The Effects of Pilates Exercises on Women With Myogenic Temporomandibular Joint Dysfunction: A Randomised Controlled, Single-Blind Study

Pressure-pain threshold will be measured using a digital algometer (Commander Algometer, J-Tech Medical Industries, Salt Lake City, USA). Assessments will be performed bilaterally on the masseter muscles to evaluate regional pain sensitivity. After a practice trial, pressure will be applied with a 1 cm² probe at a rate of 1 kg/cm² per second until participants indicate the onset of pain, and the average of three trials taken 30 seconds apart will be recorded in kg/cm².

Pressure-pain threshold will be measured using a digital algometer (Commander Algometer, J-Tech Medical Industries, Salt Lake City, USA). Assessments will be performed bilaterally on the uper trapezius muscles to evaluate regional pain sensitivity. After a practice trial, pressure will be applied with a 1 cm² probe at a rate of 1 kg/cm² per second until participants indicate the onset of pain, and the average of three trials taken 30 seconds apart will be recorded in kg/cm².

Pressure-pain threshold will be measured using a digital algometer (Commander Algometer, J-Tech Medical Industries, Salt Lake City, USA). Assessments will be performed bilaterally on the masseter muscles to evaluate regional pain sensitivity. After a practice trial, pressure will be applied with a 1 cm² probe at a rate of 1 kg/cm² per second until participants indicate the onset of pain, and the average of three trials taken 30 seconds apart will be recorded in kg/cm².

The TheraBite® Range of Motion Scale (TheraBite®, Platon Medical Ltd., UK) will be used to assess temporomandibular joint (TMJ) range of motion. TheraBite is widely used in both research and clinical practice and is considered a standard, highly reliable tool for measuring jaw mobility. Participants, seated in an upright position, will be asked to open their mouths as wide as possible, and measurements will be recorded in millimeters. Each assessment will be repeated three times, and the average value will be used for analysis.

Cranio-cervical posture will be assessed using cranio-cervical angle measurement through a photogrammetric method. Reference points, including the spinous process of the seventh cervical vertebra and the tragus of the ear, will be marked before photographing. Participants will perform repeated neck flexion and extension movements to achieve a neutral head position, then be photographed from the left side at a distance of 1.5 meters with a tripod-mounted smartphone camera. The cranio-cervical angle will be calculated using ImageJ software by measuring the angle between the horizontal line and a line connecting the C7 spinous process and the ear tragus.

Quality of life will be assessed using the Short Form-36 (SF-36) questionnaire, which evaluates overall health status. It is simple, easy to administer, and suitable for different populations. Scores range from 0 to 100, with higher scores indicating better quality of life.

Pain in the temporomandibular joint will be evaluated using the Graded Chronic Pain Scale (GCPS). The scale classifies participants into four levels based on combined pain and disability scores, ranging from mild pain with minimal disability to severe pain with high disability.

To assess jaw limitations Jaw Functional Limitation Scale-8 (JFLS-8) will be used.The JFLS-8 includes 8 items that measure difficulty in jaw-related functions, rated on a scale from 0 ("No Limitation") to 10 ("Severe Limitation"). Higher scores indicate greater dysfunction and limitation.

Depression levels of participants will be assessed using the Patient Health Questionnaire-4 (PHQ-4). The questionnaire consists of four items, and total scores range from 0 to 12. Higher scores indicate greater levels of depression.

Stiffness [N/m], is a biomechanical property of a muscle, provides information about the resistance of the tissue to an external force or contraction. stiffness will be measured using a myotonometer (MyotonPRO, Myoton AS, Tallinn, Estonia), which has been reported to be valid and reliable. Assessments will be conducted in study, masseter, upper trapezius, tibialis anterior muscles.The measurement will be repeated 3 times and the arithmetic mean of the measurements will be recorded.

Logarithmic decrease (D) gives information about the elasticity of the evaluated tissue. Logarithmic decrease will be measured using a myotonometer (MyotonPRO, Myoton AS, Tallinn, Estonia), which has been reported to be valid and reliable.Assessments will be conducted in study, masseter, upper trapezius, tibialis anterior muscles.The measurement will be repeated 3 times and the arithmetic mean of the measurements will be recorded.

The stress and anxiety levels of participants evaluated in the study will also be assessed by measuring salivary cortisol levels. In this study, blue-capped SARSTEDT Salivette tubes, specifically designed for cortisol collection, will be used for sample collection and storage. These tubes ensure high analytical performance even with small sample volumes. Participants will be asked to chew the special swab inside the blue-capped tube, made of Polypropylene (PP)/Low Density Polyethylene (LD-PE), for two minutes to stimulate saliva production, after which the swab containing absorbed saliva will be placed back into the collection tube. Salivary cortisol levels will be analyzed from the collected samples using the ECLIA method.

Pain intensity at the cervical region will be assessed using the Visual Analog Scale (VAS), where participants will mark their pain level on a 100 mm horizontal line, and scores will be recorded in millimeters.

Anxiety levels of participants will be assessed using the Patient Health Questionnaire-4 (PHQ-4). The questionnaire consists of four items, and total scores range from 0 to 12. Higher scores indicate greater levels of anxiety.

TMJ dysfunction severity will be assessed with Fonseca Anamnestic Index (FAI). The FAI consists of 10 questions with "yes," "no," and "sometimes" answer options, scored as 10, 0, and 5 points respectively, to determine the severity of temporomandibular disorder symptoms. Higher scores indicate greater TMJ dysfunction severity.