## 4 Discussion  
This pilot RCT aimed at evaluating the effects of a multidimensional rehabilitation intervention consisting of the addition of rESWT to physical therapy, in terms of pain reduction and muscle functional improvement, in patients affected by muscle-related TMD. Results of the present study showed that the synergistic approach between the rESWT and physical therapy reported a significant reduction in pain (assessed by VAS) and enhancement of the POC index on the masseter muscles compared with the only physical therapy. By comparing the pain perceived by the two study groups at each timepoint, we reported an intergroup difference at the end of treatment (T1) and at 24 weeks from the completion of the intervention. According to the DC/TMD, muscle-related TMD disorders are mylalgia and myofasical pain [3]. Local mylalgia is characterized by pain localized to the area of palpation on \begin{table}
\begin{tabular}{l c c c} \hline \hline  & **Group A (rESWT)** & **Group B (Sham rESWT)** & \(p\) **Value** \\ \hline POC TA T0 & 80.7 \(\pm\) 8.1 & 81.1 \(\pm\) 10.5 & 0.651 \\ POC TA T1 & 82.0 \(\pm\) 9.8 & 78.6 \(\pm\) 12.0 & 0.073 \\ POC TA T2 & 79.7 \(\pm\) 14.8 & 75.1 \(\pm\) 19.4 & 0.061 \\ POC TA T3 & 87.0 \(\pm\) 2.0 & 84.3 \(\pm\) 2.8 & 0.084 \\ POC MM T0 & 81.2 \(\pm\) 10.2 & 80.9 \(\pm\) 7.7 & 0.672 \\ POC MM T1 & 85.9 \(\pm\) 8.9 & 81.3 \(\pm\) 6.4 & 0.041 \({}^{*}\) \\ POC MM T2 & 84.8 \(\pm\) 5.2 & 82.3 \(\pm\) 3.6 & 0.331 \\ POC MM T3 & 84.2 \(\pm\) 6.1 & 81.7 \(\pm\) 6.8 & 0.103 \\ BAR T0 & 75.2 \(\pm\) 19.8 & 73.7 \(\pm\) 10.8 & 0.094 \\ BAR T1 & 80.5 \(\pm\) 10.7 & 75.9 \(\pm\) 11.9 & 0.066 \\ BAR T2 & 81.0 \(\pm\) 11.7 & 63.9 \(\pm\) 14.8 & 0.032 \({}^{*}\) \\ BAR T3 & 84.4 \(\pm\) 4.9 & 67.5 \(\pm\) 22.8 & 0.041 \({}^{*}\) \\ TORS T0 & 86.5 \(\pm\) 5.5 & 89.9 \(\pm\) 0.7 & 0.095 \\ TORS T1 & 87.8 \(\pm\) 3.6 & 89.2 \(\pm\) 2.8 & 0.238 \\ TORS T2 & 86.8 \(\pm\) 7.2 & 84.4 \(\pm\) 8.9 & 0.145 \\ TORS T3 & 89.4 \(\pm\) 3.0 & 88.6 \(\pm\) 3.0 & 0.621 \\ IMP T0 & 71.9 \(\pm\) 28.9 & 87.2 \(\pm\) 21.5 & 0.025 \({}^{*}\) \\ IMP T1 & 68.2 \(\pm\) 20.2 & 80.3 \(\pm\) 21.4 & 0.031 \({}^{*}\) \\ IMP T2 & 84.0 \(\pm\) 19.0 & 74.5 \(\pm\) 12.8 & 0.047 \({}^{*}\) \\ IMP T3 & 86.9 \(\pm\) 14.0 & 77.9 \(\pm\) 13.0 & 0.062 \\ ASIM T0 & \(-\)1.98 \(\pm\) 13.9 & 8.72 \(\pm\) 14.4 & 0.022 \({}^{*}\) \\ ASIM T1 & 2.35 \(\pm\) 13.0 & 10.0 \(\pm\) 15.4 & 0.021 \({}^{*}\) \\ ASIM T2 & 0.19 \(\pm\) 8.1 & 4.96 \(\pm\) 11.0 & 0.566 \\ ASIM T3 & 2.19 \(\pm\) 9.5 & 7.16 \(\pm\) 9.4 & 0.431 \({}^{*}\) \\ \hline \hline \end{tabular} Values are expressed as means \(\pm\) standard deviations. Abbreviations: \({}^{*}\): Significant between-group difference, assessed by Mann-Whitney U test. rESWT: radial Extracorporeal Shock Wave Therapy. ASIM: Asymmetry index. The distribution of the occlusal contacts considering the right and left parts of dental caches BAR: Barycenter as percentage overlapping coefficient between posterior and anterior teeth contact. IMP: Impact index as the work performed by the muscle during its contractile activity. POC TA and MM: Percentage overlapping coefficient (anterior temporalis muscles or masseter muscles). RBC: Rank Biserial Correlation. TORS: Torsion index is obtained by comparing the torque of the crossed muscle pairs.  
\end{table} 
Table 3: Between-group differences in muscle activity assessed by surface electromyography. examination, whereas myofascali pain extends beyond the area identified by palpation. Referred myofascali pain is characterized by extension towards areas distant from the area of palpation on examination. Among masticatory muscles, masseter and temporalis muscles are commonly associated with myofascali pain and considered as the main causes of TMD [47].