Abstract
Background:
The present study was conceptualized as a pilot study to examine the effects of a 3-week program consisting of strain/counterstrain technique (SCST), phonophoresis, heat therapy, and stretching exercises on pain and functions in patients with temporomandibular dysfunction (TMD).
Methods:
Seven participants (mean age 25.85 years) diagnosed with TMD having pain in the temporomandibular joint (TMJ) area with decreased jaw opening were recruited for the study. Treatment interventions consisting of SCST, phonophoresis (ultrasound gel mixed with diclofenac gel), heat therapy, and stretching (mouth-opening) exercises were performed 3 days a week for 3 weeks. SCST was performed on the masseter, medial, and lateral pterygoid muscles. No control group was present in the study.
Results:
Paired samples t test revealed a significant difference in numerical pain rating scale (NPRS) (decreased by 50%, P < .001) and jaw functional limitation scale (JFLS) (reduced by 59.58%, P < .001) scores after 3 weeks of intervention. A large effect size (Cohen d = −3.00 for NPRS and −3.16 for JFLS) was observed for both variables. No correlation (R = 0) was found between the baseline values of NPRS and JFLS.
Conclusion:
A 3-week program consisting of SCST, phonophoresis, heat therapy, and stretching exercises was effective in reducing the pain and improving the functions related to TMJ in patients suffering from TMD. However, a randomized controlled trial is needed to reach a definite conclusion.
Keywords: exercises, functions, mouth-opening, pain, ultrasound
1. Introduction
The mandibular condyle and temporal bone articular surfaces form the temporomandibular joint (TMJ), a compound articulation.[1] The muscles used for mastication include the lateral pterygoid, medial pterygoid, masseter, and temporalis. Mandibular closure and bite forces are principally controlled by the medial pterygoid, masseter, and temporalis muscles, whereas mandibular opening is controlled by the lateral pterygoid and infrahyoid muscles.[1] Temporomandibular dysfunction (TMD) refers to a group of masticatory system problems roughly categorized into muscle and temporomandibular joint issues.[2] TMD is a widespread condition that affects up to 60% to 70% of people.[3] Broadly speaking, TMD refers to pain that affects the TMJ and its associated structures, as well as joint dysfunction itself.[2] The primary muscles of mastication, that is, the lateral pterygoid, medial pterygoid, temporalis, and masseter, are involved in TMD.[2] Although the causes of TMD are not fully understood, it is likely to involve a number of pathophysiological, psychological, and anatomical variables. Fatigue, tension, or spasm in the masticatory muscles can cause myofascial disorders.[2] TMD is most frequently caused by musculoskeletal dysfunction.[4] Masticatory muscle pain and spasm may be caused by stress, anxiety, aberrant posture, bruxism, teeth grinding, or clenching. Cognitive and psychological disturbances, like anxiety and depression, fibromyalgia, autoimmune illnesses, and other chronic pain conditions usually accompany TMD.[5]
The strain/counterstrain technique (SCST) was developed by Jones (1981).[6] He discovered that tender points would become less sensitive with careful positioning of the patient and the affected area.[7] It is one of many therapeutic methods in which body posture is used to elicit a therapeutic outcome. In SCST, the affected muscle is placed in a comfortable and shortened position to lessen the excessive impulse from the spindle muscles.[8] According to Dardzinski et al,[9] patients with localized muscle pain may find the SCS approach beneficial for lowering pain and enhancing function. The SCST has been shown to be beneficial in decreasing the mechanical pain sensitivity of tender points in the upper trapezius muscle by Atienza-Meseguer et al[10] According to Rodrguez-Blanco et al,[11] a single session using the SCS approach over latent myofascial trigger points in the masseter muscle slightly increases active mouth opening. Rather than moving a dysfunctional joint into a motion restriction, the SCS approach passively moves it to a position of comfort.[12]
Ultrasound therapy (US) is also one of the therapies that can be used to treat TMD. One old study performed on 100 patients with TMD reported that TMJ dysfunction and related muscle spasm symptoms could not be effectively treated with the therapeutic US alone.[13] One recent study compared the home exercise program alone with the home exercise program along with the US for TMD patients. That study concluded that home exercises, along with the US, were more effective than home exercises alone in relieving pain and increasing mouth opening.[14] One study by Elgohary et al[15] concluded that the US could be used as an adjunct in treating TMJ pain. Therefore, these studies suggest that the US should be used along with other interventions. Several medications (e.g., diclofenac, aceclofenac gel) can be mixed with US gel, a process called phonophoresis, to get additional benefits from medicines for treating joint disorders. Heat therapy is also used for the treatment of TMD. Several benefits of heat application were reported, like reduced discomfort, muscle tension, increased mouth opening, and enhanced mandibular function in TMD patients.[16] Stretching exercises (mouth opening) are also performed to treat TMD.[17]
No study has evaluated the effects of a program consisting of SCST, phonophoresis, heat therapy, and stretching exercises on patients suffering from TMD. Therefore, the present study was conceptualized as a pilot study to examine the effects of this program on pain and function in patients with TMD. The study objective was to examine the effects of a program consisting of SCST, phonophoresis, heat therapy, and stretching exercises on pain and function in patients with TMD. The study hypothesized that a program consisting of SCST, phonophoresis, heat therapy, and stretching exercises significantly affects pain and function in patients with TMD.
2. Methods
2.1. Study design, participants, and eligibility criteria
This study was a pilot study with a quasi-experimental design; therefore, seven participants (mean age 25.85 years, 3 males and 4 females) diagnosed with unilateral temporomandibular joint dysfunctions by a medical practitioner were recruited for the study. Participants with pain in the unilateral TMJ area and decreased jaw opening were recruited for the study. Participants were recruited from the Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Ambala, India. The demographic details of the participants are presented in Table 1. Participants with cervical pain, cervical spondylosis, osteoporosis, or a history of surgery or trauma around the TMJ were excluded from the study.
Table 1.
Demographic data of participants (n = 7), dependent variables data, and P values for the Shapiro–Wilk test of normality.
| Variables | Mean ± SD | P value (Shapiro–Wilk) |
|---|---|---|
| Age (yr) | 25.85 ± 6.38 | |
| Weight (kg) | 63.57 ± 8.58 | |
| Height (m) | 1.64 ± 0.12 | |
| BMI (kg/m2) | 23.44 ± 2.17 | |
| Pre_JFLS (points) | 34.28 ± 9.39 | .141 |
| Post_JFLS (points) | 13.85 ± 5.42 | |
| Pre_NPRS (points) | 6.00 ± 0.81 | .144 |
| Post_NPRS (points) | 3.00 ± 0.81 |
JFLS = jaw functional limitation scale, NPRS = numerical pain rating scale.
2.2. Ethical consideration, informed consent, and clinical trial registration
Ethical approval was obtained from the institutional ethical committee of the Maharishi Markandeshwar Institute of Medical Sciences & Research, India (file id: IEC/MMDU/1549). The study conformed to “The Code of Ethics of the World Medical Association (Declaration of Helsinki).” Before the start of the intervention, each participant was given a description of the study protocol, risks, and benefits. Written informed consent was obtained from each participant. The study was prospectively registered in the Clinical Trials Registry—India (id: CTRI/2021/01/030209; dated: 04/01/2021). Participants were recruited from January 2021 to May 2021.
Independent variables: a program consisting of SCST, phonophoresis, moist heat therapy, and stretching exercises was the independent variable.
2.3. Outcome measures (dependent variables)
Numerical pain rating scale (NPRS): This 11-point scale allows participants to rate their pain level on a scale of 0 to 10, where 0 indicates no pain and ten indicates pain as bad as it can be.[18]
Jaw Functional Limitation Scale (JFLS): This scale measures the global functional limitation of the jaw and consists of 8 tasks. Each task is graded from 0 to 10 according to the level of difficulty faced by the participants in performing that task, where 0 indicates no limitation and 10 indicates severe limitation.[19]
Study protocol: The baseline measurement of the outcome variables was obtained before and after the application of the 3-week intervention.
Treatment intervention: This included SCST, phonophoresis, moist heat therapy, and stretching exercises. The treatment intervention was performed 3 days a week for 3 weeks.
-
1.
Strain/counterstrain technique (SCST):
-
A.
Masseter muscle: For this, the participants were made to lie in a supine position. The physical therapist (PT) palpated the tender point on the anterior border of the masseter muscle and the anterior edge of the ascending ramus of the mandible by pushing posteriorly. Then the masseter muscle is shortened by pushing the patient jaw toward the side of the tender point until the pain is maximally reduced. This position was held for 90 seconds. After a rest of 5 seconds, the PT slowly returns the patient jaw to its neutral position.
-
B.
Medial pterygoid muscle: The PT sat behind the participants. The PT pushed the opened jaw slightly lateral, away from the treatment position side. They applied stabilizing force on the opposite side of the forehead with the forearm until the pain was maximally reduced after holding the position for 90 seconds and taking 5 seconds of rest. The therapist slowly returns the patient jaw to its neutral position.
-
C.
Lateral pterygoid muscle: The participant was made to lie in a supine position. The PT stood behind the participant. Then PT located the tender point below the zygomatic arch, 1 cm anterior to the neck of the condyle. The PT protruded the participant jaw forward to open it laterally to the side opposite the tender point while stabilizing the participant head. The PT held this position for 90 seconds, and then a rest of 5 seconds was given. While gently monitoring the tender point, the participants slowly returned to the neutral position.
-
A.
-
2.
Phonophoresis: Participants were made to sit on a stool, and the area over the TMJ was cleaned. The ultrasonic gel was applied to the US transducer head along with the diclofenac gel. US therapy was given with a 1 MHz frequency and 1.5 watts/cm2 for 10 minutes.
-
3.
Moist heat therapy: a hydrocollator pack was applied to the patient in a supine position over the TMJ region for 7 to 10 minutes.
-
4.
Stretching (mouth opening) exercise: Participants were asked to start a movement from a closed mouth position. They then relaxed the jaw slowly and gently to open the mouth as wide as possible. They were instructed to hold their mouth in this position for 20 to 30 seconds. This had to be repeated 3 to 5 times daily, 3 days a week, for 3 weeks.
2.4. Statistical analysis
Data from 7 participants suffering from TMD were analyzed using SPSS statistical software version 26 (SPSS Inc., Chicago, IL). The normality of the baseline data of dependent variables (NPRS and JFLS) was assessed using the Shapiro–Wilk test of normality, which revealed a normal distribution (P > .05). Therefore, a paired samples t test was used to compare the difference in baseline and post-intervention values of the NPRS and JFLS. The effect size was calculated using Cohen d. The Pearson correlation coefficient (r) was calculated to find an association between NPRS and JFLS scores. The Pearson correlation coefficient (r) was interpreted as follows: between 0 and 1 as a positive correlation, 0 as no correlation, and between 0 and −1 as a negative correlation. To test the hypothesis of this study, P ≤ .05 was considered significant.
3. Results
The demographic details of the participants are presented in Table 1. The paired samples t test revealed a significant difference in NPRS (P < .001) and JFLS (P < .001) scores after 3 weeks of intervention, as shown in Table 2. NPRS and JFLS scores decreased by 50% and 59.58%, respectively. A large effect size (Cohen d = −3.00 for NPRS and −3.16 for JFLS) was observed for both variables. No correlation (R = 0) was found between the NPRS and JFLS baseline values, as shown in Table 3. A weak negative (r = −0.188), not significant (P > .05) correlation was found between the post-intervention scores of the NPRS and JFLS.
Table 2.
Paired samples test results for both variables.
| Mean | Std. deviation | t | df | P value | Effect size | |
|---|---|---|---|---|---|---|
| Post_JFLS - Pre_JFLS | −20.42 | 6.45 | −8.37 | 6 | <.001* | −3.16 |
| Post_NPRS - Pre_NPRS | −3.00 | 1.00 | −7.93 | 6 | <.001* | −3.00 |
JFLS = jaw functional limitation scale, NPRS = numerical pain rating scale.
Significant.
Table 3.
Correlation results.
| Pearson correlation coefficient (r) | P value | |
|---|---|---|
| Pre_NPRS and Pre_JFLS | 0.000 | 1.000 |
| Post_NPRS and Post_JFLS | −0.188 | .686 |
JFLS = jaw functional limitation scale, NPRS = numerical pain rating scale.
4. Discussion
The present study aimed to evaluate the effects of a 3-week program consisting of SCST, phonophoresis, heat therapy, and stretching exercises on pain and function in patients suffering from TMD. SCST was applied to the masseter, medial, and lateral pterygoid muscles. For phonophoresis, US was used with diclofenac gel. Stretching was performed through mouth-opening exercises. The effects of this program were evaluated on pain and functions related to TMJ. The pain and functions were assessed by measuring NPRS and JFLS, respectively. The results indicated that this 3-week program effectively improved pain and functional activities related to the jaw. Functional activities related to the jaw improved by 59.58%, and the pain in the TMJ was reduced by 50%. According to Mishra et al[20] and Rai et al,[21] for the treatment of TMD, no single method is more successful than any other. Therefore, a combination of several different treatment modalities was used in the present study.
SCST uses passive body positioning of dysfunctional joints and muscle spasms towards more comfortable postures that shorten or compress the troublesome structure.[22] In one case study, western massage techniques along with the SCST of the oral cavity, cervical region, and upper torso, for 3 weeks, reported reduced pain, jaw clicking, and increased jaw opening.[23] Another study by Calixtre et al[24] reported improvements in pressure pain threshold over the masseter and temporalis muscles where SCST was applied to trigger points and pressure biofeedback guided stabilization exercises were performed in myofascial TMD patients. However, the study by Blanco et al[11] did not report an increase in mouth opening in patients with latent myofascial trigger points following a single treatment of the SCST.
In the present study, SCST was used along with phonophoresis. The biological effects of US and the anti-inflammatory effects of diclofenac may have contributed to the pain relief obtained in the present study. The US energy is quickly attenuated in the air, so it must be effectively transported from the US transducer into the skin to be effective. The most effective coupling agents for transmitting the US waves are gel formulations.[25] A study by Shin and Choi et al[26] reported that only US did not significantly reduce TMJ pain. They reported reduced pain and improved pressure pain threshold after applying indomethacin phonophoresis over painful TMJ.[26] It has been suggested in previous reviews that TMD symptoms might be improved by administering an efficient medication to the TMJ.[27] When a medicine is administered using phonophoresis, it is transmitted to deep tissues using US energy, and the clinical outcome is related to the drug pharmacological activity.[26] Vijayalakshmi et al[28] used aceclofenac gel phonophoresis on TMD and concluded that it is effective and feasible in reducing symptoms of TMD.
A 0.5% triamcinolone acetonide gel was used by Yang et al[29] to evaluate the most efficient US frequency, intensity, and duty cycle for enhancing drug penetration through mouse skin. They concluded that the 1 MHz frequency demonstrated considerably more transport than the 3 MHz or its topical medication administration. Therefore, in the present study, a frequency of 1 MHz was used for the US.
Several theories explain the mechanism of action of phonophoresis. The US mechanically disturbs the absorbing media, and mechanical energy is continuously transformed into heat. This temperature shift is believed to facilitate phonophoretic medication distribution.[30] Cavitation, the formation of tiny gaseous inclusions, may also be linked to how the US affects a biological system. Cavitation may result in mechanical stress, an increase in temperature, or improved chemical reactivity that promotes drug transport.[26] Another theory suggests that the US affects the permeation through the skin by affecting the stratum corneum.[26] The local vasodilatation that results from the deep heating effect of the US enhances cell permeability and reduces pain.[27] In addition, acoustic pressure waves (non-thermal US effect) force the cells to vibrate rapidly and rupture the membrane, allowing the anti-inflammatory medication (diclofenac) to diffuse more readily.[28]
Moist heat therapy was also used in the present study to relieve symptoms. Previous literature has recommended heating the affected muscles in TMD.[31] Heat therapy is used to relieve pain, especially in subacute arthropathies and inflammatory rheumatic illnesses. It is reported to reduce intense pain, although the effects are often brief.[32]
Since the participants included in the present study had reduced jaw opening along with pain, stretching exercises, that is, mouth opening exercises, were also performed along with other modalities. Previously, positive effects of voluntary jaw-opening exercise have been suggested in patients with myogenic TMD.[33] It is reported that to promote mouth opening and reduce pain in TMD, range-of-motion exercises or passive and active muscle stretching are used.[34] This exercise stretches the jaw muscles and improves mouth opening.[35] One study showed that transcranial direct current stimulation and activities like manipulative stretching and self-training of mouth opening reduced pain severity and improved the range of the jaw opening in people with myogenic TMD.[36]
4.1. Limitations
Several potential limitations of the present pilot study need to be mentioned here. First, this was a pilot study where a control group could not be created due to the unavailability of a sufficient number of participants; therefore, we cannot reach a definite conclusion without a randomized controlled trial with a control group with a larger sample size. The improvements obtained in the present study may be short-lived, and the symptoms may return with the cessation of the treatment intervention. Therefore, future research should consider a long-term follow-up. Also, the improvements obtained in this pilot study were the cumulative effects of SCST, phonophoresis, heat therapy, and stretching exercises. Future research may find isolated effects of SCST, phonophoresis, heat therapy, and stretching exercises.
5. Conclusion
This pilot-level study concluded that a 3-week program consisting of SCST, phonophoresis, heat therapy, and stretching exercises was effective in reducing pain and improving the functions related to TMJ in patients suffering from TMD. A randomized controlled trial is feasible based on this pilot study results to further examine this program definite role in patients with TMD.
Acknowledgments
The authors are grateful to the Researchers Supporting Project number (RSP2023R382), King Saud University, Riyadh, Saudi Arabia for funding this research.
Author contributions
Conceptualization: Insha Azam, Faizan Z. Kashoo, Abdur Raheem Khan, Gurjant Singh.
Data curation: Insha Azam, Mohammed M. Alshehri, Abdur Raheem Khan.
Formal analysis: Ahmad H. Alghadir, Masood Khan, Mohammed M. Alshehri, Gurjant Singh.
Funding acquisition: Ahmad H. Alghadir.
Investigation: Gaurav Kapoor, Pooja Chaudhuri, Faizan Z. Kashoo, Mohammed M. Alshehri, Gurjant Singh.
Methodology: Insha Azam, Gurjant Singh.
Project administration: Aksh Chahal, Pooja Chaudhuri, Mohammad Abu Shaphe.
Resources: Gaurav Kapoor, Mohammad Abu Shaphe.
Software: Gaurav Kapoor.
Supervision: Aksh Chahal, Pooja Chaudhuri, Faizan Z. Kashoo, Vandana Esht.Validation: Pooja Chaudhuri, Vandana Esht.
Visualization: Aksh Chahal, Gaurav Kapoor, Vandana Esht.Writing – original draft: Insha Azam, Masood Khan, Faizan Z. Kashoo, Abdur Raheem Khan.
Writing – review & editing: Ahmad H. Alghadir, Masood Khan.
Corrections
The subtitle of “A pilot study” has been removed from the article title. Aksh Chahal’s affiliation has been corrected to Department of Physiotherapy, School of Medical and Allied Health Science, Galgotias University, Greater Noida, Uttar Pradesh, India from Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana, India. The title of “Rehabilitation Research Chair” has been removed from affiliation d, the affiliation of Ahmad H. Alghadir and Masood Khan.
Abbreviations:
- JFLS
- jaw functional limitation scale
- NPRS
- numerical pain rating scale
- PT
- physical therapist
- SCST
- strain/counterstrain technique
- TMD
- temporomandibular dysfunction
- US
- ultrasound therapy
The authors have no conflicts of interest to disclose.
Researchers Supporting Project number (RSP2023R382), King Saud University, Riyadh, Saudi Arabia.
The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.
How to cite this article: Azam I, Chahal A, Kapoor G, Chaudhuri P, Alghadir AH, Khan M, Kashoo FZ, Esht V, Alshehri MM, Shaphe MA, Khan AR, Singh G. Effects of a program consisting of strain/counterstrain technique, phonophoresis, heat therapy, and stretching in patients with temporomandibular joint dysfunction. Medicine 2023;102:32(e34569).
Contributor Information
Insha Azam, Email: inshaazam006@gmail.com.
Aksh Chahal, Email: prof.aksh_chahal@mmumullana.org.
Gaurav Kapoor, Email: gauravkapoor00711@gmail.com.
Pooja Chaudhuri, Email: dr.poojachaudhuri@gmail.com.
Ahmad H. Alghadir, Email: aalghadir@hotmail.com.
Faizan Z. Kashoo, Email: f.kashoo@mu.edu.sa.
Vandana Esht, Email: vandanaesht@jazanu.edu.sa.
Mohammed M. Alshehri, Email: moalshehri@jazanu.edu.sa.
Mohammad Abu Shaphe, Email: mshaphe@jazanu.edu.sa.
Abdur Raheem Khan, Email: abdurraheem@iul.ac.in.
Gurjant Singh, Email: singh.guri547@gmail.com.
References
- [1].Herb K, Cho S, Stiles MA. Temporomandibular joint pain and dysfunction. Curr Pain Headache Rep. 2006;10:408–14. [DOI] [PubMed] [Google Scholar]
- [2].Lomas J, Gurgenci T, Jackson C, et al. Temporomandibular dysfunction. Aust J Gen Pract. 2018;47:212–5. [DOI] [PubMed] [Google Scholar]
- [3].Sharma S, Gupta DS, Pal U, et al. Etiological factors of temporomandibular joint disorders. Natl J Maxillofac Surg. 2011;2:116. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [4].Reiter S, Goldsmith C, Emodi-Perlman A, et al. Masticatory muscle disorders diagnostic criteria: the American Academy of Orofacial Pain versus the research diagnostic criteria/temporomandibular disorders (RDC/TMD). J Oral Rehabil. 2012;39:941–7. [DOI] [PubMed] [Google Scholar]
- [5].Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med. 2008;359:2693–705. [DOI] [PubMed] [Google Scholar]
- [6].Jones L. Strain and Counterstrain. Newark, Ohio: American Academy of Osteopathy. 1981. [Google Scholar]
- [7].Ibáñez-García J, Alburquerque-Sendín F, Rodríguez-Blanco C, et al. Changes in masseter muscle trigger points following strain-counterstrain or neuro-muscular technique. J Bodyw Mov Ther. 2009;13:2–10. [DOI] [PubMed] [Google Scholar]
- [8].Somprasong S, Mekhora K, Vachalathiti R, et al. Effects of strain counter-strain and stretching techniques in active myofascial pain syndrome. J Phys Ther Sci. 2011;23:889–93. [Google Scholar]
- [9].Dardzinski J, Ostrov B, Hamann L. Myofascial pain unresponsive to standard treatment: successful use of a strain and counterstrain technique with physical therapy. J Clin Rheumatol. 2000;6:169–74. [DOI] [PubMed] [Google Scholar]
- [10].Atienza Meseguer A, Fernandez de las Penas C, Navarro-Poza JL, et al. Immediate effects of the strain/counterstrain technique in local pain evoked by tender points in the upper trapezius muscle. Clin Chiropr. 2006;9:112–8. [Google Scholar]
- [11].Blanco CR, de las Peñas CF, Xumet JEH, et al. Changes in active mouth opening following a single treatment of latent myofascial trigger points in the masseter muscle involving post-isometric relaxation or strain/counterstrain. J Bodyw Mov Ther. 2006;10:197–205. [Google Scholar]
- [12].Lewis C, Flynn TW. The use of strain-counterstrain in the treatment of patients with low back pain. J Man Manip Ther. 2001;9:92–8. [Google Scholar]
- [13].Grieder A, Vinton PW, Cinotti WR, et al. An evaluation of ultrasonic therapy for temporomandibular joint dysfunction. Oral Surg Oral Med Oral Pathol. 1971;31:25–31. [DOI] [PubMed] [Google Scholar]
- [14].Ucar M, Sarp U, Koca I, et al. Effectiveness of a home exercise program in combination with ultrasound therapy for temporomandibular joint disorders. J Phys Ther Sci. 2014;26:1847–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [15].Elgohary HM, Eladl HM, Soliman AH, et al. Effects of ultrasound, laser and exercises on temporomandibular joint pain and trismus following head and neck cancer. Ann Rehabil Med. 2018;42:846–53. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Furlan RMMM, Giovanardi RS, Britto ATBdO, Britto DBdO. The use of superficial heat for treatment of temporomandibular disorders: an integrative review. Paper presented at: Codas 2015. [DOI] [PubMed]
- [17].Moraes AR, Sanches ML, Ribeiro EC, et al. Therapeutic exercises for the control of temporomandibular disorders. Dental Press J Orthod. 2013;18:134–9. [DOI] [PubMed] [Google Scholar]
- [18].Spadoni GF, Stratford PW, Solomon PE, et al. The evaluation of change in pain intensity: a comparison of the P4 and single-item numeric pain rating scales. J Orthop Sports Phys Ther. 2004;34:187–93. [DOI] [PubMed] [Google Scholar]
- [19].Ohrbach R, Larsson P, List T. The jaw functional limitation scale: development, reliability, and validity of 8-item and 20-item versions. J Orofac Pain. 2008;22. [PubMed] [Google Scholar]
- [20].Mishra A, Sinha A, Mehrotra P, et al. A comparative study on efficacy of three different treatment modalities for temporomandibular joint pain and dysfunction. Oral Health Dent Manag. 2015;3:27–32. [Google Scholar]
- [21].Rai S, Kaur M, Goel S, et al. Prospective utility of therapeutic ultrasound in dentistry—Review with recent comprehensive update. Adv Biomed Res. 2012;1:47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [22].Gupta A, Bharti Arora D, Rishi P. Recovery from temporomandibular joint dysfunction: an overview of different physiotherapy approaches.
- [23].Eisensmith LP. Massage therapy decreases frequency and intensity of symptoms related to temporomandibular joint syndrome in one case study. J Bodyw Mov Ther. 2007;11:223–30. [Google Scholar]
- [24].Calixtre LB, Rezende MA, Kamonseki DH, et al. Effects of myofascial release applied to neck muscles and craniocervical flexor training in patients with chronic myofascial TMD: a single arm study. Int J Osteopath Med. 2021;41:4–10. [Google Scholar]
- [25].Benson HA, McElnay JC. Transmission of ultrasound energy through topical pharmaceutical products. Physiotherapy. 1988;74:587–9. [Google Scholar]
- [26].Shin S-M, Choi J-K. Effect of indomethacin phonophoresis on the relief of temporomandibular joint pain. Cranio. 1997;15:345–8. [DOI] [PubMed] [Google Scholar]
- [27].Fernandez-Cuadros ME, Bocanegra LOC, Albaladejo-Florin MJ, et al. Effect of diclofenac gel phonophoresis on temporomandibular joint disorders: a prospective quasi-experimental study. Middle East J Rehabil Health Stud. 2020;7. [Google Scholar]
- [28].Vijayalakshmi K, Khan M, Rajguru P. Phonophoresis in temporomandibular joint disorders: a clinical trial. J Adv Clin Res Insights. 2015;2:259–64. [Google Scholar]
- [29].Yang J-H, Kim D-K, Yun M-Y, et al. Transdermal delivery system of triamcinolone acetonide from a gel using phonophoresis. Arch Pharm Res. 2006;29:412–7. [DOI] [PubMed] [Google Scholar]
- [30].Newman JT, Nellermoe M, Carnett J. Hydrocortisone phonophoresis. A literature review. J Am Podiatr Med Assoc. 1992;82:432–5. [DOI] [PubMed] [Google Scholar]
- [31].Freesmeyer WB, Fussnegger M, Ahlers M. Diagnostic and therapeutic-restorative procedures for masticatory dysfunctions. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2005;4. [PMC free article] [PubMed] [Google Scholar]
- [32].Wieckiewicz M, Boening K, Wiland P, et al. Reported concepts for the treatment modalities and pain management of temporomandibular disorders. J Headache Pain. 2015;16:1–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [33].Michelotti A, Steenks MH, Farella M, et al. The additional value of a home physical therapy regimen versus patient education only for the treatment of myofascial pain of the jaw muscles: short-term results of a randomized clinical trial. J Orofac Pain. 2004;18:114–25. [PubMed] [Google Scholar]
- [34].Fricton JR. Management of masticatory myofascial pain. Paper presented at: Semin Orthod. 1995;1:229–43. [DOI] [PubMed] [Google Scholar]
- [35].Michelotti A, de Wijer A, Steenks M, et al. Home-exercise regimes for the management of non-specific temporomandibular disorders. J Oral Rehabil. 2005;32:779–85. [DOI] [PubMed] [Google Scholar]
- [36].Oliveira L, Lopes T, Soares C, et al. Transcranial direct current stimulation and exercises for treatment of chronic temporomandibular disorders: a blind randomised-controlled trial. J Oral Rehabil. 2015;42:723–32. [DOI] [PubMed] [Google Scholar]