Francesca Galiano
10/08/2022 - Last update 30/12/2022

Letícia Bojikian Calixtreab, Monica Ambiel Rezende, Danilo Harudy Kamonseki, Ana Beatriz de Oliveira | Year 2021

Effects of myofascial release applied to neck muscles and craniocervical flexor training in patients with chronic myofascial TMD


Temporomandibular disorders

Type of study:

self-controlled study (the participants are their own control)

Date of publication of the study’:



Purpose of the study

  • Objective: to evaluate the efficacy of the strain-counterstrain technique combined with stabilization exercises in people with myofascial temporomandibular disorders
  • Measured outcomes:
    • Primary: evaluation of the pain threshold through pressure pain threshold test
    • Secondary: evaluation of maximum pain experienced over the last week through Numeric Pain Rating Scale (NPRS) from 0 to 10, of maximum mouth opening through analog caliper, of mandibular function through the brazilian version of the Mandibular Function Impairment Questionnaire (MFIQ) and of deep neck flexor muscles function through flexion test


  • Number: 14 women
  • Criteria of inclusion: women, age 18-40 years, with orofacial pain of an intensity of at least 3 measured with NPRS, for at least 3 months, with trigger point in the superficial neck muscles; at baseline, diagnosis of myofascial temporomandibular disorder issued by a physiotherapist with 6 years of experience and research in the field, with presence of at least one trigger point, active or latent, in one of the following muscles: sternocleidomastoid, suboccipital and upper trapezius
  • Criteria of exclusion: fibromyalgia, a history of trauma or surgery to the neck or temporomandibular joint, previous dental therapy or physiotherapy for temporomandibular disorder in the last 6 months
  • Groups of study: 1 group
    Group 1: treatment, 14 women (mean age 23.9 years)

Interventions and evaluations

  • Evaluation of the threshold pain through threshold pain test applied to masseter and temporalis muscles, of the maximum pain experienced during the last week through NPRS, of mouth opening through analog caliper, of the mandibular function through MFIQ and of the function of the deep neck flexor muscles through craniocervical flexion test using a pressure biofeedback device at baseline, after 3 weeks and at the end of the study (ie, after 5 weeks)
  • 10 30-minute treatment sessions, twice a week for 5 weeks
  • Treatment: strain-counterstrain technique directed to the trigger points, associated to stabilization exercises for the craniocervical flexor muscles
  • Evaluation carried out by one physiotherapist and treatments performed by a second physiotherapist
    • both physiotherapists followed a training in order to recognise the trigger points


  • Primary outcome: the treatment favored a statistically significant increase in pain threshold with a large effect-size (actual relevance of the result obtained). In particular, at the end of the treatment period the threshold pain at the level of the masseter and left temporal muscle increased. With regard to the masseter and the right temporal muscle, there was an improvement throughout the study.
  • Secondary outcomes: The treatment favored a statistically significant reduction in the maximum pain experienced during the last week with a large effect-size also. Similarly, with statistically significant results and defined by large effect-size, the treatment favored an improvement in mandibular function and craniocervical flexor muscles. On the contrary, it does not seem to have affected mouth opening in a statistically significant manner, although it increased throughout the study.


An intervention consisting of a manipulative technique and muscle stabilization exercises showed to be able to act positively on the chronic myofascial temporomandibular disorder, both statistically and, in particular, clinically significantly, as all the positive results obtained were higher than the minimum thresholds indicating a real clinical improvement in the patients’ condition. The mouth opening was also increased by a clinically significant value.

Although there is a lot of debate about trigger points, having achieved positive results with techniques aimed specifically at them supports the idea of their primary role.

Studies are needed to analyze these results more in depth as well as the role of trigger points in myofascial temporomandibular disorder and the effectiveness of other techniques. In addition, studies are needed to fill the limits of current research, such as the recruitment of a more diverse sample and the use of one or more control groups.

The review of Osteopedia

By Marco Chiera

Strengths: good description of the nature of the myofascial temporomandibular disorder and of the utility of a manipulative approach; good description of the study methods; clinically significant results; good discussion considering the literature available; good discussion of the study limitations.
The minimum clinically important difference (MCID), or detectable difference, was reported for each test utilized, which is a necessary value to understand the clinical importance of a result and to correctly calculate a good sample size (how many people to recruit), which how it was actually done.

Limits: Limits: small sample; it is difficult to understand which of the manipulative technique or the stabilization exercises produced the main effects; Since some improvements have occurred only during the baseline period (the 3 weeks before the intervention), it is not excluded that there had already been an improvement; there is no follow-up to evaluate the duration of the results obtained.
Given the delicate topic, there is a somewhat poor description of the physiological nature of the trigger points and possible additional action mechanisms underlying the results obtained.

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