This case study describes the use of acupuncture in a professional musician with myogenic temporomandibular dysfunction. The 3-year history of symptoms was associated with persistent episodic tension-type headaches. Acupuncture was used for trigger point release, primarily of the masticatory muscles, in conjunction with exercise therapy. After 8 weekly acupuncture sessions, the patient's pain had completely resloved, headaches had resolved and the Patient-Specific Functional Scale showed significant improvements.
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The number of patient referrals to physiotherapy for treatment of temporomandibular dysfunction (TMD) is increasing; however, the evidence for specific treatment of this condition remains limited and inconclusive.1 2 This case illustrates that the use of acupuncture can be effective as part of an integrated treatment for the relief of myogenic temporomandibular joint (TMJ) dysfunction even when chronic, allowing the patient to return to the activity that precipitated the problem.
We describe the case of a 32-year-old full-time Army band player whose role involved playing the clarinet for up to 6 h/day (figure 1). She presented to physiotherapy in June 2010 with a 3-year history of TMD with referral to the lateral aspect of the neck and a long history of temporal headaches that required daily analgesia.
Her pain was intermittent, did not follow a 24-h pattern and had two components (P1 and P2) as shown in figure 2. A Patient-Specific Functional Scale (PSFS) was used to assess her functional status.3 This patient-specific outcome measure involves the patients selecting activities that they have difficulty with due to their condition and rating the functional limitation associated with these activities on a 0–10-point scale, with 0 being no pain and 10 being the worst pain. The client noted a PSFS of 3/10 when playing the clarinet for 30 min and a PSFS of 2/10 when talking, more specifically when shouting in a nightclub for 20 min. Due to the severity of her pain, she was unable to continue with her band duties, thus preventing her from carrying out her primary army work role.
No particular mechanism of injury was noted; however, she did commence her career in the armed forces when the symptoms started. Previous physiotherapy treatment within the army had included manual therapy of the cervical spine and upper quadrant, which had been unsuccessful; she had also been using a lower soft occlusal splint at night since 2009, which had not improved any of her symptoms.
Pain-relieving factors included heat and playing the clarinet out of the side of her mouth. The subject's secondary pain, P2, was associated with increasing P1. The patient also had a 2-year history of temporal headaches that was currently requiring daily doses of ibuprofen to manage. MRI revealed a normal appearance of the TMJ in the closed position with no mandibular condyle translation demonstrated on dynamic imaging. Her medical history was insignificant; however, she noted an incident 10 years ago in which she was hit with a hockey ball to the right side of the face, and no facial trauma/fracture was noted.
Assessment findings are consistent with myogenic TMJ dysfunction with underlying chronic tension-type headaches.
Temporomandibular arthropathy and associated retrodiscal dysfunction were ruled out as a cause of symptoms via comprehensive functional assessment, specifically posterior-anterior and anterior-posterior mandibular accessory mobilisations (causing compressive forces in the strati and retrodiscal tissue).4 Functional MRI displaying normal condyle–disc relationship with normal disc mobility and morphology further supported this reasoning.
It can be clinically hypothesised that her symptoms are likely myogenic in nature due to prolonged periods (6 h/day) of playing the clarinet in a restricted uniform; her standard uniform included a heavy hat with anterior chin strap. On examination of her mandibular position while wearing her hat, it was noted that the mandible was retracted. Within this position, the buccinator and temporalis muscle would both be passively held in the shortened position. In addition, the buccinator muscle would also be working to compress the cheeks tight to the teeth and pull the lips upwards and laterally while playing the clarinet; the significant shortening of these muscles was evident in the limited TMJ AROM and tenderness on palpation, specifically maximum mouth opening and protrusion (table 1). The associated pain can be related to trigger point formation within these shortened muscles which have been thought to form in response to increased or altered muscle demands. The mechanism of these demands has been suggested to include prolonged muscle contraction,5 which would relate to this case study.
Causes of tension-type headache were reviewed within this case study; however, clinical findings support the link between TMD tension and tension-types headaches. Evidence has reported a dysfunctional masticatory system, wherein the presence of muscle hyperactivity can result in TMD-related tension-type headache; this has been specifically linked with temporalis muscle.6 A survey by Ciancaglini and Radaelli7 further confirms the correlation between headache and TMD and although no definite conclusions can be drawn from their study, they hypothesised that deviations from a normal TMJ function will produce mechanical stimuli and changes in the collective activity of the jaw and mouth. It is, therefore, possible that this prolonged nociceptive stimulation of the masticatory muscles could lead to sensitisation of receptors within the pericranial and intracranial regions, thus enhancing the response within the central nervous system. This process, leading to increased pain sensitivity, could form the link between the symptoms of tension-type headache and the presenting TMD.
Management of the present condition was aimed at addressing the habitual and postural changes that were driving the TMD. In addition to weekly manual acupuncture, the management plan included passive stretches, deep neck flexor strengthening and soft tissue release of specific orofacial muscles. Specific acupuncture treatment and rationale are documented in table 2.
Table 3 outlines the subjective and objective outcome measures noted intermittently throughout treatment. The subject's pain level (visual analogue scale) reduced by 100% from the initial to the final treatment, she no longer experienced headaches and thus was not taking any analgesia by the final session. She paced her return to clarinet playing over the course of the treatment and was able to play the clarinet on a daily basis for 1 h by the final treatment. Symptoms during this activity were mainly limited by subjective muscle fatigue and associated deconditioning; as noted on the PSFS, her symptoms with this task were only mildly irritable. Furthermore, her symptoms were no longer aggravated by shouting. Four months following her final physiotherapy session, her progress was reviewed via telephone, she reported that she had returned to all premorbid activities and had returned to playing the clarinet 8 h/day without aggravation of P1, P2 or headache.
Pathologies characterised by pain in the TMJ or cheek, as a result of disorders of the TMJ itself and/or those of the craniofacial or masticatory muscles, remain controversial. The International Association for the Study of Pain classification8 uses the term temporomandibular pain and dysfunction syndrome. This is described as a condition characterised by ‘aching in the muscles of mastication with occasional brief severe pain on chewing, often associated with restricted jaw movement’. This can be differentially diagnosed against patients with intracapsular TMJ lesions as a primary disorder that will elicit different pain sensations.
Within this case study, management of myogenic TMD primarily focused on reducing masticatory muscle tension to reduce TMJ P1. Furthermore, it was clinically reasoned that the tension-type headaches would also be targeted by treating these muscles, the outcome of which was positive in both symptoms, thus supporting the link between TMD and tension-type headaches.
The elicitation of pain on palpation of the masticatory trigger points within this case study indicated the presence of active trigger points rather than latent points. Current theories suggest that the trigger point pain in this scenario is related to the stimulation of large diameter sensory fibres that have an increased response to normal mechanical stimuli.9 The pathogenesis of trigger points, although not clear, typically favours a combination of two accepted theories: the energy crisis theory5 and the motor end plate hypothesis.10
Acupuncture into muscle trigger points, described as an exquisite tenderness at the nodule in a palpable taut band of muscle,5 11 has been well documented; however, quality evidence to clarify the mechanism of action of acupuncture in this condition remains to be clarified. Research by Chou et al12 on the intensity of end plate noise in a trigger point suggests that the mechanism of remote acupuncture is via strong stimulation from the needle tip resulting in spinal modulation of the neural circuit that maintains the trigger point activity.
Given that the present subject received a combination of exercise therapy and acupuncture for the treatment of trigger points, it would be unwise to conclude that the positive effects were related to a sole specific treatment and postulate that a combination of these approaches was effective in myogenic TMD management.
The present case study demonstrates that the combination of acupuncture and exercise rehabilitation for myogenic TMD is effective in improving pain, function and mandibular range of movement. Further quality research is required to clinically reason the physiological effects of acupuncture and trigger point release.
A major limitation of this case study is the integration of a combination approach to TMD management, thus it is not possible to ascertain the sole influence of acupuncture on the positive outcomes observed.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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