Effectiveness of Telerehabilitation in Individuals With Myofascial Pain and Temporomandibular Joint Dysfunction: A Randomized Controlled Trial

ABSTRACT

Background

Temporomandibular disorders (TMD), particularly the myofascial subtype, are common and impair quality of life. Although conservative treatments are effective, limited access and adherence issues highlight the need for alternative approaches such as telerehabilitation.

Objectives

To evaluate the effects of a supervised telerehabilitation program, comparing its physical and psychosocial outcomes with those of a standard home‐based exercise program in individuals with myofascial TMD.

Methods

In this randomized, single‐blind trial, 50 individuals with myofascial TMD were assigned to a telerehabilitation (TeleR, n = 25) or a home‐based exercise group (HomeEx, n = 25), both following the same 6‐week standardized exercise protocol. Outcomes included pain intensity (NPRS, primary), palpation pain, cervical‐mandibular range of motion (ROM), TMD severity (FAI), oral habits (OBC), oral health‐related quality of life (OHIP‐14) and neck disability (NDI); analyses used non‐parametric tests and GEE with FDR correction.

Results

Significant improvements were found across all outcomes within both groups (p < 0.05, r = 0.72–0.88). TeleR showed greater reductions in pain intensity (p < 0.001), cervical and mandibular ROM except for lateral excursion, and in TMD severity, OBC, OHIP‐14 and NDI scores (p = 0.001–0.004). Palpation pain decreased in all muscles in both groups (p < 0.001), with greater improvements in the masseter muscles in TeleR (OR = 1.69–1.82; p < 0.001).

Conclusion

Both telerehabilitation and home‐based exercise programs effectively improve physical and psychosocial outcomes in myofascial TMD patients in the short term. Telerehabilitation is more effective in reducing pain scores and increasing maximum mouth opening. Long‐term clinical studies are needed to confirm the efficacy of telerehabilitation.

Trial Registration

Registered at ClinicalTrials.gov under the identification number NCT06526845

This randomized controlled trial compared a supervised telerehabilitation program with a home‐based exercise program in individuals with myofascial temporomandibular disorder (TMD). Fifty participants completed a six‐week multicomponent exercise program including jaw mobility, cervical exercises, posture training, breathing‐relaxation, and self‐massage techniques. Both groups showed significant improvements in pain intensity, mandibular and cervical mobility, oral behaviors, oral health‐related quality of life, and neck disability. However, the telerehabilitation group demonstrated greater improvements in pain intensity, most mandibular‐cervical range of motion parameters, TMD severity, oral behaviors, oral health‐related quality of life, and neck disability. These findings suggest that supervised telerehabilitation may provide additional benefits in the short‐term management of myofascial TMD.

1. Introduction

Temporomandibular joint dysfunction (TMD) is a prevalent disorder involving the musculoskeletal system [1]. It has been reported that approximately 75% of the general population experience TMD‐related symptoms at some point in their lives [2]. The aetiology of TMD is multifactorial, with contributing factors including abnormal occlusion, trauma, emotional stress, parafunctional habits such as bruxism, teeth grinding, and lip biting, and pre‐existing deep pain [3]. Clinical symptoms include joint pain, crepitus, reduced mandibular range of motion (ROM), and tenderness in the masticatory muscles [4]. These symptoms may lead to orofacial pain and cervical muscle dysfunction, negatively affecting individuals' quality of life, oral health and psychosocial well‐being [5]. One of the most common subtypes of TMD is the form associated with myofascial pain, characterized by localized muscle tenderness, trigger point activation, and widespread pain complaints in the masticatory muscles [3, 6].

Treatment typically begins with conservative approaches and includes multimodal interventions such as patient education, manual therapy, therapeutic exercises, electrotherapy, splint application and psychological support [7, 8, 9, 10, 11]. Research has shown that the application of manual therapy techniques in combination with therapeutic exercises improves clinical outcomes [12].

Interventions planned for TMD often require several weeks of clinical visits [13]. Since TMD predominantly affects active and working adults, the demands of maintaining social and professional roles, along with barriers such as limited access to healthcare facilities, time constraints, transportation difficulties, and financial burden, may limit participation in rehabilitation. Therefore, telerehabilitation has emerged as an innovative method that enhances accessibility through the remote delivery of healthcare services using information technologies [14]. This method reduces the need for clinical visits, improves accessibility and treatment adherence, and significantly alleviates both temporal and financial burdens [15]. Consequently, telerehabilitation holds potential as an effective, sustainable, and patient‐centered strategy in the management of TMD. Although there are numerous clinical studies on TMD management in the literature, controlled studies that comprehensively evaluate the clinical efficacy of telerehabilitation remain limited [15, 16, 17]. In this context, this study aimed to compare the effects of telerehabilitation with those of a home‐based exercise program on pain intensity, palpation‐induced muscle pain, cervical and mandibular mobility, TMD severity, oral habits, oral health‐related quality of life, and neck disability in individuals with TMD‐related myofascial pain. We hypothesized that the supervised telerehabilitation program would provide greater improvements in these clinical and patient‐reported outcomes than the home‐based exercise program.

2. Methods

2.1. Study Design and Setting

This study was designed as a randomized, single‐blind experimental trial and conducted in accordance with the Declaration of Helsinki between March 14, 2024, and October 31, 2024, at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem Vakif University, Istanbul. Ethical approval was obtained from the Non‐Interventional Research Ethics Committee of Bezmialem Vakif University (Protocol No. 2024/91). All volunteers participating in the study were informed about the purpose and details of the research, and written informed consent was obtained from all participants.

2.2. Participants

Based on the evaluations conducted by an oral and maxillofacial surgery specialist (NK), individuals diagnosed with myofascial TMD according to the DC/TMD [6] referred to the Physical Therapy and Rehabilitation Clinic were assessed for eligibility. The study included volunteer participants aged between 18 and 65 who had anterior disc displacement with reduction, reported pain in the masticatory muscles or temporomandibular region, and had experienced symptoms for at least 3 months. Individuals with anterior disc displacement without reduction, primary arthrogenic pain supported by radiological findings, or other temporomandibular disorders; those with neurological or psychiatric conditions; those with a history of TMJ and/or cervical spine surgery; and those using analgesic medication regularly for at least 1 month were excluded from the study.

2.3. Sample Size and Randomization

The sample size was calculated using G*Power 3.1.9.2 software (Repeated measures, within–between interaction; Düsseldorf, Germany) to assess the group × time interaction for pain intensity, which was selected as the primary outcome measure. A previous study with a similar design reported significant reductions in pain levels, with Cohen's d values ranging from 1.6 to 2.6 [9]. However, since the standard deviations for the final measurements were not reported in that study, a more conservative approach was adopted to avoid overestimation. Accordingly, a medium‐to‐large effect size (f = 0.4; d ≈ 0.8) was used. The analysis was based on the assumptions of α = 0.05, 1 − β = 0.95, a correlation coefficient of 0.5 and a non‐sphericity correction (ε) = 1. Based on these parameters, the minimum required sample size was determined to be 24 participants. During the eligibility screening, a total of 56 individuals were assessed, of whom 50 met the inclusion criteria and were enrolled in the study. Following baseline assessments, participants were randomly assigned in a 1:1 ratio into two groups: TeleR (telerehabilitation group, n = 25) and HomeEx (home exercise group, n = 25). Randomization was performed using a number table generated via the GraphPad website. Group allocation was conducted by a researcher (NK) who was blinded to both the assessments and the intervention procedures. The study flowchart is presented in Figure 1.

FIGURE 1.

CONSORT flow diagram.

2.4. Intervention

Considering the multifactorial nature of TMD, a multicomponent exercise program was implemented, incorporating methods commonly used in the conservative management of temporomandibular disorders as described in the literature [12, 18, 19, 20]. The program was scheduled for 6 weeks, with sessions conducted twice per week, and the same protocol was applied to both groups. The exercise protocol included diaphragmatic breathing and relaxation, post‐isometric relaxation, cervical isometric strengthening, mandibular mobility exercises, muscle stretching and friction massage. Diaphragmatic breathing and relaxation exercises were performed with 10 repetitions. Post‐isometric relaxation techniques and cervical isometric exercises were executed with 5 s of contraction followed by 5 s of relaxation, for a total of 10 repetitions. Mandibular mobility exercises were performed slowly and in a controlled manner, also with 10 repetitions. Stretching exercises targeting the masticatory muscles were held for 10 s in each position, repeated 10 times. Friction massage was applied to painful points on the masticatory muscles with gentle circular pressure, also for 10 repetitions. Each session lasted approximately 50–55 min. Additionally, all participants were advised to avoid hard and chewy foods, consume soft‐textured meals, maintain the jaw in a resting position, and refrain from habits that place excessive load on the TMJ during daily activities. Detailed descriptions of the exercises and patient instructions are provided in File S1. To standardize implementation, all participants attended a familiarization session on a separate day following baseline assessments, during which the exercises were demonstrated and taught. The treatment program was administered by a physiotherapist (NF) who was blinded to group allocation and outcome assessments.

2.4.1. Telerehabilitation Group (n = 25)

Participants in this group engaged in a supervised telerehabilitation program consisting of two sessions per week for 6 weeks. Each session was conducted one‐on‐one with a physiotherapist via live videoconferencing (Zoom Cloud Meetings). Session scheduling was arranged according to participant availability. The physiotherapist provided a real‐time demonstration of the movement, verbal explanation and feedback to the participants. Attendance and session tracking were documented regularly using follow‐up logs (File S1).

2.4.2. Home‐Based Exercise Group (n = 25)

Participants in this group were taught the same exercise program during a familiarization session and were provided with written exercise brochures to support their home practice. They were instructed to perform the exercises regularly at home and to complete session tracking logs (File S1). Communication with the physiotherapist was maintained via messaging throughout the intervention period.

Following the 6‐week intervention period, participants from both groups were invited to the clinic for post‐intervention assessments, which were conducted in the same order as the baseline evaluations.

2.5. Clinical Outcomes

Participants' demographic and clinical characteristics including age, sex, occupation, education level, presence of comorbidities, unilateral chewing and bruxism, were recorded on an evaluation form prepared by the researchers. Pain intensity was determined as the primary outcome measure, and the participants' pain during yawning, chewing, and at rest was assessed. Secondary outcome measures were categorized into three groups: palpation pain, cervical ROM, mandibular mobility, and patient‐reported outcomes (TMD severity, oral habits, oral health‐related quality of life, and neck‐related functional disability).

All primary and secondary assessments were conducted both before and after the 6‐week intervention by two experienced physiotherapists (BA ≥ 18 years, BKK ≥ 10 years), who were blinded to the randomization and treatment procedures.

2.5.1. Primary Outcome: Pain Intensity

The reliable and valid Numeric Pain Rating Scale (NPRS) was used to assess the participants' pain intensity [21]. NPRS is a simple and easy‐to‐administer tool consisting of a scale numbered from 0 to 10, where ‘0’ indicates no pain and ‘10’ represents unbearable pain. Participants were asked to rate their pain separately during yawning, chewing and resting. The results were recorded on the evaluation form.

2.5.2. Palpation‐Induced Muscle Pain Assessment

Palpation‐induced myofascial pain was assessed bilaterally in the masseter, temporalis, medial pterygoid and lateral pterygoid muscles. All evaluations were conducted with the participants seated in an upright position, with the head and neck in a neutral posture, as recommended in clinical protocols to allow for muscle relaxation and accurate access to anatomical landmarks. Each muscle was palpated at a standardized location: the midpoint of the muscle belly for the masseter and temporalis, and intraoral access points for the medial and lateral pterygoids. Manual pressure was applied perpendicularly to the muscle surface using the index and middle fingers.

To ensure consistency in applied pressure, physiotherapists underwent training sessions prior to data collection using a Baseline analog pressure algometer (USA). These sessions were used to calibrate and practice applying approximately 1 kg/cm² of pressure, guided by visual feedback from the device. Therapists were instructed to replicate this pressure during assessments. For each palpation point, pressure was maintained for approximately 5 s. A minimum rest period of 5 s was allowed between successive muscle assessments to prevent sensitization and ensure the reliability of pain responses.

Participants were asked to verbally report their pain intensity following palpation, and responses were categorized into three levels: mild, moderate, or severe. All palpation procedures were performed using sterile disposable gloves to maintain hygiene and prevent cross‐contamination [22].

2.5.3. Cervical Range of Motion

A digital goniometer was used to assess cervical ROM. All measurements were recorded in degrees on the evaluation form. Cervical flexion, extension, right and left lateral flexion, and right and left rotation were measured while participants were seated in a chair.

For cervical flexion and extension ROM measurements, the pivot point of the goniometer was placed on the acromion. The stationary arm was positioned parallel to the floor, and the movable arm was aligned with the midline of the ear. The motion was measured from the start to the endpoint.

In right and left lateral flexion ROM measurements, the pivot point was positioned on the C7 spinous process. The stationary arm was aligned parallel to the floor, and the movable arm followed the spinous processes of the cervical vertebrae to the end of the movement.

For right and left cervical rotation, the pivot point was referenced from the center of the head. The stationary arm was again held parallel to the floor, whereas the movable arm followed the direction of a plastic ruler held between the participant's teeth during the movement [23].

2.5.4. Mandibular Mobility

Mandibular mobility was assessed by measuring painless and painful maximum mouth opening, right and left lateral excursions, and protrusion using a sterile plastic ruler. All measurements were recorded in millimetres (mm) on the evaluation form. After use, the plastic rulers were sterilized in an autoclave at the hospital's central sterilization unit.

For the painless maximum mouth opening, participants were asked to open their mouths to the furthest point possible without pain, and the interincisal distance (the space between the upper and lower central incisors) was measured. For the painful maximum mouth opening, participants were asked to open their mouths as wide as possible regardless of pain, and the same interincisal measurement was recorded [24].

For right and left lateral excursion assessment, participants were instructed to move their mandible as far as possible to the right and left while keeping their posterior teeth in close proximation. The alignment of the upper and lower central incisors was visually assessed to determine the direction and extent of midline deviation. If the direction of mandibular movement and midline deviation matched, the deviation value was subtracted from the excursion measurement; if they were opposite, the values were added [3]. All results were recorded on the evaluation form.

For protrusion assessment, participants were asked to protrude their mandible as far forward as possible while maintaining posterior tooth contact. The horizontal distance between the upper and lower central incisors was measured in millimetres. If the mandible was in a posterior position at baseline, this value was added to the protrusion measurement; if it was in an anterior position, the value was subtracted from the protrusion amount, and the result was recorded accordingly [3].

2.5.5. Patient‐Reported Outcome Measures

2.5.5.1. Temporomandibular Disorder Severity

The severity of TMD was assessed using the Fonseca Anamnestic Index (FAI), a reliable and valid tool. The FAI is a multifactorial assessment instrument consisting of 10 questions that evaluate the presence of pain and dysfunction related to the TMJ [25]. Participants responded to each item with ‘yes’ (10 points), ‘sometimes’ (5 points) or ‘no’ (0 points). The total score was calculated and classified as follows: 0–15 points: no TMD, 20–40 points: mild TMD, 45–65 points: moderate TMD and 70–100 points: severe TMD.

2.5.5.2. Oral Habits

To assess participants' oral habits, the Oral Behaviour Checklist (OBC), a validated survey, was used. The questionnaire consists of 21 items, and participants respond to each item based on the frequency of the behaviour using the following scale: ‘always’ (4 points), ‘often’ (3 points), ‘sometimes’ (2 points), ‘rarely’ (1 point) and ‘never’ (0 points). The total score ranges from 0 to 84, with higher scores indicating a greater prevalence of harmful oral habits [26].

2.5.5.3. Oral Health‐Related Quality of Life

Oral health‐related quality of life was assessed using the Oral Health Impact Profile‐14 (OHIP‐14), a validated questionnaire. This tool consists of 14 items designed to evaluate seven domains: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap, each represented by two questions. Participants rated each item based on how frequently they experienced the issue using the following scale: ‘very often’ (4 points), ‘fairly often’ (3 points), ‘occasionally’ (2 points), ‘hardly ever’ (1 point) and ‘never’ (0 points). Higher total scores indicate more severe problems and a greater negative impact on oral health‐related quality of life [27].

2.5.5.4. Neck Disability

Functional limitations due to neck pain were assessed using the Neck Disability Index (NDI), a reliable and valid questionnaire [28]. The NDI evaluates the extent to which neck pain affects a participant's functional capacity. Each item in the questionnaire includes six response options labelled A through F. Participants are asked to select the option that best reflects their current condition. Each response is scored as follows: A = 0 points, B = 1 point, C = 2 points, D = 3 points, E = 4 points and F = 5 points. Based on the total score, disability levels are classified as follows: 0–4 = no disability, 5–14 = mild disability, 15–24 = moderate disability, 25–34 = severe disability and 35 or above = complete disability.

2.6. Statistical Analysis

All statistical analyses were performed using SPSS Statistics version 24.0 (IBM, NY, USA) and Python (Stats models package) for advanced modelling. The distribution of the data were assessed using the Shapiro–Wilk test, and as most variables were not normally distributed, non‐parametric tests were applied. Continuous outcomes were expressed as mean and standard deviation (SD), and categorical variables as frequencies (n, %).

Baseline differences between groups were analyzed using the Mann–Whitney U test for continuous/ordinal outcomes and the chi‐square test for categorical variables. Within‐group (pre–post) changes were examined using the Wilcoxon signed‐rank test for continuous/ordinal outcomes. For each Wilcoxon comparison, the effect size was calculated as (Z: Wilcoxon test statistic, N: number of participants in each group):

$$r=\frac{Z}{\surd N}$$

Effect sizes were interpreted according to Cohen's classification: small (r = 0.10–0.29), medium (r = 0.30–0.49) and large (r ≥ 0.50) [29].

To account for baseline imbalances and to estimate the overall treatment effect, generalized estimating equation (GEE) models were performed with group, time and group × time interaction as fixed effects including baseline values as covariates. For continuous outcomes, GEE with a Gaussian distribution was used, and results were reported as regression coefficients (β) with 95% confidence intervals (CI). For ordinal palpation pain scores, ordinal logistic GEE models were applied, and results were expressed as odds ratios (OR) with 95% CI. Robust standard errors were reported to account for within‐subject correlation. To adjust for multiple testing across the 18 outcomes, false discovery rate (FDR) correction using the Benjamini–Hochberg procedure was applied. A p < 0.05 was considered statistically significant.

3. Results

Baseline demographic and clinical characteristics of the participants are presented in Table 1. No significant differences were observed between groups for these measures.

TABLE 1.

Baseline demographic and clinical characteristics of the study group.

Variables	TeleR	HomeEx	p
	Mean (SD)/n (%)	Mean (SD)/n (%)
Age	28.8 (10.4)	32.1 (13.3)	0.341
Gender
Female	23 (92%)	24 (96%)	1.000
Male	2 (8%)	1 (4%)
Occupation
Employed	11 (44%)	10 (40%)	0.698
Homemaker	6 (24%)	6 (24%)
Retired	—	1 (4%)
Student	8 (32%)	8 (32%)
Education
Primary	2 (8%)	3 (12%)	0.951
Secondary	1 (4%)	1 (4%)
High school	8 (32%)	9 (36%)
Associate	1 (4%)	2 (8%)
Bachelor's	10 (40%)	7 (28%)
Master's	3 (12%)	3 (12%)
Presence of any disease
No	20 (80%)	18 (72%)	0.741
Yes	5 (20%)	7 (28%)
Unilateral chewing	23 (92%)	22 (88%)	1.000
Bruxism	19 (76%)	16 (64%)	0.537

Abbreviations: HomeEx, home‐based exercises group; n, number; SD, standard deviation; TeleR, telerehabilitation group.

Pre–and post–changes within each group, as well as baseline comparisons between groups for continuous outcomes, are shown in Table 2. Significant baseline between‐group differences were found in NRS‐yawning, NRS‐chewing, NRS‐rest, neck flexion, FAI and OHIP (p < 0.05). Within‐group comparisons showed significant improvements for all continuous outcomes in both groups (p < 0.05), with large effect sizes ranging from r = 0.72 to 0.88.

TABLE 2.

Within‐group pre–post changes and baseline between‐group comparisons of continuous outcomes.

Outcomes	TeleR		Intragroup changes a		HomeEx		Intragroup changes a		Baseline comparison b
	Pre‐mean (SD)	Post‐mean (SD)	Z	p ES (r)	Pre‐mean (SD)	Post‐mean (SD)	Z	p ES (r)	p
Pain intensity
NPRS‐yawning	7.56 (1.91)	2.80 (1.70)	−4.40	< 0.001* −0.88	4.84 (2.19)	2.56 (1.47)	−4.33	< 0.001* −0.86	< 0.001*
NPRS‐chewing	7.24 (1.98)	3.04 (1.88)	−4.40	< 0.001* −0.88	4.68 (2.23)	2.48 (1.50)	−4.37	< 0.001* −0.87	< 0.001*
NPRS‐rest	4.40 (2.06)	1.52 (1.50)	−4.40	< 0.001* −0.88	3.00 (2.14)	1.32 (1.21)	−4.19	< 0.001* −0.83	0.016*
Neck ROM (°)
Flexion	46.90 (3.62)	51.66 (3.65)	−4.37	< 0.001* −0.87	44.07 (4.06)	47.40 (4.50)	−4.28	< 0.001* −0.85	0.031*
Extension	39.05 (4.10)	43.38 (3.37)	−4.37	< 0.001* −0.87	37.15 (4.89)	39.77 (5.38)	−4.11	< 0.001* −0.82	0.073
R‐lateral flexion	36.69 (4.06)	40.72 (3.48)	−4.20	< 0.001* −0.84	36.73 (4.37)	39.82 (4.25)	−4.10	< 0.001* −0.82	0.800
L‐lateral flexion	36.89 (3.73)	40.52 (3.06)	−4.20	< 0.001* −0.84	37.30 (4.44)	39.73 (5.09)	−3.62	< 0.001* −0.72	0.391
R‐rotation	44.74 (3.70)	48.28 (3.68)	−4.37	< 0.001* −0.87	45.18 (3.07)	47.82 (3.81)	−4.11	< 0.001* −0.82	0.592
L‐rotation	45.44 (3.45)	48.84 (3.14)	−4.28	< 0.001* −0.85	45.51 (3.07)	48.13 (3.75)	−3.73	< 0.001* −0.74	0.633
Mandibular motion (mm)
Pain‐free opening	32.84 (8.24)	39.24 (6.01)	−4.38	< 0.001* −0.87	34.52 (6.04)	37.48 (6.11)	−4.13	< 0.001* −0.82	0.356
Painful opening	38.44 (7.03)	43.12 (5.86)	−4.11	< 0.001* −0.82	39.24 (5.47)	41.04 (5.38)	−4.15	< 0.001* −0.83	0.520
R‐lateral excursion	8.44 (2.04)	9.60 (1.63)	−3.92	< 0.001* −0.78	8.44 (1.85)	9.44 (1.80)	−3.99	< 0.001* −0.79	0.984
L‐lateral excursion	8.72 (2.01)	9.76 (1.58)	−3.84	< 0.001* −0.76	7.96 (2.47)	9.08 (1.97)	−3.70	< 0.001* −0.74	0.366
Protrusion	6.80 (1.97)	7.96 (1.67)	−4.15	< 0.001* −0.83	6.55 (2.12)	7.56 (1.78)	−3.96	< 0.001* −0.79	0.658
PROMs
FAI	78.00 (17.61)	29.60 (16.57)	−4.38	< 0.001* −0.87	63.80 (20.11)	30.20 (12.11)	−4.29	< 0.001* −0.85	0.009*
OBC	34.84 (8.68)	18.20 (7.39)	−4.37	< 0.001* −0.87	30.68 (9.30)	18.04 (5.87)	−4.37	< 0.001* −0.87	0.072
OHIP	26.00 (7.87)	10.76 (5.89)	−4.37	< 0.001* −0.87	15.16 (8.05)	8.72 (4.50)	−4.24	< 0.001* −0.84	< 0.001*
NDI	14.04 (5.58)	8.28 (4.43)	−4.38	< 0.001* −0.87	11.92 (6.08)	6.96 (4.58)	−4.21	< 0.001* −0.84	0.119

Abbreviations: (°), degrees; ES (r), within group effect size; FAI, Fonseca Anamnestic Index; HomeEx, home‐based exercises group; L, left; mm, millimetre; NDI, Neck Disability Index; NPRS, Numeric Pain Rating Scale; OBC, Oral Behaviour Checklist; OHIP, Oral Health Impact Profile; PROMs, patient‐reported outcome measures; R, right; ROM, range of motion; SD, standard deviation; TeleR, telerehabilitation group.

^a Wilcoxon signed rank test.

^b Mann Whitney U test.

*p < 0.05.

Intra‐ and inter‐group comparisons of palpated muscle pain, along with the pre‐ and post‐treatment distributions across the masseter, temporalis, medial pterygoid and lateral pterygoid muscles, are presented in Table 3 and Figure 2. Baseline comparisons showed significant differences between groups in the right and left masseter muscles (p = 0.004 and p = 0.002, respectively), whereas no baseline differences were found in the temporalis or pterygoid muscles (p > 0.05). Within‐group analyses indicated significant reductions in palpation pain for all muscles in both groups (p < 0.001). However, GEE models revealed that the improvements in right and left masseter muscles were significantly greater in TeleR compared with HomeEx (OR = 1.82, 95% CI: 1.31–2.54, p < 0.001; OR = 1.69, 95% CI: 1.18–2.42, p < 0.001, respectively). For the temporalis and pterygoid muscles, no significant group × time interaction effects were observed (p > 0.05).

TABLE 3.

Intra‐ and inter‐group comparisons of palpated muscle pain with baseline differences and GEE interaction effects.

Palpated pain	TeleR pre vs. post		HomeEx pre vs. post		Baseline comparison	Group × time interaction		p (FDR‐q)
Muscles	Z	p a	Z	p a	p b	GEE OR (95% CI)	p (GEE)
R masseter	−4.32	< 0.001*	−4.41	< 0.001*	0.004*	1.82 (1.31–2.54)	< 0.001*	0.001*
L masseter	−4.40	< 0.001*	−4.63	< 0.001*	0.002*	1.69 (1.18–2.42)	< 0.001*	0.001*
R temporalis	−3.63	< 0.001*	−3.00	< 0.001*	0.436	5.99 (0.03–1169.66)	0.506	0.590
L temporalis	−3.77	< 0.001*	−3.60	< 0.001*	0.532	NA (model unstable)	NA	NA
R medial pyteregoid	−3.94	< 0.001*	−3.87	< 0.001*	0.259	6.47 (0.31–133.05)	0.226	0.329
L medial pyteregoid	−4.00	< 0.001*	−4.00	< 0.001*	0.121	12.83 (0.19–869.21)	0.235	0.329
R lateral pyteregoid	−4.11	< 0.001*	−3.87	< 0.001*	0.314	5.76 (0.56–58.90)	0.140	0.327
L lateral pyteregoid	−3.94	< 0.001*	−4.12	< 0.001*	0.541	1.67 (0.14–20.46)	0.689	0.689

Abbreviations: CI, confidence interval; GEE, generalized estimating equations; HomeEx, home‐based exercises group; L, left; NA, not available; OR, odds ratios; p (FDR‐q), false discovery rate–adjusted p‐values; R, right; TeleR, telerehabilitation group.

^a Wilcoxon signed rank test.

^b Chi‐square test.

*p < 0.05.

FIGURE 2.

Distribution of pre‐ and post‐treatment palpation pain intensity across the masseter, temporalis, medial pterygoid, and lateral pterygoid muscles in both groups.

Pre–post changes and between‐group comparisons for the remaining outcomes, adjusted for baseline values, are presented in Table 4. GEE analyses adjusted for baseline values revealed significant group × time interaction effects for all NRS outcomes (p < 0.001), favouring TeleR. For neck and mandibular ROM, significant group × time interaction effects were found across all directions and movements (p = 0.001–0.040, FDR‐q = 0.003–0.040). Improvements were consistently greater in TeleR, except for right and left lateral excursions, where HomeEx exhibited slightly greater increases (p = 0.003–0.040, FDR‐q = 0.004–0.040). Among the PROMs, significant interaction effects were observed for FAI, OBC, OHIP and NDI (p = 0.001–0.004), with greater improvements in TeleR compared to HomeEx.

TABLE 4.

Pre–post changes in outcomes within groups and between‐group comparisons using generalized estimating equations.

Outcomes	TeleR	HomeEx	Group × time interaction		p (FDR‐q)
	Adjusted mean change ∆ (95% CI)	Adjusted mean change ∆ (95% CI)	GEE β (95% CI)	p (GEE)
Pain intensity
NPRS‐yawning	−4.76 (−5.26 to −4.25)	−2.28 (−2.76 to −1.79)	−2.48 (−3.13 to −1.83)	< 0.001*	0.003*
NPRS‐chewing	−4.20 (−4.69 to −3.70)	−2.20 (−2.69 to −1.71)	−2.00 (−2.72 to −1.28)	< 0.001*	0.003*
NPRS‐rest	−4.40 (−4.87 to −3.92)	−1.88 (−2.34 to −1.41)	−2.52 (−3.21 to −1.83)	< 0.001*	0.003*
Neck ROM (°)
Flexion	4.8 (3.5 to 6.1)	1.4 (0.2 to 2.6)	3.4 (1.4 to 5.4)	0.001*	0.003*
Extension	5.5 (3.9 to 7.1)	0.9 (−0.5 to 2.3)	4.6 (2.1 to 7.1)	< 0.001*	0.003*
R‐lateral flexion	4.7 (3.4 to 6.0)	1.7 (0.5 to 2.9)	3.0 (0.9 to 5.1)	0.004*	0.004*
L‐lateral flexion	4.6 (3.2 to 6.0)	1.5 (0.2 to 2.8)	3.1 (1.0 to 5.2)	0.004*	0.004*
R‐rotation	5.5 (3.7 to 7.3)	1.4 (−0.2 to 3.0)	4.1 (1.5 to 6.7)	0.002*	0.004*
L‐rotation	5.3 (3.7 to 6.9)	1.6 (0.3 to 2.9)	3.7 (1.2 to 6.2)	0.004*	0.004*
Mandibular motion (mm)
Pain‐free opening	4.8 (3.2 to 6.4)	1.2 (−0.2 to 2.6)	3.6 (1.2 to 6.0)	0.003*	0.004*
Painful opening	3.9 (2.2 to 5.6)	1.0 (−0.5 to 2.5)	2.9 (0.9 to 4.9)	0.004*	0.004*
R‐lateral excursion	−0.6 (−1.1 to −0.1)	0.2 (−0.3 to 0.7)	−0.8 (−1.6 to −0.04)	0.040*	0.040*
L‐lateral excursion	−0.6 (−1.1 to −0.1)	0.3 (−0.2 to 0.8)	−0.9 (−1.6 to −0.2)	0.015*	0.015*
Protrusion	1.3 (0.4 to 2.2)	−0.5 (−1.3 to 0.3)	1.8 (0.4 to 3.2)	0.012*	0.013*
PROMs
FAI	−27.2 (−30.4 to −24.0)	−20.4 (−23.5 to −17.3)	−6.8 (−11.4 to −2.2)	0.004*	0.004*
OBC	−10.5 (−12.6 to −8.4)	−5.2 (−7.3 to −3.1)	−5.2 (−8.5 to −1.9)	0.002*	0.004*
OHIP	−11.1 (−13.6 to −8.6)	−5.0 (−7.5 to −2.5)	−6.1 (−9.9 to −2.3)	0.001*	0.003*
NDI	−4.6 (−5.5 to −3.7)	−1.7 (−2.6 to −0.8)	−2.9 (−4.7 to −1.1)	0.002*	0.004*

Abbreviations: (°), degrees; ∆, mean change from baseline (post–pre); CI, confidence interval; FAI, Fonseca Anamnestic Index; GEE, generalized estimating equations; HomeEx, home‐based exercises group; L, left; mm, millimetre; NDI, Neck Disability Index; NPRS, Numeric Pain Rating Scale; OBC, Oral Behaviour Checklist; OHIP, Oral Health Impact Profile; p (FDR‐q), false discovery rate–adjusted p‐values; PROMs, patient‐reported outcome measures; R, right; ROM, range of motion; TeleR, telerehabilitation group.

*p < 0.05.

4. Discussion

This randomized controlled study evaluated the effects of a supervised telerehabilitation program versus an unsupervised home‐based exercise program in individuals with myofascial TMD. Both interventions led to improvements across all clinical and psychosocial outcomes. However, the telerehabilitation group showed greater improvements in pain intensity, patient‐reported outcomes, and mandibular‐cervical ROM, except for lateral excursions. Although palpation pain improved in all muscles in both groups, significant differences favouring telerehabilitation were observed only in the right and left masseter muscles. These findings suggest that although home‐based exercise is beneficial, adding real‐time supervision via telerehabilitation may enhance treatment efficacy for selected outcomes in this population.

TMD is a prevalent musculoskeletal disorder marked by myofascial pain, limited joint mobility, and impaired orofacial function [1, 30]. It is more common in females, particularly between the ages of 18 and 44, a trend linked to lower pain thresholds, higher stress levels, greater healthcare‐seeking behaviour, and hormonal and psychosocial factors [31]. Landi et al. [32] further proposed that oestrogen fluctuations may affect trigeminal nerve sensitivity, contributing to this disparity. In line with previous findings, most participants in our study were female (94%), reflecting typical clinical demographics in TMD populations.

Pain is a key symptom of TMD, particularly in those with myofascial involvement, the most common subtype [6]. This muscle‐originated pain often radiates beyond the masticatory region and intensifies during functional activities such as yawning or chewing [33, 34]. In our study, both groups showed significant reductions in pain intensity and palpation‐induced muscle tenderness after intervention, consistent with previous research supporting exercise‐based approaches in myofascial TMD management [16, 17, 35]. However, the telerehabilitation group demonstrated greater improvements, especially in overall pain intensity and masseter palpation sensitivity. Given the anatomical and functional importance of the masseter as a primary elevator of the mandible and its high activity during clenching and mastication, this muscle may be particularly responsive to interventions [36, 37]. The superior outcomes in the telerehabilitation group may stem from the synchronous, supervised delivery model, which enabled real‐time feedback and likely promoted more precise execution and sustained engagement, particularly in highly active muscles.

Neck pain is a common musculoskeletal issue that impacts quality of life and function [38]. The anatomical and biomechanical connection between the TMJ and cervical spine likely contributes to their frequent co‐occurrence [39]. Consistent with previous findings [40], our study showed reduced cervical ROM at baseline in individuals with myofascial TMD. Post‐intervention, both groups improved significantly, with greater gains in the telerehabilitation group. These improvements likely reflect the effects of the multi‐component program targeting both TMJ and cervical regions. Therapist supervision in the telerehabilitation group may have further supported adherence and neuromuscular control. Our results align with prior studies highlighting the benefits of cervical‐focused interventions in TMD management [41, 42].

Mandibular mobility, which may restrict oral functions during daily activities, is an important parameter to evaluate in individuals with myofascial TMD. Significant improvements were observed in both groups, consistent with previous studies demonstrating the effectiveness of various physiotherapy interventions in individuals with TMD [10, 43]. In the telerehabilitation group, greater gains were noted in all parameters except for lateral excursion, where improvements were slightly higher in the home‐based exercise group. This observation may be explained by patients' difficulty in isolating lateral deviation movements and the tendency to perform these exercises with excessive force or limited control in the absence of real‐time supervision, despite receiving initial instruction. Notably, such execution issues were also observed during assessment sessions, where participants were reminded and corrected as needed. Future studies should explore the quality of movement during lateral excursion exercises and consider incorporating movement‐specific feedback mechanisms to optimize exercise performance.

The FAI is a widely used, valid, and reliable tool for assessing the severity of TMD. In our study, significant reductions in FAI scores were observed in both intervention groups, indicating that the implemented exercise programs were effective in reducing the severity of TMD symptoms. These improvements may be attributed to the diversity and multicomponent structure of the exercises included in the program. Notably, the telerehabilitation group demonstrated a more pronounced reduction in FAI scores, which may be associated with the greater improvements observed in pain intensity and mandibular ROM in this group. Our findings are consistent with previous literature suggesting that reductions in TMD severity parallel improvements in pain control and jaw function [9, 16, 17, 35]. Accordingly, future studies should investigate the long‐term effects of telerehabilitation interventions on TMD severity and aim to establish clinically meaningful thresholds for change.

Oral behaviours refer to non‐functional mandibular movements and are more common in individuals with TMD than in healthy controls. These habits may contribute to peripheral nociceptive disorders and, if persistent, can cause microtraumas in the TMJ and stomatognathic system [44]. Thus, patient education and awareness are essential in TMD management.

In our study, significant improvements were observed in OBC scores in both groups following the intervention, indicating a reduction in maladaptive oral behaviours. This change may be attributed not only to the multicomponent nature of the exercise program but also to the structured patient education provided at the outset, which included recommendations such as adopting a soft diet, avoiding unilateral chewing, maintaining proper posture, and limiting excessive jaw movements. The greater improvement in the telerehabilitation group may reflect increased behavioural awareness facilitated by interactive therapist‐led sessions. These changes were accompanied by concurrent improvements in pain and mandibular function, consistent with previous findings linking reductions in oral behaviours to enhanced clinical outcomes [17, 45].

TMD can negatively impact individuals' quality of life due to associated pain, functional limitations, and other symptoms [46]. In our study, significant post‐intervention improvements in OHIP scores were observed in both groups, indicating the effectiveness of the exercise programs in enhancing quality of life. However, greater improvements were noted in the telerehabilitation group, potentially due to more substantial reductions in pain, TMD severity, and oral parafunctional habits, as well as improvements in joint mobility. Similarly, Abaci and Tuncer [17] reported enhanced quality of life following telerehabilitation in individuals with TMD and bruxism. The superiority of telerehabilitation in this context may be associated with increased patient awareness of the importance of exercise and a greater sense of motivation fostered by real‐time supervision, even when delivered remotely.

The NDI is a widely accepted tool for evaluating the functional impact of cervical dysfunction. In our study, both groups exhibited significant improvements in NDI scores following the intervention, indicating enhanced neck function. However, the telerehabilitation group demonstrated significantly greater reductions. Given that the exercise content was identical, this difference may be associated with more pronounced gains in TMD‐related pain and cervical range of motion, which are two factors known to contribute to neck‐related disability in individuals with TMD [47, 48]. These findings highlight the value of integrated rehabilitation strategies that address both orofacial and cervical components in managing myofascial TMD. To our knowledge, this is among the first studies to demonstrate significant improvements in NDI scores following such a structured program, underscoring the relevance of including cervical‐focused assessment and treatment in this population.

Recent literature emphasizes the increasing use of telerehabilitation in musculoskeletal conditions as an effective alternative when in‐person care is limited. Evidence suggests that synchronous telerehabilitation may offer superior clinical outcomes compared to unsupervised home programs, particularly in areas such as pain, function, and behavioural adaptation [17, 49].

Within this context, the current study contributes to the growing body of evidence by demonstrating that both telerehabilitation and home exercise interventions lead to significant improvements in pain, mobility, and psychosocial parameters in individuals with myofascial TMD. However, the greater gains observed in the telerehabilitation group highlight the added value of therapist‐guided delivery, particularly in promoting adherence, accurate execution, and symptom monitoring.

Importantly, no adverse events or technical issues were reported during video‐conference‐based sessions, and adherence was high in both groups, with all participants completing the program. This contrasts with a previous study citing technological barriers or dropouts from internet connectivity problems [17], suggesting that implementation feasibility may vary depending on regional infrastructure. These findings support the notion that synchronous telerehabilitation may not only bridge accessibility gaps but also enhance clinical outcomes when structured and supervised appropriately, making it a practical and effective modality for managing complex disorders such as myofascial TMD.

4.1. Limitations

This study has several limitations. First, the predominance of female participants may limit generalizability across sexes. In addition, the relatively young age of the participants may have facilitated the use of videoconference‐based telerehabilitation and contributed to high adherence; therefore, the findings should be extrapolated with caution to older individuals, those with lower digital literacy, or populations with limited access to technological resources. Second, despite post‐enrollment randomization, baseline differences were noted in pain intensity, TMD severity, oral health‐related quality of life, neck flexion and masseter palpation pain. Although adjusted analyses, including GEE models, were applied to address these imbalances, future studies should consider stratified or pre‐baseline randomization. Third, the sample size calculation was based on pain intensity, which was selected a priori as the primary outcome. Although secondary measures were analyzed using effect estimates, confidence intervals, and FDR‐adjusted comparisons, the study may not have been specifically powered to detect smaller between‐group differences across all secondary endpoints; therefore, these results should be interpreted as supportive. Fourth, satisfaction data were based on verbal feedback rather than validated tools. Fifth, the absence of a negative control group limits confidence in attributing improvements solely to the rehabilitation programs. However, physical therapy is the first‐line treatment for myofascial pain and delaying it may risk chronicity. At last, the lack of long‐term follow‐up prevents conclusions about sustainability. Future research should include extended monitoring to evaluate the durability of treatment effects and patient experience in more diverse clinical populations.

5. Conclusion

In conclusion, both supervised telerehabilitation and unsupervised home‐based exercise programs were effective in improving pain intensity, cervical and mandibular mobility, TMD severity, oral behaviours, oral health‐related quality of life, and neck disability in individuals with myofascial TMD. However, participants receiving telerehabilitation demonstrated greater improvements in several key outcomes. These findings suggest that while home‐based exercise programs may serve as a practical and accessible intervention, the addition of real‐time supervision through telerehabilitation can enhance treatment efficacy in this population.

Future studies with larger sample sizes, longer follow‐up periods, and stratified randomization are warranted to confirm these findings and to better understand the long‐term effectiveness of telerehabilitation in TMD management. Moreover, the potential role of group‐based telerehabilitation sessions and the application of different telehealth technologies should be explored to optimize accessibility, cost‐effectiveness, and clinical outcomes in individuals with myofascial TMD.

Author Contributions

Naile Fazlıoğlu: conceptualization, investigation, writing – original draft, resources, data curation, project administration, writing – review and editing. Begüm Kara Kaya: methodology, formal analysis, data curation, writing – original draft, writing – review and editing. Nükhet Kütük: methodology, writing – review and editing, formal analysis. Buket Akıncı: conceptualization, methodology, supervision, writing – review and editing.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

File S1: Includes the detailed multicomponent exercise protocol, patient instructions, exercise descriptions with illustrations, and session follow‐up logs used in the study.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.