Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 314-318  

Value of transcutaneous electric nerve stimulation in the treatment of myofascial pain dysfunction syndrome


Department of Oral Medicine and Radiology, People's Dental Academy, Bhopal, Madhya Pradesh, India

Date of Web Publication19-May-2017

Correspondence Address:
Hina Handa
Department of Oral Medicine and Radiology, People's Dental Academy, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_196_16

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  Abstract 

Pain in facial region originating from both temporomandibular joint (TMJ) and jaw muscles is a common clinical problem and is a diagnostic dilemma till today. There are many synonyms for this condition including myofascial pain dysfunction syndrome, mandibular dysfunction syndrome, and the TMJ dysfunction syndrome. With change in time, advances and new diagnostic criteria have been made in the diagnosis of myofascial pain syndrome, its epidemiology, clinical characteristics, and etiopathogenesis, but many unknowns remain. An integrated hypothesis has provided a greater understanding of the physiopathology of trigger points, which may allow the development of new diagnostic criteria and treatment of this chronic disease and combined pharmacological as well as physical therapy for the management of the disease. The purpose of this paper is to describe the multidisciplinary approach highlighting the effect of transcutaneous electric nerve stimulation (TENS) for the treatment of a 60-year-old female who suffered from myofascial pain and 5-day TENS therapy for management of pain.

Keywords: Myofascial pain syndrome, temporomandibular joint, transcutaneous electric nerve stimulation


How to cite this article:
Handa H, Deshpande A, Punyani S. Value of transcutaneous electric nerve stimulation in the treatment of myofascial pain dysfunction syndrome. Med J DY Patil Univ 2017;10:314-8

How to cite this URL:
Handa H, Deshpande A, Punyani S. Value of transcutaneous electric nerve stimulation in the treatment of myofascial pain dysfunction syndrome. Med J DY Patil Univ [serial online] 2017 [cited 2020 Apr 6];10:314-8. Available from: http://www.mjdrdypu.org/text.asp?2017/10/3/314/206575


  Introduction Top


Myofascial pain syndrome (MPS) is a muscular pain syndrome that arises from a primary dysfunction in muscle and is associated with central sensitization and a segmental spread within the spinal cord to give rise to the phenomenon of referred pain, or pain that is felt at a distance.[1]

There still exists a debate in the etiology, pathogenesis, and ideal treatment of the disease. The etiology and pathogenesis of myofascial pain dysfunction syndrome (MPDS) are controversial although they are considered to be multifactorial, such as excess tension in the muscles of mastication, malocclusion between the upper and lower teeth and jaws (dysgnathism), disturbed movement of the jaw joint, displacement or abnormal position of the jaw joint, luxation/dislocation or arthritis, and excess or limited motion of the joint, injury of the jaw or face.[2]

The pathophysiology of MPS is not completely understood. It is currently hypothesized that trigger points (TrPs), the most common feature of MPS, contain areas of sensitized low-threshold nociceptors (free nerve endings) with dysfunctional motor end plates. These motor end plates connect to a group of sensitized sensory neurons in charge of transmitting pain information from the spinal cord to the brain.[3]

The successful management of patients with MPD syndrome is dependent on establishing an accurate diagnosis and using proper therapy based on an understanding of the etiology of the disorder. Establishing an accurate diagnosis is accomplished by taking a careful history, doing a thorough examination, and having knowledge of the various other conditions that can produce signs and symptoms similar to those of MPD syndrome. Its treatment protocol still ranges from combined treatment of the disease with the physical, medical, and mechanical assistance.


  Case Report Top


A 60-year-old female, homemaker, resident of Bhopal, reported with the chief complaint of pain on the right side of the jaw during opening of mouth for 20 days. According to the patient, she was apparently alright 20 days back, developed pain on the right side of the jaw while opening the mouth. Pain was sudden in onset, dull aching, intermittent, and was nonradiating. Pain aggravated occasionally on eating hard food. There was no significant medical and dental history. Their was no such significant habit history. General physical examination appeared to be normal [Figure 1].
Figure 1: Patient's facial profile with no extraoral abnormality detected

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On extraoral examination, there was deviation of mandible on the right side during mouth opening. There was clicking noise in the right side of temporomandibular joint (TMJ) during early opening. On palpation, there was tenderness in the right preauricular and masseter region. On intraoral local examination 46 and 27 were found to be missing. Visual analog scale (VAS) score for pain recorded was 8 on the very 1st day [Figure 2].
Figure 2: No intraoral abnormality detected

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Based on the given history and clinical findings, a provisional diagnosis of MPDS was considered. Differentials included were (1) internal derangement of TMJ (2) myospasm (3) myositis (4) otitis media. Investigations advised were panaromic imaging, in which no odontogenic abnormality was detected [Figure 3].
Figure 3: Panaromic radiograph with no abnormality detected

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The patient was referred to the ENT Department of Peoples General Hospital. The specialist ruled out any kind of abnormality of otitis media and eagle syndrome. The final diagnosis given was MPDS of the right side TMJ as there was no specific orthopantomogram findings, and the left side increased joint space noted was age related not specific to disease. As the above-mentioned case fulfills all LASKIN criteria of MPDS, the diagnosis was more confirmatory. Treatment protocol advised was pharmacotherapy, soft diet and hot pack, and transcutaneous electric nerve stimulation (TENS) therapy.


  Transcutaneous Electric Nerve Stimulation Therapy Top


TENS therapy includes the following procedures:

  • Skin electrodes in the right preauricular and massetric muscle region
  • Pulse width taken was 60 microsecond frequency (40-150 Hz) and low intensity, just above threshold, with the current set between 10 and 30 mA [Figure 4]
  • 20 min on every 2nd day for 2 weeks [Table 1].
Figure 4: Transcutaneous electric nerve stimulation machine

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Table 1: Treatment regimen

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  Discussion Top


MPS is a common musculoskeletal disorder caused by myofascial TrPs. MPDS is a psychological disorder which involves the masticatory muscles and results in pain, limitation in jaw movement, joint noise, jaw deviation in closing and opening the mouth, and sensitivity in touching one or more masticatory muscles or their tendons. Maybe the patient complains about headache, earache, hypertrophy of masticatory muscles, abnormal wear of masticatory surfaces, etc.[4]

MPS associated with TrPs is a noninflammatory disorder of musculoskeletal origin, associated with local pain and muscle stiffness, characterized by the presence of hyperirritable palpable nodules in the skeletal muscle fibers, which are termed TrPs.[5]

TrPs produce pain to any activating stimulus (direct or indirect trauma) and can provoke referred pain, referred tenderness, motor dysfunction, autonomic phenomena, and hyperexcitability of the central nervous system.[6]

TENS has proven to be useful in treating many painful syndromes. Based on Wall and Melzack's gate control theory and later improved as transcutaneous electrical stimulator, TENS has been used very commonly for pain relief in the past 30 years.[7]

In the current case report, it was found that VAS score for pain was reduced from 8 to 1.

The combined pharmacotherapy which included muscle relaxant (Myospaz Forte BD) was given to the patient along with soft diet and hot pack application. The combined triad led to the improvement in pain and overall health of the patient.

TENS is a method of electrical stimulation which primarily aims to provide a degree of symptomatic pain relief by exciting sensory nerves and thereby stimulating either the pain gate mechanism and/or the opioid system. The different methods of applying TENS relate to these different physiological mechanisms. The effectiveness of TENS varies with the clinical pain being treated, but research would suggest that when used “well” it provides significantly greater pain relief than a placebo intervention.[8]

Transcutaneous electrical stimulator sends a painless electrical current to specific nerves. The mild electrical current generates heat to relieve stiffness, improve mobility, and relieve pain. The treatment is also believed to stimulate the body's production of endorphins or natural pain killers.[7] The duration of pulses and frequencies can be revised and it is possible to stimulate different types of fibers by chosen stimulation types. It is possible to stimulate selectively and carrying touch and position sensation and it is possible to block pain in medulla spinalis level, or to stimulate the C-fibers carrying pain and it blocks the pain in the upper levels.[7]

TENS is a well-known physical therapy, which is useful for the relief of pain. With TENS, electrical stimulation is transmitted to pain areas through surface electrodes, which reduces or eliminates pain. TENS is a safe, noninvasive, effective, and swift method of analgesia, and potential adverse reactions of other methods of pain control are eliminated.[9]

Graff-Radford compared the effect of 4 modes of TENS on myofascial pain. Pain reduction occurs with 100 Hz, 250 ms stimulation followed by 100 Hz, 50 ms. No pain reduction is found in 2 Hz, 250 ms. These authors reported that high-intensity TENS is effective in decreasing myofascial pain measured with a VAS.[10]

Dhindsa et al.[11] in 2011 compared efficacy of TENS with 2% lignocaine in reducing the pain during extraction, cavity preparation, pulpotomy, and pulpectomy of deciduous teeth in 180 pediatric patients. Response to pain and comfort and effectiveness of anesthesia were compared using the VAS, verbal pain scale [VPS] and Lickert scale. ANOVA values using TENS and 2% lignocaine showed no significant difference [P > 0.05]. They concluded that TENS can be a useful adjunct in pediatric patients during various minor dental procedures.[11]

Repeated daily administration of TENS causes analgesic tolerance at spinal opioid receptors on the 4th day. In the past few years, studies have investigated different strategies to improve the efficacy of TENS by preventing or delaying the development of tolerance. Hingne and Sluka showed that blockade of N-methyl-D-aspartate receptors during application of TENS prevents the onset of tolerance. Basic scientific evidence suggests that there are peripheral and central nervous system mechanisms underlying the analgesic action of TENS. Studies also show that tolerance to repeated application of TENS can be prevented by multiple strategies, both pharmacologic and nonpharmacologic.[12]

TENS therapy is supposed to 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.[13]

Kogawa EM et al., 2006 performed a comparative study on 18 patients with chronic TMD using TENS and low level laser therapy in the management of TMD conclude both therapy were effective for decreasing the symptoms of TMD patience and a cumulative effect may be responsible for the improvement.[14]

Yameen et al. in his study used TENS as a treatment modality to TMJ pain in 31 patients who were refractory or partially responsive to drug therapy. Severity of pain was assessed on a VAS prior to and 15 days after treatment. They found that 83.7% patients improved significantly with application of TENS and a constant mode gave slightly better therapeutic results than burst mode of TENS.[15]


  Conclusion Top


The diagnosis of MPDS is highly complex and is multifactorial in origin. Merely treating the patient symptomatically does not provide long-term results; at the same time, injecting TrPs and tender spots and hoping for the best does not provide satisfactory results. TENS is used as a main treatment modality for the management of MPDS along with counseling and jaw exercises as well as acceptance of the denture. The proper treatment of MPS may be one of the most rewarding if handled correctly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio 2006;24:283-91.  Back to cited text no. 13
    
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Kato MT, Kogawa EM, Santos CN, Conti PC. Role of tens and recent advances in management of TMJ: A review. J Appl Oral Sci 2006;14:130-5.  Back to cited text no. 14
    
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Yameen F, Shahbaz NN, Hasan Y, Fauz R, Abdullah M. Efficacy of transcutaneous electrical nerve stimulation and its different modes in patients with trigeminal neuralgia. J Pak Med Assoc 2011;61:437-9.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]


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Abstract
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Case Report
Transcutaneous E...
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