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1. Why the pain increase when chewing?

What is Gamma Gain:
Oftentimes, there may be hyperactivity of the gamma motor neurons. This
hyperactivity causes continual tightening of the intrafusal fibers, known as gamma
gain. Gamma gain leads to hypertonicity in the muscle , causing adaptive shortening
of surrounding fascial tissues. These taut bands of fascial tissues lead to
hypersensitive trigger points associated with myofascial pain syndrome (MFPS).
The question of what causes gamma gain is unclear. However, acute injury will result
in muscular spasm and guarding. Also, pain receptors (nociceptors) increase gamma
motor response. Chronic pain, such as that of MFPS is also a result of gamma gain.
The aforementioned hyperactivity of the gamma motor neuron, hypersensitivity to
stretch and subsequent adaptive tissue shortening becomes hypersensitive to stretch.
Stretch of fascial tissue is painful and this results in an increase in gamma motor
activity; a vicious cycle of gamma motor hyperactivity, hypersensitivity,
hypertonicity, adaptive shortening, and pain. The cycle builds from mild, localized
discomfort and will progress to a pain pattern that includes moderate to severe pain
with pain referral.

The Gamma Gain Cycle
For effective treatment of this persistent pain pattern, therapy must focus on breaking
this cycle. Breaking this cycle by blocking gamma gain is the focus of two manual
therapy techniques: myofascial release and strain–counterstrain. The positioning for
these techniques decrease gamma motor activity and interrupts the cycle.

The shortened position decreases noxious stimulus from the tissue. None of these interventions. This will decrease the afferent input from the tissue. Sometimes blood tests will be performed to look for medical causes of muscle pain. or twitch. The provider will likely perform a detailed exam of the affected muscles. and all treatment plans for myofascial pain should include active therapeutic exercise. by applying load through a restrictive barrier. including strength and range of motion testing. however. however. which in turn diminishes activity in gamma motor nerves. He or she will rub the suspected trigger points to see if the muscles respond. . sustained pressure up to the fascial resistance barrier allows the tissue to relax. Both types of techniques can be used to treat myofascial pain pattern. Myofascial release 2. including a review of symptoms.Myofascial Release: Many modalities can be used to treat physically active individuals. such as vitamin D deficiency or hypothyroidism. place muscle and fascia in positions that remove stress from the tissues. by decreasing efferent stimulus. the primary focus of the indirect technique is to address gamma gain. Why the doctor suggest to take the x-ray and special examination? Your health care provider usually begins with a thorough physical examination and medical history. more specifically indirect myofascial release techniques. http://stoneathleticmedicine. directly address the problem of fascial restrictions and gamma gain. Direct techniques attempt to stretch bound fascia. and cause pain in a predictable pattern or specific region. The application of light.

The primary goal of physical therapy is to restore balance between muscles working as a functional unit. When muscles are active. and physical examination  Testing may include x-rays. stress reduction. although dry needling is equally effective. MRI and/or CT scans. massage. Trigger Point Injection One of the most accepted means of treating myofascial pain besides physical therapy and exercise. analysis of your symptoms. Accurately determining the correct source of your pain is critical to successful treatment – diagnostic procedures include:  Begins with a thorough clinical evaluation  Including a complete medical history. Postural retraining is crucial.The type of pain that you may have with myofascial pain syndrome can be similar to the symptoms of several types of disorders. Myofascial pain syndrome resolves with treatment but many patients with myofascial pain syndrome may continue to have symptoms for years. cervical stretch and stabilization are integral parts of this approach.  These advanced diagnostic techniques definitively pinpoint the source of pain 3. Factors that make the condition worse like injury. and electro-diagnosis (EMG) An electromyogram (EMG) is a test that is used to record the electrical activity of muscles. stretching and exercise. Underlying depression should be treated and optimal sleep should be restored. Ischemic Compression . This current is usually proportional to the level of the muscle activity. Physical Therapy Myofascial release techniques. Stretch and spray This technique is performed using a vapocoolant spray applied to the affected muscle after it has been placed in passive stretch. sleep improvement. An EMG is also referred to as a myogram. and medications. Injection is performed most commonly with local anesthetic. stress should be avoided. they produce an electrical current. Treatment of Myofascial Pain Syndrome Optimal treatment of myofascial pain syndrome can includes patient education.

 Benzodiazepines have been used. non-steroidal anti-inflammatory drugs and/or muscle relaxants. baclofen. but some (fluoxetine and paroxetine) may increase bruxism and are not recommended.  One small case study suggested that tiagabine may be helpful for bruxism. Drug treatment  Analgesics. tizanidine are commonly used muscle relaxants. diclofenac and ketoprofen are commonly used drugs. press firmly on the trigger point with a thumb. e. carisoprodol. Gradually increase the pressure as the pain lessens.g. Drug Therapy Analgesics Non steroidal anti-inflammatory drugs are the drugs of choice for the initial treatment of myofascial pain. o An alternative is a newer antidepressant such as a selective norepinephrine reuptake inhibitor. Indomethacin. Ibuprofen. if helpful. They also help to treat assocoiated insomnia. but there is a risk of dependence. Tricyclic Antidepressants Tricyclic antidepressants like amitriptyline are commonly used for chronic pain. Muscle Relaxants Cyclobenzaprine. starting with a low or moderate bedtime dose for 2-4 weeks.  Antidepressants: o Tricyclic antidepressants. o Selective serotonin reuptake inhibitor (SSRI) antidepressants have been used. continue for 2-4 months and then taper down to a low maintenance dose. e. Opioid analgesics like tramadol can also be used. duloxetine. With muscle in a fully stretched position.g.13 . Anticonvulsants Gabapentin has been shown to be effective in treating myofascial and neuropathic pain.Ischemic compression involves application of sustained pressure on the trigger point. naproxen.

TMJ Arthroscopy and arthrography ? Arthroscopy: A surgical technique in which a tube-like instrument is inserted into a joint to inspect.4.[9] or it can have its own beneficial effects which may result from washing out of the joint during the procedure. It is most commonly performed in patients with diseases of the knees or shoulders. diagnose. Arthroscopy is . or as a therapeutic measure in conditions like temporomandibular joint dysfunction. TMJ arthroscopy is a type of surgery that is performed on the temporomandibular joint of the jaw. although some doctors may prefer to monitor the patient overnight in a hospital setting to make sure there are no post-surgical complications. and repair tissues. Any questions or concerns about the TMJ arthroscopy or recovery issues on an individual basis should be discussed with a doctor or other medical professional. during which time a special diet may need to be followed. and may enable a displaced disc to return to its correct position. thought to remove debris and inflammatory mediators. Recovery time following TMJ arthroscopy is usually about a week. This procedure is most frequently used to treat a medical condition known as temporomandibular joint disorder after non-surgical treatment options have failed. Temporomandibular joint Arthroscopy of the temporomandibular joint is sometimes used as either a diagnostic procedure for symptoms and signs related to these joints. TMJ arthroscopy can be a purely diagnostic procedure. This is usually an outpatient procedure.

[9] It is carried out under general anesthetic.[10] Examples include release of adhesions (e.g. particularly the length and gauge of the needles. similar to laparoscopy. Adhesions and loose bodies are the most common indications and findings for arthroscopic treatment of the temporomandibular joint. [11] Biopsies or disc reduction can also be carried out during arthroscopy. . are desired. Arthrography—jaw movements videotaped with x-rays taken after dye is injected into the joint (gerakan rahang direkam dengan x-ray diambil setelah bahan pewarna disuntikkan ke dalam sendi) Arthrography—the X-ray examination of a joint after injection of a contrast medium into the joint space Arthrogram examinations are usually performed with a local anesthetic. Conventional radiographs may be obtained when special images.also used to visualize the inside of the joint during certain surgical procedures involving the articular disc or the articular surfaces. The injection is made under careful aseptic conditions. vary according to the part being examined.[12] Arthroscopy is the endoscopic examination of the joint space. The sterile items required. The sterile tray and the nonsterile items should be set up on a conveniently placed instrument cart or a small two-shelf table. It is used for both diagnosis and treatment. Advancements in techniques have allowed arthroscopy to be employed in several internal derangement procedures.. The examination is usually performed by fluoroscopy and spot images. usually in a combination fluoroscopic-radiographic examining room that has been carefully prepared in advance. After aspirating any effusion. the radiologist injects the contrast agent or agents and manipulates the joint to ensure proper distribution of the contrast material. by blunt dissection or with a laser) or release of the disc. such as an axial projection of the shoulder or an intercondyloid fossa position of the knee. including some disc procedures.