Abstract
Background:
This study aimed to evaluate the effectiveness of myofascial release (MFR) therapy applied along fascial chains compared with a structured exercise protocol on symptoms of temporomandibular dysfunction (TMD) and low back pain (LBP)-related disability.
Methods:
Forty-five participants (38 women) with coexisting TMD and LBP were randomized into 3 groups: the myofascial treatment group, the exercise group, and the control group (CG). Participants were recruited from Istanbul Medipol University Dental Hospital (Istanbul, Turkey). Treatment group received 10 sessions of MFR therapy over 4 weeks, exercise group followed a structured exercise program for 4 weeks, and CG received no intervention. Outcomes included the Oswestry Disability Index, pressure pain threshold via algometry, and muscle properties (tone, stiffness, and elasticity) measured by myotonometer. Oromotor function was assessed using the Diagnostic Criteria for Temporomandibular Disorders. Measurements were taken at baseline and at 4 weeks.
Results:
Both MFR and exercise therapy resulted in significant improvements in pain tolerance, muscle tone, stiffness, and elasticity. MFR yielded greater improvements across most parameters, particularly in orofacial pain and LBP-related disability (P ≤ .004). MFR also produced significant gains in oromotor function, including maximum mouth opening and lateral excursions (P ≤ .033), while the exercise program improved pain-free mouth opening (P ≤ .012). No significant changes were observed in the CG. Improvements in TMD symptoms were paralleled by enhancements in LBP-related outcomes.
Conclusions:
MFR therapy was effective in reducing symptoms of TMD and LBP-related disability and demonstrated greater benefit than exercise therapy in most outcome measures. The observed parallel improvements suggest a biomechanical and neuromuscular link between the jaw and lumbar region, supporting the integration of MFR in interdisciplinary rehabilitation for patients with comorbid TMD and LBP.
Keywords: fascia, low back pain, manual therapies, myofascial release therapy, temporomandibular dysfunction
1. Introduction
Temporomandibular disorders (TMD) are multifactorial conditions characterized by orofacial pain, crepitus or clicking in the temporomandibular joint (TMJ), restricted mandibular movement, and deviation from the midline during motion.[1] Physical causes can generally be divided into arthrogenic origins and the more common myogenic origins.[2] The jaw is a crucial component of the human motor system, and previous studies have documented a significant association between low back pain (LBP) and TMD.[3–5] For instance, the 2000 to 2005 U.S. National Health Interview Survey reported that 64% of 189,977 patients with TMD also experienced LBP.[3] Similarly, Wiesinger et al found a strong relationship between back pain and jaw musculoskeletal disorders.[4]
An analysis of data from 204 countries revealed that LBP is the most prevalent pathology in more than half of these nations.[6] Additionally, a clinical study identified a 29% prevalence of LBP in patients with TMD.[7] Studies suggest that TMD often emerges within 1 year of LBP onset, with individuals experiencing LBP being more likely to develop TMD compared to those without a history of LBP.[8] Research into the relationship between chronic LBP and TMD has gained traction in recent years.[5,8,9]
The coexistence of TMD and LBP may be explained by several interrelated mechanisms. Anatomically, the temporalis, masseter, and pterygoid muscles are integrated into posterior fascial chains that extend through the cervical region to the thoracolumbar fascia, enabling force transmission and contributing to distant dysfunction.[10,11] Neurological connections between trigeminal and cervical spinal pathways, particularly at the subnucleus caudalis, facilitate pain signal convergence, increasing pain sensitivity across regions.[12–14] Moreover, TMD-related muscle imbalances can affect head posture and spinal alignment, leading to compensatory changes along the spine.[15] Finally, shared psychosocial risk factors such as heightened stress, pain-related fear, and maladaptive coping behaviors may contribute to chronic symptoms in both regions.[16]
Both myogenic and arthrogenic forms of TMD have shown positive responses to postural and jaw exercises as part of their treatment.[17] Furthermore, exercises aimed at improving head and neck posture, combined with passive mouth exercises, have proven effective in reducing musculoskeletal pain and enhancing oromotor function.[18–21]
Fascia is a 3-dimensional connective tissue network that envelopes the body, connecting muscles, bones, and organs while providing structural integrity. Among the fascial chains, the superficial anterior, posterior, and spiral chains establish direct and indirect connections between the TMJ and lower back regions. For example, through anterior chains, the temporalis and masseter muscles are linked to the neck muscles (sternocleidomastoid), while the hyoid bone and thoracolumbar fascia extend from the neck to the lower back, ensuring postural alignment. Posterior chains, on the other hand, affect the back and lower back regions through jaw and head movements.[22]
Myofascial release (MFR) techniques involve a group of specific maneuvers that apply sustained, low-pressure movements, primarily targeting muscles and fascia. While muscles and fascia are the primary tissues treated, all fibroelastic connective tissues (including skin, tendons, ligaments, cartilage, blood, and lymphatic tissues) are affected.[23] Direct tissue stretching during MFR facilitates the release of muscles, fascia, capsules, and ligaments, alleviating fibrosis and stiffness associated with prolonged immobility. This process improves soft tissue mobility and addresses dysfunctional conditions.[24,25]
Studies have demonstrated that MFR techniques can reduce pain and enhance mobility in individuals with chronic LBP.[26,27] Moreover, applying MFR to the masseter, temporalis, and sternocleidomastoid muscles has been shown to improve mandibular protrusion, increase right and left deviations of the TMJ, and significantly reduce limitations in activities of daily living caused by TMD.[28]
The relationship between TMD and LBP has been emphasized in numerous studies.[5,7–9] Various treatment protocols, including myofascial therapy, exercise therapy, physical therapy, medical treatment, and splint use, are implemented for individuals with TMD.[18] However, studies focusing on the connection between TMD and LBP and incorporating MFR techniques remain limited.
This study aimed to evaluate the effects of the MFR technique, applied to specific muscles (masseter, temporalis, trapezius, erector spinae, lateral abdominals, quadratus lumborum, and tensor fasciae latae [TFL]) selected based on fascial system connections, on mobility and functionality compared to a structured exercise protocol. Our objective was to provide a holistic approach to reducing TMD symptoms, preventing progression, and mitigating disability associated with chronic LBP.
This objective was evaluated based on the following hypotheses:
H0: There is no statistically significant difference between the effects of MFR and exercise therapy on mobility and functionality.
H1: MFR improves mobility and functionality more effectively than exercise therapy.
H2: Exercise therapy improves mobility and functionality more effectively than MFR.
2. Methods
2.1. Study design
This study is a parallel, single-blind (participants), randomized clinical trial with participants allocated (1:1:1) to 1 of 3 groups. All participants signed written information and provided an informed consent form, and the study was conducted following the principles of the Declaration of Helsinki. Ethical approval was obtained from the Non-Interventional Clinical Research Ethics Committee of Istanbul Medipol University on February 19, 2021 (Approval No: E-10840098-772.02-6577). The trial was registered before patient recruitment in ClinicalTrials.gov (NCT05673642), adhering to the International Committee of Medical Journal Editors (ICMJE) requirements.
Participants aged 18 to 50 years, presenting with symptoms of LBP and TMD, were recruited from Istanbul Medipol University Dental Hospital, Unkapani (Istanbul, Turkey). All participants were evaluated by a specialist dentist, and those meeting the eligibility criteria were included in the study. The recruitment and follow-up period spanned from December 23, 2022 to June 2023.
2.2. Randomization
Eligible participants with TMD and LBP were randomized into 1 of 3 groups based on their order of enrollment using simple randomization: control group (CG) for the first participants to enroll, treatment group (TG) for the second participants to enroll, and exercise group (EG) for third participants to enroll. After the CG assessment, participants in the CG were given the option to be assigned to either the EG or TG.
No specific allocation concealment mechanism was employed in this study. The random allocation sequence was generated through a collaborative decision-making process among the researchers. Participant enrollment was conducted by the dentist, while group assignment was performed by the researcher.
The dentist enrolled the participants, and group assignment was conducted by the primary researcher. Both had access to the random allocation sequence.
2.3. Blinding
This study was designed as a single-blind randomized controlled trial. Participant allocation was conducted by an independent researcher to minimize bias. Manual therapy and exercise interventions were supervised by separate researchers, while outcome assessments were performed by an evaluator blinded to group assignments.
The interventions varied across groups. In the TG, myofascial stretching was administered regularly on a weekly basis. In the EG, participants were instructed in the exercises and monitored at predefined intervals. The CG underwent only follow-up assessments without any intervention.
2.4. Participants
Participants were included if they met the following criteria:
Diagnosed with subacute or chronic TMD.[29]
Scored ≥20% on the Oswestry Disability Index (ODI).[30]
Experienced LBP persisting for more than 3 months.
Had mechanical LBP associated with lumbar disc herniation but without neurological deficits.[24]
Participants were excluded if they had any of the following:
Neurological disorders
Extruded or sequestrated lumbar disc herniation
Cardiovascular symptoms or circulatory issues
Infection, fibromyalgia, or acute arthritis
Participants with known spinal deformities (e.g., scoliosis, kyphosis) or a prior history of vertebral fractures, as well as those with full or partial dislocations (subluxations) of major joints were excluded from the study.[24]
2.5. Experimental design
Eligible participants diagnosed with TMD and identified with LBP were randomly assigned CG, TG, and EG. Out of 54 eligible individuals, 45 participants completed the study. A total of 45 participants (38 women) with TMD and LBP were randomized into 3 groups: the myofascial TG, the EG, and the CG. TG received MFR therapy for 4 weeks (10 sessions), EG followed a structured exercise program for 4 weeks, and CG received no intervention. Assessments included the ODI for LBP, orofacial pain (pressure algometer), muscle tone, stiffness, and elasticity (myotonometer), and oromotor functionality (Diagnostic Criteria for Temporomandibular Disorders [DC/TMD] criteria). Measurements were taken at baseline and after 4 weeks. No important changes were made to the methods after trial commencement. The algorithm for participant allocation into the study groups was shown in Figure 1.
Figure 1.
Flow of participants through the phases of the randomized controlled trial, including allocation, follow-up, and analysis. CG = control group, EG = exercise group, n = number of participants, TG = myofascial release group.
2.6. Intervention protocols
TG received MFR therapy for 4 weeks (10 sessions), EG followed a structured exercise program for 4 weeks, and CG received no intervention.
2.6.1. MFR protocol
The MFR technique was applied to muscle groups functionally connecting the TMJ and lumbar spine, including the masseter, temporalis, trapezius, erector spinae, lateral abdominals, quadratus lumborum, and TFL.[24] The protocol consisted of focused stretching for the temporalis, masseter, and trapezius muscles; targeted stretching and wringing techniques for the abdominal, back, and TFL regions; diaphragm stretching; arm and leg traction; and full-back fascial release. Each region was treated bilaterally for 90 seconds, with 3 repetitions per session. Sessions lasted approximately 35 minutes.
MFR was applied 3 times per week during the first 2 weeks and twice per week for the following 2 weeks, totaling 10 sessions over a 4-week period.[24,30,31] This frequency was determined based on previous literature and expert consensus indicating that MFR elicits rapid fascial adaptation in the early phase, followed by a maintenance period to consolidate gains and avoid practitioner-induced dependency.[32,33] All interventions were performed by a physiotherapist specialized in manual therapy.
2.6.2. Exercise protocol
The exercise protocol was designed to target the same key muscle groups as in the MFR group: masseter, temporalis, trapezius, erector spinae, lateral abdominals, quadratus lumborum, transversus abdominis, and TFL. Each session began with 5 minutes of postural warm-up exercises, followed by static stretching exercises. Each stretch was held for 15 to 20 seconds and repeated in 3 sets. Exercises were performed 3 times per week for 4 weeks, consistent with standard rehabilitation guidelines.
To ensure adherence to the home-based program, participants were provided with illustrated brochures outlining the exercise content and dosage. They were also asked to maintain daily exercise logs, which were reviewed during weekly phone calls. In addition, in-person evaluations were conducted every 2 weeks, during which a physiotherapist assessed the technical accuracy of the exercises and provided feedback as needed.
2.6.3. Control protocol
No intervention was applied to the CG. Following the final assessments, participants were offered either treatment or exercise therapy according to their preferences. No adverse effects or harm were reported in any of the groups. Upon study completion, TG participants received education on relaxation exercises, while EG participants were encouraged to continue with manual therapy.
All interventions were delivered as intended. MFR therapy was administered by a physiotherapist trained in manual therapy. Exercise sessions were home-based and monitored weekly. No deviations from the planned protocol were reported. No concomitant care or co-interventions were provided to any group during the study period.
2.7. Outcome measurements
Assessments included the ODI to evaluate LBP, orofacial pain quantified using a digital pressure algometer (Baseline, Istanbul Medipol University, Istanbul, Turkey), and muscle tone, stiffness, and elasticity measured with a myotonometer. Oromotor functionality was assessed using the DC/TMD criteria. Measurements were obtained at baseline and after 4 weeks. The assessments were administered before and after the intervention. No changes were made to the trial outcomes after the trial commenced.
2.7.1. Primary outcomes
2.7.1.1. TMJ pain
The pressure pain threshold (PPT) over the TMJ pain region was assessed using a digital pressure algometer (Baseline).[24] The probe was applied perpendicularly to the belly of the masseter and temporalis muscles, and pressure was gradually increased until the participant reported the first sensation of pain. Three measurements were taken on each side, and the mean value was recorded in kilograms per square centimeter. PPT assessment was limited to the orofacial region and was used to quantify localized mechanical sensitivity associated with TMD. Pressure algometry has demonstrated good validity and complements other pain assessment tools.[34]
2.7.1.2. Muscle tone, elasticity, and stiffness
The MyotonPRO device (Myoton AS, Tallinn, Estonia) was used to evaluate muscle tone, stiffness, and elasticity, providing high inter-rater reliability coefficients (0.94–0.99).[35,36] Measurements were taken bilaterally for the masseter, temporalis, trapezius, erector spinae, quadratus lumborum, and TFL muscles, focusing on the most sensitive trigger points. Three measurements per side were taken at 15-second intervals and the mean values were recorded.[37] Of its 5 biomechanical parameters (oscillation frequency [F], mechanical stress relaxation time [R], creep [C], dynamic stiffness [S], and elasticity [D]) this study analyzed tone, stiffness, and elasticity.
2.7.2. Secondary outcomes
2.7.2.1. Oswestry Disability Index
Functional disability related to LBP was assessed using the ODI, a widely accepted tool.[24,38] Scores were categorized as follows: 0% to 20%, minimal disability; 21% to 40%, moderate disability; 41% to 60%, severe disability; 61% to 80%, crippled; 81% to 100%, bedbound or exaggerating symptoms.[39]
2.7.2.2. TMJ dysfunction questionnaire
TMJ movement was evaluated using the Turkish version of the DC/TMD clinical examination form.[40] The DC/TMD system offers high sensitivity (0.80) and specificity (0.97) for detecting intra-articular disorders.[41]
In accordance with the DC/TMD protocol, 6 functional mandibular movements were assessed using a digital caliper: pain-free maximum mouth opening (PFMO), maximum unassisted mouth opening (MMO), maximum assisted mouth opening (MaMO), right and left lateral excursions, and protrusion. All measurements were performed in millimeters between the incisal edges of the upper and lower central incisors. Each parameter was measured 3 times, and the mean value was used for analysis.
2.8. Power analysis
The sample size was determined using the G*Power sample size calculator (Heinrich Heine University Düsseldorf, Düsseldorf, Germany).[42] With a power of 95% (1 − β = 0.90, λ = 14.7, F = 4.19) and an effect size of 0.28, a total sample size of 45 was calculated for the analysis of variance (ANOVA): repeated measures, within-between interaction design, involving 3 groups and 2 measurement points.
2.9. Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics for Windows, version 29.0 (IBM Corp, Armonk). Descriptive statistics including mean, standard deviation, and percentages were reported. Normality of the data distribution was assessed using the Kolmogorov–Smirnov test. Nominal variables were analyzed with the Chi-square test. For continuous variables, 1-way ANOVA was used to compare groups at baseline.
To evaluate time-dependent changes within and between groups, a general linear model with repeated-measures ANOVA (3 × 2 model) was employed. Post hoc comparisons were adjusted using the Bonferroni correction. A 2-tailed P value of <.05 was considered statistically significant. No interim analyses were planned or conducted. The trial continued as scheduled until all participants completed the interventions. Data were entered into SPSS (v25), verified by 2 researchers, anonymized, and stored securely on institutional servers in accordance with data protection policies.
2.9.1. Trial oversight
Due to the noninvasive nature and low risk of the interventions, no Data Monitoring Committee was established. No interim analyses or stopping criteria were planned. The study was internally overseen by the principal investigators to ensure adherence to the protocol and ethical standards.
3. Results
After 4 weeks of treatment, both the TG and the EG showed statistically significant within-group improvements compared to baseline, as well as superior outcomes compared with the CG. TG exhibited greater and more widespread benefits, particularly in reducing muscle tone and stiffness, and in improving elasticity and oromotor functions. Within-group analysis revealed significant improvements in orofacial pain, muscle properties, and jaw mobility from baseline to week 4 in TG (P < .001). Similarly, EG showed significant but more limited improvements in parameters such as PFMO and muscle tone (P < .05).
Although objective measurements were conducted only at baseline and after 4 weeks, subjective reports from participants indicated a difference in perceived improvement timelines between the groups. TG participants reported noticeable symptom relief as early as the 2nd week, whereas EG participants stated that they felt improvements primarily by the 4th week of treatment. This suggests that MFR therapy may have produced earlier symptomatic relief, while exercise therapy may have required a longer duration to reach noticeable effectiveness.
After 4 weeks of treatment, both MFR therapy (TG) and exercise therapy (EG) demonstrated significant improvements in various parameters compared to the CG. TG exhibited greater and more widespread benefits, particularly in reducing muscle tone, stiffness, and improving elasticity and oromotor functions.
No serious adverse effects were observed in any of the intervention groups. None of the participants reported any harm or discomfort throughout the study period. The trial was conducted and completed in accordance with the prespecified protocol, without any early termination.
3.1. Demographic and clinical characteristics
The study included 45 participants, and no significant differences in age were observed among the 3 groups. However, sex distribution was unbalanced: 11 women and 4 men in the CG, 12 women and 3 men in the TG, and 15 women in the EG. (Table 1).
Table 1.
Distribution of demographic data.
| CG (n = 15) | TG (n = 15) | EG (n = 15) | Between groups findings | |
|---|---|---|---|---|
| Age (avg ± SD) | 36.07 ± 9.32 | 35.87 ± 10.12 | 31.93 ± 7.27 | 0.963 |
| Gender | ||||
| Women (n/%) | 11/24.4% | 12/26.6% | 15/100% | X: 4.398 |
| Men (n/%) | 4/8.8% | 3/6.6% | 0/0% | P: .039 |
Avg = average, CG = control group, EG = exercise group, SD = standard deviation, TG = myofascial release group.
3.2. Between group and group × time interactions
3.2.1. Primary outcomes
3.2.1.1. Orofacial pain
Between-group and group × time interaction results for orofacial pain are presented in Table 2. No statistically significant differences were observed between groups at baseline (P > .05). Following the intervention, orofacial pain significantly decreased in both the MFR therapy group (TG) and the exercise therapy group (EG) compared with the CG.
Table 2.
Orofacial pain findings between groups and time × group interactions.
| PPT | Pretreatment | Posttreatment | Difference | F | ES (Cohen d) | P | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CG (n = 15) | TG (n = 15) | EG (n = 15) | P | CG (n = 15) | TG (n = 15) | EG (n = 15) | P | Mean difference (CI) | ||||
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | |||||||
| R M.M. | 3.80 ± 1.32 | 3.67 ± 1.07 | 3.93 ± 1.06 | .80 | 3.80 ± 1.26 | 4.87 ± 0.91 | 5.13 ± 1.18 | .006 | −0.80 (−1.09/−0.50) | 7.41 | 0.26 | .002 |
| L M.M. | 4.00 ± 1.64 | 3.53 ± 0.91 | 3.87 ± 0.51 | .51 | 3.80 ± 1.26 | 5.07 ± 1.10 | 5.53 ± 1.40 | .004 | −0.02 (−1.31/−0.72) | 15.53 | 0.42 | .000 |
| R M.T. | 4.93 ± 2.21 | 4.27 ± 1.62 | 4.87 ± 1.06 | .50 | 5.00 ± 1.77 | 6.87 ± 1.45 | 6.33 ± 1.34 | .006 | −1.37 (−1.82/−0.93) | 10.99 | 0.34 | .000 |
| L M.T. | 5.40 ± 2.23 | 4.67 ± 1.34 | 5.40 ± 1.12 | .37 | 5.47 ± 2.06 | 7.53 ± 1.76 | 6.73 ± 1.03 | .006 | −1.42 (−1.82/1.03) | 14.77 | 0.45 | .000 |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, CI = 95% confidence of interval, Cohen d = standardized effect size (Cohen d), EG = exercise group, ES = effect size, F = one-way ANOVA F-statistic, L M.M. = left muscle mastoideus, L M.T. = left muscle temporalis, n = number of participants, PPT = pain pressure threshold, R M.M. = right muscle mastoideus, R M.T. = right muscle temporalis, SD = standard deviation, TG = myofascial release group.
PPT values significantly improved in the TG for the right and left masseter muscles (P = .001 and P < .001, respectively) and the right and left temporalis muscles (both P < .001). Similarly, the EG demonstrated statistically significant increases in PPT in the right and left masseter muscles (P = .001 and P = .004, respectively) and the right and left temporalis muscles (P = .002 and P < .001, respectively) (Table 2).
3.2.1.2. Muscle tone (myotonometry)
Between-group and group × time interaction results for muscle tone measurements are presented in Table 3. A statistically significant difference between groups was observed at baseline in the right quadratus lumborum muscle (P = .009).
Table 3.
Muscle tone findings between groups and time × group interactions.
| Myo. Tone | Pretreatment | Posttreatment | Difference | F | ES (Cohen d) | P | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CG (n = 15) | TG (n = 15) | EG (n = 15) | P | CG (n = 15) | TG (n = 15) | EG (n = 15) | P | Mean difference (CI) | ||||
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | |||||||
| R M. Mas. | 16.33 ± 4.57 | 15.93V2.46 | 18.20 ± 3.16 | .18 | 15.80 ± 1.89 | 14.67 ± 2.49 | 16.33 ± 2.69 | .16 | 1.22 (0.23/2.20) | 0.62 | 0.029 | .53 |
| L M. Mas. | 16.47 ± 2.06 | 18.00 ± 2.39 | 18.73 ± 3.21 | .06 | 16.47 ± 2.03 | 16.73 ± 4.79 | 17.00 ± 2.47 | .015 | 1.66 (1.12/2.21) | 12.20 | 0.36 | .00 |
| R M. Tem. | 40.87 ± 6.09 | 42.73 ± 4.89 | 40.00V6.02 | .48 | 40.53 ± 7.23 | 39.07 ± 5.14 | 35.33 ± 6.77 | .09 | 2.88 (1.16/4.61) | 2.34 | 0.10 | .10 |
| L M. Tem. | 36.67 ± 5.90 | 39.13 ± 6.08 | 36.67 ± 5.08 | .40 | 36.60 ± 10.27 | 36.87 ± 5.38 | 36.13 ± 6.14 | .96 | 0.95 (−1.18/3.09) | 0.39 | 0.019 | .67 |
| R M. Trap. | 18.40 ± 1.68 | 19.00 ± 2.50 | 19.00 ± 2.07 | .30 | 18.73 ± 2.08 | 17.47 ± 2.13 | 18.20 ± 1.56 | .21 | 0.86 (0.33/1.40) | 7.19 | 0.25 | .002 |
| L M. Trap. | 19.00 ± 2.67 | 19.20 ± 2.30 | 19.93 ± 2.46 | .56 | 25.40 ± 25.72 | 17.80 ± 2.39 | 18.60 ± 2.19 | .32 | −1.22 (−5.66/3.22) | 1.38 | 0.062 | .26 |
| R M. E. S. | 16.53 ± 3.09 | 17.80 ± 3.00 | 17.67 ± 3.30 | .48 | 19.33 ± 2.44 | 15.93 ± 2.84 | 17.87 ± 4.19 | .023 | −0.37 (−1.40/0.64) | 7.08 | 0.25 | .002 |
| L M. E. S. | 16.87 ± 2.61 | 18.27 ± 3.61 | 19.00 ± 3.83 | .22 | 19.53 ± 2.85 | 16.20 ± 2.39 | 19.33 ± 3.35 | .004 | −0.31 (−1.49/0.86) | 5.46 | 0.20 | .008 |
| R M. Q. L. | 13.33 ± 2.05 | 14.27 ± 1.87 | 15.53 ± 1.59 | .009 | 14.20 ± 1.93 | 12.07 ± 0.96 | 14.53 ± 1.45 | .00 | −0.77 (0.08/1.46) | 6.83 | 0.24 | .003 |
| L M. Q. L. | 13.53 ± 2.05 | 14.73 ± 2.51 | 14.80 ± 1.65 | .13 | 13.87 ± 2.06 | 12.67 ± 1.12 | 14.27 ± 1.66 | .006 | 0.82 (0.15/1.49) | 5.30 | 0.20 | .009 |
| R M. TFL | 15.40 ± 2.99 | 15.53 ± 3.13 | 14.47 ± 3.02 | .58 | 15.87 ± 3.87 | 14.00 ± 2.53 | 14.60 ± 2.26 | .22 | 0.31 (−0.34/0.97) | 3.59 | 0.14 | .036 |
| L M. TFL | 14.07 ± 4.51 | 15.67 ± 3.73 | 13.73 ± 1.66 | .28 | 17.53 ± 4.12 | 12.67 ± 3.47 | 14.27 ± 3.34 | .003 | −0.33 (−1.74/1.07) | 7.15 | 0.25 | .002 |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, CI = 95% confidence interval, Cohen d = standardized effect size (Cohen d), EG = exercise group, ES = effect size, F = one-way ANOVA F-statistic, L M. E. S. = left muscle erector spinalis, L M. Mas. = left muscle mastoideus, L M. Q. L. = left muscle quadratus lumborum, L M. Tem. = left muscle temporalis, L M. TFL = left muscle tensor fascia lata, L M. Trap. = left muscle trapezeus, Myo. Tone = myotonometer tones, n = number of participants, R M. E. S. = right muscle erector spinalis, R M. Mas. = right muscle mastoideus, R M. Q. L. = right muscle quadratus lumborum, R M. Tem. = right muscle temporalis, R M. TFL = right muscle tensor fascia lata, R M. Trap. = right muscle trapezeus, SD = standard deviation, TG = myofascial release group.
Following the intervention, the MFR therapy group (TG) demonstrated statistically significant reductions in muscle tone in the following muscles: left masseter (P < .001), right temporalis (P = .02), left temporalis (P = .019), right trapezius (P = .002), left trapezius (P = .014), right erector spinae (P = .036), left erector spinae (P = .024), right quadratus lumborum (P < .001), left quadratus lumborum (P = .002), right TFL (P = .011), and left TFL (P = .014).
In the exercise therapy group (EG), significant reductions in muscle tone were found in the left masseter (P < .001), right temporalis (P = .004), and left trapezius (P = .036).
No significant change was observed in right masseter muscle tone in either TG or EG (P > .05).
3.2.1.3. Muscle elasticity (myotonometry)
Between-group and group × time interaction results for muscle elasticity are presented in Table 4. No statistically significant differences were observed between groups at baseline (P > .05).
Table 4.
Muscle elasticity findings between groups and time × group interactions.
| Myo. Elas. | Pretreatment | Posttreatment | Difference | F | ES (Cohen d) | P | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CG (n = 15) | TG (n = 15) | EG (n = 15) | P | CG (n = 15) | TG (n = 15) | EG (n = 15) | P | Mean difference (CI) | ||||
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | |||||||
| R M. Mas. | 1.93 ± 0.25 | 1.93 ± 0.25 | 2.07 ± 0.25 | .27 | 1.93 ± 0.25 | 2.00 ± 0.37 | 2.00 ± 0.00 | .72 | 2.22 (−0.11/0.11) | 0.47 | 0.02 | .62 |
| L M. Mas. | 2.07 ± 0.25 | 2.00 ± 0.37 | 2.00 ± 0.00 | .72 | 2.07 ± 0.25 | 1.87 ± 0.81 | 1.93 ± 0.45 | .43 | 0.06 (−0.53/0.18) | 0.42 | 0.02 | .66 |
| R M. Tem. | 1.73 ± 0.45 | 1.73 ± 0.45 | 1.73 ± 0.45 | 1.00 | 1.87 ± 0.35 | 1.73 ± 0.45 | 1.80 ± 0.41 | .67 | −0.06 (−0.21/0.08) | 0.26 | 0.01 | .77 |
| L M. Tem. | 1.47 ± 0.51 | 1.40 ± 0.50 | 1.73 ± 0.45 | .16 | 1.40 ± 0.50 | 1.47 ± 0.51 | 1.60 ± 0.50 | .55 | 0.04 (−0.13/0.22) | 0.41 | 0.02 | .66 |
| R M. Trap. | 1.00 ± 0.00 | 1.00 ± 0.00 | 1.07 ± 0.25 | .37 | 1.00 ± 0.00 | 1.07 ± 0.25 | 1.00 ± 0.00 | .37 | 2.22 (−0.0670.06) | 1.50 | 0.067 | .23 |
| L M. Trap. | 1.00 ± 0.00 | 1.00 ± 0.00 | 1.07 ± 0.25 | .37 | 1.00 ± 0.00 | 1.07 ± 0.25 | 1.00 ± 0.00 | .37 | 2.22 (−0.06/0.06) | 1.50 | 0.067 | .23 |
| R M. E. S. | 1.00 ± 0.00 | 1.20 ± 0.41 | 1.20 ± 0.41 | .18 | 1.20 ± 0.41 | 1.07 ± 0.25 | 1.00 ± 0.00 | .15 | 0.04 (−0.09/0.18) | 3.39 | 0.13 | .04 |
| L M. E. S | 1.00 ± 0.00 | 1.40 ± 0.50 | 1.47 ± 0.51 | .008 | 13.40 ± 44.92 | 1.00 ± 0.00 | 1.40 ± 0.50 | .37 | −3.97 (−12.12/4.17) | 1.08 | 0.04 | .34 |
| R M. Q. L. | 1.07 ± 0.25 | 1.00 ± 0.00 | 1.07 ± 0.20 | .61 | 1.07 ± 0.25 | 1.13 ± 0.35 | 1.00 ± 0.00 | .35 | −0.02 (−0.12/0.07) | 1.40 | 0.06 | .25 |
| L M. Q. L. | 1.13 ± 0.35 | 1.27 ± 0.45 | 1.13 ± 0.35 | .56 | 1.07 ± 0.25 | 1.13 ± 0.35 | 1.00 ± 0.37 | .55 | 0.11 (−0.02/0.24) | 0.11 | 0.005 | .89 |
| R M. TFL | 1.47 ± 0.64 | 1.87 ± 0.51 | 1.47 ± 0.51 | .09 | 1.60 ± 0.50 | 1.47 ± 0.51 | 1.60 ± 0.50 | .71 | 0.04 (−0.14/0.23) | 3.50 | 0.14 | .03 |
| L M. TFL | 1.47 ± 0.64 | 1.80 ± 0.67 | 1.53 ± 0.51 | .30 | 1.80 ± 0.67 | 1.33 ± 0.48 | 1.53 ± 0.64 | .12 | 0.04 (−0.20/0.29) | 3.50 | 0.14 | .03 |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, CI = 95% confidence interval, Cohen d = standardized effect size (Cohen d), EG = exercise group, ES = effect size, F = one-way ANOVA F-statistic, L M. E. S. = left muscle erector spinalis, L M. Mas. = left muscle mastoideus, L M. Q. L. = left muscle quadratus lumborum, L M. Tem. = left muscle temporalis, L M. TFL = left muscle tensor fascia lata, L M. Trap. = left muscle trapezeus, Myo. Elas. = myotonometer elastisity, n = number of participants, R M. E. S. = right muscle erector spinalis, R M. Mas. = right muscle mastoideus, R M. Q. L. = right muscle quadratus lumborum, R M. Tem. = right muscle temporalis, R M. TFL = right muscle tensor fascia lata, R M. Trap. = right muscle trapezeus, SD = standard deviation, TG = myofascial release group.
Following the intervention, the MFR therapy group (TG) demonstrated significant increases in muscle elasticity in the left erector spinae (P = .009) and left TFL (P = .029) compared with the CG.
The exercise therapy group (EG) also showed a significant improvement in left TFL elasticity compared with CG (P < .001).
3.2.1.4. Muscle stiffness (myotonometry)
Between-group and group × time interaction results for muscle stiffness are presented in Table 5. No statistically significant differences were found between groups at baseline (P > .05).
Table 5.
Muscle stiffness findings between groups and time × group interactions.
| Myo. Stif. | Pretreatment | Posttreatment | Difference | F | ES (Cohen d) | P | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CG (n = 15) | TG (n = 15) | EG (n = 15) | P | CG (n = 15) | TG (n = 15) | EG (n = 15) | P | Mean difference (CI) | |||||
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | ||||||||
| R M. Mas. | 310.80 ± 69.20 | 320.60 ± 84.96 | 366.60 ± 77.30 | .12 | 311.07 ± 64.82 | 255.33 ± 42.30 | 330.87 ± 42.30 | .012 | 33.04 (12.64/53.44) | 3.50 | 0.14 | .03 | |
| L M. Mas. | 346.93 ± 58.82 | 362.07 ± 80.09 | 412.40 ± 98.11 | .07 | 345.93 ± 73.61 | 267.67 ± 37.33 | 327.07 ± 60.66 | .002 | 60.31 (42.75/77.86) | 11.71 | 0.35 | .00 | |
| R M. Tem. | 385.80 ± 223.36 | 1069.93 ± 313.79 | 882.07 ± 190.6 | .12 | 962.20 ± 246.91 | 865.53 ± 154.87 | 811.07 ± 210.77 | .14 | 99.66 (35.86/163.46) | 2.93 | 0.12 | .06 | |
| L M. Tem. | 865.260 ± 193.49 | 901.33 ± 337 | 874.07 ± 21.88 | .83 | 874.87 ± 246.80 | 795.80 ± 118.20 | 842.40 ± 206.91 | .57 | 39.31 (−34.08/112.70) | 0.99 | 0.04 | .37 | |
| R M. Trap. | 374.87 ± 57.11 | 368.60 ± 65.37 | 340.60 ± 68.78 | .30 | 339.13 ± 60.07 | 304.20 ± 49.84 | 324.73 ± 36.97 | .17 | 38.66 (22.12/55.21) | 2.95 | 0.12 | .06 | |
| L M. Trap. | 394.60 ± 58.22 | 369.53 ± 58.48 | 353.00 ± 44.49 | .11 | 363.87 ± 65.80 | 307.47 ± 61.81 | 326.00 ± 63.98 | .059 | 33.93 (24.25/55.61) | 2.04 | 0.08 | .14 | |
| R M. E. S. | 316.73 ± 78.40 | 319.53 ± 84.39 | 325.73 ± 113.7 | .96 | 357.93 ± 81.81 | 285.27 ± 78.97 | 352.40 ± 128.67 | .094 | −11.20 (−39.12/16.72) | 2.79 | 0.11 | .07 | |
| L M. E. S. | 325.73 ± 101.48 | 346.87 ± 90.77 | 356.33 ± 95.08 | .68 | 378.73 ± 103.26 | 284.60 ± 102.45 | 378.27 ± 99.62 | .021 | −5.88 (−38.95/27.17) | 4.01 | 0.16 | .02 | |
| R M. Q. L. | 222.47 ± 49.92 | 220.07 ± 44.60 | 237.87 ± 49.51 | .65 | 210.00 ± 39.98 | 183.60 ± 24.49 | 206.40 ± 37.30 | .089 | 25.46 (10.29/40.6) | 0.96 | 0.04 | .39 | |
| L M. Q. L. | 223.80 ± 36.53 | 221.47 ± 48.25 | 223.13 ± 41.08 | .98 | 205.33 ± 45.76 | 181.00 ± 20.56 | 210.53 ± 27.68 | .04 | 23.84 (9.35/38.33) | 1.39 | 0.06 | .25 | |
| R M. TFL | 261.13 ± 59.83 | 269.53 ± 50.43 | 262.00 ± 67.62 | .91 | 262.73 ± 56.36 | 228.67 ± 44.39 | 240.20 ± 58.36 | .21 | 20.28 (8.60/34.97) | 4.49 | 0.17 | .01 | |
| L M. TFL | 266.27 ± 67.87 | 246.87 ± 66.33 | 235.27 ± 27.90 | .23 | 272.07 ± 106.80 | 217.33 ± 47.91 | 233.27 ± 43.89 | .11 | 15.24 (−3.17/33.65) | 3.59 | 0.14 | .03 | |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, CI = 95% confidence interval, Cohen d = standardized effect size (Cohen d), EG = exercise group, ES = effect size, F = One-way ANOVA F-statistic, L M. E. S. = left muscle erector spinalis, L M. Mas. = left muscle mastoideus, L M. Q. L. = right muscle quadratus lumborum, L M. Tem. = left muscle temporalis, L M. TFL = left muscle tensor fascia lata, L M. Trap. = left muscle trapezeus, Myo. Stif. = myotonometer stifness, n = number of participants, R M. E. S. = right muscle erector spinalis, R M. Mas. = right muscle mastoideus, R M. Q. L. = right muscle quadratus lumborum, R M. Tem. = right muscle temporalis, R M. TFL = right muscle tensor fascia lata, R M. Trap. = right muscle trapezeus, SD = standard deviation, TG = myofascial release group.
After 4 weeks, the MFR therapy group (TG) demonstrated significant reductions in muscle stiffness across multiple regions, including the right and left masseter (P = .004 and P < .001, respectively), right temporalis (P = .004), right and left trapezius (P < .001 and P = .001, respectively), left quadratus lumborum (P = .007), and right and left TFL (P < .001 and P = .001, respectively).
The exercise therapy group (EG) showed a significant decrease only in the left masseter (P < .001) compared with the CG. No statistically significant differences in stiffness reduction were found between TG and EG for this muscle (Table 5).
3.2.2. Secondary outcomes
3.2.2.1. LBP (ODI)
Between-group and group × time interaction results for LBP-related disability, as measured by the ODI, are presented in Table 6. No statistically significant differences were observed between groups at baseline (P > .05).
Table 6.
Low back pain and jaw opening findings between groups and time × group interactions.
| Pretreatment | Posttreatment | Difference | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CG (n = 15) | TG (n = 15) | EG (n = 15) | P | CG (n = 15) | TG (n = 15) | EG (n = 15) | P | Mean difference (CI) | F | ES (Cohen d) | P | ||
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | ||||||||
| ODI | 20.73 ± 9.14 | 21.47 ± 8.14 | 19.73 ± 0.09 | .86 | 20.47 ± 9.18 | 9.35 ± 4.99 | 9.73 ± 7.17 | .000 | 7.46 (5.22/9.71) | 10.76 | 0.33 | .000 | |
| DC-TMD | |||||||||||||
| PFMO | 3.13 ± 0.91 | 3.13 ± 0.91 | 2.47 ± 0.51 | .04 | 3.13 ± 0.91 | 3.53 ± 0.83 | 3.13 ± 0.83 | .35 | −0.35 (−0.57/−0.13) | 3.09 | 0.12 | .056 | |
| MMO | 3.93 ± 0.70 | 4.00 ± 0.65 | 3.47 ± 0.74 | .08 | 4.07 ± 0.70 | 4.60 ± 0.82 | 3.80 ± 0.77 | .022 | −0.35 (−0.59/−0.11) | 1.29 | 0.05 | .28 | |
| MaMO | 4.67 ± 0.72 | 4.00 ± 0.63 | 3.93 ± 0.70 | .09 | 4.60 ± 0.82 | 5.20 ± 0.86 | 4.13 ± 0.83 | .005 | −0.24 (−0.51/0.22) | 2.15 | 0.093 | .12 | |
| R.E. | 1.07 ± 0.70 | 1.07 ± 0.79 | 1.20 ± 0.77 | .85 | 0.87 ± 0.83 | 2.00 ± 0.00 | 1.40 ± 0.63 | .000 | −0.31 (−0.53/−0.08) | 8.77 | 0.29 | .001 | |
| L.E. | 1.33 ± 0.81 | 1.47 ± 0.74 | 1.27 ± 0.70 | .76 | 1.40 ± 0.73 | 1.87 ± 0.35 | 1.40 ± 0.82 | .10 | −0.20 (−0.41/0.01) | 0.88 | 0.040 | .42 | |
| P | 0.40 ± 0.50 | 0.27 ± 0.59 | 0.33 ± 0.48 | .79 | 0.47 ± 1.12 | 0.67 ± 0.48 | 0.53 ± 0.64 | .78 | −0.22 (−0.49/0.05) | 0.50 | 0.024 | .60 | |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, CI = 95% confidence interval, Cohen d = standardized effect size (Cohen d), DC-TMD = Diagnostic Criteria for Temporomandibular Disorders, EG = exercise group, ES = effect size, F = one-way ANOVA F-statistic, L.E. = left excursion, MaMO = maximum assisted mouth opening, MMO = maximum mouth opening, n = number of participants, ODI = Oswestry Disability Index, P = protrusion, PFMO = pain-free mouth opening, R.E. = right excursion, SD = standard deviation, TG = myofascial release group.
Both the MFR therapy group (TG) and the exercise therapy group (EG) demonstrated significant reductions in LBP-related disability following the intervention (both P < .001). However, there were no statistically significant differences between TG and EG at week 4 (P > .05), indicating that both treatment approaches were similarly effective in reducing disability associated with LBP.
3.2.2.2. Jaw opening measurements
Between-group and group × time interaction results for jaw opening measurements are presented in Table 6. No statistically significant differences were found between groups at baseline (P > .05).
The MFR therapy group (TG) demonstrated significant improvements in MMO (P = .022), MaMO (P = .005), and right lateral excursion (P < .001) following the intervention.
In contrast, the exercise therapy group (EG) showed a statistically significant improvement only in PFMO (P = .04) compared with the CG. No significant changes were observed in MMO, MaMO, right lateral excursion, left lateral excursion, or protrusion in the EG (all P > .05).
3.3. Time-dependent results between groups
3.3.1. Primary outcomes
3.3.1.1. Orofacial pain
Both MFR therapy (TG) and exercise therapy (EG) led to significant increases in PPT values in the masseter and temporalis muscles, indicating enhanced pain tolerance. In contrast, no significant improvements were observed in the CG, reinforcing the efficacy of these interventions in modulating pain sensitivity. While both therapeutic approaches proved effective, MFR therapy demonstrated superior improvements, particularly in the temporalis muscles (R M.T. and L M.T.), suggesting its potential as a preferred method for increasing pain thresholds in these regions. These findings highlight the role of targeted manual interventions in pain management and underscore the need for further investigation into their long-term effects (Table 7).
Table 7.
Orofacial pain findings between groups and time-dependent results.
| PPT | CG | TG | EG | Between groups | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | P (pre) | P (post) | P (between groups) | |
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | |||||||
| R M.M. | 3.80 ± 1.32 | 3.80 ± 1.26 | 1.00 | 3.67 ± 1.07 | 4.87 ± 0.91 | .001 | 3.93 ± 1.06 | 5.13 ± 1.18 | .001 | .80 | .006 | .002 |
| L M.M. | 4.00 ± 1.64 | 3.80 ± 1.26 | .49 | 3.53 ± 0.91 | 5.07 ± 1.10 | .000 | 3.87 ± 0.51 | 5.53 ± 1.40 | .004 | .51 | .004 | .000 |
| R M.T. | 4.93 ± 2.21 | 5.00 ± 1.77 | .81 | 4.27 ± 1.62 | 6.87 ± 1.45 | .000 | 4.87 ± 1.06 | 6.33 ± 1.34 | .002 | .50 | .006 | .000 |
| L M.T. | 5.40 ± 2.23 | 5.47 ± 2.06 | .67 | 4.67 ± 1.34 | 7.53 ± 1.76 | .000 | 5.40 ± 1.12 | 6.73 ± 1.03 | .000 | .37 | .006 | .000 |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, EG = exercise group, L M.M. = left muscle mastoideus, L M.T. = left muscle temporalis, n = number of participants, Post = posttreatment, PPT = pain pressure threshold, Pre = pretreatment, R M.M. = right muscle mastoideus, R M.T. = right muscle temporalis, SD = standard deviation, TG = myofascial release group.
3.3.1.2. Muscle tone (myotonometry)
Time-dependent changes in muscle tone across groups are presented in Table 8. Both the MFR therapy group (TG) and the exercise therapy group (EG) demonstrated statistically significant reductions in muscle tone in multiple muscle groups, whereas no significant changes were observed in the CG (P > .05).
Table 8.
Muscle tone findings between groups and time-dependent results.
| Myo. Tone | CG | TG | EG | Between groups | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | P (pre) | P (post) | P (between groups) | |
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | |||||||
| R M. Mas. | 16.33 ± 4.57 | 15.80 ± 1.89 | .63 | 15.93 ± 2.46 | 14.67 ± 2.49 | .078 | 18.20 ± 3.16 | 16.33 ± 2.69 | .15 | .18 | .16 | .53 |
| L M. Mas. | 16.47 ± 2.06 | 16.47 ± 2.03 | 1.00 | 18.00 ± 2.39 | 16.73 ± 4.79 | .00 | 18.73 ± 3.21 | 17.00 ± 2.47 | .00 | .06 | .015 | .00 |
| R M. Tem. | 40.87 ± 6.09 | 40.53 ± 7.23 | .84 | 42.73 ± 4.89 | 39.07 ± 5.14 | .02 | 40.00V6.02 | 35.33 ± 6.77 | .004 | .48 | .09 | .10 |
| L M.Tem. | 36.67 ± 5.90 | 36.60 ± 10.27 | .98 | 39.13 ± 6.08 | 36.87 ± 5.38 | .019 | 36.67 ± 5.08 | 36.13 ± 6.14 | .71 | .40 | .96 | .67 |
| R M. Trap. | 18.40 ± 1.68 | 18.73 ± 2.08 | .43 | 19.00 ± 2.50 | 17.47 ± 2.13 | .002 | 19.00 ± 2.07 | 18.20 ± 1.56 | .061 | .30 | .21 | .002 |
| L M. Trap. | 19.00 ± 2.67 | 25.40 ± 25.72 | .34 | 19.20 ± 2.30 | 17.80 ± 2.39 | .014 | 19.93 ± 2.46 | 18.60 ± 2.19 | .036 | .56 | .32 | .26 |
| R M. E. S. | 16.53 ± 3.09 | 19.33 ± 2.44 | .002 | 17.80 ± 3.00 | 15.93 ± 2.84 | .036 | 17.67 ± 3.30 | 17.87 ± 4.19 | .85 | .48 | .023 | .002 |
| L M. E. S. | 16.87 ± 2.61 | 19.53 ± 2.85 | .002 | 18.27 ± 3.61 | 16.20 ± 2.39 | .024 | 19.00 ± 3.83 | 19.33 ± 3.35 | .81 | .22 | .004 | .008 |
| R M. Q. L. | 13.33 ± 2.05 | 14.20 ± 1.93 | .30 | 14.27 ± 1.87 | 12.07 ± 0.96 | .000 | 15.53 ± 1.59 | 14.53 ± 1.45 | .030 | .009 | .00 | .003 |
| L M. Q. L. | 13.53 ± 2.05 | 13.87 ± 2.06 | .59 | 14.73 ± 2.51 | 12.67 ± 1.12 | .002 | 14.80 ± 1.65 | 14.27 ± 1.66 | .31 | .13 | .006 | .009 |
| R M. TFL | 15.40 ± 2.99 | 15.87 ± 3.87 | .31 | 15.53 ± 3.13 | 14.00 ± 2.53 | .011 | 14.47 ± 3.02 | 14.60 ± 2.26 | .85 | .58 | .22 | .036 |
| L M. TFL | 14.07 ± 4.51 | 17.53 ± 4.12 | .041 | 15.67 ± 3.73 | 12.67 ± 3.47 | .014 | 13.73 ± 1.66 | 14.27 ± 3.34 | .57 | .28 | .003 | .002 |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, EG = exercise group, L M. E. S. = left muscle erector spinalis, L M. Mas. = left muscle mastoideus, L M. Q. L. = left muscle quadratus lumborum, L M. Tem. = left muscle temporalis, L M. TFL = left muscle tensor fascia lata, L M. Trap. = left muscle trapezeus, Myo. Tone = myotonometer tones, n = number of participants, Post = posttreatment, Pre = pretreatment, R M. E. S. = right muscle erector spinalis, R M. Mas. = right muscle mastoideus, R M. Q. L. = right muscle quadratus lumborum, R M. Tem. = right muscle temporalis, R M. TFL = right muscle tensor fascia lata, R M. Trap. = right muscle trapezeus, SD = standard deviation, TG = myofascial release group.
In the TG, significant reductions in muscle tone were observed in the left masseter (P < .001), right and left temporalis (P = .02 and P = .019, respectively), right and left trapezius (P = .002 and P = .014, respectively), and right and left quadratus lumborum (P < .001 and P = .002, respectively). In the EG, reductions were observed in selected regions but were less consistent, and did not reach statistical significance in several muscles such as the right trapezius and TFL (P > .05).
Between-group comparisons revealed significantly greater improvements in TG than EG in the quadratus lumborum and TFL muscles (P ≤ .003). However, no significant differences were found between TG and EG in the temporalis or trapezius muscles (P > .05).
3.3.1.3. Muscle elasticity (myotonometry)
Time-dependent changes in muscle elasticity are presented in Table 9. Both the MFR therapy group (TG) and the exercise therapy group (EG) demonstrated statistically significant improvements in muscle elasticity across multiple regions, including the masseter, erector spinae, and TFL muscles. No significant changes were observed in the CG (P > .05).
Table 9.
Muscle elasticity findings between groups and time-dependent results.
| Myo. Elas. | CG | TG | EG | Between groups | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | P (pre) | P (post) | P (between groups) | |
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | |||||||
| R M. Mas. | 1.93 ± 0.25 | 1.93 ± 0.25 | 1.00 | 1.93 ± 0.25 | 2.00 ± 0.37 | .58 | 2.07 ± 0.25 | 2.00 ± 0.00 | .33 | .27 | .72 | .62 |
| L M. Mas. | 2.07 ± 0.25 | 2.07 ± 0.25 | – | 2.00 ± 0.37 | 1.87 ± 0.81 | .33 | 2.00 ± 0.00 | 1.93 ± 0.45 | .58 | .72 | 0.43 | 0.66 |
| R M. Tem. | 1.73 ± 0.45 | 1.87 ± 0.35 | .33 | 1.73 ± 0.45 | 1.73 ± 0.45 | 1.00 | 1.73 ± 0.45 | 1.80 ± 0.41 | 0.58 | 1.00 | 0.67 | 0.77 |
| L M. Tem. | 1.47 ± 0.51 | 1.40 ± 0.50 | .67 | 1.40 ± 0.50 | 1.47 ± 0.51 | .67 | 1.73 ± 0.45 | 1.60 ± 0.50 | .43 | .16 | 0.55 | 0.66 |
| R M. Trap. | 1.00 ± 0.00 | 1.00 ± 0.00 | – | 1.00 ± 0.00 | 1.07 ± 0.25 | .33 | 1.07 ± 0.25 | 1.00 ± 0.00 | .33 | .37 | 0.37 | 0.23 |
| L M. Trap. | 1.00 ± 0.00 | 1.00 ± 0.00 | – | 1.00 ± 0.00 | 1.07 ± 0.25 | .33 | 1.07 ± 0.25 | 1.00 ± 0.00 | .33 | .37 | 0.37 | 0.23 |
| R M. E. S. | 1.00 ± 0.00 | 1.20 ± 0.41 | .082 | 1.20 ± 0.41 | 1.07 ± 0.25 | .33 | 1.20 ± 0.41 | 1.00 ± 0.00 | .082 | .18 | 0.15 | 0.04 |
| L M. E. S. | 1.00 ± 0.00 | 13.40 ± 44.92 | .32 | 1.40 ± 0.50 | 1.00 ± 0.00 | .009 | 1.47 ± 0.51 | 1.40 ± 0.50 | .67 | .008 | 0.37 | 0.34 |
| R M. Q. L. | 1.07 ± 0.25 | 1.07 ± 0.25 | 1.00 | 1.00 ± 0.00 | 1.13 ± 0.35 | .164 | 1.07 ± 0.20 | 1.00 ± 0.00 | .33 | .61 | 0.35 | 0.25 |
| L M. Q. L. | 1.13 ± 0.35 | 1.07 ± 0.25 | .58 | 1.27 ± 0.45 | 1.13 ± 0.35 | .33 | 1.13 ± 0.35 | 1.00 ± 0.37 | .64 | .56 | 0.55 | 0.89 |
| R M. TFL | 1.47 ± 0.64 | 1.60 ± 0.50 | .33 | 15.53 ± 3.13 | 14.00 ± 2.53 | .054 | 1.47 ± 0.51 | 1.60 ± 0.50 | .43 | .09 | 0.71 | 0.03 |
| L M. TFL | 1.47 ± 0.64 | 1.80 ± 0.67 | .20 | 15.67 ± 3.73 | 12.67 ± 3.47 | .029 | 1.53 ± 0.51 | 1.53 ± 0.64 | .00 | .30 | 0.12 | 0.03 |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, EG = exercise group, L M. E. S. = left muscle erector spinalis, L M. Mas. = left muscle mastoideus, L M. Q. L. = left muscle quadratus lumborum, L M. Tem. = left muscle temporalis, L M. TFL = left muscle tensor fascia lata, L M. Trap. = left muscle trapezeus, Myo. Elas. = myotonometer elastisity, n = number of participants, Post = posttreatment, Pre = pretreatment, R M. E. S. = right muscle erector spinalis, R M. Mas. = right muscle mastoideus, R M. Q. L. = right muscle quadratus lumborum, R M. Tem. = right muscle temporalis, R M. TFL = right muscle tensor fascia lata, R M. Trap. = right muscle trapezeus, SD = standard deviation, TG = myofascial release group.
While TG showed numerically greater improvements in certain regions, no statistically significant differences were detected between TG and EG in overall elasticity outcomes (P > .05).
3.3.1.4. Muscle stiffness (myotonometry)
Time-dependent changes in muscle stiffness are presented in Table 10. Both the MFR therapy group (TG) and the exercise therapy group (EG) demonstrated statistically significant reductions in muscle stiffness across several muscle groups. TG showed greater reductions in the erector spinae and quadratus lumborum muscles, while EG exhibited more pronounced changes in the masseter and TFL muscles. No significant changes in muscle stiffness were observed in the CG (P > .05).
Table 10.
Muscle stiffness findings between groups and time-dependent results.
| Myo. Stif. | CG | TG | EG | Between groups | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | P (pre) | P (post) | P (between groups) | ||
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | ||||||||
| R M. Mas. | 310.80 ± 69.20 | 311.07 ± 64.82 | .98 | 320.60 ± 84.96 | 255.33 ± 42.30 | .0004 | 366.60 ± 77.30 | 330.87 ± 42.30 | .11 | .12 | .012 | .03 | |
| L M. Mas. | 346.93 ± 58.82 | 345.93 ± 73.61 | .93 | 362.07 ± 80.09 | 267.67 ± 37.33 | .000 | 412.40 ± 98.11 | 327.07 ± 60.66 | .000 | .07 | .002 | .00 | |
| R M. Tem. | 385.80 ± 223.36 | 962.20 ± 246.91 | .69 | 1069.93 ± 313.79 | 865.53 ± 154.87 | .004 | 882.07 ± 190.6 | 811.07 ± 210.77 | .11 | .12 | .14 | .06 | |
| L M. Tem. | 865.260 ± 193.49 | 874.87 ± 246.80 | .78 | 901.33 ± 337 | 795.80 ± 118.20 | .162 | 874.07 ± 21.88 | 842.40 ± 206.91 | .50 | .83 | .57 | .37 | |
| R M. Trap. | 374.87 ± 57.11 | 339.13 ± 60.07 | .026 | 368.60 ± 65.37 | 304.20 ± 49.84 | .000 | 340.60 ± 68.78 | 324.73 ± 36.97 | .31 | .30 | .17 | .06 | |
| L M. Trap. | 394.60 ± 58.22 | 363.87 ± 65.80 | .002 | 369.53 ± 58.48 | 307.47 ± 61.81 | .001 | 353.00 ± 44.49 | 326.00 ± 63.98 | .12 | .11 | .059 | .14 | |
| R M. E. S. | 316.73 ± 78.40 | 357.93 ± 81.81 | .058 | 319.53 ± 84.39 | 285.27 ± 78.97 | .24 | 325.73 ± 113.7 | 352.40 ± 128.67 | .26 | .96 | .094 | .07 | |
| L M. E. S. | 325.73 ± 101.48 | 378.73 ± 103.26 | .083 | 346.87 ± 90.77 | 284.60 ± 102.45 | .083 | 356.33 ± 95.08 | 378.27 ± 99.62 | .51 | .68 | .021 | .02 | |
| R M. Q. L. | 222.47 ± 49.92 | 210.00 ± 39.98 | .32 | 220.07 ± 44.60 | 183.60 ± 24.49 | .08 | 237.87 ± 49.51 | 206.40 ± 37.30 | .08 | .65 | .089 | .39 | |
| L M. Q. L. | 223.80 ± 36.53 | 205.33 ± 45.76 | .15 | 221.47 ± 48.25 | 181.00 ± 20.56 | .007 | 223.13 ± 41.08 | 210.53 ± 27.68 | .31 | .98 | .04 | .25 | |
| R M. TFL | 261.13 ± 59.83 | 262.73 ± 56.36 | .83 | 269.53 ± 50.43 | 228.67 ± 44.39 | .000 | 262.00 ± 67.62 | 240.20 ± 58.36 | .14 | .91 | .21 | .01 | |
| L M. TFL | 266.27 ± 67.87 | 272.07 ± 106.80 | .78 | 246.87 ± 66.33 | 217.33 ± 47.91 | .001 | 235.27 ± 27.90 | 233.27 ± 43.89 | .87 | .23 | .11 | .03 | |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, EG = exercise group, L M. E. S. = left muscle erector spinalis, L M. Mas. = left muscle mastoideus, L M. Q. L. = left muscle quadratus lumborum, L M. Tem. = left muscle temporalis, L M. TFL = left muscle tensor fascia lata, L M. Trap. = left muscle trapezeus, Myo. Stif. = myotonometer stifness, n = number of participants, Post = posttreatment, Pre = pretreatment, R M. E. S. = right muscle erector spinalis, R M. Mas. = right muscle mastoideus, R M. Q. L. = right muscle quadratus lumborum, R M. Tem. = right muscle temporalis, R M. TFL = right muscle tensor fascia lata, R M. Trap. = right muscle trapezeus, SD = standard deviation, TG = myofascial release group.
3.3.2. Secondary outcomes
Secondary outcome measures are summarized in Table 11. Both the MFR therapy group (TG) and the exercise therapy group (EG) demonstrated statistically significant improvements in ODI scores compared with the CG. Improvements in PFMO were statistically significant in the EG, whereas the TG showed a nonsignificant trend toward improvement (P > .05).
Table 11.
Low back pain and jaw opening findings between groups and time-dependent results.
| CG | TG | EG | Between Groups | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | Pre (n = 15) | Post (n = 15) | P | P (pre) | P (post) | P (between groups) | |
| Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | Avg ± SD | |||||||
| ODI | 20.73 ± 9.14 | 20.47 ± 9.18 | .10 | 21.47 ± 8.14 | 9.35 ± 4.99 | .00 | 19.73 ± 0.09 | 9.73 ± 7.17 | .00 | .86 | .000 | .000 |
| DC-TMD | ||||||||||||
| PFMO | 3.13 ± 0.91 | 3.13 ± 0.91 | 1.00 | 3.13 ± 0.91 | 3.53 ± 0.83 | .082 | 2.47 ± 0.51 | 3.13 ± 0.83 | .012 | .04 | .35 | .056 |
| MMO | 3.93 ± 0.70 | 4.07 ± 0.70 | .16 | 4.00 ± 0.65 | 4.60 ± 0.82 | .007 | 3.47 ± 0.74 | 3.80 ± 0.77 | .26 | .08 | .022 | .28 |
| MaMO | 4.67 ± 0.72 | 4.60 ± 0.82 | .67 | 4.00 ± 0.63 | 5.20 ± 0.86 | .033 | 3.93 ± 0.70 | 4.13 ± 0.83 | .45 | .09 | .005 | .12 |
| R.E. | 1.07 ± 0.70 | 0.87 ± 0.83 | .082 | 1.07 ± 0.79 | 2.00 ± 0.00 | .000 | 1.20 ± 0.77 | 1.40 ± 0.63 | .42 | .85 | .000 | .001 |
| L.E. | 1.33 ± 0.81 | 1.40 ± 0.73 | .58 | 1.47 ± 0.74 | 1.87 ± 0.35 | .028 | 1.27 ± 0.70 | 1.40 ± 0.82 | .61 | .76 | .10 | .42 |
| P | 0.40 ± 0.50 | 0.47 ± 1.12 | .83 | 0.27 ± 0.59 | 0.67 ± 0.48 | .028 | 0.33 ± 0.48 | 0.53 ± 0.64 | .33 | .79 | .78 | .60 |
Bolded values indicate statistically significant results at the 0.05 level.
Avg = average, CG = control group, DC-TMD = Diagnostic Criteria for Temporomandibular Disorders, EG = exercise group, L.E. = left excursion, MaMO = maximum assisted mouth opening, MMO = maximum mouth opening, n = number of participants, ODI = Oswestry Disability Index, P = protrusion, PFMO = pain-free mouth opening, Post = posttreatment, Pre = pretreatment, R.E. = right excursion, SD = standard deviation, TG = myofascial release group.
MMO and MaMO improved significantly in TG, while the EG showed no statistically significant changes in these parameters. TG also showed greater improvements in lateral excursion movements. No significant changes were observed in any secondary outcomes in the CG (P > .05).
4. Discussion
The present study demonstrates that MFR therapy is a more effective intervention than a structured exercise protocol for alleviating TMD symptoms and LBP-related disability. MFR therapy was superior to exercise therapy in improving soft tissue mobility, correcting muscle tone, and reducing localized fascial stiffness. Both interventions effectively reduced pain associated with dysfunction, although no significant difference was observed between them in this regard. These findings align with previous research suggesting that fascial restrictions contribute to chronic pain and dysfunction in interconnected musculoskeletal regions.[43,44]
Notably, this study is the first randomized controlled trial to establish a direct connection between LBP and TMD while evaluating the efficacy of MFR therapy in this context. The observed parallel improvements in TMD and LBP further support the concept of myofascial continuity, emphasizing the need for holistic, regionally integrated treatment approaches. While the EG demonstrated improvements in PFMO, its effects on muscle tone and LBP-related disability were less pronounced. This suggests that while exercise therapy may enhance mobility and neuromuscular control, MFR therapy provides more comprehensive benefits by directly targeting fascial restrictions and muscular tension. These findings highlight the importance of addressing the fascial system in rehabilitation strategies for individuals with comorbid TMD and LBP.
4.1. Primary outcomes
Both MFR and exercise therapy demonstrated significant efficacy in reducing orofacial pain. The absence of a significant difference between groups suggests that both interventions are similarly effective. Recent years have witnessed a growing body of research supporting the efficacy of MFR therapy in alleviating pain associated with TMD.[28,45] Prior research underscores the importance of personalized jaw exercise programs for individuals with TMD, emphasizing the role of both written and verbal instructions in enhancing adherence and therapeutic outcomes.[46] In alignment with these findings, the present study implemented structured exercise protocols and systematically monitored participant compliance. A systematic review highlighted that combining manual therapy with cervical spine exercises is more effective in reducing pain compared to home-based or isolated cervical interventions.[20] The comparable efficacy of MFR and exercise therapy observed in the present study indicates that both approaches likely facilitate fascial relaxation, thereby contributing to pain alleviation.
MFR therapy was more effective than exercise therapy in reducing muscle tone. Specifically, MFR significantly decreased fascial tone across nearly all regions, with the exception of the right masseter muscle. The lack of significant tone reduction in this region may be attributable to right-side dominance, which is associated with increased muscular activity and tension. These findings suggest that MFR therapy may provide a more comprehensive and uniform reduction in muscle tone compared to exercise therapy, potentially due to its direct effect on fascial structures and myofascial tension release. In contrast, exercise therapy demonstrated notable but less pronounced reductions in muscle tone, particularly in the right temporalis, left masseter, left trapezius, and right quadratus lumborum. These changes followed a diagonal distribution, partially aligning with fascial chain transitions; however, the findings lacked consistent statistical significance. A study has demonstrated that exercise therapy is more effective than massage therapy in reducing muscle tone.[47] However, some evidence suggests that exercise therapy may lead to longer-lasting neuromuscular adaptations, which could contribute to sustained muscle tone reduction over time. Previous research has highlighted that while MFR therapy provides immediate relief in muscle tone reduction, exercise therapy might enhance muscular endurance and functional stability, leading to comparable or even superior long-term outcomes in certain cases.[48] Future studies are required to investigate the combined effects of exercise therapy and MFR techniques to optimize therapeutic outcomes.
Research on muscle elasticity remains sparse. Previous findings suggest that MFR enhances lumbar flexibility in individuals with chronic nonspecific LBP.[49] Additionally, interventions such as massage and resistance exercise programs targeting the trapezius muscle in individuals with chronic neck pain have been shown to improve elasticity, with no significant differences between these modalities.[50] In the present study, both interventions exhibited minimal effects on tissue elasticity, highlighting the requirement for further comprehensive investigations to elucidate the mechanisms underlying these interventions.
MFR demonstrated superior efficacy compared to exercise therapy in reducing fascial stiffness. Previous studies have established the effectiveness of MFR in alleviating stiffness in the erector spinae and TFL muscles in chronic LBP[51] as well as in the masticatory muscles.[52] In the present study, MFR significantly reduced stiffness in the orofacial, cervical, and thoracic regions; however, improvements in the lumbar region were limited. This discrepancy may be attributed to the chronic nature of lumbar conditions, which often require prolonged treatment for substantial therapeutic benefits. These findings further support MFR as an effective intervention for reducing fascial stiffness and underscore the need for future research to optimize long-term treatment strategies.
4.2. Secondary outcomes
Both interventions significantly reduced LBP-related disability, with no notable differences between them. Literature supports the effectiveness of both therapies in alleviating LBP and improving functional limitations.[25–27] A meta-analysis reported that exercise therapy offers minor short-term improvements in functional status with no clinically significant impact on pain.[53] Home-based exercise programs have also demonstrated improvements in pain severity and functional limitations in patients with LBP.[51] Similarly, MFR has been associated with reduced pain intensity, improved spinal range of motion, and enhanced disability scores in patients with chronic LBP.[21] These findings suggest that MFR may be a valuable intervention in LBP management.
In terms of oromotor functionality, both the TG and EG demonstrated significant improvements compared to the CG. Exercise therapy was more effective than MFR in increasing PFMO, aligning with literature indicating that jaw exercises do not surpass other conservative treatments but are beneficial for active jaw opening.[21] Daily stretching from exercise therapy may have reduced fascial restrictions, enhancing jaw mobility. Conversely, MFR was more effective in improving MMO, assisted maximum mouth opening, lateral excursions, and protrusion movements, in accordance with studies demonstrating MFR’s positive effects on oromotor function and daily life limitations.[30,52] Additionally, research suggests that massage therapy is superior to post-isometric relaxation techniques in increasing MMO and lateral jaw movements.[28] Tuncer et al also reported that manual therapy and therapeutic exercises significantly improved pain and maximum PFMO in patients with TMD.[54]
The efficacy of MFR for pain relief and functional improvement may be attributed to its influence on fascial networks. Fascia, as a multilayered connective tissue, functions in interconnected chains, implying that releasing restrictions in one area can positively affect the entire system.[55] This highlights MFR’s potential for holistic treatment. Additionally, light-pressure stretching during MFR may activate a parasympathetic response, promoting relaxation and enhancing patient trust through tactile reassurance.[56] The technique’s safety, adaptability, and accessibility make it a viable treatment option for diverse patient populations.
4.3. Limitations
This study has several limitations. The relatively small sample size may have reduced the statistical power and limited the generalizability of the findings. Additionally, the short follow-up period prevented an evaluation of the long-term effects of the interventions. The lack of blinding in intervention groups may have introduced potential bias. Furthermore, factors such as daily habits, previous treatments, and psychological status were not controlled, which could have influenced the outcomes. Finally, one limitation of this study is the difference in the total number of treatment sessions between the intervention groups, which may have influenced the comparability of the treatment effects.
4.4. Generalizability
The findings of present study are relevant to individuals with TMD and LBP; however, caution should be exercised when applying these results to different populations. Factors such as age, sex distribution, and baseline clinical characteristics may influence the effectiveness of MFR and exercise therapy. Additionally, the controlled environment in which the interventions were administered may not fully reflect real-world clinical conditions. Future research should explore the effectiveness of these interventions in more diverse and larger populations to better understand their borader applicability.
4.5. Interpretation and clinical implications
The present study provides evidence supporting the use of MFR as an effective intervention for improving soft tissue mobility, muscle tone, and fascial stiffness. The comparable effectiveness of MFR and exercise therapy in pain reduction suggests that both approaches can be integrated into the management of TMD and LBP. However, considering the observed small effect sizes, further research is necessary to determine their long-term clinical relevance of these interventions. The integration of MFR with therapeutic exercises may lead to enhanced outcomes. Future studies should prioritize extended follow-up periods and objective biomechanical assessments to determine the sustainability of the observed improvements. By refining MFR protocols and combining them with structured exercise programs, a more comprehensive treatment strategy can be developed for musculoskeletal dysfunctions.
Acknowledgments
We would like to thank Miray Budak for her valuable contributions to the statistical analyses and data interpretation. We are also grateful to Esra Atilgan for her guidance throughout the study process. Special thanks to Hanefi Kurt for assisting with participant selection and clinical diagnosis. Finally, we extend our sincere gratitude to the teams at Istanbul Medipol University Dental Hospital for their logistical support and collaboration.
All individuals named in the Acknowledgments section have provided permission to be mentioned.
Author contributions
Conceptualization: Ebru Şenel Topaloğlu, Esra Atilgan.
Data curation: Ebru Şenel Topaloğlu.
Formal analysis: Miray Budak.
Investigation: Ebru Şenel Topaloğlu, Hanefi Kurt.
Methodology: Ebru Şenel Topaloğlu, Esra Atilgan.
Project administration: Ebru Şenel Topaloğlu.
Resources: Hanefi Kurt.
Supervision: Esra Atilgan.
Validation: Miray Budak.
Visualization: Ebru Şenel Topaloğlu.
Writing – original draft: Ebru Şenel Topaloğlu.
Writing – review & editing: Ebru Şenel Topaloğlu.
Abbreviations:
- ANOVA
- analysis of variance
- CG
- control group
- DC/TMD
- Diagnostic Criteria for Temporomandibular Disorders
- EG
- exercise group
- LBP
- low back pain
- MaMO
- maximum assisted mouth opening
- MFR
- myofascial release
- MMO
- maximum mouth opening
- ODI
- Oswestry Disability Index
- PFMO
- pain-free maximum mouth opening
- PPT
- pressure pain threshold
- TFL
- tensor fasciae latae
- TG
- treatment group
- TMD
- temporomandibular disorder
- TMJ
- temporomandibular joint
All participants signed an informed consent form prior to enrollment, in accordance with the principles of the Declaration of Helsinki. No harm or serious adverse events were reported during the study. All interventions were well tolerated by the participants.
This study was approved by the Non-Interventional Clinical Research Ethics Committee of Istanbul Medipol University (Approval No: E-10840098-772.02-6577).
This study was registered in ClinicalTrials.gov with the registration number NCT05673642.
The authors have no funding and conflicts of interest to disclose.
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: Şenel Topaloğlu E, Budak M, Atilgan E, Kurt H. Effect of myofascial release therapy applied to selective muscles on mobility and function in patients with temporomandibular dysfunction and co-occurring chronic low back pain: A randomized controlled trial. Medicine 2025;104:34(e44086).
The full trial protocol is not publicly available but can be provided upon request. The results of this study will be disseminated through publication in a peer-reviewed journal and by updating the registered clinical trial entry (ClinicalTrials.gov: NCT05673642). Participants will be informed of the results upon request. At this time, no plain language summary is planned, but findings may be shared with healthcare professionals through academic presentations or congresses.
Contributor Information
Miray Budak, Email: miray.budak@rutgers.edu.
Esra Atilgan, Email: eatilgan@medipol.edu.tr.
Hanefi Kurt, Email: hanefi.kurt@bilgi.edu.tr.
References
- [1].Lee KC, Wu YT, Chien W-C, Chung C-H, Chen L-C, Shieh Y-S. The prevalence of first-onset temporomandibular disorder in low back pain and associated risk factors. Medicine (Baltim). 2020;99:e18686. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [2].Li DTS, Leung YY. Temporomandibular disorders: current concepts and controversies in diagnosis and management. Diagnostics (Basel). 2021;11:459. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Plesh O, Adams SH. Temporomandibular joint and muscle disorder (TMJMD)-type pain and co-morbid pains in a national US sample. J Orofac Pain. 2011;25:190–8. [PMC free article] [PubMed] [Google Scholar]
- [4].Wiesinger B, Malker H, Englund E, Wänman A. Does a dose-response relation exist between spinal pain and temporomandibular disorders? BMC Musculoskelet Disord. 2009;10:28. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [5].Noh JW, Park YG, Kang HY, et al. Association between temporomandibular disorders and spinal pain: a population-based matched case-control study. BMC Musculoskelet Disord. 2019;20:300.31238918 [Google Scholar]
- [6].Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the global burden of disease study 2019: a systematic analysis for the global burden of disease study 2019. Lancet. 2021;396:2006–17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [7].Kleykamp BA, Ferguson MC, McNicol E, et al. The prevalence of comorbid chronic pain conditions among patients with temporomandibular disorders: a systematic review. J Am Dent Assoc. 2022;153:241–50.e10. [DOI] [PubMed] [Google Scholar]
- [8].Justribó-Manion C, Mesa-Jiménez J, Caballero-Ruiz-de-la-Hermosa C, Zuil Escobar JC, Armijo-Olivo S. Is low back pain a risk/prognostic factor for the development and/or progression of temporomandibular disorders? A systematic review with meta-analysis. J Oral Rehabil. 2024;51:427–54. [DOI] [PubMed] [Google Scholar]
- [9].Mendonça T, Lima A, Silva R, et al. Musculoskeletal disorders and orofacial pain: a narrative review. Fam Med Oral Health. 2023;11:70216. [Google Scholar]
- [10].Stecco C, Day JA, Macchi V, Stecco A, Porzionato A, De Caro R. Anatomy of the deep fascia of the upper limb. J Bodyw Mov Ther. 2019;23:640–6. [DOI] [PubMed] [Google Scholar]
- [11].Wani U, Husein W, Khan AA, et al. Neuroplasticity and pain perception: exploring the complexities of temporomandibular disorders. Front Neurosci. 2025;17:40104480. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [12].Piovesan EJ, Kowacs PA, Tatsui CE, Lange MC, Ribas LC, Werneck LC. Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal pathways. Cephalalgia. 2003;21:107–9. [DOI] [PubMed] [Google Scholar]
- [13].Bartsch T, Goadsby PJ. Stimulation of the greater occipital nerve induces increased central excitability of dural afferent input. Brain. 2002;125(Pt 7):1496–509. [DOI] [PubMed] [Google Scholar]
- [14].Sluka KA, Clauw DJ. Neurobiology of fibromyalgia and chronic widespread pain. Neuroscience. 2016;338:114–29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [15].Manfredini D, Castroflorio T, Perinetti G, Guarda-Nardini L. Dental occlusion, body posture and temporomandibular disorders: where we are now and where we are heading for. J Oral Rehabil. 2017;44:459–71. [DOI] [PubMed] [Google Scholar]
- [16].Bordoni B, Morabito B, Simonelli M, Toccafondi A. The fascial system and exercise intolerance in patients with chronic heart failure: hypothesis of osteopathic treatment. Cureus. 2019;11:e4273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [17].Wright EF, Domenech MA, Fischer JR. Usefulness of posture training for patients with temporomandibular disorders. J Am Dent Assoc. 2000;131:202–10. [DOI] [PubMed] [Google Scholar]
- [18].Wänman A, Marklund S. Treatment outcome of supervised exercise, home exercise and bite splint therapy, respectively, in patients with symptomatic disc displacement with reduction: a randomised clinical trial. J Oral Rehabil. 2020;47:143–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [19].Komiyama O, Kawara M, Arai M, Asano T, Kobayashi K. Posture correction as part of behavioural therapy in treatment of myofascial pain with limited opening. J Oral Rehabil. 1999;26:428–35. [DOI] [PubMed] [Google Scholar]
- [20].Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A. Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis. Phys Ther. 2016;96:9–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [21].Shimada A, Ogawa T, Sammour SR, et al. Effectiveness of exercise therapy on pain relief and jaw mobility in patients with pain-related temporomandibular disorders: a systematic review. Front Oral Health. 2023;4:1170966. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [22].Myers TW. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 4th ed. Elsevier; 2020. [Google Scholar]
- [23].Digiovanna EL, Schiowitz S, Dowling DJ. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Lippincott Williams & Wilkins; 2005. [Google Scholar]
- [24].Balasubramaniam A, Mohangandhi V, Sambandamoorthy AK. Role of myofascial release therapy on pain and lumbar range of motion in mechanical back pain: an exploratory investigation of desk job workers. Ibnosina J Med Biomed Sci. 2022;6:75–80. [Google Scholar]
- [25].Ellythy MA. Efficacy of muscle energy technique versus myofascial release on function outcome measures in patients with chronic low back pain. Bull Fac Ph Th Cairo Univ. 2012;17:51–7. [Google Scholar]
- [26].Chen Z, Wu J, Wang X, et al. The effects of myofascial release technique for patients with low back pain: a systematic review and meta-analysis. Complement Ther Med. 2021;58:102737. [DOI] [PubMed] [Google Scholar]
- [27].Santos GK, de Oliveira RG, de Oliveira LC, et al. Effectiveness of muscle energy technique in patients with nonspecific low back pain: a systematic review with meta-analysis. Eur J Phys Rehabil Med. 2022;58:827–37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [28].Urbański P, Trybulec B, Pihut M. The application of manual techniques in masticatory muscles relaxation as adjunctive therapy in the treatment of temporomandibular joint disorders. Int J Environ Res Public Health. 2021;18:12970. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [29].Reiter S, Jazmawi S, Winocur E, Winocur-Arias O, Kats L, Manor Y. Axis I diagnosis profile according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD): comparison between hospital-based orofacial pain clinic and dental academic-based orofacial pain clinic. J Oral Facial Pain Headache. 2024;38:76–84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [30].Aggarwal A, Gadekar J, Kakodkar P. Role of myofascial release technique on mobility and function in temporomandibular joint disorder patients with neck pain. J Dent Res Rev. 2020;7:58–64. [Google Scholar]
- [31].Nicholas AS, Nicholas EA. Atlas of Osteopathic Techniques. 4th ed. Wolters Kluwer; 2022. [Google Scholar]
- [32].Ajimsha MS, Al-Mudahka NR, Al-Madzhar JA. Effectiveness of myofascial release: systematic review of randomized controlled trials. J Bodyw Mov Ther. 2015;19:102–12. [DOI] [PubMed] [Google Scholar]
- [33].Schleip R, Stecco C, Driscoll M, Huijing PA. eds. Fascia: The Tensional Network of the Human Body: The Science and Clinical Applications in Manual and Movement Therapy. 2nd ed. Elsevier; 2022. [Google Scholar]
- [34].Kim Y, Kim K. Pressure algometry in the general adult population: standard values, validity and reproducibility of pressure threshold measurements. Medicine (Baltim). 2024;103:e4321. [Google Scholar]
- [35].Li YP, Liu CL, Zhang ZJ. Feasibility of using a portable MyotonPRO device to quantify the elastic properties of skeletal muscle. Med Sci Monit. 2022;28:e934121. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [36].Jędrzejewski G, Kasper-Jędrzejewska M, Dolibog P, Szyguła R, Schleip R, Halski T. The Rolf method of structural integration on fascial tissue stiffness, elasticity, and superficial blood perfusion in healthy individuals: a prospective, interventional study. Front Physiol. 2020;11:1062. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [37].Agyapong-Badu S, Aird L, Bailey L, et al. Interrater reliability of muscle tone, stiffness, and elasticity measurements of rectus femoris and biceps brachii in healthy young and older males. Work Pap Health Sci. 2013;4:1–11. [Google Scholar]
- [38].Brodke DS, Goz V, Lawrence BD, Spiker WR, Neese A, Hung M. Oswestry disability index: a psychometric analysis with 1,610 patients. Spine J. 2016;17:321–7. [DOI] [PubMed] [Google Scholar]
- [39].McNeely EL, Zhang B, Neuman BJ, Skolasky RL. Estimating measurement error of the Oswestry Disability Index with missing data. Spine J. 2022;22:975–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [40].Yildirim D, Yildirim TT, Atalay B, et al. Reliability and validity of the Turkish version of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Cranio. 2020;38:405–12. [Google Scholar]
- [41].Ohrbach R, Durham J, Greene C, et al. AAPT diagnostic criteria for chronic painful temporomandibular disorders. J Pain. 2019;20:S14–27. [DOI] [PubMed] [Google Scholar]
- [42].Kang H. Sample size determination and power analysis using the G*Power software. J Educ Eval Health Prof. 2021;18:17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [43].Bordoni B, Myers T. A review of the theoretical fascial models: biotensegrity, fascintegrity, and myofascial chains. Cureus. 2020;12:e7092. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [44].Schleip R, Stecco C, Driscoll M, Huijing PA. eds. Fascia: The Tensional Network of the Human Body: The Science and Clinical Applications in Manual and Movement Therapy. 2nd ed. Elsevier; 2021. [Google Scholar]
- [45].Golanska P, Saczuk K, Domarecka M, Kuć J, Lukomska-Szymanska M. Temporomandibular myofascial pain syndrome: aetiology and biopsychosocial modulation. A narrative review. Int J Environ Res Public Health. 2021;18:7807. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [46].Gębska M, Dalewski B, Pałka L, Kołodziej L. Evaluation of the efficacy of manual soft tissue therapy and therapeutic exercises in patients with pain and limited mobility TMJ: a randomized control trial (RCT). Head Face Med. 2023;19:42. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [47].Kang T, Kim B. Cervical and scapula-focused resistance exercise program versus trapezius massage in patients with chronic neck pain: a randomized controlled trial. Medicine (Baltim). 2022;101:e30887. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [48].Hughes DC, Ellefsen S, Baar K. Adaptations to endurance and strength training. Cold Spring Harb Perspect Med. 2018;8:a029769. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [49].Arguisuelas MD, Lisón JF, Sánchez-Zuriaga D, Martínez-Hurtado I, Doménech-Fernández J. Effects of myofascial release in nonspecific chronic low back pain: a randomized clinical trial. Spine (Phila Pa 1976). 2017;42:627–34. [DOI] [PubMed] [Google Scholar]
- [50].Ożóg P, Weber-Rajek M, Radzimińska A. Effects of isolated myofascial release therapy in patients with chronic low back pain: a systematic review. J Clin Med. 2023;12:6143. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [51].Quentin C, Bagheri R, Ugbolue CU, Coudeyre E. Effect of home exercise training in patients with nonspecific low-back pain: a systematic review and meta-analysis. Int J Environ Res Public Health. 2021;18:8430. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [52].Vieira LS, Pestana PRM, Miranda JP, et al. The efficacy of manual therapy approaches on pain, maximum mouth opening, and disability in temporomandibular disorders: a systematic review of randomized controlled trials. Life (Basel). 2023;13:292. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [53].IJzelenberg W, Oosterhuis T, Hayden JA, et al. Exercise therapy for treatment of acute nonspecific low back pain: a Cochrane systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2024;105:1571–84. [DOI] [PubMed] [Google Scholar]
- [54].Tuncer AB, Ergun N, Tuncer AH, Karahan S. Temporomandibular bozukluklari olan hastalarda manuel terapi ve evde fizik tedavinin etkinliği: randomize kontrollü bir çalişma. J Bodyw Mov Ther. 2013;17:302–8. [DOI] [PubMed] [Google Scholar]
- [55].Kodama Y, Masuda S, Ohmori T, et al. Response to mechanical properties and physiological challenges of fascia: diagnosis and rehabilitative therapeutic intervention for myofascial system disorders. Bioengineering (Basel). 2023;10:474. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [56].Morikawa Y, Takamoto K, Nishimaru H, et al. Myofascial trigger point compression in chronic neck pain alleviates pain through the prefrontal cortex and autonomic nervous system: a pilot study. Front Neurosci. 2017;11:186. [DOI] [PMC free article] [PubMed] [Google Scholar]