Journal of Bodywork & Movement Therapies 28 (2021) 104e113

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Myofascial Pain and Treatment

Myofascial pain in temporomandibular disorders: Updates on

etiopathogenesis and management
Mythili Kalladka a, Andrew Young b, Junad Khan a, *
a
Orofacial Pain and TMJ Disorders, Eastman Institute for Oral Health, University of Rochester, 625 Elmwood Ave, NY, 14620, USA
b
Orofacial Pain Clinic, University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, CA, 94103, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Temporomandibular disorders (TMDs) are an umbrella term encompassing disorders of both
Received 22 December 2020 the temporomandibular joint (TMJD) and masticatory musculature (MMD). The objective of this review
Received in revised form is to provide an overview of the etiopathogenesis, clinical features and diagnosis of MMD, and to
14 June 2021
summarize the current trends in the therapeutic management.
Accepted 13 July 2021
Methods: A review of the literature was performed from 1985 to 2020. The keywords included were
“temporomandibular disorders OR temporomandibular joint disorders” AND “myofascial pain OR
Keywords:
masticatory myofascial pain OR trigger point”. A total of 983 articles were screened with abstracts and
Temporomandibular disorder
Myofascial pain
approximately 500 full text articles were included in the review based on their relevance to the topic.
Trigger point Results: MMD's present significant challenges in diagnosis and treatment. Effective treatment requires a
clear diagnosis based on an understanding of pathophysiologic mechanisms, a detailed history with
assessment of predisposing local and systemic factors, perpetuating factors, a comprehensive clinical
evaluation and a diagnostic workup.
Conclusion: A thorough history and clinical examination are the gold standards for diagnosis of MMD.
Serological testing may help identify underlying co-morbidities. Recent diagnostic modalities including
ultrasound sonoelastography and magnetic resonance elastography (MRE) have shown promising re-
sults. The treatment goals for MMD are to control pain, restore mandibular function and facilitate the
return to normal daily activity and improve the overall quality of life of a patient. Conservative modalities
including home care regimens, pharmacotherapy, intraoral appliance therapy, local anesthetic trigger
point injections, physiotherapy and complementary modalities may be beneficial in patients with
MMD's.
© 2021 Elsevier Ltd. All rights reserved.

1. Introduction In contrast, chronic pain is considered a disease by itself, and

Pain is a complex multidimensional experience resulting from the
confluence of peripheral and central sensory mechanisms and
modified by various biological and psychosocial parameters. An
intricate sequence of events in both the peripheral (PNS) and central
nervous system (CNS) orchestrate the perception of pain. It is initiated
by transduction and transmission of nociceptive impulses from the
PNS to the CNS and the higher centers of the brain where it is
modulated and finally perceived as “pain”. Acute pain is normally
considered protective and is integral to the survival of an organism.
* Corresponding author. Orofacial Pain and TMJ Disorders, Eastman Institute for
Oral Health, 625 Elmwood Ave, Box 683, Rochester, NY, 14642, USA.
E-mail addresses: dr.mythili@gmail.com (M. Kalladka), ayoung@pacific.edu
(A. Young), Junad_khan@urmc.rochester.edu (J. Khan).
lacks a biological purpose. An estimated 50 million Americans
suffer from chronic pain (James Dahlhamer, 2018), placing a sig-
nificant economic burden on society in terms of utilization of
healthcare resources and lost productivity. Temporomandibular
disorders (TMD's) are the most common chronic musculoskeletal
orofacial pain conditions and the second most common musculo-
skeletal condition following chronic low back pain (Maisa Soares
and Rizzatti-Barbosa, 2015; "Management of temporomandibular
disorders, 1996). TMD's are a collective term describing a number
of painful and non-painful disorders that involve the masticatory
musculature, the temporomandibular joint (TMJ) and the associ-
ated structures (International Classification of Orofacial Pain, 2020).
Disorders of the muscles of mastication (MMD) are more frequently
encountered compared to temporomandibular joint disorders
(TMJD). The spectrum of disorders of masticatory muscles ranges

https://doi.org/10.1016/j.jbmt.2021.07.015
1360-8592/© 2021 Elsevier Ltd. All rights reserved.
M. Kalladka, A. Young and J. Khan
from localized myofascial pain disorders like local myalgia and
myofascial pain at one end of the spectrum to generalized pain
disorders like fibromyalgia at the other end. Systematic and liter-
ature reviews comparing individual management modalities are
available. However, comprehensive reviews incorporating current
theories of etiopathogenesis and different management modalities
for myofascial pain in TMDs are lacking. The objective of this review
is to summarize the current knowledge on pathophysiologic
mechanisms, clinical presentation and therapeutic implications for
MMDs.
2. Epidemiology of MMD's
Epidemiological studies have reported variations in the preva-
lence of TMD's based on factors such as study design and diagnostic
and inclusionary criteria. Self-reports on TMD symptoms in the
general population in the United States have estimated a preva-
lence of 5% (Maixner et al., 2016). A systematic review and meta-
analysis analyzing studies strictly adhering to the guidelines of
research diagnostic criteria (Schiffman et al.) have estimated the
prevalence of TMD's in the general and patient population
(Manfredini et al., 2011). In the general population, MMD (including
categories of myofascial pain and myofascial pain with limited
opening) was shown to be present in 9.7% while TMJ disc
displacement with reduction was present in 11.4%. However, in a
patient population with TMD, MMD was the most common diag-
nosis (including categories of myofascial pain and myofascial pain
with limited opening) at 45.3% of the patient population. A total of
41.1% of the TMD patients had TMJ disc displacements (including
categories of disc displacement with reduction, disc displacement
without reduction with limited mouth opening and disc displace-
ment without reduction and without limited opening) and 30.1%
had arthralgia, osteoarthritis, or osteoarthrosis (Manfredini et al.,
2011).
The condition is most prevalent in young and middle-aged
adults (mean age of 30e40 years) with a higher prevalence in fe-
males (Manfredini et al., 2011; Reny de Leeuw, 2018). Ethnic vari-
ations have also been reported with a higher prevalence in African
Americans (Reny de Leeuw, 2018).
2.1. Classification of TMD's
Over the years several classification systems have been pro-
posed; one of the most widely accepted classification for research is
the Diagnostic Criteria for Temporomandibular Disorders (DC-
TMD). The DC-TMD classification broadly classifies TMD into Axis I
and Axis II categories. Axis I deals with measures of physical
diagnosis while Axis II deals with psychosocial and pain-related
disability measures. The Axis II measures in DC-TMD include
comprehensive self-report assessment tools and screening tools
(Schiffman et al., 2014).
Recently, the International Classification of Orofacial Pain (ICOP)
was proposed, and this classification uses a comprehensive term
“myofascial orofacial pain” (MOP) (International Classification of
Orofacial Pain, 2020) to encompass all MMD in the orofacial re-
gion. The classification categorizes MOP into primary and second-
ary MOP on basis of etiology, similar to the principles of
International Classification of Headache Disorders (ICHD-3). The
novel feature of ICOP is its emphasis on the temporal nature of pain.
The ICOP classification divides MOP into primary and secondary,
and subdivides primary MOP into acute and chronic. Chronic pri-
mary MOP is further separated into infrequent, frequent (with and
without referral), and highly frequent. Secondary MOP is divided
based on cause: myositis, tendonitis or muscle spasm (International
Classification of Orofacial Pain, 2020).
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Journal of Bodywork & Movement Therapies 28 (2021) 104e113
Axis I criteria for RDC-TMD has been reported to have a lower
sensitivity and specificity than desired (Schiffman et al., 2014). Also
RDC-TMD can be time consuming to use. Hence the DC-TMD was
developed which provide short, simple, validated and compre-
hensive screening instruments for Axis I and II conditions in both
clinical and research settings. Overall dentists, health care pro-
fessionals and researchers tend to prefer the use of DC-TMD. In this
article, we will be adhering to DC-TMD criteria. The most common
clinical MMD's include myospasm (sudden onset, involuntary
reversible, tonic contraction of the muscle, accompanied by im-
mediate myalgia and limited jaw range) (Peck et al., 2014), myalgia
(pain of muscle origin affected by function, parafunction and jaw
movements with pain replication during provocation tests) which
is subdivided into local myalgia (features of myalgia with pain
present only at the site of palpation), myofascial pain (features of
myalgia and additional with spread of pain beyond the site of
palpation but limited to the boundary of the muscle) and myofas-
cial pain with referral (features of myalgia with pain referral beyond
the boundary of the muscle examined) (Schiffman et al., 2014). The
examination protocol for all the conditions has been detailed in the
Research Diagnostic Criteria for Temporomandibular Disorders/
Diagnostic Criteria for Temporomandibular Disorders (RDC-TMD/
DC-TMD) guidelines (Dworkin and LeResche, 1992; Schiffman et al.,
2014).
2.2. Pathophysiology of MMD's
MMD in the orofacial region includes myalgia, which can be
subdivided into local myalgia, myofascial pain and myofascial pain
with referral. The etiopathogenesis for MMD in the orofacial region
has not been completely elucidated, but it has been suggested that
the same underlying mechanisms involved in the etiopathogenesis
of MPS are also involved in MMD.
2.2.1. Theories of trigger points (TrP) formation
Myofascial pain is primarily initiated and sustained by under-
lying TrPs (hyperirritable spots in a taut band of muscle fibers). TrPs
have been proposed to occur when the functional demands on the
muscle exceeds its capacity for adaptation. The exact pathophysi-
ology for genesis and sustenance of TrPs (Travell & Simons'
Myofascial Pain and Dysfunction: The Trigger Point Manual, 1999) in
myofascial pain is still not completely understood. The integrated
theory is one of the comprehensive theories to explain the phe-
nomenon of TrPs (Muscle Pain: its Nature, Diagnosis, and Treatment,
2001; Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger
Point Manual, 1999). An addition to this theory was proposed by
Gerwin, who suggested that an acidic milieu inhibits acetylcho-
linesterase, resulting in excess acetylcholine (ACh) in the region of
synaptic cleft and causes prolonged contraction of the sarcomere
(Gerwin et al., 2004). Over the years several modifications have
been added to the integrated theory (Gerwin et al., 2004; J.M.
McPartland, 2006). It is described here:
2.2.2. Excessive activity of ACh and formation of taut bands
Spontaneous and sustained intense electromyogram (EMG) ac-
tivity has been reported in the area of a TrP or at the region of
neuromuscular endplate (Hubbard and Berkoff, 1993; Simons et al.,
2002). This has been attributed to dysfunctional endplates.
Dysfunctional endplates and alterations in the neuromuscular
junction may occur due to excess release of ACh, alterations in the
number or activity of acetylcholine receptors (AChR), or inhibition
of acetylcholinesterase (AChE). These changes lead to an excess ACh
in the region of the end plate and may lead to prolonged contrac-
tion of the sarcomere (Gerwin et al., 2004; Simons, 2004). Two
additional mechanisms contribute to dysfunctional end plates:
M. Kalladka, A. Young and J. Khan
calcitonin gene-related peptide (CGRP) related mechanism and an
acidic environment (Jafri, 2014). Release of CGRP by motor nerve
endings and nociceptors in the muscles is facilitated by the in-
flammatory milieu following peripheral sensitization. CGRP may
inhibit AChE or upregulate AChR. Augmentation of the activity of
ACh also occurs by inhibition of AChE in an acidic environment
following muscle damage (Gerwin et al., 2004) and release of ACh
by the sympathetic nervous system subsequent to peripheral
sensitization (Hubbard and Berkoff, 1993). Thus, a confluence of
multiple mechanisms may result in excessive activity of ACh,
resulting in prolonged and sustained contraction of a sarcomere
producing taut bands or nodules (TrPs).
2.2.3. Local hypoxia and energy crisis
The tautness in the bands and the sustained contraction of the
sarcomeres restricts the arteriolar and capillary microvascular
blood flow resulting in local hypoxia, reduced glucose levels and
accumulation of metabolic waste products. These events place a
high metabolic demand on oxygen and glucose, and affects the
energy metabolism pathway in the mitochondria, which in turn
affects the production of adenosine tri phosphate (ATP). ATP is also
essential for the reuptake of calcium, and a deficit of ATP prolongs
contraction. Thus an energy crisis ensues (Travell & Simons’
Myofascial Pain and Dysfunction: The Trigger Point Manual, 1999).
2.2.4. Role of peripheral and central sensitization
Sensory phenomenon such as pain, hyperalgesia, and allodynia
associated with TrPs may be attributed to the release of inflam-
matory mediators by the damaged muscle. A study conducted by
Shah and colleagues confirmed the presence of an inflammatory
biochemical milieu (substance P (subs P), serotonin, norepineph-
rine (NE), CGRP, proinflammatory cytokines (TNF-alpha, IL-1 beta,
IL-6, IL-8) and an acidic pH in the active TrPs compared to controls
with latent TrPs with no pain, and controls with no TrPs and no pain
(Shah et al., 2008). This offers support to the integrated hypothesis
and suggests that peripheral sensitization by a plethora of inflam-
matory mediators may act in concert with an acidic environment
and local ischemia to sensitize peripheral sensory muscle noci-
ceptors (Shah et al., 2008; Shah et al., 2005). These mediators may
function directly by binding to their peripheral receptors and
generating an action potential, or they may function indirectly by
sensitizing the neuron and reducing the threshold potential (Shah
et al., 2005), resulting in a reduction in the pain pressure
threshold in patients with active TrPs. The study found significant
subs P and CGRP at site of active TrPs. Persistent noxious input
results in antidromic and additional orthodromic release of subs P
and CGRP, which may sensitize dorsal root ganglion (DRG) cells and
result in changes in neuronal matrix of the CNS and lead to central
sensitization. Prolonged peripheral sensitization and an acidic
environment may also facilitate the release of excitatory neuro-
transmitters such as glutamate and aspartate, which sensitize wide
dynamic range neurons (WDR) and N-methyl-D-aspartate re-
ceptors (NMDA) in the spinal cord (Radhakrishnan and Sluka,
2009). Glutamate is a primary excitatory neurotransmitter that
plays a vital role in central sensitization. Peripheral sensitization
enhances the release of excitatory neurotransmitters such as
glutamate from primary afferent nociceptors in the trigeminal
nucleus and/or spinal cord. This can result in neuronal hyper-
excitablity and hyperactivity, leading to central sensitization. In
addition, central sensitization is induced and maintained by the
activity of glutamate on post synaptic NMDA and AMPA receptors
(Ji et al., 2018).
Convergence of primary afferent nociceptive stimuli in the spi-
nal cord and activation of sleeping nociceptors may also contribute
to central sensitization and referral of pain. Clinical features such as
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Journal of Bodywork & Movement Therapies 28 (2021) 104e113
allodynia, hyperalgesia, and referred pain have been attributed to
central sensitization. Subs P also triggers degranulation of mast
cells and the release of serotonin, histamine and proinflammatory
cytokines. Proinflammatory cytokines like TNF-alpha have a direct
effect on increasing levels of prostaglandin E2 (PGE2), CGRP and
nerve growth factor (NGF) one day following injection (Schafers
et al., 2003). Elevated NE at the nociceptor terminal may reflect
enhanced sympathetic activity at motor end plates and add to the
feedback loop of activating ACh.
The degree of peripheral and central sensitization may vary in
different myalgic conditions, with a predominant peripheral
mechanism in local myalgia as opposed to prominent central
mechanisms in myofascial pain with referral and generalized pain
conditions like fibromyalgia.
2.2.5. Cinderella theory
Although the integrated theory with the modification by Gerwin
explains the pathogenesis of the TrP, it was unable to describe the
reason for the onset and energy crisis in a normal muscle. The
Cinderella theory hypothesizes that small muscle fibers are most
susceptible to damage and the development of energy crisis. This is
related to the hierarchical manner of recruitment of muscle fibers
during contraction (smallest to largest) and the reverse pattern
during relaxation (largest to smallest). Thus, small muscle fiber
groups are subject to prolonged periods of contraction, which
makes them more susceptible to an energy crisis (Kadefors et al.,
1999).
2.2.6. Shift theory
Recent findings by DeLuca and colleagues suggest that the
Cinderella theory may be true for phasic muscles containing a
predominance of fast twitch fibers, but the pattern may be different
for tonic muscles containing a predominance of slow twitch fibers
(Westgaard and De Luca, 2001). Hence, a new theory called the
“Shift Theory” was proposed, which suggests that any muscle
recruited in a shift pattern with a prolonged contraction and
insufficient relaxation time may be subject to developing an energy
crisis (Minerbi and Vulfsons, 2018).
2.2.7. Is there a role for descending modulation in myofascial pain?
The role of the central mechanisms and descending modulatory
systems have been under increased scrutiny in the recent years. The
descending pain modulation pathway is mediated by projections to
the periaqueductal grey (PAG) and communicates with the rostro
ventral medulla (RVM) and other medullary nuclei, which then
descend down via the spinal cord. The PAG also receives inputs
from hypothalamus. The locus coeruleus is primarily noradrenergic
and receives information from the PAG and has relay connections
with the RVM, which sends noradrenergic descending pathways to
the spinal cord (Ossipov et al., 2010). Thus, stress may activate
pathways via the RVM and affect the endogenous pain modulatory
responses. The balance between pain facilitatory and inhibitory
system is disrupted in chronic pain patients with either or both
upregulation of central nociceptive processing and downregulation
of descending modulatory systems (Radhakrishnan and Sluka,
2009). These reports have been confirmed in several chronic pain
conditions such as TMDs, fibromyalgia, and headache disorders. We
have previously reported that pain modulation is suppressed in
patients with chronic masticatory pain compared to healthy con-
trols (Nasri-Heir et al., 2019). Upregulated processing of central
nociceptive impulses has been reported to be more significant in
females. Inter-hemispheric disinhibition and disinhibition of the
motor cortex and descending modulating system is seen in TMDs
and myofascial pain (Caumo et al., 2016).
M. Kalladka, A. Young and J. Khan
2.3. Clinical presentation
The confluence of motor, sensory, and autonomic inputs may
result in varied clinical presentation resulting in diagnostic di-
lemmas. The most prominent clinical feature of MMD is the pres-
ence of TrP characterized by nodules or taut bands in muscle fibers
which may cause spontaneous pain (active TrP) or pain when
provoked (latent TrP) at the site of palpation or at distant sites with
characteristic patterns of referral (Travell & Simons' Myofascial Pain
and Dysfunction: The Trigger Point Manual, 1999). A classic twitch
response may be elicited when a TrP is palpated. TrPs may cause
pain or tenderness at the site of palpation, pain referral, restriction
in the range of motion, and occasional autonomic or sensory phe-
nomenon such as allodynia (Travell & Simons’ Myofascial Pain and
Dysfunction: The Trigger Point Manual, 1999).
The sensory phenomenon such as pain in MMD is generally
described as intermittent or continuous dull aching pain, aggra-
vated by jaw movements, chewing and parafunctional habits. Oc-
casionally the pain may be severe, and, in such instances, it may
present as sharp, radiating pain. Occasionally, there may be sec-
ondary hyperalgesia (increased pain to a painful stimuli) and allo-
dynia (pain to a non-painful stimuli) indicative of central
sensitization.
2.3.1. Myospasm
The symptoms of myospasm may include immediate onset of
pain in the masticatory muscles, acute malocclusion, and limitation
in range of movements. It is confirmed by an elevation in the
electromyographic activity in the affected muscle as compared to
the contralateral side (2018).
2.3.2. Myalgia
As per DC-TMD, the primary symptoms of myalgia include pain
in the jaw, ear, preauricular area and the temples and on exami-
nation the pain complaints of the patient are replicated with either
palpation of the masticatory muscle (temporalis, master or other
masticatory muscles as necessary) or with maximum assisted and
unassisted opening movements of the jaw (Schiffman et al., 2014).
Myalgia has been further subdivided into local myalgia, myo-
fascial pain and myofascial pain with referral.
2.3.3. Local myalgia
It presents with the characteristics of myalgia and localization of
pain restricted to the site of palpation (Schiffman et al., 2014).
2.3.4. Myofascial pain
The DC-TMD criteria for myofascial pain includes characteristics
of myalgia with additional spreading of pain beyond the site of
palpation but restricted to the boundary of the muscle being
palpated (Schiffman et al., 2014).
2.4. Myofascial pain with referral
The characteristics of symptoms and signs include those speci-
fied for myalgia with additional referral of pain beyond the muscle
being palpated (Schiffman et al., 2014). Fig. 1 depicts local myalgia,
myofascial pain and myofascial pain with referral.
2.5. Diagnosis of MMDs
The temporomandibular joint and its associated structures form
one of the “most” complex articulations in the body and it has held
the interest of clinicians and researchers alike for decades. However,
lack of specific diagnostic tests, definitive pathophysiological causes,
and limited research in the field have contributed to diagnostic
107
Journal of Bodywork & Movement Therapies 28 (2021) 104e113
enigmas in the field (Simons, 2004). History and clinical examina-
tion are still the gold standards for diagnosis of MMD. A detailed
medical history and review of symptoms is essential to identify
systemic comorbidities and overlapping systemic pain conditions
such as fibromyalgia. Physical therapy diagnosis includes TMJ
dysfunction, cervicalgia, polymyositis (with myopathy), muscle
spasm, myalgia, muscle weakness, myofascial syndrome and
contracture of muscle. Clinical examination with replication of pain
complaints are still the mainstay of diagnosis. The masticatory
muscles are palpated per the guidelines provided in the DC-TMD
(Dworkin and LeResche, 1992; Schiffman et al., 2014). Muscles may
be palpated for TrP by two techniques: flat (for muscles with un-
derlying bone) or pincer palpation (for muscles such as the sterno-
cleidomastoid and upper trapezius, which do not have underlying
bone). The general guidelines for palpation of muscles include
palpation at the origin, body and insertion of muscles and palpation
perpendicular to the direction of muscle fibers. The pressure on a TrP
should be maintained for 5e10 s to detect referral patterns for
spread of pain (Dworkin and LeResche, 1992; Schiffman et al., 2014).
Serological testing may help identify underlying co-morbidities
such as iron deficiency anemia, vitamin deficiency, generalized
rheumatic and musculoskeletal disorders, hypothyroidism etc.,
which may predispose and perpetuate chronic MMDs (Gerwin,
2014). Iron is crucial for oxygenation, production of energy and
enables the muscle to meet energy demands. Vitamin deficiencies
are closely related to muscle pain. Vitamin B12 and folic acid play
an important role in the production of red blood cells which
transport oxygen and are important for oxygenation of various
tissues including muscle tissue. Oxygen is essential for energy
metabolism. Local hypoxia and energy crisis are important mech-
anisms proposed to play a role in the biogenesis of trigger points
(Okumus et al., 2010). Trace elements such as zinc and selenium are
also essential co factors for anti-oxidant enzymes. Zinc has shown
to have an antioxidant response to stress. Magnesium which is
another trace element is necessary for ATP synthesis and ample
muscle metabolism. ATP and energy play an important role in the
biogenesis of trigger points (Okumus et al., 2010). Recently, ultra-
sound sonoelastography has shown promising results (Gerwin,
2014; Turo et al., 2013) and high definition ultrasonography is be-
ing increasingly used to guide needle positions during difficult TrP
injections (Kalladka et al., 2020) and TrP injections to deep muscles
(Gerwin, 2014). Magnetic resonance elastography (MRE) has shown
promising results in the recent years (Chen et al., 2007). The
technique is a modification of magnetic resonance imaging (MRI)
and enables identification of taut bands using phase-contrast im-
aging (Chen et al., 2007). Spontaneous electrical activity detected
by single needle electromyogram (EMG) has shown increased ac-
tivity at the TrP coupled with an increase in the mean EMG
amplitude when compared to healthy controls, and this may also be
used as an adjunct diagnostic tool (Hubbard and Berkoff, 1993).
2.5.1. Quantitative sensory testing and somatosensory profiles
Quantitative sensory testing may also be used as an adjunct
diagnostic testing modality. A study using QST in the orofacial re-
gion has suggested that it may be beneficial in distinguishing
arthralgia conditions from myalgic conditions and may thus help
improve treatment outcomes (Eliav et al., 2003). The study re-
ported that the electrical detection threshold in the auric-
ulotemporal nerve territory was significantly elevated in patients
with muscle related facial pain (Eliav et al., 2003). Large myelinated
fiber hyposensitivity manifesting as an elevated monofilament
detection threshold has been reported in the affected and contra-
lateral side, suggesting central mechanisms (Stohler et al., 2001).
These changes in somatosensory testing may extend to extra ter-
ritorial regions as well (Yang et al., 2016).
M. Kalladka, A. Young and J. Khan
Fig. 1. Figure depicting pain referral patterns in local myalgia, myofascial pain and myofascial pain with referral.
A thorough history and clinical examination with replication of
pain complaints are still the mainstay and gold standards for
diagnosis. Often patients with chronic MMDs will have undiag-
nosed underlying conditions that can contribute to the overall pain
and wellbeing of the patient. Serological testing is generally advised
to identify co-morbidities such as iron deficiency anemia, vitamin
deficiency, generalized rheumatic and musculoskeletal disorders,
hypothyroidism or other suspected associated conditions which
may predispose and perpetuate chronic MMDs. Recent diagnostic
aids such as ultrasound sonoelastography, magnetic resonance
elastography (MRE), single needle electromyogram (EMG) may be
in used in complex cases or cases which present as diagnostic di-
lemmas. QST is mainly used for research purposes and as an adjunct
diagnostic aid.
2.6. Management of MMD
The history of therapeutic interventions involving the TMJ has
been contentious. Recent advances in research have significantly
improved an understanding of MMDs. Emerging data on MMDs
suggests that demands on mandibular function can induce
morphologic adaptations. The outcome is clinically relevant
because extremely strict adherence to narrow definitions in past
have led to overzealous treatment in the past. To provide a rational
basis for treatment, it is important to determine the nature and
relative contribution of predisposing, perpetuating and precipi-
tating factors (3 P's) as comprehensively as possible. The specific
etiology of the most MMDs are unknown. The lack of a clear single
cause has resulted in the proposal of a multifactorial etiology.
Numerous biological, psychological and social factors may
contribute to the initiation and perpetuation of the disorder. Some
of the factors proposed are the following: parafunctional habits,
sustained overuse, microtrauma, emotional distress, acute trauma
from blows or impacts, trauma from hyperextension, laxity of the
joint, comorbidity of other rheumatic, musculoskeletal disorders or
chronic pain conditions, poor general health and an unhealthy
lifestyle (Fricton, 2016). A detailed history and comprehensive
clinical exam serve to determine the contribution of predisposing,
perpetuating and precipitating factors, medical comorbidities, and
the degree of involvement and extent of adaptation of various
structures, and enable the clinician to formulate a diagnosis.
Myofascial pain is one of the most elusive and enigmatic con-
ditions to diagnose and treat. Treatment goals for MMD are to
control pain, restore mandibular function, and facilitate the return
to normal daily activity. No one treatment has emerged as superior,
although many of the treatments studied have shown some
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Journal of Bodywork & Movement Therapies 28 (2021) 104e113
beneficial effect. Distinction between acute and chronic myofascial
pain is crucial for success. Acute myofascial pain is associated with
an acute onset (less than 3 months) secondary to a precipitating
event and associated with acute limitation of the musculoskeletal
system. Chronic pain is complex with multiple comorbidities
including psychological overplay, and often benefit from multidis-
ciplinary treatment.
Nociceptive pathways may be activated by a variety of condi-
tions such as trauma, drug treatment, surgery, autoimmune con-
ditions, viral infections and cancer, producing a state of neuro
inflammation. When acute pain states are primed by elements such
as genetic factors, stress, environmental and psychological in-
fluences, they may transition to chronic pain (Ji et al., 2018). Recent
animal and human studies indicate that an inefficient pain modu-
lation system or cytokine profile may play a role in this transition
from acute to chronic pain (Khan et al., 2015, 2018; Khan et al.,
2019; Nishihara et al., 2020). Several factors may play a role in
the transition of acute to chronic pain including poor coping skills,
multiple comorbid pain conditions, persistence of perpetuating
factors after acute injury, and decreased pain modulation. Identi-
fying and addressing these factors are critical to prevent acute pain
from transitioning to chronic pain.
2.6.1. Acute MMD
These conditions mostly occur as a response to a specific
precipitating event such as trauma, overuse or infection. Nonin-
vasive, conservative treatment modalities including rest, home care
regimen, pharmacotherapy, short-term appliance therapy and
physiotherapy have been suggested for most TMDs by the Amer-
ican Academy of Orofacial Pain (Reny de Leeuw, 2018). If an infec-
tive cause is found, antibiotic therapy may be initiated. Successful
treatment of acute MMD is paramount to prevent the transition to
chronic MMDs.
2.6.2. Chronic MMD
The symptoms of chronic MMD tend to be intermittent, fluc-
tuate over time, and are often self-limiting. Persistence and recur-
rence of myofascial trigger points make it difficult to treat. The
process of deciding whether to treat and how aggressively to treat
should include an assessment of the course of symptoms. Patients
who are improving at the time of assessment may require a mini-
mum of care and monitoring, compared to the individual whose
symptoms are becoming progressively more severe and disabling.
Home care, patient education, physical therapy, intraoral appliance
therapy, pharmacotherapy, behavioral/relaxation techniques have
been recommended as the first line treatment in most instances
M. Kalladka, A. Young and J. Khan
Table 1
Table depicting management strategies for myofascial pain and Fibromyalgia.
Treatment Myofascial pain
Modalities
Non- Patient education, home care regimen and home care exercises
Pharmacologic Intra oral appliance therapy
Injections and dry needling
Physiotherapy
Complementary therapy
Biofeedback
Cognitive behavioural therapy
Exercises
Acupuncture
Pharmacologic Cyclic medications-Cyclobenzaprine
Tricyclic antidepressants- amitriptyline and nortriptyline
Selective serotonin reuptake inhibitors (SSRI's), serotonin norepinephrine reuptake inhibitors (SNRI's),
Benzodiazepines, Steroids and Muscle relaxants
and follow the recommendations of the American Academy of
Orofacial Pain (Reny de Leeuw, 2018). Long term studies have re-
ported that 85e90% of the patients experienced significant relief of
symptoms with conservative measures (Apfelberg et al., 1979;
Okeson and Hayes, 1986). Another factor which is crucial in
enhancing the degree of success in the management of chronic
MMDs is discerning the degree of peripheral and central mecha-
nisms as contributors to the initiation and sustenance of these
conditions. Conditions such as myospasm and local myalgia with a
predominant peripheral mechanism may have better response
targets in the PNS, whereas conditions such as fibromyalgia may
require treatment modalities directed at central pain mechanisms.
Table 1 depicts the treatment strategies for myofascial pain vs
fibromyalgia.
2.6.3. Home care regimen and exercises
Home care regimen to provide rest to the jaw and increase
awareness and promote avoidance of parafunctional habits is an
essential part of management of MMDs. Additional home phys-
iotherapy including home care exercises, gentle massage and hot/
cold compress may be beneficial in patients with MMDs (Reny de
Leeuw, 2018). Home care regimen and exercises are generally
helpful in mild cases of MMD. For moderate to severe cases
generally home care and exercises may not suffice alone. In such
instances they may be beneficial when used in combination with
other therapeutic modalities. Nutritional deficiencies may play a
role in intensifying pain responses in patients with chronic
musculoskeletal pain. Evidence based recommendations by an
expert panel concluded that at present there is insufficient sci-
entific evidence to make clinical practice recommendations.
However, they conditionally recommended ginger, curcuma, Av-
ocado soybean unsaponifiables, polyunsaturated fatty acids,
melatonin, capsaicin, glucosamine, and vitamin D (Crawford et al.,
2019).
2.6.4. Pharmacotherapy
Commonly-used groups of medications for the treatment of
MMD include non-steroidal anti-inflammatory (NSAIDs), tricyclic
anti-depressants (TCAs), selective serotonin reuptake inhibitors
(SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs),
109
Journal of Bodywork & Movement Therapies 28 (2021) 104e113
Fibromyalgia
Exercise
Patient education
Low impact aerobic exercise
Balance and strength training
Conservation of energy
Biofeedback
Cognitive behavioural therapy
Nutrition
Acupuncture
FDA Approved Medications
Pregabalin
Duloxetine
Milnacipran
Treatments with demonstrated efficacy
(Non-FDA Approved)
Cyclic medications-Cyclobenzaprine
Tricyclic antidepressants- amitriptyline
and nortriptyline
Alpha-2-delta ligands
Gabapentin
Sleep medicine
Sodium oxybate
benzodiazepines, steroids and muscle relaxants (Sharav Yair, 2015).
No one medication has emerged superior to the others per RCTs.
NSAIDs are advised for short term use in acute MMDs. Safety
concerns regarding a greater risk for cardiovascular events and
gastritis limit extended use of these medications. TCAs have a
favorable safety profile for extended use and are beneficial in pa-
tients with chronic pain. Additional benefits on sleep and mood
disorders make them a drug of choice in chronic MMD patients
with such disorders. However, the side effect profile of nortriptyline
has been reported to be slightly more favorable than amitriptyline
(Haviv, Zini, Sharav, Almoznino, & Benoliel). SSRIs and SNRIs have
also been used in the management of MMD, but one has not
emerged superior to the other. Steroids are generally advised for
acute inflammatory disorders and in patients with comorbidities
such as autoimmune disorders. Cyclobenzaprine has insufficient
evidence in MFP (Leite et al., 2009), although it is commonly used in
clinical practice. Only two small studies have been reported, with
one comparing to clonazepam showing it to be slightly better.
Medications used for MMD such as non-steroidal anti-inflamma-
tory (NSAIDs), tricyclic anti-depressants (TCAs), selective serotonin
reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake
inhibitors (SNRIs), benzodiazepines, steroids and muscle relaxants
are often contraindicated in patients with systemic disorders such
as liver/renal failure, gastric ulcers, cardiac failure, narrow angle
glaucoma, diabetes, bipolar disorders and bleeding disorders.
Caution must be taken when prescribing these medications in the
elderly and managing polypharmacy. NSAIDs and steroids, gener-
ally cannot be used long-term due to adverse effects. Caution
should be exercised when considering use of benzodiazepines
long-term due to the risk for addiction.
2.6.5. Intra oral appliance therapy
Oral appliances can be broadly categorized into complete
coverage and partial coverage appliances. Another classification is
based on the ability to reposition mandible: those that attempt to
reposition the maxillomandibular relation and those that do not. At
present, the evidence is insufficient to draw definitive conclusions
to promote or refute the use of appliances in the management of
MMDs, with some studies reporting it to be effective and others not
(Christidis et al., 2019) (Roldan-Barraza et al., 2014). The differences
M. Kalladka, A. Young and J. Khan
in results may be attributed to variations in study design, type of
splint, controls and definitional criteria.
A systematic review and meta-analysis suggest that the stabi-
lization splint may provide short term benefit, and its long-term
benefit may equal that provided by other therapeutic modalities.
However, the review suggests better study designs with stan-
dardized diagnostic and assessment criteria are required to draw
definitive conclusions (Kuzmanovic Pficer et al., 2017).
Studies suggest the concept that oral appliances may function as
a behavioral intervention and may help in load distribution. In
addition, it can certainly function as physical device that protects
teeth from attrition and high force loading when worn (Dao and
Lavigne, 1998). Thus, when such a clinical situation exists along
with a parafunctional habit, prescription of oral appliances may be
reasonable and rational. Joint stabilization appliances can be diffi-
cult to fabricate in edentulous patients with no teeth and non-
compliant patients.
2.6.6. Injections and dry needling
Trigger point injections with local anesthetics or substances
such as Botulinum Toxin A (Botox), dry needling and nerve blocks
have been used in the management of myofascial pain. A systematic
review on injections of different substances and dry needling
suggests that local anesthetic injection and dry needling may be
promising. However, data on well controlled trials are lacking
(Machado et al., 2018). Although there was no statistical signifi-
cance, low quality evidence suggests that local anesthetic injections
may be slightly better than dry needling (Nouged et al., 2019) and
lidocaine may have favorable results immediately following treat-
ment and dry needling at 3e6 months (Nouged et al., 2019).
Masseteric nerve blocks have been used in the management of pain
of masseteric origin whereas masseteric and deep temporal blocks
have been indicated for the reduction of mandibular dislocations
and pain (S. Y. Quek et al., 2015; Young et al., 2009). Recently the
twin block nerve block injection has been used for management of
myofascial pain in masseter and temporalis with promising results
(Ananthan et al., 2020; Kanti et al., 2017; S. Y. Quek et al., 2015; S. Y.
P. Quek, Kalladka, Kanti and Subramanian, 2018).
One of the techniques for treatment of chronic refractory myo-
fascial trigger points is BOTOX injections. A meta-analysis reported
that local anesthetic injections were more efficacious at reducing
intensity of pain than BOTOX-A, and multi session local anesthetic
injections were more effective than single session injections
(Ahmed et al., 2019a). However, compared to placebo, patients
receiving Botox A in the head and neck region had significant pain
relief at 2e6 months without significant effect in the short term
(4e6 weeks) (Khalifeh et al., 2016). However, caution must be
maintained when considering Botox, and the option must be uti-
lized after careful deliberation and failure of other modalities.
A systematic review on ischemic compression and dry needling
of the upper trapezius suggests that both may have effects similar
to local anesthetic injection and increase the side range of motion,
but their effect on other functionalities and quality of life is weak
(Cagnie et al., 2015). A systematic review of dry needling versus wet
needling suggested that dry needling in neck and shoulders was
effective in short and medium term. However, wet needling in the
same areas may be more effective in the medium term (Liu et al.,
2015). A meta-analysis on dry needling in the orofacial area sug-
gests that it may provide results better than other interventions for
pain intensity or sham for pressure pain threshold, but it suffered
from low quality evidence and small effect size (Vier et al., 2019).
Current grade A recommendations for upper quarter myofascial
pain suggest that dry needling may provide immediate pain relief
compared to sham and placebo, which may be sustained for up to 4
weeks (Kietrys et al., 2013). Depending on the experience of the
110
Journal of Bodywork & Movement Therapies 28 (2021) 104e113
healthcare provider and country/state regulations different
healthcare providers may be authorized to perform dry needling
for the treatment of myofascial trigger points. Injections and dry
needling are contraindicated in patients with bleeding disorders,
un co-operative patients and patients with active local or systemic
infections.
2.6.7. Physiotherapy
Physical therapy is a highly effective treatment modality in pa-
tients with pain. Overall it can help a patient recover and get
stronger from a variety of pain conditions. Physical therapists often
not only treat the pain but also target the source of pain. In many
conditions the site and source of pain may be different, which re-
quires extensive training and experience to properly diagnose and
manage these patients. Physical therapy diagnosis includes TMJ
dysfunction, cervicalgia, polymyositis (with myopathy), muscle
spasm, myalgia, muscle weakness, myofascial syndrome and
contracture of muscle. Initially a health care provider can teach the
patient some exercises but if the patient is non-compliant or if the
case is too complex, it is important to refer the patient to a phys-
iotherapist for proper management. A treatment plan can initially
include 6e8 sessions of physical therapy followed by more if
needed. A combination of strengthening exercises, pain relief ex-
ercises, joint mobilization, soft tissue techniques and low impact
aerobic training are often beneficial to reduce pain in both short
and long term. Physiotherapy modalities can include but not
limited to manual release, dry needling, manual release and low-
level laser therapy, myofascial release, deep tissue massage,
ischemic compression and TMJ mobilization. Manual therapy aims
to improve range of motion and perfusion, and much of it can be
done as part of a home care regimen. Opening and excursive
mandibular movements can be done in combination with massage
of the masticatory muscles. Thermal compresses can also be com-
bined with the same mandibular stretches. Studies have shown
that manual therapy alone may be better than home therapy,
counselling and no treatment (de Melo et al., 2020). A meta-
analysis of two studies on symptomatic patients with latent TrP
in the jaw muscles suggested that manual therapy may improve
range of motion in these subjects and reduce pain (Webb and
Rajendran, 2016). A systematic review and meta-analysis
concluded that manual therapy alone or in combination with jaw
exercises and cervical exercises may be beneficial and had prom-
ising results (Armijo-Olivo et al., 2016). Another systematic review
of randomized controlled trails concluded that manual therapy
may improve maximum mouth opening, pain pressure threshold,
and pain (Calixtre et al., 2015). A systematic study comparing
manual release acupuncture and cupping for myofascial pain sug-
gested that manual release may have a moderate effect, whereas
the other 2 modalities may not be better than sham (Charles et al.,
2019). Post intervention kinesio taping has been recommended to
relieve pain and improve range of motion (Zhang et al., 2019). Ev-
idence suggests that low level laser therapy may have a moderate
benefit in chronic neck pain (Skelly et al., 2020). However, the ev-
idence from a systematic analysis is inconclusive due to study
heterogeneity and risks of bias (Kadhim-Saleh et al., 2013). Certain
physiotherapy modalities are contraindicated in acute phases of
viral infections, cancers, increased intracranial pressure and history
of recent fracture in the maxilla or mandible.
2.6.8. Complementary therapy
2.6.8.1. Acupuncture. A systematic review on acupuncture in TMD
suggests it may provide an efficacy similar to occlusal splints, and in
spite of weak evidence it may be helpful in myofascial TMD
(Fernandes et al., 2017). Another systematic review and meta-
analysis suggests limited evidence for the use of acupuncture for
M. Kalladka, A. Young and J. Khan
symptomatic TMD (Jung et al., 2011). In patients with chronic neck
pain, acupuncture has a low degree of evidence suggesting it may
provide short and moderate term improvement in function, but
compared to sham it did not provide significant pain relief (Skelly
et al., 2020). A recent meta-analysis suggests a moderate degree of
evidence exists for the effectiveness of acupuncture in head and
neck myofascial pain, and suggests that it may be a safe alternate for
pain relief in these conditions (Farag et al., 2020). Acupuncture may
be used in combination with other pain-relieving modalities, and
further well designed RCTs are essential to draw definitive conclu-
sions on their efficacy and safety (Li et al., 2017). Electroacupuncture
is also being used, and studies report it be better when compared to
TENS for pain relief (Ahmed et al., 2019b). Acupuncture is contra-
indicated in bleeding disorders, drug intoxication, patients with
pacemakers, seizure disorders and skin infections. Exercise has been
proven to be beneficial in improving pain and function in the short
term, and function in the long term, in patients with chronic neck
MMD. The combination of stretching and strengthening exercises
may have additional benefits (Mata Diz, de Souza, Leopoldino and
Oliveira, 2017). A study by Nasri et al. reported that chronic masti-
catory pain patients with reduced pain modulation may exhibit a
delayed hypoalgesia to mechanical stimulation following non-
strenuous aerobic exercises (Nasri-Heir et al., 2019). Patients with
chronic masticatory muscle pain exhibit enhanced mechanical
temporal summation and less efficient exercise induced hypo-
algesia. Following non-strenuous aerobic exercises, patients with
chronic masticatory muscle pain exhibited delayed response to
mechanical stimulation in contrast to healthy controls, where there
was immediate and persistent reduction in mechanical temporal
summation. It has been suggested to be through endogenous pain
modulation system and primarily by activation of opioid, cannabi-
noid, dopaminergic, serotonergic and noradrenergic pathways
(Nasri-Heir et al., 2019). Yoga, meditation, massage, tai-chi, cognitive
behavioural therapy, mindfulness practices, and mind-body prac-
tices have been proven to be beneficial with significant improve-
ments in pain, function, mood disorders, sleep in several chronic
pain conditions (Lorenc et al., 2018; Skelly et al., 2020). Specific to
TMDs, CBT and home care have similar effects on improvement of
pain and function. However, CBT fared significantly better for pa-
tients with depression and activity interference, and combined with
standard treatment it provided better pain relief than standard care
alone. Intra oral myofascial therapy was also suggested to be bene-
ficial in TMD patients for improvement of pain and limitation
(Randhawa et al., 2016).
2.6.9. Precision medicine-the future and the solution?
Individual variations in the pain susceptibility, processing and
modulation combined with variations in the 3 P's lead to enormous
variations in pain perception and response to treatment. Devel-
oping somatosensory profiles, and phenotyping and genotyping
different subsets of MMD patients may help individualize treat-
ment and improve clinical outcome in the management of chronic
MMD patients.
3. Conclusion
Efficacious treatment requires definitive diagnosis, clear
comprehension of underlying pathophysiologic mechanisms,
diagnostic evaluation, and treatment planning based on scientific
evidence. In most cases, the correct diagnostic classification can be
reached by using the self-reporting of the patient and the findings
on the clinical examination. As clinicians and researchers, we hope
to see more well-validated research and technological advances
that will improve our understanding, diagnosis and management of
MMD.
111
Journal of Bodywork & Movement Therapies 28 (2021) 104e113
CRediT authorship contribution statement
Mythili Kalladka: Conceptualization, Formal analysis, Writing
e review & editing. Andrew Young: Conceptualization, Formal
analysis, Writing e review & editing. Junad Khan: Conceptualiza-
tion, Formal analysis, Writing e review & editing, All authors were
involved in the conceptualization, analysis, structuring, writing,
editing, revisons and final submission of the manuscript.
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