Journal of Advanced Clinical and Research Insights

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Motwani, Balpande, Pajnigara, Pajnigara, Shweta, and Iyer:

Dry needling technique in myogenous temporomandibular disorders: A clinical commentary

P. Rajkannan

Department of Orthopedics, The Oxford College of Physiotherapy, Hongasandra, Bengaluru, Karnataka, India. E-mail: raajei@yahoo.com

Received 01 January 2016;
Accepted 20 February 2016
doi: 10.15713/ins.jcri.116

Dry needling technique has gained huge popularity in recent years, and physical therapists (PTs) all around the globe are keen to learn this technique. Dry needling is a skilled intervention provided by PTs that uses a monofilament needle to advance into the skin and to treat the underlying myofascial trigger points (MTrPs), muscular tissues, and connective tissues for neuromuscular pain and movement impairments.[1] Dry needling is certainly different from acupuncture in a very fundamental way. Acupuncture is a traditional form of Chinese assessment and treatment system, whereas dry needling is thoroughly based on western scientific principles. Except for the usage of needles both is completely different in terms of assessment and treatment. APTA and AAOMPT had released positional statements stating that dry needling is falling under the scope of physiotherapy.[2] About 36 states in the USA have approved PTs to practice dry needling. PTs in other countries such as Canada, UK, Australia, New Zealand, South Africa, and India are regularly using dry needling technique to treat patients with pain and movement dysfunction.

Although there are various schools of thought in dry needling, the trigger point dry needling is the widely accepted form of dry needling. Dry needling targets the MTrPs, which is the common cause of pain and dysfunction. A MTrP is defined as hyperirritable spot in the taut bands of the skeletal muscle that are tender to touch and that cause local and referred pain.[3] About one-third of the patients with musculoskeletal pain meet the diagnostic criteria for myofascial pain syndrome.[4]

Dry needling is used in all common musculoskeletal conditions and recently PTs are finding a good degree of success in treating temporomandibular disorders (TMD). TMD is a very common problem affecting up to 33% of people within the lifetime.[5] The causes can be odontogenic (dental issues), arthrogenic (joint and disc issues), and myogenic (trigger points, tightness, spasm).[6]

Myogenic causes of TMD are often characterized by the presence of MTrPs in the masticatory and craniocervical muscles. It includes masseter, temporalis, medial pterygoid, lateral pterygoid, digastric, sternocleidomastoid, splenius capitis, suboccipital muscles, and upper trapezius. Each muscle can have one or more MTrPs within it, which can refer pain both locally and to the distant site (Figure 1). Some of the referral pains can be even misdiagnosed as a headache, ear pain, tinnitus, sinus block, tooth ache, etc. Studies show that one-third of the patients suffering from ear pain are actually due to TMD.[7]

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Figure 1: Pain referral pattern of myofascial trigger points

Hence, these patients seek help from varied specialties in line with their referral symptoms (Table 1). Sometimes, the dentist might extract the teeth presuming that the pain is emanating from the tooth. Neurologist and ENT specialists assess and treat this condition in perspectives related to their domain, and they even might refer them for further investigations.

Table 1: Common symptoms pertaining to myogenous TMD[6]

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It is imperative that these patients are properly tested for myogenous sources of their pain and be referred to the PTs who have expertise in treating such problems. Most of the times, these patients will be juggled between different specialties seeking for a permanent cure. Such delay in the treatment will only add more chronicity to the condition.

Myogenous TMD, regardless of the chronicity, tend to respond swiftly with dry needling technique. After precise palpation of the involved muscles, the needles are advanced into the muscle to hit the MTrP. Ideally, a fast-in and fast-out technique must be employed to elicit a local twitch response (LTR).[8] An LTR is a momentary contraction (fasciculation) of the taut band in response to mechanical stimulation. An LTR is visible or palpable when a needle hits the MTrP. Thus, elicitation of the LTR is diagnostic criteria for the presence of MTrP.[9] Elicitation of LTR indicates that the needled point is correct; hence, it is assumed that the underlying MTrP was treated correctly. LTR is also strongly associated with imminent pain relief.

Apart from pain relief, the jaw clicks would reduce and mouth opening improves. Although the patient might feel pain during and after the treatment, most of the times with proper patient education, the treatment is well tolerated. There are randomized controlled studies and case series done to find the efficacy of dry needling on masticatory muscles. Masseter, temporalis and lateral pterygoid are the common muscles needled. The result revealed that after dry needling, the pain pressure threshold had improved, pain decreased and mouth opening improved compared to the control or sham group.[10] One particular study revealed that patients with a cervicogenic headache having associated TMD with a prevalence of 44.1%. Moreover, the group which received additional treatment for their TMD had shown better clinical outcomes in terms of their headache and neck functions.[11] Another study done by Fernandez-Carnero et al. found that dry needling over the masseter muscle reduced the pain pressure threshold and increased the maximum mouth opening.[12] There is also a single case study done on a unilateral ear pain successfully treated by dry needling on temporomandibular joint muscles.[13] Similarly, there are other studies supporting the usage of Dry Needling for MTrPs in the other regions of the body. Unfortunately, masticatory muscle MTrPs are not generally considered as a cause of pain and dysfunction in TMD patients. Considering these MTrPs and treating it using dry needling would offer an effective solution to resolve such conditions.

The mechanism of dry needling was proposed in various studies (Table 2). There are many ways by which the dry needling helps to relieve pain.[14] The actual mechanism of dry needling is debated, but PTs performing dry needling believe that eliciting LTR is vital for pain relief. This LTR, when coupled with stretching, helps to relax the actin-myosin bonds, thereby loosening the tight bands.[15] In addition, dry needling of the MTrPs will help to normalize muscle tone and the neurological interface, and improve the flow of acetylcholinesterase, thus correcting bradykinin, calcitonin gene-related peptide, and substance P levels in the affected muscle.[16] It is certain that there are many ways that dry needling helps in altering the pain and dysfunction.

Table 2: Physiological mechanism of dry needling

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Dry needling offers excellent scope to PTs treating TMDs. Other medical specialties must be aware of myogenous TMD and must refer those types of patients to PTs, who are licensed to perform dry needling. Ideally, every dental hospitals and colleges must have PTs visiting their facility to offer therapy to TMD patients because the dentists are the first contact practitioners for these patients. Before addressing odontogenic sources, these patients must be screened for myogenous sources of pain and treated accordingly, (Table 3). It must be a team work between dentists and PTs to decide on who has to intervene first. The interrelationship between dentistry and physiotherapy in TMD was well proven in a study on 300 TMD patients.[17] This study did not mention anything related to dry needling usage but in myogenous TMD, usage of dry needling would offer great benefit to the patients.

Table 3: Clinical tips for physical therapists treating TMD

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Conclusion

TMD is quite a common disorder that causes significant pain and disability. Despite its high prevalence, these patients hardly visit to physiotherapy clinic. A high level of unawareness prevails in this area and PTs must take initiative to create awareness so that those patients turn to PTs for therapy. Dentist must also have awareness and knowledge in this area so that they can do appropriate referral. Dry needling will give dramatic results in TMD patients if the patients are correctly assessed and treated. With that, these patients can have a pain free and quality life. PTs must get appropriately trained and licensed to needle these critically positioned muscles.

References

1. APTA. Description of Dry Needling in Clinical Practice: An Educational Resource Paper 2013; Alexandria, VA, USA: APTA Public Policy, Practice, and Professional Affairs Unit;

2. American Academy of Orthopaedic Manual Physical Therapists. Position Statement: Dry Needling 2009; Baton Rouge, LA: American Academy of Orthopaedic Manual PTs;

3. Simons DG, Travell JG, Simons LS, Travell and Simons’Myofascial Pain and Dysfunction; The Trigger Point Manual 1999; 2nd ed. Baltimore: Williams & Wilkins;

4. Rickards LD, The effectiveness of non-invasive treatments for active myofascial triggers point pain: A systematic review of the literatureInt J Osteopath Med 2006; 9: 120e36-

5. Wright EF, North SL, Management and treatment of temporomandibular disorders: A clinical perspectiveJ Man Manip Ther 2009; 17: 247-54.

6. Van Selms MK, Myogenous temporomandibular disorder pain: Diagnosis, etiology, motor consequences, and treatment follow-up 2007;

7. Jaber JJ, Leonetti JP, Lawrason AE, Feustel PJ, Cervical spine causes for referred otalgiaOtolaryngol Head Neck Surg 2008; 138: 479-85.

8. Hong CZ, Lidocaine injection versus dry needling to myofascial trigger point: The importance of the local twitch responseAm J Phys Med Rehabil 1994; 73: 256-63.

9. Rha DW, Shin JC, Kim YK, Jung JH, Kim YU, Lee SC, Detecting local twitch responses of myofascial trigger points in the lower-back muscles using ultrasonographyArch Phys Med Rehabil 2011; 92: 1576-1580.e1.

10. Kietrys DM, Palombaro KM, Mannheimer JS, Dry needling for management of pain in the upper quarter and craniofacial regionCurr Pain Headache Rep 2014; 18: 437-

11. von Piekartz H, Lüdtke K, Effect of treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: A single-blind, randomized controlled studyCranio 2011; 29: 43-56.

12. Fernandez-Carnero J, LaTouche R, Ortega-Santiago R, Galan-del-Rio F, Pesquera J, Ge HY, Fernández-de-Las-Peñas C, Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in patients with temporomandibular disordersJ Orofacial Pain 2010; 24: 106-12.

13. Asha V, Kannan R, Jacob TR, A novel case of orofacial pain treated by dry needling technique - A case reportDentistry 2015; 5: 319-

14. Dommerholt J, Dry needling in orthopedic physical therapy practiceOrthop Phys Ther Pract 2004; 16: 15-20.

15. Chu J, Does EMG (dry needling) reduce myofascial pain symptoms due to cervical nerve root irritation?Electromyogr Clin Neurophysiol 1997; 37: 259-72.

16. Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM, Effectiveness of dry needling for upper-quarter myofascial pain: A systematic review and meta-analysisJ Orthop Sports Phys Ther 2013; 43: 620-34.

17. de Toledo EG, JrSilva DP, de Toledo JA, Salgado IO, The interrelationship between dentistry and physiotherapy in the treatment of temporomandibular disordersJ Contemp Dent Pract 2012; 13: 579-83.