IMMEDIATE CHANGES IN MASTICATORY MECHANOSENSITIVITY,

MOUTH OPENING, AND HEAD POSTURE AFTER MYOFASCIAL

TECHNIQUES IN PAIN-FREE HEALTHY PARTICIPANTS: A
RANDOMIZED CONTROLLED TRIAL
Alberto Marcos Heredia-Rizo, PhD, a ngel Oliva-Pascual-Vaca, PhD, b Cleofs Rodrguez-Blanco, PhD, b
Fernando Pia-Pozo, BSc, c Antonio Luque-Carrasco, BSc, d and Patricia Herrera-Monge, BSc e

ABSTRACT

Objective: This study aimed to assess the immediate effects on masticatory muscle mechanosensitivity, maximal
vertical mouth opening (VMO), and head posture in pain-free healthy participants after intervention with myofascial
treatment in the temporalis and masseter muscles.
Methods: A randomized, double-blind study was conducted. The sample group included 48 participants (n = 48), with a
mean age of 21 2.47 years (18-29). Two subgroups were defined: an intervention group (n = 24), who underwent a
fascial induction protocol in the masseter and temporalis muscles, and a control group (n = 24), who underwent a sham
(placebo) intervention. The pressure pain threshold in 2 locations in the masseter (M1, M2) and temporalis (T1, T2)
muscles, maximal VMO, and head posture, by means of the craniovertebral angle, were all measured.
Results: Significant improvements were observed in the intragroup comparison in the intervention group for the
craniovertebral angle with the participant in seated (P b .001; F1,23 = 16.45, R 2 = 0.41) and standing positions (P =
.012, F1,23 = 7.49, R 2 = 0.24) and for the pressure pain threshold in the masticatory muscles, except for M2 (P = .151;
M1: P = .003; F1,23 = 11.34, R 2 = 0.33; T1: P = .013, F1,23 = 7.25, R 2 = 0.23; T2: P = .019, F1,23 = 6.41, R 2 = 0.21).
There were no intragroup differences for the VMO (P = .542). Nevertheless, no significant differences were observed
in the intergroup analysis in any of the studied variables (P N .05).
Conclusion: Myofascial induction techniques in the masseter and temporalis muscles show no significant differences
in maximal VMO, in the mechanical sensitivity of the masticatory muscles, and in head posture in comparison with a
placebo intervention in which the therapist's hands are placed in the temporomandibular joint region without exerting
any therapeutic pressure. (J Manipulative Physiol Ther 2013;36:310-318)
Key Indexing Terms: Head; Manual Therapy; Masticatory Muscles; Pain Threshold; Posture

emporomandibular disorders (TMDs) have been of the body. 2,3 The relationship between head and neck

T related to dysfunctions from neighboring segments

(the cervical spine, for instance) 1 and other regions
posture and the temporomandibular joint (TMJ) has been
widely discussed in the scientific literature. 4 Any variation

a e
Physiotherapist, Professor of Department of Physical Therapy, Physiotherapist, Andalusian Health Service, Sevilla, Spain.
Faculty of Nursing, Physiotherapy and Podiatry, University of Submit request for reprint to Alberto Marcos Heredia-Rizo,
Sevilla, Sevilla, Spain. PhD, Physiotherapist, Professor of Department of Physical
b
Physiotherapist, Osteopathic Physician, DO, Professor of Therapy, Department of Physical Therapy, Faculty of Nursing,
Department of Physical Therapy, Faculty of Nursing, Physiotherapy, and Podiatry, University of Sevilla, Sevilla, Spain
Physiotherapy and Podiatry, University of Sevilla, Sevilla, (e-mail: amheredia@us.es).
Spain. Paper submitted October 31, 2012; in revised form January 27,
c
Physiotherapist. Osteopathic Physician, Andalusian Health 2013; accepted February 20, 2013.
Service, Sevilla, Spain. 0161-4754/$36.00
d
Physiotherapist, Osteopathic Physician, Cesma Mutuality, Copyright 2013 by National University of Health Sciences.
Sevilla, Spain. http://dx.doi.org/10.1016/j.jmpt.2013.05.011

310
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Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 5
in craniomandibular biomechanics may potentially change
the growth, statics, and dynamics of the participant. 5
Besides, a dysfunction of the masticatory muscles has also
been associated with a higher incidence of craniofacial
pain syndromes. 6
Use of manual therapy for TMJ disorders has become
increasingly relevant in the clinical setting. There have been
many proposals of interventions since manual therapy was
suggested for the temporomandibular area. The approach to
the joint complex includes a wide range of articular,
structural, and/or muscular techniques, among others. 7
Some of them have demonstrated to be effective. However,
some may be painful for the patient, such as ischemic
compression techniques, 8 or be seen as aggressive or
invasive, and some, including spinal manipulation, have
had occasional reported adverse effects. 9,10
Myofascial induction techniques are noninvasive thera-
peutic procedures, purported to cause no adverse reactions, 11
and they are widely used in daily practice in the field of
manual therapy. 12 Moreover, these techniques have shown a
positive repercussion on local tissues 13,14 as well as on
general aspects of the organism, by reducing the levels of
anxiety 15 and the variability of cardiac rate. 16
The fascial system is a continuous net divided into
different compartments that separate and support all body
parts. Thus, any functional limitation in a specific region
will have an effect on the whole system. 11 Relaxation
through induction techniques that release fascial tissue can
consequently be transmitted via the fascial system to distal
areas. 2 Saz Llamosas et al 13 recommended that research-
ing with these therapeutic maneuvers should start in pain-
free participants who do not have central or peripheral
sensitization processes. Sensitization operates after noci-
ceptive stimuli. Hence, new conservative, analgesic, and
gentle therapeutic approaches should be evaluated. 17
The aim of this study was to assess if a protocol of
myofascial induction intervention in the masseter and
temporalis muscles has an immediate impact on several
aspects of craniomandibular functionality, such as fol-
lows: (a) maximal amplitude of vertical mouth opening
(VMO) with the participant seated and laying down, (b)
head posture with the participant seated and standing still,
and (c) mechanical sensitivity of the masseter and
temporalis muscles.
METHODS
Design and Participants
Based on a nonprobabilistic convenience sampling, one
researcher selected 48 participants with ages between 18
and 29 years (mean age, 21 2.47 years). Participants were
recruited from the University of Sevilla, where the study
took place. The participants were distributed, by means of a
randomized number table designed by an external online
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Heredia-Rizo et al 311
Myofascial Treatment and Mastication
Fig 1. Flowchart of the studied participants in the selection
process, data collection, and analysis of the results.
company (randomized.com), into a control group (CG; n =
24) and an intervention group (IG; n = 24). The study was
conducted according to the ethical principles of the Helsinki
Declaration (2008 revision) and received the approval of
the Ethical Committee on Research of the University of
Sevilla (Spain). It was subsequently registered in the
Australian and New Zealand Clinical Trial Registry, with
registry number ACTRN 12612000733875.
The study was a double-blind protocol (evaluators and
participants were unaware of the aims of the research).
Sample size calculation was made based on a previous pilot
study, taking into account a 1-tailed hypothesis, a large
effect size (d = 0.8), an value of .05, and an 80%
statistical power. Thus, 21 participants per group were
necessary to complete the study (software: Gpower 3.1.2;
Kiel University, Kiel, Germany). Established inclusion
criteria were as follows: (i) age between 18 and 30 years;
(ii) absence of symptoms in the cervical spine, TMJ, upper
limbs, and craniofacial area within the 4 weeks before data
collection, by means of asking about the prevalence of pain,
discomfort, or functional limitation in the above-mentioned
regions; and (iii) willingness to participate in the research
confirmed by filling in a written informed consent form.
Likewise, participants with any of the following character-
istics were excluded from the study: (i) medical diagnosis of
TMD and/or mandibular parafunctions (bruxism and/or
trismus); (ii) previous whiplash; (iii) fractures and/or sur-
gery in the cranial vault, craniofacial region, and/or any
spinal level; (iv) degenerative, systemic, rheumatic, and/or
tumoral diseases; (v) medicine intake in the 72 hours before
measurements; and (vi) having received soft tissue therapy
within the year before the study. Figure 1 shows the
flowchart of the studied participants during the selection
process, data collection, and posterior analysis.
Measurement protocol was conducted by 2 therapists
before and after intervention in both study groups. The
evaluators had been previously trained in managing the
assessment tools (algometry, digital caliper, and photo-
312 Heredia-Rizo et al Journal of Manipulative and Physiological Therapeutics
Myofascial Treatment and Mastication June 2013

graphs). Moreover, they had previously collaborated in

different clinical trials using the same assessment protocol.
An independent assessor performed the intervention in the
study sample. The independent examiner was a physical
therapist with more than 9 years experience in the field of
manual therapy, including more than 200 hours of education
and training in myofascial induction techniques and having
completed 2 postgraduate university courses in myofascial
techniques and craniosacral therapy.
Interventions were made in both groups 5 minutes after
the first assessment, and the second evaluation process was
carried out 5 minutes after intervention. The main reason for
this is that after a myofascial induction protocol, the
participant should remain in the treatment table for at least 2
to 3 minutes. 11

Blinding
All participants were informed of the general aspects of
the study (possible benefits, risks, precautions, and adverse
effects of the assessments and the interventions). They were
told before randomization that different types of treatments
would be compared in the study and that the therapist's
hands would be placed gently on different parts of their
heads and faces. However, participants and evaluators who
collected or analyzed data remained unaware of the
treatment allocation group. Moreover, as stated before,
participants and evaluators remained unaware of the
specific study aims.
Measurement of the Craniovertebral Angle
The craniovertebral angle (CVA) is the angle resultant
from the intersection between a horizontal line that crosses
the seventh cervical vertebra body (C7) and the line that goes
from C7 to the ear tragus. Craniovertebral angle was
obtained with 2 photographs from the right side of the
participant, one of them with the participant in a seated
position and the other one standing still. The protocol has
been described in recent studies. 14 To increase measurement
accuracy, the CVA was measured twice, taking the mean as
the reference value: (i) the first measurement was taken from
a print of the photograph based on the aforementioned
anatomical referents, and (ii) the second one was made from
the digital photograph using the National Institutes of Health
Image J 1.32 program for Windows. 18 Although many
different methods (cephalometry and magnetic resonance,
among others) are available to evaluate craniocervical
posture, taking lateral photographs has shown high reliability
(intraclass correlation coefficient, 0.88). 19 Besides, it is easy
to use, is cheap, and produces immediate results. 20
Maximal VMO
To measure the maximal amplitude of VMO, the
participant was asked to lay in a supine position first and
Fig 2. Reference points for assessing PPT in temporalis (T1 and
T2) and masseter (M1 and M2) muscles. M1: 2.5 cm anterior to
the ear tragus and 1.5 cm below this point. M2: 1 cm above and 2
cm anterior to the jaw angle. T1: 3 cm above the line that goes
from the lateral eye limit to the external ear and 2 cm behind the
anterior edge of the temporal muscle. T2: 1 cm cranial and
anterior to the external ear.
then to seat comfortably with back support and feet resting
on the floor. We used a digital caliper (Fino Digital Caliper,
Model 59112, Schweinfurt, Germany), with a sensitivity of
0.01 mm. The participants were instructed to open their
mouths as much as possible without pain or discomfort.
Then, the evaluator placed the ends of the caliper in the
middle incisor of the upper and lower jaw. This procedure
has shown high intraevaluator reliability. 21 The mean of 3
consecutive measurements, with a 30-second of resting
period, was taken for further analysis.
Pressure Pain Threshold of the Masseter and Temporalis Muscles
Pressure pain threshold (PPT) is the minimal pressure
necessary to cause pain or discomfort. 22 It was quantified
with a digital algometer of 1-cm 2 contact area (Wagner
Instruments Greenwich, CT; model FPX 25) and applying
increasing pressure of approximately 1 kg/cm 2 per second.
Measurements were taken in 2 locations, in the masseter
muscle (M1 and M2) and in another 2 points in the
temporalis muscle (T1 and T2), in both sides (dominant and
nondominant). The sites were chosen according to the
anatomical references previously described for the tense
bands of these masticatory muscles (Fig 2). 23 The
participant was seated and asked to keep her mouth slightly
open to tense the masticatory muscles. 24 The cervical spine
was stabilized by holding the participant's head during

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Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 5
Fig 3. Deep longitudinal fascial induction of masseter muscles
(phase I).
measurements. The patient was instructed to tell the
evaluator when starting to feel pain or discomfort. The
mean of 3 measurements in each point, with a 30-second
interval between them, was taken as reference value.
Myofascial Induction Maneuvers in the IG
The protocol started with a deep fascial induction
technique of the temporal region. The participant was
placed in a supine position with the therapist sitting at the
headboard of the table. According to the literature, 11 the
therapist placed her cranial hand covering the temporalis
muscle and her caudal hand on the zygomatic arch. In this
position, the cranial hand exerted a slight pressure in the
cranial direction, and the caudal hand did the same in the
caudal direction. Once the tissue was relaxed (about 4
minutes time), the caudal hand moved toward the pectoral
region, always respecting tissue restriction while it moved
forward. This technique was applied bilaterally, first in the
dominant side and, subsequently, in the nondominant side.
Afterward, the therapist performed a deep myofascial
induction of the masseter muscles (phase I). Keeping
the same therapist-patient position, the therapist placed the
cranial hand's fingers on the zygomatic arch and either the
thenar eminence or the thumb of the caudal hand right
beneath it. Then, the therapist exerted a cranial tension with
the cranial hand and a caudal tension with the caudal hand,
which was slid slowly toward the jaw angle after tissue
relaxation (Fig 3). As previously, this maneuver was
applied on both sides of the face, and an intervention time
of 4 minutes for each side was set.
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Heredia-Rizo et al 313
Myofascial Treatment and Mastication
Fig 4. Transverse myofascial induction of masseter muscles
(phase II).
Subsequently, the protocol was finished with a trans-
verse myofascial induction of the masseter muscles (second
phase; 4 minutes). The therapist placed 3 fingers of each
hand on the insertion of the muscle on both zygomatic
arches and exerted sustained pressure toward the medial
line of the face (Fig 4). Once tissue relaxation was attained,
contact was smoothly released. 11 The overall intervention
protocol took 20 minutes for the IG.
Intervention Protocol for the CG
In the CG, the same therapist-patient position was used
than in the IG for each maneuver. The sham (placebo)
protocol consisted in keeping the same therapist's contacts
in the described positions for each myofascial induction
procedure. However, the therapist tried not to exert any
pressure or therapeutic intention. In this way, as relaxation
was not induced, the therapist's hands were not accompa-
nied by any relaxation movements of the fascia. The time
set for each intervention was maintained as in the IG; thus,
the overall protocol also took 20 minutes to homogenize
both interventions.
Statistical Analysis
Statistical analyses were made using the PASW
Advanced Statistics 18.0 (SPSS Inc, Chicago, IL)
software. The results are expressed as the mean with the
corresponding SD and/or 95% confidence intervals, or as
percentage frequencies for the categorical variables. Vari-
ables showed a normal distribution with the Kolmogorov-
Smirnov test (P N .05). Baseline characteristics (age, sex,
handedness, body mass index) of the studied groups (CG
314 Heredia-Rizo et al Journal of Manipulative and Physiological Therapeutics
Myofascial Treatment and Mastication June 2013

Table 1. Physical characteristics of the participants in the studied groups: age, sex, body mass index (BMI) and handedness
Total sample (n = 48) CG (n = 24) IG (n = 24) Difference
Age (y) 21 2.47 20 2.36 21 2.51 P = .146
Sex (male/female) 37.5% (18/48) 41.7% (10/24) 33.3% (8/24) P = .083
62.5% (30/48) 58.3% (14/24) 66.7% (16/24)
BMI (kg/cm2) 22.73 2.68 22.46 2.29 23.00 3.05 P = .493
Handedness 95.8% (46/48); 2.1% 95.8% (23/24); 95.8% (23/24); P = .976
(right; left; ambidextrous) (1/48); 2.1% (1/48) 0% (0/24); 4.2% (1/24) 4.2% (1/24); 0% (0/24)
Data are reported as mean SD or in percentages (%). Difference indicates statistical significance of the between-group difference.
CG, control group; IG, intervention group.

Table 2. Initial and final values and intragroup/intergroup differences in PPT (in kilograms per centimeter squared) of temporalis
(T1, T2) and masseter (M1, M2) muscles, CVA (in degrees), and VMO (in centimeters) for CG and IG
Changes in the intragroup means
Preintervention Postintervention (preintervention postintervention) Difference in the intergroup means
PPT-M1
CG 2.09 0.85 2.17 0.91 0.08 ( 0.22/0.06) 0.06 a ( 0.09/0.23)
IG 1.71 0.63 1.86 0.65 0.14 ( 0.24/ 0.05) b
PPT-M2
CG 1.96 0.84 2.02 0.93 0.06 ( 0.16/0.03) 0.01 a ( 0.12/0.14)
IG 1.67 0.64 1.75 0.58 0.07 ( 0.17/0.02)
PPT-T1
CG 2.22 0.90 2.32 0.94 0.09 ( 0.22/0.03) 0.03a ( 0.12/0.19)
IG 1.84 0.65 1.97 0.67 0.12 ( 0.22/ 0.02) b
PPT-T2
CG 2.74 1.12 2.79 1.12 0.04 ( 0.20/0.10) 0.11 a ( 0.08/0.31)
IG 2.38 0.87 2.54 0.85 0.16 ( 0.29/ 0.02) b
VMO
CG 4.46 0.70 4.49 0.59 0.02 ( 0.13/0.09) 0.00 a ( 0.13/0.13)
IG 4.39 0.52 4.41 0.50 0.02 ( 0.09/0.05)
CVA seated
CG 51.99 4.33 52.82 4.13 0.83 ( 1.78/0.11) 0.99 a ( 0.30/2.28)
IG 56.62 4.15 58.45 4.46 1.82 ( 2.75/ 0.89) b
CVA standing
CC 52.09 4.45 52.95 4.15 0.85 ( 2.09/0.37) 0.76 a ( 0.92/2.46)
IG 54.86 4.08 56.49 3.42 1.62 ( 2.85/-0.39) b
Data are reported as mean SD or 95% confidence level.
CG, control group; CVA seated, craniovertebral angle in seated position; CVA standing, craniovertebral angle in standing position; IG, intervention group;
PPT, Pressure pain threshold; VMO, vertical mouth opening.
a
Indicates no statistically significant intergroup differences (P N .05).
b
Indicates statistically significant intragroup differences (P b .05).

and IG) were evaluated with the 2 test for qualitative
variables and the Student t test for independent samples for
quantitative variables.
An analysis of variance for repeated measures with
group (control or intervention) as interparticipant variables
was used to evaluate the differences in the PPT of the
masticatory muscles, maximal amplitude of VMO, and
CVA. The clinical effect was assessed with Cohen test.
Clinical effects higher than 0.8 are considered high, around
0.5 are moderate, and under 0.2 are low. 25 The statistical
analysis was conducted, considering statistically significant
a P value less than .05.
RESULTS
General baseline characteristics of the studied popula-
tion are shown in Table 1. No significant differences were
observed in the comparison between groups (P N .05 in all
cases). Table 2 lists the results of the variables under study
(CVA in seated and standing positions, PPT of the
temporalis and masseter muscles and maximal VMO)
before and after intervention as well as the differences in the
intragroup and intergroup comparisons.
No statistically significant differences were observed for
PPT in the measurements of both sides (dominant and
nondominant) or for VMO in the evaluated positions
(seated and supine). Hence, the mean of the different
measurements of each variable has been taken as the
reference value for the analysis.
In the intragroup comparison, the PPT of masticatory
muscles increased in all reference points in both groups. In
the IG, we found statistically significant differences in
temporalis muscle (T1: P = .013, F1,23 = 7.25, R 2 = 0.23;
T2: P = .019, F1,23 = 6.41, R 2 = 0.21) and in the upper

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Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 5
point of the masseter muscle (M1: P = .003, F1,23 = 11.34,
R 2 = 0.33). Significant differences were not observed for
M2 (P = .151). However, effect sizes were close to low in
all cases. Maximal VMO showed similar values when
comparing preintervention and postintervention measure-
ments in both groups, without statistical significance in the
intragroup comparison (P = .542 in the IG). Regarding head
position, in the intragroup analysis of the IG, the CVA
increased when the participant was in seated (P = .001,
F1,23 = 16.57, R 2 = 0.41) and standing still positions (P =
.012, F1,23 = 7.49, R 2 = 0.24). No intragroup differences
were found in the CG (P N .05).
Despite the differences observed in the intragroup
analysis, the intergroup comparison of changes in the
postintervention values compared with preintervention scores
shows no differences in any measured variable (M1: P =
.401, M2: P = .879, T1: P = .676, T2: P = .248, VMO: P =
.997, CVA seated: P = .130, CVA standing: P = .367).
DISCUSSION
The myofascial induction protocol slightly improved in
short-term sensitivity to stimulation by mechanical pressure
in the masseter and temporalis muscles, as well as head
position (Table 2). However, that postintervention values in
the CG were also better than preintervention scores might
explain why statistically significant differences were not
reported in the intergroup analysis.
A continuous manual contact (about 20 minutes) without
applying any therapeutic intention showed positive effects in
the CG, by means of modifying the tissue threshold to painful
stimuli, which also had an impact on head posture. For Butler
and Moseley, 26 a light and soft skin contact is a way to
refresh the virtual and real body and may lead to changes in
pain perception. Besides, the mere weight of the therapist's
hands may have activated the propioceptive receptors of the
TMJ region, although the therapist tried not to exert any
pressure. Hence, we must question if the proposed placebo
intervention is not really a powerful intervention itself, and it
should not be considered as a sham intervention.
Applying myofascial techniques gently and kindly may
be part of the derived benefits of these techniques. 27
Nonetheless, despite an extensive use of these maneuvers in
clinical practice, neurophysiologic changes associated with
myofascial induction still lack of a profound explanation
from a scientific point of view. The tensegrity (tension +
integrity) theory proposes a structural concept of the body
that provides stability and permits transfer of mechanical
forces within the whole fascial system. 28 Hence, this model
helps to explains how movement of one part of the body
involves movement of the whole structure, which it is one
of the bases of myofascial techniques. 29
Our results are in accordance with previous findings
from Saz Llamosas et al 13 and Antolinos-Campillo et al, 30
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Heredia-Rizo et al 315
Myofascial Treatment and Mastication
who found no changes in PPT or pain perception at a local
level after fascial induction on the cervical region. Thus, a
fascial protocol alone does not seem to be enough to
activate the descendent inhibitory system at least in healthy
free-pain participants, as already pointed out by Fernndez
de las Peas et al. 31 The TMJ possesses pain-modulation
properties, and the masticatory system has antinociceptive
functions, 32 which explains the relation between TMD and
chronic pain syndromes. 33 Hence, participants with TMD
show a much higher sensitivity compared with pain-free
healthy participants. Fischer et al 2 obtained significant
changes on range of motion of a distal joint, the hip, when
applying an anterior-distal myofascial technique in the TMJ
in participants with complex regional pain syndrome. We
must stress the importance of assessing the results of the
proposed intervention techniques in participants with a
current functional limitation in the TMJ. Consequently, it is
reasonable to assume that therapeutic interventions at the
temporomandibular system may require observed pain or
dysfunction to report clinical effects.
On the other hand, a recent study found a significant
improvement in local PPT after intervention with a
suboccipital muscle inhibition technique. 14 Nevertheless,
the described effect was low, referred to a nerve, and the
sample size was small. It is difficult to compare between
studies because different techniques have been used on
different body regions. For instance, Kalamir et al 27 have
shown very positive functional changes in participants with
chronic myogenous TMD after intraoral myofascial
therapy. They observed that in the long term (1-year
follow-up), the participants who followed consciousness
therapy through education, exercises, and a self-stretching
protocol, along with myofascial techniques, show better
results than participants who only underwent myofascial
manual therapy. Myofascial techniques have also been
combined with spinal manipulation proving to have a
positive effect in participants with tension-type headache. 34
Based on these observations, the effects from myofascial
induction may improve in combination with other therapeu-
tic approaches. Therapeutic exercises have shown positive
results along with manual therapy in several disorders and
conditions, such as shoulder impingement 35 and osteoar-
thritis, 36 among others. Hence, we consider that myofascial
induction may increase its benefits and display better results
when combined with therapeutic exercises. Nevertheless,
this aspect needs to be investigated in future studies.
In the IG, the improvement in PPT was linked to an
increase in the CVA (a more upright cervical spine),
especially with the participant in a seated position. This
observation can be explained by the close biomechanical
and functional relationship between head posture and
TMJ. 4,23 Changes in head position affect the PPT of the
jaw muscles innervated by the trigeminal nerve. 23,37
Oliveira-Campelo et al 38 applied an inhibition technique
in the suboccipital muscles and found an immediate change
316 Heredia-Rizo et al
Myofascial Treatment and Mastication
in masseter and temporalis muscles PPT. The present
results also corroborate the inverse relationship. Another
possible explanation of the phenomenon is the so-called
craniocervical synergy. This synergy is involved in the
convergence of proprioceptive and nociceptive stimuli
from the posterior branches of the 3 first cervical nerves
with branches of the trigeminal nerve. 39 Moreover,
neuromuscular chains may elucidate the complex rela-
tionship between head and masticatory muscles. Tempor-
alis and masseter muscles are part of the same
neuromuscular chain (straight anterior chain) than supra
and infrahyoid muscles, responsible for the rolling
movements of the head. 40 For that reason, changes in
jaw muscles tone and TMJ stiffness are prone to produce
changes in head posture.
Regarding VMO, the intervention protocol produced no
changes in the IG. Rodrguez-Blanco et al. 41 obtained
similar results after applying a strain-counterstrain tech-
nique in the latent myofascial trigger points of the
masseter muscle. Moreover, VMO has immediately
improved after isometric relaxation 41 and neuromuscular
techniques on the trigger points of the masseter muscles. 42
Besides, intraoral therapy improves amplitude of VMO in
a short and in a long term. 27 In the latter case, manual
therapy was conducted along with therapeutic exercise in
one study group.
Limitations
An important limitation of the study is that it was
conducted in pain-free healthy participants. Although
participants were only included in the research if they
showed no previous pain or discomfort in the craniocervical
area, upper limbs, or TMJ, at least in the 4 weeks before
data collection, we could have used a validated tool to
assess TMJ functionality. For instance, the clinical
dysfunction component of the Helkimo Index or the
research diagnostic criteria for TMDs would have produced
a better characterization of the evaluated population.
Besides, it remains unknown if there would be different
results in participants with pain or who have a central or
peripheral sensitization process. Hence, it would be of great
interest to develop future case-control studies in participants
with TMD, associated or not with cranial pain. Moreover,
we have not assessed maximal painful tolerance of the
masticatory muscles. The results might be different
considering suprathreshold stimulation.
As previously discussed, it remains questionable if the
intervention in the CG can be considered a placebo
technique because results were positive in the CG for all
measured variables. An expectant observation technique
could have been used for participants in the CG. However,
it was considered to be more accurate that both intervention
procedures involved touching and the same skin contacts to
respect blindness in the research protocol. 12
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Journal of Manipulative and Physiological Therapeutics
June 2013
CONCLUSIONS
A myofascial induction protocol in the temporalis and
masseter muscles leads to slight immediate changes in
mechanosensitivity of the masticatory muscles and head
position in pain-free healthy participants. However, the
proposed myofascial protocol showed no differences in the
variables or in VMO with a sham (placebo) intervention in
which the therapist's hands are placed on the TMJ region
without exerting any therapeutic pressure.
Practical Applications
A continuous manual contact in the TMJ
region applying no pressure or therapeutic
intention might exert slight improvements in
head posture and masticatory muscle's
mechanosensitivity.
A myofascial induction protocol in the
masseter and temporalis muscles is not
enough to produce changes in pain percep-
tion in comparison with a placebo interven-
tion in pain-free healthy participants.
Changes obtained in masticatory sensitivity
to mechanical pressure have an impact on
head posture with the participant in seated
and standing positions.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
No funding sources or conflicts of interest are reported
for this study.
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