Effects of Rocabado's Approach Versus Kraus Exercise Therapy on Pain and Disability in Patients with Temporomandibular Dysfunction: Randomized Clinical Trial

Background and Aim: TMD is a common condition that causes pain, limited jaw mobility, and other symptoms, significantly affecting daily activities. The objective was to assess the impact of exercise regimens on improving TMJ function, reducing pain, and enhancing overall quality of life for TMD patients. This study aimed to evaluate the effectiveness of Rocabado's approach and Kraus exercises in managing temporomandibular joint dysfunction (TMD). The findings provided evidence-based insights into the most effective physical therapy interventions for TMD.

Objective: To compare the effects of Rocabado’s Approach and Kraus exercise therapy on pain and disability in patients with TMJ dysfunction.

Materials and Methods: A randomized clinical trial was carried out at Fatima Memorial Hospital and Boston Physiotherapy Clinic, Lahore from November 2022 to February 2023. Sample Size of 40 participants with ages ranging from 20 to 60 years were allocated using random sampling technique through opaque sealed enveloped into Group 1 and Group 2. Group 1 was treated with Rocabado’s approach and Group 2 was treated with Kraus exercises. The treatment consisted of 12 sessions in 4 weeks for both groups. Numeric Pain Rating Scale (NPRS), temporomandibular disability Index (TMDI) and Fonseca Amnestic Index (FAI) were used to measure the impact of the treatment at baseline and after 4 weeks of the treatment. Patients received three sessions per week for four consecutive weeks. Data analysis included non-parametric test (Wilcoxon signed rank test and Mann Whitney Test) which were applied to analyze the data.

Results: Participants (n=40) were split randomly into two groups with Group 1 (Rocabado’s approach) and Group 2 (Kraus exercises). The mean age and standard deviation of Group 1 was 29.80± 7.88 and for Group 2 was 30.15±7.80. There was a significance difference was seen for NPRS, TMD Index questionnaire and Fonseca Anamnestic Index with p value < 0.05 in both study groups. The inter group comparison showed statistically significance difference for pain measured by NPRS (p= 0.00), disability by TMDI (p=0.01) and severity by FAI (p=0.00).

Conclusion: The study results concluded that both treatment techniques Rocabado’s approach and Kraus exercise were effective and produced significant difference in NPRS, TMDI and FAI to decrease pain, disability level and severity of TMJ dysfunction. However, Rocabado’s approach had shown more significant results in treating pain, disability and severity of TMJ dysfunction as compared to Kraus exercise in patients with temporomandibular dysfunction.

Temporomandibular joint (TMJ) is one of the body's most intricate parts and the joint must be biomechanically sound to perform its desired functions [1]. Temporomandibular joint disorders consist of craniofacial problems that affect the temporomandibular joint (TMJ), muscles of mastication, and other musculoskeletal tissues in the head and neck region [2,3]. TMD is a significant contributor to non-dental symptoms in the orofacial region [4]. Studies have shown that prevalence of TMD rises between the ages 45 to 64 and gradually declines with age [5], whereas some studies showed that frequency was highest in women who are at childbearing age (20-40) [6]. TMD is divided into four categories by the American Academy of Orofacial Pain (AAOP): TMJ disorders, headaches, masticatory problems, and surrounding structures [7]. The clinical symptoms of TMD include locking or limitation in mouth opening, pain or stiffness in the TMJ region, and popping, clicking, or crepitus sounds during jaw motions [8]. Based on chronicity of the problem, chronic TMDs significantly affects women, while acute TMDs are equally common in both genders [9]. Studies have shown that prevalence of TMD rises between the ages 45 to 64 and gradually declines with age, whereas some studies showed that frequency was highest in women who are at childbearing age (20-40) [10,11]. An interdisciplinary strategy incorporating conservative and surgical treatments can be used to treat temporomandibular disorders. Education, self-care, medications, physiotherapy, occlusive splint therapy, behavioral and psychotherapy are examples of conservative treatments [12] Physical therapy, such as TENS, massage, ultrasound, iontophoresis, jaw exercises, TMJ distraction and mobilization along with Behavior therapy, such as biofeedback, relaxation exercises, cognitive behavioral therapy [CBT], habit reversal, might help patients develop behavioral coping mechanisms and alter their perceptions of TMD [13]. This study aims to determine the most effective exercise regimen for individuals with temporomandibular joint dysfunction, using Rocabado's approach and Kraus exercises. By offering a clinical viewpoint on the usefulness of these exercise therapies would help the clinicians to provide evidence-based approach towards the application of intervention.

This randomized clinical trial was carried out at Fatima memorial hospital Physical therapy clinic and Boston Physiotherapy and wellness clinic, Lahore, Pakistan. Ethical approval was sought from research ethical committee of Riphah International University, Lahore campus (Ref. No. REC/RCR &AHS/22/0151) and the data was collected between November 2022 to February 2023. This study was registered at Clinical Trials with identifier no: NCT05618938. Participants were selected through consecutive sampling. Sample size of 40 was calculated by EPITOOL software using TMDI tool values (10) with confidence interval 0.95. The initial sample size was 40, but after accounting for a 10% attrition rate to accommodate dropouts, the final sample size was increased to 44 [14]. Inclusion criteria consisted of both male and female, age range 20 to 60 years with NPRS value < 8> 8 and patients in severe category based on (FAI), Any diagnosis of the underlying medical condition causing the tinnitus in the ear, nose, and throat and pregnancy were excluded from the study [16]. All the participants were randomly allocated through simple random sealed opaque enveloped method into two groups. Informed consent was taken from all the participants. Outcome measures used were the NPRS, the TMDI and the FAI. This was a single blinded study in which assessor was blind.

Group 1 was treated with Rocabado’s approach. Group 2 was treated with Kraus Exercises. Rocabado’s approach consisted of 6 exercises including Tongue at Rest position, Control of TMJ rotation, Rhythmic stabilization technique, Neck Axial extension, Posture of Shoulder joint, Head flexion Stabilization. The participants received Rocabado’s approach consisting of 6 repetitions six times a day thrice per week for four weeks [17]. Group 2 was treated with Kraus exercises with the frequency of 2 sets and 10 repetitions twice a day three times per week for four weeks. Kraus exercises consisted of eight exercises. It included resting position of Tongue, Teeth distant, Nasal-diaphragmatic breathing, Tongue upward and wiggle, Strengthening, Touch and bite, Neuro-muscular control, Isometric exercises [17]. Patients were requested to avoid performing other treatment protocol during study duration. The data was analyzed by using SPSS version 25. Statistical significance was set at p= 0.05. Shapiro wilk test was used to analyze the normality of data. Variable NPRS p-value 0.002 and TMDI Variable have p value 0.009. Both values were lessthan 0.05 which showed that data is not-normally distributed and non-parametric test were applied. For within group analysis Wilcoxon signed rank test was used and for between group analysis Mann Whitney Test was used.

The total number of participants was 40 (Group 1 Rocabado’s approach =20 and Group B Kraus exercise =20). The study included 32.5% males and 67.5percentage females in Table 1.

Table 1: Gender of Group 1 and 2 Participants.

Descriptive data for Age, weight, height, and BMI values for group A and group B shown in Table 2. The mean and standard deviation for Age in group A was 40.23 + 6.33 whereas for group B 38.76 +5.804.

Table 2: Descriptive Statistics of Group 1 and 2 Participants.

Within Group analysis was done by Wilcoxon signed test for pre and post treatment comparison. Within Group 1 analysis for NPRS shows p value 0.00 and for TMDI shows p value 0.00 and FAI Shows p value 0.00 shown in Table 3. Within Group 2 analysis for NPRS shows p value 0.00 and for TMDI shows p value 0.00 shown and FAI Shows p value 0.00 in Table 4.

Table 3: Within Group-1 (Rocabado’s approach) Analysis.

Table 4: Within Group-2 (Kraus exercise) Analysis.

Between Group 1 and 2 analysis was done by Mann Whitney Test. The results showed that there was significant difference in post treatment value between the two groups with p value lessthan 0.05 for NPRS and TMDI and FAI as shown in Table 5.

Table 5: Between Group analysis.

In the current study, Rocabado's approach and Kraus exercise were compared for pain and disability in individuals with Temporomandibular dysfunction with sample size 40. There were significant differences in before treatment and after treatment status in both groups, Group 1 (Rocabado's approach) and Group 2 groups (Kraus exercise). An RCT in 2021 investigated the effects of the ischemic compression technique on pain and functionality in temporomandibular disorders. 50 patients diagnosed with TMDs were randomly assigned into two groups. For four weeks, both groups performed the Rocabado exercise, but only Group 1 additionally received ischemic compression to the masseter muscle over the course of three sessions. The results concluded that exercise alone and exercise combined with ICT have equal effects on ROM, discomfort, the PPT, and functionality in people with temporomandibular disorders [18]. A study conducted in 2022, discussed the effects of ultrasound, TMJ manipulation and exercise on pain and mouth opening in patients with chronic temporomandibular joint disorder. The exercises regimen used in the study was cervical range of motion exercises. The study found that a systematic physiotherapy intervention programme that included non-thermal ultrasound, manipulation, and exercise targeting the TMJ and upper quadrant was effective in improving functions and minimizing signs and symptoms of chronic TMJ dysfunction, which can be extremely incapacitating [19].

In 2021, to compare the effectiveness of various physiotherapy techniques in individuals with TMD, studied exercise therapy; laser therapy and manual pressure release were studied by the authors for the treatment of temporomandibular dysfunction. Rocabado’s and Kraus exercise therapy was utilized in the participants in one group. Although the Rocabado’s and Kraus exercise were not compared in the study independently, but the study's findings demonstrated a significant improvement in pain threshold value for every muscle in each of the three groups. TMJ activity pain, headache, and clicking all significantly improved, according to intragroup comparisons. But it was discovered that these improvements were the same across all groups [20]. In another study in 2015 determined the effectiveness of Rocabado’s exercises in patients with temporomandibular dysfunction and subsequent pain and decreased range of motion (ROM) with limitation in jaw movements. After a pre and post group comparative analysis, which was measured after two weeks using VAS for pain, Fonseca’s questionnaire for TMD and general TMJ ROM, the study results showed a significant difference [21].

A 2007 randomized clinical trial examined the effectiveness of adding Rocabado exercises to self-care for masticatory myofascial pain. The study found significant improvements in jaw and neck pain for both groups, but no changes in head posture, possibly due to the short treatment duration (four weeks). The results concluded that combining Rocabado’s exercises with self-care was as effective as self-care alone. Our study similarly showed improvements in pain, disability, and temporomandibular joint dysfunction, with Rocabado exercises demonstrating significant difference [22]. The above-mentioned studies support current study for reducing pain and disability by Rocabado’s approach and Kraus exercise. This research provides useful insight for management of temporomandibular dysfunction patients.

Limitations of Study

The participants’ choice of food they preferred before and after treatment was not taken into consideration and that might have an impact on pain, disability and quality of life. Some participants used night guard to prevent teeth grinding and to avoid psychological distress recommended by dentists.

Recommendations

TMJ should be an integral part of curriculum at undergraduate and postgraduate level for rehabilitation programs across the world and the importance of Rocabado’s approach and Kraus exercises in TMJ rehabilitation must be emphasized in clinical training. Both Rocabado’s approach and Kraus exercises are advised to be used by clinicians for wider application on patients seeking rehabilitation for TMJ pathologies. For future researchers there is a profound opportunity to develop more exercise therapy interventions as a progression of Rocabado's and Kraus protocols alongside manual and other conventional physical therapy interventions.

This study concluded that both treatment groups i.e., Rocabado’s approach and Kraus exercises were effective in reducing pain, disability and severity among temporomandibular dysfunction patients. However, Rocabado’s approach was more effective in comparison to Kraus exercises.

Conflict of Interest

None.