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Article

Assessment Framework of the Shoulder Girdle in Participants with Temporomandibular Disorders: Delphi Study

by
Micaela Weinberg
1,*,
Benita Olivier
1,2 and
Siyabonga Kunene
1
1
Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2050, South Africa
2
Oxford Institute of Applied Heath Research, Faculty of Health, Science and Technology, Oxford Brookes University, Oxford OX3 0BP, UK
*
Author to whom correspondence should be addressed.
Int. J. Orofac. Myol. Myofunct. Ther. 2026, 52(2), 14; https://doi.org/10.3390/ijom52020014
Submission received: 10 April 2026 / Revised: 2 September 2026 / Accepted: 3 September 2026 / Published: 12 September 2026
(This article belongs to the Special Issue Temporomandibular Disorders from an Orofacial Myofunctional Perspective)
Review Reports Versions Notes

Abstract

Background: Temporomandibular disorders (TMDs) are multifactorial conditions involving the joint, musculature, and associated systems. While physiotherapy commonly addresses the temporomandibular joint and cervical spine, emerging evidence suggests that dysfunction may extend to the shoulder girdle, influencing posture, muscle activity, and functional performance. Despite this, no structured framework exists to guide clinicians in assessing the shoulder girdle in individuals with TMD. Objective: To establish a clinically relevant assessment framework for the shoulder girdle in individuals with TMD using expert consensus via the Delphi method. Methods: A two-round Delphi study was conducted with an international panel of physiotherapy experts experienced in TMD management. Eleven statements relating to subjective and objective shoulder girdle assessment were evaluated using a 5-point Likert scale. Consensus thresholds were set at ≥70% for round one and ≥60% for round two. Data were analyzed using descriptive statistics. Results: Eleven experts participated in round one and nine in round two. Consensus was achieved for nine assessment components, including both subjective (pain, symptoms, injury history, and outcome measures) and objective (trigger points, muscle length, strength testing, and jaw-related influences on muscle performance) domains. Conclusion: This study presents the first known expert-derived framework for assessing the shoulder girdle in individuals with TMD. The findings support a broader, integrative clinical approach that considers regional interdependence.

1. Introduction

Temporomandibular disorders (TMDs) encompass a group of conditions affecting the temporomandibular joint, muscles of mastication, and associated structures These disorders are multifactorial, involving interactions between neuromuscular, biomechanical, and psychosocial components [1]. The temporomandibular joint operates within a complex system that includes not only the craniofacial region but also cervical and postural networks, reflecting the principle of regional interdependence [2,3].
The prevalence of TMD is high, with studies reporting that between 40 and 75% of the general population present with at least one sign, and approximately one-third report symptoms [2]. Beyond localized pain and dysfunction, TMD has been associated with broader impairments, including altered breathing patterns, swallowing dysfunction, and postural adaptations [4]. These findings align with the scope of myofunctional therapy, which emphasizes the integration of structure and function across interconnected systems.
Physiotherapy management of TMD traditionally focuses on the temporomandibular joint and cervical spine, aiming to reduce pain and restore mobility through manual therapy and soft-tissue techniques [1,2]. However, despite high rates of treatment utilization, a substantial proportion of patients continue to experience persistent symptoms [5]. This suggests that current treatment approaches may not fully address all contributing factors.
Emerging evidence indicates that dysfunction in individuals with TMD may extend beyond the craniofacial and cervical regions. Alterations in shoulder girdle muscle activity, strength, and pain have been demonstrated in individuals with TMD [3,6,7]. Additionally, a high prevalence of shoulder pain has been reported in this population [5,8]. These findings suggest a functional relationship between the temporomandibular joint and shoulder girdle.
Despite this growing body of evidence, current clinical assessment frameworks for TMD do not routinely incorporate evaluation of the shoulder girdle [4]. Furthermore, there is no consensus regarding which shoulder-related assessments are most relevant or clinically meaningful in this population. This gap limits the ability of clinicians to adopt a comprehensive, functionally oriented approach consistent with myofunctional therapy principles.
The Delphi method provides a structured approach to achieving expert consensus in areas where evidence is limited or evolving [9]. By integrating available evidence with expert clinical reasoning, it enables the development of practical frameworks to guide clinical assessment.
The aim of this study was to establish an assessment framework of the shoulder girdle in participants with TMD through consensus from international experts using the Delphi method.

2. Methodology

Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics (Medical) Committee (M2111110). The Delphi technique was chosen as it is a commonly used procedure to collect a group of experts’ opinions and ideas on a certain topic through a varying number of rounds [9].
This study consisted of two rounds to achieve a consensus on the content of an assessment framework of the shoulder girdle in participants with TMD. The study took place from November 2023 to January 2024. Data were collected on Research Electronic Data Capture (REDCap), which is an online tool used to collect and capture information [10]. No identifying questions were asked, and only information on participants’ age, gender, work environment, and the number of years of work experience was included in the survey. The planning and execution of the study was conducted based on the Guidance on Conducting and Reporting Delphi Studies (CREDES) [9].
The initial threshold of consensus for including statements in the overall assessment framework was set at 70%. Statements that did not reach this consensus in the first round were modified and included in the second round to gain consensus from the panelists on their opinion on including them in the overall assessment framework. However, results from the first round showed that the included statements, which were based on conclusive findings from the literature, did not reach the 70% level of consensus. This was potentially due to a lack of research on the topic or bias based on their own assessments in clinical practice. Therefore, the consensus for the second round was modified to 60% in order to ensure that a comprehensive framework assessment was compiled that was both evidence-based but also considered the experts’ opinions. Previous TMD-related Delphi studies also used the 60% consensus as their threshold for consensus, further providing support for the use of this level in the current study [11].
The statements in the study were designed from the current literature and findings from the other studies published by Weinberg et al. (2023, 2025) [5,12]. These were pilot-tested among three physiotherapists (the authors) with doctoral degrees in neuromusculoskeletal physiotherapy. Each member of the panel was sent an email with an invitation to participate in the study with a link to the survey on the REDCap server.
The landing page included an information sheet that explained the purpose of the study and provided an explanation for each statement. This was followed by an instruction to rate the importance of including each statement in the assessment framework, according to the five-point Likert scale, ranging from 0 to 4 (4 = strongly agree, 3 = agree, 2 = disagree, 1 = strongly disagree, and 0 = neutral). Finally, there was a box for panelists to give suggestions and comments.

2.1. Participants

When choosing participants, the most common criteria among studies was the representation of a specific profession, followed by a specific work environment, and lastly, relevant academic achievements [9]. In the current study, the criterion used was local or international physiotherapists that had more than five years of experience working in the field of TMJ. They were identified by the primary author through their publications in this field. Furthermore, snowball sampling also took place, whereby panelists who agreed to be a part of the study were asked to suggest other physiotherapists who were then contacted and invited to participate.

2.2. Number of Rounds

In a systematic review that aimed to develop guidelines for the reporting of Delphi studies in palliative care, among the 30 articles included, the number of rounds varied from one to five [9]. The most common amount was two rounds in fourteen studies followed by three rounds in eight studies.
In terms of duration, most of the studies did not report on the time frames of the surveys, but of the seven that did, the time frames varied between seven days to seven weeks [9]. Ours consisted of two rounds that were open for three weeks each. A reminder was sent to each participant in the middle of each round to encourage higher levels of participation.

3. Results

3.1. Round One

The eleven statements in round one were sent to 21 international experts (Table 1).
Scapulohumeral rhythm is assessed through visual observation during active bilateral shoulder elevation in the sagittal and frontal planes. Participants are instructed to elevate and lower both arms in a smooth, controlled manner while the examiner observes the timing and coordination of scapular upward rotation relative to glenohumeral movement. The SHR is classified as normal or abnormal based on the presence of asymmetrical scapular movement, early scapular elevation, excessive scapular motion, delayed upward rotation, or scapular dysrhythmia during arm elevation and lowering. Visual observation of scapular movement has demonstrated acceptable inter-rater reliability when performed by experienced clinicians, particularly when combined with standardized assessment procedures [14,15].
The length of the SCM muscle is assessed using a standardized muscle length test. Participants lie supine while the examiner passively positions the cervical spine into extension, ipsilateral lateral flexion, and contralateral rotation to place the SCM on stretch. Muscle length is considered reduced when the expected range could not be achieved or when excessive resistance or symptom reproduction occurred before reaching the normal end position. Standardized cervical muscle length tests have demonstrated moderate to good intra- and inter-rater reliability [16].
Muscle strength is assessed bilaterally using standardized manual muscle testing procedures based on the methods described by Kendall et al. Each muscle is graded on a six-point ordinal scale ranging from 0 (no visible or palpable contraction) to 5 (normal strength against maximal resistance). Manual muscle testing has demonstrated moderate to excellent reliability when standardized procedures are followed and assessments are performed by trained examiners [17].
Biceps strength is assessed with the participant seated, the elbow flexed to approximately 90°, and the forearm supinated. Resistance is applied at the distal forearm while the participant maintains elbow flexion. The middle deltoid is assessed with the participant seated and the shoulder abducted to approximately 90°. Downward resistance is applied proximal to the elbow while the participant resists shoulder abduction. Testing of the middle trapezius consists of the participant lying prone with the shoulder abducted to 90° and externally rotated. The participant retracts the scapula while resistance is applied against horizontal abduction and scapular retraction. Lower trapezius involves the participant lying prone with the arm elevated diagonally in line with the lower trapezius fibers (approximately 130–145° of abduction). Resistance is applied against shoulder elevation while maintaining scapular depression and upward rotation.
Serratus anterior is tested with the participant seated or supine with the shoulder flexed to 90–120°. Resistance is applied against scapular protraction while the participant maintains the position without scapular winging. For infraspinatus, the participant is seated with the elbow flexed to 90° and held against the side. Resistance is applied against external rotation of the shoulder while maintaining the elbow against the trunk.
Of the 21 experts invited to participate, 11 (52%) responded. The mean age of the respondents was 53.41 years (SD = 13.12) and consisted of six males (54.5%) and five females (45.5%). The majority of participants (n = 10, 91%) reported having more than 16 years of work experience, with only one participant reporting between 10 and 15 years. With regards to work environment, there was diversity among the panelists, with two participants (19%) working in outpatient only, three (27%) in academics only, three (27%) in a combination of outpatient and academics, and three (27%) in a combination of outpatient, academics, and hospital.
After the first round, three of the 11 statements reached 70% consensus and were put aside. These were the presence of pain in the shoulder as well as the presence of other symptoms. The full results for each statement can be found in Table 2.

3.2. Round Two

Round two included eleven statements: eight from round one that did not reach 70% consensus and an additional three that were added based on comments and suggestions from the panelists. The eight statements that were included from round one were modified to be more clear or changed according to the suggestions from the panelists. The full list of statements sent to panelists is shown in Table 3.
Of the 21 experts invited to participate in round two, 9 (43%) responded. The mean age of the respondents was 52.56 years (SD = 9.44) and included five males (55.5%) and four females (44.5%). The majority of participants (n = 8, 89%) reported having more than 16 years of work experience, with only one participant having between 10 and 15 years. With regards to work environment, two participants (22%) worked in outpatient only, three (33%) in academics only, three (33%) in a combination of outpatient and academics, and one participant was retired. After round two, six of the eleven statements reached 60% consensus, with the full results for each statement shown in Table 4. These statements included a previous injury of the shoulder girdle and if it correlated with the timing of the onset/worsening of TMD symptoms; a standardized measurement of shoulder pain and disability using the SPADI; evaluation of the presence and the area of referral of trigger points in the SCM; upper and middle fibers of trapezius; muscle length testing of SCM and upper trapezius; muscle strength testing of the biceps, deltoid, and rotator cuff, and presence of clenching during the muscle strength testing; and when corrected to a rested position, if there is a change in the muscle strength of the shoulder.
In the subjective examination, the majority of participants (>70%) agreed in the first round to the inclusion of the presence of pain and other symptoms of the shoulder. A suggestion was given by a panelist to add a standard outcome measure for shoulder pain, which was done so in the second round. The use of the Numerical Rating Scale in measuring shoulder pain received consensus and was also included.
After not receiving consensus in round one, the question on the presence of a previous injury of the shoulder girdle was modified to add whether it related to the onset/worsening of the symptoms of TMD. This gained consensus among the experts and was included in the final framework.
Table 5 shows the statements that were included in the final framework after both rounds of the Delphi study.

4. Discussion

This study established an expert consensus-based framework for assessing the shoulder girdle in individuals with TMD. The final framework incorporated both subjective and objective components. The subjective assessment included the presence and intensity of shoulder pain, other shoulder girdle symptoms, previous shoulder injury in relation to the onset or worsening of TMD symptoms, and shoulder pain and disability measured using the SPADI. The objective assessment included evaluation of trigger points in the SCM and trapezius muscles, muscle length testing of the SCM and upper trapezius, strength testing of the biceps, deltoid, and rotator cuff muscles, and assessment of clenching during shoulder strength testing. In contrast, the panel did not reach consensus on the assessment of previous shoulder surgery, SHR, the SDT, or shoulder elevation. Collectively, the findings indicate that the panel placed greater importance on clinically identifiable symptoms and neuromuscular impairments than on postural or scapular movement measures for which the evidence is currently more limited.

4.1. Subjective Assessment of the Shoulder Girdle

The panel reached consensus on the importance of assessing current shoulder pain and other shoulder symptoms, supporting the inclusion of shoulder symptom screening when assessing individuals with TMD. This consensus is consistent with previous evidence demonstrating a high prevalence of shoulder complaints in this population, as shown by Weinberg, Olivier, and Kunene (2025) [12]. Their study found that participants with TMD were more than twice as likely to have received previous treatment for the shoulder and reported a high prevalence of shoulder pain (n = 13, 72%), compared with participants without TMD (n = 5, 28%). In a larger sample of 186 participants with TMD, 56% (n = 104) reported shoulder pain [5]. Similarly, Correia et al. (2015) [8] reported shoulder girdle pain in 33% of participants on the left and 35% on the right. The agreement between the Delphi findings and the existing literature therefore provides support for screening the shoulder girdle for pain and associated symptoms as part of a broader assessment of individuals with TMD.
Consensus was also reached on quantifying shoulder pain using the NRS and assessing shoulder-related pain and disability using the SPADI. Notably, consensus on the SPADI was achieved only in the second Delphi round. Previous research has demonstrated significant associations between SPADI pain, disability, and total scores and measures of TMD severity and associated disability [5,12]. The eventual inclusion of the SPADI suggests that the panel considered the functional consequences of shoulder symptoms relevant to the assessment of individuals with TMD, rather than considering shoulder pain in isolation. However, the reason that consensus was achieved only after the second round cannot be determined from the present study. One possible explanation is the relatively limited literature examining shoulder disability specifically in individuals with TMD; this interpretation should therefore be considered cautiously.
The panel also reached consensus on asking about previous shoulder injury when the timing of the injury corresponded with the onset or worsening of TMD symptoms. In contrast, previous shoulder surgery did not reach consensus, even when the statement was modified to consider its temporal relationship with TMD symptoms. Existing evidence supporting an association between shoulder surgery and TMD is limited. In one study, only 2.6% of 186 participants with TMD reported previous shoulder surgery [5]. The difference in consensus between previous injury and previous surgery may therefore indicate that the panel considered a broader history of shoulder injury more clinically relevant than surgery specifically. Further research would be required before any relationship between shoulder surgery and the development or worsening of TMD could be proposed.

4.2. Neuromuscular Components of the Objective Assessment

The objective components that achieved consensus were predominantly neuromuscular measures. Trigger point assessment of the SCM and upper and middle trapezius was the only objective statement to reach the predetermined consensus threshold in the first round. This finding is supported by evidence of greater myofascial involvement of the cervical and shoulder girdle musculature in individuals with TMD. Fernández-de-las-Peñas et al. (2010) [18] identified significantly more trigger points in the SCM and upper trapezius in individuals with TMD than in those without TMD, with referral from these muscles commonly reproducing pain in the temporal region. Inoue et al. (2010) [19] similarly reported greater SCM and trapezius tenderness on the side of temporomandibular joint disk displacement. The Delphi consensus therefore corresponds with existing evidence supporting an association between TMD and altered pain responses within the neck and shoulder girdle musculature.
Muscle length testing of the SCM and upper trapezius also reached consensus in the second round. This finding can be considered alongside evidence demonstrating altered activity of these muscles in individuals with TMD. Increased resting activity of the SCM and upper trapezius has previously been reported in this population [20]. Furthermore, treatment directed at SCM trigger points has been associated with improvements in TMJ range of motion [6]. Although these findings provide a physiological rationale for considering the SCM and upper trapezius during assessment, they do not establish that reduced muscle length causes or contributes to TMD. The inclusion of muscle length testing should therefore be interpreted as an expert-supported component of the clinical assessment rather than evidence of a causal relationship.
The panel also reached consensus on strength testing of the biceps, deltoid, and rotator cuff muscles. Previous studies have demonstrated changes in upper-limb muscle performance associated with alterations in occlusion and jaw activity [21]. This is further supported by findings of lower muscle activity of the biceps, medial deltoid, infraspinatus, inferior trapezius, and serratus anterior during weighted shoulder flexion and abduction in participants with TMD compared with those without TMD [12]. Together, these findings provide context for the panel’s inclusion of shoulder muscle strength assessment, although further research is required to determine the clinical significance of these differences.
An important related finding was the panel’s consensus on observing whether patients clench their teeth during shoulder strength testing and whether muscle strength changes when the jaw is returned to a relaxed position. This component directly considers whether jaw activity influences shoulder muscle performance during clinical examination. Previous studies have demonstrated an ergogenic effect of clenching, with greater upper-limb force production reported during voluntary teeth clenching [21,22]. The Delphi finding therefore extends this experimental evidence into a potentially relevant clinical assessment consideration. Importantly, the present study establishes expert agreement regarding its inclusion in assessment; it does not establish that clenching contributes to shoulder dysfunction or TMD.

4.3. Components That Did Not Reach Consensus

The measures that did not reach consensus are also informative. In particular, the panel did not support including SHR or the SDT in the final assessment framework. To the authors’ knowledge, there is currently limited evidence demonstrating differences in SHR between individuals with and without TMD or establishing a relationship between SHR and mandibular movement. Consistent with the Delphi findings, Weinberg, Olivier, and Kunene (2025) [12] found no significant differences in SDT scores between participants with and without TMD. Although altered activity of muscles contributing to scapular control, including the inferior trapezius and serratus anterior, has been identified in individuals with TMD [12], altered muscle activity does not necessarily indicate clinically observable scapular dyskinesis. The absence of consensus for SHR and the SDT therefore appears consistent with the current lack of direct evidence supporting their inclusion in routine assessment.
Shoulder elevation similarly did not reach the predetermined consensus threshold and was therefore not included as a consensus component of the framework. It was retained only as a suggested assessment consideration because previous studies have reported a greater prevalence of shoulder asymmetry or elevation in individuals with TMD [23,24,25], alongside evidence of altered upper trapezius activity [20]. The discrepancy between the published literature and the Delphi panel is noteworthy. It suggests that the presence of an association in observational research may not be sufficient for experts to consider a measure essential to clinical assessment. Consequently, shoulder elevation should be regarded as an area requiring further investigation rather than an established component of the framework.

4.4. Interpretation of the Findings

Taken together, the pattern of consensus provides a more specific interpretation than simply demonstrating a relationship between the TMJ and shoulder girdle. The panel predominantly supported assessment components that identify shoulder symptoms, quantify their functional impact, and examine neuromuscular features that may interact with jaw function. Conversely, measures relating to scapular posture and movement received less support. This distinction is broadly consistent with the available literature, in which evidence for pain and neuromuscular associations between the TMJ and shoulder girdle is more developed than evidence for alterations in scapular biomechanics.
The framework should therefore be interpreted as a structured approach to identifying potentially relevant shoulder girdle findings in individuals with TMD, rather than evidence that shoulder girdle dysfunction causes TMD. The Delphi process establishes expert consensus regarding assessment; it does not establish diagnostic validity, causality, or treatment effectiveness.
Overall, this study provides an initial expert-informed framework for extending assessment beyond the temporomandibular and cervical regions when clinically indicated. As evidence regarding the relationship between the TMJ and shoulder girdle continues to develop, the framework can be refined and validated to determine its role in the comprehensive assessment of individuals with TMD.

4.5. Clinical Implications

Clinicians managing individuals with TMD should consider incorporating shoulder girdle assessment into routine evaluation. This includes:
  • Screening for shoulder pain and dysfunction
  • Assessing myofascial contributions (trigger points, muscle length)
  • Evaluating the influence of jaw position on upper limb strength
This integrative approach aligns with the principles of myofunctional therapy, which emphasize restoring normal muscle function, posture, breathing patterns, and movement coordination rather than treating symptoms in isolation. From this perspective, TMDs are considered within the broader context of the cranio-cervical and shoulder girdle system, where altered muscle recruitment, postural dysfunction, and impaired neuromuscular control may contribute to symptoms. Assessing and addressing impairments in the cervical spine and shoulder girdle therefore reflects a myofunctional approach that seeks to optimize function across the entire interconnected musculoskeletal system, potentially improving patient outcomes [26].

4.6. Limitations

A further limitation was the limited demographic and professional information collected from the Delphi panelists. While age, gender, work environment, and years of professional experience were recorded, additional characteristics such as geographical location, the age groups and populations treated, and the socioeconomic context of their clinical practice were not collected. These factors may influence clinicians’ experiences and assessment practices and would have provided a more comprehensive description of the expert panel and greater insight into the generalizability of the consensus findings.
Furthermore, as responses were anonymous, it was not possible to determine whether the nine panelists who participated in the second round were the same individuals who participated in the first round. Given the relatively small panel and the reduction in responses from eleven participants in round one to nine in round two, differences in panel composition between rounds may have influenced the consensus reached and, consequently, the components included in the final assessment framework. Future Delphi studies should consider using anonymous participant identifiers to allow participation across rounds to be tracked while maintaining confidentiality.
Despite the information sheet including references and explanations of statements that experts may have been less familiar with, a trend seemed to be the exclusion of statements that had less research supporting its inclusion. These statements were based on research conducted by Weinberg, Olivier and Kunene (2023) [5] that was not yet published and therefore could have influenced the panelists’ choice of including these statements in the final consensus. According to the researcher’s knowledge, there was no previous research on the prevalence of shoulder girdle pain and dysfunction in participants with TMD prior to these publications.

5. Conclusions

This Delphi study established an expert consensus-based framework for the assessment of the shoulder girdle in individuals with TMD. Consensus supported the inclusion of subjective measures of shoulder pain, symptoms, disability, and previous injury, together with objective assessment of trigger points, muscle length, shoulder muscle strength, and the influence of jaw clenching on shoulder strength. In contrast, consensus was not reached for measures of scapular movement and shoulder elevation. The findings provide an initial framework to guide shoulder girdle assessment in individuals with TMD while highlighting the need for further research to establish the clinical relevance, reliability, and validity of these assessment components.

Author Contributions

Conceptualization, M.W. and B.O.; methodology, M.W.; software, M.W.; validation, M.W.; formal analysis, M.W.; investigation, M.W.; resources, M.W.; data curation, M.W.; writing—original draft preparation, M.W.; writing—review and editing, M.W.; visualization, M.W.; supervision, B.O. and S.K.; project administration, M.W. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the University of the Witwatersrand (M2111110 MED21-11-098 on 26 November 2021).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author due to the anonymity of the responses.

Acknowledgments

During the preparation of this manuscript, the authors used ChatGPT (5.6 Sol) for the purposes of checking information. The authors have reviewed and edited the output and take full responsibility for the content of this publication.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Pelicioli, M.; Myra, R.S.; Florianovicz, V.C.; Batista, J.S. Physiotherapeutic treatment in temporomandibular disorders. Rev. Dor 2017, 18, 355–361. [Google Scholar] [CrossRef] [Scilit]
  2. Craciun, M.D.; Geman, O.; Leuciuc, F.V.; Holubiac, I.S.; Gheorghi, D.; Filip, F. Effectiveness of Physiotherapy in the Treatment of Temporomandibular Joint Dysfunction and the Relationship with Cervical Spine. Biomedicines 2021, 10, 2962. [Google Scholar] [CrossRef] [Scilit]
  3. von Piekartz, H.; Ruinemans, T. Orofacial Treatment of Overhead Athletes with Persistent Shoulder Problems (GIRD Syndrome)—Multidisciplinary Teamwork between Specialized Manual Therapist and Dentist Case Study Series. Man. Ther. 2017, 21, 73–81. [Google Scholar] [CrossRef] [Scilit]
  4. Minervini, G.; Franco, R.; Marrapodi, M.M.; Fiorillo, L.; Cervino, G.; Cicciù, M. Prevalence of temporomandibular disorders in children and adolescents evaluated with Diagnostic Criteria for Temporomandibular Disorders: A systematic review with meta-analysis. J. Oral Rehabil. 2023, 50, 522–530. [Google Scholar] [CrossRef] [Scilit]
  5. Weinberg, M.; Olivier, B.; Kunene, S. Shoulder Girdle Disability, Dysfunction, and Pain in Participants With Temporomandibular Joint Disorders: A Cross-Sectional Survey on Prevalence and Associations. Physiother. Can. 2023, 77, 466–476. [Google Scholar]
  6. Bae, Y. Change the Myofascial Pain and Range of Motion of the Temporomandibular Joint Following Kinesio Taping of Latent Myofascial Trigger Points in the Sternocleidomastoid Muscle. J. Phys. Ther. Sci. 2014, 26, 1321–1324. [Google Scholar] [CrossRef] [Scilit]
  7. Ceneviz, C.; Mehta, N.R.; Forgione, A.; Sands, M.J.; Abdallah, E.F.; Lobo Lobo, S.; Mavroudi, S. The Immediate Effect of Changing Mandibular Position on the EMG Activity of the Masseter, Temporalis, Sternocleidomastoid, and Trapezius Muscles. CRANIO® 2006, 24, 237–244. [Google Scholar] [CrossRef] [Scilit]
  8. Correia, L.M.F.; Guimarães, A.S.; Teixeira, M.L.; Rodrigues, L.L. Evaluation of body painful areas in patients with muscular temporomandibular disorder: A retrospective study. Rev. Dor 2015, 16, 249–253. [Google Scholar] [CrossRef] [Scilit]
  9. Jünger, S.; Payne, S.A.; Brine, J.; Radbruch, L.; Brearley, S.G. Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review. Palliat. Med. 2017, 31, 684–706. [Google Scholar] [CrossRef] [Scilit]
  10. Patridge, E.F.; Bardyn, T.P. Research Electronic Data Capture (REDCap). J. Med. Libr. Assoc. 2018, 106, 142. [Google Scholar] [CrossRef] [Scilit]
  11. Von Piekartz, H.; Schwiddessen, J.; Reineke, L.; Armijo-Olivio, S.; Bevilaqua-Grossi, D.; Biasotto Gonzalez, D.A.; Carvalho, G.; Chaput, E.; Cox, E.; Fernández-de-las-Peñas, C.; et al. International consensus on the most useful assessments used by physical therapists to evaluate patients with temporomandibular disorders: A Delphi study. J. Oral Rehabil. 2020, 47, 685–702. [Google Scholar] [CrossRef] [Scilit]
  12. Weinberg, M.; Olivier, B.; Kunene, S. Shoulder girdle muscle activity at rest and during jaw and shoulder movements in participants with and without temporomandibular disorders: A cross-sectional observational study. J. Bodyw. Mov. Ther. 2025, 42, 211–220. [Google Scholar] [CrossRef] [Scilit]
  13. Roach, K.E.; Budiman-Mak, E.; Songsiridej, N.; Lertratanakul, Y. Development of a Shoulder Pain and Disability Index. Arthritis Care Res. 1991, 4, 143–149. [Google Scholar] [CrossRef] [Scilit]
  14. McClure, P.; Tate, A.R.; Kareha, S.; Irwin, D.; Zlupko, E. A clinical method for identifying scapular dyskinesis, part 1: Reliability. J. Athl. Train. 2009, 44, 160–164. [Google Scholar] [CrossRef] [Scilit]
  15. Uhl, T.L.; Kibler, W.B.; Gecewich, B.; Tripp, B.L. Evaluation of clinical assessment methods for scapular dyskinesis. Arthrosc. J. Arthrosc. Relat. Surg. 2009, 25, 1240–1248. [Google Scholar] [CrossRef] [Scilit]
  16. Reese, N.B.; Bandy, W.D. Joint Range of Motion and Muscle Length Testing, 4th ed.; Elsevier: Amsterdam, The Netherlands, 2024. [Google Scholar]
  17. Kendall, F.P.; McCreary, E.K.; Provance, P.G.; Rodgers, M.M.; Romani, W.A. Muscles: Testing and Function with Posture and Pain, 5th ed.; Lippincott Williams & Wilkins: Baltimore, MD, USA, 2005. [Google Scholar]
  18. Fernández-de-las-Peñas, C.; Galán-del-Río, F.; Alonso-Blanco, C.; Jiménez-García, R.; Arendt-Nielsen, L.; Svensson, P. Referred Pain from Muscle Trigger Points in the Masticatory and Neck-Shoulder Musculature in Women with Temporomandibular Disoders. J. Pain 2010, 11, 1295–1304. [Google Scholar] [CrossRef] [Scilit]
  19. Inoue, E.; Maekawa, K.; Minakuchi, H.; Nagamatsu-Sakaguchi, C.; Ono, T.; Matsuka, Y.; Clark, G.T.; Kuboki, T. The relationship between temporomandibular joint pathosis and muscle tenderness in the orofacial and neck/shoulder region. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endodontol. 2010, 109, 86–90. [Google Scholar] [CrossRef] [Scilit]
  20. Sójka, A.; Huber, J.; Hędzelek, W.; Wiertel-Krawczuk, A.; Szymankiewicz-Szukała, A.; Seraszek-Jaros, A.; Kulczyk, A.; Wincek, A.; Sobieska, M. Relations between the results of complex clinical and neurophysiological examinations in patients with temporomandibular disorders symptoms. CRANIO® 2018, 36, 44–52. [Google Scholar] [CrossRef] [Scilit]
  21. Alghadir, A.H.; Zafar, H.; Iqbal, Z.A.; Al-Eisa, E.S. Effect of voluntary teeth clenching and sitting posture on maximal static force of limb muscles. J. Sports Med. Phys. Fit. 2019, 59, 774–778. [Google Scholar] [CrossRef] [Scilit]
  22. Venegas, M.; Valdivia, J.; Fresno, J.M.; Miralles, R.; Gutiérrez, F.M.; Valenzuela, S.; Fuentes, A. Clenching and Grinding: Effect on Masseter and Sternocleidomastoid Electromyographic Activity in Healthy Subjects. CRANIO® 2009, 27, 159–166. [Google Scholar] [CrossRef] [Scilit]
  23. Chaves, P.; de Oliveira, F.E.; Damázio, L.C. Incidence of postural changes and temporomandibular disorders in students. Acta Ortopédica Bras. 2017, 25, 162–164. [Google Scholar] [CrossRef] [Scilit]
  24. Cox, K.W.; Klein, R. Craniofacial and Shoulder Asymmetry and its Relationship to Temporomandibular Disorder: A Study of 183 Patients. Ear Nose Throat J. 2013, 92, 142–148. [Google Scholar] [CrossRef] [Scilit]
  25. Munhoz, W.; Marques, A. Body Posture Evaluations in Subjects with Internal Temporomandibular Joint Derangement. CRANIO® 2019, 27, 231–322. [Google Scholar] [CrossRef] [Scilit]
  26. de Felício, C.M.; Melchior, M.O.; da Silva, M.A.M.R. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio® 2009, 27, 249–259. [Google Scholar] [CrossRef] [Scilit]
Table 1. Statements included in round one of the Delphi study.
Table 1. Statements included in round one of the Delphi study.
Subjective Examination of the Shoulder Girdle:
  • Presence of current pain in the shoulder girdle
  • Presence of other symptoms of the shoulder girdle
  • Presence of a previous injury of the shoulder girdle
  • Presence of previous treatment of the shoulder girdle
  • Scores of shoulder pain and disability according to the SPADI [13]
Objective examination of the shoulder girdle:
  • Postural evaluation of shoulder elevation
  • A visual assessment of SHR during active shoulder flexion and abduction bilaterally
  • Muscle strength testing of biceps, middle trapezius, inferior trapezius and deltoid, serratus anterior and infraspinatus muscles bilaterally
  • Assessment of the presence of the clenching and the position of the jaw during shoulder strength testing
  • Muscle length testing of SCM and upper trapezius
  • Evaluation of the presence and area of referral of trigger points in the SCM, upper and middle fibers of trapezius
SCM, sternocleidomastoid; SHR, scapulohumeral rhythm; SPADI, Shoulder Pain and Disability Index.
Table 2. Ratings for each of the statements on a 5-point scale in round one of the Delphi study. Numbers represent the number of panelists who selected each rating.
Table 2. Ratings for each of the statements on a 5-point scale in round one of the Delphi study. Numbers represent the number of panelists who selected each rating.
Questions on the ShoulderStrongly Agree
(5)		Agree (4)Neutral
(3)		Disagree
(2)		Strongly
Disagree
(1)
Subjective:
1. Pain64100
2. Other symptoms 27200
3. Previous injury 13430
4. Previous treatment05222
5. SPADI 14222
Objective:
1. Elevation 04520
2. SHR15401
3. Strength testing 23600
4. Clenching/jaw position during strength testing 34310
5. Muscle length testing 43130
6. Trigger points62210
SHR, scapulohumeral rhythm; SPADI, Shoulder Pain and Disability Index.
Table 3. Statements included in round two of the Delphi study.
Table 3. Statements included in round two of the Delphi study.
Subjective Examination of the Shoulder Girdle:
  • A previous injury of the shoulder girdle and if it correlated with the timing of the onset/worsening of TMD symptoms
  • A previous injury of the shoulder girdle and if it was the same side as the current symptoms of the TMD
  • Previous surgery of the shoulder girdle and if that related to the onset/worsening of TMD symptoms
  • A standardized measurement of shoulder pain using the NRS
  • A standardized measurement of shoulder pain and disability using the SPADI
Objective examination of the shoulder girdle:
  • Evaluation of the presence of shoulder elevation and if it correlates to the side of TMD symptoms
  • Observation of SHR during shoulder flexion and if the pattern relates to the mandibular deviation on that side
  • An objective evaluation of SHR according to the SDT [14] and determining if there is an improvement of the score with an improvement of symptoms of TMD
  • Manual strength testing of biceps, deltoid and rotator cuff muscles
  • Observation if the patient is clenching during shoulder strength testing and when corrected to a relaxed jaw position, if there is a change in the shoulder muscle strength
  • Muscle length testing of SCM and upper trapezius
NRS, Numerical Rating Scale; SCM, sternocleidomastoid; SDT, Scapular Dyskinesis Test; SHR, scapulohumeral rhythm; SPADI, Shoulder Pain and Disability Index; TMD, temporomandibular disorders.
Table 4. Results of the statements in Delphi round two.
Table 4. Results of the statements in Delphi round two.
Questions on the ShoulderSTRONGLY AGREE (5)AGREE (4)NEUTRAL (3)DISAGREE (2)STRONGLY DISAGREE (1)
Subjective:
1. Previous injury timing 16110
2. Previous injury side 13230
3. Previous surgery 13311
4. NRS62100
5. SPADI 17100
Objective:
1. Elevation 14310
2. SHR32400
3. SDT13320
4. Strength testing 51210
5. Clenching during strength testing 27000
6. Muscle length testing24120
NRS, Numerical Rating Scale; SDT, Scapular Dyskinesis Test; SHR, scapulohumeral rhythm; SPADI, Shoulder Pain and Disability Index.
Table 5. Statements included in the final assessment framework of the shoulder girdle in participants with TMD.
Table 5. Statements included in the final assessment framework of the shoulder girdle in participants with TMD.
Subjective Examination of the Shoulder Girdle:
  • Presence of current pain in the shoulder girdle
  • Measuring current pain in the shoulder girdle using the NRS
  • Presence of other symptoms in the shoulder girdle
  • A previous injury of the shoulder girdle and if it correlated with the timing of the onset/worsening of TMD symptoms
  • A standardized measurement of shoulder pain and disability using the SPADI
Objective examination of the shoulder girdle:
  • Evaluation of the presence and the area of referral of trigger points in the SCM, upper and middle fibers of trapezius
  • Muscle length testing of SCM and upper trapezius
  • Muscle strength testing of the biceps, deltoid and rotator cuff
  • Presence of clenching during the muscle strength testing and when corrected to a rested position, if there is a change in the muscle strength of the shoulder
Suggested addition:
  • Evaluation of the presence of shoulder elevation and if it relates to the same side as the TMD symptoms.
NRS, Numerical Rating Scale; SCM, sternocleidomastoid; SPADI, Shoulder Pain and Disability Index; TMD, temporomandibular disorders.
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MDPI and ACS Style

Weinberg, M.; Olivier, B.; Kunene, S. Assessment Framework of the Shoulder Girdle in Participants with Temporomandibular Disorders: Delphi Study. Int. J. Orofac. Myol. Myofunct. Ther. 2026, 52, 14. https://doi.org/10.3390/ijom52020014

AMA Style

Weinberg M, Olivier B, Kunene S. Assessment Framework of the Shoulder Girdle in Participants with Temporomandibular Disorders: Delphi Study. International Journal of Orofacial Myology and Myofunctional Therapy. 2026; 52(2):14. https://doi.org/10.3390/ijom52020014

Chicago/Turabian Style

Weinberg, Micaela, Benita Olivier, and Siyabonga Kunene. 2026. "Assessment Framework of the Shoulder Girdle in Participants with Temporomandibular Disorders: Delphi Study" International Journal of Orofacial Myology and Myofunctional Therapy 52, no. 2: 14. https://doi.org/10.3390/ijom52020014

APA Style

Weinberg, M., Olivier, B., & Kunene, S. (2026). Assessment Framework of the Shoulder Girdle in Participants with Temporomandibular Disorders: Delphi Study. International Journal of Orofacial Myology and Myofunctional Therapy, 52(2), 14. https://doi.org/10.3390/ijom52020014

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