maluf2010 RPG E DESORDENS TEMPORO MANDIBULARES

Prévia do material em texto

GLOBAL POSTURAL REEDUCATION AND STATIC STRETCHING
EXERCISES IN THE TREATMENT OF MYOGENIC
TEMPOROMANDIBULAR DISORDERS: A RANDOMIZED STUDY
Sâmia A. Maluf, PhD,a Bruno G.D. Moreno, MS,b Osvaldo Crivello, PhD,c Cristina M.N. Cabral, PhD,d
Gislaine Bortolotti, PhD,e and Amélia P. Marques, PhDf
a Physiotherap
Centre), Campina
b Physiotherap
nenses School, A
c Dentist, Scho
Paulo SP, Brazil.
d Physiotherap
Paulo University,
e Statistician, U
f Physiotherapi
Occupational Th
Paulo, São Paulo
Submit reque
Department of
Therapy, School
Cipotânea 51, Ci
Brazil (e-mail: pa
Paper submitt
2010; accepted Ju
0161-4754/$3
Copyright © 2
doi:10.1016/j.
500
ABSTRACT
Objective: The purpose of this study was to compare 2 different interventions, global postural reeducation (GPR) and
static stretching exercises (SS), in the treatment of women with temporomandibular disorders (TMDs).
Methods: A total of 28 subjects with TMDs were randomized into 2 treatment groups: GPR, where therapy involved
muscle global chain stretching, or SS, with conventional static stretching; but only 24 completed the study. Eight
treatment sessions lasting 40 minutes each (weekly) were performed. Assessments were conducted at baseline,
immediately after treatment end, and 2 months later. Measurements included pain intensity at the temporomandibular
joint, headache, cervicalgia, teeth clenching, ear symptoms, restricted sleep, and difficulties for mastication, using a
visual analogue scale. In addition, electromyographic activity and pain thresholds were measured at the masseter,
anterior temporalis, sternocleidomastoid, and upper trapezius muscles. Two-way analysis of variance with Tukey post
hoc test was used for between-group comparisons. Significance level was .05.
Results: Comparing the pain assessments using the visual analogue scale, no significant differences were seen with
the exception of severity of headaches at treatment end (GPR, 3.92 ± 2.98 cm; SS, 1.64 ± 1.66 cm; P b .024). In
addition, no significant differences were seen for pain thresholds and for electromyographic activity (P N .05).
Conclusions: For the subjects in this study, both GPR and SS were similarly effective for the treatment of TMDs
with muscular component. They equally reduced pain intensity, increased pain thresholds, and decreased
electromyographic activity. (J Manipulative Physiol Ther 2010;33:500-507)
Key Indexing Terms: Muscle Stretching Exercises; Temporomandibular Joint; Pain Measurement; Pain
Threshold; Electromyography
ist, Movicet (Movement–Therapy and Research
s SP, Brazil.
ist, Department of Physical Therapy, Adamanti-
damantina SP, Brazil.
ol of Odontology, University of São Paulo, São
ist, Department of Physical Therapy, City of São
São Paulo SP, Brazil.
niararas, Araras SP, Brazil.
st, Department of Speech, Physical Therapy and
erapy, School of Medicine, University of São
SP, Brazil.
sts for reprints to: Amélia P. Marques, PhD,
Physical Therapy, Speech and Occupational
of Medicine, University of São Paulo, Rua
dade Universitária, 05360-160, São Paulo SP,
squal@usp.br).
ed October 22, 2009; in revised form May 22,
ne 8, 2010.
6.00
010 by National University of Health Sciences.
jmpt.2010.08.005
Temporomandibular disorders (TMDs) represent the
consequences of several disorders affecting the
temporomandibular joint (TMJ), the masticatory
muscles, or both. Temporomandibular disorders may be
classified as myogenic, when muscular factors explain
patient's symptoms, and arthrogenic (due to arthralgia,
arthritis, or arthrosis), when symptoms are caused by joint
degenerative diseases.1 Myogenic TMD is characterized by
function-related pain, pain at local palpation, increased
muscular electrical activity, and presence of trigger points.2
Prevalence of TMD is highest from 20 to 45 years and is
5 times more common in women than men. From the ages
of 15 to 30 years, myogenic TMDs are more common,
whereas in individuals older than 40 years, arthrogenic
TMDs are more common.3 More than 70% of the adults in
the population have at least one symptom of TMD and/or
symptoms of muscular origin; of them, one third have
multiple symptoms.4
mailto:pasqual@usp.br
http://dx.doi.org/10.1016/j.jmpt.2010.08.005
501Maluf et alJournal of Manipulative and Physiological Therapeutics
Stretching Exercises and TMDVolume 33, Number 7
Because TMD is a complex syndrome characterized by
chronic pain with multifactorial etiology, a multidisciplin-
ary treatment approach is appropriate. Different exercises
can be proposed for rehabilitation and prevention of
TMDs.5-7 Conventional physical therapy uses static
stretching (SS), which consists of stretching a single muscle
up to a tolerable point and sustaining the position for a
certain period.8 On the other hand, the method called global
posture reeducation (GPR) is based on the recognition of 2
muscle chains, divided into posterior and anterior chains,9
and proposes global stretching of antigravity muscles.
Whereas static stretching of a single muscle or a small
group of muscles usually lasts 30 seconds,10 in GPR, all
muscles of the same chain are simultaneously stretched
during a 15-minute posture, avoiding compensations.
Several Brazilian physical therapists have been using the
GPR method with satisfactory empiric results. Although the
method is often clinically practiced, few studies show its
efficacy.11-13 A previous study concluded that patients with
TMD have many postural alterations (local and in distant
segments, like lower limbs).14 Considering this, it would be
important to investigate the application of GPR method as
treatment. Until this time, no studies were found on its use
in TMD. The aim of the present study was to compare 2
different exercise intervention, GPR and SS, for the
treatment of TMD symptoms (pain intensity at the TMJ,
headache, cervicalgia, teeth clenching, ear symptoms,
restricted sleep, and difficulties for mastication), as well
as to assess pain threshold (PT) and electromyographic
(EMG) activity of several muscles (masseter, anterior
temporalis, upper trapezius and sternocleidomastoid mus-
cles) in women with myogenic TMD.
METHODS
Subjects were recruited from a list supply and had
diagnosed TMD, which was previously confirmed by
experienced odontologists of the Faculty of the Department
of Surgery, Prothesis, and Maxillofacial Trauma of the
School of Odontology, University of São Paulo, Brazil.
Participants were selected according to the following
criteria: chronic pain (duration N3 months), Helkimo
index III, myogenic TMD, and presence of parafunctional
habits, such as bruxism, teeth clenching, mouth breathing,
and lip biting. Exclusion criteria included surgery or trauma
in the orofacial region; systemic or degenerative diseases in
spine and upper limbs; and undergoing odontologic,
psychologic, or physical therapy treatments.
A total of 28 subjects with TMD 19 to 40 years of age
were randomized, by means of opaque envelopes, into 2
treatment groups: GPR group (n = 14) had muscle
stretching according to the GPR method, and the SS
group (n = 14) was submitted to conventional muscular
static stretching; but only 24 completed the study (4
subjects abandoned treatment for work-related reasons).
During the study, patients were not receiving any kind of
parallel intervention or medication (Fig 1).
To characterize patients, cervical alignment was deter-
mined by radiograph and mandibular depression by paqui-
meter (Digimess, www.digimess.com.br, São Paulo, Brazil).
Sample size was calculated using 80% statistical power
to detect 30% of improvement in pain, with a standard
deviation of 2 points and a significance level of 5%. The
required sample would be 8 patients per group.
The study received approval by the Institutional Review
Board School of Medicine, University of São Paulo, Brazil. All
subjects were informed properly and provided written consent.
Outcome Measures
Symptoms and Pain Intensity. Severity of symptoms was
measured as the primary outcome using a visual analogue
scale (VAS),a 10-cm horizontal line.15 Symptoms included
pain at the TMJ, headache, cervicalgia, teeth clenching, ear
symptoms, restricted sleep, and difficulties for mastication.
The labels “no pain” (left) and “worst possible pain” (right)
were used to assess pain at the TMJ, headache, and
cervicalgia. For teeth clenching, the labels “absence” (left)
and “maximum clenching” (right) were used; for ear
symptoms, “without” and “unbearable symptoms”; and
for restricted sleep and difficulties for mastication, “no
difficulty” and “very difficult.” Participants were instructed
to mark the intensity of symptoms.
Pain Threshold. Pain threshold was assessed using an
algometer (Fischer, www.wagnerinstruments.com, Green-
wich, CT) with a rubber extremity with 1 cm of diameter.
Perpendicular pressure on the skin was applied on the motor
point of the masseter, anterior temporalis, upper trapezius,
and sternocleidomastoid muscles on the symptomatic side
and increased at a rate of approximately 1 kg/s. Motor
points were determined using an universal pulse generator
(Quark, www.quarkmedical.com.br, São Paulo, Brazil) that
delivers a monophasic pulsed current with the following
parameters: pulse duration, 0.5 millisecond; frequency, 150
Hz; cycle on, 0.5 second; and cycle off, 0.5 second. The
pulse amplitude was gradually increased from 4 to 6 mA,
according to subject's tolerance. The point where the
contractions were more intense was determined as the
motor point. Participants were asked to report onset of pain.
Pain threshold was considered positive when values were
lower than 2.6 kg/cm2.16 Pain threshold is an established
method for monitoring changes in levels of chronic pain,
reflecting the lowest intensity of pressure in which an
individual perceives pain.17
EMG Activity. Electromyographic evaluation was conducted
using an 8-channel EMG equipment with analog-digital 12-bit
resolution converter CAD 12/32 and active surface electrodes
(EMG System do Brasil, www.emgsystem.com.br, São José
dos Campos, São Paulo, Brazil). Data collection was performed
http://www.digimess.com.br
http://www.wagnerinstruments.com
http://www.quarkmedical.com.br
http://www.emgsystem.com.br
Fig 1. Flow diagram for the study.
502 Journal of Manipulative and Physiological TherapeuticsMaluf et al
September 2010Stretching Exercises and TMD
through the software AqDados 5.0 (Lynx, www.lynxtec.com.
br, São Paulo, Brazil) with 1000-Hz frequency per channel. To
minimize the contact impedance, local body hair was shaved
with a razor; and skin was swabbed with 70% alcohol and
abraded with sandpaper.
A reference electrode was attached to each subject's
ipsilateral wrist. Pairs of electrodes were placed on subjects'
symptomatic side at a distance of approximately 2 cm between
centers on the motor point of the masseter, anterior temporalis,
upper trapezius, and sternocleidomastoid muscles. Motor points
were chosen to ensure reliability as well as reproducibility of
tests,18 and their determination was described previously.
A total of 3 measures with 7 seconds of duration were
recorded for each patient. Patients remained in a comfortable
and rested position, sitting on a chair without back support,
with hands resting on the knees and feet touching the floor
without load. Electromyographic data were processed using
the softwareOrigin 6.0 (OriginLabCorporation, Northampton,
MA). To improve data reliability, the first and last seconds of
the signal were discarded; and only the intermediate 5 seconds
was analyzed. Signals were rectified, mean-normalized, and
subsequently converted to root mean square (RMS).
All evaluations and interventions were made at baseline
(first evaluation), after treatment end (second evaluation),
and at a follow-up 8 weeks after treatment (third evaluation)
by an experienced investigator previously trained and
blinded. Data were collected in the Clinical Evaluation and
Intervention Laboratory of the Department of Speech,
Physical Therapy, and Occupational Therapy of the
University of São Paulo.
Interventions
Treatment consisted of 8 individual sessions (once a
week) over 2 months. At the first 10 minutes of sessions,
patients rested (supine position) with all limbs relaxed.
http://www.lynxtec.com.br
http://www.lynxtec.com.br
Fig 2. Global postural reeducation exercises (A, posterior muscle
chain; B, anterior muscle chain).
503Maluf et alJournal of Manipulative and Physiological Therapeutics
Stretching Exercises and TMDVolume 33, Number 7
Manual therapy maneuvers were made as described by
Bienfait,19 associated to breathing exercises, to stretch the
fasciae that recover the shoulders, as well as the cervical
spine muscles. After that, stretching treatment (global or
static) was conducted for another 30 minutes.
GPR Group. During the stretching session, care was taken to
avoid postural compensation (due to tension increase in
response to muscular tightness) on specific body segments;
and patients maintained free breathing, with no breath holding.
At each session, patients maintained 2 different postures
(15 minutes each), according to Cunha et al.13 To stretch
the posterior muscle chain, patients were positioned in the
supine position; and the goal was to achieve the final
stretching position with adducted upper limbs and lower
limbs at 90° hip flexion supported by a hanging strap.
Gradual knee extensions were progressively performed
(respecting patient's limit) until tolerated, with ankle in
dorsal flexion, keeping the occipital, lumbar region, and
sacrum stabilized, as rectified as possible (Fig 2A).
Anterior muscle chains were stretched with the patient
lying in the supine position and upper limbs abducted at
30°, with supine forearms. Pelvis was kept in retroversion,
whereas the lumbar spine remained stabilized. Hips were
flexed, abducted, and laterally rotated, with the soles of the
feet touching each other. Lower limbs were progressively
extended to maximum knee extension, while maintaining
the tibiotarsal angle at 90°, with relaxed toes and lumbar
region fully touching the table; and at the end of the
exercises, the arms reached 140° of abduction (Fig 2B).
SS Group. Patients performed static stretching exercises for
the cervical spine, head, upper limbs, and mandibular
muscles (masseter and anterior temporalis). Each stretching
position was held for 30 seconds, keeping a slow breathing
rhythm and avoiding compensations. Exercises were bilater-
ally repeated for 3 times after a 10-second rest pause.
Patient's limits and possibilities were taken into account.
Statistical Analysis
Descriptive statistics included mean, standard deviation,
and percentage of occupation and cervical alignment
variables. Data normality was tested by the Shapiro-Wilk
test; and homogeneity of variance, by the Levene test. Two-
way analysis of variance with Tukey post hoc test was used
for between-group comparisons, before and after treatment
(first and second evaluations) and between the first and the
third evaluations, as well as for intergroup results. The
significance level adopted was α b .05. Data were analyzed
using SigmaStat 3.5 (Systat Software, Inc, Chicago, IL).
RESULTS
Characteristics of the sample are summarized in Table 1.
No significant between-group differences were seen for age
(P = .97) and mandibular depression (P = .44). Cervical
rectification was observed in 50% of the patients.
Table 2 contrasts the mean scores (in centimeters) of
VAS for the symptoms at each of the 3 evaluations.
Statistically significant decreases were seen at the second
evaluation (P b .05), with the exception of restricted sleep
and restricted mastication (both groups) and ear symptoms
(GPR). When comparing both interventions, the only
significant difference was seen for headache at the second
evaluation (P b .024). As for the third evaluation, pain at the
TMJ, headache, and teeth clenching were significantly
improved (vs baseline assessment) for both groups, whereas
cervicalgia was reduced in the GPR group only (P b .002).
Results of pressure dolorimetryare shown in Table 3.
Significant improvements, for all muscles, were seen at the
second evaluation (P b .05). At the third evaluation, values
were decreased in the SS group; but with the exception of
the masseter muscle (P b .016), no significant differences
were found. Similar trend was seen for the GPR group, with
significant difference for the anterior temporalis muscle
only (P b .027). No significant differences were seen when
comparing both treatment groups (P N .05).
Table 1. Demographic and clinical characteristics of studied
sample
Variables GPR (n = 12) SS (n = 12) P
Age (y), mean (SD) 30.0 (4.30) 30.08 (7.07) .97
Mandibular depression (cm),
mean (SD)
3.90 (0.73) 4.0 (0.70) .44
Occupation, n (%)
Housewife 3 (25%) 4 (33.33%) –
Student 1 (8.33%) 3 (25%) –
Office clerk 3 (25%) 2 (16.67%) –
Technical professional 2 (16.67%) 1 (8.33%) –
Maid 2 (16.67%) 1 (8.33%) –
Higher education 1 (8.33%) 1 (8.33%) –
Cervical alignment, n (%)
Normal 5 (41.67%) 4 (33.33%) –
Hyperlordosis 1 (8.33%) 2 (16.67%) –
Rectification 6 (50%) 6 (50%) –
504 Journal of Manipulative and Physiological TherapeuticsMaluf et al
September 2010Stretching Exercises and TMD
Results of the EMG activity of the assessed muscles are
shown in Table 4. Significant decreases were seen for the
masseter, anterior temporalis, and sternocleidomastoid
muscles at the second vs first evaluation for both groups
(P b .05). Differences remained significant at the third
evaluation only for sternocleidomastoid muscle (GPR, P b
.007; SS, P b .005). No differences were seen between
treatment groups (P N .05).
DISCUSSION
The aim of this study was to compare 2 different stretching
exercises for the treatment of functional variables of TMD; and
our hypothesis was that GPR would be better than static
stretching, considering its satisfactory clinical results.
Different exercises have long been used in the treatment of
TMD. Most exercise programs aim to improve muscular
coordination, to relax tensed muscles, to increase the range of
motion, and to increase muscular strength (force-generating
capacity). They seem to be useful in the treatment of TMDwith
anterior disk displacements without reduction.20 Manual
therapy, muscle stretching, and strengthening exercises seem
to be the most useful techniques.21
We used 2 different stretching techniques. Static
stretching of a single muscle or of a small group of
muscles usually lasts 30 seconds,10 whereas muscle chain
stretching consists of active progressive stretching over
15 minutes.11,13,22
Despite the differences between the programs, outcomes
were similar with the exception of headache, where SS
yielded superior improvement. Indeed, some common
points exist for both strategies. Whereas GPR postures
were maintained for a relatively long span, 15 minutes each,
totaling 30 minutes, each SS patient stretch took 30
seconds. However, because stretching was repeated 3
times for each muscle group of head, cervical spine,
upper limbs, and masticatory muscles, this also adds up to
30 minutes.
A marked difference between the 2 programs is that, in
SS, stretching was applied directly in the head, cervical
spine, upper limbs, and mastication muscles, whereas, in
GPR, the stretching focused on muscle chains. This may
impact results because, in SS, intervention directly
manipulated the target area. Fernández-de-Las-Peñas
et al,11 studying ankylosing spondylitis, concluded that
the difference between both interventions is the integration
of the affected muscles in different shortened muscle
chains. They found no substantial differences between the
groups. Further studies are required to elucidate the role of
muscle chains in TMD patients.
In our study, both techniques followed the same principles,
avoiding compensations, requesting slow breathing pace with
no inspiratory breath-hold, and respecting patients' limits.
Exercises should be performed without pain. Static stretching
is easier to learn and to perform, but its adequate performance
requires careful attention. Nonetheless, in GPR, by correctly
approaching muscle chains, symptom improvement at
distance may be achieved, guaranteeing a global character to
this technique.9,11,13
Individual (vs group) sessions allowed for individual-
ized attention, from the same therapist, improving the
establishment of links and efforts to reach therapy goals.
Care and counseling, as part of the pedagogic role in
guiding and learning exercises, certainly influenced results,
including the lack of differences between groups.
Results suggest that both muscle chain and static stretching
associated to manual therapy decrease pain intensity at the
TMJ, headache, and teeth clenching. Previous studies found
that therapeutic exercises associated to interocclusal appliance
improve pain relief and reduce TMJ dysfunction23 and also
that therapeutic exercise alone is effective. The latter is indeed
recommended as the first treatment option for myogenic
TMD.7,24 Nonetheless, the topic remains controversial
because Grace et al5 did not demonstrate differences in the
efficacy of traditional therapy for TMD, traditional therapy
associated to interocclusal appliance and exercise, or appliance
associated to counseling only. Interest also focuses on the
efficacy of the association of exercises and electrotherapy for
myogenic TMD, which seems to normalize range of motion,
decrease pain, and improve overall mandibular function.25,26
Studies27,28 also reported improvement of signs and
subjective clinical symptoms of TMD after manual therapy.
As a caveat about interstudy comparisons, the VAS has an
intrinsically variable component; and because pain report is
subjective by nature and TMD is multifactorial, compar-
isons of VAS findings should be seen with caution.2
We found that PT increased after both interventions;
after treatment, mean values were close to normal standards
(N2.6 kg/cm2, according to Marques et al16). Other studies
have also observed decreased pain at palpation in
masticatory muscles after treatment with exercises.19,29
Decreased activity of the masseter muscle in rest, after
stretching treatments, was also observed. Because, in
Table 3. Pain threshold (in kilograms per square centimeter) in muscle points of masseter, anterior temporalis, sternocleidomastoid,
and upper trapezius muscles as a function of treatment assessment
GPR (n = 12) SS (n = 12)
Variables Evaluation P value Evaluation P value
PT (kg/cm2) 1st 2nd 3rd 1st-2nd 1st-3rd 1st 2nd 3rd 1st-2nd 1st-3rd
Masseter 2.01 (0.63) 2.81 (0.82) 2.65 (0.94) .014 .059 1.95 (0.61) 2.73 (0.29) 2.75 (0.42) .013 .016
Anterior temporalis 2.43 (0.52) 3.39 (0.82) 3.22 (0.92) .006 .027 2.3 (0.43) 3.35 (0.62) 2.87 (0.61) .002 .140
SCM 1.59 (0.42) 2.41 (0.59) 2.11 (0.48) .002 .057 1.49 (0.73) 2.22 (0.83) 1.75 (0.74) .005 .464
Upper trapezius 2.05 (0.43) 3.25 (0.91) 2.60 (0.50) .001 .197 2.11 (0.64) 3.04 (0.96) 2.67 (0.67) .013 .188
Data are reported as mean ± SD.
SCM, Sternocleidomastoid.
Table 4. Electromyographic variables (in RMS, microvolts) in motor points of masseter, anterior temporalis, sternocleidomastoid, and
upper trapezius muscles as a function of treatment assessment
GPR (n = 12) SS (n = 12)
Variables Evaluation P value Evaluation P value
RMS (μV) 1st 2nd 3rd 1st-2nd 1st-3rd 1st 2nd 3rd 1st-2nd 1st-3rd
Masseter 0.80 (0.13) 0.68 (0.04) 0.73 (0.05) .013 .230 0.81 (0.13) 0.68 (0.08) 0.71 (0.08) .004 .045
Anterior temporalis 0.82 (0.09) 0.69 (0.58) 0.75 (0.06) .001 .109 0.82 (0.09) 0.74 (0.06) 0.76 (0.09) .024 .072
SCM 0.79 (0.08) 0.69 (0.10) 0.69 (0.08) .005 .007 0.76 (0.13) 0.67 (0.06) 0.66 (0.11) .004 .005
Upper trapezius 0.81 (0.08) 0.72 (0.14) 0.77 (0.10) .181 .068 0.78 (0.09) 0.69 (0.05) 0.77 (1.18) .171 .951
Data are reported as mean ± SD.
Table 2. Severity of symptoms assessed by the VAS (in centimeters) as a function of treatment assessment
GPR (n = 12) SS (n = 12)
Variables Evaluation P value Evaluation P value
Symptom (cm) 1st 2nd 3rd 1st-2nd 1st-3rd 1st 2nd 3rd 1st-2nd 1st-3rd
TMJ pain 8.47 (1.38)3.02 (2.51) 3.74 (2.44) b.001 b.001 7.20 (1.10) 2.28 (1.93) 3.45 (1.93) b.001 b.001
Headache 7.35 (2.62) 3.92 ⁎ (2.98) 3.55 (2.65) .003 b.001 6.57 (2.17) 1.64 ⁎ (1.66) 3.00 (1.90) b.001 .002
Cervicalgia 7.33 (2.71) 3.59 (2.80) 3.85 (2.09) b.001 .002 5.68 (2.59) 2.41 (1.92) 3.45 (1.93) .004 .067
Teeth clenching 7.14 (2.71) 4.25 (2.55) 4.33 (3.09) .020 .024 6.45 (2.51) 2.90 (2.35) 3.52 (1.46) .003 .017
Ear symptoms 4.69 (3.31) 2.99 (3.11) 2.55 (2.94) .272 .130 5.85 (1.93) 2.80 (2.08) 3.52 (2.07) .019 .092
Restricted sleep 5.69 (3.45) 3.08 (3.05) 3.22 (3.31) .100 .127 4.65 (3.36) 3.00 (2.38) 3.02 (2.33) .389 .400
Restricted mastication 4.57 (2.79) 2.34 (2.38) 4.01 (3.01) .106 .864 4.36 (2.72) 2.23 (2.29) 2.93 (2.37) .128 .388
Data are reported as mean ± SD.
⁎ Statistically significant difference (P = .024).
505Maluf et alJournal of Manipulative and Physiological Therapeutics
Stretching Exercises and TMDVolume 33, Number 7
addition to EMG activity, pain intensity also decreased, it
may be suggested that there is an association between these
variables.30 Opposite results were found by Capellini et al1
who reported pain decrease without reduction in EMG
activity; authors suggest that the small sample size may
have interfered in the results.
The greatest decrease of EMG activity happened at the
masseter; the smallest was seen at the upper trapezius,
possibly because of its important head-, cervical spine-, and
shoulder-stabilizing functions, as well as being a frequent
tension spot in the general population.29 In myogenic TMD,
a relationship between pain intensity and postural EMG
activity at the upper trapezius and sternocleidomastoid
muscles is commonly found,31,32 suggesting a functional
link between masticatory and cervical muscles, probably due
to a coactivation mechanism. This was assessed on the
cervical muscles during mastication7 and during combined
movement of mandibular depression and head extension.33
The comparison of the second (immediately after
treatment) and third (2 months after treatment end)
assessments suggested some losses in previous gains,
regardless of the treatment group, although patients have
not undergone any treatment or received guidance during
this period. Losses would probably be reduced to a
minimum if patients had been oriented to conduct
maintenance exercises. In the clinical essay of Truelove et
al,7 after receiving conservative treatment of TMD, patients
were also educated and used an appliance. They were
evaluated 3 months, 6 months, and 1 year after treatment
end; all patients maintained improvement over the long
506 Journal of Manipulative and Physiological TherapeuticsMaluf et al
September 2010Stretching Exercises and TMD
term. We hypothesize that, in our sample, if sessions were
more frequent and treatment duration was longer, results at
the third evaluation would have been better.
Studies of Magnusson and Syren23 and Carlson et al34
compared the benefits of appliance and exercises for
myogenic TMD patients after 6 months of treatment and
at a long-term revaluation. Both procedures yielded positive
results, and exercises were suggested as the first treatment
option because of cost benefits.
Several studies conclude that exercise therapy may
contribute to reducing symptoms of myogenic TMD, and
our study also supports this conclusion considering the
application of stretching exercises. Ideal exercise parameters,
including type, duration, frequency, and intensity of
exercises, are yet to be determined by standardized
intervention and evaluation procedures.
The primary aim of this study of comparing the efficacy
of muscle chain stretching and static stretching exercises on
TMD symptoms, PT, and EMG activity in women with
myogenic TMD was achieved. Muscle chain stretching and
static stretching in association with manual therapy were
equally effective in reducing myogenic TMD.
Limitations of the Study
The major study limitation was the absence of a control
group, which would permit to know the natural course of the
disease. This would be important considering the lack of
evidence in the literature regarding the application of
stretching exercises in the treatment of TMD. Future studies
should include a control group and a long term of follow-up
assessment. More information about the sample character-
istics could be important to facilitate the clinical diagnosis of
the patients.
CONCLUSION
For the participants of this study, both GPR and SS were
similarly effective for the treatment of TMD with muscular
component. They equally reduced pain intensity, increased
PTs, and decreased EMG activity.
Practical Applications
• Both global posture reeducation and static
stretching exercises are similarly effective in
reducing pain intensity, increasing PT, and
decreasing EMG activity in women with myo-
genic TMD.
• Benefits are partially lost after 2 months of
interventions.
• No significant differences are seen between
methods.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
REFERENCES
1. Capellini KV, Souza SG, Faria SRC. Massage therapy in the
management of myogenic TMD: a pilot study. J Appl Oral Sci
2006;14:1-11.
2. Fricton J. Myogenous temporomandibular disorders: diag-
nostic and management considerations. Dent Clin North Am
2007;5:61-83.
3. Franco RLR, Guimarães JP, Posselini AF. Desordem
temporomandibular e reposição hormonal em pacientes com
síndrome climatérica: prevalência e terapêutica. Rev Serviço
ATM 2005;5:32-9.
4. Ash MM, Ramjford S. Oclusão. São Paulo: Santos; 2001.
5. Grace EG, Sarlane E, Reid B. The use of an oral exercise device
in the treatment of muscular TMD. Cranio 2002;20:204-8.
6. Mcneely ML, Armijo Olivo S, Magee DJ. A systematic
review of the effectiveness of physical therapy interventions
for temporomandibular disorders. Phys Ther 2006;86:710-25.
7. Truelove E, Huggins KH, Mancl L, Dworkin SF. The efficacy
of traditional, low-cost and non splint therapies for temporo-
mandibular disorder: a randomized controlled trial. J Am Dent
Assoc 2006;137:1099-107.
8. Shrier I, Gossal K. Myths and truths of stretching. Phys Sports
Med 2000;28:57-63.
9. Marques AP. Cadeias musculares: um programa para ensinar
avaliação fisioterapêutica global. São Paulo: Manole; 2005.
10. Bandy WD, Irion JM, Briggler M. The effect of time and
frequency of static stretching on flexibility of the hamstring
muscles. Phys Ther 1997;77:1090-6.
11. Fernández-de-las-Peñas C, Alonso-Blanco C, Morales-Cabe-
zas M, et al. Two exercise interventions for the management
of patients with ankylosing spondylitis. Am J Phys Med
Rehabil 2005;84:407-19.
12. Fernández-de-las-Peñas C, Alonso-Blanco C, Alguacil-Diego
IM, et al. One-year follow-up of two exercise interventions for
the management of patients with ankylosing spondylitis. Am J
Phys Med Rehabil 2006;85:559-67.
13. Cunha ACV, Burke TN, França FJR, Marques AP. Effect
of global posture reeducation and of static stretching onto
pain, range of motion, and quality of life in women with
chronic neck pain: a random clinical trial. Clinics 2008;63:
763-70.
14. Munhoz WC, Marques AP. Body posture evaluations in
subjects with internal temporomandibular joint derangement.
J Craniomand Pract 2009;27:231-42.
15. Melzack R, Katz J. Measurement of pain. Surg Clin North Am
1996;79:231-52.
16. Marques AP, Ferreira EA, Matsutani LA, Pereira CA,
Assumpção A. Quantifying pain threshold and quality of
life of fibromyalgia patients. Clin Rheumatol 2005;24:
266-71.
17. Prushansky T, Handelzalts S, Pevzner E. Reproducibility of
pressure pain threshold and visual analog scale findings in
chronic whiplash patients. Clin J Pain 2007;23:339-45.
18. Sacco ICN, Konno GK, Rojas GB, Arnone AC, Pássaro AC,
Marques AP, et al. Functional and EMG responses to a
physical therapy treatment in patellofemoral syndrome
patients. J Electromyogr Kinesiol 2006;16:167-74.
507Maluf et alJournal of Manipulative and Physiological Therapeutics
Stretching Exercises and TMDVolume33, Number 7
19. Bienfait M. La fascia et son traitement: les pompages. Paris:
Spek; 1995.
20. McKay DC, Christensen IV. Electrognathographic and
electromyographic observations on jaw depression during
neck extension. J Oral Rehabil 1999;26:865-76.
21. Nicolakis P, Erdogmus B, Kopf A, Ebenbichler G, Kollmitzer
J, Piehslinger E, et al. Effectiveness of exercise therapy in
patients with internal derangement of the temporomandibular
joint. J Oral Rehabil 2001;28:1158-64.
22. Rosário JLP, Sousa A, Cabral CMN, João SMA, Marques AP.
Reeducação postural global e alongamento estático segmentar
na melhora da flexibilidade, força muscular e amplitude de
movimento: um estudo comparativo. Fisioter Pesq 2008;15:
12-8.
23. Magnusson T, Syren M. Therapeutic jaw exercises and
interocclusal appliance therapy: a comparison between two
common treatments of temporomandibular disorders. Swed
Dent J 1999;23:27-37.
24. DeVocht JW, Long CR, Zeitler DL, Schaeffer W. Chiroprac-
tic treatment of temporomandibular disorders using the
activator adjusting instrument: a prospective case series. J
Manipulative Physiol Ther 2003;26:421-5.
25. De Laat A, Stappaerts K, Papy S. Counseling and physical
therapy as treatment for myofascial pain of masticatory
system. J Orofac Pain 2003;17:42-9.
26. Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner J,
Massoth D, et al. A randomized clinical trial of a tailored
comprehensive care treatment program for temporomandibu-
lar disorders. J Orofac Pain 2002;16:259-76.
27. Chiba M, Echigo S. Longitudinal MRI follow-up of
temporomandibular joint internal derangement with closed
lock after successful disk reduction with mandibular manip-
ulation. Dentomaxillofac Radiol 2005;34:106-11.
28. Furto ES, Cleland JA, Whitman JM, Olson KA. Manual
physical therapy interventions and exercise for patients with
temporomandibular disorders. Cranio 2006;24:283-91.
29. Huddleston SJJ, Lobbeso F, Hofman N, Naeije M. Case report
of a posterior disc displacement without and with reduction. J
Orofac Pain 2005;19:337-42.
30. Wright EF, Domenech MA, Fischer JR. Usefulness of posture
training for patients with temporomandibular disorders. J Am
Dent Assoc 2000;131:202-10.
31. Kraus S. Temporomandibular disorders, head and orofacial
pain: cervical spine considerations. Dent Clin North Am 2007;
51:161-93.
32. Pallegama RW, Ranasinghe AW, Weeransinghe VS, Sithee-
que MAM. Influence of masticatory muscle pain on
electromyographic activities of cervical muscles in patients
with myogenous temporomandibular disorders. J Oral Rehabil
2004;31:423-9.
33. Chandu A, Suvinen TI, Reade PC, Borromeo GL. Electro-
myographic activity of frontalis and sternocleidomastoid
muscles in patients with temporomandibular disorders. J
Oral Rehabil 2005;32:571-6.
34. Carlson CR, Bertrand PM, Ehrlich AD, Maxwell AW,
Burton RG. Physical self-regulation training for the manage-
ment of temporomandibular disorders. J Orofac Pain 2001;
15:47-55.
	Global Postural Reeducation and Static Stretching Exercises in the Treatment of Myogenic Temporomandibular Disorders: A Ran...
	Methods
	Outcome Measures
	Symptoms and Pain Intensity
	Pain Threshold
	EMG Activity
	Interventions
	GPR Group
	SS Group
	Statistical Analysis
	Results
	Discussion
	Limitations of the Study
	Conclusion
	Funding Sources and Potential Conflicts of Interest
	References