Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / Name of Candidate
& Address / ILLAHI ZAHOOR KINU
CHATTABAL, GUZERBAL, SRINAGAR,
KASHMIR, J &K.
2 /

Name of the Institution

/ DAYANANDA SAGAR COLLEGE OF PHYSIOTHERAPY
3 /

Course of study and subject

/ MASTER OF PHYSIOTHERAPY
(Physiotherapy in Musculoskeletal
disorders & Sports physiotherapy)
4 /

Date of admission to course

/ June;2012
5 /

TITLE OF THE TOPIC:

EFFECT OF ULTRASOUND VERSUS TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION ON PAIN IN TEMPOROMANDIBULAR JOINT DYSFUNCTION (OCCLUSIVE MUSCULAR LEVEL) –A COMPARATIVE STUDY.
6 / Brief resume of the intended work:
6.1 INTRODUCTION
Temporomandibular joint disorder (TMD) is a generic term to describe a group of disorders or diseases affecting masticatory muscles, the Temporomandibular joint (TMJ) and associated structures1. Epidemiologic studies show that approximately 75% of the population have some TMD sign, while 33% have at least one symptom.2
Study showed that people with TMD can experience severe pain and discomfort that can be temporary or last for many years. More women (6.3%) than men (2.8%) experience TMD. TMD is most common in people between the ages of 20-40. The prevalence of TMD is between 3-15% in the General population with an incidence between 2-4%.3
Temporomandibular Disorders (TMD) is a collective term embracing all the problems relating to Temporomandibular joint (TMJ) and related musculoskeletal masticatory structures4. It refers to a cluster of disorders characterized by pain in the preauricular region, pain in TMJ, or the masticatory muscles, limitation or deviations in mandibular range of motion and noises in the TMJ during mandibular function. TMJ disorders are also sometimes referred to as Myofascial pain dysfunction, Craniomandibular Disorder and Costen's syndrome.5
The Temporomandibular Joint (TMJ) is the site of articulation between the mandible and the skull, specifically the area about the articular eminence of the temporal bone. The articulation consists of parts of the mandible and temporal bones, which are covered by dense, fibrous connective tissue and are surrounded by several ligaments. The TMJ is a synovial, condylar and hinge-type joint with fibro cartilaginous surfaces rather than hyaline cartilage and an articular disc. The disc completely divides each joint into two cavities. The joint connects the lower jaw (mandible) to the temporal bone of the skull.6
The joints are flexible, allowing the jaw to move smoothly up and down and side to side and enabling one to talk, chew and yawn. Muscles attach to and surround the jaw joint to control the position and movement of the jaw. The muscles include masseter, temporalis, medial pterygoid and later pterygoid.7 Because muscles and joints work together, a problem with either one can lead to following TMJ disorders. Teeth grinding and teeth clenching (bruxism) increase the wear on the cartilage lining of the TMJ. Many patients awaken in the morning with jaw or ear pain, Habitual gum chewing or fingernail biting, Misalignment of the teeth (malocclusion), Trauma to the jaws: Previous fractures in the jaw or facial bones can lead to TMJ disorders, Problematic relation between the jaw and malocclusions with deflective contacts in the teeth, Stress frequently leads to unreleased nervous energy. It is very common for people under stress to release this nervous energy by either consciously or unconsciously grinding and clenching their teeth, Occupational tasks or habits such as holding the telephone between the head and shoulder may contribute to TMJ disorders.8
Symptoms associated with TMD are: pain or tenderness of the aching pain in and around the ear, difficulty chewing or discomfort while chewing, aching facial pain, locking of the joint, difficultly with opening or closing of the mouth, headaches, uncomfortable bite, or uneven bite. Clicking, popping or grating sounds in the joint with opening and closing of the mouth. Other common symptoms include toothaches, neck pain, dizziness, earaches and hearing problems.9
Piper’s Classification Of TMJ Disorders:
Piper I: Normal disc and ligaments
Piper II: Normal disc position; ligaments torn or stretched
Piper IIIa: Partial displacement of the disc, reduces on opening; ligaments torn or stretched
Piper IIIb: Partial displacement of the disc, nonreducing on opening; ligaments torn or stretched
Piper IVa: Full dispacement of disc, reduces on opening; ligaments torn or stretched
Piper IVb: Full displacement of disc, nonreducing on opening; ligaments torn or stretched
Piper Va: Bone-to-bone contact; active degeneration
Piper Vb: Bone-to-bone contact; bone has become eburnated10
TMD handling may be simple or may require a multidisciplinary approach. Dentists, physicians, psychologists and physical therapists work together to cope with such condition afflicting patients. Clinical treatment is considered the first choice11. Numerous physical therapy methods are effective to treat TMD, such as moist heat, ultrasound, TENS, microwaves, laser, exercises and manual therapy techniques12. These methods aim at decreasing musculoskeletal load and pain effects, at decreasing inflammation, at restoring normal joint function (strength, movement and resistance) and at helping return to daily activities.13
TENS is the method by which controlled, low voltage electrical pulses are applied to the nervous system. TENS is used to reduce the symptoms of pain. Secondary benefits, such as sedation and increased tissue temperature, are noted; however, the primary effect of TENS is to produce analgesia. TENS therapy stimulate large, fast ,myelinated, non-nociceptive neurons in the painful area “closing the central gate” for those stimuli generated by pain specific fibers. This system, associated to the activation of an endogenous opioid system is supposed to be responsible for the analgesic effect of the TENS.14
Ultrasound therapy used by physical therapists that utilize high or low frequency sound waves. These sound waves are transmitted to the surrounding tissue and vasculature. They penetrate the muscles to cause deep tissue/muscle warming. This promotes tissue relaxation and the warming effect of the sound waves also cause vessel vasodilatation and increase circulation to the area that assists in healing, decrease in pain from the reduction of swelling and edema.15
Joint vibration analysis (JVA) or Electro vibrato graphy is based on simple principles of motion and friction. When surfaces rub together, they cause vibration. The greater the surface roughness, the greater the vibration, and this vibration can be captured by accelerometers. Human joints have surfaces which rub together in function. Smooth, lubricated surfaces in a proper biomechanical relationship in theory should produce little friction and little vibration. But surface changes, such as those caused by tissue degeneration, tears, or displacements of the disc; are thought to produce greater friction and greater vibration. Computer assisted vibration analyses is claimed to identify these patterns and helps distinguish among various temporomandibular disorders.Vibration analysis of the temporomandibular joint is thus, a quantitative process that measures the absolute intensity and frequency distribution of vibratory waves emanating from the joint as it is exercised throughout its full range of motion. Tissue vibrations (motions) are recorded down to the level of approximately one micron.16
JVA is a device that: 1) objectively records all of the vibrations of the underlying tissue during function, 2) distinguishes which side the vibration originates on, 3) creates a visual image of the vibration, 4) measures the intensity of the vibration, 5) precisely quantifies the frequency content and 6) provides a permanent record for future comparison. JVA is less invasive and more accurate than auscultation or palpation with a repeatable permanent record of TM joint function or dysfunction. And, it can be recorded by a staff member in about a minute.17
JVA is a great screening test since it has such a high specificity. It is also the ideal, low cost way to monitor joint function during the course of treatment. While it does not eliminate the need for expensive imaging, it allows the practitioner to make a more informed decision whether the cost of imaging is justified.17
6.2 Need for the study
Temporomandibular disorders (TMDs) refer to an aggregate of clinical pain conditions that involve the craniofacial muscles, the Temporomandibular joint and associated structures. TMDs are considered to be a subclass of the musculoskeletal disorders and are a major source of non-dental pain in the orofacial region.Temporomandibular joint (TMJ) dysfunction is often the cause of varied symptoms throughout the head and neck is becoming widely recognized among health professionals.
Currently dentists are the professionals involved in TMJ evaluation and treatment. However, procedures such as ROM measurements, muscle tests, joint play test, cervical spine evaluation and pain relief are not usually performed by dentists but by physical therapists.
TENS is a method by which controlled, low voltage electrical pulses are applied to the nervous system. TENS is used to reduce the symptoms of pain. Several studies have been done to studies have been done to study the effectiveness of TENS on pain relief in TMD.
Similarly therapeutic ultrasound has been a widely used and well accepted physical therapy adjunct modality particularly for the management of musculoskeletal conditions. Few studies have been done to study the efficacy of therapeutic ultrasound on pain in TMJ.
But no study has been done till date comparing which modality between therapeutic ultrasound and TENS is more effective in reducing pain in TMJ dysfunction. So, this this study has been done to compare whether therapeutic ultrasound or TENS is more effective in reducing pain in TMJ dysfunction
6.3 Hypothesis :
Null Hypothesis: There will be no significant difference between Transcutaneous electrical nerve stimulation and Ultrasound Therapy on pain in patients with Temporomandibular dysfunction at the OML.
Experimental Hypothesis: There will be significant difference between Transcutaneous electrical nerve stimulation and Ultrasound Therapy on pain in patients with Temporomandibular dysfunction at the OML.
6.4 Review of Literature:
OUTCOME MEASURES
Joint Vibration Analysis:
Sharma, Sonia (2011). This observational study was designed to evaluate the clinical reliability and diagnostic validity of the Joint Vibration Analysis (JVA) in patients with disc displacement with reduction. The short term reliability of the JVA outcome variables showed excellent results, the Intraclass correlation coefficients (ICCs) ranged from 0.63 to 0.90. A sensitivity of 48% and specificity of 94% was obtained for the correct identification of subjects with and without disc displacement with reduction.18
Visual Analogue Scale:
Polly E. Bijur, Phd, Wendy Silver, Ma, E. John Gallagher, Md;(2001). The objective of the study was to assess the reliability of the VAS for measurement of acute pain. And it was concluded that Reliability of the VAS for acute pain measurement as assessed by the ICC appears to be high.19
Ruler For ROM:
Nancy Walker, Richard W. Bohannon, Denise Cameron (2000). This study was done to determine the discriminant validity and intrarater and interrater reliability of measurements of temporomandibular joint (TMJ) range of motion (ROM) with ruler. Mouth opening was the only TMJ ROM measurement to discriminate between subjects with and without TMJ disorders (mean 36.2 2 6.4 versus 43.5 2 6.1 mm). The technical error of measurement of the measures varied from .2 to 2.5 mm. lntrarater reliability coefficients (ICC 3,l) varied from .70 to .99. Interrater reliability coefficients (ICC 2,k) varied from .90 to 1 .O. Although all TMJ ROM measurements tended to be reliable, only mouth opening was found to be valid in discriminating between patients with and without a TMJ disorder).20
TEMPOMANDIBULAR JOINT DYSFUNCTION
Shalender Sharma, D. S. Gupta, U. S. Pal, and Sunit Kumar Jurel ; (2011). This study concluded that there is successful management of temporomandibular disorders is dependent on identifying and controlling the contributing factors. The temporomandibular disorders are more common in females, the reason is not clearly known.21
Edward F. Wright, Sarah L. North; (2009). This study concluded that routinely managed by medical and dental practitioners, TMD may be more effectively cared for when physical therapists are involved in the treatment process. Hence, a listing of situations when practitioners should consider referring TMD patients to a physical therapist can be provided to the practitioners in each physical therapist’s region.22
Milan Knežević, Miranda Guillermo, Mario Vicente1, Garcia Francisco, Sergio Dominguez, Slađana Petrović et al;(2008). this study deals with conservative non-surgical treatment of painful temporomandibular joint (TMJ) syndrome administered in thirty patients. The treatment involved TENS applications, and particularly extension exercises of the masseter muscle, temporalis and pterygoid muscles, as well as the local application of ultrasound. The result was an evident improvement in a significant number of cases. Physical exercises represent a useful treatment modality for TMPDS patients. TMPDS treatment should be organized in a multidisciplinary way, with dentists, physiotherapists and psychologists being all equally involved.23
Marega S Medlicott and Susan R Harris;(2006). This systematic review analysed studies examining the effectiveness of various physical therapy interventions for Temporomandibular disorder and it was concluded that the following active exercises and manual mobilizations postural training, mid-laser therapy, relaxation techniques and biofeedback, electromyography training, and proprioceptive re-education and combinations may be effective.24
Margaret L McNeely, Susan Armijo Olivo and David J Magee ;( 2006). The purpose of this qualitative systematic review was to assess the evidence concerning the effectiveness of physical therapy interventions in the management of Temporomandibular Disorders. Most of the studies included in this review were of very poor methodological quality, there is a clear need for well-designed RCTs examining physical therapy interventions for TMD. Trials should be large enough to be clinically meaningful and include valid and reliable outcome measures. Based on the positive effects of active and passive exercise, postural exercises, and manual therapy, high-quality trials with larger sample sizes are clearly warranted in these areas.25
INTERVENTION
Eduardo Grossmann, Joseane Steckel Tambara, Thiago Kreutz Grossmann, José Tadeu Tesseroli de Siqueira;(2012). This article aimed at reviewing the scientific literature on the use of TENS in Temporomandibular joint patients. TMD has different aetiologies and specific treatments, among them the transcutaneous electrical nerve stimulation (TENS) is used which administers electrical current to the skin surface, to relax hyperactive muscles and promote pain relief. And futher it was concluded that Although there are controversies about the use of TENS to control chronic pain, its use for masticatory muscle pain is still relevant. However, an accurate diagnosis is needed to prevent its inadequate use. There is still need of controlled randomized studies including selected samples to homogenize the use of TENS in TMD patients.26