Intraoral Myofascial Therapy for Chronic Myogenous Temporomandibular Disorder: A Randomized Controlled Trial

WFC 2011 AWARD WINNING PAPER INTRAORAL MYOFASCIAL THERAPY FOR CHRONIC MYOGENOUS TEMPOROMANDIBULAR DISORDER: A RANDOMIZED CONTROLLED TRIAL Allan Kalamir, BSc, MChiro, a Rodney Bonello, GradDip, HSc, b Petra Graham, PhD, c Andrew L. Vitiello, PhD, d and Henry Pollard, PhD e

ABSTRACT Objective: Studies investigating the efficacy of intraoral myofascial therapies (IMTs) for chronic temporomandibular disorder (TMD) are rare. The present study was an expansion of a previously published pilot study that investigated whether chiropractic IMT and the addition of education and self-care were superior to no-treatment or IMT alone for 5 outcome measures—interincisal opening range, jaw pain at rest, jaw pain upon opening, jaw pain upon clenching, and global reporting of change—over the course of 1 year. Methods: Ninety-three participants with myogenous TMD between the ages of 18 and 50 years experiencing chronic jaw pain of longer than 3 months in duration were recruited for the study. Successful applicants were randomized into 1 of 3 groups: (1) IMT consisting of 2 treatment interventions per week for 5 weeks, (2) IMT plus education and “selfcare” exercises (IMTESC), and (3) wait-list control. The main outcome measures were used. Range of motion findings were measured by vernier callipers in millimeters, and pain scores were quantified using an 11-point self-reported graded chronic pain scale. Global reporting of change was a 7-point self-reported scale, balanced positively and negatively around a zero midpoint. Results: There were statistically significant differences in resting, opening and clenching pain, opening scores, and global reporting of change (P b .05) in both treatment groups compared with the controls at 6 months and 1 year. There were also significant differences between the 2 treatment groups at 1 year. Conclusions: The study suggests that both chiropractic IMT and IMTESC were superior to no-treatment of chronic myogenous TMD over the course of 1 year, with IMTESC also being superior to IMT at 1 year. (J Manipulative Physiol Ther 2012;35:26-37) Key Indexing Terms: Manual Therapies; Exercise; Self-Care; Education; Chiropractic; Temporomandibular Disorder

a

PhD Student, Faculty of Science, Macquarie University, Sydney, Australia. b Associate Professor, Department of Chiropractic, Macquarie University, Sydney, Australia. c Lecturer, Department of Statistics, Macquarie University, Sydney, Australia. d Lecturer, Anglo-European College of Chiropractic, Bournemouth University, Bournemouth, England, UK. e Associate Professor, Faculty of Health Science, Australian Catholic University, Brisbane, Australia. Submit request for reprints to: Allan Kalamir, BSc, MChiro, 249 Edensor Road, Edensor Park, NSW 2176, Australia (e-mail: [email protected]). Paper submitted April 22, 2011; in revised form June 2, 2011; accepted June 2, 2011. 0161-4754/$36.00 Copyright © 2012 by National University of Health Sciences. doi:10.1016/j.jmpt.2011.09.004

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emporomandibular disorders (TMDs) are a multifactorial complex of clinical entities that involve the masticatory musculature, the temporomandibular joints, and associated structures. 1,2 The shift from a predominantly mechanistic to a more biopsychosocial health paradigm has resulted in a growing body of evidence supporting the use of reversible and noninvasive methods of treatment of TMD, often as stand-alone interventions. Some of these modalities include physical therapies, 3-12 psychological-behavioral–based therapies, 13-18 and selfcare strategies including exercises. 8,12,19-24 Several studies have suggested that multimodal approaches may have better or longer lasting results, 4,8,23,25 notably where psychological factors are prevalent. 26 Indeed, psychosocial factors and their persistent influence on craniomandibular physiology (eg, posturing, clenching, grinding) might be described as

T

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being representative of the “dental aspect” of the flight/fight mechanism, the prolonged effects of which may resemble that of other chronic sympathicotonic illnesses. 27-29 Studies investigating relationships between the occlusion, dental attrition, articular degeneration, alveolar bone changes, and TMD have shown mixed results. 30-33 Traditionally held beliefs about the role of so-called parafunctional activities (bruxism—clenching and grinding) in the onset of TMD have also not been found to be conclusive. 34-38 Where these activities have been identified as factors in TMD, they have usually been identified as part of a wider (particularly psychoemotional) health concern. 39,40 Several studies have suggested that TMD may not be self-resolving. 41,42 Factors such as the influence of the temporomandibular apparatus on other regions of the body 43; frequency of TMD signs and symptoms in the general population approaching 40% to 50% 44-47; the common finding of TMD among the young 44,48; its reported association with other conditions such as headache and fibromyalgia 49-51; and its effects on quality of life 52 not only highlight the need for continued research but, more importantly, suggest that those with this disorder should be empowered with as many self-care strategies as possible to ensure successful long-term management. Several disciplines involved in managing TMD use manual therapy of one kind or another. Such may involve articular manipulation or displacement, mobilization, or soft tissue techniques such as trigger-point therapy or massage. Some of these techniques (such as manipulation) may require considerable skill and training 53; others (such as myofascial trigger-point releases) require less. 54 Manipulation has been the subject of several studies 55-57 ; likewise, mobilization and exercise have been subjected to several studies. 21,22,58-62 However, there has been little research on the use of myofascial trigger-point therapies (particularly orofacial) of TMD. 9,63-67 Myogenous forms of TMD have been suggested to be the most common. 68 Moreover, because arthrogenous forms of TMD will also encompass at least some degree of associated myospasm or contracture, the authors considered that trialing a novel intraoral myofascial therapy (IMT) protocol may provide clinicians such as dentists and manual therapy practitioners additional data in TMD management. Given that the techniques herein described are easy to learn and apply, this renders them potentially useful to both manual therapists and dental practitioners alike. The value of self-care jaw exercises in chronic TMD has been well established. 21,22,58 It has been proposed that they encourage self-management and ameliorate the patient's coping ability and are also thought to have beneficial neuromuscular, vascular, and rehabilitatory effects. 23 Patient education on the anatomy, pathophysiology, natural history of TMD, and the benefits of relaxation has been shown to also positively influence TMD outcomes. 15,18,69-71 A pilot study

Kalamir et al Intraoral Myofascial TMD Therapy

that investigated a smaller sample of patients has previously been published. 72 In keeping with a model of multimodal treatment and an emphasis on self-care, it was decided to additionally trial a combined IMT, education, and self-care group (IMTESC), to observe whether this strategy enhances overall outcomes. The purposes of the trial were to investigate whether IMT and IMTESC are superior to no-treatment and to investigate whether IMTESC is superior to IMT, over the course of 1 year.

METHODS Design Ethics approval for this study was granted by the Macquarie University Ethics Committee, approval number HE26AUG2005-M04263, and ruled to be in conformance to the National Statement on Ethical Conduct in Human Research. It was further registered with the Australian New Zealand Clinical Trials Register (ACTRN12610000329066). The study design was that of a randomized, controlled clinical trial consisting of 3 participant groups: IMT, IMTESC, and no-treatment (ie, wait-list control). The trial team consisted of 1 receptionist, 1 study assistant, 1 independent assessor, and 1 practitioner (the primary author). The receptionist answered telephone enquiries, screened enquirers for primary inclusion and exclusion criteria, made appointments, prepared participant files, and consecutively numbered them for allocation. She was blinded to both the randomization schedule and assessment outcomes. The study assistant generated a randomization schedule using a Webbased number generator (http://www.randomizer.org) and consecutively allocated each numbered participant file into 1 of 3 groups according to the randomization schedule. The assistant was blinded to all assessments. The assessor was an independent dental nurse who had previously undergone training for 6 hours during a period of 1 week in the administration of the research diagnostic criteria (RDC) for TMD. The training was conducted by the primary author, using a comprehensive original video footage by the originators of the protocol and practice sessions aimed at calibrating for palpation pressure and location, as well as appropriate interaction with participants. The data were collected on the premises by appointment with the assessor, who was blinded to group allocation of the participants. The practitioner was blinded to the randomization schedule and assessment outcomes until the conclusion of the study.

Subjects The project was undertaken at the primary author's private practice in Edensor Park, NSW, Australia. Recruitment occurred between March 2006 and March 2007 and consisted of referrals from local dental clinics.

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Primary inclusion criteria consisted of an age restriction between 18 and 50 years, a daily history of periauricular pain with or without joint sounds of at least 3 months in duration, voluntary participation in the study, and a willingness to contribute long-term follow-up data. The primary exclusion criteria screened by the receptionist included previous attendance at the primary author's clinic; edentulous (toothless) applicants; a history of malignancy in the last 5 years; other physical contraindications such as inflammatory arthritides, fracture, dislocations, or known instability of the jaws or neck; metabolic diseases (such as Cushing disease, gout, and osteoporosis); connective tissue diseases and rheumatic disorders (such as systemic lupus erythematosus or scleroderma); and hematologic disorders (such as anemia or leukemia). Successful applicants attended a subsequent appointment to read and sign an informed consent form, after which they were assessed according to the RDC protocol, which has received wide recognition among TMD researchers as a comprehensive, valid, and reliable biaxial diagnostic tool. 73-76 The RDC uses self-reported pain and dysfunction scales, assessor-measured range of motion findings, and pain reports based on assessor palpation. In addition, it involves a psychosocial assessment questionnaire. The RDC was used as a vehicle for the application of secondary inclusion criteria, which was the identification of those with myogenous TMD, and a minimum baseline graded chronic pain score of 3 of 10 on each of the 3 symptom outcome measures determined for the project, which is in line with other studies. 23 A secondary exclusion criterion was a finding of severe depression on the RDC psychosocial assessment. The sample size was estimated according to the article published by Dao et al. 77 Using their power analysis, setting α at .05 and β at .2 (ie, 80% power), and estimating a 45% to 60% decrease in pain intensity to be a clinically relevant improvement, a figure of 63 to 108 patients would be needed (ie, 21-36 participants per group).

Outcome measures This study used the same primary outcome measures as the previously published pilot study. These included 3 pain measures: jaw pain at rest, jaw pain upon maximal active opening, and jaw pain upon clenching. It was hypothesized that these 3 measures reasonably represented the craniofacial apparatus in its (relatively) passive, active, and resisted contractile states and would serve as useful comparative benchmarks. These measures were based on a 11-point graded chronic pain scale reported by the participant. The minimal detectable change (MDC) of a measure gives an indication of the degree to which scores fluctuate in the absence of actual change in the patient and is based on the following formula: standard error of the measurement multiplied by 1.65 multiplied by √2. For 11-point graded scales, 78-81 the change has been calculated to be 0.45.

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A secondary outcome measure was that of the interincisal range of opening in millimeters, measured by vernier callipers. The MDC in a continuous measure such as this has been reported to be between 5 and 9 mm. Accordingly, a change of greater than 9 mm was considered to be clinically significant for the purposes of this study. Other ranges (such as laterotrusion, protrusion, and retrusion) were not included because of they showed limited reliability and validity in other studies. The minimum clinically important change is the change likely to be relevant to a patient. This has been found to generally correspond to half the standard deviation of the measure. Several studies of 11-point self-reported scales have shown standard deviations with an upper range of 2.7. Given the discrete nature of the scale, a change of greater than 2 points can thus be said to be a clinically meaningful change. Guidelines for TMD researchers have also advocated the inclusion of global reporting of change (GRC) findings in therapeutic trials. 75,82 Findings of the GRC are said to represent changes that are important to the patient and add a further facet to the assessment of clinical change. 83 They are simple and free to use and can be easily administered and scored. Several studies have investigated the validity of GRC scales, as well as their correlation to other health and morbidity markers. 83,84 For the purposes of this study, a 7-point GRC balanced around 0 (unchanged) with positive (improvement) and negative (worsening) extensions at the 1-year assessment was included in this study.

Interventions Control group participants were informed that after a symptom monitoring period of 1 year, they would be eligible for treatment. They were blinded to their control status during that time. The intervention groups received the same treatment protocols as previously published in the pilot study. 72 The IMT group underwent 2 treatment sessions per week for 5 weeks. Each treatment session lasted approximately 10 to 15 minutes, and interventions were performed by the primary author. The techniques used consisted of the following in sequential order: 1. Intraoral temporalis release (Fig 1). Practitioner is positioned homolateral to the side being treated. A gloved, index contact of the caudad hand onto the coronoid process of the mandible, applies light posterior and caudad pressure within the pain tolerance of the patient. The cephalad index and middle fingers apply superior pressure longitudinally along the fibers of the temporalis muscle moving gradually anterior to posterior. The patients are asked to incrementally open their mouth to its maximum range. This technique was chosen because of the involvement of the temporalis muscle in various craniofacial pain syndromes. 85,86

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Fig 3. Intraoral sphenopalatine ganglion technique. Fig 1. Intraoral temporalis release.

Fig 2. Intraoral medial and lateral pterygoid (origin) technique. 2. Intraoral medial and lateral pterygoid (origin) technique (Fig 2). The practitioner is seated either homolateral or contralateral to the side being treated. A gloved index finger is inserted along the lateral wall of the pharynx, posterior to the last molar. Posterior and cephalad pressure is applied into the pharyngeal tissues overlying the pterygoid origins arising from the lateral pterygoid plate of the sphenoid. Care is taken to avoid direct contact of the hamulus. The contact is maintained for 5 seconds. This choice of techniques was based on known pterygoid involvement in chronic degenerative conditions of the temporomandibular joint (TMJ) 87-89 and the

direct influence of the lateral pterygoid in particular on disk position. 89-92 Hypertrophy of the pterygoids has also been shown to irritate or compress the auriculotemporal nerve. 93 Palpation of the individual medial and lateral pterygoid origins has been described in the literature. 94 However, the close proximity of their intraorally palpable origins on the lateral pterygoid plate, the general sensitivity of pharyngeal tissues, and the tendency toward restricted opening and limited access in patients with TMD makes their palpatory differentiation academic rather than practical in many cases, and so, they are described together for the purposes of this protocol. 3. Intraoral sphenopalatine ganglion technique (Fig 3). The gloved fifth finger of the caudad hand is slowly inserted along the buccal surface of the lightly occluded teeth. The patient is asked to briefly clench their teeth, and upon relaxing, the practitioner gradually works their finger behind the lingual surface of the masseter and medial pterygoid. This process is repeated until the tip of the finger tip reaches as close to the anterior aspect of the infratemporal fossa/sphenopalatine fossa as is comfortable to the patient. The patient is then asked to lift their head off the table, pushing into the contact. In this way, excessive force by the practitioner is checked by an apprehension response of the patient. After 3 repetitions, the patient relaxes, resting their head back onto the headrest, and gentle buccal pressure is now applied into the masseter and medial pterygoid muscles by the practitioner's finger tip before gently being removed from the mouth. The name of this technique is based on its proposed parasympathetic neurologic effects (stimulation of the sphenopalatine ganglion resulting in increased cerebral circulation), with texts suggesting that lacrimation of the ipsilateral eye indicates a successful digital application of the technique. 95 Evidence in support of this is lacking. Nevertheless, the potential use of myofascial stretch upon the masseter,

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Fig 4. Mandibular body—condylar cross-pressure chewing technique.

pterygoid(s), and temporalis muscles commonly encountered in the primary author's clinical experience was the rationale behind the inclusion of this technique. Participants in the IMTESC group (receiving additional education and self-care) were given a scripted short lecture by the practitioner for 2 minutes at the conclusion of each of the first 4 visits on topics including basic TMJ anatomy, biomechanics, disk displacement and dysfunction, the role of psychoemotional factors in TMD particularly relating to parafunctional activity, and mandibular exercises to be performed at home twice a day (morning and night) as outlined below: 1. Self-administered modification of a chiropractic technique known in the Macquarie University curriculum as “Mandibular body—condylar cross-pressure chewing technique” (Fig 4). The patient applies a thenar or pisiform contact to the condyle of one side of the mandible, whereas the thenar of the other hand is applied to the ramus of the other side. Both sides exert even pressure upon their contacts while the patient opens and closes their mouth 5 times. The contacts are reversed and repeated on the other side. 2. Postisometric relaxation stretches—laterotrusion and opening (Figs 5 and 6). The patient applies a contact to the right side of the chin with the heel of their right hand. An isometric resistance is applied to the chin for 10 seconds in a medial direction while the patient laterotrudes against their own hand. The chin is then contralaterally laterotruded incrementally, and then the procedure is repeated from that point. Progressing in this way, the chin continues to laterotrude toward its maximum limit. The same procedure is then repeated on the other side, and then it is applied to the opening of the jaw, with the patient now resisting closing of the

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Fig 5. Postisometric relaxation stretches—laterotrusion. mandible by cupping their chin with their hands. Patients are encouraged to perform these 2 exercises in front of a mirror, to ensure stability and neutrality of their head position in space during the exercises. Visit numbers and frequency determination were without precedent in the literature, so a modification of the 6-week, 12-visit musculoskeletal rehabilitation protocol commonly used within the chiropractic outpatient clinics of Macquarie University (modeled after Mercy Hospital guidelines) was recommended based on the relative sensitivity of orofacial structures and the personal clinical experience of the primary author in managing patients with TMD.

Statistical Analysis Five outcomes were examined, including opening range of motion (OROM), resting pain (RP), opening pain (OP), clenching pain (CP), and GRC. The 3 pain scores (RP, OP, CP) and the GRC, being ordinal measures, were analyzed using an ordinal logistic regression analysis. Because the analysis also needed to account for a random effect of participant, an ordinal generalized linear mixed model was fitted to the data using ASReml v.3.0alpha (VSN International Ltd, Hempstead, UK). The model fitted to the data were as follows:  loge

PðY V k PðY N kÞ



= hk + Group + Period + GroupPeriod + Particpant where Y = change score (k = 1, 2, 3, 4); θk = intercept on the logit scale for the score of k;

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Recruitment (Referral)

Initial Phone Screen

221 enquiries

Initial Assessment 134 Applicants Enrolment, randomization

Control Group N = 31

IMT Group N = 31

93 Participants

IMTESC Group N = 31

6 week Assessment 1 drop out

Fig 6. Postisometric relaxation stretches—opening.

6 month Assessment

Group = effect of treatment group (1, 2, or 3); Period = effect of period (2, 3, or 4); and Participant = random effect of participant, assumed N (0, σP2). The secondary outcome, OROM, was analyzed as a continuous variable using a random-effects model. This allowed for repeated measures over time, as well as the effects of time, sex, and participant variation on each outcome. The model fitted was as follows: ROM = Constant + Group + Time + Group  Time + Participants + e where Participant ∼ N(0, σP2) and ɛ ∼ N(0, σɛ2) are random effects. The model was fitted using a REML procedure in GenStat Release 12 (VSN International Ltd, Hemel Hempstead, UK).

RESULTS The study flowchart is presented in Figure 7. Participant recruitment commenced in January 2006 and was concluded by November 2006. Interventions were concluded by February 2007. There were a total of 221 enquiries, of which 134 applicants met the primary inclusion criteria and were invited to an assessment. Of these, 33 failed to meet secondary inclusion criteria, and 8 lost interest in enrolling in the trial. Ninety-three

1 year Assessment

Fig 7. Study flowchart.

Table 1. Baseline characteristics of the study participants Characteristic

NT (n = 31)

IMT (n = 31)

IMTESC (n = 31)

Age (y) a Sex, male:female OR b RP a OP a CP a

35 (6.7) 13:17 36.32 3.85 (3.90) 4.76 (4.80) 5.05 (1.04)

34 (6.1) 13:17 37.42 4.46 (6.41) 5.15 (7.28) 6.21 (1.07)

35 (5.0) 15:16 39.89 4.26 (7.49) 5.09 (8.76) 5.36 (1.06)

NT, no treatment; OR, opening range. a Means (standard deviations in parentheses). b Means in millimeters.

consecutive applicants were block randomized using a pregenerated schedule into 3 groups. Treatments commenced in March 2006 and were concluded by February 2007. The last of the 1-year assessments was concluded in March 2008, with 1 dropout in the control group after 6 months, citing impatience with being on the “waiting list.” Other participants generally complied well with their scheduled appointments. The data were analyzed on an intention-to-treat basis, replacing missing values with baseline figures for analysis purposes. Baseline characteristics are presented in Table 1.

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Table 2. Change scores for the 3 treatment groups Time

Group

Outcome χ2

df P

OR RP OP CP GRC

3 3 3 3 2

197.2 113.1 129.9 118.9 4.3

F

df

Time × Group P

b.001 83.08 2 b.001 b.001 6.35 2,81 .003 b.001 5.32 2,78 .007 b.001 7.81 2,80 .001 .12 38.3 2,97 b.001

χ2

df P

128.34 136.4 138.1 162.8 12.2

6 6 6 6 4

b.001 b.001 b.001 b.001 .016

Significance was assessed using Wald χ2 and F tests; significance at P = .05. OR, opening range.

At baseline, there were no significant differences between groups except for opening range, with no plausible reason for this finding besides a chance effect. After the treatment, there were significant treatment effects (see Table 2), but these changed over the course of the study, as indicated by the significant time × group interactions. Both treatment groups had significantly lower pain scores than the control group after the baseline period. By the 1-year assessment, the IMTESC group had significantly lower pain scores than did the IMT group, although these findings were not apparent at the 6-week or 6-month marks (see Fig 8). These 1-year findings met both the MDC and minimal clinically important difference criteria for significance, with the IMT group achieving mean score changes for RP, OP, and CP of 3.1, 1.9, and 1.7 scale points, respectively; whereas the IMTESC group achieved mean score changes of 4.0, 4.1, and 3.6 scale points, respectively. These were supported by the GRC figures in Table 2, which showed significant differences in change scores between the 3 treatment groups, with the IMTESC group showing the best scores at 1 year. The box plots (Fig 8) for the pain and range of motion findings suggest that at the posttreatment assessment (6 weeks) and up until the 6-month assessment, both treatment groups achieved similar outcomes, with the IMT group plateauing and then regressing at the 1-year assessment. Nevertheless, outcomes remained significantly different from the control group even at 1 year. No adverse outcomes were reported by any of the participants during the course of this study.

DISCUSSION The use of myofascial therapies such as trigger-point releases was popularized by authors such as Travell and Simons 54 during the latter part of the 20th century. A movement away from invasive and irreversible treatments has seen a recent proliferation of studies investigating myofascial treatment in areas as diverse as podiatry, 96,97 cephalagia, 98 shoulder pain, 99 systemic conditions such as fibromyalgia, 100 and even organ dysfunction such as prostatitis, incontinence, and pelvic dysfunction. 101 The

physiologic mechanisms implicated in the formation and treatment of various myofascial syndromes (such as trigger points) have been discussed at length. 54,102-112 Current support lies with an integrated model 113 incorporating both the energy crisis model 114 and the motor endplate hypothesis. 115 Although myofascial dysfunction of the jaw (most notably in the form of myogenous TMD) has long been the subject of dental research, there has been little investigation into manual therapies directed at these structures, when compared with studies of manual therapies for other regions of the body. It was the purpose of this study to address that paucity by exploring the effectiveness of a simple series of myofascial techniques commonly taught within the chiropractic and other manual therapy professions, both on their own, and in conjunction with patient education and self-care. The results of this study suggest that these techniques can be used safely and be well tolerated by patients. The lack of any adverse reactions in the participants is probably caused by both the simplicity and relative gentleness of the techniques and is typical of other myofascial release studies. 96,99-101,116,117 The treatment groups yielded positive short- and intermediate-term outcomes, which is in line with outcomes of studies investigating manual and myofascial treatment for other regions of the body. 97,99,117-119 Surprisingly, although both treatment groups demonstrated significant differences to no-treatment by the first posttreatment assessment (6 weeks), the effect of combining education and self-care with myofascial manual therapy did not show significant superiority to manual therapy alone for the first 6 months of the study. The superiority of combining treatment, education, and self-care strategies only became obvious for pain outcomes at the 1-year assessment, where the IMT group showed some sign of regression that was not experienced by the IMTESC group. A possible explanation may be that most treatment effects were caused by the myofascial manual therapy component, with education and self-care sustaining those outcomes. It is also possible that there may have been compliance or execution issues with the performance of self-care exercises, negating the anticipated effects of these additional modalities. Such compliance difficulties have been reported in the TMD literature. 23 However, it has been suggested that patient beliefs about the value of self-care, their attitude, and compliance to self-care programs are influenced by the state of their condition. 120 Perhaps, the somewhat delayed additional effectiveness of the education and self-care component in the IMTESC group depended, in part, on a change in belief that it was self-dependant on some “preliminary” improvement (ie, resulting from the myofascial treatment component). A further study comparing myofascial therapy alone compared with education and self-care alone is currently being

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8

10

8

6

OP

RP

6 4

4 2 2

0

0

BL

6w

6m

1y

10

BL

6w

6m

1y

BL

6w

6m

1y

60

8 50

CP

ORange

6

4

40

30

2

0

20

BL

6w

6m

1y

No Treatment Group IMT Group IMTESC Group

Fig 8. Box plots showing group comparisons over time.

undertaken by the authors, which may go some way to answering this question.

Limitations Limitations of the study include the use of a private chiropractic office and recruitment of study participants. The group of participants may not necessarily reflect those of other practices. The source of participants was largely from dental practices, which biases the selection of participants. The low attrition rate of this study after the initial loss after group allocation possibly highlights the

need for treatment that those with TMD may face compared with other trials with lower retention rates, although it may also be a reflection of the convenience to participants of running a trial within a residential suburb.

CONCLUSION This study demonstrated that it is possible to conduct a clinical trial investigating the treatment of myogenous TMD from a chiropractic/manual therapy orientation. Furthermore, the use of IMT techniques combined with education and self-care showed that these techniques can be

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Kalamir et al Intraoral Myofascial TMD Therapy

safely used and may be superior to no-treatment as well as IMT alone at 1 year. This study also suggests that chiropractors may play a role in the management of this complex and multifactorial disorder.

Practical Application • Both treatment groups showed significant improvement in pain scores at 6 weeks, 6 months, and 1 year compared with the control group (notreatment group), with the combination group only showing general clinical superiority over the treatment-only group at 1 year.

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12.

13.

14. 15. 16.

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST No funding sources or conflicts of interest were reported for this study.

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