A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder.

Temporomandibular disorder (TMD) includes a variety of conditions associated with pain and dysfunction of the temporomandibular joint (TMJ) and the masticatory muscles. (1) An estimated 20% of the population is affected, with 10% to 20% of those seeking treatment. (2-5) These disorders also are referred to as "temporomandibular dysfunction," "craniomandibular disorders," and "mandibular dysfunction." (5)

The presenting symptoms of TMD are: (1) intermittent or persistent pain in the masticatory muscles or the TMJ, and less frequently in adjacent structures; (2) limitations or deviations of mandibular movement; and (3) TMJ sounds. (6) A variety of other symptoms, such as tinnitus, abnormal swallowing, and hyoid bone tenderness, also may occur. (7) Quality of life may be affected, with a negative effect on social function, emotional health, and energy level. (6)

Currently, there is lack of consensus among researchers regarding the etiology, diagnosis, and management of this disorder. The diagnosis of TMD is commonly based on the presenting signs and symptoms. (8) The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) applies a dual-axis system to diagnose and classify patients with TMD. (6,8-10) The first axis is divided into 3 groups of commonly occurring TMDs:

1. Muscle disorders, including myofascial pain with and without limited mandibular opening.

2. Disk displacement with or without reduction or limited mandibular opening.

3. Arthralgia, arthritis, and arthrosis.

The second axis includes a 31-item questionnaire, used to evaluate relevant behavioral, psychological, and psychosocial factors (eg, pain status variables, depression, nonspecific physical symptoms, disability levels). (6,8,10)

Noninvasive, conservative treatments generally provide improvement or relief of symptoms and are recommended in the initial management of TMD. (11) Physical therapists are frequently involved in the management of TMD, often in collaboration with dental professionals. In a survey of members of the American Dental Association, physical therapy was listed among the 10 most common treatments used, involving 10% to 17% of patients. (12) A wide variety of physical therapy techniques, including joint mobilization, exercise prescription, electrotherapy, education, biofeedback and relaxation, and postural correction, have been used in the management of this disorder. (1,6,13)

Research evaluating the effects of physical therapy in the management of TMD has been criticized for its lack of methodological rigor. (14, 15) However, recent studies have attempted to address some previously identified limitations. Because much of the research examining the effects of physical therapy on TMD has not been published in physical therapy journals, developing an evidence base for managing TMD is not easy.

This systematic review of randomized controlled trials (RCTs) and nonrandomized controlled trials assessed the physical therapy management of acute and chronic TMD on clinically relevant outcomes such as pain, range of motion (ROM), disability and function, joint noise, tenderness, and psychological factors. Based on duration of the disorder, TMD was defined as acute (<6 months) or chronic (>6 months). Sackett's levels of evidence facilitate the categorization of studies according to the strength of the research design and the degree of control for potential threats to internal validity. (16,17) Based on 5 hierarchical levels of evidence, which have been used in previous systematic reviews of physical therapist practice, recommendations can be made regarding treatment options. (17,18)

Method

The literature search was restricted to English-language publications from 1966 through January 2005. Index Medicus (MEDLINE), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials were searched using the text words "facial pain," "physical therapy," "rehabilitation," "temporomandibular disorder (TMD)," "temporomandibular joint (TMJ)," "temporomandibular joint syndrome," and "therapy."

Study Selection Criteria

To be included in the systematic review, studies had to meet the following criteria: (1) subjects were from 1 of the 3 groups identified in the first axis of the RMC/ TMD, (6) (2) the intervention was within the realm of physical therapist practice, (3) an experimental design was used (eg, an RCT or nonrandomized controlled trial), and (4) the outcome measures assessed one or more of the primary presenting symptoms (eg, pain, ROM, disability or function).

Studies with any of the following exclusion criteria were not included in the review: (1) interventions post--TMJ surgery, (2) physical therapy interventions in combination with other non-physical therapy interventions, (3) acupuncture as an intervention, (4) interventions involving passive ROM devices. Studies that assessed only electromyographic (EMG) results were not included.

Review Criteria

Studies were evaluated according to Sackett's initial rules of evidence, (17) as described by Barry. (16) These levels (I-V) are hierarchical and represent the confidence generated by the results produced in the studies.

Level I: (a) systematic review (with homogeneity) of RCTs

(b) individual RCT (with narrow confidence interval)

(c) all or none

Level II: (a) systematic review (with homogeneity) of cohort studies

(b) individual cohort study, including low-quality RCTs (eg, <80% follow-up)

(c) "outcomes" research

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

(b) individual case-control studies

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

Level V: expert opinion without explicit critical appraisal, or based on physiology, bench research, or "first principles"

Methodological Quality of Reviewed Studies

Methodological rigor of the studies was evaluated using the following criteria, adapted from Megens and Harris (18,19) and the McMaster Occupational Therapy Evidence-Based Practice Research Group (20):

(1) randomization,

(2) inclusion and exclusion criteria were listed for the subjects (and were subsequently grouped, by the primary author of this review, into 1 the categories on the first axis of the RMC/TMD),

(3) similarity of groups at baseline (if the study design used 2 or more groups),

(4) the treatment protocol was sufficiently described to be replicable,

(5) reliability of data obtained with the outcome measures was investigated,

(6) validity data obtained with the outcome measures was addressed,

(7) blinding of patient, treatment provider, and assessor,

(8) dropouts were reported,

(9) long-term (6 months or greater) results were assessed via follow-up, and

(10) adherence to home programs was investigated (if included in the intervention).

We rated the methodological rigor of the study as "strong" ("yes" score of 8-10), "moderate" ("yes" score of 6 or 7), or "weak" ("yes" score of [less than or equal to] 5). To assess the reliability of different raters' judgments in classifying studies, 4 randomly selected articles were independently reviewed and classified according to Sackett's levels of evidence (17) and methodological rigor criteria by 2 different raters.

Results

A large number of articles were identified that included physical therapy management of TMD. Many articles were general reviews or were descriptive in nature. Of the 108 articles that reported experimental studies, 30 articles met the inclusion criteria. No studies could be located that solely assessed disability related to TMD. The primary reason for the exclusion of all except 30 studies was the incorporation of non-physical therapy management, such as medication or surgery. One reviewer completed the study literature search and the study selection and data abstraction.

Interrater agreement (percentage of agreement) on the levels of evidence for each of the 4 studies independently reviewed was 100%. Interrater agreement, using the McMaster University Critical Review Form for Quantitative Studies (20) to assess methodological rigor, was 73.5%.

The 30 studies included in this review were divided into groups based on the primary intervention used. Fourteen studies (4,9,21-34) investigated the use of exercise or manual therapy, 8 studies (5,35-41) investigated the use of electrotherapy, 7 studies (42-49) investigated the use of relaxation training or biofeedback, and 1 study (50) investigated the use of exercise and electrotherapy. The study characteristics are summarized in Tables 1 through 3 (see pages 962-970), organized according to primary type of intervention.

Effect Size

Effect size r was calculated using Meta-Analysis Programs by Schwarzer. (51) If means and standard deviations were available, these data were used to calculate effect size r. In some cases, other statistics were reported, such as F values or chi-square values, which were transformed into an effect size r. A 95% confidence interval was subsequently calculated. (51) Effect size measurements can indicate the relative magnitude of the experimental treatment and can allow comparison of the magnitude of experimental treatments between experiments. The suggestion by Cohen (52) that effect sizes of 0.20 are small, 0.50 are medium, and 0.80 are large facilitates the comparison of the effect size results of an experiment with known benchmarks. Effect size was calculated for 24 studies; however, due to lack of data, it was not always possible to calculate effect sizes for all of the outcome measures utilized (ie, the remaining 6 studies lacked raw data), although the results were reported in terms of statistical significance with P<.05.

Levels of Evidence

Of the 30 studies reviewed, 22 were RCTs and were identified as level lib due to low study quality. Four studies (27,28,30,31) had a single-group pretest-posttest design with a nontreatment control period, 2 studies (23,26) had a case series design, 1 study (4) had a single-group randomized (treatment or placebo) crossover design, and 1 study (40) involved 1 group with a randomized order of treatments (treatment or placebo) within sessions (with session 1 before session 2); these 8 studies were identified as level IV due to the lack of a control group.

Scientific Rigor of the Studies

The methodological rigor of the studies was evaluated using the 10 criteria shown in Table 4 (see page 971). The studies were organized in Table 4 according to score on the methodological criteria. The study quality scores ranged from 1 to 7.3, with a median score of 4.0 and a mean score of 4.15. None of the studies could be judged as "strong" ("yes" score of 8-10), 5 studies (22,24,25,34,49) could be judged as "moderate" ("yes" score of 6 or 7), and the remaining 25 studies (4,5,9,21,23,26-28,30-32,35-4-3,45-48,50) would be considered "weak" ("yes" score or [less than or equal to] 5).

Randomization

Subjects were randomly assigned to 2 or more groups in 24 studies, (4,5,9,21,22,24,25,32,34-43,45-50) including the 2 studies that involved cross-over designs. The 6 studies in which subjects were not randomly assigned to groups were all single-group designs. (23,26-28,30,31)

Subject Inclusion and Exclusion Criteria

Inclusion and exclusion criteria varied among the studies and in relation to the subgroup of TMD diagnosis of the sample studied. Subjects were classified into subgroups identified in the RDC/TMD. Seventeen studies (4,21,22,24,25,27,34,38,41-50) involved subjects with myofascial TMD, and 6 studies (9,23,26,30,31,39) involved subjects with disk displacement (1 study with subjects with reduction, (31) 3 studies with subjects without reduction, (23,26,30) and 2 studies with subjects with unspecified status as to reduction (9,39)). One other study (37) involved subjects with myofascial TMD (50%) and subjects with arthritis (50%). Six studies (5,28,99,32,33,35,36,40) involved people with arthritis (2 studies with subjects with disk displacement without reduction, 1 study with 89% of the subjects having rheumatoid arthritis, 1 study with 56% of the subjects having rheumatoid arthritis, 1 study with 64% of the subjects having ankylosing spondylitis, and 1 study unspecified).

Studies involving subjects from all subgroups of TMD were included in the systematic review, despite differences among subgroups. Inclusion criteria were not identified in 7 of the 30 studies. In 3 studies, (21,32,46) a reference source was provided, but criteria were not otherwise defined. In the other 4 studies, (9,26,43,48) inclusion criteria were unclear.

For the 23 studies that described inclusion (and exclusion) criteria, 12 required self-reported symptoms, most commonly pain (ranging from 1 month to 1 year in duration). (22,24,25,27-29,31,34,41,42,47,50) The other 11 studies (4,5,23,30,35-39,45,49) required self-reported symptoms of an unspecified length of time. Five of the studies involving subjects with arthritic TMD (23,28,29,36,40) required radiological evidence of osteoarthritis among the inclusion criteria. One study involving disk displacement (30) required magnetic resonance imaging (MRI) evidence. Six studies (5,30,36,39,49,50) required that subjects have limited mandibular movement. Evidence of "postural dysfunction" was required in 3 studies, (27,30,31) although postural dysfunction was not defined in detail. Five of the studies involving subjects with myofascial TMD (4,22,39,42,50) required the presence of tenderness on palpation of masticatory muscles. Four studies (25,27,31,42) also directly referenced the source of the inclusion criteria. Exclusion criteria tended to rule out a history of trauma or malocclusion, prior or concurrent treatment for TMD, and specific contraindications relating to electrotherapy modalities.

Similarity of Groups at Baseline

Fourteen studies (21,22,24,25,35,37-39,43,45-47,49,50) reported on the similarity of groups at baseline.

Repeatability of the Treatment Protocol

Of the 14 studies involving exercise or manual therapy, 9 studies (4,9,21-23,25,26,32,34) provided sufficient description to allow replication of the intervention. In the remaining 6 studies, (24,27-31) 5 of which were by Nicolakis and colleagues, exercises were not described in detail sufficient to replicate the treatments.

All studies involving electrotherapy as the primary intervention described the intervention in sufficient detail to allow for replication. (5,36-42) Of the 8 studies involving biofeedback or education, 6 studies (43,45-49) provided adequate information to allow replication of the intervention. Two studies (42,43) failed to provide sufficient detail on the interventions utilized, preventing replication, although 1 study (42) referred to a manual for the description of the intervention involved.

Outcome Measure Reliability

Reliability of data obtained with the outcome measures was reported in only 8 studies. Carmeli and colleagues (9) reported intrarater reliability for the measurement of active ROM of the TMJ, whereas Taylor et al (4) reported interrater reliability for maximal mandibular opening and lateral movement. Carlson and colleagues (42) reported the internal consistency and intrarater reliability for subscales from the Multidimensional Pain Inventory (MPI) measuring pain severity, life interference from pain, and perception of life control. This group of researchers also reported the internal consistency and intrarater reliability for the somatization, depression, anxiety, and obsessive-compulsive scales of the Revised Symptom Checklist (SCL-90-R). (42) Internal consistency and intrarater reliability for the affective distress scale from the MPI, as well the internal consistency and the intrarater reliability for the sleep dysfunction scale, also were reported. (42)

Internal consistency and interrater reliability for the muscle palpation pain index (PPI) and internal consistency for credibility ratings were reported by Turk and colleagues. (49) Okeson and colleagues (48) reported on the internal consistency for muscle and TMJ palpation. One of the studies by Nicolakis and colleagues (27) referenced the reliability of scores for the visual analog scale (VAS). (53) Wright et [al.sup.34] referenced previously reported intrarater and interrater reliability of data for the modified symptom severity index (SSI-5 VAS), maximum pain-free opening, and muscle pain threshold. (46,54,55) De Laat and colleagues (22) referenced the reliability of data for the VAS, pressure pain threshold (PPT), and the Mandibular Functional Impairment Questionnaire (MFIQ). (56,57) Of the 8 studies that reported reliability of data for outcome measures, only 2 studies (22,34) reported reliability for all of the outcome measures used.

Outcome Measure Validity

Validity of data for outcome measures was reported in 3 studies. (22,34,35) Wright and colleagues (34) indicated that the validity of data for their outcome measures had been reported previously. (48,53,54) Al-Badawi and colleagues (35) indicated that the 10-point Numerical Pain Scale had been reported to be statistically sensitive when measuring pain and discomfort. (53) De Laat and colleagues (22) referenced the smallest detectable difference on a VAS to be considered clinically relevant in TMD secondary to disk displacement without reduction (58) in subjects with myofascial TMD. None of the other studies presented any information on the validity for outcome measures used.

In the 30 studies reviewed, over 75 different outcome measures were utilized. The outcomes of interest were self-reported pain, pain on palpation, active ROM, EMG levels, questionnaires regarding self-reported symptom severity and frequency, dysfunction indexes related to impairment, and psychological status scales. A large variety of tools and other assessment methods were used to measure the outcomes of interest with different studies using different tools or methods to evaluate the same outcome.

Blind Assessment

Blinded treatment providers and outcome measure assessors were used in 11 of the 30 studies. (9,22,25,34-38,40-42)

Account for Attrition

Subject attrition was reported in 15 of the 30 studies. (5,22,24,25,27,28,30,31,34,36,39,41,42,49,50) In the study by Moystad et al, (40) 6 subjects were inexplicably unaccounted for during the second phase of treatment. In the remaining 15 studies, subject attrition was not explicitly described.

Long-Term Follow-up

Long term-follow-up (6 months or greater) was reported in 10 of the 30 studies reviewed, (24,27-33,42,45,46,49) with the "long-term" assessment occurring from 6 months to 4 years after treatment.

Adherence to Home Programs

Although home intervention programs were explicitly identified in 20 of the 30 studies reviewed, the rate of adherence was not reported in 17 of those studies. (9,21,22,27,28,30-32,39,42,43,45-50) Only 3 studies identified the rate of adherence (via self-report). Magnusson and Syren (24) reported adherence at long-term follow up as less than 50%, Wright and colleagues (34) reported a mean adherence of 75% after treatment, and Michelotti and colleagues (25) reported adherence to the home physical therapy regimen as poor (27%) or medium (46%).

Discussion and Conclusions

The 22 RCTs included in the systematic review were ranked level II, using Sackett's rules of evidence, (17) due to low study quality. The remaining 8 studies were ranked level IV due to decreased rigor of the research designs.

Feine and Lund (15) performed an analysis of review articles and controlled clinical trials to assess the efficacy of physical therapy and physical modalities for the control of chronic musculoskeletal pain disorders, which included TMD; they reported that symptoms improved during treatment with most forms of physical therapy, including placebo. Physical therapy was reported as almost always better than no treatment, with efficacy increasing in direct proportion to the amount of treatment received. In addition, those subjects who received more treatment modalities seemed to do better than those who received fewer modalities. (15)

With respect to specific interventions, 4 systematic reviews were located, none of which were included in the analysis performed by Feine and Lund. (15) A 1996 systematic review (59) stated that there was insufficient evidence to refute or support either manipulation or mobilization in treatment of the TMJ. A more recent systematic review of low-level laser therapy (60) showed a reduction in pain and improvement in health status in chronic joint disorders. However, a systematic review of ultrasound in the management of chronic musculoskeletal disorders (61) showed little evidence to support its use. A meta-analysis (62) concluded that, although limited in extent, the available data support the efficacy of EMG biofeedback treatments for TMD.

Inclusion criteria varied among the studies we reviewed, likely due to the lack of consensus regarding the diagnosis of TMD. The lack of standardized inclusion criteria is a limitation when comparing studies, as well as with respect to the recommendations made. Subjects with myofascial TMD were included in 60% of the studies selected. The majority of patients who sought treatment for TMD and were subsequently involved in the studies were women. (63) This finding may relate to a difference in treatment-seeking behavior between men and women, as well as the greater likelihood for women to have somatization disorders. (63) The external validity of the recommendations is limited, due, in part, to the differences in the groups studied. There also may be differences between those who agree to participate in an RCT and those who do not. For example, one study (64) showed that the patients who refused to participate had more pain and more condition-related interference in daily life when compared with those who participated.

Temporomandibular disorder-related pain of [greater than or equal to] 6 months may represent a shift from acute to chronic TMD. Five of the studies in this review required a duration of pain for [greater than or equal to] 6 months. (4,24,34,49,50) The second axis of the RDC/TMD includes the more psychosocial aspects of TMD. (6,8) Women and men who develop chronic TMD display more psychosocial distress than those whose acute TMD resolves. Other predictors of chronicity are TMD of the myofascial type and being female. (64,65)

Within our systematic review, a variety of interventions were used to treat the 3 TMD subgroups in the first axis. Interventions were grouped into 1 of 3 areas: exercise, electrotherapy, and biofeedback. Within the 3 areas, the interventions were often heterogeneous, making comparisons difficult. The use of multiple interventions in a number of studies resulted in recommendations based on a multi-intervention program because the effectiveness of a single intervention alone was not examined.

A spectrum of different outcome measures was used in the studies reviewed. Most of the studies included between 2 and 5 outcome measures. Although there was some continuity in the outcome areas assessed, the actual measures differed among the studies, with over 75 different methods used to assess the outcomes. Reliability was reported in only 8 studies, (4,9,22,27,34,42,48,49) with only 2 studies (22,34) reporting reliability on all of the outcome measures involved. Validity was reported in 3 studies, (22,34,35) with only 1 study (34) reporting on all of the outcome measures involved. Only 3 studies (22,25,42) reported whether outcomes were clinically important. The lack of demonstrated reliability or validity for the outcome measures used limits the confidence with which the results may be interpreted.

Five studies (22,24,25,34.49) fulfilled 6 or more (of 10) criteria for methodological rigor (Tab. 4). The majority of the remaining studies failed to report either reliability or validity for the outcome measures used, creating less confidence in the study results. The importance of long-term follow-up to assess the retention of short-term treatment effects is critical to examining the efficacy of the interventions involved.

This review has several limitations. Because only English-language articles were included, it is possible that this review is a not complete representation of the available evidence. The review was limited to published articles and thus may have missed those that were not submitted or accepted for publication, presenting a possible publication bias. As only the first author preformed the literature search and the subsequent selection of the studies to be considered in this review, a selection bias may be present. Additionally, the first author performed the data abstraction, as well as a significant proportion of the rating and classification of the studies, which may present a data abstraction and evaluation bias.

Implications for Clinical Practice

Despite reported limitations of this systematic review of the scientific evidence for physical therapy interventions for TMD, the following clinical recommendations are suggested:

(1) Active exercises and manual mobilizations, alone or in combination, may be effective in the short term in increasing total vertical opening (TVO) in people with TMD resulting from acute disk displacement, acute arthritis, or acute or chronic myofascial TMD. A home exercise program was often included in the treatment protocol.

(2) Postural training may be used in combination with other treatment techniques because the effects, independent of other treatments, are not known (eg, postural training combined with a home exercise program may decrease pain and increase TVO in people with myofascial TMD).

(3) Mid-laser therapy may decrease pain and improve TVO and lateral excursion in people with TMD secondary to acute disk displacement and may be more effective than other electrotherapy modalities in the short term, although comparison is difficult.

(4) Programs involving relaxation techniques and biofeedback, EMG training, proprioceptive reeducation may be more effective than placebo treatment or occlusal splints in decreasing pain and increasing TVO in people with acute or chronic myofascial or muscular TMD in the short term and the long term.

(5) Programs involving combinations of active exercises, manual therapy, postural correction, and relaxation techniques may decrease pain and impairment and increase TVO in the short term in people with TMD resulting from acute disk displacement, acute arthritis, or acute myofascial TMD. However, it is impossible to discern whether a combination program is more effective than providing the separate elements of the program as individual treatment techniques.

Implications for Future Research

The foregoing clinical implications should be considered with caution because none were supported by numerous, decisive studies. Consensus on the definition of TMD, and subsequent inclusion and exclusion criteria, would allow further comparison across groups studied. In addition, agreement on use of valid and reliable outcome measures would yield more rigorous research.

This article was received June 6, 2005, and was accepted January 31, 2006.

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(47) Hijzen TH, Slangen JL, Van Houweligen HC. Subjective, clinical and EMG effects of biofeedback and splint treatment. J Oral Rehabil. 1986;13:529-539.

(48) Okeson JP, Kemper JT, Moody PM, Haley JV. Evaluation of occlusal splint therapy and relaxation procedures in patients with temporomandibular disorders. J Am Dent Assoc. 1983;107:420-424.

(49) Turk DC, Zaki HS, 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 Pros Dent. 1993;70:158-164.

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(58) Kropmans THJB, Dijkstra PU, van Veen A, et al. The smallest detectable difference of mandibular function impairment in patients with painfully restricted temporomandibularjoint function. J Dent Res. 1999;78:1445-1449.

(59) Coulter I. Manipulation and mobilization of the cervical spine: the results of a literature survey and consensus panel. J Musculoskeletal Pain. 1996;4:113-123.

(60) Bjordal JM, Couppe C, Chow RT, et al. A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiother. 2003;49:107-116.

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MS Medlicott, BScPT, is Physical Therapist, Lion's Gate Hospital, North Vancouver, British Columbia, Canada. Address all correspondence to Ms Medlicott at 2759 Webster Rd, Nanaimo, British Columbia, Canada, V9R 6W7 ([e-mail]).

SR Harris, PT, PhD, FAPTA, is Professor, School of Rehabilitation Sciences-Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Ms Medlicott provided concept/idea/research design. Both authors provided writing and data collection and analysis. Dr Harris provided consultation (including review of manuscript before submission).

Table 1.
Studies on Exercise and Manual Therapy (a)

                     Design and
                     Level of
Authors              Evidence            Subjects

Burgress et          RCT                 N-29 My, F=74%,
  al, (21) 1998      Level II              mean age=34.8 y,
                                           A/R=n/a
Carmeli et al, (9)   RCT                 N-36 DD, F=72%,
  2001               Level II              mean age=30.3 y,
                                           A/R-n/a
De Loat et al, (22)  RCT                 N=26 My, F=85%,
  2003               Level II              mean age=42.5 y,
                                           A/R=22/26
Jagger, (23) 1991    Pretest-posttest,   N=12 DD without
                       case series         reduction, F=67%,
                     Level IV              mean age=21.8 y,
                                           A/R=n/a
Magnusson and        RCT                 N=26 chronic My,
  Syren, (24)        Level II              F=n/a, mean
  1999                                     age-35 y,
                                           A/R=23/26
Michelotti           RCT, control        N-70 My, F=88%,
  et al, (25)          Level II            mean age-30 y,
  2004                                     A/R=49/70
Minagi et al, (26)   Pretest-posttest,   N-35 DD without
  1991                 case series         reduction, F=94%
                     Level IV              mean age=36.4 y,
                                           A/R=n/a
Nicolakis            Pretest-posttest,   N=20 My, F=80%,
  et al, (27)          pretreatment        mean age-34.5 y,
  2002                 control period,     A/R=20/20, 6 mo
                       case series         A/R=19/20
                     Level IV
Nicolakis            Pretest-posttest,   N=20 Ar, F=90%,
  et al, (28)          pretreatment        mean age-48.8 y,
  2001                 control period,     A/R=20/20, 6 mo
Nicolakis              case series         A/R-19/20, 3 y
  et al, (29)        Level IV              A/R=17/20
  2002
  (3-y follow-up)
Nicolakis            Pretest-posttest,   N-20 DD without
  et al, (30)          pretreatment        reduction, F-75%,
  2001                 control period,     mean age-37.3 y,
                       case series         A/R=20/20, 6 mo
                     Level IV              A/F-18/20
Nicolakis            Pretest-posttest,   N=30 DD with
  et al, (31)          pretreatment        reduction, F=93%,
  2000                 control period,     mean age=33.1 y,
                       case series         A/R=30/30,
                     Level IV              6 mo A/R=26/30
Taylor et al, (4)    Randomized,         N=15 chronic My,
  1994                 placebo,            F=93%, age
                       crossover           range=20-35 y,
                     Level IV              A/R=n/a
Tegelberg and        RCT, control        N=50 Ar (56% RA,
  Kopp, (32)         Level II              64% AS), F=64%,
  1988                                     mean age=48.1 y,
Tegelberg and                              A/R=n/a
  Kopp, (33)
  1996 (3 y
  follow-up)
Wright et al, (34)   RCT, control        N=60 chronic My,
  2000               Level II              F=85%, mean
                                           age=31.8 y,
                                           A/R=60/61

Authors              Intervention

Burgress et          A: masticatory and neck
  al, (21) 1998        musculature chilling,
                       stretches, HP
                     B: maximal mouth opening
                       against resistance, HP
                     C: no rx (2 rx over ~3 wk)
Carmeli et al, (9)   A: occlusal splint
  2001               B: manual mobilizations and
                       active exercises, HP (~15
                       rx over 5 wk)
De Loat et al, (22)  A: education, PT--massage,
  2003                 ultrasound; continuous, 5
                       min, muscle stretching,
                       warm pad, HP (18 rx over
                       6 wk)
                     B: education with PT (as per
                       A) initiated after 2 wk
                       (12 rx over 6 wk)
Jagger, (23) 1991    Manual mobilization (1 rx)
Magnusson and        A: occlusal night splint
  Syren, (24)        B: active exercises, HP
  1999                 (mean=4.9 rx over 6 mo)
                     C: combination rx after 3 mo
                       (n=5) (mean=9.4 rx over
                       9 mo)
Michelotti           A: education, relaxation
  et al, (25)          techniques, moist heat
  2004                 pads, stretching,
                       coordination exercises, HP
                     B: education (4 rx over 3 mo)
Minagi et al, (26)   Manual mobilization, 1 rx
  1991
Nicolakis            Active exercises, manual
  et al, (27)          therapy, postural
  2002                 correction, relaxation
                       techniques, HP
                       (mean=10.8 rx over mean
                       of 51.2 d)
Nicolakis            Active exercises, manual
  et al, (28)          therapy, postural
  2001                 correction, relaxation
Nicolakis              techniques, HP
  et al, (29)          (mean=10.8 rx over mean
  2002                 of 46.5 d)
  (3-y follow-up)
Nicolakis            Active exercises, manual
  et al, (30)          therapy, postural
  2001                 correction, relaxation
                       techniques, HP (mean=11
                       rx over 51.2 d)
Nicolakis            Active exercises, manual
  et al, (31)          therapy, postural
  2000                 correction, relaxation
                       techniques, HP (mean
                       9.9 rx over 30 d)
Taylor et al, (4)    A: manual mobilizations
  1994               B: sham rx (2 rx over
                       1 d)
Tegelberg and        A: active ROM exercises, HP
  Kopp, (32)           (1 rx over 3 wk)
  1988               B: no rx
Tegelberg and
  Kopp, (33)
  1996 (3 y
  follow-up)
Wright et al, (34)   A: postural correction, HP
  2000                 (2 rx over 2 wk)
                     B: no rx

Authors              Outcome Measures and Results (b)

Burgress et          McGill PRI scores: post-rx
  al, (21) 1998      --A+B: ES=0.38 (-0.06-0.70)
                     --A+C: ES=0.72 (0.38-0.89)
                     --B+C: ES=0.16 (-0.32-0.57)
                     Self-reported pain change (PRI) from pre-rx 1 to
                       pre-rx 2
                     --A+B: ES=0.22 (-0.26-0.61)
                     --A+C: ES=0.50 (0.00-0.80)
                     --B+C: ES=0.40 (-0.14-0.76)
                     TVO: pre-rx 2
                     --A+B: ES=0.08 (-0.38-0.50)
                     --A+C: ES=0.30 (-0.15-0.65)
                     --B+C: ES=0.36 (-0.14-0.70)
Carmeli et al, (9)   Pain levels: ES=0.44 (0.13-.67)
  2001               TVO: ES=0.19 (-0.15-0.49)
De Loat et al, (22)  Pain--VAS, % of pain relief, jaw function--MFIQ,
  2003                 PPT
                     --Decrease in pain in A and B
                     --Increase in jaw function and PPT in A and B
                     --No significant differences between A and B
Jagger, (23) 1991    TVO: ES=0.51 (0.13-0.76)
Magnusson and        Clinical and onamnestic dysfunction indexes,
  Syren, (24)          behavior rating scale
  1999               --Greater improvement in clinical parameters and
                       self-reported symptoms in A and B
                     --Increase in TVO in B (no statistical analysis)
Michelotti           No. of sites tender to palpation: ES=0.05
  et al, (25)          (-0.23-0.33)
  2004               Pain intensity (VAS): ES=0.10 (-0.19-0.37)
                     Pain-free TVO: ES=0.29 (-0.01-0.53)
                     Pain on chewing (VAS): ES=0.16 (-0.13-0.42)
                     Headache (VAS): ES=0.03 (-0.26-0.31)
                     PPT
                     --Masseter: ES=0.01 (-0.28-0.29)
                     --Temporalis: ES=0.07 (-0.22-0.34)
                     Patient-based treatment contrast: ES=0.19
                       (-0.10-0.45)
                     Clinician-based treatment contrast: ES=0.09
                       (-0.20-0.36)
                     Total treatment contrast: ES=0.19 (-0.10-0.44)
Minagi et al, (26)   TVO: ES=0.58 (0.33-0.76)
  1991
Nicolakis            Pain at rest: ES=0.19 (-0.13-0.47)
  et al, (27)        Pain at stress: ES=0.41 (0.12-0.64)
  2002               Impairment: ES=0.57 (-0.32-0.75)
                       TVO: ES=0.40 (0.10-0.63)
                     No. of patients experiencing no pain at stress:
                       ES=0.58 (-0.17-0.82)
                     No. of patients experiencing impaired TVO:
                       ES=0.60 (-0.21-0.82)
                     Perceived improvement of jaw pain: ES=0.75
                       (0.46-0.90)
                     Perceived improvement of jaw function: ES=0.75
                       (-0.46-0.90)
Nicolakis            No. of patients experiencing no pain at stress:
  et al, (28)          ES=0.45 (-0.01-0.75)
  2001                 No. of patients experiencing no impairment:
Nicolakis            ES=0.42 (-0.05-0.73)
  et al, (29)        Perceived improvement of jaw pain: ES=0.76
  2002                 (0.47-0.90)
  (3-y follow-up)    Perceived improvement of jaw function: ES=0.77
                       (0.50-0.91)
Nicolakis            Pain at rest: ES=0.34 (0.03-0.59)
  et al, (30)        Pain at stress: ES=0.47 (0.19-0.68)
  2001               Impairment: ES=0.47 (0.19-0.68)
                     TVO: ES=0.36 (0.05-0.60)
                     No. of patients experiencing no pain at stress:
                       ES=0.42 (-0.02-0.73)
                     No. of patients experiencing impaired TVO:
                       ES=0.66 (0.31-0.86)
                     Perceived improvement of jaw pain: ES=0.66
                       (0.31-0.85)
                     Perceived improvement of jaw function: ES=0.72
                       (0.40-0.88)
Nicolakis            Pain at rest: ES=0.52 (0.31-0.69)
  et al, (31)        Pain at stress: ES=0.70 (0.54-0.81)
  2000               Impairment: ES=0.65 (0.48-0.78)
                     TVO: ES=0.15 (-0.1 1-0.39)
                     No. of patients experiencing no pain at all:
                       ES=0.42 (0.07-0.68)
                     No. of patients experiencing no pain at rest:
                       ES=0.32 (-0.05-0.61)
                     No. of patients with a TVO <40 mm: ES=0.49
                       (0.15-0.72)
                     Perceived improvement of jaw pain: ES=0.76
                       (-0.56-0.88)
                     Perceived improvement of jaw function: ES=0.74
                       (0.53-0.87)
                     Perceived improvement of jaw clicking: ES=0.48
                       (0.15-0.72)
Taylor et al, (4)    EMG activity:
  1994               --Resting: ES=0.40 (0.05-0.67)
                     --Open/close: ES=0.33 (-0.03-0.62)
                     --LT: ES=0.26 (-0.11-0.57)
                     --Clenching: ES=0.42 (0.08-0.68)
                     TVO: ES=0.59 (0.29-0.78)
                     LT: ES=0.47 (0.14-0.71)
Tegelberg and        ESR, CRP, severity of symptoms (5-point scale),
  Kopp, (32)           Helkimo Dysfunction Index, CDS, TVO
  1988               --Decrease in severity of symptoms in A and B
Tegelberg and          (greater in A [RA])
  Kopp, (33)         --Reduction in CDS (RA) and increase in TVO
  1996 (3 y            greater in A
  follow-up)         --No change in ESR and CRP in A or B
Wright et al, (34)   MMSI
  2000               --TMD: ES=0.55 (0.35-0.71)
                     --Neck: ES=0.50 (0.28-0.67)
                     TVO: ES=0.27 (0.02-0.49)
                     Pressure algometer pain threshold:
                     --Masseter: ES=0.31 (0.06-0.53)
                     --Tropezius: ES=0.36 (0.11-0.56)
                     Perceived symptom improvement
                     --TMD: ES=0.48 (0.26-0.66)
                     --Neck: ES=0.44 (0.21-0.62)

Authors              Follow-up Results (b)

Burgress et          None
  al, (21) 1998
Carmeli et al, (9)   None
  2001
De Loat et al, (22)  None
  2003
Jagger, (23) 1991    None
Magnusson and        6 mo and 1-4 yr: maintenance
  Syren, (24)          of improvements in A and B
  1999                 (no statistical analysis)
Michelotti           None
  et al, (25)
  2004
Minagi et al, (26)   None
  1991
Nicolakis            6 mo
  et al, (27)        Difference between treatment
  2002                 period and follow-up:
                       ES=0.00 (-0.45-0.45)
Nicolakis            6 mo and 3 y
  et al, (28)        6 mo:
  2001               Perceived improvement of jaw
Nicolakis              pain: ES=0.02
  et al, (29)          (-0.44-0.47)
  2002               Perceived improvement of jaw
  (3-y follow-up)      function: ES=0.02 (-0.44-
                       0.47)
Nicolakis            6 mo:
  et al, (30)        Perceived improvement of jaw
  2001                 pain: ES=0.05 (-0.43-0.50)
                     Perceived improvement of jaw
                       function: ES=0.25 (-0.25-
                       0.64)
Nicolakis            6 mo:
  et al, (31)        No. of patients experiencing
  2000                 no pain at all: ES=0.33
                       (-0.07-0.64)
                     No. of patients experiencing
                       no pain at rest: ES=0.20
                       (-0.20-0.55)
                     No. of patients with a TVO
                       <40 mm: ES=0.06 (-0.33-
                       0.44)
                     Perceived improvement of jaw
                       pain: ES=0.18
                       (-0.22-0.53)
                     Perceived improvement of jaw
                       function: ES=0.29 (-0.12-
                       0.61)
                     Perceived improvement of jaw
                       clicking: ES=0.21 (-0.19-
                       0.55)
Taylor et al, (4)    None
  1994
Tegelberg and        3 y (n=35):
  Kopp, (32)         -Reduction in CDS maintained
  1988                 clinical (RA) in A
Tegelberg and        -Increase in TVO maintained
  Kopp, (33)           in A
  1996 (3 y          -Increase in ESR in RA
  follow-up)
Wright et al, (34)   None
  2000

(a) A=group I, Ar=arthritis, A/R=analyzed/randomized, AS=ankylosing
spondylitis, B=group II, C=group III, CDS=clinical dysfunction score,
CRP=C-reactive protein, DD=disk displacement(s), EMG=electromyography,
ES=effect size (95% confidence interval), ESR=erthrocyte sedimention
rate, F=female, HP=home program, LT=lateral excursion (left and right),
MFIQ=Mandibular Function Impairment. Questionnaire, MMSI=modified
symptom severity index, My=myofascial/muscular, n/a=data not available,
PPT=pressure pain threshold, PRI=pain rating intensity, PT=physical
therapy, RA=rheumatoid arthritis, RCT=randomized controlled trial,
ROM=range of motion, rx=treatment, TMD=temporomandibular disorder,
TVO=total vertical opening, VAS=visual analog scale.

(b) Statistically significant unless noted.

Table 2.
Studies on Electrotherapy (a)

                    Design and
                    Level of
Authors             Evidence             Subjects

Al-Badawi et        RCT, placebo         N=40 Ar, F=78%, age
  al, (35) 2004     Level II               range-22-55 y,
                                           A/R=n/a
Bertolucci and      RCT, placebo         N=32 Ar (with DD without
  Grays 1995        Level II               reduction), F=n/a, mean
                                           age=n/a, A/R=32/33
Bertolucci and      RCT, placebo         N=48 Ar (with DD without
  Gray, (36) 1995   Level II               reduction), F=n/a, mean
                                           age=n/a, A/R=47/48
Conti, (37) 1997    RCT, placebo         N=20 50% Ar and 50%
                    Level II               My, F=90%, mean
                                           age=39.9 y, A/R=n/a
Gray et al,         RCT, placebo         N=139 My, F=86%, age
  (38) 1995         Level II               range=15-30 y,
                                           A/R=139/176
Linde et al,        RCT                  N=31 DD, F=84%, mean
  (39) 1995         Level II               age=37 y, A/R=n/a
Moystad et al,      Randomized order     N=19, Ar (89% RA)
  (40) 1990           of treatments      F=89%, mean age=
                      within sessions    33 y, A/R=n/a
                      (treatment
                      session 1 before
                      2), placebo
                    Level IV
Taube et al,        RCT, placebo         N=49 My, F=90%, mean
  (41) 1998         Level II               age=-~46.7 y,
                                           A/R=49/49

Authors             Intervention

Al-Badawi et        A: PRFE, 250 kHz, pulsed 600 Hz,
  al, (35) 2004       6 x 15 s, 7-s rest intervals
                    B: sham PRFE, (6 rx over 2 wk)
Bertolucci and      A: mid-laser, 904 nm, 700 Hz, 27 W,
  Grays 1995          100% power output, 9 min
                    B: placebo mid-laser (9 rx over 3 wk)
Bertolucci and      A: microcurrent electrical neuromuscular
  Gray, (36) 1995     stimulation; 100 [micro]A, 0.3 Hz, 10 min
                    B: mid-laser, 904 nm, 700 Hz, 27 W,
                      100% power output, 9 min
                    C: mid-laser placebo (9 rx over 3 wk)
Conti, (37) 1997    A: low-level laser, 830 nm, 100 mW,
                      4 J, 40 s
                      B: placebo laser (3 rx over 3 wk)
Gray et al,         A: short-wave diathermy, mild thermal
  (38) 1995           setting, 10 min
                    B: megapulse, 60-ms pulse, 100 pps,
                      20 min
                    C: ultrasound, 0.25 W/[cm.sup.2], 3 MHz,
                      pulsed at 2:1, 2 min
                    D: laser, 904 nm, 4 J/[cm.sup.2], 3 min
                    E: placebo (12 rx over 4 wk)
Linde et al,        A: TENS, 90 Hz, 30 min, just below
  (39) 1995           pain threshold, 3x per day, HP
                    B: occlusal splint (6 rx in 6 wk)
Moystad et al,      1a: TENS, 100 Hz, pulse width
  (40) 1990           0.15 ms, constant sensation TMl area
                    1b: placebo, 30 min (2 rx over 2 wk)
                    2a: TENS, 2 Hz, pulse width 0.2 ms,
                      acupuncture point on hand
                    2b: placebo, 30 min (2 rx over 2 wk)
Taube et al,        A: ultrasound, 0.08 W/[cm.sup.2], pulsed
  (41) 1998         B: ultrasound, 0.5 W/[cm.sup.2], pulsed
                    C: placebo, 5 min per TMJ
                      (mean-8.9 rx)

                    Outcome Measures and
Authors             Results (b)

Al-Badawi et        TMJ pain: ES=0.66 (0.45-0.81)
  al, (35) 2004     TVO: ES=0.14 (-0.18-0.43)
                    Right LT: ES=0.88 (0.78-0.94)
                    Left LT: ES=0.88 (0.78-0.94)
Bertolucci and      Pain index: ES=0.82 (0.67-
  Grays 1995          0.91)
                    TVO: ES=0.73 (0.51-0.86)
                    LT: ES=0.84 (0.70-0.92)
Bertolucci and      Pain index
  Gray, (36) 1995   --A+B: ES=0.40 (0.06-0.66)
                    --A+C: ES=0.74 (0.57-0.85)
                    --B+C: ES=0.83 (0.67-0.91)
                    TVO
                    --A+B: ES=0.40 (0.06-0.66)
                    --A+C: ES=0.52 (0.21-0.74)
                    --B+C: ES=0.73 (0.51-0.86)
                    LT
                    --A+B: ES=0.09 (-0.27-0.43)
                    --A+C: ES=0.83 (0.68-0.92)
                    --B+C: ES=0.80 (0.63-0.90)
Conti, (37) 1997    Pain-VAS, TVO, LT, PR: no
                      differences in improvements
                      between A and B
Gray et al,         Improvers and nonimprovers
  (38) 1995         --A: ES=0.10 (-0.37-0.53)
                    --B: ES=0.10 (-0.36-0.52)
                    --C: ES=0.10 (-0.35-0.51)
                    --D: ES=0.10 (-0.35-0.52)
                    --E: ES=0.36 (-0.21-0.75)
                    TVO, overall state (5-point
                      scale), joint and muscle
                      tenderness and sounds on
                      palpation
Linde et al,        TVO: ES=0.01 (-0.34-0.37)
  (39) 1995         LT: ES=0.11 (-0.26-0.44)
                    PR: ES=0.28 (-0.08-0.58)
                    Symptoms (5- and 6-step scales),
                      pain--VAS, pain track device,
                      TVO, tenderness and joint
                      sounds on palpation
                    --Greater decrease in pain in B
Moystad et al,      Pain--VAS, TMJ and muscle
  (40) 1990           tenderness on palpation (3-
                      point scale), TVO, LT, and PR
                    --Greater decrease in 1a
                    --No difference in improvements
                      in all other areas between
                      groups
Taube et al,        TVO, muscle tenderness on
  (41) 1998           palpation (3-point scale)
                    --No difference in improvements
                      between groups

Authors             Follow-up Results (b)

Al-Badawi et        None
  al, (35) 2004
Bertolucci and      None
  Grays 1995
Bertolucci and      None
  Gray, (36) 1995
Conti, (37) 1997    None
Gray et al,         3 mo, improvers and nonimprovers
  (38) 1995         -A: ES=0.15 (-0.32-0.57)
                    -B: ES=0.14 (-0.31-0.54)
                    -C: ES=0.14 (-0.30-0.53)
                    -D: ES=0.14 (-0.14-0.28)
                    -E: ES=0.91 (-0.71-0.99)
Linde et al,        None
  (39) 1995
Moystad et al,      None
  (40) 1990
Taube et al,        None
  (41) 1998

(a) A=group I, Ar=arthritis, A/R=analyzed/randomized, B=group II,
C=group III, D=group IV, DD=disk displacement(s), E=group V, ES=
effect size (95% confidence interval), F=female, HP=home program,
LT=lateral excursion (left and right), My=myofascial/muscular,
n/a=data not available, pps=pulses per second, PR=protusive
excursion, PRFE=pulsed radio frequency energy, PT=physical
therapy, RA=rheumatoid arthritis, RCT=randomized controlled trial,
rx=treatment, TENS=transcutaneous electrical nerve stimulation,
TMJ=temporomandibular joint, TVO=total vertical opening, VAS=
visual analog scale.

(b) Statistically significant unless noted.

Table 3.
Studies on Relaxation Training and Education (a)

                  Design and
                  Level of
Authors           Evidence            Subjects

Carlson et al,    RCT                 N=44 My, F=77%,
  (42) 2001       Level II              mean age-34.6 y,
                                        A/R=44/44,
                                        26 wk A/R=32/44
Crockett et       RCT, placebo        N=21 chronic My,
  al, (50) 1986   Level II              F=100%, age > 19 y,
                                        mean age=n/a,
                                        A/R=21/28
Dahlstrom et      RCT                 N=30 My, F=100%,
  al, (43) 1982   Level II              mean age=28.6 y,
Dahlstrom and                           A/R=n/a
  Carlsson,
  (44) 1984
Dolen et al,      RCT, control        N=19 My, F=95%,
  (45) 1986       Level II              mean age=n/a,
                                        A/R=n/a
Dohrmann and      RCT, placebo        N=24 My, F=88%,
  Laskin,         Level II              mean age-37 y,
  (46) 1978                             A/R=n/a
Hijzen et al,     RCT, control        N=48 My, F=94%,
  (47) 1986       Level II              mean age=n/a,
                                        A/R=n/a
Okeson et al,     RCT                 N=24 My, F=86%,
  (48) 1983       Level II              mean age-30 y,
                                        A/R=n/a
Turk et al,       RCT control         N-58 chronic My,
  (49) 1993       Level II              F=82% mean age=
                                        34.1 y, A/R=78/80

Authors           Intervention

Carlson et al,    A: breathing and postural relaxation
  (42) 2001         techniques, proprioceptive
                    re-education, HP
                  B: occlusal splint, education
                    (2 rx over 3 wk)
Crockett et       A: occlusal splint, hot/cold
  al, (50) 1986     application, postural correction,
                    active exercises, HP
                  B: muscle relaxation training, EMG
                    biofeedback, HP
                  C: minimal rx, TENS, 100 Hz,
                    50 [micro]A, minimal sensation,
                    30 min, HP (8 rx over 8 wk)
Dahlstrom et      A: occlusal splint (2 rx over 6 wk)
  al, (43) 1982   B: EMG biofeedback, HP
Dahlstrom and       (mean=5.3 rx over 6 wk)
  Carlsson,
  (44) 1984
Dolen et al,      A: EMG biofeedback, HP
  (45) 1986       B: control (8 rx over 4 wk)
Dohrmann and      A:P biofeedback, HP
  Laskin,         B: sham biofeedback, HP (12 rx
  (46) 1978         over 6 wk)
Hijzen et al,     A: occlusal night splint
  (47) 1986       B: biofeedback (10 rx over 5 wk)
                  C: control (splint therapy delayed)
Okeson et al,     A: occlusal splint
  (48) 1983       B: relaxation tape, 20 min, HP
                    (4-6 rx over 4-6 wk)
Turk et al,       A: occlusal splint
  (49) 1993       B: biofeedback, stress management
                    education
                  C: waiting list control group (6 rx
                    over 6 wk)

Authors           Outcomes Measures and Results (b)

Carlson et al,    Pain measures
  (42) 2001       --Daily self-monitoring: ES=0.57 (0.33-0.74)
                  --Pain severity: ES=0.67 (0.47-0.81)
                  --Life interference: ES=0.57 (0.33-0.74)
                  --Life control: ES=0.43 (0.15-0.65)
                  Physical examination
                  --Opening without pain: ES=0.45 (0.18-0.66)
                  --Opening with pain: ES=0.33 (0.04-0.57)
                  --Muscle pain index: ES=0.44 (0.17-0.65)
                  --Awareness of tooth contact: ES=0.72 (0.54-0.84)
                  Psychologic variables
                  --Affective distress: ES=0.39 (0.11-0.62)
                  --Somatization: ES=0.33 (0.04-0.57)
                  --Depression: ES=0.28 (-0.02-0.53)
                  --Anxiety: ES=0.28 (-0.02-0.53)
                  --Obsessive/compulsive: ES=0.37 (0.08-0.60);
                  --Fatigue: ES=0.12 (-0.18-0.40)
                  Overall sleep dysfunction: ES=0.32 (0.03-0.56)
Crockett et       Pain to palpation
  al, (50) 1986   --A+B: ES=0.06 (-0.48-0.58)
                  --A+C: ES=0.25 (-0.32-0.69)
                  --B+C: ES=0. 19 (-0.38-0.65)
                  TVO
                  --A+B: ES=0.17 (-0.40-0.64)
                  --A+C: ES=0.01 (-0.53-0.54)
                  --B+C: ES=0.15 (-0.42-0.63)
                  Worst pain rating
                  --A+B: ES=0.25 (-0.32-0.69)
                  --A+C: ES=0.17 (-0.40-0.64)
                  --B+C: ES=0.10 (-0.46-0.60)
                  Adjectival pain rating
                  --A+B: ES=0.10 (-0.46-0.60)
                  --A+C: ES=0.08 (-0.47-0.58)
                  --B+C: ES=0.16 (-0.41-0.64)
                  Average weekly frequency of pain
                  --A+B: ES=0.02 (-0.52-0.55)
                  --A+C: ES=0.75 (0.36-0.92)
                  --B+C: ES=0.58 (0.07-0.85)
                  Average weekly pain intensity
                  --A+B: ES=0.50 (-0.05-0.81)
                  --A+C: ES=0.01 (-0.53-0.53)
                  --B+C: ES=0.44 (-0.11-0.79)
Dahlstrom et      Self-reported symptom rating: ES=0.15
  al, (43) 1982     (-0.23-0.48)
Dahlstrom and     Self-reported symptoms-5-point scale, clinical
  Carlsson,         dysfunction (Helkimo Index), TVO
  (44) 1984       --increase in TVO in B
Dolen et al,      EMG
  (45) 1986       --Masseter: ES=0.39 (-0.08-0.72)
                  --Frontalis: ES=0.48 (0.04-0.76)
                  EMG 1 wk posttreatment (frontalis): ES=0.63
                    (0.26-0.85)
                  EMG 8 wk posttreatment (frontalis): ES=0.52
                    (0.08-0.79)
                  Pain duration: ES=0.85 (-0.65-0.94)
                  Pain intensity variable: ES=0.76 (0.47-0.90)
Dohrmann and      EMG: ES=0.39 (-0.01-0.69)
  Laskin,         Pain (3-point scale), TVO, pain-free TVO, pain on
  (46) 1978         muscle palpation, self-report on joint sounds,
                    overall treatment success (patient and examiner),
                    EMG levels:
                  --Greater reduction in pain and tender on palpation
                    in A
                  --Increase in TVO in A (no statistical analysis)
Hijzen et al,     TVO: ES=0.89 (0.81-0.94)
  (47) 1986       Joint sounds: ES=0.88 (0.79-0.93)
                  Grinding: ES=0.58 (0.35-0.74)
                  Stuffed or dull feeling in ears: ES=0.53 (0.20-0.71)
                  Jaw muscle stiffness on awakening: ES=0.76 (0.61-
                    0.86)
                  Pain intensity: ES=0.93 (0.88-0.96)
                  Frequency of pain periods: ES=0.92 (0.85-0.95)
                  Control over jaw muscles: ES=0.96 (0.94-0.98)
                  Attention to jaw muscle activity: ES=0.67
                    (0.47-0.80)
                  Jaw muscle relaxation: ES=0.97 (0.95-0.98)
                  Helkimo Dysfunction Index: ES=0.89 (0.82-0.94)
Okeson et al,     Total observable pain scores: ES=0.86 (0.69-0.94)
  (48) 1983       Maximum comfortable TVO: ES=0.89 (0.75-0.95)
                  Mean maximum TVO: ES=0.83 (0.65-0.93)
Turk et al,       CES-D
  (49) 1993       --A+B: ES=0.01 (-0.25-0.27)
                  --A+C: ES=0.42 (0.16-0.63)
                  --B+C: ES=0.41 (0.15-0.62)
                  POMS
                  --A+B: ES=0.15 (-0.24-0.27)
                  --A+C: ES=0.25 (-0.04-0.50)
                  --B+C: ES=0.23 (-0.04-0.48)
                  PSS
                  --A+B: ES=0.32 (-0.07-0.53)
                  --A+C: ES=0.45 (-0.20-0.65)
                  --B+C: ES=0.2 1 (-0.07-0.46)
                  Muscle PPI
                  --A+B: ES=0.36 (0.14-0.57)
                  --A+C: ES=0.50 (0.25-0.69)
                  --B+C: ES=0.28 (0.00-0.51)
                  Treatment credibility
                  --A+B: ES=0.04 (-0.22-0.30)

Authors           Follow-up Results (b)

Carlson et al,    26 wk: less pain and greater
  (42) 2001         TVO in A
Crockett et       None
  al, (50) 1986
Dahlstrom et      12 mo: no further significant
  al, (43) 1982     changes
Dahlstrom and
  Carlsson,
  (44) 1984
Dolen et al,      6 mo
  (45) 1986       --EMG 12 wk posttreatment
                    (frontalis): ES=0.63
                    (0.25-0.84)
Dohrmann and      6 and 12 mo: further rx
  Laskin,           required in 25% of A (no
  (46) 1978         statistical analysis)
Hijzen et al,     None
  (47) 1986
Okeson et al,     None
  (48) 1983
Turk et al,       6 mo
  (49) 1993       --CES=D, A and B: ES=0.34
                    (0.09-0.55)
                  --POMS, A and B: ES=0.36
Authors             (0.12-0.57)
                  --PSS, A and B: ES=0.10
Carlson et al,      (-0.16-0.35)
  (42) 2001       --PPI, A and B: ES=0.20
                    (-0.06-0.44)

Table 4.
Evaluative Criteria for Studies Reviewed

                                                    Inclusion
                                                    and
                                                    Exclusion
Author                              Randomization   Criteria

Wright et al, (34) 2000             Y               Y
De Laot et al, (22) 2003            Y               Y

Michelotti et al, (25) 2004         Y               Y
Turk et al, (49) 1993               Y               Y

Al-Badawi et al, (35) 2004          Y               Y
Magnusson and Syren, (24)           Y               Y
  1999
Carlson et al, (42) 2001            Y               Y

Gray et al, (38) 1995               Y               Y
Taube et al, (41) 1988              Y               Y
Dolen et al, (45) 1986              Y               Y
                                    Y               Y
Conti, (37) 1997                    Y               Y
Bertolucci and Gray, (36) 1995      Y               Y
Bertolucci and Gray, (5) 1995       Y               Y
Crockett et al, (50) 1986           Y               N (a)
Dohrmann and Laskin, (46)
  1978
Hijzen et al, (47) 1986             Y               Y
Linde et al, (39) 1995              Y               Y
Moystad et al, (40) 1990            Y (b)           Y
Taylor et al, (4) 1994              Y (c)           Y

Carmeli et al, (9) 2001             Y               N
Nicolakis et al, (27) 2002          N (d)           Y

Burgess et al, (21) 1998            Y               N (a)
Dahlstrom and colleagues, (43,44)   Y               N
  1982, 1984
Tegelberg and Kopp, (32,33)         Y               N (a)
  1988, 1996
Nicolakis et al, (31) 2000          N (d)           Y
Nicolakis et al, (28,29)            N (d)           Y
  2001, 2002
Nicolakis et al, (30) 2001          N (d)           Y
Okeson et al, (48) 1983             Y               N

Jagger, (23) 1991                   N (e)           Y
Minagi et al, (26) 1991             N (e)           N

                                    Similarity
                                    of Groups
Author                              at Baseline     Replicability

Wright et al, (34) 2000             N               Y
De Laot et al, (22) 2003            Y               Y

Michelotti et al, (25) 2004         Y               Y
Turk et al, (49) 1993               Y               Y

Al-Badawi et al, (35) 2004          Y               Y
Magnusson and Syren, (24)           Y               N
  1999
Carlson et al, (42) 2001            N               Y

Gray et al, (38) 1995               Y               N
Taube et al, (41) 1988              N               Y
Dolen et al, (45) 1986              Y               Y
                                    Y               Y
Conti, (37) 1997                    N               Y
Bertolucci and Gray, (36) 1995      N               Y
Bertolucci and Gray, (5) 1995       Y               N
Crockett et al, (50) 1986           Y               Y
Dohrmann and Laskin, (46)
  1978
Hijzen et al, (47) 1986             Y               Y
Linde et al, (39) 1995              Y               Y
Moystad et al, (40) 1990            N               Y
Taylor et al, (4) 1994              N               Y

Carmeli et al, (9) 2001             N               Y
Nicolakis et al, (27) 2002          N/A             N

Burgess et al, (21) 1998            Y               Y
Dahlstrom and colleagues, (43,44)   Y               Y
  1982, 1984
Tegelberg and Kopp, (32,33)         N               Y
  1988, 1996
Nicolakis et al, (31) 2000          N/A             N
Nicolakis et al, (28,29)            N/A             N
  2001, 2002
Nicolakis et al, (30) 2001          N/A             N
Okeson et al, (48) 1983             N               Y

Jagger, (23) 1991                   N/A             Y
Minagi et al, (26) 1991             N/A             Y

Author                              Reliability     Validity

Wright et al, (34) 2000             Y (a)           Y (a)
De Laot et al, (22) 2003            Y (a)           Y (1/3)
                                                    N (2/3)
Michelotti et al, (25) 2004         N               N
Turk et al, (49) 1993               Y (1/4)         N
                                    N (3/4)
Al-Badawi et al, (35) 2004          N               Y (1/2) (a)
Magnusson and Syren, (24)           N               N
  1999
Carlson et al, (42) 2001            Y (3/6)         N
                                    N (3/6)
Gray et al, (38) 1995               N               N
Taube et al, (41) 1988              N               N
Dolen et al, (45) 1986              N               N
                                    N               N
Conti, (37) 1997                    N               N
Bertolucci and Gray, (36) 1995      N               N
Bertolucci and Gray, (5) 1995       N               N
Crockett et al, (50) 1986           N               N
Dohrmann and Laskin, (46)
  1978
Hijzen et al, (47) 1986             N               N
Linde et al, (39) 1995              N               N
Moystad et al, (40) 1990            N               N
Taylor et al, (4) 1994              Y (1/2)         N
                                    N (1/2)
Carmeli et al, (9) 2001             Y               N
Nicolakis et al, (27) 2002          Y (2/5) (a)     N
                                    N (3/5)
Burgess et al, (21) 1998            N               N
Dahlstrom and colleagues, (43,44)   N               N
  1982, 1984
Tegelberg and Kopp, (32,33)         N               N
  1988, 1996
Nicolakis et al, (31) 2000          N               N
Nicolakis et al, (28,29)            N               N
  2001, 2002
Nicolakis et al, (30) 2001          N               N
Okeson et al, (48) 1983             Y (1/2)         N
                                    N (1/2)
Jagger, (23) 1991                   N               N
Minagi et al, (26) 1991             N               N

                                    Blinding
                                    (a=Patient,
                                    b=Provider,
Author                              c=Assessor)     Dropouts

Wright et al, (34) 2000             Y (c)           Y
De Laot et al, (22) 2003            Y (c)           Y

Michelotti et al, (25) 2004         Y (c)           Y
Turk et al, (49) 1993               N               Y

Al-Badawi et al, (35) 2004          Y (a,b,c)       N
Magnusson and Syren, (24)           N               Y
  1999
Carlson et al, (42) 2001            Y (c)           Y

Gray et al, (38) 1995               Y (a,b,c)       Y
Taube et al, (41) 1988              Y (a,c)         Y
Dolen et al, (45) 1986              N               N
                                    Y (a,c)         N
Conti, (37) 1997                    Y (a)           Y
Bertolucci and Gray, (36) 1995      N               Y
Bertolucci and Gray, (5) 1995       N               Y
Crockett et al, (50) 1986           N               N
Dohrmann and Laskin, (46)
  1978
Hijzen et al, (47) 1986             N               N
Linde et al, (39) 1995              N               N
Moystad et al, (40) 1990            Y (a,c)         N
Taylor et al, (4) 1994              N               N

Carmeli et al, (9) 2001             Y (c)           N
Nicolakis et al, (27) 2002          N               Y

Burgess et al, (21) 1998            N               N
Dahlstrom and colleagues, (43,44)   N               N
  1982, 1984
Tegelberg and Kopp, (32,33)         N               N
  1988, 1996
Nicolakis et al, (31) 2000          N               Y
Nicolakis et al, (28,29)            N               Y
  2001, 2002
Nicolakis et al, (30) 2001          N               Y
Okeson et al, (48) 1983             N               N

Jagger, (23) 1991                   N               N
Minagi et al, (26) 1991             N               N

                                    Long-Term
Author                              Results         Adherence

Wright et al, (34) 2000             N               Y
De Laot et al, (22) 2003            N               N

Michelotti et al, (25) 2004         N               Y
Turk et al, (49) 1993               Y               N

Al-Badawi et al, (35) 2004          N               N/A
Magnusson and Syren, (24)           Y               Y
  1999
Carlson et al, (42) 2001            Y               N

Gray et al, (38) 1995               N               N/A
Taube et al, (41) 1988              N               N/A
Dolen et al, (45) 1986              Y               N
                                    N               N/A
Conti, (37) 1997                    N               N/A
Bertolucci and Gray, (36) 1995      N               N/A
Bertolucci and Gray, (5) 1995       N               N
Crockett et al, (50) 1986           Y               N
Dohrmann and Laskin, (46)
  1978
Hijzen et al, (47) 1986             N               N
Linde et al, (39) 1995              N               N
Moystad et al, (40) 1990            N               N/A
Taylor et al, (4) 1994              N               N/A

Carmeli et al, (9) 2001             N               N
Nicolakis et al, (27) 2002          Y               N

Burgess et al, (21) 1998            N               N
Dahlstrom and colleagues, (43,44)   N               N
  1982, 1984
Tegelberg and Kopp, (32,33)         Y               N
  1988, 1996
Nicolakis et al, (31) 2000          Y               N
Nicolakis et al, (28,29)            Y               N
  2001, 2002
Nicolakis et al, (30) 2001          Y               N
Okeson et al, (48) 1983             N               N

Jagger, (23) 1991                   N               N/A
Minagi et al, (26) 1991             N               N/A

                                    Total           Level of
Author                              Score           Evidence

Wright et al, (34) 2000             7.3/10          IIb
De Laot et al, (22) 2003            6.6/10          IIb

Michelotti et al, (25) 2004         6.3/10          IIb
Turk et al, (49) 1993               6.25/10         IIb

Al-Badawi et al, (35) 2004          5.5/9           IIb
Magnusson and Syren, (24)           6/10            IIb
  1999
Carlson et al, (42) 2001            5.8/10          IIb

Gray et al, (38) 1995               5/9             IIb
Taube et al, (41) 1988              4.6/9           IIb
Dolen et al, (45) 1986              5/10            IIb
                                    4.6/9           IIb
Conti, (37) 1997                    4.3/9           IIb
Bertolucci and Gray, (36) 1995      4/9             IIb
Bertolucci and Gray, (5) 1995       4/10            IIb
Crockett et al, (50) 1986           4/10            IIb
Dohrmann and Laskin, (46)
  1978
Hijzen et al, (47) 1986             4/10            IIb
Linde et al, (39) 1995              4/10            IIb
Moystad et al, (40) 1990            3.6/9           IV
Taylor et al, (4) 1994              3.5/9           IV

Carmeli et al, (9) 2001             3.3/10          IIb
Nicolakis et al, (27) 2002          3.4/9           IV

Burgess et al, (21) 1998            3/10            IIb
Dahlstrom and colleagues, (43,44)   3/10            IIb
  1982, 1984
Tegelberg and Kopp, (32,33)         3/10            IIb
  1988, 1996
Nicolakis et al, (31) 2000          3/9             IV
Nicolakis et al, (28,29)            3/9             IV
  2001, 2002
Nicolakis et al, (30) 2001          3/9             IV
Okeson et al, (48) 1983             2.5/10          IIb

Jagger, (23) 1991                   2/8             IV
Minagi et al, (26) 1991             1/8             IV

(a) Referenced.

(b) Randomized order of treatment or placebo within
sessions (treatment session I before 2), crossover.

(c) Randomized order of treatment or placebo, crossover.

(d) Pretest-posttest, pretreatment control period.

(e) Pretest-posttest.