Postural habits & awareness and its relationship to pain, functionality, cervical muscle endurance & position sense in temporomandibular joint disorders

Abstract

Background

Although the pain, functionality, proprioception in temporomandibular disorders (TMD) have been frequently investigated, there has been limited knowledge on postural habits & awareness and relation to musculoskeletal parameters. It was aimed to explore the postural habits and awareness level and to investigate the relationship to temporomandibular pain level & pain pressure threshold, functionality, cervical muscle endurance and position sense in individuals with myogenousTMD.

Methods

This case–control study included fifty subjects with myogenous TMD and fifty age- and sex-matched controls. Postural habits & awareness levels were assessed using the Postural Habits and Awareness Scale (PHAS). The pain level and pain pressure threshold were assessed by the Numeric Rating Scale (NRS) and an algometer; functionality was assessed using the Helkimo Clinical Dysfunction Index (HCDI) and the Mandibular Function Impairment Questionnaire (MFIQ). Cervical muscle endurance was performed using flexor and extensor endurance tests, while position sense was tested using the Laser Pointer Assisted Angle Reproduction Test (LP-ART).

Results

PHAS score were significantly lower in the myogenous TMD group (p < 0.001). Within the myogenous TMD group, a moderate negative correlation was found between PHAS score and activity-related pain level (-0.429). Low-moderate level of negative correlations was observed between the scores of PHAS and the HCDI (-0.337), MFIQ (-0.445 & -0.496). and LP-ART in cervical extension (-0.326) & lateral flexion (-0.406, -0.365).

Conclusions

Low level of postural habits & awareness and its relationship with pain level, jaw functionality and cervical proprioception were observed in individuals with myogenous TMD. Current findings highlight the importance of considering postural awareness along with local symptoms in myogenous TMD by the clinicians working with this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-08036-9.

Introduction

Temporomandibular disorders (TMD) are defined as a group of musculoskeletal and neuromuscular conditions involving the masticatory muscles, the temporomandibular joint (TMJ), or associated structures [1]. TMD, affecting approximately 34% of the general population, includes a variety of diseases and disorders that impact the structure, function, and physiology of the masticatory system. Recent epidemiological projections further suggest that the global prevalence of TMD may increase to 44% by 2050, highlighting its growing public health relevance [2]. In addition to contributing to other chronic pain conditions such as migraine and fibromyalgia, functional limitations caused by TMD are frequently associated with neck and back pain, as well as comorbidities in different body regions [3].

TMD represents a heterogeneous group of conditions that can be broadly categorized into myogenous, arthrogenous, and mixed subtypes, which may differ in their underlying mechanisms and clinical presentation [4]. Although the theory of a pathophysiological relationship between temporomandibular and cervical disorders has been investigated [5], there is still no definitive consensus on the nature of this relationship in the context of myogenous TMD. While the studies have attempted to confirm a connection between temporomandibular and cervical disorders based on parameters such as head and neck posture, cervical spine mobility, and muscle tenderness [6, 7], other studies have emphasized the need for further research [8, 9]. In addition to environmental and biomechanical explanations, contemporary pain models emphasize the role of central pain mechanisms, particularly central sensitization, in the co-occurrence of myogenous TMD with other chronic pain conditions [10]. This framework suggests that the symptom overlap between myogenous TMD, migraine, fibromyalgia, and spinal pain should be considered along with biomechanical interactions and pain processing processes.

Disrupted neuromuscular control of the cervical spine may provoke pain-sensitive structures in the neck, potentially leading to increased pain in both cervical and orofacial areas. Individuals with myogenous TMD may experience neck pain, restricted range of motion, and functional and behavioral changes [11]. Postural changes in head position and the cervical spine may lead to excessive loading on the TMJ, contributing to the development of myogenous TMD [12, 13]. Some studies have reported alterations in mandibular joint position sense and postural control in individuals with myogenous TMD; however, the current evidence remains limited and heterogeneous [14–16].

Postural awareness is closely related to the proprioceptive system. It refers to the subjective and conscious perception of posture, which is formed through proprioceptive feedback from the body to the central nervous system [17]. While postural awareness reflects a perceptual and cognitive dimension of body position, postural habits represent behavioral patterns adopted in daily life. Although related, these constructs are conceptually distinct. Several studies in the literature have shown that patients with back and neck pain tend to have impaired proprioceptive sense [18, 19], suggesting that those individuals may also have lower levels of postural awareness [17]. Improving habitual postural patterns is thought to contribute to recovery in musculoskeletal pain conditions or related to further deterioration [20, 21]. However, altering habitual postural patterns necessitates a certain level of postural awareness. In this regard, postural awareness serves as a key prerequisite for developing and sustaining healthy posture and movement behaviours in daily life [17].

Although there are studies evaluating musculoskeletal problems related to postural habits and awareness in school-aged children or adolescents [22, 23], no studies have been found that investigate postural habits and awareness levels or the relationship between these awareness level and other musculoskeletal parameters in individuals with myogenous TMD. In this context, the primary aim of the present study is to compare postural habits and awareness levels between individuals with and without myogenous TMD. We hypothesized that individuals with myogenous TMD would demonstrate lower postural habits and awareness levels compared to controls. The secondary objective of the study is to explore potential cross-sectional associations between postural habits and awareness, as well as parameters such as pain level, TMJ functionality, cervical muscle endurance, and proprioception sense, in individuals with myogenous TMD. We further hypothesized that lower postural habits and awareness would be associated with higher pain intensity and poorer functional outcomes within the TMD group.

Methods

This cross‑sectional, case–control study was conducted between October 2024 and January 2025 at Oral, Maxillofacial and Dental Health Clinic of Central Hospital, located in the Kadıkoy district of Istanbul city. The study protocol was approved by the Clinical Research Ethics Committee of Marmara University Faculty of Medicine (09.2024.61). Before proceeding with the test procedure, the subjects were informed about the research, and their written and verbal consent was obtained.

A total of 100 participants were included in the study: 50 subjects aged between 20 and 60 who had been diagnosed with myogenous TMD by the dentist and met the inclusion criteria, and 50 controls who had not been previously diagnosed with myogenous TMD and met the inclusion criteria. The clinical evaluation of the presence and type of TMDs were performed according to the Diagnostic Criteria for TMDs (DC/TMD) by a maxilla facial surgeon with 12 years of professional experience and individuals with only myogenous TMDs were included. The DC/TMD Axis I protocol was used for clinical diagnosis and classification. Axis II psychosocial assessment was not performed in the present study.No a priori sample size calculation was performed before the study initiation. The sample size (50 patients and 50 controls) was determined based on feasibility and recruitment capacity. According to recent methodological recommendations [24], a case–control design with 50 participants per group is generally sufficient to detect medium effect sizes with approximately 80% power. The inclusion criteria for the myogenous TMD group were; experiencing pain in the jaw, facial, or temporal region for at least 3 months, reporting a pain intensity of at least 3 on the Numeric Rating Scale (NRS), and being newly diagnosed with myogenous TMD at the time of assessment. All assessments were performed prior to the initiation of any pharmacological or rehabilitative treatment. The exclusion criteria applied to both groups: undergoing orthodontic or splint therapy; having symptoms of orofacial diseases (e.g., neuralgia, migraine); presence of disc displacement; previous botulinum toxin intervention around the TMJ; regular use of analgesics or anti-inflammatory drugs; history of TMJ or cervical surgery or trauma (e.g., whiplash injury, condylar trauma, fracture); history of facial paralysis; history of alcohol or drug addiction; inability to understand study instructions or to comply with assessment procedures;; diagnosed psychiatric disorders; being pregnant or breastfeeding; systemic pathological conditions such as rheumatoid diseases; or other musculoskeletal problems affecting the cervical region, such as impingement or thoracic outlet syndrome. Individuals with a diagnosis of migraine were excluded to minimise potential confounding effects related to central pain processing and pain sensitivity, which could independently influence postural awareness, pain perception, and functional parameters. This approach was adopted to obtain a more homogeneous sample of patients with isolated myogenous TMD.

The demographic characteristics, the information of medical and family history, educational background, occupation, medication use, and any chronic or psychological conditions of subjects were recorded. A comprehensive explanation of the study protocol was provided to all subjects, and they were asked to sign the “Informed Consent Form”.

Data collection

The postural habits and awareness levels of subjects were assessed using the Postural Habits and Awareness Scale (PHAS). To evaluate musculoskeletal parameters, the NRS and pressure pain threshold measurement with an algometer were used to assess pain intensity. The DC/TMD was used for diagnostic classification of TMD subtypes. The Helkimo Clinical Dysfunction Index (HCDI) and Mandibular Function Impairment Questionnaire (MFIQ) were particularly employed to assess the severity of clinical dysfunction and functional impairment, as DC/TMD does not provide a graded dysfunction index. Cervical muscle endurance was evaluated using neck flexor and extensor endurance tests, while proprioception was assessed using the Laser Pointer-Assisted Angle Reproduction Test (LP-ART).

Postural habits and awareness

Individuals’ posture habits adopted in daily life and their awareness of these postures were assessed using the PHAS. The scale, developed in Turkish, was administered to native Turkish speakers. It comprises 7 items focusing on postural habits and 12 items assessing postural awareness, all rated on a 5-point Likert scale (English translation of the items is included in the appendix). The scale includes 7 items that are reverse-scored. Total scores range from 0 to 95, with higher scores reflecting better postural habits and greater postural awareness. The scale was recently developed in 2023 by Bayar et al., and its validity and reliability have been established (internal consistency coefficient > 0.85, p < 0.05) [25].

Pain

The NRS is a widely used, valid, and reliable tool that was utilised to assess pain intensity as reported by the subjects [26]. The NRS is a linear scale ranging from 0 to 10, where 0 indicates “no pain” and 10 represents “the worst pain imaginable.” Participants were asked to indicate or verbalise the number that best reflected the intensity of their perceived pain. The pain intensity related to the TMJ region was assessed by NRS as a single measurement at rest, during activity, and throughout the night.

Pressure algometer was designed to measure deep pressure pain thresholds or tolerance to sensitivity. A mechanical algometer device (Baseline brand Dolorimeter, 22LB/10 kg) was used to assess pain threshold and tolerance of subjects. Pressure was gradually increased at a constant rate of approximately 1 kg/cm² per second until the participant indicated the first sensation of pain. Measurements were performed bilaterally at each anatomical site. Three consecutive measurements were obtained at each location with 30-second intervals between trials, and the mean value was used for statistical analysis. All measurements were performed by the same trained examiner using a standardised protocol to eliminate inter-examiner variability. The device features a rubber disk with a surface area of 1 cm², which is pressed against a specific body region to display the applied pressure. The pressure pain threshold measurement was taken over the temporalis, trapezius, and sternocleidomastoid muscles, the lateral and dorsal regions of the temporomandibular capsule [27]. The selected assessment sites were chosen to evaluate not only local masticatory muscle sensitivity, but also peripheral and cervical pain sensitivity potentially associated with postural alterations. The temporalis muscle was included as a representative craniofacial muscle, whereas the sternocleidomastoid and upper trapezius muscles were selected due to their functional relationship with cervical posture. The lateral and dorsal regions of the temporomandibular capsule were assessed to capture joint-related pain sensitivity. The aim was not to provide a comprehensive mapping of all masticatory muscles but to examine pain sensitivity in regions potentially related to cervical and postural interactions.

Functional assessment

The HCDI, developed by Helkimo in 1974, is a test designed to quickly and simply assess limitations in mandibular movement, pain, and joint function. The HCDI is not a self-report scale; rather, it is administered by clinicians. It has been shown to have a sensitivity of 86.67% and specificity of 68.09% in predicting the presence of TMD [28].

The validated Turkish version MFIQ was developed by Stegenga et al. in 1993 to evaluate mandibular functional impairments in patients with TMD [29]. It consists of 17 items divided into 2 subscales. Each item is rated on a 5-point scale from 0 to 4 (0 = no difficulty; 1 = slight difficulty; 2 = some difficulty; 3 = severe difficulty; 4 = very difficult or impossible without assistance). Total scores range from 0 to 68. The first 11 items represent the “Functional Capacity” subscale, while the last 6 items comprise the “Feeding” subscale. Higher total scores indicate greater mandibular dysfunction, while lower scores indicate reduced impairment. A new Turkish version of the questionnaire was developed by Yıldız et al., demonstrating strong internal consistency (Cronbach’s alpha = 0.916) [30].

Muscle endurance

The neck flexor endurance test was performed as the subject lies in a hook-lying position with their hands resting on the abdomen. While maintaining maximum chin tuck, they are asked to lift their head 2.5 cm off the surface and hold the position for as long as possible. The duration (in seconds) is recorded, and the test is terminated when the participant experiences pain or can no longer maintain the position [31]. The neck extensor endurance test was performed as the subject lies prone with their head and neck unsupported beyond the edge of the examination table and arms positioned along the sides of the body. They are asked to maintain this position for as long as possible. The endurance time is measured with a stopwatch and recorded in seconds. The test is ended if pain occurs or the position is lost [32].

Proprioception

Cervical proprioception test is typically evaluated using head repositioning tests, which are considered valid and reliable method. The test protocol of LP-ART defined by Revel et al. was performed to assess neck proprioception sense in the directions of flexion, extension, bilateral rotations and lateral flexions [33].

Statistical analysis

All evaluation data were analysed using IBM SPSS Statistics 26 (SPSS Inc., Chicago, IL, USA). The normality of the data distribution was assessed using the Kolmogorov-Smirnov test and other parametric test assumptions. The Independent Samples t-test was conducted to compare postural habits and awareness levels of subjects with and without TMD. The relationship between postural habits and awareness and variables such as values of HCDI, MFIQ-1, muscle endurance tests, and LP-ART was researched by using Spearman correlation analysis. The relationship between postural habits and awareness and MFIQ-2 was assessed using Pearson correlation analysis The effect size thresholds in accordance with established guidelines: for Pearson’s r, 0.20 for small effects, 0.40 for medium effects, and 0.70 for large effects; and for Cohen’s d or Hedges’ g, 0.10 for small effects, 0.40 for medium effects, and 0.90 for large effects [24].

Results

A total of 100 individuals participated in the study, comprising 50 subjects with myogenous TMD (mean age: 34.52 ± 12.61) and 50 healthy controls (mean age: 38.00 ± 10.92). There was no statistically significant difference in age between the groups (Z =-1.886, p = 0.059). The gender distribution in the myogenous TMD group was 29 females and 21 males, while in the control group it was 26 females and 24 males, with no significant difference in gender between the groups (p = 0.54).

The myogenous TMD group had significantly lower postural habits and awareness levels compared to the control group (59.42 ± 6.71 vs. 66.90 ± 6.78; t = -5.541, p < 0.001), with a large effect size (Cohen’s d = 1.11). In the myogenous TMD group, the mean NRS pain scores were 3.58 ± 0.94 at rest, 4.82 ± 1.39 during activity, and 4.00 ± 1.32 at night.

In the myogenous TMD group, the relationship between postural habits and awareness levels and selected musculoskeletal parameters was examined. A moderate, statistically significant negative correlation was found between postural habits and awareness levels and NRS scores during activity (r =-0.429, p = 0.002). This indicates that individuals in the myogenous TMD group who had lower postural habits and awareness experienced higher pain during activity. No significant correlation was found between postural habits and awareness levels, and NRS scores during rest or throughout the night (r = -0.210, p = 0.143; and r = -0.258, p = 0.070, respectively). No significant relationship was found between postural habits and awareness levels and pressure pain thresholds measured over the right and left temporalis, trapezius, sternocleidomastoid muscles, and the lateral and dorsal capsule (Table 1, p> 0.05).

Table 1.

Correlation between parameters of postural habits and awareness, and pressure pain threshold

	Temporalis		Trapezius		SCM
	Right	Left	Right	Left	Right	Left
r	0.002	0.033	− 0.111	− 0.027	− 0.079	0.087
p	0.989	0.820	0.442	0.853	0.586	0.550

	Lateral Capsule			Dorsal Capsule
	Right	Left		Right		Left
r	− 0.033	0.158		0.266		0.241
p	0.820	0.272		0.062		0.092

Spearman Correlation Analysis, SCM: Sternocleidomastoid

In terms of TMJ functionality, a significant correlation was found between postural habits and awareness level and the HCDI score (r =-0.337, p = 0.017) (Fig. 1). This indicates higher functional capacity in the jaw as the postural habits and awareness score increase, in the individuals with myogenous TMD. Additionally, a moderate negative correlation was observed between postural habits and awareness level and MFIQ-1 (8.78 ± 5.66) and MFIQ-2 (6.96 ± 4.10) scores in relation to TMJ functionality (r =-0.445, p = 0.001; r =-0.496, p = 0.001, respectively) in the myogenous TMD group (Figs. 2 and 3). This finding suggests that individuals who have higher postural habits and awareness, has higher TMJ functional performance.

Fig. 1.

The correlation analysis between the PHAS and the HCDI scores PHAS: Postural Habits and Awareness Scale, HCDI: Helkimo Clinical Dysfunction Index

Fig. 2.

The correlation analysis between the PHAS and the MFIQ-1 scores PHAS: Postural Habits and Awareness Scale, MFIQ-1: Mandibular Function Impairment Questionnaire-1

Fig. 3.

The correlation analysis between the PHAS and the MFIQ-2 scores PHAS: Postural Habits and Awareness Scale, MFIQ-2: Mandibular Function Impairment Questionnaire-2

In the myogenous TMD group, no significant correlation was found between postural habits and awareness level, and neck flexor and extensor muscle endurance (r = 0.012, p = 0.933; and r = -0.115, p = 0.425).

The relationship between postural habits and awareness level, and cervical proprioception was examined using the LP-ART in the myogenous TMD group. Negative correlations were found between PHAS total score and LP-ART parameters in the selected neck movements. A weak negative correlation in extension (r =-0.326), a moderate negative correlation in right lateral flexion (r =-0.406), and weak negative correlations in left lateral flexion (r =-0.365) and right rotation (r =-0.294) (Table 2). No significant correlation was observed in flexion and left rotation movements (p> 0.05). As the level of postural habits and awareness decreases, proprioception is getting weaker in various directions in the subjects with myogenous TMD.

Table 2.

Correlation between postural habits and awareness, and cervical proprioception sense

		Postural Habits and Awareness Scale Score
Flexion	r	− 0.261
	p	0.067
Extension	r	− 0.326*
	p	0.021
Right Lateral Flexion	r	− 0.406*
	p	0.003
Left Lateral Flexion	r	− 0.365*
	p	0.009
Right Rotation	r	− 0.294*
	p	0.038
Left Rotation	r	− 0.258
	p	0.071

r: Spearman Correlation, *p < 0.05

Discussion

In the present study, postural habits and awareness were primarily investigated comparatively individuals with and without myogenous TMD and it has shown that individuals with TMD had lower levels of postural habits and awareness than controls. Secondarily, it was aimed to research the relationship between the level of postural habits and awareness and various parameters such as pain intensity, TMJ functionality, cervical muscle endurance, and proprioception in individuals with myogenous TMD. According to the findings, individuals with myogenous TMD who had higher levels of postural habits and awareness demonstrated better TMJ functionality, improved proprioception sense, and lower pain intensity during activity. Due to the cross-sectional design, causal relationships cannot be inferred.

Although there have been studies on the musculoskeletal system that examine the level of postural habits and postural awareness [22, 23, 34, 35], no previous research has been found that investigates these parameters explicitly in individuals with TMD. Thus, the findings of the present study contribute to the existing literature by specifically examining postural habits and postural awareness in individuals with myogenous TMD, a research field that has received limited direct investigation. with myogenous TMD [36], and the between-group difference demonstrated a large effect size (d = 1.11), indicating a substantial magnitude of difference in postural awareness between individuals with and without myogenous TMD, beyond mere statistical significance. Meanwhile, the PHAS total score encompasses both behavioural and perceptual dimensions; therefore, the present findings should not be interpreted as reflecting a single unified functional construct.

People experiencing jaw and neck pain may experience changes in neck posture or jaw position to alleviate discomfort. From another perspective, abnormal cranio-cervical posture has been reported to be associated with TMD in some studies; however, current evidence remains inconsistent and methodologically heterogeneous [37, 38]. Such postural changes can disrupt the neutral alignment of the head and negatively related to proprioceptive input and postural stability [39, 40]. The individuals with lower proprioception sense exhibited lower postural habits and awareness in the level of weak-moderate correlation in the current study. Misperceiving a faulty posture as correct may is associated with inappropriate motor responses and alterations in muscle activity [41]. Therefore, it is essential to examine postural habits and awareness in detail and monitor them over the long term in individuals with TMD, in addition to other musculoskeletal parameters.

The body awareness, which is also related with postural awareness, is considered directly associated with musculoskeletal pain and emotional state [42]. In the present study, individuals who reported higher pain levels during activity also demonstrated lower postural awareness and habit scores. A moderate negative association was observed between postural awareness and pain during activity. However, the directionality of this relationship cannot be determined. It is possible that reduced postural awareness is associated with higher pain levels, but it is equally plausible that increased pain interferes with perceptual and sensorimotor processing, leading to diminished postural awareness. Habitual teeth clenching is considered one of the major contributing factors to myogenous TMD [37]. Such habitual postural patterns exhibited by individuals in the myogenous TMD group during activity may have also showed lower postural habit and awareness scores. One possible explanation of higher level of pain during activity in the individuals with lower postural awareness would be that pain may occur when individuals revert to a habitual poor postural pattern during activity or periods of concentration. It has been suggested that painful myogenous TMD can influence postural control through the jaw sensorimotor system [40]. Considering current results and literature, increasing postural awareness by receiving postural training may have direct or indirect positive impact on musculoskeletal pain and emotional conditions according to TMD [43].

Another parameter examined in individuals with myogenous TMD is cervical proprioception sense has been to be negatively related [15]. However, to date, no previous study has directly investigated the relationship between postural habits and awareness level and proprioception sense in myogenous TMD group. In the present study, individuals with myogenous TMD who exhibited poorer joint position sense had lower levels of postural habits and awareness. In individuals with chronic neck pain or fibromyalgia syndrome, decreased proprioception sense has been reported to negatively related to neck functionality, postural control, and quality of life [44]. Although its role has not been conclusively demonstrated, the stomatognathic system is considered to contribute to postural control [45]. Proprioceptive signals from the stomatognathic system are believed to interact with vestibular and oculomotor inputs, and changes in trigeminal stimulation could result in dysfunction within these systems [46]. In myogenous TMD, reduced proprioceptive feedback and low postural awareness levels may be explained by the involvement of the stomatognathic system. In addition, it have been suggested that modifications in mandibular position, which can alter proprioceptive and periodontal afferents, may also influence postural mechanisms [47]. Although altered stomatognathic afferentation may contribute to changes in proprioception and postural awareness, contemporary models of TMD emphasise the role of central pain mechanisms, including central sensitisation, as well as psychosocial factors. Therefore, the observed alterations are likely multifactorial rather than attributable to a single peripheral mechanism. In addition, Parafunctional behaviours such as tooth clenching may contribute to increased mechanical loading and nociceptive input in the stomatognathic system [48, 49]. Nevertheless, current evidence supports a multifactorial framework in which peripheral factors, central pain mechanisms, and psychosocial influences interact dynamically.

Considering that myogenous TMD may alter neuromuscular control and is associated with abnormal afferent input, TMJ functions may be related to because of the strong functional connection between the cervical spine and the masticatory system during activities such as swallowing, chewing, and cervical movements [50, 51]. It was observed that individuals with higher postural habits and awareness levels had better TMJ functionality. This finding is consistent with the results of Miçooğulları et al., who reported impaired postural stability and mandibular function in individuals with myogenous TMD [52]. Lower level of postural habit and awareness may be one of the risk factors of occurring poor TMJ functionality. We suggest of consideration that feature beside other risk factors of myogenous TMD by clinicians. As mentioned above, postural awareness training may also have positive effects on TMJ functionality.

The jaw and neck pain can associated with muscle imbalances, related to proprioception and impairments in dynamic postural stability [39]. Many studies have demonstrated reduced endurance of cervical flexor and extensor muscles in individuals with myogenous TMD [11, 53]. Considering the literature, there have also been other research examining muscle endurance in chronic neck pain [54]. In individuals with chronic neck pain, a low to moderate correlation was found between chronic neck pain intensity and cervical muscle endurance [54]. Although the relationship between muscle endurance and various parameters in different subjects and myogenous TMD has been investigated, the relationship between postural habits & awareness and cervical flexor & extensor muscle endurance investigated in the current study from a different perspective. Although deficiencies in muscle endurance have been previously identified in the presence of myogenous TMD or cervical postural disorders and pain [51, 54, 55], cervical flexor and extensor muscle endurance was not observed to be associated with poor postural awareness in the current study. It is possible that postural awareness is more closely related to sensorimotor processing and perceptual mechanisms than to peripheral muscular endurance capacity. Therefore, postural awareness should not be interpreted as a determinant of all musculoskeletal performance parameters in individuals with myogenous TMD.

This study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design precludes any inference regarding causality or directionality between postural habits, postural awareness, and musculoskeletal parameters. Second, the study was conducted at a single centre, which may limit generalisability and introduce potential selection bias. Third, although standardised procedures were applied, the assessors were not blinded to group allocation during pressure pain threshold and functional assessments, which may have introduced measurement bias. Additionally, sample size estimation was supported by post-hoc power analysis rather than an a priori calculation, which may limit the strength of statistical inference. The use of self-reported measures, including the PHAS, NRS, and MFIQ, may also increase the risk of reporting bias. Furthermore, no objective assessment of global body posture (e.g., photographic or radiographic analysis) was performed to directly correlate with postural awareness findings. Finally, although the PHAS has demonstrated acceptable psychometric properties in the general population, it has not been specifically validated in individuals with chronic facial pain or myogenous TMD, and therefore the interpretation of postural awareness results in this clinical population should be approached with caution.

Future research should employ longitudinal designs to determine whether changes in postural awareness are temporally associated with clinical improvement in individuals with TMD. Interventional studies are also warranted to investigate whether structured postural or body awareness–based programmes influence pain intensity, TMJ functionality, and proprioceptive parameters. Such trials would help clarify potential therapeutic relevance while addressing the limitations of cross-sectional data. Additionally, broader inclusion of different TMD subtypes, including arthrogenous and mixed forms, as well as analyses exploring potential sex-specific and age-related differences, would contribute to a more comprehensive understanding of the role of postural constructs within the heterogeneous TMD population.

Conclusion

In summary, individuals with myogenous TMD demonstrated lower postural habits and awareness levels compared to controls. Within the TMD group, postural awareness was associated with pain during activity, TMJ functionality, and selected proprioceptive parameters. These findings suggest an association between postural awareness and clinical characteristics in myogenous TMD; however, causal relationships cannot be inferred due to the cross-sectional design. Postural awareness may represent a potential area of interest in rehabilitation contexts, and further longitudinal and interventional studies are required to clarify its clinical relevance.

Supplementary Information

Below is the link to the electronic supplementary material.

Authors' contributions

All authors contributed to the study conception and design. Material preparation and data analysis was performed by [24]. Data collection was performed with [Zeynep Damar] and [Şeyma Alla]. The first draft of the manuscript was written by [Zeynep Damar], [Bahar Özgül] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval and consent to participate

The study protocol was approved by the Clinical Research Ethics Committee of Marmara University Faculty of Medicine (09.2024.61).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.