Effects of transcutaneous electrical nerve stimulation combined with manual therapy on pain and masticatory function in women with temporomandibular disorder: An exploratory pilot studyABSTRACT
Purpose: to evaluate the efficacy of Transcutaneous Electrical Nerve Stimulation (TENS) combined with manual therapy on the masticatory function and pain in women with Temporomandibular Disorder (TMD).
Methods: an exploratory, randomized, controlled, and blinded pilot clinical trial. The sample consisted of 11 women with muscular TMD, assessed using the Visual Analog Scale (VAS) and Surface Electromyography (sEMG) with Root Mean Square (RMS) signal processing. Participants were allocated into two groups: Manual Therapy Group (MG, n=5) and Manual Therapy combined with TENS Group (TG, n=6). The protocol comprised four weekly 30-minute sessions of manual therapy for both groups, with the TG participants additionally undergoing 25 minutes of TENS.
Results: a statistically significant pain reduction was observed in both groups (MG: p=0.002; TG: p=0.026). However, only the TG showed a significant reduction in electromyographic activity for the right masseter (p=0.008) and left temporal (p=0.028) muscles, indicating a reduction of hyperactivity.
Conclusion: both interventions were effective in reducing pain. The combination of manual therapy and TENS suggests additional benefits in modulating electromyographic activity and neuromuscular balance, enhancing the efficacy of multimodal approaches in the clinical management of TMD within an exploratory framework.
Keywords:
Musculoskeletal Manipulations; Temporomandibular Joint Dysfunction Syndrome; Transcutaneous Electric Nerve Stimulation; Electromyography; Mastication
RESUMO
Objetivo: analisar a eficácia da Transcutaneous Electric Nerve Stimulation (TENS) associada à terapia manual na função mastigatória e na dor em mulheres com Disfunção Temporomandibular (DTM).
Métodos: estudo piloto exploratório de um ensaio clínico randomizado, controlado e cego. A amostra consistiu em 11 mulheres com DTM muscular, avaliadas pela Escala Visual Analógica (EVA) e Eletromiografia de Superfície (EMG), com processamento de sinal em Root Mean Square (RMS). As participantes foram alocadas em: grupo terapia manual (GM, n=5) e grupo terapia manual associada à TENS (GT, n=6). O protocolo compreendeu quatro sessões semanais de 30 minutos de terapia manual para ambos os grupos, sendo que o GT recebeu, adicionalmente, 25 minutos de TENS.
Resultados: observou-se redução estatisticamente significativa da dor em ambos os grupos (GM: p=0,002; GT: p=0,026). Contudo, apenas o GT apresentou redução significante na atividade eletromiográfica para os músculos masseter direito (p=0,008) e temporal esquerdo (p=0,028), indicando menor hiperatividade.
Conclusão: ambas as intervenções foram eficazes na redução da dor. A associação da TENS à terapia manual sugere benefícios adicionais na modulação da atividade eletromiográfica e no equilíbrio neuromuscular, reforçando a eficácia de abordagens multimodais no manejo clínico da DTM num contexto exploratório.
Descritores:
Manipulações Musculoesqueléticas; Síndrome da Disfunção da Articulação Temporomandibular; Estimulação Elétrica Nervosa Transcutânea; Eletromiografia; Mastigação
INTRODUCTION
The temporomandibular joint (TMJ) is one of the most complex joints in the human body, connecting the mandible to the base of the skull. This structure enables essential movements such as opening and closing the mouth, chewing, and speaking. However, imbalances in this joint or in the surrounding tissues can trigger the Temporomandibular Disorder (TMD), causing discomfort and impairing stomatognathic functions1,2.
TMD presents a multifactorial etiology and is considered a significant public health problem. It is the most common cause of chronic non-dental pain in the orofacial region and ranks as the second leading musculoskeletal condition causing disabling pain, surpassed only by chronic low back pain1. From a clinical perspective, TMDs are classically defined as muscular disorders, encompassing the masticatory musculature and articular disorders involving the TMJ and its adjacent structures3,4.
Although internal derangements such as Disc Displacement with Reduction (DDR) are common in the clinical practice, muscle-related (myofascial) pain stands out as the most prevalent and disabling pain. Joint abnormalities often trigger an adaptive response in the masticatory muscles, resulting in hyperactivity and muscle fatigue. Therefore, speech-language pathology management should give priority to strategies that restore the neuromuscular balance, regardless of the sole joint diagnosis5.
In addition to the muscular and articular repercussions, the symptomatology of TMD directly impacts the primary stomatognathic functions, especially mastication6. The presence of pain and structural alterations frequently induces a dysfunctional unilateral masticatory pattern, which imposes an asymmetric load on the masseter and temporalis muscles7. This compensation cycle exacerbates the TMD condition, leading to increased fatigue and orofacial discomfort which characterize the dysfunction as being disabling, requiring effective conservative interventions8,9.
The speech-language pathologist assesses the muscular and articular structures that allow the design of personalized therapeutic approaches tailored to the participants’ individual needs. The speech-language pathology objective focuses on optimizing muscle function and mandibular movements during the chewing, speaking, and swallowing processes with the purpose to balance the stomatognathic system and eliminate harmful habits10-12. In this connection, manual therapy is widely recognized as the gold standard for the conservative treatment of TMD. The application of myofascial release maneuvers and stretching exercises yields immediate physiological benefits, such as increased local blood flow, reduction of the trigger points, and improved soft-tissue extensibility. These mechanisms are crucial for reducing excessive muscle tension and restoring mandibular function non-invasively, thereby facilitating motor unit recruitment12.
Electro-stimulation stands out as a complementary resource to this gold standard practice. Transcutaneous Electrical Nerve Stimulation (TENS) is a frequently used tool that activates specific nerve fibers via surface electrodes and low-intensity currents. This technique operates through the gate control theory and the release of endogenous opioids, exerting a potent analgesic effect that aids in pain modulation and in the relaxation of hyperactive muscles13.
sEMG serves as an essential tool for objectively quantifying the benefits of these interventions. Unlike subjective pain scales, sEMG allows for the precise analysis of electrical activity, demonstrating muscle rebalancing through reduced bilateral asymmetry, which suggests an optimization of the neuromuscular pattern14.
Although the TENS and the manual therapy efficacy are well documented, there is a scarcity of evidence evaluating the synergistic effect of these interventions using objective biometric parameters. The need to investigate whether combining TENS with manual therapy can enhance the benefits of the latter is the reason for this study. Thus, this research aimed to assess the efficacy of TENS combined with manual therapy on the pain and the masticatory function in patients with myogenic TMD, using an exploratory analysis. It was hypothesized that combining these techniques would yield additional benefits in rebalancing electromyographic activity compared to manual therapy alone.
METHODS
Study design and ethical aspects
This is a pilot, randomized, controlled, assessor-blinded clinical trial. The study was approved by the Comitê de Ética em Pesquisa com Seres Humanos Universidade Federal de Santa Catarina (CEPSH/UFSC, Human Research Ethics Committee of the Federal University of Santa Catarina), Brazil, under opinion number 5.402.772 and CAEE number 54374121.5.0000.0121. All participants signed the Informed Consent Form (ICF) before starting the procedures.
The study was registered in the Registro Brasileiro de Ensaios Clínicos (REBEC, Brazilian Clinical Trials Registry) under the number and name RBR-633rr3r: Benefits of Electrostimulation in Facial Pain.
Sample and eligibility
The final sample consisted of 11 women recruited via an electronic form distributed through the social media and the university clinics. The investigation was performed at the Speech-Language Pathology Teaching Clinic of the home institution. The detailed recruitment flow and reasons for exclusion are presented in Figure 1.
Women aged 18 to 45 years with a body mass index (BMI) between 18.5 and 29.9 kg/m² and a diagnosis of muscular TMD (with or without disc displacement with reduction), determined using the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) protocol15, were included. Subsequently, the participants underwent an orofacial myofunctional evaluation based on the MBGR protocol to characterize the stomatognathic functions16.
The exclusion criteria were: a diagnosis of TMD of exclusively articular origin; extensive tooth loss (more than three missing teeth or the loss of two occlusal pairs); a history of recent facial trauma; use of occlusal splints; and prior speech therapy for TMD. Participants who would use analgesic, muscle relaxant, or anti-inflammatory medications during the study period were also excluded.
Although the sample size was initially determined via a prior sample size calculation, the study experienced attrition inherent to the longitudinal nature of the combined clinical interventions. Consequently, the final sample of 11 participants was assessed as an exploratory pilot study, with data interpreted in light of the investigation's feasibility and the clinical relevance of the preliminary findings.
Randomization and blinding
Random group allocation was performed using the Randomizer® software. To ensure allocation concealment, the randomization result was kept confidential by an independent investigator until the beginning of the intervention. A double-blind design was adopted to minimize bias. The assessor responsible for sEMG (a specialist with 23 years of experience in this area) was completely blinded to the group assignments thus ensuring impartiality during data collection and processing. Similarly, participants were also blinded to their allocation, as they were unaware of the study's exact hypothesis and the existence of intervention modalities other than the ones they were receiving. Participants were divided into two groups: the Manual Therapy Group (MG, n=5) and the Manual Therapy combined with TENS Group (TG, n=6).
Assessment procedures
Pain assessment
Pain intensity was assessed using the Visual Analog Scale (VAS), consisting of a 10-centimeter line graduated from 0 (absence of pain) to 10 (worst pain imaginable).
Surface electromyography (sEMG)
The electrical activity of the masseter and temporalis muscles was recorded using a Miotool 400 electromyography (Miotec®, Brazil). Prior to the electrode placement, the skin was cleansed with gauze soaked in 70% ethyl alcohol to reduce tissue impedance. DoubleTrace bipolar electrodes (Miotec®) and a ground electrode (Kendall® Meditrace 200), placed over the participants' ulnar styloid process to eliminate electrical interference, were used.
The electromyography set up was configured with a 20 Hz high-pass filter, a 500 Hz low-pass filter, and an acquisition rate of 2000 samples/second per channel. The signals were processed using Root Mean Square (RMS) and normalized to the Maximum Voluntary Contraction (MVC).
MVC was used for signal normalization. Prior to official data collection, participants underwent a training session to ensure correct execution of the movement. MVC values were obtained through three cycles of maximum voluntary clenching (five seconds each) on gauze rolls positioned bilaterally between the first and second molars, with a one-minute interval between trials, in order to prevent muscle fatigue. Habitual chewing was assessed using a standardized material with elastic consistency (gelatin-based gummy candy, Fini® brand "gummy bears") placed on the dorsum of the tongue to ensure uniformity in the consistency of the food bolus.
For signal analysis, the central segment of each recording was selected (discarding the initial and final seconds to avoid instabilities). The data were normalized by the mean MVC value, enabling inter-subject comparison and reducing variability inherent to skin impedance and muscle anatomy.
Speech-language pathology intervention
The sessions took place weekly over a period of four weeks. For ethical reasons, manual therapy was administered identically in both groups, as it is a recognized technique for pain management, as described in Chart 1.
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MG Group (Control): received exclusively the Manual Therapy protocol (30 minutes).
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TG Group (Experimental): received the same manual therapy protocol (30 minutes), followed immediately by the application of TENS (25 minutes).
TENS was administered using the Fono Stim® (HTM) device, with unipolar electrodes (Medix®) placed bilaterally over the masseter muscle belly (at the mandibular angle and the insertion point). Prior to electrode placement, the skin was cleansed with 70% ethyl alcohol. The protocol required burst stimulation at a frequency of 130 Hz and a pulse width of 100 μs. Intensity was adjusted according to each participant's sensitivity, increasing by 2 mA whenever sensory accommodation occurred.
The time difference in the total session duration between the groups (30 minutes for the MG and 55 minutes for the TG) was a grounded methodological and ethical decision. Since manual therapy is the established gold standard for treating muscular TMD, its dosage (30 minutes) was kept strictly the same for both groups, ensuring that all participants received the full therapeutic benefit of the primary technique. Reducing the manual therapy in the TG in order to equalize the total session time would have compromised the efficacy of the speech-language therapy. Control over the placebo effect was ensured by blinding participants to the therapeutic options of the other group, thereby mitigating expectation bias.
Statistical analysis
Data normality was assessed using the Shapiro-Wilk test. For within-group comparisons (pre- vs. post-intervention), the paired Student's t-test or the Wilcoxon test was used. For between-group comparisons, the unpaired Student's t-test or the Mann-Whitney test was applied. Sample attrition during follow-up was addressed through per-protocol analysis, including only participants who fully completed the four-session intervention cycle. A significance level of 5% (p < 0.05) was adopted, and the analyses were performed using the Stata software (version 14.0). Due to the reduction in the sample and the resulting final sample size, the statistical analysis focused on within-group and between-group comparison tests. Failure to calculate the effect size is acknowledged as a limitation resulting from loss to follow-up; therefore, these findings should be considered exploratory evidence and should help in the development of future studies.
RESULTS
Eleven women participated in the study; five were assigned to the MG (massage) and six to the TG (massage + TENS).
Data regarding the primary clinical outcome (pain) are presented in Table 1. There was no statistically significant difference between the groups at either the initial or final assessment. However, within-group analysis showed a marked and clinically relevant reduction in pain intensity for both groups following the intervention. The MG showed a reduction in the mean score from 4.6 to 0.6 points (p=0.002), and the TG from 5.5 to 0.7 points (p=0.026).
In the between-group comparison performed after the intervention period, no statistically significant difference in pain intensity was observed between the MG and TG (p=0.913), indicating that both modalities were effective.
Regarding masticatory function (sEMG), described in Table 2 and illustrated in Figure 2, there was no statistical difference between the groups at the pre-intervention stage. Following treatment, only the TG group showed a statistically significant reduction in electrical activity in the right masseter muscle (p=0.008) and left temporalis muscle (p=0.028) in the within-group comparison, indicating improved muscle balance. Although the MG group showed a trend toward a numerical reduction, it did not reach statistical significance for these parameters.
Comparison of mean electromyographic activity values for each muscle area during the masticatory function pre- and post-intervention, according to the intervention groups. Florianópolis, 2026
DISCUSSION
Electromyographic assessment in the present study revealed baseline hyperactivity of the masseter and temporalis muscles in all participants prior to the intervention. Following the therapeutic protocol, a trend toward reduced contraction amplitude was observed in these muscles, although this change did not reach statistical significance across all parameters. This finding is aligned with data from previous studies17, which documented a decrease in electrical activity and pain symptoms in the masseter and temporalis muscles after treatment, indicating the restoration of a more balanced functional pattern and the efficacy of muscle hyperactivity modulation in women with TMD.
In this context of functional recovery, another study18 found that the group undergoing manual therapy demonstrated balanced electrical muscle activity, achieving electromyographic normalization, that is, the restoration of activation patterns and symmetry comparable to those of the asymptomatic patients. Although the strategies associated with manual therapy in that study18 differed from those employed in the present investigation, the convergence of results enhances the premise that manual therapy is effective in modulating muscle activity, serving as solid therapeutic grounds for speech-language pathology intervention.
In addition to the benefits of manual therapy, the literature highlights the role of physical therapies, such as TENS. A comparative study19 between TENS and massage therapy showed a significant reduction in VAS scores for both groups, demonstrating the hypoalgesic effect of both approaches. Thus, the findings of the present study are aligned with the literature in demonstrating that both TENS and manual therapy promote benefits regarding muscle function and analgesia in patients with TMD19.
However, the distinguishing feature of this investigation lies in the comparative analysis between the groups. The data demonstrate that, regarding the masticatory function, the TENS Group (TG) showed more pronounced reductions in electrical activity during the post-intervention phase, whereas the Manual Group (MG) demonstrated no statistically significant differences in certain parameters. The additional benefits observed in the TG regarding neuromuscular rebalancing are supported by the neurophysiological mechanisms intrinsic to electrostimulation. While manual therapy acts predominantly through mechanical myofascial release and increased local blood circulation, TENS, in addition to providing analgesia via the Gate Control Theory, promotes a change in motor neuron excitability11,12.
This direct electrical modulation facilitates the reorganization of motor unit recruitment. Furthermore, this combination suggests a synergistic effect, wherein the analgesia and neuromuscular modulation provided by TENS prepare the stomatognathic system for the tissue manipulation involved in manual therapy. Such synergy allows for more effective access to myofascial structures and accelerates functional rebalancing; this explains the more pronounced electromyographic results observed in the experimental group and promotes functional symmetry, an effect that the intervention alone does not appear to achieve to the same magnitude in the short term. The improvement in temporal coordination and the paired muscles proportional activation intensity reflecting a reduction in bilateral asymmetry, is in line with previous studies20 and supports the above interpretation. Research evaluating the effectiveness of TENS revealed a significant reduction in asymmetry within the electromyographic findings of the masseter and temporalis muscles in groups undergoing the active technique20. This effectiveness is corroborated by studies with large sample sizes21, which demonstrated improvements in average pain levels and optimized electromyographic values following TENS application, thereby confirming the technique as an effective tool for modulating muscle electrical activity.
Regarding the specific clinical outcome of pain, no statistical difference was observed in the between-group comparison at the end of the study. However, the within-group analysis revealed a substantial and clinically relevant reduction in pain intensity in both groups: the MG showed a decrease from 4.6 to 0.6 points, while the TG dropped from 5.5 to 0.7 points on the VAS. This hypoalgesic efficacy is supported by studies linking myofunctional therapies with physical modalities22,23, demonstrating that multimodal approaches tend to yield superior clinical outcomes and a significant improvement in the participants' quality of life.
Finally, it was observed that recent literature20,24 indicates that TENS therapy promotes a balance in muscle electrical activity during MVC and mastication in women with orofacial pain. Therefore, the results presented here are aligned with a body of evidence validating the combination of manual and electrotherapeutic techniques in speech-language pathology rehabilitation, representing an essential resource for speech-language pathologists working across different levels of healthcare.
A limitation of this exploratory pilot study is the small number of final participants, resulting from sample attrition inherent to the longitudinal design. This factor restricted the possibility of generalization of the findings and precluded the inclusion of additional statistical analyses, such as effect size calculations. Furthermore, the difference in intervention time duration between groups, while ethically justified to ensure all participants received the full dose of the gold standard (manual-based) therapy, is a factor to be considered when designing future studies. Conducting clinical trials with larger samples is suggested to confirm the synergistic benefits observed in this study and to evaluate the durability of the therapeutic response.
CONCLUSION
Combining TENS with manual therapy yielded significant benefits regarding the relief of pain symptoms and the restoration of neuromuscular balance in women presented with TMD. Although both modalities demonstrated a hypoalgesic effect, the combined intervention offered additional benefits by promoting more efficient motor coordination during masticatory function. While these findings are preliminary due to the study's exploratory nature, they enhance the feasibility of this integrated approach as an effective therapeutic tool in speech-language pathology rehabilitation, aiming not only at pain relief but also at patients’ functional recovery and improved quality of life.
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A study conducted at the Federal University of Santa Catarina (UFSC), Trindade Campus, Florianópolis, SC, Brazil.
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Financial support
Nothing to declare
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Data sharing statement
The authors declare that all data generated and reviewed during this study, as well as the supplementary materials and the research protocol, are fully publicly available. Individual participant data (anonymized), data dictionaries, the statistical analysis plan, the informed consent form, and analysis code have been deposited in the public repository of the Graduate Program in Speech-Language Pathology and Audiology at the Universidade Federal de Santa Catarina (UFSC, Federal University of Santa Catarina) and can be accessed via the link: https://ppgfon.ufsc.br. This study data will be available as of January 2026 and will remain publicly accessible indefinitely and with no restrictions.
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Artificial Intelligence tools statement
During the preparation of this study, the authors used Google's Gemini tool (2026) to improve the text's grammar and fluency. After using this tool, the authors reviewed and edited the content as required. Furthermore, they assume full responsibility for the content of the publication.
The authors declare that all data generated and reviewed during this study, as well as the supplementary materials and the research protocol, are fully publicly available. Individual participant data (anonymized), data dictionaries, the statistical analysis plan, the informed consent form, and analysis code have been deposited in the public repository of the Graduate Program in Speech-Language Pathology and Audiology at the Universidade Federal de Santa Catarina (UFSC, Federal University of Santa Catarina) and can be accessed via the link: https://ppgfon.ufsc.br. This study data will be available as of January 2026 and will remain publicly accessible indefinitely and with no restrictions.
Source: Prepared by the authors (2023).
Captions: MG = Manual therapy group; TG = Manual therapy with TENS group; RM = Right masseter; LM = Left masseter; RT = Right temporalis; LT = Left temporalis.Paired-samples t-test.* Wilcoxon test.Note: A statistically significant intra-group difference was observed in the TG Group for the right masseter (p=0.008) and left temporalis (p=0.028).