RJ, Turk DS (eds). Psychological Approaches to Pain Management. New York: Guilford Press, 1996:3–32.

39. De Boever JA, Van Wormhoudt K, De Boever EH. Reasons that patients do not return for appointments in the initial phase of treatment of temporomandibular disor-ders. J Orofac Pain 1996;10:66–72.

40. Feine JS, Lund JP. An assessment of the efficacy of physical modalities for the control of chronic musculoskeletal pain. Pain 1997;71:5–23.

41. Kropmans TJB, Dijkstra PU, Stegenga B, Stewart R, de Bont LGM. Smallest detectable difference in outcome variables related to painful restriction of the temporo-mandibular joint. J Dent Res 1999;78:784–789.

42. Simons DG, Travell JG, Simons LS (eds). Myofascial pain and dysfunction: The trigger point manual. Baltimore: Williams and Wilkins, 1999:94–177.

43. Shoemaker JK, Tiidus PM, Mader R. Failure of manual massage to alter limb blood flow: Measures by Doppler ultrasound. Med Sci Sports Exerc 1997;29:610–614.

44. Tiidus PM. Manual massage and recovery of muscle function following exercise: A literature review. J Orthop Sports Phys Ther 1997;27:203–210.

45. Grzesiak RC, Gregg MU, Dworkin RH. Psychodynamic psychotherapy with chronic pain patients. In: Gatchel RJ, Turk DC (eds). Psychological approaches to pain manage-ment. New York: Guilford Press, 1996:148–177.

46. Rowbotham MC. What is a “clinically meaningful” reduction in pain? Pain 2001;94:131–132.

47. Roberts AH, Kewman DG, Mercier L, Hovell M. The power of nonspecific effects in healing: Implications for psychological and biological treatments. Clin Psychol Rev 1993;13:375–391.

48. Fricton JR, Olsen T. Predictors of outcome for treatment of temporomandibular disorders. J Orofac Pain 1996;10:54–65.

49. Malow RM, West JA, Sutker PB. Anxiety and pain response changes across treatment: sensory decision analysis. Pain 1989;38:35–44.

50. Cornwall A, Donderi DC. The effect of experimentally induced anxiety on the experience of pressure pain. Pain 1988;35:105–113.

51. Rhudy JL, Meager MW. Fear and anxiety: Divergent effects on human pain threshold. Pain 2000;84:65–75.

52. Michelotti A, Farella M, Tedesco A, Cimino R, Martina R. Changes in pressure-pain threshold of the jaw muscles during a natural stressful condition in a group of symptom-free subjects. J Orofac Pain 2000;14:279–285.