Journal of Bodywork and Movement Therapies
MYOFASCIAL PAIN AND TREATMENT | VOLUME 28, P104-113, OCTOBER 01, 2021
Mythili Kalladka
Published: August 07, 2021
DOI:https://doi.org/10.1016/j.jbmt.2021.07.015
Abstract
Objectives
Temporomandibular disorders (TMDs) are an umbrella term encompassing disorders of both the temporomandibular joint (TMJD) and masticatory musculature (MMD). The objective of this review is to provide an overview of the etiopathogenesis, clinical features and diagnosis of MMD, and to summarize the current trends in the therapeutic management.
Methods
A review of the literature was performed from 1985 to 2020. The keywords included were “temporomandibular disorders OR temporomandibular joint disorders” AND “myofascial pain OR masticatory myofascial pain OR trigger point”. A total of 983 articles were screened with abstracts and approximately 500 full text articles were included in the review based on their relevance to the topic.
Results
MMD’s present significant challenges in diagnosis and treatment. Effective treatment requires a clear diagnosis based on an understanding of pathophysiologic mechanisms, a detailed history with assessment of predisposing local and systemic factors, perpetuating factors, a comprehensive clinical evaluation and a diagnostic workup.
Conclusion
A thorough history and clinical examination are the gold standards for diagnosis of MMD. Serological testing may help identify underlying co-morbidities. Recent diagnostic modalities including ultrasound sonoelastography and magnetic resonance elastography (MRE) have shown promising results. The treatment goals for MMD are to control pain, restore mandibular function and facilitate the return to normal daily activity and improve the overall quality of life of a patient. Conservative modalities including home care regimens, pharmacotherapy, intraoral appliance therapy, local anesthetic trigger point injections, physiotherapy and complementary modalities may be beneficial in patients with MMD’s.
From Table 1. – Table depicting management strategies for myofascial pain and Fibromyalgia.
Non Pharmacologic Management:
Patient education, home care regimen and home care exercises
Intra oral appliance therapy
Injections and dry needling
Physiotherapy
Complementary therapy
Biofeedback
Cognitive behavioural therapy
Exercises
Acupuncture
Home care regimen and exercises
Evidence based recommendations by an expert panel concluded that at present there is insufficient scientific evidence to make clinical practice recommendations. However, they conditionally recommended ginger, curcuma, Avocado soybean unsaponifiables, polyunsaturated fatty acids, melatonin, capsaicin, glucosamine (prescription Rx), and vitamin D.
Physiotherapy
A treatment plan can initially include 6-8 sessions of physical therapy followed by more if needed. A combination of strengthening exercises, pain relief exercises, joint mobilization, soft tissue techniques and low impact aerobic training are often beneficial to reduce pain in both short and long term. Physiotherapy modalities can include but not limited to manual release, dry needling, manual release and low level laser therapy, myofascial release, deep tissue massage, ischemic compression and TMJ mobilization. Manual therapy aims to improve range of motion and perfusion, and much of it can be done as part of a home care regimen. Opening and excursive mandibular movements can be done in combination with massage of the masticatory muscles. Thermal compresses can also be combined with the same mandibular stretches. Studies have shown that manual therapy alone may be better than home therapy, counselling and no treatment (de Melo et al., 2020). A meta analysis of two studies on symptomatic patients with latent TrP in the jaw muscles suggested that manual therapy may improve range of motion in these subjects and reduce pain (Webb and Rajendran, 2016). A systematic review and meta-analysis concluded that manual therapy alone or in combination with jaw exercises and cervical exercises may be beneficial and had promising results (Armijo-Olivo et al., 2016). Another systematic review of randomized controlled trails concluded that manual therapy may improve maximum mouth opening, pain pressure threshold, and pain (Calixtre et al., 2015). A systematic study comparing manual release acupuncture and cupping for myofascial pain suggested that manual release may have a moderate effect, whereas the other 2 modalities may not be better than sham (Charles et al., 2019). Post intervention kinesio taping has been recommended to relieve pain and improve range of motion (Zhang et al., 2019). Evidence suggests that low level laser therapy may have a moderate benefit in chronic neck pain (Skelly et al., 2020). However, the evidence from a systematic analysis is inconclusive due to study heterogeneity and risks of bias (Kadhim-Saleh et al., 2013).
Complementary Therapy
Acupuncture. A systematic review on acupuncture in TMD suggests it may provide an efficacy similar to occlusal splints, and in spite of weak evidence it may be helpful in myofascial TMD (Fernandes et al., 2017). Another systematic review and meta analysis suggests limited evidence for the use of acupuncture for symptomatic TMD (Jung et al., 2011). In patients with chronic neck pain, acupuncture has a low degree of evidence suggesting it may provide short and moderate term improvement in function, but compared to sham it did not provide significant pain relief (Skelly et al., 2020). A recent meta-analysis suggests a moderate degree of evidence exists for the effectiveness of acupuncture in head and neck myofascial pain, and suggests that it may be a safe alternate for pain relief in these conditions (Farag et al., 2020). Acupuncture may be used in combination with other pain-relieving modalities, and further well designed RCTs are essential to draw definitive conclusions on their efficacy and safety (Li et al., 2017). Electroacupuncture is also being used, and studies report it be better when compared to TENS for pain relief (Ahmed et al., 2019b). Acupuncture is contraindicated in bleeding disorders, drug intoxication, patients with pacemakers, seizure disorders and skin infections. Exercise has been proven to be beneficial in improving pain and function in the short term, and function in the long term, in patients with chronic neck MMD. The combination of stretching and strengthening exercises may have additional benefits (Mata Diz, de Souza, Leopoldino and Oliveira, 2017). A study by Nasri et al. reported that chronic masticatory pain patients with reduced pain modulation may exhibit a delayed hypoalgesia to mechanical stimulation following nonstrenuous aerobic exercises (Nasri-Heir et al., 2019). Patients with chronic masticatory muscle pain exhibit enhanced mechanical temporal summation and less efficient exercise induced hypoalgesia. Following non-strenuous aerobic exercises, patients with chronic masticatory muscle pain exhibited delayed response to mechanical stimulation in contrast to healthy controls, where there was immediate and persistent reduction in mechanical temporal summation. It has been suggested to be through endogenous pain modulation system and primarily by activation of opioid, cannabinoid, dopaminergic, serotonergic and noradrenergic pathways (Nasri-Heir et al., 2019). Yoga, meditation, massage, tai-chi, cognitive behavioural therapy, mindfulness practices, and mind-body practices have been proven to be beneficial with significant improvements in pain, function, mood disorders, sleep in several chronic pain conditions (Lorenc et al., 2018; Skelly et al., 2020). Specific to TMDs, CBT and home care have similar effects on improvement of pain and function. However, CBT fared significantly better for patients with depression and activity interference, and combined with standard treatment it provided better pain relief than standard care alone. Intra oral myofascial therapy was also suggested to be beneficial in TMD patients s for improvement of pain and limitation (Randhawa et al., 2016).