Treatment of Temporomandibular Pain and Disorders With Applied Relaxation Trained Using a Web Application- a Randomized Controlled Trial

Background and significance More than 30% of people worldwide suffer from chronic pain, which causes human suffering for the individual and burdens the society financially. Musculoskeletal diseases are the most functionally impairing diseases in Europe. Masticatory muscle/jaw joint pains and dysfunctions (temporomandibular disorders, TMD) located in the face and head area are the second most common musculoskeletal pain conditions after low back pain. Various biopsychosocial risk factors, such as stress, depressive symptoms, anxiety, and sleep problems are related to chronic pain, including TMD pain. On the other hand, treating sleep disorders can also alleviate pain. Psychological stress and disturbances in the regulation of the pain mechanism related to chronic pain can manifest as dysfunction in the autonomic nervous system (ANS) activity. Compared to healthy people, TMD patients have impaired response of the ANS activity as indicated by higher heart rate, lower heart rate variability and lower baroreflex. Oral prafunctions, such as awake bruxism (tooth clenching during awakefulness) are also common in individuals with TMD and may share common psychosocial background factors with TMD, such as somatic symptoms, depression and anxiety.

Treatment of TMD aims to relieve pain and improve function. Usual treatment methods are counselling and guidance, muscle exercises, manual therapy, and occlusal splint therapy. Motivation and activation of the patient instead of the patient "receiving" passive treatment is important. Structured self-care methods should also be developed and evaluated considering cost-effectiveness. The Current Care Guidelines of pain emphasize the use of patient's own coping strategies. Relaxation training is mentioned as one of these methods, in addition to information, cognitive coping methods, and physical exercises.

Applied relaxation (AR) is a self-management method developed on the basis of Jacobson's progressive relaxation. The method is based on step-by-step training during a six-week programme where the person gradually learns the skill of relaxing his/her body in about 30 seconds. Learning this skill can be compared, for example, to learning to ride a bicycle, where the skill eventually becomes automatic.

AR has been used in treatment of various psychological and somatic conditions, such as anxiety disorders, panic disorders, dental fear, stress problems, gynaecological pain problems, tinnitus, musculoskeletal pains, as well as TMD symptoms, based on a previous randomised controlled trial. As a method that activates the patient and is easy to use independently, AR has several advantages compared to other coping or imagination-based methods. The patient is guided to control his/her reactions and sensations of the ANS by relaxing the body and/or muscle groups. The time needed for relaxation gradually decreases from 20 minutes to less than a minute and transforms from conscious to unconscious through active practice. This method is generally used in the treatment of chronic pain, mostly in specialised medical care units in group meetings under the guidance of a health care professional. There is a need for digital technology for training of AR, which could target it at a wider group of patients.

For training of AR a web application, named Relappy, was developed in University of Oulu and Oulu University Hospital in company collaboration as well as using the expertise on the field of psychology. The Relappy contains instructions, self-instructed exercises and exercise diaries for independent training of AR.