Abstract
Background
Temporomandibular disorders (TMD) are musculoskeletal disorders frequently seen in physiotherapy and dental practices, affecting the temporomandibular joint (TMJ) and central nervous system. A multimodal treatment could be more beneficial with limitations of traditional treatment.
Objective
The purpose of this research was to compare the outcomes of cranio-mandibular stabilisation exercises and a structured manual therapy protocol on pain reduction in TMD patients. A secondary purpose was to quantify improvements in mechanical tenderness and active mouth function.
Methods
This single-blind, randomized trial recruited 146 participants (95 women, 51 men) aged 18–50 years with TMD. Participants were randomly allocated into two groups to maintain allocation concealment. The intervention was standardized, administered by skilled physical therapists. Validated instruments measured outcomes, namely pain intensity, mechanical tenderness and active mouth function tests.
Results
Participants receiving cranio-mandibular stabilisation and manual therapy had significantly greater improvements in pain (P = 0.001, 95 %), mechanical tenderness (P = 0.001, 95 %) and active mouth function (P = 0.001, 95 %) compared to controls.
Conclusions
Findings suggest that a multimodal treatment of cranio-mandibular stabilisation and structured manual therapy significantly decreases pain and improves mechanical tenderness and active mouth function in TMD patients. Future research should include long-term follow-up to assess effect sustainability and optimize treatment protocols for maximum benefits.
Keywords: Cranio-mandibular stabilisation, Manual therapy, Temporomandibular disorders, Physical therapy, Central nervous system
1. Introduction
1.1. Introduction to temporomandibular disorders (TMD)
Temporomandibular disorders (TMD) are a type of musculoskeletal disease that is commonly seen in dental and physiotherapy settings.1 A multifactorial cervical-cranio- mandibular disorder affecting the temporomandibular joint (TMJ) and central nervous system, TMD was coined by the American Academy of Orofacial Pain.2 In addition to emotional stress, poor posture, malocclusion, tooth loss and other intrinsic and extrinsic biomechanical alterations in the articular and muscular components of the temporomandibular joint, the aetiology includes biomechanical, neuromuscular and bio-psychosocial variables. TMD are the most prevalent chronic orofacial pain disorder, having major impact on patient's quality of life by impairning capacity to socialise.3 This illness affects 3–15 % of people worldwide and it seems to affect women more than men.4
1.2. Symptoms and mechanical changes in TMD
Changes to the TMJ can result in muscle and articular adaptations, which can disrupt the alignment of the cranium and mandible by causing abnormal posture and changing the biomechanics of the cranium and mandible.5 Numerous occlusion kinds, head anterioration, craniofacial dimensions and postural instability have been shown to correlate with TMD in recent studies.5,6 According to Girard et al.7 TMD typically requires a multidisciplinary treatment approach, conservative methods including as occlusal splints, physical therapy, medicationand orthodontic treatment are used to control TMD symptoms. Numerous people claim that, because TMD is so complex, they benefit from a variety of therapies, such as medication, behavioural therapies, dietary counselling, dental therapy, manual therapy and physiotherapy, orthodontics, prostheses, orthotics and surgery.8
1.3. Multimodal treatment and manual therapy
In TMD, there are extensive alterations in the muscles, neurones, articulations and biomechanics, the treatment strategy needs to be tailored appropriately.9 Based on efficiency and cost-effectiveness, the healthcare professional should determine which therapies are appropriate for the patient. Soft tissue inhibition, mobilisation and dry needling are examples of manual treatment that has become quite popular.10 For improved cervical and postural adjustments, many patients are also said to benefit from physical therapy, which consists of manual techniques, exercise instructions and patient awareness.11,12 While manual methods involve TMJ manipulations, stretching exercises and mobilisations, exercise instructions typically call for patients to perform mobility and self-stretching exercises on their own. Education and awareness focus on holistic treatment by teaching patients how to correct their posture, relax and take care of their general health. In order to treat a variety of pain conditions, dry needling entails inserting bare monofilament needles into trigger sites, such as muscles, tendons, ligaments, scar tissue, peripheral nerves, etc.13, 14, 15 Research has indicated that dry needling significantly reduces pain in myofascial TMD patients.16 When combined, these methods can restore joint stability and result in a notable improvement in motor function. According to Gonz'alez-Iglesias et al.17 spine manipulation, dry needling and mobilisation with movement were all successful multimodal treatments for TMD. However, there are very few reports of the use of dry needling and muscular inhibition techniques in conjunction with exercises to treat TMD patients. For the treatment of patients with TMD, the purpose of this study is to assess the combined benefits of a systematic manual therapy protocol and cranio-mandibular stabilisation exercises.
1.4. Addressing mechanical tenderness, mouth function and patient challenges in TMD management
1.4.1. Mechanical tenderness and mouth function
The goal of cranio-mandibular stabilisation exercises is to increase joint stability and muscle function, which will lessen mechanical soreness and improve oral function. Patients with TMD have demonstrated a considerable improvement in their functional control and symptoms when these exercises are paired with manual therapy. Stud-ies have indicated significant pre-post variations in mouth opening and pain levels, supporting the efficacy of this combination. strategy.5,17
1.4.2. Common patient complaints and challenges in TMD
Temporomandibular disorders (TMD) often lead to a range of debilitating symptoms, including:
Chronic Pain: Many patients complain of chronic orofacial pain that interferes with day-to-day activities. Research indicates that by addressing musculoskeletal dys-functions, a multimodal strategy that incorporates systematic manual therapy and cranio-mandibular stabilisation exercises can significantly reduce pain.7,10
Functional Limitations: Many people have limited jaw opening and struggle to carry out basic tasks like speaking and eating. These issues are immediately addressed by research that backs the use of combination therapy to improve jaw movement.11,12
Psychosocial Impact: Depression, anxiety and a lower quality of life can result from functional impairments and chronic pain. According to Al-Moraissi et al.8 this therapy strategy may have a good impact on social relationships and mental well-being by enhancing jaw function and pain management.
1.5. Rationale for a multimodal treatment approach
Given its substantial influence on patients' quality of life, it is evident that TMD management requires an evidence-based, comprehensive strategy. Pain, mechanical sorenessand limited oral function are common symptoms of TMD, which calls for all-encompassing therapeutic approaches.
The goal of cranio-mandibular stabilisation exercises is to improve joint stability and neuromuscular control.9 Restoring mobility and reducing discomfort are the goals of structured manual therapy.13,14 The integration of cranio-mandibular stabilisation exercises and structured manual therapy has been emphasised as an effec-tive approach to enhancing joint stability, neuromauscular control and mobility, while synergistically reducing pain and functional limitation.
In order to identify a non-invasive, practical and patient-centered therapy strategy, this study assesses their combined efficacy.
1.6. Primary & secondary objectives of the study
1.6.1. Primary objective: evaluating combined effects
It has been demonstrated that manual therapy and cranio-mandibular stabilisation exercises work in concert to reduce pain and functional impairments.According to earlier research, manual therapy methods including stretching and mobilisations can improve joint mobility and lessen discomfort.5
1.6.2. Secondary objective: assessing specific symptom improvements
Pain Reduction: By focussing on trigger points in the masseter muscle, which is frequently implicated in TMD, dry needling, a crucial component of organised man-ual therapy, has shown notable pain alleviation.According to research, dry needling improves maximum jaw opening and increases pressure pain thresholds, which helps TMD patients with their pain and functional deficits.13,16
Enhancement of Mouth Function and Mechanical Tenderness: Studies show that integrating manual treatment with stabilisation exercises results in signif-icant gains in jaw function, muscle tenderness and pain levels. The efficacy of this combination therapy approach in enhancing functional control in patients with TMD was demonstrated by a study that emphasised the pre-post differences in mouth opening and pain.5,17
The study's hypothesis is that in addition to improving patients' psychosocial well-being, cranio-mandibular stabilisation exercises and structured manual therapy will result in notable improvements in pain, mouth function, muscle tenderness and joint stability in the patient with Temporomandibular Disorders (TMD) will enhancing their well-being. Existing literature support the multifocal nature of TMD and the need for a multimodal treatment approach.1,2 Research indicates that manual therapy, including mobilization and dry needling, effectively relieves pain and restores func-tion.13,14,16 Additionally, stabilisation exercises enhance neuromuscular control and joint stability, leading to better patient outcomes.9 Given the complexity of TMD and its impact on quality of life, this study aims to validate the effectiveness of a holistic, patient-centered therapeutic strategy.7,8
A patient-centered, evidence-based strategy for the therapy of TMD, this organised approach guarantees that both pain alleviation and functional recovery are successfully addressed.7,8
2. Material and methods
2.1. Ethical approval statement
The study was approved by the Institutional Riview Board (IRB). The Ethical Approval No. is LPU/IEC/2018/01/09.
2.2. Justification for single-blind randomized controlled trial design
The selection of a single-blind randomized controlled trial (RCT) design for the study on temporomandibular disorders (TMD) is well-founded for several reasons.
Reduction of Participant Bias: In a single-blind design, participants are not aware of their treatment group assignment (control or experimental). Their responses and expectations regarding treatment outcomes are less biassed as a result of this ignorance, guaranteeing that their opinions won't affect the study's findings.
Random Assignment: To ensure that any differences between the groups can be attributed to the treatment rather than pre-existing differences among participants, the study used a random assignment method, in which participants were divided into groups using a straightforward lottery method. This method improves the study's internal validity.
Control of Confounding Variables: Potential biases in therapy delivery are effectively controlled for in this study by not disclosing the group assignments to the therapists. This is especially crucial in physical therapy since patient outcomes may be unintentionally impacted by the expectations of the therapist.
Statistical Rigor: The study's sample size of 146 participants was sufficiently large to improve the findings' statistical power. More accurate findings regarding the efficacy of the combined treatment method are possible with a bigger sample size.
2.3. Study design
A randomised, single-blind clinical trial investigation including 146 participants was carried out. Using a straightforward lottery technique (sealed envelope), each participant was split into two groups at random. The patients were not recruited or evaluated by their physical therapists.
2.4. Study setting and participants
The experiment was conducted at Uni-health Care Centre, Lovely Professional University, Phagwara, Punjab, from July 2019 to January 2022. It was filed under CTRI/2019/06/019858. The participants were chosen using simple randomised sampling. Consent was acquired with awareness. Using G-power software, the sample was computed with a Cohen's d effect size of 0.45, a 95 % confidence intervaland an 80 % research power, taking a 15 % dropout rate into account.
A total of 196 volunteers aged 18–50 were selected. 40 participants were eliminated following primary screening because they did not fit the study's requirements. The remaining 156 were split into 78 experimental and control groups at random. 10 patients stopped receiving treatment—6 from the control group and 4 from the experimental group. There were 146 participants in the final analysis (95 women and 51 men), with 74 and 72 participants in the experimental and control groups, respectively. The control group performed conventional physiotherapy with home-based cervical and TMJ range of motion exercises, while the experimental group received a manual therapy approach with supervised exercises. A synopsis of the study protocol can be seen in Fig. 1.
Fig. 1.
A summary of the study protocol.
2.5. Rationale for choosing cranio-mandibular stabilisation exercises and structured manual therapy
In this study "Multimodal physical therapy approach for the management of patients with temporomandibular disorder: randomized control trial," cranio-mandibular stabilisation exercises and structured manual therapy were selected due to their demonstrated effectiveness in addressing the complex nature of temporomandibular disorders (TMD).
Pain Reduction: The techniques used particularly target the pain pathways linked to TMD. By focussing on trigger points in the masseter muscle, which is frequently implicated in TMD, dry needling, a kind of structured manual therapy, has been demonstrated to dramatically reduce pain. Research shows that dry needling can improve maximum jaw opening and increase pressure pain thresholds, which directly addresses pain and functional constraints in people with TMD.
Effectiveness of Manual Therapy and Dry Needling: The usefulness of these approaches in treating TMD is supported by the literature. For TMD patients, a multimodal strategy that included manual therapy and dry needling significantly improved pain management and functional outcomes. Furthermore, although it has not been widely documented, the use of muscle inhibition techniques in conjunction with these medicines has the potential to improve treatment outcomes.
2.6. Sampling criteria
2.6.1. Inclusion criteria
Age between 18 and 50 years.
Pain history of at least 3 months and lowest score in NPRS ≥3.
Constant, unexpected, disruptive, limited Maximal Mouth Opening (MMO) of less than 30 mm (but not necessarily unpleasant) that appears to originate in the TMJ.
Hampered movements of the unaffected side.
Opening and appeared movements deviate to the affected side.
Exacerbation of discomfort or stress in the TMJ on the impacted side.
The medical treatment was resistant to conservative treatment.
2.6.2. Exclusion criteria
TMJ arthritis that has progressed to the point of degeneration or that is inflamed.
TMJ arthritis caused by an infection.
Cancerous tumors of the face and jaw.
A history of TMJ dislocation.
A history of jaw fractures.
Previous jaw or TMJ surgery history.
Patients who are using anti-inflammatory and analgesic medications.
2.7. Interventions
2.7.1. Manual therapy
The experimental group, for four weeks had eight manual therapy sessions—two sessions each week, separated by 48 h—four sessions of dry needling and four sessions of muscle inhibition. Physical therapists 1 and 2 were in charge of applying dry needling and muscle inhibition, respectively. They got manual treatment in addition to exercise under the supervision of a skilled physical therapist. Only at-home neck and jaw workout programs were given to the control group.
2.7.2. Dry needling
A plastic acupuncture needle measuring 0.22 × 30 mm was used for dry needling and it was put into the masseter, temporalisand sub-occipital muscles' sensitive points. Eight sessions in all were held, separated by four days. Prior to receiving dry needling treatments, participants gave their written consent.
2.7.3. Muscular inhibition
The masseter, temporalis, medial, lateral pterygoid and sub-occipital muscles were subjected to ischemic-sustained pressure for 5–10 s to induce muscular inhibition following 48 h of dry needling sessions. While the patient was lying in a comfortable supine position, the aching region was palpated with the fingertip.
2.7.4. Exercises
Stabilisation exercises for the neck and jaw were performed under the supervision of an experienced physical therapist on alternate days.
2.7.5. Home based exercises
The protocal for home based exercise are as following in the given Table 1.
Table 1.
The summary of home-based exercise protocol.
| Name of exercise | Description of exercise |
|---|---|
| Relaxed Jaw exercise | The patient rests his tongue gently on the top of his mouth behind the upper front teeth. The patient is then asked to slowly allow his teeth to come apart and relax his jaw muscles. Patient was advise to do this exercise for 10–12 times |
| Partial mouth opening exercise | The therapist instructs the patient to place his tongue on the roof of the mouth at same time one of the finger in front of the ear just over the TMJ. The patient is then asked to put his middle or pointer finger on his chin with the other hand. In the next step the patient drops his lower jaw halfway and then closes. There can be mild resistance in movement but not pain. A variation of this exercise can be done by placing one finger on each TMJ and dropping the lower jaw halfway and closing again. The repetition of exercise is 10–12 times. |
| Full mouth opening exercise | The patient keeps his tongue on the roof of his mouth. Then is asked to place one finger on his TMJ. Patients use his other hand and places one finger on the chin. The patient then drops his lower jaw completely and back. For a variation of this exercise, one finger is placed on each TMJ and the lower jaw is completely dropped. The repetition of exercise is 10–12 times. |
| Resisted opening of the mouth | The patient is asked to hold his chin in such a way such that he places his thumb under his chin. He is further instructed to open his mouth slowly, pushing gently against the resistance provided by his thumb. Hold for three to 6 s and then close mouth slowly. The repetition of exercise is 10–12 times. |
| Resisted closing of mouth | The patients squeeze his chin with his index finger and thumb with one hand. He is then instructed to close his mouth and apply gentle pressure on his chin. This helps to strengthen the muscles of mastication. The repetition of exercise is 10–12 times. |
| Side to side Jaw movement | In this the patients puts a ¼ inch object between his front teeth. He then moves his bottom jaw forward so that his bottom teeth are in front of his top teeth. As the exercise becomes easier, the thickness of the object between the teeth is increased. The repetition of exercise is 10–12 times. |
| Sub-occipital distraction | This technique is use to create a distraction force on the upper cervical spine and provides relief from mechanical compression by elongating the posterior and sub occipital cervical muscles. The subject is advised to hold both hands with fingers interlaced, behind the neck to stabilize the middle and lower cervical spine (C-3 to C-70. Then asked to nod their head forward six times while stabilizing the cervical spine in only 15 degrees of anterior cranial rotation. The repetition of exercise is 10–12 times. |
| Cranio-cervical stabilisation | An air filled inflatable cuff pressure sensor was used for this exercise and the base line was considered of 20 mm Hg. The patient was asked for crook lying position then the pressure sensor was placed under the neck and patient was asked to nod the head gently and slowly as if say “yes”. The pressure was measured 2 mm above the baseline and then 4 mm followed by 6 mm, 8 mm and 10 mm continuously without any rest. Each position must hold for 2 s a total of 10 s after 5 repetition. This repetition of this exercise is 10. |
| Temporalis muscle releasing exercise | The patient sits upright in a chair which is supported at the back. He is then instructed to place his index, middle and ring finger approximately 2 cm above his cheekbone, just in front of his ear and in line with his eyebrow. Then he Gently pulls down towards his cheekbone, stopping when he feels the bone. It is Repeated for 10 to12 times. |
| Masseter muscle releasing exercise | The patient Sits upright in a chair which is supported at the back. He is then asked to place his index, middle and ring finger against the side of his cheek just under the cheekbone. A small amount of pressure is applied and the patient pulls his fingers down towards the angle of his jaw. This is repeated this for 10 to12 times. |
2.8. Measurement of outcome
2.8.1. Numeric pain rating scale (NPRS)
The NPRS is a self-reported discomfort assessment tool that asks patients to rate their level of pain verbally on a scale of 0–10. It has been determined to have sufficient accuracy and dependability for usage with people who have chronic pain.
2.8.2. Maximal mouth opening (MMO)
MMO was measured with a digital vernier calliper that was 10 cm long. In order to measure the distance between the upper and lower central incisors, participants were instructed to expand their mouths as wide as they could without experiencing discomfort or pain.
2.8.3. Pressure pain threshold
Wagner FDX-25 Algometer measured the lowest pressure necessary to produce pain at selected trigger points. Measurements were taken before and after the 4-week treatment period and verbal cues were utilised to identify when subjects felt uncomfortable.
2.9. Data analysis
Statistical analysis was done using SPSS software version 28.0. The normal distribution was evaluated by the Kolmogorov-Smirnov test (p > 0.05). Baseline categorical variables were assessed using chi-square. Mann-Whitney and student t-test The U test assessed clinical and demographic factors.
The study comes to the conclusion that structured manual therapy and cranio-mandibular stabilisation exercises are two examples of a multimodal physical therapy method that works well for treating TMD. According to the findings, in order to improve patient outcomes, healthcare providers ought to think about incorporating these techniques into routine treatment regimens.
3. Result
3.1. Study methodology and participant demographics
Initially, 196 volunteers between the ages of 18 and 50 were initially chosen. 40 participants were eliminated following primary screening because they did not fit the study's requirements. The remaining 156 were split into 78 each in experimental and control groups at random. 10 patients stopped receiving treatment—6 from the control group and 4 from the experimental group. There were 146 individuals in the final analysis (95 women and 51 males), with 74 and 72 people in the experimental and control groups, respectively. Fig. 1 displays the process flow chart. Although participants were asked to describe any negative effects they experienced throughout therapy, none were noted.
The experimental group received a variety of treatments, including dry needling, manual therapyand muscle inhibition. The control group, under the guidance of an experienced therapist, engaged in at-home exercises aimed at sub-occipital distraction, cranio-cervical stabilisation, side-to-side jaw movement, resisted opening and closing of the mouth, relaxed jaw, partial and full mouth openingand temporalis and masseter muscle releasing.
The experimental and control groups' individuals shared similar demographic traits. They were 35 and 36 years old, weighed roughly 62 and 61 kg and were roughly 163 and 162 cm tall, respectively. In both groups, the average BMI was comparable. Women made up two-thirds of the participants in both groups. In the experimental group, 16 % claimed having smoked, while 10 % in the control group did the same. In each group, the percentage of married participants was over 75 %. In each group, undergraduates with a typical socioeconomic background made up more than half of the participants. For an overview of participant demographics, refer Table 2.
Table 2.
The baseline demographic characteristics of data for experimental groups and control.
| Characteristic | Variable | Experimental group (n = 74) | Control Group (n = 72) |
|---|---|---|---|
| Age (years, mean ± sd) | 35 ± 10.11 | 36 ± 12.12 | |
| Weight (kg, mean) | 62.37 | 61.45 | |
| Height (cm, mean) | 163.03 | 162.24 | |
| BMI (kg/m2, mean) | 23.45 | 23.27 | |
| Gender (%) | Female | 63.50 | 66.67 |
| Male | 36.50 | 33.33 | |
| Smoking history (%) | No | 83.78 | 90.28 |
| Yes | 16.22 | 9.72 | |
| Marital status (%) | Married | 75.68 | 76.39 |
| Not married | 24.32 | 23.61 | |
| Education history (%) | School level | 13.52 | 16.67 |
| Undergraduate | 54.05 | 59.72 | |
| Postgraduate | 32.43 | 23.61 | |
| Socioeconomic status | Below average | 1.35 | 4.17 |
| Average | 62.16 | 69.44 | |
| High | 36.49 | 26.39 |
sd = standard deviation, BMI= Body mass index, kg/m2 = kilogram/meter.
In Fig. 2 it is shows the comparison of the experimental (n = 74, mean age 3510.11) and control (n = 72, mean age 3612.12) groups. The mean height, weight and BMI of the control group are marginally higher. The percentages of women (90.28 % vs. 66.67 %), smokers (23.61 % vs. 11.11 %), single people (40.28 % vs. 23.61 %) and postgraduates (34.23 % vs. 15.52 %) are likewise greater. On the other hand, the experimental group contains a higher percentage of married people (76.39 % vs. 59.72 %) and people who don't smoke (88.89 % vs. 76.39 %). While most are classified as "average," the control group includes a higher percentage of people in the "high" category (33.49 % vs. 26.39 %).
Fig. 2.
The baseline demographic characteristics of data for experimental groups and control
Stacked Percentage Bar Chart - Represents percentage-based demographic data for Experimental group and control group. Error Bar Plot - Displays the mean values of Age, Weight, Height and BMI with Standard Deviation bars, highlightening variability. Group Bar Chart - Campares the mean values of the Experimental and Control groups for the key characteristics. Box Plot - Shows the distribution and spread of Age for both groups, including the median, quartiles and outliers.
3.2. Measurements and results
A comparison of pain-free mouth function and pressure pain threshold between the experimental and control groups is shown in Table 3.
Table 3.
Comparison of pain free mouth function, pressure pain threshold within the experimental groups and control.
| Groups | Outcomes | Pre-treatment | Post-treatment | Pre-post Differences | p-value |
|---|---|---|---|---|---|
| Experimental group (n = 72), Mean ± SD | NPRS-1 | 7.53 ± 3.01 | 1.45 ± 0.67 | 6.08 | 0.001 |
| NPRS-2 | 5.6 ± 3.33 | 1.95 ± 0.87 | 3.65 | 0.001 | |
| PPT1(kg/cm2) | 2.11 ± 1.12 | 3.93 ± 1.54 | 2.62 | 0.001 | |
| PPT-2(kg/cm2) | 2.91 ± 1.32 | 4.55 ± 1.56 | 1.64 | 0.001 | |
| PPT-3(kg/cm2) | 3.13 ± 1.12 | 4.84 ± 1.52 | 1.71 | 0.001 | |
| MMO(mm) | 31.50 ± 3.70 | 41.23 ± 4.90 | 8.73 | 0.001 | |
| Control Group (n = 74), Mean ± SD | NPRS-1 | 7.83 ± 3.01 | 7.55 ± 0.62 | 0.28 | 0.451 |
| NPRS-2 | 6.72 ± 2.33 | 5.35 ± 0.87 | 1.37 | 0.121 | |
| PPT-1(kg/cm2) | 2.35 ± 1.52 | 2.43 ± 1.24 | 0.08 | 0.233 | |
| PPT-2(kg/cm2) | 3.11 ± 1.12 | 3.25 ± 1.56 | 0.14 | 0.444 | |
| PPT-3(kg/cm2) | 3.43 ± 1.12 | 3.63 ± 1.52 | 0.19 | 0.451 | |
| MMO(mm) | 30.50 ± 6.70 | 31.35 ± 5.90 | 0.85 | 0.131 |
NPRS-1 = Numerical Pain Rating Scale during mouth opening. NPRS-2 = Numerical Pain Rating Scale over past 7 days, PPT-1 = Pressure Pain Threshold for masseter, PPT-2 = Pressure Pain Threshold for temporalis, PPT-3 = Pressure Pain Threshold for sub-occipital muscle, kg/cm = kilogram/centimeter, MMO = maximal mouth opening mm = millimeter.
A comparison of pain-free mouth function and pressure pain threshold between the experimental and control groups is shown in Fig. 3.
Fig. 3.
Experimental group pre-post treatment Outcomes
Stacked Bar Chart - Displays cumulative mean values for pre- and post-treatment outcomes of the Experiment group and Control group Error Bar Plot (Means & Standard Deviation)- Shows the mean values across the Experiment group and Control groups. Group Bar Chart - Campares pre- and post-treatment mean values across the Experimental and Control groups. Box Plot (Box-and-Whisker) - Represent data distribution, median, quartiles and potential outliers for pre- and post-treatment outcomes.
Fig. 3. Shows that there are notable variations in the effectiveness of treatment between the experimental and control groups when comparing their pressure pain threshold and pain-free oral function. After therapy, significant improvements were seen in all evaluated parameters in the experimental group (n = 72). Pressure pain thresholds (PPT-1, PPT-2, and PPT-3) rose, indicating decreased sensitivity, whereas pain levels, as measured by NPRS-1 and NPRS-2, showed significant decreases of 6.08 and 3.65 points, respectively. Furthermore, there was an improvement of 8.73 mm in maximum mouth opening (MMO), indicating increased mobility. These changes were all statistically significant (p = 0.001), indicating that the intervention was successful in lowering pain and enhancing function. In comparison, pre-post differences were negligible across all parameters, and the control group (n = 74) showed only modest and statistically insignificant changes in post-treatment values.
3.2.1. NPRS measurement
NPRS measurement during mouth opening (NPRS-1) and over the past 7 days (NPRS-2) showed a significant difference between the experimental and control groups. There was a significant pre-post difference of 6.08 (p = 0.001) between the experimental group's pre-treatment and post-treatment NPRS-1 values, which were 7.53 ± 3.01 and 1.45 ± 0.67, respectively. The NPRS-1 pre-post difference in the control group was 0.28, with a p-value of 0.451. Likewise, the experimental and control groups' pre-post differences in NPRS-2 levels were 3.65 (p = 0.001) and 1.37 (p = 0.121), respectively.
3.2.2. Pressure pain threshold (PPT)
PPT-1, PPT-2and PPT-3 stand for the masseter, temporalisand sub-occipital muscles' pressure pain thresholds, respectively. The experimental group's pre-treatment and post-treatment values for each of the three thresholds showed substantial (p = 0.001) variations. In PPT-1, PPT-2and PPT-3, the pre-post changes were 0.08 kg/cm2 (p = 0.233), 0.14 kg/cm2 (p = 0.444)and 0.19 kg/cm2 (p = 0.451) in the control group, respectively.
3.2.3. Maximum mouth opening (MMO)
The experimental group's pre-treatment MMO was 31.50 ± 3.70 mm and following treatment, it rose to 41.23 ± 4.90 mm, indicating a significant difference of 8.73 mm (p = 0.001). The MMO increase in the control group was a mere 0.85 mm (p = 0.131).
The results indicate that the experimental and control groups differed significantly. Significant differences were seen between the experimental group and the control group in terms of discomfort, pain-free mouth openingand pressure pain threshold before and after treatment. The experimental group showed a substantial improvement in all parameters within the individual group (p = 0.001).
Table 4 elucidates the comparison of post-intervention outcomes for pain, pressure pain thresholdand mouth function in the control and experimental groups. The experimental and control groups' respective mean NPRS-1 levels were 1.45 ± 0.67 and 7.55 ± 0.62, with a significant difference of 6.10 (p = 0.001). Similarly, NPRS-2 mean values in the experimental and control groups were 1.95 ± 0.87 and 5.35 ± 0.87, respectivelyand the difference was significant (3.40, p = 0.001). The two groups' respective post-intervention PPT-1, PPT-2and PPT-3 values were 1.51 kg/cm2 (p = 0.001), 1.31 kg/cm2 (p = 0.001)and 1.24 kg/cm2 (p = 0.001). Additionally, there was a substantial difference in the groups' post-intervention MMO. The experimental group's average MMO was 41.23 ± 4.90 mm, while the control group's was 31.35 ± 5.90 mm. Their MMOs differed by 9.88 mm, with a p-value of 0.001.
Table 4.
Comparison of post intervention outcomes for pain, pressure pain threshold and mouth function for control and experimental groups.
| Outcomes | Experimental group (n = 74), Mean ± SD |
Control group (n = 72), Mean ± SD |
Differences between the control group | p-value |
|---|---|---|---|---|
| NPRS-1 | 1.45 ± 0.67 | 7.55 ± 0.62 | 6.10 | 0.001 |
| NPRS-2 | 1.95 ± 0.87 | 5.35 ± 0.87 | 3.40 | 0.001 |
| PPT-1(kg/cm2) | 3.93 ± 1.54 | 2.43 ± 1.24 | 1.51 | 0.001 |
| PPT-2(kg/cm2) | 4.55 ± 1.56 | 3.26 ± 1.56 | 1.31 | 0.001 |
| PPT-3(kg/cm2) | 4.84 ± 1.52 | 3.60 ± 1.52 | 1.24 | 0.001 |
| MMO (mm) | 41.23 ± 4.90 | 31.35 ± 5.90 | 9.88 | 0.001 |
NPRS-1 = Numerical Pain Rating Scale during mouth opening. NPRS-2 = Numerical Pain Rating Scale over past 7 days, PPT-1 = Pressure Pain Threshold for masseter, PPT-2 = Pressure Pain Threshold for temporalis, PPT-3 = Pressure Pain Threshold for sub-occipital muscle, MMO = maximal mouth opening.
The result provides compelling proof of the efficacy of a multimodal strategy to TMD treatment. Significant improvements in mouth function, painand pressure pain threshold demonstrate how manual therapy, dry needling and muscle inhibition may be used in conjunction to manage TMD more successfully than at-home exercises alone. These results help to advance patient-centered therapy approaches and bridge the research gap.
In Fig. 4, the experimental and control groups are contrasted in on maximum mouth opening (MMO), pressure pain thresholds (PPT-1, PPT-2 and PPT-3) and pain ratings (NPRS-1, NPRS-2). With reduced variations in PPT values, the experimental group (blue) exhibits higher MMO and lower pain ratings than the control group (orange). Group differences are shown by green bars, while p-values are shown by light blue bars. The biggest disparity is seen in the MMO category.
Fig. 4.
Comparison of post intervention outcomes for pain, pressure pain threshold and mouth function for control and experimental groups.
Stacked Bar Chart - Displays total contributionof Experiment group and control group while maintaining individual values. Error Bar Plot- Shows mean and Standard Deviation, highlighting variability with quartiles. Group Bar Chart - Campares mean values of outcomes of both Experimental and Control groups. Box Plot (Box-and-Whisker) - Visualizes data distribution, median, quartiles and potential outliers for pre- and post-treatment outcomes.
In comparison to home-based exercises alone, this study hypothesises that a multimodal strategy combining organised manual therapy and cranio-mandibular stabilisation exercises will dramatically improve oral function, discomfortand soreness in TMD patients. It is anticipated that the combination of these therapy will work better than either one alone.
By emphasising efficient pain management, enhanced functional capacitiesand all-encompassing treatment, the study seeks to improve patient outcomes and overall quality of life. Significant pain alleviation from manual treatment and dry needling may improve everyday functioning and promote comfort. Furthermore, improving oral function can have a good effect on vital functions like speaking, eating and interacting with others, which can eventually improve a patient's wellbeing. The study's multimodal approach recognises the complexity of temporomandibular disorder (TMD) and provides a comprehensive, patient-centered treatment plan that is customised to meet the needs of each individual.
4. Discussion
This study's merits, practical implications and suggestions for further research are compared to the body of existing literature. This methodical methodology guarantees a thorough comprehension of the study's contributions. In a study involving 146 patients, TMD—a multifactorial disorder affecting muscle, TMJ and cranial stability—was examined. When compared to individuals who only performed exercises at home, the experimental group's results in terms of pain reduction, mouth opening and pressure pain threshold were noticeably improved after receiving dry needling and muscle inhibition sessions.
4.1. Manual therapy for TMD
TMD has been shown to be successful in managing short-term pain when used as a manual therapy in the cervical region. It can result in long-term symptom relief when combined with therapeutic activities.18
4.2. Dry needling and muscle inhibition
Studies show that in individuals with myofascial TMD, dry needling of the masseter muscle increases PPT and improves maximum jaw opening.16 Muscle inhibition helps TMD patients function better by lowering the frequency and severity of kinesiological episodes.
4.2.1. Study on pain reduction
According to Dias et al.19 this treatment improved bite force, expanded range of motion by 2 mm and decreased discomfort from 6.3 to 2.3 in a research involving seven female participants.
4.3. Combined therapy effects
In comparison to individual therapies, multimodal methods demonstrated quicker and more significant improvements in pain alleviation and functional control in TMD patients. Every patient in a trial with nine patients who received multimodal treatment, including targeted dry needling to the wrist extensor muscles, reported a significant improvement in both function and PPT over the afflicted muscles.20 The combination method significantly improved the patients’ mouth function and quality of life, according to Patra et al.21 study on the com-bined effects of dry needling and cranial stabilisation technique on TMD patients. In order to treat TMD patients, Gil-Mart'ınez et al.6 emphasised the necessity of a multi-faceted physical therapy strategy. They stressed that interdisciplinary approaches are necessary for a better prognosis, even though physiotherapy treatments help reduce symptoms. For effective treatment of TMD symptoms, numerous other studies have also recommended combining different medications.22,23 These studies place a strong emphasis on giving exercises to TMD patients in a methodical way to achieve desired results.
4.4. Multimodal approach
In this case, a multimodal treatment that included dry needling, manual therapyand muscle inhibition showed notable improvements in TMD patients' functional control and symptoms. Compared to the control group, which received just home-based exercises, the experimental group showed a considerably higher improvement in pain, mouth openingand pressure pain threshold before and after the trial.
4.4.1. Manual therapy techniques
Several manual therapy procedures, such as TMJ manipulations, stretching and mobilisations, are used to treat TMD. To speed up their recuperation, patients are also given mobility and self-stretching instructions. The emphasis is on education and awareness to support posture correction, relaxation methods and general well-being as part of a comprehensive therapeutic strategy.
4.4.2. Integration of dry needling and exercise therapy
Although dry needling and muscle inhibition have been used extensively to treat TMD, their combination with exercise therapy has seldom been documented in the literature to far. Physical therapists with twelve years of clinical experience designed and implemented super-vised evidence-based exercise programs for this study. Based on the finding that the trigemino-vestibular nuclei regulate the body's equilibrium system, the program included cervical and mandibular stabilisation.24 Because the atlanto-occipital joint and jaw's functional integration might change stability, TMD sufferers need this kind of stabilisation.25
4.5. Physiological effects of dry needling and muscular inhibition
The mechano-transduction of peri-articular connective tissue, which promotes vasodilatation, was made easier by dry needling. This improves joint lubrication, opioid recruitment and blood flow to the muscle. Furthermore, the autonomic nervous system is brought into balance by the stimulation of mechanoreceptors by the muscular inhibition approach.26 According to the research of Manolopoulos et al.27 nociceptive impulses from the upper cervical spine are necessary for masticatory muscle contractions. Techniques for muscular inhibition that target the sub-occipital region therefore seem to lessen reflex contraction of the muscles and aid in their relaxation, thereby improving mouth function.
4.6. Interpretation
In contrast to home-based exercises alone, the results of this study show that a multimodal strategy that includes dry needling, muscle inhibition, and structured manual therapy produces better results for TMD patients. Significant gains in mouth opening, pressure pain threshold, and pain reduction were shown by participants in the experimental group. According to Carnero et al.16 these findings are consistent with earlier research showing the advantages of dry needling in enhancing muscular performance and lowering anxiety. Furthermore, the incorporation of muscle inhibition strategies improved neuromuscular control and overall function.
4.7. Clinical implications
The study emphasises how important it is to manage TMD with a thorough, evidence-based treatment plan. Although dry needling and manual therapy are frequently used separately, their combination usage, along with stabilisation exercises, seems to improve therapeutic outcomes. These results give physical therapists a methodical way to treat TMD and encourage the incorporation of multimodal therapies into standard clinical practice. The study further emphasises the significance of cervical-mandibular stabilisation in rehabilitation programs by highlighting the involvement of trigemino-vestibular interactions in postural stability.
4.8. Constraints
While this study provides valuable insights into the effectiveness of a multimodal approach for TMD management, certain limitation should be acknowledged. The brief follow-up time restricts evaluation of long-term effects, and the sample size does not adequately reflect patient variability. Biomechanical variations and severity were not taken into account. Results may also have been impacted by differences in how different practitioners administered the treatment. To improve clinical applicability, these criteria should be the focus of future studies.
Hence, TMD is a musculoskeletal condition that frequently results in limited jaw movement and excruciating orofacial pain. Multimodal treatment approaches provide a higher possibility for a quicker recovery, even though physical therapy is a popular management technique. This study demonstrates that systematic manual therapy, including dry needling, in conjunction with cranio-mandibular stabilisation exercises can improve patient results.
5. Conclusion
The findings in this study, temporomandibular dysfunction (TMD) can be effectively managed using a multimodal physical therapy approach that incorporates structured manual therapy and cranio-mandibular stabilisation exercises. When compared to patients who merely engaged in at-home exercises, those undergoing this all-encompassing treatment showed notable improvements in mechanical discomfort, pain reductionand mouth function. These results demonstrate the clinical benefit of combining various therapy approaches to address the complexity of TMD, thereby improving the functional recovery and quality of life for those who are impacted.
5.1. Limitations
The study has a number of limitations despite its encouraging findings. Its short-term concentration is one of its main limitations, which makes it difficult to determine whether the gains made are long-lasting. Furthermore, the findings' generalisability may be constrained by the sample size and demographic variety. The study is unable to completely isolate the effects of the multimodal therapy due to the lack of a placebo or sham treatment group. Furthermore, there is a chance that bias was introduced into treatment outcomes due to the variation in therapist expertise. Lack of thorough control over other confounding variables, such as lifestyle choices, psychological stressand co-existing musculoskeletal disorders, may have impacted the findings.
5.2. Future recommendations
Long-term follow-ups should be carried out to evaluate the sustainability of treatment benefits in order to support future study. The generalisability of the results will be enhanced by increasing the sample size and incorporating a more varied population. Furthermore, implementing a placebo-controlled design can assist in ascertaining the therapy's actual efficacy. Consistency in treatment application will be ensured by standardising the delivery of interventions through consistent practitioner training. Finally, in order to provide a more comprehensive and patient-centered therapy strategy, future research should examine the impact of behavioural and psychological aspects in TMD care.
Consent to participate
All participants provided written informed consent before enrollment, agreeing to participate in the study and allowing data usage for the publication.
Ethical approval
The study was approved by the Institutional Riview Board (IRB). The Ethical Approval No. is LPU/IEC/2018/01/09.
Clinical relevance
The findings demonstrate that a multimodal physical therapy approach, combining crania-mandibular stabilisation exercises and structured manual therapy, significantly reduces pain and enhances mechanical tenderness and mouth function in patients with Temporomandibular Disorder (TMD).
Funding
None.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
All the authors would like to thank and express regard to the patients who participated in this study.
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