Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178

ASAA

Headache Medicine

DOI: 10.48208/HeadacheMed.2021.18

Review

Immediate effect of a motor control exercise target to the neck muscles

on upper cervical range of motion and motor control in patients with

temporomandibular disorder

Alexandra Daniele de Fontes Coutinho Ana Izabela Sobral de Oliveira-Souza Lais Ribeiro Sales, Daniella

Araújo de Oliveira

Universidade Federal de Pernambuco, Recife, Brazil

Abstract

Objective

To evaluate whether a single specic motor control training session for the neck exor and

deep extensor muscles improves upper cervical range of motion and neck motor control in

patients with temporomandibular disorder (TMD) and compare them to a group without

TMD.

Methods

This is a before and after, controlled study. The TMD group included women aged between

18-45 years old, complaining of pain in the orofacial region in the last 6 months and diag-

nosed with masticatory myofascial pain according to Research Diagnostic Criteria (RDC/

MD). The control group included match-controls without TMD. The participants were evaluated

to global and upper (Flexion Rotation Test - FRT) neck range of motion (ROM) and to neck

motor control (Cranio-Cervical Flexion Test - CCFT). They were treated with a protocol of

specic motor control exercises targeted to exor and extensor neck muscles for 30 minutes.

One day after the protocol the patients were reevaluated.

Results

A total of 23 volunteers were evaluated. The TMD group showed immediate improvement in

left cervical rotation (p=0.043) and right FRT (p=0.036), while the control group did not show

any improvement. There was no difference between the groups before and after treatment in

relation to cervical movements. Regarding cervical motor control in both groups, the highest

prevalence was of results between 24 and 26 mmHg after treatment, different from before

the intervention (20 and 22 mmHg) in both groups.

Conclusion

A single session of specic neck motor control training only improved the left cervical rotation

and upper right rotation in the TMD group, but not in the control group. There is no difference

at the end of treatment between the groups. Volunteers with TMD showed improvement in

the pattern of motor control of the neck when compared to volunteers without TMD.

Daniella Araújo de Oliveira

Av. Jorn. Aníbal Fernandes, 173

- Cidade Universitária, Recife,

Pernambuco, Brazil, 50740-560

E-mail: sabinodaniellaufpe@

gmail.com

Edited by:

Marcelo Moraes Valença

Keywords:

Temporomandibular joint disorders

Range of motion

Facial pain

Exercise

Rotation

Women

Received: August 12, 2021

Accepted: September 30, 2021

ASAA

Coutinho ADF, Oliveira-Souza AIS, Sales LR, Oliveira DA

Immediate effect of a motor control exercise target to the neck muscles on upper cervical range of motion and motor control in patients with temporomandibular disorder

Introduction

emporomandibular joint (TMJ) is an element of the

stomatognathic system formed by several internal and

external structures, it is located anteriorly to the external

acoustic meatus, inferiorly to the temporal bone and supe-

riorly to the mandible and contains an intra-articular disk

within the articular capsule that divides it into superior and

inferior. This joint can perform complex movements such as

protrusion, retrusion, elevation and excursions (right and

left). The functions of mastication, swallowing, phonation,

and cervical posture depend heavily on TMJ function, health,

and stability to work properly.

Temporomandibular disorder (TMD), in turn, is a collective

term for structural and functional disorders involving

the TMJ and/or masticatory muscles, head and neck

muscles, and contiguous tissue components.

Biological,

anatomical, biomechanical, behavioral, environmental,

and emotional factors affect the masticatory system,

causing the development of signs and symptoms and/or

perpetuation of TMD.

Therefore, TMD can be considered

a multifactorial disease entity.

It is primarily characterized

by pain and restricted jaw movement, with pain being the

most common symptom and the most frequent reason for

seeking treatment.

The literature points out that patients with TMD have cranio-

cervical changes besides indicating that orofacial pain may

be related to changes in the upper region of the cervical

spine.

In addition, patients with TMD have self-reported

cervical pain, limited cervical range of motion (ROM),

6,7

decreased pain threshold to pressure in the scalene

anterior, upper trapezius, and sternocleidomastoid (SSTM)

muscles.

8,9

As well as changes in cervical motor control,

resulting from a reduced activity of the deep cervical

muscles added to a hyperactivity of the supercial cervical

muscles (scalene anterior and sternocleidomastoid muscle)

and reduced strength and endurance of the extensor and

exor cervical muscles.

9,10

The relationship between TMD and pain and functional

changes in the muscles of the cervical spine can be

explained by the neuroanatomical mechanism of

convergence between trigeminal afferences and three upper

cervical nerves. This convergence occurs in an area called

the trigeminocervical nucleus.

The caudal trigeminal

nucleus (V cranial nerve) is a collection of neuronal cells

(gray matter) in longitudinal arrangement from the bulbar

pyramid to the upper 3-4 segments of the spinal cord.

The anatomical convergence of the nociceptive bers of

the trigeminal (V) nerve, especially those of its ophthalmic

branch (V1) with those coming from the cervical spinal

nerves from C1 to C3-C4 is the basis of referred pain from

the upper cervical region to the head, including its frontal

region.

In this context, several studies have taken into consideration

the entire cranio-cervico-mandibular complex in clinical

decision making. Among the treatments proposed manual

therapy has been considered a viable and useful approach

for TMD management.

However, a systematic review

by Medlicott and Harris

evaluated the effectiveness of

physical therapy interventions for patients with TMD and

specically reported the value of a combined approach

of active exercises, manual therapies, and relaxation

techniques. While a second review on the effectiveness of

physical therapy in patients with TMD found that postural

training, manual therapies and exercise demonstrated

signicant benets. The authors concluded that active,

passive, and postural exercises are effective interventions

to decrease symptoms associated with TMD.

Exercise has been an effective treatment for people with

chronic neck pain,

and various exercises including

motor control training

17,18

and resistance training

19,20

in the neck have been shown to relieve pain, probably

due to facilitation of the endogenous analgesia pathway

by different mechanisms. In addition, exercise may have

positive psychological effects, including reduced pain

catastrophizing.

The improvement in clinical symptoms coming from

neuromuscular changes provided by training goes

according to the type of exercise performed. For

example, craniocervical exion exercise, designed to

emphasize activation of the deep cervical exors and

minimize activation of the supercial exors,

17,18

increases

activation of the deep cervical exors

which are often

less activated in patients with neck pain.

In addition,

this exercise reduces activation of the sternocleidomastoid

muscle,

which is often hyperactive in association with

reduced activity of the deep cervical exors.

22,23

Enhanced

activation of the deep cervical exor muscles was not

achieved with general neck resistance training,

17,18

despite

comparable changes in pain. The deep cervical extensor

muscle, cervical semispinalis, may also exhibit reduced

activation in people with neck pain.

Therefore, exercises for the neck muscles showed positive

results, so this training target to the neck muscles seems

to be a benecial and positive approach to treat patients

ASAA

Coutinho ADF, Oliveira-Souza AIS, Sales LR, Oliveira DA

Immediate effect of a motor control exercise target to the neck muscles on upper cervical range of motion and motor control in patients with temporomandibular disorder

with TMD, since these have similar motor control disorders

to those found in patients with chronic neck pain, making

the patient more autonomous with their treatment. Thus, the

main objective of the present study was to evaluate whether

a single specic motor control training target to exor and

deep extensor neck muscles improves upper and global

cervical range of motion and motor control of the cervical

spine in patients with TMD. It also compares them to a

group without the dysfunction.

Methods

This is a before and after, controlled study that was carried

out in the period from August 2018 to August 2019, in

the Laboratory of Learning and Motor Control, of the

Department of Physical Therapy, of the Federal University

of Pernambuco. The present study was approved by the

Ethics Committee of the Federal University of Pernambuco,

under process number: 2.131.546.

Sample

Patients in the TMD group were included according to the

following inclusion criteria: women aged between 18 and

45 years; complaints of orofacial pain in the last 6 months;

diagnosis of myofascial masticatory pain determined

according to the criteria established by the Research

Diagnostic Criteria (RDC/TMD); complete dentition except

for third molars. The control group included women

aged between 18 and 45 years old, with no history of

complaints in the orofacial region. In both groups we

excluded participants with a history of facial and/or

cervical trauma, surgical procedures performed on the

cervical spine and/or craniofacial segment, neurological

disorders, bromyalgia, chronic systemic diseases, previous

TMD treatments performed in the last six months, use of

dental prostheses and ongoing orthodontic treatment.

Sample

The participants were initially submitted to a screening to

determine whether they met the inclusion criteria of the

study. This was followed by an evaluation that consisted of

using the RDC/TMD and three measurement tests: global

cervical range of motion (ROM); upper cervical ROM

(exion rotation test - FRT) and the cervical motor control

test (cranio-cervical exion test - CCFT).

Diagnostic criteria for TMD (RDC/TMD)

Diagnosis was performed with the RDC/TMD, which is a

questionnaire reported by several authors as a reliable

tool for evaluating myogenic, arthrogenic, and mixed

TMD, and is widely used as diagnostic criteria in clinical

TMD research.

This questionnaire model was based

on the biopsychosocial model of pain. This classication

system was based on the biopsychosocial model of pain

that included an Axis I which is composed of the physical

assessment that includes pain assessment, mouth range

of motion, presence, or absence of otologic noises and

symptoms, and muscle palpation, using reliable and

well operationalized diagnostic criteria and an Axis

II assessment of psychosocial status and pain-related

disability. Through this one can classify TMD into three

groups: Muscle diagnoses (Myofascial pain and/or

Myofascial pain with limited opening), Disk displacement

(Disk displacement with reduction, Disk displacement

without reduction, with limited opening and/or Disk

displacement without reduction, without limited opening)

and arthralgia, arthritis, arthrosis (arthralgia, TMJ

osteoarthritis and/or TMJ osteoarthritis).

Global cervical range of motion

Cervical range of motion was measured using the CROM®

instrument, which consists of an acrylic device attached to

the volunteer's head and secured with a Velcro strap. It has

two inclinometers attached to the device plus a removable

inclinometer that moves due to the presence of a magnetic

eld placed on the patient's neck. This instrument aims to

determine the range of motion of the cervical spine when

it moves in the sagittal and frontal planes, performing

exion, extension, tilt to the right and left and rotation to

the right and left.

25,26

The participants were evaluated for cervical extension,

exion, rotation (right and left) and inclination (right and

left). The patients were positioned seated in a chair with

their feet on the oor. They were instructed to look at their

horizon line and perform the movements twice to obtain an

average of each movement.

Upper cervical range of motion

To evaluate the mobility of the upper cervical spine,

segments C1-C2, the FRT was performed with the CROM®

attached to the head of the volunteer. The participants

were in dorsal decubitus and the passive movement of

cervical exion was performed, followed by a rotation of

the upper cervical spine (right and left). The movement was

performed twice for each side so that the average between

them could be calculated. This test is used to measure

small changes in the amplitude of the individual upper

ASAA

Coutinho ADF, Oliveira-Souza AIS, Sales LR, Oliveira DA

Immediate effect of a motor control exercise target to the neck muscles on upper cervical range of motion and motor control in patients with temporomandibular disorder

cervical segment. When a change of more than 10° occurs

in the measurement, it is considered a minimal important

difference. Volunteers with values less than 33° means that

they have upper neck hypomobility.

Cervical motor control

The CCFT consisted of a motor control exam in which

patients perform the cranio-cervical exion movement in

ve progressive stages of increasing pressure by 2 mmHg

(22, 24, 26, 28, and 30 mmHg) with a visual feedback

pressure device under the base of the occipital bone

(Biofeedback Stabilizer Pressure; Chattanooga, Hixson,

TN, USA). Participants were instructed to perform the

cranio-cervical exion movement in a slow, controlled

manner until they reached the in requested target pressure

levels. The participants had to maintain a constant pressure

at each target level for a duration of 10 seconds. They

performed the sustained contraction twice at each level,

with a 1-minute rest period between repetitions to avoid

the effects of fatigue.

For the performance of the test, the

participants were in a supine position. The last level that

the participant successfully achieved the movement was

noted by the evaluator.

Treatment protocol

On the same day of assessment, the participant underwent

a motor control training protocol based on the Falla et

al.

protocol, with the aid of a pressure device with visual

biofeedback. The cervical motor control training consisted

of the cranial exion exercise, which was performed with

the volunteer positioned in a relaxed supine position. This

exercise encompasses the deep cervical stabilizer, long

head, and long neck muscles.

Participants were instructed

to perform and maintain positions that were progressively

evolved during the execution of the cranio-cervical exion

movement. During the task, participants were guided from

feedback from a pressure unit (Biofeedback Stabilizer

Pressure; Chattanooga, Hixson, TN, USA), placed

posteriorly to the cervical spine under the occipital bone,

to monitor the reduction of cervical lordosis, which occurs

with the contraction of the long neck muscle.

The training began with the device inated to a base

pressure of 20 mmHg and the participant was asked to

perform a head exion movement (NOD movement, as

short "yes" movement), and she should maintain it for

10 seconds with ten repetitions with a 10-second interval

between them, this sequence being like a single repetition

that lasts 190 seconds, from then on she should progress

the exercise during ve stages of 2 mmHg each, reaching

the maximum pressure of 30 mmHg. The participant should

perform the contractions slowly and smoothly, not allowing

retraction or elevation of the head of the stretcher and

avoiding simultaneous contraction of sternocleidomastoid

muscle and scalene.

Data collection procedure

The data collection was done in two days. At the rst

day there was the evaluation, composed by the CCFT,

the global cervical range of motion (CROM®) and upper

ROM (FRT) and the intervention that consisted of motor

control exercises. 24 hours later the reevaluation was done

using the same instruments and tests of the evaluation.

Data analysis procedure

The data were arranged in mean and condence intervals.

Statistical analysis was performed in SPSS software

version 20.2. For the analysis of data distribution and

population histogram, the Shapiro-Wilk normality test was

performed to verify the data distribution. For the intragroup

comparison (pre- and post-treatment) and for the intergroup

comparison, the Student t-test was used, with the p-value

set at 0.05. For the comparison of the prevalence of the

motor control test result, the subgroups of 20-22 mmHg;

24-26 mmHg; 28-30 mmHg were established, and the

comparison before and after treatment within and between

group was performed with the chi-square test.

Results

In all, 23 volunteers were evaluated in the two groups, with

no statistical difference between groups in the variables age

(p=0.098) and BMI (p=0.477). Patients in the TMD group

had a mean age of 27.9 (SD 7.7) years old with a BMI of

22.5 (SD 3.8), while in the control group the mean age was

22.3 (SD 1.6) years old and BMI of 21.1 (SD 4.7).

The TMD group showed immediate improvement in left

rotation (p=0.043) and right FRT (p=0.036) after the

application of the protocol, while the control group did not

show any improvement (Tables 1 and 2). However, there

was no difference between the groups before and after

treatment regarding cervical movements (Tables 3 and 4).

Regarding neck motor control in both TMD and control

groups, the highest prevalence was between 24 and

26 mmHg at the end of treatment, unlike before the

intervention, when the highest prevalence was between

20 and 22 mmHg in the TMD and control group (Figures

1 and 2).

ASAA

Coutinho ADF, Oliveira-Souza AIS, Sales LR, Oliveira DA

Immediate effect of a motor control exercise target to the neck muscles on upper cervical range of motion and motor control in patients with temporomandibular disorder

Table 1. Comparison of before and after TMD patients' cervical range of motion variables

Variables Before After MD (95%CI) pValue

Flexion 47.1 (10.5) 44.4 (11.1) 2.8 (-2.5: 8) 0.279

Extension 52.4 (8.2) 49.9 (8.2) 2.5 (-1.25: 6.3) 0.176

Right lateral exion 34.9 (6.5) 36.2 (6.8) -1.3 (-4.5: 1.8) 0.377

Left lateral exion 37.7 (6.7) 37.3 (5.6) 0.3 (-1.5: 2.2) 0.697

Right rotation 60.4 (6.7) 62.9 (6.6) -2.5 (-5.9: 0.9) 0.134

Left rotation 63.0 (7.2) 59.3 (8.5) 3.7 (0.1: 7.3) 0.043*

Right FRT 36.8 (11.4) 39.6 (8.5) -2.8 (-5.4: -0.2) 0.036*

Left FRT 38 (10.9) 40.6 (11.8) -2.6 (-7: 1.8) 0.232

MD: mean differences; FRT: exion rotation test.

Table 2. Comparison between TMD and control groups, in cervical range of motion variables

Variable TMD Control MD (95%CI) pValue

Flexion 48.0 (5.6) 48.0 (2.3) 0 (-6.4: 6.4) 1.000

Extension 56.2 (6.4) 56.2 (6.4) -3.3 (-11.7: 5) 0.351

Right lateral exion 39.2 (5) 40.7 (5.8) -1.5 (-3.7: 0.7) 0.137

Left lateral exion 40.5 (4.3) 42.0 (4.4) -1.5 (-5.8: 2.8) 0.415

Right rotation 57.5 (6.6) 59.2 (8.7) -1.7 (-9.2: 5.8) 0.593

Left rotation 59.2 (8.7) 62.2 (5) -2.5 (-10.9: 5.9) 0.477

Right FRT 38.2 (5) 40.0 (2) -2.2 (-8: 3.6) 0.381

Left FRT 37.2 (6) 40.5 (1.8) -3.3 (-9.8: 3.1) 0.240

MD: mean differences; FRT: exion rotation test.

Table 3. Comparison between the TMD patients and the control group in the variables of cervical range of motion, before the intervention.

Variable TMD Control MD (95%CI) pValue

Flexion 47.1 (10.5) 48.0 (5.7) -0.9 (-10.2: 8.6) 0.848

Extension 52.4 (8.2) 52.8 (2.3) -0.4 (-8.7; 7.9) 0.917

Right lateral exion 34.9 (6.5) 39.2 (5) -4.3 (-10.4: 1.8) 0.158

Left lateral exion 37.5 (5.6) 40.5 (4.3) -2.8 (-8.8; 3.2) 0.348

Right rotation 60.4 (6.7) 57.5 (6.7) 2.9 (-3.7: 9.5) 0.372

Left rotation 63.1 (7.2) 59.6 (8.7) 3.4 (-4.1: 10.0) 0.358

Right FRT 36.8 (11.4) 38.2 (5) -1.4 (-11.5: 8.7) 0.776

Left FRT 38.0 (11) 37.2 (6) 0.8 (-8.9: 10.6) 0.861

MD: mean differences; FRT: exion rotation test.

Table 4. Comparison between the TMD patients and the control group in the variables of cervical range of motion, after the intervention.

Variable TMD Control MD (95%CI) pValue

Flexion 44.3 (11.1) 48 (2.3) -3.6 (-13.3: 6) 0.439

Extension 49.9 (8.2) 56.2 (6.4) -6.3 (-14: 1.5) 0.106

Right lateral exion 36.2 (6.8) 40.7 (5.8) -4.4 (-10.9: 2.1) 0.172

Left lateral exion 37.3 (5.6) 42.0 (4.4) -4.6 (-9.9: 0.62) 0.081

Right rotation 62.9 (6.6) 59.2 (8.7) 3.7 (-3.3: 10.8) 0.280

Left rotation 59.3 (8.5) 62.2 (5) -2.8 (-8.8: 3.2) 0.343

Right FRT 39.6 (8.5) 40.0 (2) -0.75 (-8.1: 6.6) 0.836

Left FRT 40.6 (11.8) 40.5 (1.8) 0.09 (-10.2: 10.3) 0.986

MD: mean differences; FRT: exion rotation test.

ASAA

Coutinho ADF, Oliveira-Souza AIS, Sales LR, Oliveira DA

Immediate effect of a motor control exercise target to the neck muscles on upper cervical range of motion and motor control in patients with temporomandibular disorder

Figure 1. Comparison of prevalence of volunteers with TMD in the cervical motor control test.

Figure 2. Comparison of prevalence of volunteers without the dysfunction on the cervical motor control test.

ASAA

Coutinho ADF, Oliveira-Souza AIS, Sales LR, Oliveira DA

Immediate effect of a motor control exercise target to the neck muscles on upper cervical range of motion and motor control in patients with temporomandibular disorder

Discussion

These results indicate that the cervical motor control

protocol seems to be an interesting approach strategy to

patients with TMD, since only one day of intervention has

showed changes in neck mobility and neck motor control.

However, these results were not seen when the protocol

was applied to volunteers without neck pain.

The different results found between the groups could be due

to the fact that healthy volunteers do not present changes

in mobility level and cervical motor control as it commonly

happens in patients with TMD.

Thus, it is not possible to

verify any biomechanical changes in one day of protocol

in people who do not present previous neck biomechanical

alterations.

The protocol emphasizes and conrms that the neck

biomechanical changes present in patients with TMD

are due especially to the motor and movement control

difculties that these patients have. Therefore, training and

practice in the correct execution of movements will result in

clinical improvement in this group of patients.

Shimada

et al.

found in a previous systematic review that studies

who applied exercise therapy for the treatment of TMD

showed positive effects on various clinical conditions of

TMD including pain and disability. The study by Garrigós-

Pedrón et al.

concluded that after performing physical

therapy treatment, such as cervical manual therapy in

chronic cervicalgia and cervical and orofacial treatment in

TMD, there was a reduction in pain intensity.

However, it is known that association between exercise

therapy and manual therapy could be more benecial to

patients with chronic pain compared to the application of

each technique isolate. Previous studies have demonstrated

that the inclusion of manual therapies in the TMJ, cervical,

and masticatory regions was able to induce clinical

symptoms (i.e., tinnitus-related disability, TMD-related

disability), psychological (i.e., depressive symptoms),

and physical (i.e., active mandibular range of motion)

improvements in patients with TMD.

Despite the neck motor control protocol has been seen as

a very promising treatment approach to patients with TMD,

since it makes the patients more autonomous with their

treatment, probably an ideal number of sessions would be

necessary, since our propose immediate effects was not

effective for all patients.

Conclusions

A single specic motor control training for the exor and deep

extensor muscles of the cervical spine only improves neck

range of motion of left and superior right rotation in the TMD

group, but not in the control group. There is no difference at

the end of treatment between the groups. Regarding motor

control of the cervical spine, patients with TMD beneted from

the protocol by improving their motor control pattern, while

this did not happen in the control group.

Conflict of Interest: The authors declare no conict of interest.

Funding information

Coordenação de Aperfeiçoamento de Pessoal de Nível

Superior, Grant/Award Number: 001

Alexandra Daniele de Fontes Coutinho

https://orcid.org/0000-0001-9287-9320

Ana Izabela Sobral de Oliveira-Souza

https://orcid.org/0000-0002-7825-2676

Lais Ribeiro Sales

https://orcid.org/

Daniella Araújo de Oliveira

https://orcid.org/0000-0002-6013-978X

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