Postural Habits & Awareness in Individuals With Temporomandibular Joint Disorders and Its Relationship to Musculoskeletal Parameters

Postural Habits & Awareness in Individuals With Temporomandibular Joint Disorders and Its Relationship to Musculoskeletal Parameters | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Postural Habits & Awareness in Individuals With Temporomandibular Joint Disorders and Its Relationship to Musculoskeletal Parameters Zeynep Damar, Şeyma Alla, Bahar Özgül This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7851947/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Although the pain, functionality, proprioception in temporomandibular disorders (TMD) have been frequently investigated, there has been limited knowledge on postural habits & awareness and relation to musculoskeletal parameters. It was aimed to explore the postural habits and awareness level and to investigate the relationship to various musculoskeletal parameters in individuals with TMD. Methods Fifty subjects with TMD and fifty controls were included. Postural habits & awareness levels were assessed using the Postural Habits and Awareness Scale (PHAS). The pain level and pain pressure threshold were assessed by the Numeric Rating Scale (NRS) and an algometer; functionality was assessed using the Helkimo Clinical Dysfunction Index (HCDI) and the Mandibular Function Impairment Questionnaire (MFIQ). Cervical muscle endurance was performed using flexor and extensor endurance tests, while position sense was tested using the Laser Pointer Assisted Angle Reproduction Test (LP-ART). Results PHAS score were significantly lower in the TMD group (p < 0.001). Within the TMD group, a moderate positive correlation was found between PHAS score and activity-related pain level (0.429). Low-moderate level of negative correlations was observed between the scores of PHAS and the HCDI (-0.337), MFIQ (-0.445 & -0.496). and LP-ART in cervical extension (-0.326) & lateral flexion (-0.406, -0.365). Conclusion Low level of postural habits & awareness and its relationship with pain level, jaw functionality and cervical proprioception were observed in individuals with TMD. Current findings highlight the importance of considering postural awareness along with local symptoms in TMD by the clinicians working with this population. Temporomandibular Joint Disorders Posture Awareness Musculoskeletal System Figures Figure 1 Figure 2 Figure 3 1. INTRODUCTION Temporomandibular disorders (TMD) are defined as a group of musculoskeletal and neuromuscular conditions involving the masticatory muscles, the temporomandibular joint (TMJ), or associated structures [1]. TMD, affecting approximately 34% of the general population, includes a variety of diseases and disorders that impact the structure, function, and physiology of the masticatory system [2]. In addition to contributing to other chronic pain conditions such as migraine and fibromyalgia, functional limitations caused by TMD are frequently associated with neck and back pain, as well as comorbidities in different body regions [3]. Although the theory of a pathophysiological relationship between temporomandibular and cervical disorders has been investigated [4], there is still no definitive consensus on the nature of this relationship in the context of TMD. While the studies have attempted to confirm a connection between temporomandibular and cervical disorders based on parameters such as head and neck posture, cervical spine mobility, and muscle tenderness [5,6], other studies have emphasised the need for further research [7,8]. Disrupted neuromuscular control of the cervical spine may provoke pain-sensitive structures in the neck, potentially leading to increased pain in both cervical and orofacial areas. Individuals with TMD may experience neck pain, restricted range of motion, and functional and behavioural changes [9]. Postural changes in head position and the cervical spine may lead to excessive loading on the TMJ, contributing to the development of TMD [10,11]. Although structures associated with proprioception sense are often affected in individuals with TMD, including the TMJ disc, retrodiscal tissue, and joint capsule, research on proprioception in this population are still limited [12]. Postural awareness is closely related to the proprioceptive system. It refers to the subjective and conscious perception of posture, which is formed through proprioceptive feedback from the body to the central nervous system [13]. Several studies in the literature have shown that patients with back and neck pain tend to have impaired proprioceptive sense [14,15], suggesting that those individuals may also have lower levels of postural awareness [13]. Improving habitual postural patterns is thought to contribute to recovery in musculoskeletal pain conditions or prevent further deterioration [16,17]. However, altering habitual postural patterns necessitates a certain level of postural awareness. In this regard, postural awareness serves as a key prerequisite for developing and sustaining healthy posture and movement behaviours in daily life [13]. Although there are studies evaluating musculoskeletal problems related to postural habits and awareness in school-aged children or adolescents [18,19], no studies have been found that investigate postural habits and awareness levels or the relationship between these awareness level and other musculoskeletal parameters in individuals with TMD. In this context, the primary aim of the present study is to compare postural habits and awareness levels between individuals with and without TMD. The secondary objective of the study is to investigate the relationship between postural habits and awareness, as well as parameters such as pain level, TMJ functionality, cervical muscle endurance, and proprioception sense, in individuals with TMD. 2. METHODS The study was conducted between October 2024 and January 2025 at Oral, Maxillofacial and Dental Health Clinic of XXXXXX Hospital, located in the XXXXX district of XXXXX city. The study protocol was approved by the Clinical Research Ethics Committee of XXXXXXX University Faculty of Medicine (XXXXXX). Before proceeding with the test procedure, the subjects were informed about the research, and their written and verbal consent was obtained. A total of 100 participants were included in the study: 50 subjects aged between 20 and 60 who had been diagnosed with TMD by the dentist and met the inclusion criteria, and 50 controls who had not been previously diagnosed with TMD and met the inclusion criteria. The clinical evaluation of the presence and type of TMDs were performed according to the Diagnostic Criteria for TMDs (DC/TMD) by a maxilla facial surgeon with 12 years of professional experience and individuals with only myogenic TMDs were included. The inclusion criteria for the TMD group were; experiencing pain in the jaw, facial, or temporal region for at least 3 months, reporting a pain intensity of at least 3 on the Numeric Rating Scale (NRS), and currently undergoing treatment but not receiving medical therapy. The exclusion criteria included for both groups: undergoing orthodontic or splint therapy; having symptoms of orofacial diseases (e.g., neuralgia, migraine); presence of disc displacement; previous botulinum toxin intervention around the TMJ; regular use of analgesics or anti-inflammatory drugs; history of TMJ or cervical surgery or trauma (e.g., whiplash injury, condylar trauma, fracture); history of facial paralysis; history of alcohol or drug addiction; uncooperative behaviour; diagnosed psychiatric disorders; being pregnant or breastfeeding; systemic pathological conditions such as rheumatoid diseases; or other musculoskeletal problems affecting the cervical region, such as impingement or thoracic outlet syndrome. The demographic characteristics, the information of medical and family history, educational background, occupation, medication use, and any chronic or psychological conditions of subjects were recorded. A comprehensive explanation of the study protocol was provided to all subjects, and they were asked to sign the “Informed Consent Form”. 2.1 Data Collection The postural habits and awareness levels of subjects were assessed using the Postural Habits and Awareness Scale (PHAS). To evaluate musculoskeletal parameters, the Numeric Rating Scale (NRS) and pressure pain threshold measurement with an algometer were used to assess pain intensity. The Helkimo Clinical Dysfunction Index (HCDI) and the Mandibular Function Impairment Questionnaire (MFIQ) were used to assess functional status. Cervical muscle endurance was evaluated using neck flexor and extensor endurance tests, while proprioception was assessed using the Laser Pointer-Assisted Angle Reproduction Test (LP-ART). Postural Habits and Awareness Individuals' posture habits adopted in daily life and their awareness of these postures were assessed using the PHAS. The scale, developed in Turkish, was administered to native Turkish speakers. It comprises 7 items focusing on postural habits and 12 items assessing postural awareness, all rated on a 5-point Likert scale (English translation of the items is included in the appendix). The scale includes 7 items that are reverse-scored. Total scores range from 0 to 95, with higher scores reflecting better postural habits and greater postural awareness. The scale recently was developed in 2023 by Bayar et al., and its validity and reliability have been established (internal consistency coefficient > 0.85, p < 0.05) [20]. Pain The NRS is a widely used, valid, and reliable tool that was utilised to assess pain intensity as reported by the subjects [21]. The NRS is a linear scale ranging from 0 to 10, where 0 indicates “no pain” and 10 represents “the worst pain imaginable.” Participants were asked to indicate or verbalise the number that best reflected the intensity of their perceived pain. The pain intensity related to the TMJ region was assessed by NRS at rest, during activity, and throughout the night. Pressure algometer was designed to measure deep pressure pain thresholds or tolerance to sensitivity. A mechanical algometer device (Baseline brand Dolorimeter, 22LB/10 kg) was used to assess pain threshold and tolerance of subjects. The device features a rubber disk with a surface area of 1 cm², which is pressed against a specific body region to display the applied pressure. The pressure pain threshold measurement was taken over the masseter, temporalis, trapezius, and sternocleidomastoid muscles, the lateral and dorsal regions of the temporomandibular capsule [22]. Functional Assessment The HCDI, developed by Helkimo in 1974, is a test designed to quickly and simply assess limitations in mandibular movement, pain, and joint function. The HCDI is not a self-report scale; rather, it is administered by clinicians. It has been shown to have a sensitivity of 86.67% and specificity of 68.09% in predicting the presence of TMD [23]. The MFIQ was developed by Stegenga et al. in 1993 to evaluate mandibular functional impairments in patients with TMD [24]. It consists of 17 items divided into 2 subscales. Each item is rated on a 5-point scale from 0 to 4 (0 = no difficulty; 1 = slight difficulty; 2 = some difficulty; 3 = severe difficulty; 4 = very difficult or impossible without assistance). Total scores range from 0 to 68. The first 11 items represent the “Functional Capacity” subscale, while the last 6 items comprise the “Feeding” subscale. Higher total scores indicate greater mandibular dysfunction, while lower scores indicate reduced impairment. A new Turkish version of the questionnaire was developed by Yıldız et al., demonstrating strong internal consistency (Cronbach’s alpha = 0.916) [25]. Muscle Endurance The neck flexor endurance test was performed as the subject lies in a hook-lying position with their hands resting on the abdomen. While maintaining maximum chin tuck, they are asked to lift their head 2.5 cm off the surface and hold the position for as long as possible. The duration (in seconds) is recorded, and the test is terminated when the participant experiences pain or can no longer maintain the position [26]. The neck extensor endurance test was performed as the subject lies prone with their head and neck unsupported beyond the edge of the examination table and arms positioned along the sides of the body. They are asked to maintain this position for as long as possible. The endurance time is measured with a stopwatch and recorded in seconds. The test is ended if pain occurs or the position is lost [27]. Proprioception Cervical proprioception test is typically evaluated using head repositioning tests, which are considered valid and reliable method. The test protocol of LP-ART defined by Revel et al. was performed to assess neck proprioception sense [28]. 2.2 Statistical Analysis All evaluation data were analysed using IBM SPSS Statistics 26 (SPSS Inc., Chicago, IL, USA). The normality of the data distribution was assessed using the Kolmogorov-Smirnov test and other parametric test assumptions. The Independent Samples t-test was conducted to compare postural habits and awareness levels of subjects with and without TMD. The relationship between postural habits and awareness and variables such as values of HCDI, MFIQ-1, muscle endurance tests, and LP-ART was researched by using Spearman correlation analysis. The relationship between postural habits and awareness and the CVA and MFIQ-2 was assessed using Pearson correlation analysis. The power of research data was calculated using the G*Power software (version 3.1, Universität Düsseldorf, Düsseldorf, Germany), and the post-hoc power analysis revealed a power of 1-β = 0.99, α = 0.05, and an effect size of 1.043 [29]. 3. RESULTS A total of 100 individuals participated in the study, comprising 50 subjects with TMD (mean age: 34.52 ± 12.61) and 50 healthy controls (mean age: 38.00 ± 10.92). There was no statistically significant difference in age between the groups (Z =-1.886, p = .059). The gender distribution in the TMD group was 29 females and 21 males, while in the control group it was 26 females and 24 males, with no significant difference in gender between the groups (p= 0.54). When the postural habits and awareness levels of the groups were compared, the TMD group had significantly lower levels of postural habits and awareness (59.42 ± 6.71) compared to the control group (66.90 ± 6.78) (t =-5.541, p <.001). In the TMD group, the relationship between postural habits and awareness levels and selected musculoskeletal parameters was examined. A moderate, statistically significant negative correlation was found between postural habits and awareness levels and NRS scores during activity (r =-0.429, p = .002). This indicates that individuals in the TMD group who had lower postural habits and awareness experienced higher pain during activity. No significant correlation was found between postural habits and awareness levels, and NRS scores during rest or throughout the night (r = -0.210, p = .143; and r = -0.258, p = .070, respectively). No significant relationship was found between postural habits and awareness levels and pressure pain thresholds measured over the right and left temporalis, trapezius, sternocleidomastoid muscles, and the lateral and dorsal capsule (Table 1, p> .05). In terms of TMJ functionality, a significant correlation was found between postural habits and awareness level and the HCDI score (r =-0.337, p = 0.017) (Fig 1). This indicates higher functional capacity in the jaw as the postural habits and awareness score increase, in the individuals with TMD. Additionally, a moderate negative correlation was observed between postural habits and awareness level and MFIQ-1 (8.78 ± 5.66) and MFIQ-2 (6.96 ± 4.10) scores in relation to TMJ functionality (r =-0.445, p = 0.001; r =-0.496, p = 0.001, respectively) in the TMD group (Fig 2-3). This finding suggests that individuals who have higher postural habits and awareness, has higher TMJ functional performance. In the TMD group, no significant correlation was found between postural habits and awareness level, and neck flexor and extensor muscle endurance (r = 0.012, p = 0.933; and r = -0.115, p = 0.425). The relationship between postural habits and awareness level, and cervical proprioception was examined in the TMD group using the Laser Pointer-Assisted Angle Reproduction Test (LP-ART). Negative correlations were found between PHAS total score and LP-ART parameters in the selected neck movements. A weak negative correlation in extension (r =-0.326), a moderate negative correlation in right lateral flexion (r =-0.406), and weak negative correlations in left lateral flexion (r =-0.365) and right rotation (r =-0.294) (Table 2). No significant correlation was observed in flexion and left rotation movements (p> .05). As the level of postural habits and awareness decreases, proprioception is getting weaker in various directions in the subjects with TMD. 4. DISCUSSION In the present study, postural habits and awareness were primarily investigated comparatively individuals with and without TMD and it has shown that individuals with TMD had lower levels of postural habits and awareness than controls. Secondarily, it was aimed to research the relationship between the level of postural habits and awareness and various parameters such as pain intensity, TMJ functionality, cervical muscle endurance, and proprioception in individuals with TMD. According to the findings, individuals with TMD who had higher levels of postural habits and awareness demonstrated better TMJ functionality, improved proprioception sense, and lower pain intensity during activity. Although there have been studies on the musculoskeletal system that examine the level of postural habits and postural awareness [18,19,30,31], no previous research has been found that investigates these parameters explicitly in individuals with TMD. Thus, the outputs obtained in this study fill a gap in the literature as it is the first study explored postural habits and awareness in individuals with TMD, and it was observed that they had lower level of postural habits and awareness compared to the controls. People experiencing jaw and neck pain may experience changes in neck posture or jaw position to alleviate discomfort. From another perspective, it is suggested that a misaligned craniocervical posture may contribute to the development of TMD [32]. Such postural changes can disrupt the neutral alignment of the head and negatively affect proprioceptive input and postural stability [33,34]. The individuals with lower proprioception sense exhibited lower postural habits and awareness in the level of weak-moderate correlation in the current study. Misperceiving a faulty posture as correct may lead to inappropriate motor responses and alterations in muscle activity [35]. Therefore, it is essential to examine postural habits and awareness in detail and monitor them over the long term in individuals with TMD, in addition to other musculoskeletal parameters. The body awareness, which is also related with postural awareness, is considered directly associated with musculoskeletal pain and emotional state [36]. Supporting that, it was observed that individuals who experienced higher pain levels during activity also had lower postural awareness and habits in the present study. Habitual teeth clenching is considered one of the major contributing factors to TMD [32]. Such habitual postural patterns exhibited by individuals in the TMD group during activity may have also showed lower postural habit and awareness scores. One possible explanation of higher level of pain during activity in the individuals with lower postural awareness would be that pain may occur when individuals revert to a habitual poor postural pattern during activity or periods of concentration. It has been suggested that painful TMD can influence postural control through the jaw sensorimotor system [34]. Considering current results and literature, increasing postural awareness by receiving postural training may have direct or indirect positive impact on musculoskeletal pain and emotional conditions according to TMD [37]. Another parameter examined in individuals with TMD is cervical proprioception sense has been to be negatively affected [38]. However, to date, no previous study has directly investigated the relationship between postural habits and awareness level and proprioception sense in TMD group. In the present study, individuals with TMD who exhibited poorer joint position sense had lower levels of postural habits and awareness. In individuals with chronic neck pain or fibromyalgia syndrome, decreased proprioception sense has been reported to negatively affect neck functionality, postural control, and quality of life [39]. Although its role has not been conclusively demonstrated, the stomatognathic system is considered to contribute to postural control [40]. Proprioceptive signals from the stomatognathic system are believed to interact with vestibular and oculomotor inputs, and changes in trigeminal stimulation could result in dysfunction within these systems [41]. In TMD, reduced proprioceptive feedback and low postural awareness levels may be explained by the involvement of the stomatognathic system. In addition, it have been suggested that modifications in mandibular position, which can alter proprioceptive and periodontal afferents, may also influence postural mechanisms [42]. Considering that TMD may alter neuromuscular control and lead to abnormal afferent input, TMJ functions may be affected because of the strong functional connection between the cervical spine and the masticatory system during activities such as swallowing, chewing, and cervical movements [43,44]. It was observed that individuals with higher postural habits and awareness levels had better TMJ functionality. This finding is consistent with the results of Miçooğulları et al., who reported impaired postural stability and mandibular function in individuals with TMD [45]. Lower level of postural habit and awareness may be one of the risk factors of occurring poor TMJ functionality. We suggest of consideration that feature beside other risk factors of TMD by clinicians. As mentioned above, postural awareness training may also have positive effects on TMJ functionality. The jaw and neck pain can lead to muscle imbalances, affecting proprioception and impairments in dynamic postural stability [33]. Many studies have demonstrated reduced endurance of cervical flexor and extensor muscles in individuals with TMD [9,46]. Considering the literature, there have also been other research examining muscle endurance in chronic neck pain, postural disorders and phone addiction levels [47-49]. In individuals with chronic neck pain, a low to moderate correlation was found between chronic neck pain intensity and cervical muscle endurance [47]. In case of smartphone addiction, increasing smartphone addiction level was found to be associated with reduced cervical extensor muscle endurance [48,49]. Although the relationship between muscle endurance and various parameters in different subjects and TMD has been investigated, the relationship between postural habits & awareness and cervical flexor & extensor muscle endurance investigated in the current study from a different perspective. Although deficiencies in muscle endurance have been previously identified in the presence of TMD or cervical postural disorders and pain [47,50,44], cervical flexor and extensor muscle endurance was not observed to be associated with poor postural awareness in the current study. 5. CONCLUSION As a summary, the results of our study revealed that individuals with TMD had lower levels of postural habits and awareness compared to individuals without TMD. This finding suggests that TMD may influence not only craniocervical function and symptoms but also habitual behaviours and general postural awareness in daily life. Considering the observed lower pain during activity, higher proprioception sense and TMJ functionality in individuals with higher postural habits and awareness, implementing postural training and awareness-enhancing interventions in individuals with TMD may have a beneficial effect in the therapy sessions. The findings also underscore the importance of addressing not only local symptoms but also postural habits in the assessment and rehabilitation of TMD. Improving posture-related habits and enhancing postural awareness may help prevent the development of TMD or support the rehabilitation process by reducing existing symptoms. Declarations Competing Interests: The authors report there are no competing interests to declare. Funding: None Human Ethics and Consent to Participate: The study protocol was approved by the Clinical Research Ethics Committee of XXXXXXX University Faculty of Medicine (XX.XXXX.XX). Consent, Data, Materials and/or Code Availability: The consent of participants was obtained and documented prior to data collection. The data that support the findings of this study are not openly available due to reasons of sensitivity. (This manuscript does not report data generation or analysis.) Authors’ Contribution Statements: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [XXXXXX XXXXXX]. Data collection was performed with [XXXXX XXXXX]. The first draft of the manuscript was written by [XXXXX XXXXX], [XXXXX XXXXX] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgments: The authors would like to thank all volunteers who participated in the testing protocol of the research. 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J Phys therapy Sci 28(12):3468–3472 Wieckiewicz W, Wozniak K, Piatkowska D, Szyszka-Sommerfeld L, Lipski M (2015) The diagnostic value of pressure algometry for temporomandibular disorders. Biomed Res Int 2015:575038 Yildiz NT, Alkan A, Kulunkoglu BA (2024) Validity and Reliability of the Turkish Version of Mandibular Function Impairment Questionnaire. Cranio 42(2):160–170 Yuzbasioglu U, Kaynak BA, Tas S (2025) Assessment of Cervical Joint Position Sense and Head Posture in Individuals With Myogenic Temporomandibular Dysfunctions and Identifying Related Factors: A Case-Control Study. J Oral Rehabil 52(2):160–168 Zafar H, Alghadir AH, Iqbal ZA (2017) Effect of different head-neck-jaw postures on cervicocephalic kinesthetic sense. J Musculoskelet Neuronal Interact 17(4):341–346 Tables Table 1 Correlation between Parameters of Postural Habits and Awareness, and Pressure Pain Threshold Temporalis Trapezius SCM Right Left Right Left Right Left r .002 .033 − .111 − .027 − .079 .087 p .989 .820 .442 .853 .586 .550 Lateral Capsule Dorsal Capsule Right Left Right Left r − .033 .158 .266 .241 p .820 .272 .062 .092 Spearman Correlation Analysis, SCM: Sternocleidomastoid Table 2 Correlation between Postural Habits and Awareness, and Cervical Proprioception Sense Postural Habits and Awareness Scale Score Flexion r − .261 p .067 Extension r − .326* p .021 Right Lateral Flexion r − .406* p .003 Left Lateral Flexion r − .365* p .009 Right Rotation r − .294* p .038 Left Rotation r − .258 p .071 r: Spearman Correlation, *p < 0.05 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7851947","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":530492397,"identity":"e747aa75-66e5-48d4-b35f-f2cc402e780d","order_by":0,"name":"Zeynep Damar","email":"","orcid":"","institution":"Marmara University","correspondingAuthor":false,"prefix":"","firstName":"Zeynep","middleName":"","lastName":"Damar","suffix":""},{"id":530492398,"identity":"6e4b3f86-6460-4c8b-8995-9a819b1606a2","order_by":1,"name":"Şeyma Alla","email":"","orcid":"","institution":"Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Şeyma","middleName":"","lastName":"Alla","suffix":""},{"id":530492399,"identity":"ec249599-0794-4e4e-8e2a-1834716250db","order_by":2,"name":"Bahar Özgül","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYBAC9gYGNgbGBijvQQWQYGZuwK0eCHgOMCNpSTgD0gLnEqMlsQ1EEtLCf/7Yg5877PL5+Y9fk0icVxvN3w7U8qNiG24tDIfZDXvPJFvObDhTJpG47XjujMOMDYw9Z27j1GLP2MwmwdvGbGBwsCcNqOVYbgNQCzNjG24tPMzMbJJ/2+oNDA7zALXMOZY7n6AWNmY2ad62wwYGx9iPSSQ21ORuIKiFh9ncWLbtuIFkDw+zRcKxA7kbgVoO4vMLD//BZw/ftlUbAEPs4Y0PNXW5884fPvjgRwVuLci6DYDEYTDzADHqgYD9AZCoI1LxKBgFo2AUjCQAAKRCWLRdJkUIAAAAAElFTkSuQmCC","orcid":"","institution":"Marmara University","correspondingAuthor":true,"prefix":"","firstName":"Bahar","middleName":"","lastName":"Özgül","suffix":""}],"badges":[],"createdAt":"2025-10-13 19:23:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7851947/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7851947/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95221349,"identity":"bf9657e4-7da3-4758-ac76-a5417ad1e053","added_by":"auto","created_at":"2025-11-05 16:18:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49973,"visible":true,"origin":"","legend":"\u003cp\u003eThe correlation analysis between the PHAS and the HCDI scores\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePHAS: Postural Habits and Awareness Scale, HCDI: Helkimo Clinical Dysfunction Index.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7851947/v1/0e92efb2a116e41f2235d303.png"},{"id":95027032,"identity":"ac803711-422b-4f81-8e3f-f1aa2cbb02cc","added_by":"auto","created_at":"2025-11-03 13:37:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":52867,"visible":true,"origin":"","legend":"\u003cp\u003eThe correlation analysis between the PHAS and the MFIQ-1 scores\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePHAS: Postural Habits and Awareness Scale, MFIQ-1: Mandibular Function Impairment Questionnaire-1.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7851947/v1/fcb0c3317f1438eeee551849.png"},{"id":95027030,"identity":"0a24232a-d574-4281-bb04-5bb74f53a423","added_by":"auto","created_at":"2025-11-03 13:37:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":53025,"visible":true,"origin":"","legend":"\u003cp\u003eThe correlation analysis between the PHAS and the MFIQ-2 scores\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePHAS: Postural Habits and Awareness Scale, MFIQ-2: Mandibular Function Impairment Questionnaire-2.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7851947/v1/a0ed4807c26da26e34bd38cb.png"},{"id":95828862,"identity":"9386403c-6335-4aec-919e-3da41f719e3a","added_by":"auto","created_at":"2025-11-13 11:53:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":717812,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7851947/v1/639146d7-07d7-4da9-b869-d4bf9d226f9f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePostural Habits \u0026amp; Awareness in Individuals With Temporomandibular Joint Disorders and Its Relationship to Musculoskeletal Parameters\u003c/p\u003e","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eTemporomandibular disorders (TMD) are defined as a group of musculoskeletal and neuromuscular conditions involving the masticatory muscles, the temporomandibular joint (TMJ), or associated structures [1]. TMD, affecting approximately 34% of the general population, includes a variety of diseases and disorders that impact the structure, function, and physiology of the masticatory system [2]. In addition to contributing to other chronic pain conditions such as migraine and fibromyalgia, functional limitations caused by TMD are frequently associated with neck and back pain, as well as comorbidities in different body regions [3].\u003c/p\u003e\n\u003cp\u003eAlthough the theory of a pathophysiological relationship between temporomandibular and cervical disorders has been investigated [4], there is still no definitive consensus on the nature of this relationship in the context of TMD. While the studies have attempted to confirm a connection between temporomandibular and cervical disorders based on parameters such as head and neck posture, cervical spine mobility, and muscle tenderness [5,6], other studies have emphasised the need for further research [7,8].\u003c/p\u003e\n\u003cp\u003eDisrupted neuromuscular control of the cervical spine may provoke pain-sensitive structures in the neck, potentially leading to increased pain in both cervical and orofacial areas. Individuals with TMD may experience neck pain, restricted range of motion, and functional and behavioural changes [9]. Postural changes in head position and the cervical spine may lead to excessive loading on the TMJ, contributing to the development of TMD [10,11]. Although structures associated with proprioception sense are often affected in individuals with TMD, including the TMJ disc, retrodiscal tissue, and joint capsule, research on proprioception in this population are still limited [12].\u003c/p\u003e\n\u003cp\u003ePostural awareness is closely related to the proprioceptive system. It refers to the subjective and conscious perception of posture, which is formed through proprioceptive feedback from the body to the central nervous system [13]. Several studies in the literature have shown that patients with back and neck pain tend to have impaired proprioceptive sense [14,15], suggesting that those individuals may also have lower levels of postural awareness [13]. Improving habitual postural patterns is thought to contribute to recovery in musculoskeletal pain conditions or prevent further deterioration [16,17]. However, altering habitual postural patterns necessitates a certain level of postural awareness. In this regard, postural awareness serves as a key prerequisite for developing and sustaining healthy posture and movement behaviours in daily life [13].\u003c/p\u003e\n\u003cp\u003eAlthough there are studies evaluating musculoskeletal problems related to postural habits and awareness in school-aged children or adolescents [18,19], no studies have been found that investigate postural habits and awareness levels or the relationship between these awareness level and other musculoskeletal parameters in individuals with TMD. In this context, the primary aim of the present study is to compare postural habits and awareness levels between individuals with and without TMD. The secondary objective of the study is to investigate the relationship between postural habits and awareness, as well as parameters such as pain level, TMJ functionality, cervical muscle endurance, and proprioception sense, in individuals with TMD.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cp\u003eThe study was conducted between October 2024 and January 2025 at Oral, Maxillofacial and Dental Health Clinic of XXXXXX Hospital, located in the XXXXX district of XXXXX city. The study protocol was approved by the Clinical Research Ethics Committee of XXXXXXX University Faculty of Medicine (XXXXXX). Before proceeding with the test procedure, the subjects were informed about the research, and their written and verbal consent was obtained.\u003c/p\u003e\n\u003cp\u003eA total of 100 participants were included in the study: 50 subjects aged between 20 and 60 who had been diagnosed with TMD by the dentist and met the inclusion criteria, and 50 controls who had not been previously diagnosed with TMD and met the inclusion criteria. The clinical evaluation of the presence and type of TMDs were performed according to the Diagnostic Criteria for TMDs (DC/TMD) by a maxilla facial surgeon with 12 years of professional experience and individuals with only myogenic TMDs were included. The inclusion criteria for the TMD group were; experiencing pain in the jaw, facial, or temporal region for at least 3 months, reporting a pain intensity of at least 3 on the Numeric Rating Scale (NRS), and currently undergoing treatment but not receiving medical therapy. The exclusion criteria included for both groups: undergoing orthodontic or splint therapy; having symptoms of orofacial diseases (e.g., neuralgia, migraine); presence of disc displacement; previous botulinum toxin intervention around the \u0026nbsp;TMJ; regular use of analgesics or anti-inflammatory drugs; history of \u0026nbsp;TMJ or cervical surgery or trauma (e.g., whiplash injury, condylar trauma, fracture); history of facial paralysis; history of alcohol or drug addiction; uncooperative behaviour; diagnosed psychiatric disorders; being pregnant or breastfeeding; systemic pathological conditions such as rheumatoid diseases; or other musculoskeletal problems affecting the cervical region, such as impingement or thoracic outlet syndrome.\u003c/p\u003e\n\u003cp\u003eThe demographic characteristics, the information of medical and family history, educational background, occupation, medication use, and any chronic or psychological conditions of subjects were recorded. A comprehensive explanation of the study protocol was provided to all subjects, and they were asked to sign the \u0026ldquo;Informed Consent Form\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1 Data Collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe postural habits and awareness levels of subjects were assessed using the Postural Habits and Awareness Scale (PHAS). To evaluate musculoskeletal parameters, the Numeric Rating Scale (NRS) and pressure pain threshold measurement with an algometer were used to assess pain intensity. The Helkimo Clinical Dysfunction Index (HCDI) and the Mandibular Function Impairment Questionnaire (MFIQ) were used to assess functional status. Cervical muscle endurance was evaluated using neck flexor and extensor endurance tests, while proprioception was assessed using the Laser Pointer-Assisted Angle Reproduction Test (LP-ART).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePostural Habits and Awareness\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividuals\u0026apos; posture habits adopted in daily life and their awareness of these postures were assessed using the PHAS. The scale, developed in Turkish, was administered to native Turkish speakers. It comprises 7 items focusing on postural habits and 12 items assessing postural awareness, all rated on a 5-point Likert scale (English translation of the items is included in the appendix). The scale includes 7 items that are reverse-scored. Total scores range from 0 to 95, with higher scores reflecting better postural habits and greater postural awareness. The scale recently was developed in 2023 by Bayar et al., and its validity and reliability have been established (internal consistency coefficient \u0026gt; 0.85, p \u0026lt; 0.05) [20].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePain\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe NRS is a widely used, valid, and reliable tool that was utilised to assess pain intensity as reported by the subjects [21]. The NRS is a linear scale ranging from 0 to 10, where 0 indicates \u0026ldquo;no pain\u0026rdquo; and 10 represents \u0026ldquo;the worst pain imaginable.\u0026rdquo; Participants were asked to indicate or verbalise the number that best reflected the intensity of their perceived pain. The pain intensity related to the TMJ region was assessed by NRS at rest, during activity, and throughout the night.\u003c/p\u003e\n\u003cp\u003ePressure algometer was designed to measure deep pressure pain thresholds or tolerance to sensitivity. A mechanical algometer device (Baseline brand Dolorimeter, 22LB/10 kg) was used to assess pain threshold and tolerance of subjects. The device features a rubber disk with a surface area of 1 cm\u0026sup2;, which is pressed against a specific body region to display the applied pressure. The pressure pain threshold measurement was taken over the masseter, temporalis, trapezius, and sternocleidomastoid muscles, the lateral and dorsal regions of the temporomandibular capsule [22].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunctional Assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe HCDI, developed by Helkimo in 1974, is a test designed to quickly and simply assess limitations in mandibular movement, pain, and joint function. The HCDI is not a self-report scale; rather, it is administered by clinicians. It has been shown to have a sensitivity of 86.67% and specificity of 68.09% in predicting the presence of TMD [23].\u003c/p\u003e\n\u003cp\u003eThe MFIQ was developed by Stegenga et al. in 1993 to evaluate mandibular functional impairments in patients with TMD [24]. It consists of 17 items divided into 2 subscales. Each item is rated on a 5-point scale from 0 to 4 (0 = no difficulty; 1 = slight difficulty; 2 = some difficulty; 3 = severe difficulty; 4 = very difficult or impossible without assistance). Total scores range from 0 to 68. The first 11 items represent the \u0026ldquo;Functional Capacity\u0026rdquo; subscale, while the last 6 items comprise the \u0026ldquo;Feeding\u0026rdquo; subscale. Higher total scores indicate greater mandibular dysfunction, while lower scores indicate reduced impairment. A new Turkish version of the questionnaire was developed by Yıldız et al., demonstrating strong internal consistency (Cronbach\u0026rsquo;s alpha = 0.916) [25].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMuscle Endurance\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe neck flexor endurance test was performed as the subject lies in a hook-lying position with their hands resting on the abdomen. While maintaining maximum chin tuck, they are asked to lift their head 2.5 cm off the surface and hold the position for as long as possible. The duration (in seconds) is recorded, and the test is terminated when the participant experiences pain or can no longer maintain the position [26]. The neck extensor endurance test was performed as the subject lies prone with their head and neck unsupported beyond the edge of the examination table and arms positioned along the sides of the body. They are asked to maintain this position for as long as possible. The endurance time is measured with a stopwatch and recorded in seconds. The test is ended if pain occurs or the position is lost [27].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProprioception\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCervical proprioception test is typically evaluated using head repositioning tests, which are considered valid and reliable method. The test protocol of LP-ART defined by Revel et al. was performed to assess neck proprioception sense [28].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Statistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll evaluation data were analysed using IBM SPSS Statistics 26 (SPSS Inc., Chicago, IL, USA). The normality of the data distribution was assessed using the Kolmogorov-Smirnov test and other parametric test assumptions. The Independent Samples t-test was conducted to compare postural habits and awareness levels of subjects with and without TMD. The relationship between postural habits and awareness and variables such as values of HCDI, MFIQ-1, muscle endurance tests, and LP-ART was researched by using Spearman correlation analysis. The relationship between postural habits and awareness and the CVA and MFIQ-2 was assessed using Pearson correlation analysis. The power of research data was calculated using the G*Power software (version 3.1, Universit\u0026auml;t D\u0026uuml;sseldorf, D\u0026uuml;sseldorf, Germany), and the post-hoc power analysis revealed a power of 1-\u0026beta; = 0.99, \u0026alpha; = 0.05, and an effect size of 1.043 [29].\u0026nbsp;\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eA total of 100 individuals participated in the study, comprising 50 subjects with TMD (mean age: 34.52 \u0026plusmn; 12.61) and 50 healthy controls (mean age: 38.00 \u0026plusmn; 10.92). There was no statistically significant difference in age between the groups (Z =-1.886, p = .059). The gender distribution in the TMD group was 29 females and 21 males, while in the control group it was 26 females and 24 males, with no significant difference in gender between the groups (p= 0.54).\u003c/p\u003e\n\u003cp\u003eWhen the postural habits and awareness levels of the groups were compared, the TMD group had significantly lower levels of postural habits and awareness (59.42 \u0026plusmn; 6.71) compared to the control group (66.90 \u0026plusmn; 6.78) (t =-5.541, p \u0026lt;.001).\u003c/p\u003e\n\u003cp\u003eIn the TMD group, the relationship between postural habits and awareness levels and selected musculoskeletal parameters was examined. A moderate, statistically significant negative correlation was found between postural habits and awareness levels and NRS scores during activity (r =-0.429, p = .002). This indicates that individuals in the TMD group who had lower postural habits and awareness experienced higher pain during activity. No significant correlation was found between postural habits and awareness levels, and NRS scores during rest or throughout the night (r = -0.210, p = .143; and r = -0.258, p = .070, respectively). No significant relationship was found between postural habits and awareness levels and pressure pain thresholds measured over the right and left temporalis, trapezius, sternocleidomastoid muscles, and the lateral and dorsal capsule (Table 1, p\u0026gt; .05).\u003c/p\u003e\n\u003cp\u003eIn terms of TMJ functionality, a significant correlation was found between postural habits and awareness level and the HCDI score (r =-0.337, p = 0.017) (Fig 1). This indicates higher functional capacity in the jaw as the postural habits and awareness score increase, in the individuals with TMD. Additionally, a moderate negative correlation was observed between postural habits and awareness level and MFIQ-1 (8.78 \u0026plusmn; 5.66) and MFIQ-2 (6.96 \u0026plusmn; 4.10) scores in relation to TMJ functionality (r =-0.445, p = 0.001; r =-0.496, p = 0.001, respectively) in the TMD group (Fig 2-3). This finding suggests that individuals who have higher postural habits and awareness, has higher TMJ functional performance.\u003c/p\u003e\n\u003cp\u003eIn the TMD group, no significant correlation was found between postural habits and awareness level, and neck flexor and extensor muscle endurance (r = 0.012, p = 0.933; and r = -0.115, p = 0.425).\u003c/p\u003e\n\u003cp\u003eThe relationship between postural habits and awareness level, and cervical proprioception was examined in the TMD group using the Laser Pointer-Assisted Angle Reproduction Test (LP-ART). Negative correlations were found between PHAS total score and LP-ART parameters in the selected neck movements. A weak negative correlation in extension (r =-0.326), a moderate negative correlation in right lateral flexion (r =-0.406), and weak negative correlations in left lateral flexion (r =-0.365) and right rotation (r =-0.294) (Table 2). No significant correlation was observed in flexion and left rotation movements (p\u0026gt; .05). As the level of postural habits and awareness decreases, proprioception is getting weaker in various directions in the subjects with TMD.\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eIn the present study, postural habits and awareness were primarily investigated comparatively individuals with and without TMD and it has shown that individuals with TMD had lower levels of postural habits and awareness than controls. Secondarily, it was aimed to research the relationship between the level of postural habits and awareness and various parameters such as pain intensity, TMJ functionality, cervical muscle endurance, and proprioception in individuals with TMD. According to the findings, individuals with TMD who had higher levels of postural habits and awareness demonstrated better TMJ functionality, improved proprioception sense, and lower pain intensity during activity.\u003c/p\u003e\n\u003cp\u003eAlthough there have been studies on the musculoskeletal system that examine the level of postural habits and postural awareness [18,19,30,31], no previous research has been found that investigates these parameters explicitly in individuals with TMD. Thus, the outputs obtained in this study fill a gap in the literature as it is the first study explored postural habits and awareness in individuals with TMD, and it was observed that they had lower level of postural habits and awareness compared to the controls. People experiencing jaw and neck pain may experience changes in neck posture or jaw position to alleviate discomfort. From another perspective, it is suggested that a misaligned craniocervical posture may contribute to the development of TMD [32].\u0026nbsp;Such postural changes can disrupt the neutral alignment of the head and negatively affect proprioceptive input and postural stability [33,34]. The individuals with lower proprioception sense exhibited lower postural habits and awareness in the level of weak-moderate correlation in the current study. Misperceiving a faulty posture as correct may lead to inappropriate motor responses and alterations in muscle activity\u0026nbsp;[35]. Therefore, it is essential to examine postural habits and awareness in detail and monitor them over the long term in individuals with TMD, in addition to other musculoskeletal parameters.\u003c/p\u003e\n\u003cp\u003eThe body awareness, which is also related with postural awareness, is considered directly associated with musculoskeletal pain and emotional state [36]. Supporting that, it was observed that individuals who experienced higher pain levels during activity also had lower postural awareness and habits in the present study. Habitual teeth clenching is considered one of the major contributing factors to TMD [32]. Such habitual postural patterns exhibited by individuals in the TMD group during activity may have also showed lower postural habit and awareness scores. One possible explanation of higher level of pain during activity in the individuals with lower postural awareness would be that pain may occur when individuals revert to a habitual poor postural pattern during activity or periods of concentration. It has been suggested that painful TMD can influence postural control through the jaw sensorimotor system [34]. Considering\u0026nbsp;current results and literature, increasing postural awareness by receiving postural training may have direct or indirect positive impact on musculoskeletal pain and emotional conditions according to TMD\u0026nbsp;[37].\u003c/p\u003e\n\u003cp\u003eAnother parameter examined in individuals with TMD is cervical proprioception sense has been to be negatively affected [38]. However,\u0026nbsp;to date, no previous study has directly investigated the relationship between postural habits and awareness level and proprioception sense in TMD group. In the present study, individuals with TMD who exhibited poorer joint position sense had lower levels of postural habits and awareness. In individuals with chronic neck pain or fibromyalgia syndrome, decreased proprioception sense has been reported to negatively affect neck functionality, postural control, and quality of life\u0026nbsp;[39]. Although its role has not been conclusively demonstrated, the stomatognathic system is considered to contribute to postural control\u0026nbsp;[40]. Proprioceptive signals from the stomatognathic system are believed to interact with vestibular and oculomotor inputs, and changes in trigeminal stimulation could result in dysfunction within these systems\u0026nbsp;[41]. In TMD, reduced proprioceptive feedback and low postural awareness levels may be explained by the involvement of the stomatognathic system. In addition, it have been suggested that modifications in mandibular position, which can alter proprioceptive and periodontal afferents, may also influence postural mechanisms\u0026nbsp;[42].\u003c/p\u003e\n\u003cp\u003eConsidering that TMD may alter neuromuscular control and lead to abnormal afferent input, TMJ functions may be affected because of the strong functional connection between the cervical spine and the masticatory system during activities such as swallowing, chewing, and cervical movements [43,44]. It was observed that individuals with higher postural habits and awareness levels had better TMJ functionality. This finding is consistent with the results of Mi\u0026ccedil;ooğulları et al., who reported impaired\u0026nbsp;postural stability and mandibular function in individuals with TMD [45]. Lower level of postural habit and awareness may be one of the risk factors of occurring poor TMJ functionality. We suggest of consideration that feature beside other risk factors of TMD by clinicians. As mentioned above, postural awareness training may also have positive effects on TMJ functionality.\u003c/p\u003e\n\u003cp\u003eThe jaw and neck pain can lead to muscle imbalances, affecting proprioception and impairments in dynamic postural stability [33]. Many studies have demonstrated reduced endurance of cervical flexor and extensor muscles in individuals with TMD [9,46]. Considering the literature, there have also been other research examining muscle endurance in chronic neck pain, postural disorders and phone addiction levels [47-49]. In individuals with chronic neck pain, a low to moderate correlation was found between chronic neck pain intensity and cervical muscle endurance [47]. In case of smartphone addiction, increasing smartphone addiction level was found to be associated with reduced cervical extensor muscle endurance [48,49]. Although the relationship between muscle endurance and various parameters in different subjects and TMD has been investigated, the relationship between postural habits \u0026amp; awareness and cervical flexor \u0026amp; extensor muscle endurance investigated in the current study from a different perspective. Although deficiencies in muscle endurance have been previously identified in the presence of TMD or cervical postural disorders and pain [47,50,44], cervical flexor and extensor muscle endurance was not observed to be associated with poor postural awareness in the current study.\u003c/p\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eAs a summary, the results of our study revealed that individuals with TMD had lower levels of postural habits and awareness compared to individuals without TMD. This finding suggests that TMD may influence not only craniocervical function and symptoms but also habitual behaviours and general postural awareness in daily life. Considering the observed lower pain during activity, higher proprioception sense and TMJ functionality in individuals with higher postural habits and awareness, implementing postural training and awareness-enhancing interventions in individuals with TMD may have a beneficial effect in the therapy sessions. The findings also underscore the importance of addressing not only local symptoms but also postural habits in the assessment and rehabilitation of TMD. Improving posture-related habits and enhancing postural awareness may help prevent the development of TMD or support the rehabilitation process by reducing existing symptoms.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors report there are no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate:\u003c/strong\u003e The study protocol was approved by the Clinical Research Ethics Committee of XXXXXXX University Faculty of Medicine (XX.XXXX.XX).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent, Data, Materials and/or Code Availability:\u003c/strong\u003e The consent of participants was obtained and documented prior to data collection. The data that support the findings of this study are not openly available due to reasons of sensitivity. (This manuscript does not report data generation or analysis.)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contribution Statements:\u0026nbsp;\u003c/strong\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [XXXXXX XXXXXX]. Data collection was performed with [XXXXX XXXXX]. The first draft of the manuscript was written by [XXXXX XXXXX], [XXXXX XXXXX] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The authors would like to thank all volunteers who participated in the testing protocol of the research.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlonso-Royo R, Sanchez-Torrelo CM, Ibanez-Vera AJ et al (2021) Validity and Reliability of the Helkimo Clinical Dysfunction Index for the Diagnosis of Temporomandibular Disorders. Diagnostics (Basel) 11 (3)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArmijo-Olivo S, Silvestre RA, Fuentes JP et al (2012) Patients with temporomandibular disorders have increased fatigability of the cervical extensor muscles. 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J Musculoskelet Neuronal Interact 17(4):341\u0026ndash;346\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCorrelation between Parameters of Postural Habits and Awareness, and Pressure Pain Threshold\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTemporalis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTrapezius\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSCM\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.079\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.087\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.989\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.820\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.853\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.586\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.550\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eLateral Capsule\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eDorsal Capsule\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.241\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.820\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.092\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003csup\u003e\u003cem\u003eSpearman Correlation Analysis, SCM: Sternocleidomastoid\u003c/em\u003e\u003c/sup\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCorrelation between Postural Habits and Awareness, and Cervical Proprioception Sense\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostural Habits and Awareness Scale Score\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eFlexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.261\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eExtension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.326*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eRight Lateral Flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.406*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLeft Lateral Flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.365*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eRight Rotation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.294*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLeft Rotation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.258\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.071\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\u003cem\u003er: Spearman Correlation, *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Temporomandibular Joint Disorders, Posture, Awareness, Musculoskeletal System","lastPublishedDoi":"10.21203/rs.3.rs-7851947/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7851947/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eAlthough the pain, functionality, proprioception in temporomandibular disorders (TMD) have been frequently investigated, there has been limited knowledge on postural habits \u0026amp; awareness and relation to musculoskeletal parameters. It was aimed to explore the postural habits and awareness level and to investigate the relationship to various musculoskeletal parameters in individuals with TMD.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eFifty subjects with TMD and fifty controls were included. Postural habits \u0026amp; awareness levels were assessed using the Postural Habits and Awareness Scale (PHAS). The pain level and pain pressure threshold were assessed by the Numeric Rating Scale (NRS) and an algometer; functionality was assessed using the Helkimo Clinical Dysfunction Index (HCDI) and the Mandibular Function Impairment Questionnaire (MFIQ). Cervical muscle endurance was performed using flexor and extensor endurance tests, while position sense was tested using the Laser Pointer Assisted Angle Reproduction Test (LP-ART).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePHAS score were significantly lower in the TMD group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Within the TMD group, a moderate positive correlation was found between PHAS score and activity-related pain level (0.429). Low-moderate level of negative correlations was observed between the scores of PHAS and the HCDI (-0.337), MFIQ (-0.445 \u0026amp; -0.496). and LP-ART in cervical extension (-0.326) \u0026amp; lateral flexion (-0.406, -0.365).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eLow level of postural habits \u0026amp; awareness and its relationship with pain level, jaw functionality and cervical proprioception were observed in individuals with TMD. Current findings highlight the importance of considering postural awareness along with local symptoms in TMD by the clinicians working with this population.\u003c/p\u003e","manuscriptTitle":"Postural Habits \u0026amp; Awareness in Individuals With Temporomandibular Joint Disorders and Its Relationship to Musculoskeletal Parameters","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-03 13:36:58","doi":"10.21203/rs.3.rs-7851947/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7437c53c-5b20-4988-bafd-78d8afbb38e9","owner":[],"postedDate":"November 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-13T11:53:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-03 13:36:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7851947","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7851947","identity":"rs-7851947","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}