Telerehabilitation effectiveness for iIndividuals with temporomandibular disorders

Abstract

Background: Temporomandibular joint disorders (TMD) are the second most common musculoskeletal cause of pain and disability. Physical therapy (PT) is an effective treatment, but patients report difficulty accessing high quality care. Telehealth delivery increases access to care, but whether or to what extent telerehabilitation (TR) can effectively deliver care for this population is unknown.Objectives: 1. Determine PT diagnostic reliability for in-person (IP) and TR diagnosis of TMD; 2. Determine noninferiority of telerehabilitation for individuals with TMD as compared to in-person PT; and 3. Explore telerehabilitation feasibility and long-term outcomes. Methods: After ethical approval, 207 patients with TMD ages 18-69 chose telehealth (n=113) or in-person (n=94) PT in this open-label prospective cohort noninferiority trial. Telehealth adaptations included guiding patient self-assessment with verbal instructions and visual cues. The PT diagnosis of masticatory myalgia was compared to Orofacial Pain (OFP) specialist clinical diagnoses (reference) to calculate diagnostic agreement in each group using percent agreement and prevalence-adjusted bias-adjusted kappa (PABAK). After 6 weeks of individualized PT treatment, the difference between the proportion of therapy responders in each group was compared to a 10% noninferiority margin. The acceptability, practicability, effectiveness, affordability, side effects/safety, and equity (APEASE) criteria characterized feasibility using data from a post-discharge qualitative questionnaire. Results: 200 participants completed the PT evaluation (TR=106, IP=94) and 89 participants completed 6-week questionnaires. Both groups had 95% raw agreement and almost perfect diagnostic agreement between PT and reference diagnosis of masticatory myalgia (IP PABAK=0.89[0.76,0.97]; TR PABAK=0.91[0.79,0.97]). The proportion of 6-week therapy responders in each group was TR = 73(62,82)% and IP=62(51,72)% with a small effect size for TR (h=0.30) and the difference between group proportions was 11(-2,25)%. Intervention evaluation revealed that it satisfied each APEASE criterion for the 11 participants who gave qualitative feedback. Conclusion: Telediagnosis of TMD by a PT was reliable, and after 6 weeks TR was effective and noninferior to IP care according to quality-of-life improvement. Patients demonstrated willingness to engage in TR with higher numbers preferring remote care delivery. Clinically these results show that TR is a viable and desirable care option for this population to increase accessibility for patients with TMD.