van Grootel Robert J, Buchner Rob, Wismeijer Daniël, van der Glas Hilbert W
Meander Medical Centre, Amersfoort, The Netherlands.
, Sleen, The Netherlands.
BMC Musculoskelet Disord. 2017 Feb 10;18(1):76. doi: 10.1186/s12891-017-1404-9.
Temporomandibular Disorders (TMD) may be characterized by pain and restricted jaw movements. In the absence of somatic factors in the temporomandibular joint, mainly myogenous, psychobiological, and psychosocial factors may be involved in the aetiology of myogenous TMD. An occlusal appliance (splint) is commonly used as a basic therapy of the dental practice. Alternatively, a type of physiotherapy which includes, apart from massage of sore muscles, aspects of cognitive-behavioural therapy might be a basic therapy for myogenous TMD. Treatment outcome of physiotherapy (Ph-Tx) was evaluated in comparison to that of splint therapy (Sp-Tx), using the index Treatment Duration Control (TDC) that enabled a randomized controlled trial with, comparable to clinical care, therapy-and-patient-specific treatment durations.
Seventy-two patients were randomly assigned to either Ph-Tx or Sp-Tx, with an intended treatment duration between 10 and 21 or 12 and 30 weeks respectively. Using TDC, the clinician controlled treatment duration and the number of visits needed. A blinded assessor recorded anamnestic and clinical data to determine TDC-values following treatment and a 1-year follow-up, yielding success rate (SR) and effectiveness (mean TDC) as treatment outcomes. Cohen's d, was determined for pain intensity. Overall SR for stepped-care was assessed in a theoretical model, i.e. a second of the two studied therapies was applied if the first treatment was unsuccessful, and the effect of therapy sequence and difference in success rates was examined.
SR and effectiveness were similar for Ph-Tx and Sp-Tx (long-term SR: 51-60%; TDC: -0.512- -0.575). Cohen's d was 0.86 (Ph-Tx) and 1.39 (Sp-Tx). Treatment duration was shorter for Ph-Tx (on average 10.4 weeks less; p < 0.001). Sp-Tx needed 7.1 less visits (p < 0.001).
Physiotherapy may be preferred as initial therapy over occlusal splint therapy in stepped-care of myogenous TMD. With a similar SR and effectiveness, physiotherapy has a shorter duration. Thus patients whose initial physiotherapy is unsuccessful can continue earlier with subsequent treatment. The stepped-care model reinforces the conclusion on therapy preference as the overall SR hardly depends on therapy sequence.
isrctn.com/ISRCTN17469828 . Retrospectively registered: 11/11/2016.
颞下颌关节紊乱病（TMD）的特征可能是疼痛和下颌运动受限。在颞下颌关节不存在躯体因素的情况下，主要是肌源性、心理生物学和社会心理因素可能参与了肌源性TMD的病因。咬合器（牙合板）是牙科实践中常用的基本治疗方法。另外，一种物理治疗方法，除了对疼痛肌肉进行按摩外，还包括认知行为治疗的各个方面，可能是肌源性TMD的基本治疗方法。使用治疗持续时间控制（TDC）指数，将物理治疗（Ph-Tx）与牙合板治疗（Sp-Tx）的治疗结果进行比较，该指数能够进行一项随机对照试验，其治疗持续时间与临床护理相当，具有治疗和患者特异性。
72例患者被随机分配到Ph-Tx组或Sp-Tx组，预期治疗持续时间分别为10至21周或12至30周。使用TDC，临床医生控制治疗持续时间和所需就诊次数。一名盲法评估者记录病史和临床数据，以确定治疗后和1年随访后的TDC值，得出成功率（SR）和有效性（平均TDC）作为治疗结果。确定疼痛强度的Cohen's d值。在一个理论模型中评估分步护理的总体SR，即如果第一种治疗不成功，则应用两种研究治疗中的第二种，并检查治疗顺序和成功率差异的影响。
Ph-Tx和Sp-Tx的SR和有效性相似（长期SR：51%-60%；TDC：-0.512至-0.575）。Cohen's d值为0.86（Ph-Tx）和1.39（Sp-Tx）。Ph-Tx的治疗持续时间较短（平均少10.4周；p<0.001）。Sp-Tx所需就诊次数少7.1次（p<0.001）。
在肌源性TMD的分步护理中，物理治疗可能比咬合板治疗更适合作为初始治疗。在SR和有效性相似的情况下，物理治疗的持续时间较短。因此，初始物理治疗不成功的患者可以更早地继续后续治疗。分步护理模型强化了关于治疗偏好的结论，因为总体SR几乎不依赖于治疗顺序。
isrctn.com/ISRCTN17469828。回顾性注册：2016年11月11日。
