Journal of Bodywork & Movement Therapies (2013) 17, 302e308

Available online at www.sciencedirect.com

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COMPARATIVE STUDY

Effectiveness of manual therapy and

home physical therapy in patients with
temporomandibular disorders: A
randomized controlled trial
Aysenur Besler Tuncer, PT, Ph.D. a,*,
Nevin Ergun, PT, Ph.D. a, Abidin Hakan Tuncer,
DDS, M.P.H. b, Sevilay Karahan, M.Sc. c

a
Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences,
Hacettepe University, Ankara, Turkey
b
Department of Developmental Biology, Harvard School of Medicine and Dentistry,
Harvard University, Boston, USA
c
Department of Biostatistics, Faculty of Medicine, Hacettepe University, Ankara, Turkey

Received 1 July 2012; received in revised form 20 September 2012; accepted 1 October 2012

KEYWORDS Summary The purpose of this study was to compare the short-term effectiveness of home
TMD; physical therapy (HPT) alone with that of manual therapy (MT) in conjunction with home physical
Manual therapy; therapy (MTeHPT) performed for four weeks in patients with temporomandibular disorders
Home physical (TMD). Forty subjects (nine males and 31 females; age, 18e72 years) with TMD were randomly
therapy; divided into two groups: HPT (n Z 20; five males and 15 females; mean age, 34.8  12.4 years)
Pain; and MTeHPT (n Z 20; four males and 16 females; mean age, 37.0  14.6 years). Pain intensity
Maximum mouth was evaluated at rest and with stress using a visual analogue scale (VAS). Pain-free maximum
opening mouth opening (MMO) was also evaluated. Mean change score (MCS) in VAS and the smallest
detectable difference (SDD) in pain-free MMO were measured over time. The results were ana-
lysed by MANOVA to evaluate the effects of treatment over time. At baseline, the groups did not
differ from each other with respect to VAS scores and pain-free MMO (p > 0.05). Within each
group, VAS with stress decreased (p < 0.001) and pain-free MMO increased (p < 0.001) over time.
Between groups, both time*treatment effect and treatment effect were significant for VAS with
stress (p < 0.001); however, only time*treatment effect was significant for pain-free MMO
(p Z 0.009). In the MTeHPT group, MCS for VAS with stress was 91.3% and SDD for pain-free

* Corresponding author. 1691 Beacon Street, Unit # 2, Brookline, MA 02445 USA.

E-mail address: tuncer.aysenur@gmail.com (A.B. Tuncer).

1360-8592/$ - see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2012.10.006
Effectiveness of manual therapy and home physical therapy in patients with temporomandibular disorders
MMO was 10 mm. Our results suggest that a four-week period of MTeHPT has a clinically signif-
icant effect on both pain and pain-free maximum mouth opening in patients with TMD.
2012 Elsevier Ltd. All rights reserved.
Introduction
Temporomandibular disorder (TMD) is a collective term for
structural and functional disorders involving the temporo-
mandibular joint (TMJ) and/or the masticatory muscles,
muscles of the head and neck and contiguous tissue
components (Okeson, 1996). Biological, anatomical, bio-
mechanical, behavioural, environmental and/or emotional
factors affect the masticatory system, contributing to the
development of signs and symptoms and/or perpetuation of
TMD. Therefore, TMD can be considered a multifactorial
disease entity (De Leeuw, 2008). It is mainly characterized
by pain and restricted jaw movement, with pain being the
most common symptom and the most frequent reason for
seeking treatment (Dworkin et al., 1990).
In the literature, the treatments available for TMD
include pharmacological management, oral appliances,
occlusal equilibration, physical therapy, TMJ surgery, bio-
behavioural treatments and patient education (Wright and
Sluka, 2001; Okeson, 2003).
Home physical therapy (HPT) for TMD includes self-care
treatment, patient education, lifestyle modification and
self-awareness about the aggravating factors. Specifically,
it involves active jaw movements, stretching exercises and
correction of body and head posture. It is relatively simple,
incurs little cost compared with other treatments and
ensures the active involvement of patients (Michelotti
et al., 2005). HPT has also been shown to provide relief
of masticatory muscle and joint pain (Hanten et al., 2000;
Michelotti et al., 2004).
Manual therapy (MT) is an area of specialization that has
evolved within the field of physical therapy and is the most
commonly used approach for the management of spinal
symptoms (Gross et al., 2002; Aure et al., 2003). Manual
therapy for TMD includes TMJ mobilization, soft tissue mobi-
lization of painful muscles, active or passive muscle stretch-
ing exercises, gentle isometric tension exercises against
resistance and guided opening and closing jaw movements
(Rocabado and Iglarsh, 1991; Von Piekartz, 2005). These
relatively reversible, non-invasive treatments are intended to
decrease muscle spasm, alter jaw openingeclosing patterns
and improve coordination of the muscles of mastication.
Various reports have suggested that MT is a viable and useful
approach towards the management of TMD (Carmeli et al.,
2001; Nicolakis et al., 2002; Kalamir et al., 2007).
A systematic review by Medlicott and Harris (2006) eval-
uated the literature on the efficacy of physical therapy
interventions for TMD patients and specifically reported the
value of a combined approach of active exercises, MT and
relaxation techniques. This review favoured the use of
multifaceted TMD treatments. A second review on the effi-
cacy of physical therapy for TMD patients found that postural
training, MT and exercise demonstrated significant benefits.
The authors concluded that active, passive and postural
303
exercises are effective interventions for decreasing the
symptoms associated with TMD (McNeely et al., 2006).
Although a combination of MT and HPT, including patient
education, may have been effective for TMD in the past, no
reported studies have compared a MT treatment in
conjunction with HPT treatment to HPT treatment alone in
TMD patients. Therefore, this study aimed to determine the
effectiveness of the treatments on pain intensity and pain-
free maximum mouth opening in patients with TMD.
Methods
This study was approved by the Ethics Committee of
Hacettepe University, Faculty of Medicine, Ankara, Turkey.
All subjects were provided with an explanation of the study
and informed consent was obtained from the study
subjects. Subjects with a chief complaint of pain in the TMJ
region during mandibular movements participated in this
study at Hacettepe University, Faculty of Dentistry. One
dentist experienced in TMD diagnosed the subjects
according to the Research Diagnostic Criteria for Tempo-
romandibular Disorders (RDC/TMD) (Dworkin and LeResche,
1992). RDC/TMD applies a dual-axis system to diagnose and
classify patients with TMD. The first axis is divided into
three groups of commonly occurring TMDs as follows:
Group 1: Muscle disorders, including myofascial pain (Ia)
and myofascial pain with limited mandibular opening (Ib)
Group 2: Disc displacement with reduction (IIa) and disc
displacement without reduction, with limited mandibular
opening (IIb) or without limited mandibular opening (IIc)
Group 3: Arthralgia, arthritis and arthrosis of the TMJ (III)
Inclusion criteria
1. Subjects with a diagnosis of myogenous TMD according to
categories Ia and Ib of the RDC/TMD (Dworkin and
LeResche, 1992) were included. In addition to a diag-
nosis of myofascial pain, the presence of pain on palpa-
tion of at least three of 12 muscular points bilaterally was
required; these points were present on the temporalis
(anterior, medial and posterior bellies) and masseter
muscles (deep belly and inferior and anterior portions of
the superficial belly) (Friction and Schulman, 1987).
2. Subjects with a diagnosis of anterior disc displacement
with reduction according to category IIa of the RDC/
TMD (Dworkin and LeResche, 1992) were included.
Painful clicking, crepitation or pain on opening and
loaded closing with reproducibility in at least two of
three consecutive trials, elimination of a clicking sound
on openingeclosing movements from a protruded jaw
position and pain in the TMJ during the compression
304
test (De Wijer et al., 1995; Naeije et al., 2009) were
additional inclusion criteria for patients with anterior
disc placement with reduction.
3. Subjects with pain that was not related to acute
trauma, active inflammation or infection in the masti-
catory muscles/TMJ for at least three months were
included. Forty subjects who met the inclusion criteria
were enrolled as study subjects.
Exclusion criteria
Subjects were excluded if they exhibited any of the
following signs or symptoms: disc displacement without
reduction, arthritis or TMJ arthritis according to categories
IIb and III of the RDC/TMD (Dworkin and LeResche, 1992);
a history of chronic TMJ pain, clinical pathology, or previous
surgery related to the masticatory system or cervical spine;
a history of TMD treatment within the previous three
months; neurological or psychiatric disorders that could
interfere with the procedure and intake of any medication
that affects the musculoskeletal system.
Subjects selected for the study received unique identi-
fication numbers to conceal their names and designated
groups. Based on a computer-generated randomization list,
each subject was allocated to one of the treatment groups.
All subjects were informed about the treatments; however,
the control treatment was not disclosed. In addition,
subjects were instructed not to mention their group and
treatment during clinical evaluation.
Baseline measurements were obtained before group
assignment by a physical therapist experienced in musculo-
skeletal rehabilitation and TMD and was blinded to the
subjects groups. After four weeks of treatment, the patients
final assessments were recorded by the same physical thera-
pist. The physical therapist had no access to baseline data at
the time of final assessment; furthermore, she was not
involved in recruitment, group assignment or data analysis.
Interventions
After baseline assessment, the HPT was explained to all
subjects by the same physical therapist who performed the
baseline assessments.
Group I: home physical therapy (HPT)
Group I comprised 20 subjects (five males and 15 females;
age range, 20e63 years; mean age, 34.8  12.4 years) who
received only the HPT treatment, which involved subject
education concerning the presumed aetiology of the pain,
ergonomic advice, breathing exercises, relaxation tech-
niques, posture correction exercises and mandibular exer-
cises such as active and repetitive assisted muscle
stretching, mouth opening and closing, medial and lateral
gliding and resistance exercises (Morrone and Makofsky,
1991; Hanten et al., 2000; Michelotti et al., 2004).
Group II: manual therapy in conjunction with home
physical therapy (MTeHPT)
Group II also comprised 20 subjects (four males and 16
females; age range, 18e72 years; mean age, 37.0  14.6
A.B. Tuncer et al.
years) who received MT in conjunction with the HPT treat-
ment being the same as that prescribed to the HPT treat-
ment group. MT included soft tissue mobilization (intra- and
extra-oral deep friction massage of painful muscles), TMJ
mobilization (caudal and ventro-caudal traction, ventral
and mediolateral translation), TMJ stabilization (gentle
isometric tension exercises against resistance), coordina-
tion exercises (guided opening and closing jaw movements),
cervical spine mobilization (traction and translation) and
post-isometric relaxation and stretching techniques for the
masticatory and neck muscles (Evjenth and Hamberg, 1980;
Rocabado and Iglarsh, 1991; Kaltenborn, 2003; Von Piekartz,
2005). MT was administered by another physical therapist
who was clinically experienced and trained in TMD and MT
and was not involved in subject recruitment, group assign-
ment, data collection or evaluation of the MT treatment. All
subjects received MT three times a week during the four-
week treatment period. Each treatment session lasted
30 min and was adapted individually to the needs of each
subject.
Subjects in both groups were instructed to continue HPT
for four weeks even if they were relieved of the pain.
Outcome variables
The outcome variables were pain intensity at rest, pain
intensity with stress and pain-free maximum mouth
opening.
Pain intensity
Pain intensity at rest was measured first, followed by with
stress. Pain at rest was defined as pain intensity without
stress and was measured in mandibular resting position
where the jaws were in the neutral position without any
contact between the mandibular and maxillary teeth and
any stress on the mandibular muscles.
Pain with stress was considered as pain intensity during
chewing. Subjects were asked to chew a stick of chewing
gum using both sides of their jaws for 60 s and immediately
rate their pain on a visual analog scale (VAS). As the tissues
became stressed, a response was elicited that determined
the presence of TMJ pain (Michelotti et al., 2004).
The VAS, which was used to record pain scores in this
study, has been shown to be a reliable and valid instrument
for measuring pain intensity (Bijur et al., 2001). VAS scores
were recorded at baseline and at the end of four weeks,
i.e. after the last treatment session. Subjects were told to
place a vertical mark along the line to indicate their current
pain status, ranging from no pain at all (0) to worst
possible pain (100).
Pain-free maximum mouth opening
Pain-free maximum mouth opening (MMO) was measured in
millimetres at baseline and after the last intervention at
the end of the four-week period. Subjects were instructed
to open their mouth as wide as possible without causing
pain. The inter-incisal distance, i.e. the distance between
the maxillary and mandibular central incisors was measured
using a millimetre ruler. Because repeated measurements
decrease the standard error of measurements (Kropmans
et al., 2000), maximum unassisted mouth opening was
Effectiveness of manual therapy and home physical therapy in patients with temporomandibular disorders 305

recorded three times, and the largest recorded range

Table 1 Baseline characteristics of the study population.
was considered as the MMO before and after treatment
(Von Piekartz and Ludke, 2011). HPT MT-HPT p
(n Z 20) (n Z 20)
Gender (female/male)a 15/5 16/4 1.000
Statistical analysis
Age (years)b 34.8  12.4 37.0  14.6 0.611
Height (cm)b 166.4  7.5 163.8  7.9 0.291
Data analyses were performed using SPSS software (SPSS
Weight (kg)b 62.6  9.9 64.1  8.6 0.612
15.0, Chicago, IL, USA). Continuous variables were
Complaint duration 14.1  9.7 13.0  11.8 0.565
expressed as mean  standard deviation or median (inter-
(months)c
quartile), whereas categorical variables were given as
Diagnosis (ADDwR/MP)a 14/6 17/3 0.451
frequencies and percentages. The KolmogoroveSmirnov test
Effected side 5/10/5 9/8/3 0.389
was used to check for normal distribution. The independent
(left/right/both)a
samples t-test was used to evaluate differences in baseline
VAS at rest (mm)d 17.5  21.5 23.0  23.6 0.446
characteristics, namely age, height and weight between the
VAS with stress (mm)d 66.5  20.6 62.5  20.5 0.542
groups. The ManneWhitney U test was used to compare the
MMO (mm)d 39.0  6.1 38.6  6.7 0.865
duration of the complaint. The Chi e square test was used to
compare categorical variables, including sex, diagnosis and n: sample size, HPT: home physical therapy, MT-HPT: manual
affected side. VAS and pain-free MMO were compared over therapy in conjunction with home physical therapy, ADDwR:
time within each treatment group and between groups with anterior disc displacement with reduction, MP: myofascial pain,
repeated measures MANOVA. The Bonferroni test was used VAS: visual analog score, MMO: pain-free maximum mouth
opening.
for post hoc analysis. The intra-class correlation coefficient a
Chi e square test.
(ICC) was calculated to measure testeretest reliability, and b
Independent sample t-test.
the results were considered excellent when ICC was >75% c
ManneWhitney U test.
(Fleiss et al., 2003). For all analyses, 95% confidence inter- d
Repeated measures MANOVA.
vals were presented for each measurement time-point. A p-
value of <0.05 was considered statistically significant for all
analysed data. All subjects completed the four-week intervention with
no adverse effects. No subject required drug therapy during
the study. The ICC (intra-class correlation coefficient) for
Effectiveness of the interventions VAS and pain-free MMO was highly significant (>90%).

Mean change scores (MCS) were used to measure the clin-

ically important change in VAS score (Kovacs et al., 2008)
and change of minimum 30% was considered a clinically
relevant statistical result (Farrar et al., 2001). MCS was
calculated by subtracting the final VAS scores from baseline
VAS scores to correspond to clinical effectiveness (mean
change score/baseline*100) (Kovacs et al., 2008).
The smallest detectable difference (SDD) was used to
evaluate the clinical relevance of pain-free MMO. The
clinician was required to have measured a minimum
improvement of 9 mm to indicate clinical success (Kropmans
et al., 2000). The formula for SDD was 1,96*O2*standard
error of measurement (SEM). SEM was calculated as the
square root of the absolute error variance.
Effectiveness of the interventions was defined as within-
group and between-group effects on the outcome variables
and was assessed as per statistical significance and clinical
relevance of the statistical results.
Results
Baseline characteristics of the subjects are presented in
Table 1. A total of 40 subjects (nine males and 31 females)
participated in this study. The HPT group (group I) included
five males and 15 females while the MTeHPT group (group
II) included four males and 16 females. There were no
statistically significant differences between the two groups
in age, height, weight, complaint duration, diagnosis,
affected side, VAS at rest, VAS with stress and pain-free
MMO (p > 0.05) at baseline.
Pain intensity
VAS scores, both at rest and with stress, significantly
decreased in both groups over time (p < 0.001). Time*treat-
ment effect as well as treatment effect were significant only
for VAS with stress in the MTeHPT group (p < 0.001). This
indicates that VAS with stress was different between the two
groups after treatment. It significantly decreased in the
MTeHPT group compared with that in the HPT group. MCS for
VAS at rest was 34.6% and 59.2% in the HPT and MTeHPT
groups, respectively, whereas that with stress was 35.7% and
91.3%, respectively. The clinical significance of MT in the
MTeHPT group was higher compared with HPT alone (Table 2).
Pain-free maximum mouth opening
Pain-free MMO significantly increased in both groups over
time (p < 0.001). Time*treatment effect was significant
between groups (p Z 0.009), with a greater increase in the
MTeHPT group than in the HPT group. The SDD in pain-free
MMO after the treatment period was 4.4 and 10.0 mm in the
HPT and MTeHPT groups, respectively, indicating the
clinical effectiveness of treatment in the MTeHPT group
(Table 3).
Discussion
The purpose of this study was to compare the short-term
effectiveness of HPT alone with that of MT in conjunction
306 A.B. Tuncer et al.

Table 2 Changes of pain intensity of the treatment groups.

Outcome variables Treatment Baselinea After MCSb p valued
groups interventiona Time Treatment Time*treatment
c
VAS at rest
HPTe 17.5  21.5 4.5  10.0 34.6 <0.001 0.86 0.15
MT-HPTf 23.0  23.6 0.5  2.2 59.2
VAS with stressc
HPTe 66.5  20.6 43.5  20.8 35.7 <0.001 <0.001 <0.001
MT-HPTf 62.5  20.5 7.0  12.6 91.3
a
Mean  standard deviation.
b
Mean change score in percentage.
c
Visual analog score in millimeters.
d
Repeated measures MANOVA.
e
Home physical therapy.
f
Manual therapy in conjunction with home physical therapy.

with HPT in patients with TMD. The decrease in VAS and
improvement in pain-free MMO were significantly higher in
the MTeHPT group than in the HPT group, indicating the
clinical effectiveness of MT-HPT treatment.
Treatment approaches for TMD vary largely according to
different opinions based on its main aetiology. TMD can
have multiple causative factors, and the precise causes are
not clearly understood (Okeson, 1996; De Leeuw, 2008).
The signs and symptoms of TMD may be transient and self-
limiting over time, and most resolve without serious long-
term effects. Therefore, the early administration of
aggressive and irreversible treatments such as complex
occlusal therapy or surgery should be avoided (Okeson,
2003). A review on the management of TMD by List and
Axelsson (2010) found that surgery, occlusal adjustment
and electro-physical modalities had no effect in alleviating
pain related to TMD. The goals of managing TMD are best
achieved by using multidisciplinary approaches aimed at
decreased pain and increased muscular coordination and
strength (McNeely et al., 2006; De Leeuw, 2008).
Exercise and patient education have been shown to be
effective in the management of TMD (Michelotti et al.,
2004). Recently, Michelotti et al. (2012) stated that
a patient education programme was slightly more effective
than an occlusal splint in decreasing muscle pain in patients
with TMD. In our study, we focused on subject education,
posture and mandibular exercises using HPT, which both
groups received. Postural exercises have been
recommended by several authors for the rehabilitation of
the craniomandibular system because there is a known
relationship between posture and TMJ function (Komiyama
et al., 1999; Wright et al., 2000). As per our study results,
both the HPT and MTeHPT groups showed an improvement
in VAS and pain-free MMO after four weeks of treatment.
Multifactorial models have been presented to explain
the effect of MT (Gross et al., 2002; Kalamir et al., 2007; La
Touche et al., 2009), which is commonly used to decrease
pain and restore mobility (Carmeli et al., 2001; Cuccia
et al., 2010; La Touche et al., 2011; Von Piekartz and
Ludke, 2011). Passive and active stretching of muscles or
range-of-motion exercises are performed to increase mouth
opening and restore physiological mandibular movements
(Evjenth and Hamberg, 1980; Rocabado and Iglarsh, 1991;
Ajimsha, 2011). A post-isometric relaxation technique was
found to improve active mouth opening in a study (Blanco
et al., 2006), while isometric tension exercises against
resistance were performed for strengthening the mandib-
ular muscles in another (Nicolakis et al., 2001, 2002).
Considering that pain is one of the main reasons for
patients seeking care (Dworkin et al., 1990; Okeson, 1996),
pain relief is a commonly used outcome measurement while
assessing the effectiveness of interventions for TMD. In our
study population, pain was the main symptom. Although
VAS at rest and VAS with stress decreased over time in both
groups, we found that the decrease was larger and the
effect of the four-week intervention was more significant in

Table 3 Changes of pain-free maximum mouth opening of the treatment groups.

Outcome Treatment Baselinea After SDDb p valued
variable groups interventiona Time Treatment Time*treatment
MMOc
HPTe 39.0  6.1 41.4  4.7 4.4 <0.001 0.44 0.009
MT-HPTf 38.6  6.7 44.4  4.4 10
a
Mean  standard deviation.
b
Smallest detectable difference in millimeters.
c
Pain-free maximum mouth opening in millimeters.
d
Repeated measures MANOVA.
e
Home physical therapy.
f
Manual therapy in conjunction with home physical therapy.
Effectiveness of manual therapy and home physical therapy in patients with temporomandibular disorders
the MTeHPT group. The decrease in VAS at rest and VAS
with stress was clinically relevant as it exceeded the MCS in
VAS. Farrar et al. (2001) determined a 30% decrease in pain
to be a clinically relevant difference in patients with
chronic pain. In our study, MCS supported the clinical
effectiveness of treatment in both groups. In addition, it
may be speculated that MT had positive contributions of
nearly 25% and 55% on VAS at rest and VAS with stress,
respectively, in the MTeHPT group.
With regard to the management of TMD, the restoration
of physiological mandibular movement is essential. Pain-
free MMO has been recommended as an outcome
measurement in clinical trials on TMD (Carmeli et al., 2001;
Blanco et al., 2006; Cuccia et al., 2010) and has been shown
to be a reliable clinical sign (Kropmans et al., 1999). In our
study, pain-free MMO significantly increased over time in
both groups; however, the effect of treatment over time
was significantly greater in terms of an increase in pain-free
MMO in the MTeHPT group in comparison with the HPT
group. According to Kropmans et al. (2000), 9 mm of SDD is
used to determine the clinical effectiveness of an inter-
vention with regard to pain-free MMO in patients with TMD.
The increase in pain-free MMO after the treatment period
was clinically relevant in the MTeHPT group as it exceeded
the recommended SDD score (4.4 and 10.0 mm in the HPT
and MTeHPT groups, respectively), supporting the clinical
effectiveness of treatment in the MTeHPT group.
Our findings are in agreement with those from other
studies, indicating the effectiveness of MT with exercise in
patients with TMD. Nicolakis et al. (2001) demonstrated an
overall decrease in pain and improvement in function after
treatment in patients with anterior disc displacement with
reduction. The treatment included manual joint distrac-
tion, disc/condyle mobilization and posture correction.
Carmeli et al. (2001) compared the benefit of repositioning
splints and manual mobilization combined with exercise for
anterior disc displacement and found mobilization with
exercise more effective than splints alone.
There are factors in this study that justify the
improvements observed in the MTeHPT group. MT may
influence pain modulation through neurophysiological
effects and may influence mobility through a neuromus-
cular mechanism (Gross et al., 1996). A treatment session
tends to motivate a patient to be more compliant with the
exercises. In our study, subjects in the MTeHPT group
attended 12 MT sessions by meeting the physical therapist
three times per week. These sessions had positive effects
on the subjects. First, the physical therapist could assess
the signs and symptoms at each phase of the recovery
process. Second, proper instruction and interaction by the
physical therapist can exert positive psychological effects
on the subjects, thus alleviating their symptoms to
a certain extent. Last, as stated by Feine and Lund (1997),
those groups who received more treatment modalities
showed better results than those who received fewer.
There are limitations to our study. First, the study design
did not allow for an evaluation period longer than four
weeks. Second, we did not assess the subjects compliance
level with the recommended treatments. Third, our TMD
subjects had myofascial pain with or without limited
opening and/or anterior disc displacement with reduction.
307
Future research is necessary for investigating the long-term
effects of MTeHPT and HPT alone in homogeneous TMD
populations; these studies should include assessment of the
subjects compliance levels as well.
Conclusion
In the short term, manual therapy in conjunction with home
physical therapy is more effective than home physical
therapy alone for the treatment of TMD, particularly with
regard to decreasing pain and increasing pain-free
maximum mouth opening.
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