May Discussion Post

[August Winter]

Hey all, I’m posting two articles that relate to a patient that Eric and I saw during residency time several weeks ago. The first article is the one to be reviewed/discussed. The second article is in reference to a conversation I had with Michael about TMD and the aural symptoms that can accompany it. It’s a quick and interesting read!

Some brief case details:
Subjective: 1 mo h/o L sided mid jaw pain radiating to the ear. Aggs: full opening, chewing on that side, abdominal exercises. Denies bruxism, current HAs, trauma, neck pain, locking, clicking/popping. Pt has a filling on a L upper molar but this is not recent and saw her dentist who confirmed the filling was in place. Pt is moving and changing jobs and reports an increase in her stress level.

Objective:
– Compression (-) TMJ palpation (-) masseter palpation (+) for typical pain, temporalis (-)
– AROM: no deviation, only min typical sx w/opening OP
– MMT: resisted closing reproduces typical sx
– Observation: forward head posture at rest, cervical flexion with jaw clenching with performance of a crunch
– Cervical: no pain with AROM, articular pillar lateral glide quick test (-) for pain provocation or gross mobility differences. Significant differences with AA screening with both R flexion rotation and L SB R rotation tests. R OA opening PPIVM limited > L

At first follow up the patient no longer had jaw pain and only had deep L ear pain per her report. Palpation and resisted closing were no longer painful.

On to the article…

Purpose
Investigate the effect of cervical treatments (MT and exercise) on myogenic TMD.

Methods
– Diagnosis of bilateral myofascial TMD with the presence of a trigger point, h/o sx > 3 months, at least 30 mm on the VAS. Exclsuion: S/S disc displacement or TMJ arthrosis, fibromyalgia, systemic disease, trauma, HA
– VAS, pain pressure threshold (PPT) of the masseter and temporalis, pain free maximal mouth opening (MMO) measured at baseline, 48 hours after the last treatment, and 12 weeks post
– Treatment: 10 sessions over 5 weeks. Upper cervical flexion mobilization x10 min, C5 CPA x9 min, craniocervical DNF training with the use of a pressure biofeedback system

Results
– 19 patients (mean age 37)
– Significant improvements in masseter and temporalis PPT pre-intervention versus post-intervention
– Large effect size change in MMO pre-intervention versus post-intervention
– VAS changes from pre- to post-intervention that are significant and meet the MCID for improvement

1) Thoughts on the article? This article is several years old at this point, and while this group of researchers has put out several new cervical and TMD articles, I did not find a more suitable choice that focused on only myofascial TMD and not mixed symptoms. What are the articles strengths, weaknesses? What would you want to see in future research?
2) For those (hopefully faculty can assist here) who have seen cases of TMD with a predominantly myogenic component, what local treatments have worked best for you? Even if it is not pain provoking, how much time have you spent at the cervical spine? What techniques seemed to be most beneficial
3) What other good TMD resources are you familiar with?
4) What are everyone’s thoughts on the ear only pain that my patient presented with most recently?

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[Erik Lineberry]

1. I thought it was a well-designed article overall. A relatively small sample size, but I have found that to be common with TMD articles. I would like to see more studies of this manner that categorize TMD and treat with manual/exercises directed at muscle, TMJ, and Csp or a combination. Studies with bigger sample sizes or a SR would be interesting as well.
2. I have found STM and trigger point release to be effective for TMD with masseter and temporalis muscles. I have treated Csp with every TMD pnt I have seen will good results. What techniques I used depended on the deficits I found with cervical assessment. I also found that lateral glides of the TMJ itself to be effective with the patients I have treated with a unilateral deficit in motion or with mechanical sxs.
3. Attached is a physioedge synopsis I reviewed a few months ago that I found helpful.
4. Were you able to change these sxs with manual techniques or changes in TMJ position just to rule in TMJ as the structure at fault? The biggest concern for me with pnts that have TMD and ear sxs are hearing loss or disturbances. I would monitor those sxs carefully and refer if/when appropriate.

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[August Winter]

Erik,
Thanks for posting that review. I especially liked the mention of red flags and the detail in the subjective section. Sometimes knowing the right special questions can be the hardest part of seeing a diagnosis that is less common in your practice.

As for my patient, she had primarily OA and AA restrictions in motion. This is a patient that wanted to consult with PT but did not want to be seen regularly, especially since her symptoms were improving. Given the limited time frame for treatment, what home program would you give for exercises/self mobilizations for these areas in order to continue to work on motion and motor control?

And for the ear only symptoms, I was not able to reproduce them in the clinic with cervical assessment or local jaw assessment. Subjectively she felt like the ear symptoms would somtimes occur when she was exercising (doing a crunch w/a significant amount of superficial neck flexor activation) but this did not reproduce her symptoms in clinic. Given the findings of the second article, in which 25% of patients had mild hearing loss, what prompts your concern over hearing symptoms in this population? Have you had situations where these symptoms have progressed to be more severe?

[Erik Lineberry]

I do not any go-to self AO or AA mobs unfortunately. My first thought for motor control exercise for the upper Csp would be chin tucks with progressive head nodding and cervical rotation while holding the tuck. Attempting this in supine, seated and prone on elbows positions depending on the pnt’s ability to perform exercise and your goals. I think prone wors well for pnts that just cannot figure out what muscles they are supposed to use, but it can be challenging if their DNF are weak or fatigable.

For the TMJ specifically, I have found that working on control of lateral deviation has been effective for a few pnts starting with the use of a mirror to reduce shakiness of motion. I will progress this to restrictive lateral deviation with the pnt’s hand. I have never utilized a lateral pterygoid release, but have seen this be effective with pnts and it can be given as a self-STM for the right pnt.

As far as hearing changes go, I would love to hear others’ thoughts on this. I have had TMD for years. It has never given me much trouble, but within the last 1-2yrs have noticed more auditory sxs. I have started to worry that it may be time I seriously treat myself to prevent progression of these sxs. If I had a pnt report these sxs and they were not changing with TMD intervention after 2ish weeks I would most likely talk to them about seeing an ENT to rule out big scary stuff and prevent permanent hearing changes.

[August Winter]

I like the suggestion of the mirror exercises for lateral deviation for this patient. It’s like the article that Mike Reiman was talking about for upper trap endurance, maybe the muscle is painful and tender because of a lack of proper endurance versus an extensibility problem. This makes a lot of sense for muscles of mastication/speech.

[Scott Resetar]

1) Really great article. I like the treatments they chose, and it shows the CNS influence on orofacial pain. I am curious as to the rationale for using a C5 CPA for 9 minutes. Was this to mainly elicit CNS inhibitory mechanisms, or was this an attempt to change dysfunctional posture/biomechanics of poor upper cervical posture. My guess is the former, but I think hearing the authors’ rationale would be very interesting.

2) Personally I have used soft tissue work and inhibitive pressure. I have also referred some of these patients for dry needling with good results. As Erik said, I also have treated the cervical spine in all of my TMJ patients. The main TMJ directed technique I have used is a CAM glide ( Caudal, anterior, medial).

3) As far as resources, the two Shaffer articles from 2014 that were given to use as part of the VOMPTI weekend 1 cervical course have been my bible.

4) At the very least, if the patient hasn’t seen an ENT doc, I would refer them for exam. Wouldn’t want to miss something big. Same questions as erik, can you change any of the ear pain with manual techniques? I have a patient that has primarily tinnitus and not pain in his ear which can be changed with upper cervical techniques, by I have not had anyone with primarily deep ear pain.

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[August Winter]

Scott,
I did discuss making an appointment with an ENT with this patient. I think I was concerned about the ear symptoms, but after reading the second article I think I may have been a little hasty in referring out. I think if her ear symptoms were getting worse in terms of pain severity or frequency then a referral out may have been more warranted, but I admittedly could have done more to try to provoke it in clinic.

As for the choice of cervical treatments, I definitely was curious about their rational and what everyone else thought. For the CPA mobilization, my thinking is that if you were trying to target the C spine to influence the TMJ, wouldn’t you want to provide a treatment at C1-C3 so you are getting input to the trigemino-cervical nucleus? And I’ve seen that OA flexion mobilization before and utilized it only once, but I felt like it was kind of clunky.

Thanks for posting those articles again…

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