物理治療與咬合板治療對於顳顎關節障礙相關之肌筋膜疼痛的療效比較

Abstract

顳顎關節障礙之盛行率為20%~60%，其中大多數患者屬於「肌筋膜疼痛亞型」。由於顳顎關節區域之肌筋膜疼痛，可能源自咀嚼肌或是顳顎關節之病理變化，故本研究使用「顳顎關節障礙相關之肌筋膜疼痛」一詞，以指稱續發於顳顎關節發炎，且發炎症狀緩解後仍未消失的肌筋膜疼痛。 傳統治療顳顎關節相關之肌筋膜疼痛的方法包括藥物、局部肌肉注射以及咬合板。除此之外，物理治療是最常接受牙科醫師轉介處理顳顎關節障礙之專業。各種單一物理治療介入的療效已有研究探討，其中徒手肌筋膜放鬆術具有顯著的立即效果，但長期療效卻不得而知；目前臨床上，通常執行一組包含各種介入方法的物理治療計畫，結合徒手肌筋膜放鬆術與運動治療的介入計畫，其療效亦有待證明。故本研究的目的在於比較整合型物理治療與咬合板治療對於顳顎關節障礙相關之肌筋膜疼痛的療效。 本研究設計為前瞻性隨機分組臨床試驗，於臺大醫院顳顎關節特別門診，徵召49名患有顳顎關節相關之肌筋膜疼痛的女性病患進行研究，最後共有41名受試者完成治療與追蹤。受試者隨機被分入「物理治療組」與「咬合板組」。物理治療組接受一週兩次的治療，內容包含徒手肌筋膜放鬆術以及運動治療；咬合板組則於每天睡覺時，配戴客製化之咬合板。兩組的治療週期皆為八週。 本研究主要成果評量為疼痛狀況，包括主觀疼痛與客觀疼痛。前者以疼痛視覺類比量表(visual analogue scale, VAS)測量，後者則以壓痛閾值(pressure pain threshold, PPT)測量。次要成果評量包括主動與被動最大開口量、嚼肌韌度(stiffness)、最大咬力、閉口肌重複動作次數(repetitions of bite)以及生活品質。各個項目在分組前進行初評，於八週治療結束時後測。物理治療計畫組另於開始治療後第四週與第十二週，進行追蹤。各項結果以SPSS第十三版進行統計分析，兩組基本資料以敘述性統計表示，成果評量以2-way ANOVA或Mann-Whitnney U test比較兩組於治療後的差異，組內治療前後差異以paired t-test或Wilcoxon signed-rank test分析。p值小於0.05被視為有統計上顯著差異。未完成追蹤者之資料，以最後一次測得之結果納入分析。 經過八週的治療，所有參與者在生活品質的能量與疲乏層面、社交功能層面與疼痛層面有顯著進步(p<0.05)。物理治療組與咬合板組相比，在整體健康狀況有較顯著的進步(p<0.05)，並在主觀疼痛狀況及情緒問題造成之角色限制，有組內之顯著進步(p<0.05)。其餘成果評量，包括客觀疼痛狀況、最大開口量、嚼肌韌度、最大咬力及閉口肌重複動作次數，兩組參與者於治療前後並無顯著差異。 總結本研究結果，物理治療與咬合板治療對於顳顎關節障礙相關之肌筋膜疼痛患者在生活品質的疲乏、社交功能與疼痛層面有相同療效；物理治療計畫在整體健康狀況層面有較好的療效，並對主觀疼痛有顯著改善。

The prevalence of temporomandibular disorders (TMD) is 20 to 60%. Most patients suffer from myofascial pain (MFP) subtype of TMD. Since the MFP can be resulted from pathologies of masticatory muscles as well as temporomandibular joints (TMJs), the term ‘TMD-related MFP’ will be used in the study to indicate MFP secondary to TMJ inflammation with subsided primary symptoms. To treat TMD-related MFP, dentists may use medication, local muscle injection or oral appliance. They also refer the patients to physical therapists frequently. Many physical therapy (PT) modalities and techniques are applied on these patients. The effectiveness of single PT approach is well studied. However, previous studies only confirmed the immediate effect of manual myofascial release. It is worthwhile to investigate the long-term effect of this technique on patients with TMD-related MFP. Since physical therapists usually treat patients with program which consists of passive and active approach, the effect of program consisting of manual myofascial release and exercise also needs investigation. Therefore, the purpose of this study is to compare the effect of PT intervention and oral appliance on subjects with TMD-related MFP. This study was a prospective randomized controlled trial. Forty-nine women with TMD-related MFP were recruited from TMJ special clinic of National Taiwan University Hospital (NTUH) and 41 of them completed intervention course and follow-up. After pre-intervention evaluation, the subjects were randomly allocated into ‘PT program group’ (PT group) or ‘oral appliance group’ (Splint group). Subjects in PT group visited physical therapists twice per week to receive manual myofascial release and exercise therapy. Those in Splint group received a custom-made fabricated appliance and wore it during night every day. The treatment duration was 8 weeks for both groups. Post-intervention evaluation was performed after intervention for both groups. Subjects in PT group received additional follow-up evaluation at the fourth week of intervention and 4 weeks after intervention completion. Primary outcomes were subjective and objective pain status. Visual Analog Scale (VAS) was used for subjective pain status measurement and pressure pain threshold (PPT) was used for objective one. Secondary outcomes were active and passive maximal mouth opening range (AMMO and PMMO), stiffness of masseter taut band, maximal bite force, repetitions of bite, as well as Quality of Life (QoL). Statistical analyses were performed by SPSS 13.0. Descriptive statistics was used for presenting the basic data. Two-way ANOVA was used to investigate the group by time effect. Nonparametric between group comparisons was investigated through Mann-Whitney U test. The paired t-test or Wilcoxon signed-rank test was used to investigate the pre- to post-intervention effect. All analyses were tested with a significance level of p<0.05 by using the intention to treat principle. After intervention, there were time effects on energy/ fatigue, social functioning and pain domain of QoL in patients with TMD-related MFP (p<0.05). Physical therapy had significant better effect on general health domain of QoL (p<0.05). There was also significant pre- to post-intervention improvement on subjective pain status in PT group. However, there was no significant difference of other outcomes between or within groups. In conclusion, the present study suggests that physical therapy program has the same and even superior effect comparing oral appliance on TMD-related MFP. However, these results should be interpreted with caution, considering the limitation such as small power and effect size.