Objective We explored the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD). Design Systematic review and network meta-analysis of randomised clinical trials (RCTs). Data sources MEDLINE, EMBASE, CINAHL, CENTRAL, and SCOPUS were searched to May 2021, and again in January 2023. Study selection Interventional RCTs that enrolled patients presenting with chronic pain associated with TMD. Data extraction and synthesis Pairs of reviewers independently identified eligible studies, extracted data, and assessed risk of bias. We captured all reported patient-important outcomes, including pain relief, physical functioning, emotional functioning, role functioning, social functioning, sleep quality, and adverse events. We conducted frequentist network meta-analyses to summarise the evidence and used the GRADE approach to rate the certainty of evidence and categorise interventions from most to least beneficial. Results 233 trials proved eligible for review, of which 153—enrolling 8713 participants and exploring 59 interventions or combinations of interventions—were included in network meta-analyses. All subsequent effects refer to comparisons with placebo or sham procedures. Effects on pain for eight interventions were supported by high to moderate certainty evidence. The three therapies probably most effective for pain relief were cognitive behavioural therapy (CBT) augmented with biofeedback or relaxation therapy (risk difference (RD) for achieving the minimally important difference (MID) in pain relief of 1 cm on a 10 cm visual analogue scale: 36% (95% CI 33 to 39)), therapist-assisted jaw mobilisation (RD 36% (95% CI 31 to 40)), and manual trigger point therapy (RD 32% (29 to 34)). Five interventions were less effective, yet more effective than placebo, showing RDs ranging between 23% and 30%: CBT, supervised postural exercise, supervised jaw exercise and stretching, supervised jaw exercise and stretching with manual trigger point therapy, and usual care (such as home exercises, self stretching, reassurance). Moderate certainty evidence showed four interventions probably improved physical functioning: supervised jaw exercise and stretching (RD for achieving the MID of 5 points on the short form-36 physical component summary score: 43% (95% CI 33 to 51)), manipulation (RD 43% (25 to 56)), acupuncture (RD 42% (33 to 50)), and supervised jaw exercise and mobilisation (RD 36% (19 to 51)). The evidence for pain relief or physical functioning among other interventions, and all evidence for adverse events, was low or very low certainty. Conclusion When restricted to moderate or high certainty evidence, interventions that promote coping and encourage movement and activity were found to be most effective for reducing chronic TMD pain. Registration PROSPERO (CRD42021258567) Details of the characteristics of the included studies were shared in the supplementary materials. The study specific data included in the meta-analysis can be obtained from the first author at yaol12@mcmaster.ca.

中文翻译：

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颞下颌疾病继发慢性疼痛的治疗：随机试验的系统评价和网络荟萃分析


目的 我们探讨了与颞下颌关节紊乱 (TMD) 相关的慢性疼痛的现有疗法的比较效果。设计随机临床试验（RCT）的系统回顾和网络荟萃分析。数据源 MEDLINE、EMBASE、CINAHL、CENTRAL 和 SCOPUS 的检索时间截至 2021 年 5 月，并于 2023 年 1 月再次检索。研究选择 介入性随机对照试验，纳入了患有 TMD 相关慢性疼痛的患者。数据提取和综合 成对的评审员独立识别合格的研究、提取数据并评估偏倚风险。我们记录了所有报告的对患者重要的结果，包括疼痛缓解、身体功能、情绪功能、角色功能、社交功能、睡眠质量和不良事件。我们进行了频率论网络荟萃分析来总结证据，并使用 GRADE 方法来评估证据的确定性，并将干预措施从最有益到最不有益进行分类。结果 233 项试验被证明符合审查资格，其中 153 项试验（招募 8713 名参与者并探索 59 种干预措施或干预措施组合）被纳入网络荟萃分析。所有后续效果均指与安慰剂或假手术的比较。八种干预措施对疼痛的影响得到了高到中等确定性证据的支持。对于缓解疼痛最有效的三种疗法是认知行为疗法 (CBT)，辅以生物反馈或放松疗法（风险差 (RD)，用于在 10 厘米视觉模拟量表上实现 1 厘米疼痛缓解的最小重要差异 (MID)） ：36%（95% CI 33 至 39））、治疗师协助下颌活动（RD 36%（95% CI 31 至 40））和手动触发点治疗（RD 32%（29 至 34））。 五种干预措施的效果较差，但比安慰剂更有效，显示 RD 范围在 23% 至 30% 之间：CBT、监督姿势运动、监督下颌运动和拉伸、通过手动触发点治疗进行监督下颌运动和拉伸以及常规护理（例如如家庭锻炼、自我伸展、安慰）。中等确定性证据表明，四种干预措施可能改善身体功能：监督下颌运动和伸展（在简短形式 36 身体成分总分上达到 5 分的 MID 的 RD：43%（95% CI 33 至 51））、操纵（ RD 43%（25 至 56））、针灸（RD 42%（33 至 50））以及监督下颌运动和活动（RD 36%（19 至 51））。其他干预措施中疼痛缓解或身体功能的证据以及不良事件的所有证据的确定性较低或非常低。结论 当仅限于中等或高度确定性证据时，促进应对和鼓励运动和活动的干预措施被发现对于减轻慢性 TMD 疼痛最有效。注册 PROSPERO (CRD42021258567) 补充材料中分享了纳入研究的详细特征。荟萃分析中包含的研究具体数据可以通过第一作者 yaol12@mcmaster.ca 获得。