Accuracy of the surface electromyography RMS processing for the diagnosis of myogenous temporomandibular disorder
Introduction
The temporomandibular joint (TMJ) and masticatory muscles can be affected by temporomandibular disorder (TMD) (Sharma et al., 2011, Vuckovic et al., 2012). Due to the multifactor etiology of this condition, the precise diagnosis remains a matter of debate (Medllicott and Harris, 2006) and validated diagnostic tools are needed (Gonzalez et al., 2008). Electronic equipment may provide reliable quantitative data to assist in the clinical evaluation of TMD (Schmitter et al., 2005, Manfredini et al., 2006, Hugger et al., 2008, Lauriti et al., 2014).
The diagnosis of TMD should be based on a combination of a clinical exam and reported history of the disorder (Sener and Akgunlu, 2011). The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) has been designed to assist in the diagnosis (Dworkin and LeResche, 1992, Mafredini et al., 2010). While studies have demonstrated that the RDC/TMD is reliable for myogenous TMD, this tool exhibits low accuracy for the arthrogenous TMD diagnosis (Schmitter et al., 2005, Look et al., 2010, Schiffman et al., 2010, Park et al., 2012).
Surface electromyography (sEMG) is a noninvasive technique for recording muscle activity that may be employed in the assessment of TMD (Suvinen et al., 2009). However, its use in the diagnosis of this disorder has been called into question due to the considerable variability in the findings described in the literature (Klasser and Okeson, 2006). Studies addressing the diagnosis of different health conditions have evaluated the accuracy and correlation of different assessment tools for the determination of reference values and the best form of diagnosis (Manfredini et al., 2011, De Felício et al., 2012, Reneker et al., 2011, Piancino et al., 2012).
While sEMG indices have been employed as a complementary exam in the diagnosis of TMD, previous studies have exhibited poor methodological quality, with a failure to describe the techniques, tools and interpretation of the data, as well as a lack of reference values that differentiate individuals with and without TMD (Gonzalez et al., 2008).
In a recent research, Lauriti et al. (2014) reported a good to excellent reproducibility (ICC: 0.66–0.99) for the sEMG evaluation in TMD and asymptomatic subjects during maximum voluntary teeth clenching on parafilm and at rest, for the masticatory muscles. Moreover, the sensitivity, specificity and accuracy of sEMG activity assessed in the amplitude domain by the root mean square (RMS) in the diagnosis of myogenous TMD, have not been established in the literature so far. Indeed, Manfredini et al. (2011) reported that sEMG indices collected during teeth clenching task exhibit moderate accuracy, but should not be used in the diagnosis of TMD due to high rates of false-positive found in subjects without TMD (TMD-free subjects). On the other hand, Santana-Mora et al. (2014) reported a moderate degree of accuracy of the sEMG (integrated processing) at rest, for discrimination between TMD and asymptomatic subjects, specifically for left anterior temporalis muscle.
Given the above, the aim of the present study was to assess the accuracy of RMS sEMG data of the masticatory muscles in the diagnosis of myogenous TMD.
Section snippets
Sample
One hundred fifty-one female volunteers were consecutively recruited for the study. Following an evaluation with the RDC/TMD (Dworkin and LeResche, 1992), volunteers diagnosed with myofascial pain (Ia) or myofascial pain with limited mouth opening (Ib); simultaneous diagnoses (disc displacement or arthralgia) (Table 1) and present pain and/or fatigue in masticatory muscles during functional activities for more than six months (Ohrbach et al., 2011) were included in the TMD group. Women with no
Experimental procedure
The RDC/TMD was used as the gold standard. As mentioned, volunteers with myofascial pain (Ia or Ib) were included due to the reported accuracy of this assessment tool regarding the diagnosis myogenous TMD (Look et al., 2010). The clinical exam (Axis I of the RDC/TMD) was performed by a single examiner who had undergone a training and calibration exercise, following the specifications of the International RDC/TMD Consortium.
Results
Table 2 displays the RMS sEMG data for the two groups. With the mandible at rest, the TMD group exhibited significantly greater activity in all muscles evaluated in comparison to the control group. During MVC on parafilm, the TMD group exhibited significantly lower activity in the masseter muscles and significantly greater activity in the suprahyoid muscles in comparison to the control group.
On the ROC curve, the RMS sEMG data for the mandible at rest were distributed in the upper left region
Discussion
It is reported that between 80% and 90% of the general population experience signs or symptoms of TMD at some time in life (Pedroni et al., 2003), with 40–60% exhibiting this disorder at any given moment (Plesh et al., 2011). These data underscore the importance of the correct diagnosis (Guarda-Nardini et al., 2012). Currently, the RDC/TMD has been commonly used in diagnostic studies to identify individuals with TMD (Hasanain et al., 2009). However, despite the adequate reliability of this
Conclusion
sEMG activity (RMS processing) of the masticatory muscles at rest and the suprahyoid muscles during MVC on parafilm demonstrated a moderate degree of accuracy for the diagnosis of myogenous TMD and should be used as a complementary tool in the diagnosis of this disorder as well as during the treatment follow up.
Therefore, the reported cutoff point values, following the same methodological parameters described in this study, are valuable information for both researchers and clinicians in the
Conflicts of interest
The authors have no personal or financial conflicts of interest related to the present work.
Kelly Cristina dos Santos Berni graduated in Physical Therapy at the Methodist University of Piracicaba (Brazil) in 2006, Master’s degree in Physical Therapy at the Methodist University of Piracicaba (Brazil) in 2009, and PhD in Anatomy Pathology Bucco Dental at the State University of Campinas (Brazil) in 2013. She is currently professor of the Physical Therapy course at the College of Americana (Brazil). She conducts research mainly focusing on the following topics: Musculoskeletal System,
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Kelly Cristina dos Santos Berni graduated in Physical Therapy at the Methodist University of Piracicaba (Brazil) in 2006, Master’s degree in Physical Therapy at the Methodist University of Piracicaba (Brazil) in 2009, and PhD in Anatomy Pathology Bucco Dental at the State University of Campinas (Brazil) in 2013. She is currently professor of the Physical Therapy course at the College of Americana (Brazil). She conducts research mainly focusing on the following topics: Musculoskeletal System, Myofascial Pain, Temporomandibular Disorders, and Electromyography.
Almir Vieira Dibai-Filho graduated in Physical Therapy at the Center of Higher Studies of Maceió (Brazil) in 2008, master’s degree in Physical Therapy at the Methodist University of Piracicaba (Brazil) in 2012. He is currently PhD student in Postgraduate Program in Rehabilitation and Functional Performance at the University of São Paulo (Brazil) and researcher at the Laboratory of Physiotherapeutic Resources of the University of São Paulo. He has experience in Physical Therapy with emphasis on Physical Therapy Assessment and Intervention. He conducts research mainly focusing on the following topics: Physical Therapy Modalities, Musculoskeletal System, Myofascial Pain, Temporomandibular Disorders, and Rehabilitation of the Locomotor System.
Paulo Fernandes Pires graduated in Physical Therapy at the State University of Northern Paraná (Brazil) in 2007, master’s degree in Physical Therapy at the Methodist University of Piracicaba (Brazil) in 2013. He is currently PhD student in Postgraduate Program of Human Movement Sciences at the Methodist University of Piracicaba (Brazil) and researcher at the Laboratory of Therapeutic Resources of the Methodist University of Piracicaba. He has experience in Physical Therapy with emphasis on Manual Therapy and Intervention. He conducts research mainly focusing on the following topics: Physical Therapy Modalities, Manual Therapy, Surface Electromyography, Chronic Neck Pain, Temporomandibular Disorders and Low Back Pain.
Delaine Rodrigues-Bigaton is professor in the Master and PhD in Human Movement Sciences and she is professor of the Physical Therapy course at the Methodist University of Piracicaba (Brazil). She has a degree in Physical Therapy from the Methodist University of Piracicaba (Brazil) in 1997, Master’s degree in Physical Therapy from the Federal University of São Carlos (Brazil) in 2000 and PhD in Biology Pathology Bucco Dental from State University of Campinas (Brazil) in 2002. She is responsible for Laboratory of Therapeutic Resources of the Methodist University of Piracicaba (Brazil) and conducts research mainly focusing on the following topics: Physical Therapy Modalities, Surface Electromyography, Chronic Neck Pain and Temporomandibular Disorders.