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12 Articles in Volume 9, Issue #1
Atypical Herpetic Reactivation and Chronic Pediatric Pain
Blending Prescription Pain Treatments with Alternative Medicine
Cervical Disc Disease with Referred Pain to TMJ
Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 1
In My Opinion
Laser Therapy: Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Pain Management in the Elderly
Personality Disorders in Migraineurs
Surgical Implants for Pain Management
Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Trigger Point Ablation and TMJ Syndrome
What a Decade of the Mind Affords the Decade of Pain Control and Research

Trigger Point Ablation and TMJ Syndrome

A self-management approach to eradicating trigger points contributing to TMJ disorder or facial pain.

“Give a man a fish and you feed him for a day, teach him how to fish and you feed him for a lifetime.”

- Chinese Proverb

We have all heard this message before and most of us would attest to the validity of this statement. It is with this philosophical message in mind that we present our first clinical report on a product that is not at all representative of high technology. It is not expensive, not technically difficult to use, does not require professional study or a degree as a prerequisite for use and, all in all, has little glamour. It is, I believe, a good current day example of teaching patients how to treat themselves. The device itself is actually quite unimpressive by first appearance and it would be quite natural for many to relegate in the realm of “clinical junk.” I would, however, caution those who might be drawn to this conclusion. The instrument is called the MyoFreeTM (see Figure 1) and is a tool that uses intra-oral ischemic compression (pressure) to obliterate trigger points that can be the source of pain and dysfunction in the jaw and face. This instrument that can be used at home by the patient to treat intra-muscular trigger points (TPs) around the tempero-mandibular joint that often play a role in clinical TMJ syndrome.

Not only is this tool rapidly becoming a popular therapy for pain management, but it is also consistent with the idea that patients can be taught to positively impact their own condition or problem. Home pain management is empowering for patients, and represents responsible medicine as it enlists the notions of shared decision-making while encouraging the patient to be self-directed and take ownership of a chronic problem. Patients thus become active participants in their own care plan. When clinicians are faced with treating recurrent myofascial problems, it makes good sense to provide a treatment regime that is both effective and can be sustained without regular visits to a medical provider. The MyoFree tool appears to be a cost-effective intervention for the treatment of TMJ and oro-facial pain syndromes that have trigger points as the basis for their genesis.

Figure 1. Illustration of the MyoFreeTM device.

Trigger Points

Trigger points were popularized by Travell and Simon1 and figure prominently in their view of craniofacial pain disorders in general. They felt that TPs were the underlying basis for much of the morbidity associated with head, neck and facial pain. In the years subsequent to their treatise, there have been a plethora of scientific and clinical papers pointing to trigger point infestation as either the central cause or significant contributor to painful syndromes and myofascial disorders such as is seen in TMJ.2-4 Figure 2 shows potential trigger point foci in the masseter muscle of the jaw and indicative of where treatment with the MyoFree tool might begin. The hooked nature of the device allows the patient to reach back into the mouth and apply sustained pressure to these points with little effort and training.

The clinical characteristics of a trigger point are that they tend to be hyperirritable spots located in skeletal muscle tissue that, when compressed, cause significant pain and pain referral. The TP feels like a nodule or taut band on palpation. There is a classic “jump sign” that is elicited during vigorous palpation by the examiner which aids in TP verification. These palpable contraction knots or taut bands will ultimately change or alter the muscle tension characteristics of a jaw muscle such as the masseter—leading to secondary problems of internal derangement, arthritis and/or simply faulty joint mechanics leading to ultimate joint erosion and breakdown.5,6

Figure 1. Potential trigger point foci in the masseter muscle

Trigger points are not always the primary cause of a TMJ dysfunction and can develop as a result of another type of problem such as disc deformation/tearing (internal derangement), in which case the TPs would be secondary to internal derangement. Whether primary or secondary entities, the presence of trigger points can perpetuate disability and worsen the prognosis and interfere with primary interventions if they are not considered and treated. It has been well established that although we might be uncertain as to how TPs actually form, we are more certain that they do appear as a sequelae to such things as trauma, faulty posture, repetitive motion, muscle imbalance, disease entities, and debilitation to name a few.7

Trigger Points and TMJ Syndrome

There is strong research evidence to show the correlation between presence of trigger points and resultant TMJ syndrome and/or face/head pain in general.8 As well, when trigger point treatment is included in a care plan for an individual who has TMJ, the outcomes appear to be superior than in those treatment regimes that do not address trigger points in the intervention.9 There appear to be several scenarios in which trigger points become important predisposing, initiating, and/or precipitating factors in TMJ syndrome or dysfunction. Those who primarily treat trigger points for this condition will argue that TPs are involved no matter what the primary diagnosis might be. Trigger points have both a sensory component but also manifest as tension-altering entities which, over time, can lead to uneven bite mechanics and mouth opening restriction —further leading to pathologic mechanical changes in both joint and surrounding soft tissues.10 Furthermore, there could be a direct link between trigger points and trigeminal nerve involvement. Trigger point alterations in muscle (tenderness and sensitization) could conceivably spread to the major nerves servicing the TMJ region.

Figure 3A. Medial pterygoid pain referral patterns. Figure 3B. Lateral pterygoid pain referral patterns.

It is not uncommon for trigger points to be identified as contributing factors and co-existing with internal disc derangement, TMJ synovitis, TMJ arthritis, as well as being the primary pathological entity in myofascial pain syndrome (MPS) of the TMJ.11 In a study involving 300 patients who had all been involved in a motor vehicle accident, the most common clinical findings identified on medical examination were the following; jaw pain, neck pain, post traumatic headache, jaw fatigue, and severe TMJ crepitus or clicking. The most common diagnosis were the following in rank order: masseter muscle trigger points, closing jaw muscle hyperactivity, TMJ synovitis, opening jaw hyperactivity, and advanced disc derangement.12 What we are seeing is that trigger points are an important treatment consideration when formulating a treatment plan for the various diagnoses involving the TMJ, orofacial, and/or head regions of the body.

Discussion

The MyoFree device is designed to be able to eradicate trigger points located in the accessible muscles of the TMJ. This tool actually “releases” tissue versus simply relaxing tissue. There is a difference. For example, a therapeutic massage (effleurage) can act to relax soft tissues and provides a very pleasant body sensation for a short period of time. There can be some more permanent changes, but it is arguably considered more a short term intervention with mostly superficial changes. A muscular release is usually a more vigorous intervention, oftentimes painful, and attempts to affect deeper tissues and in a more permanent manner—at least that is the goal. In regards to trigger point eradication, the application of direct pressure using a probe-like device such as the this device can act to release the affected tissue structure such as the powerful masseter muscle of the jaw. Trigger points do not respond to passive stretching techniques since the TPs simply stretch along with the fibers of the target muscle. Based on sonographic and MRI elastographic evidence, the TP can be embedded in the architecture of a muscle and become locked into a contraction state. Passive tissue stretching around the TP entity will simply cause more pain and irritation thus further perpetuating the pain-spasm cycle. Two trigger point states have been identified by researchers including active and latent TPs. So far we have been discussing the active trigger point where pain is part of the symptom profile and thus manifests itself through pain. Experienced practitioners know, however, that TPs also come in an “inactive” or latent form. These TPs are not painful but are indeed tender to palpation and almost always form a taut band which can restrict range of motion and inhibit masticatory strength through reflex inhibition. The message here is that the practitioner might want to scan the jaw muscles for TPs even in the absence of pain.

Figure 4. Digastric pain referral pattern. Figure 5. Masseter pain referral patterns.

We would be remiss in engaging in a TP discussion without elaborating on the pain referral phenomenon that is so characteristic of trigger points and is used as a sign to differentially diagnose TP versus simply a tender point. Simply stated, the direct application of pressure over either an active or latent trigger point will usually refer pain to a different area. These pain referral zones, as they are called, have been well documented. Some common pain referral zones are shown in Figures 3, 4 and 5 for specific muscles. Pain referral almost always seems to complicate the diagnostic process by leading the examiner into areas of perceived pain that could be quite distant from the actual source of pain. Those clinicians who understand and recognize the potential pain referral patterns of masticatory muscles will be in a better position to correctly diagnose and effectively intervene with an appropriate treatment intervention.

The MyoFree device comes in a kit format and includes a DVD to teach the patient how to perform the intra-oral pressure application. Patients are taught how to “sweep” an area for TPs much like a metal detector sweeps an area for target artifacts. It is not uncommon for TMJ practitioners to learn how to use the MyoFree device so that they may utilize and teach the method to their patients. The DVD is interactive and uses excellent three dimensional imagery of the head, neck and facial dimensions to clearly illustrate the application.

Conclusion

In twenty-two years of product research, I have had the opportunity to “test drive” many different products in the field of rehabilitation and sports medicine. I have seen my share of ineffective therapy products/procedures, as well as some that are truly both useful and innovative. I like the idea of self-help products but have found so many that are disappointing—those being designed, marketed, and sold, only to make a profit. This device is not one of them. The MyoFree kit addresses an important, possibly critical, aspect of TMJ disorder and facial pain treatment in general. It is clear that trigger points are a common component of many of the more popular diagnoses relating to the head, neck and jaw. Any therapy that can eradicate or control TPs should eventually become a standard part of the total treatment intervention for these often difficult to treat conditions.

The inventor of the MyoFree device is Gail Falzon, RN. She explicitly does not make any claims suggesting complete cures using her method or that by using this device the patient will permanently eliminate the possibility of developing any future TPs. Every patient scenario is different and unique with some patients getting significant relief and restoration of function almost immediately, while others might require a more sustained effort over the course of multiple treatment sessions. What the device does provide is a way for patients to eradicate TPs associated with TMJ dysfunction by providing effective pain relief eventually leading to restoration of proper muscle function. This, in turn, will help re-establish correct joint mechanics and a lower likelihood of continued TP formation. Information about this device can be found at www.tmjpainsolutions.com.

Last updated on: January 5, 2012
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