TMJ case

[lacarroll]

Hey guys. I have an interesting TMJ case on my patient load right now, so I thought I would share the details and the articles I found, along with my problem-solving/thought process during the eval and treatments.

Patient Profile: 25 yo female
Chief complaint:
– Intermittent jaw pain L>R
– Occasional headaches
MOI:
– 4-year history of jaw pain that started during her first year in college, progressively increased through 2nd-3rd years of college;
Previous treatment:
– PT previously that helped some- massage mainly
– Psychiatrist for depression, stress management
– Mouth guard from dentist (fitted)
Imaging:
– MRI in 2016: “Severe right and moderate to severe left TMJ joint degeneration”
Aggs:
– Talking too much
– chewing too much
– hard/crunchy food
– laying on left side
Relieving:
– Prescription meds
– NSAIDs
– Rest
– soft foods
– cutting down on talking
Objective:
– Posture:
o Rounded shoulders, forward head
– Observation:
o “C” motion with mouth opening (convexity on L)
o Facial mm asymmetry
– ROM:
o Cervical: all motions APR WFL with no symptom provocation
o Mouth opening: limited with audible click upon max opening
o Protrusion: ~1 mm
o Lateral deviation: L>R
– TTP: B TM joint line, B masseter, B temporalis

Treatment for Day 1:
– Education on posture, stress, clenching, chin tucks , stress management

Treatment for next visit:
– Distraction and anterior glides of R TMJ
– Seated chin tucks with rot
– Cervical isometrics with scap retraction
– More education

So I know that’s a lot of stuff, but I’d love to hear what y’all think and what you would have done differently, especially with the eval or treatment, or if you think there’s something I should do/try going forward with her.

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[Taylor Blattenberger]

Yikes! I don’t think I’ve looked at a single TMJ case since school. Great share on the article. That really helped review the anatomy and concepts around the joint/pathology.

Leaning on the article(s) you shared, I’m going to utilize the RDC/TMD. From the subjective and some of the objective info it seems she fits in the myogenic category at least, and we can rule out cervical involvement. Did you test any joint compression or glides? We know the radiograph found abnormalities, but I am curious if the joint is driving any of the symptoms especially given the audible mechanical symptoms.

[helenrshep]

So I’ll give you my 2 cents but like Taylor I haven’t done a whole ton of TMD stuff…

Cervical spine: The research points out that the cervical spine is almost always involved. I saw that you cleared the cervical spine but then gave her c-spine exercises anyway. I would maybe take a closer look at her cervical spine (especially upper given the headaches – does she feel those are associated her jaw pain?). That way maybe your treatment/exercises can be more specific to your findings, even if a general APR didn’t reveal much.

Activity modification – did you guys talk about foods to limit/limiting chewing gum?

What do you think about the Rocabado exercises and the Kraus TMJ exercises? And what about the multimodal approaches discussed in the second article? Maybe incorporating some ideas from those could be good for home exercises.

Which classification system would you put her in? I think myogenic and disk displacement with reduction. Did you look at the joint compression test?

What did you think her severity/irritability level was? Seems like determining irritability is especially important with TMD due to it’s influence on how you dose exercise (avoid under or over dosing).

Shout out to dry needling! I’ve had some good success with needing TMJ so it might be something on the books if you end up needing a leg up in the right direction. I’d at least incorporate a fair bit of soft tissue work with the masseter and temporalis.

[Steven Lagasse]

Interesting case. I also had a recent TMD case. Thankfully this individual came in during my mentorship time with AJ. After looking at the script “TMJ Dysfunction” AJ stated, “TMD tends to be associated with cervical pain, and a host of biopsychosocial factors – I wouldn’t be surprised if she was anxious and catastrophizing.” Sure enough, the body chart showed cervical pain, and her PMHx had anxiety and depression checked off. You cleared out the cervical spine nicely. However, were you able to dive deeper into their depression? They’re being treated but is this treatment working for them? If they’re taking medication, is this medication helping them to manage their feelings/emotions?

[Michael McMurray]

I have no personal experience with TMD, so I have no golden nuggets to give you unfortunately.

I see that you cleared the cervical spine with APR with no limitations or symptoms but did you do any quadrants or combined movements? In the articles provided, cervical spine was involved with majority of TMD cases and therefore I am slightly skeptical that there were no limitations or symptom provocations especially with concurrent headaches. Also did you do any PPIVMs/PAIVMs of cervical spine?

Objective
Were the limitations found with TMJ movements active or passive and did you perform any accessory mobility testing of the TMJ?

Interventions
Cervical isometrics – With no limitations or symptom provocations with cervical testing, what made you choose this intervention?
Did you think about utilizing any of Rocabado’s or Kraus’ interventions to directly address with limitations found in the eval such as: rest position of tongue for promotion of diaphragmatic breathing which may help with relaxation, control of TMJ rotation which could prove as a good NM control intervention, Rhythmic stabilization technique for isometric strengthening and relaxation via reciprocal inhibition, touch and bite for proprioceptive re-education, and other TMJ isometric exercises
Lastly if you find/found limitations with accessory motion you may be able to teach her some self mobilizations for HEP.

Awesome job and good luck with future treatments!

[awilson12]

Thanks for the post! Definitely helpful to see a case spelled out to think about what I might expect and things to look at before I am thrown in the hot seat when I have this diagnosis. Also the articles provide some good guidance for examination and treatment.

Kind of going off what Helen and Brandon hit on… with there traditionally being a high likelihood of a cervical component along with TMD, what exact cervical screening did you do? Did you do quadrants, compression, or specific OA and AA differentiation tests? Definitely seems like TMJ is involved from your findings, but could just help identify another area of treatment if you didn’t already do as provocative cervical spine tests in your eval.

What method did you use to quantify TMJ range of motion?

From my (limited) understanding I think I remember learning that with a C curve it deviates to the side of the hypomobility? So if its convex to the left then that would mean R was more hypomobile?
Evaluation wise were you able to identify specific TM joint restrictions that guided your treatment in addition to range of motion loss? What did you use as your test-treat-reassess asterisk for TM joint mobilization?

[lacarroll]

Sorry it took me awhile to get these answered, it’s been a long couple of days, so I’m going to do my best to go down the list and clear up all the questions/thoughts. Here goes:
– Taylor: I definitely thought she fit into the disk displacement with reduction category WITH myogenic involvement. I did not assess joint glides day 1, just because I wasn’t sure me sticking my hand in her mouth to move stuff around was the best idea.
– Helen: so this girl was great in telling me in the subjective that she no longer chews gum, has switched to a soft food diet, and noticed that her headaches tend to come on when she’s been clenching more throughout the day, so that helped me a lot in the decision between cervical vs TMD. I did not do the compression test, but that’s something I definitely want to take a closer look at in future cases. As far as irritability, she was having a really good day when she came in for the eval, so she was pretty low irritability with minimal symptoms. She has SO MUCH muscle involvement that I’ve actually considered dry needling for her. Do you have any good articles supporting dry needling in this area??
– Steven: her psychosocial components were high on my list for the eval. I asked her about her depression and it’s currently under control, but there was a point in time where she took 1-2 years off in college because of stress and depression, so it’s definitely on my radar for this one. I talked with her a lot about her day to day activities and asked her to tell me about some of her stress management techniques and that made me feel better that she had a solid grip on it, along with taking a prescription medication.
– Brandon: I was actually surprised her cervical spine didn’t seem to be involved, but I didn’t do PPIVMs/PAIVMs during the eval. The limitations I found were active with ROM at the TMJ, and again, I didn’t do more accessory testing than that. I chose cervical isometrics for posture because hers is just so bad. I also kind of picked through the Rocabado’s and Kraus’ and mixed and matched techniques for this patient. I had her perform the cervical isos and scap retraction exercises with the tongue on roof of mouth position (TROM), isometric lateral deviations & mouth opening also with TROM, and she fatigued out with these really quickly. And I’ll definitely look into the self-mobs for the HEP, I think that would be a good addition to the treatments in the clinic.

[lacarroll]

Anna: that’s how I understand the hyper/hypo mobile C curve to work too. With her Cspine, I did cervical APR and axial compression, but I think I should have done Spurling’s as well to maximally stress those tissues and feel more confident that they aren’t involved. As far as quantifying her ROM, I used her teeth as landmarks for measuring deviation, 2-3 knuckle method for mouth opening, and her protrusion was to the line of her upper teeth, so that was harder to measure because it was such little motion. As far as test/treat/reassess after joint mobilization, I have looked at the quality of her mouth opening (decrease in C curve) as well as pure ROM for mouth opening, which is showing improvement so that’s pretty cool to see within session.

[Steven Lagasse]

I am writing up a Clinical Reasoning Form on my TMD patient. My PICO question led me to this systematic review. It’s quite long but there is a short and sweet section regarding some of the current evidence (or lack thereof) on manual therapy and exercise therapy.

Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis

[helenrshep]

Here are 2 articles about dry needling for TMD. Sounds like you’re on the right track with this patient!

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