May 7, 2020 at 5:32 pm #8615
A 34 year old female mother of three children under 6 years old is referred from her dentist with chronic pain and intermittent clicking in her right jaw for approximately four years duration. She reports constant clicking and headaches in her head and jaw. With further questioning, she reports having anxiety and depression since she was 14 years old. Her husband works and travels often leading to her managing 90% of the household. Her family just moved to the area leaving her extended family for her husbands job leaving her without help around the house.
Attached are 3 articles for the research folder.
Questions for thought
Let’s talk subjective first – what are 1-2 questions that you want to make sure to ask this patient to help with your differential diagnosis? Be specific about what those questions would then lead you towards in differential lists, POC, etc.
I’ve attached a great two-part review paper on TMD eval/treatment. Pay attention to the diagnosis and interventions sections.
There is a clear underlying psychosocial issue occurring with this patient. Look at the third article and discuss your thoughts on when and how you will address this aspect of her care.
Knowing there is a psych piece to this case, how will you still treat the impairments? How will you organize visits to maximize time and address all patient needs.
May 16, 2020 at 1:36 pm #8635awilson12Participant
– want to know more about headaches (see if they are cervicogenic in nature and joint vs myofascial)- are they unilateral, where exactly are they, are they associated with n/v, light intolerance, etc, any neck pain associated with these
– does she feel like her jaw gets stuck/limited in range of motion (can help to differentiate disc displacement w/ or w/o reduction going on)
Thoughts on addressing psychosocial component:
A good starting point may be asking her if she has noticed any relationship between increased pain and increased stress/emotions and then this may be a good lead in to starting to get her to realize the multifactorial contributions to pain
I think that care needs to be taken with education and treatment to address psychosocial contributions while treating underlying impairments that may also be contributing
May 17, 2020 at 3:39 pm #8636
Great points Anna
When someone has high pain levels, changes in ADLS due to psychosocial factors, do you find that pain education goes smooth?
How have you changed your education with these patients?
If the patient said the clicking was early in the opening vs end range would that change your treatment approach clinically?
May 21, 2020 at 11:52 am #8639Taylor BlattenbergerParticipant
Subjective – I think Anna had great points about identifying the nature of her pain and the way it behaves. This can tell us a lot about the structure at fault (if there is one).
I would also like to know about the aggs/eases/limitations for this patient. When does she experience this pain? Talking (how long?), chewing (what kind of foods, how long?), brushing her teeth (manual, electric toothbrush?). With the common association of TMD and cervical pain, does she have classic cervical aggs such as rotation, postural intolerance, etc. This will let me know where and when she is functionally limited and how we can ease that with out POC.
Psychosocial – In my experience people are usually accepting of the link between “stress” and TMD. They already associate stress with “tension” in the neck and jaw and this can be an easier sell in terms of education. I want to know more about how this stress affects her and how she’s managed it in the past. Due to her recent move she may have less time allocated to her own pleasure and stress relief activities. This may be a good place to start before making a full psych referral.
Management – **Assuming this case is CS and psychosocial > mechanical** I think this may be a case that is managed best with infrequent visits over a longer period of time. She may need some impairment based treatment that can be easily worked into an HEP, but I think a touch and go approach would be best. It would also help to ensure she took the necessary steps to improve her stress management long term.
May 21, 2020 at 12:33 pm #8640awilson12Participant
I feel like a lot of times people are able to relate increased pain with increased stress, but getting them to really understand this and steer them away from the “something must be wrong” mentality is tough. I have tried to change my education in these situations to be more reflection for the patient and a conversation vs spitting pain science at them. Still a work in progress and patient dependent on what is successful.
I’m not sure that when the click happens within the range changes a whole lot treatment wise, but I could definitely be off on that. From my understanding a click usually represents the disc translating/moving at inappropriate times. If it is a motor control type issue or due to hyper or hypomobilities on either side then you should treat those impairments and reassess.
Anyone else have thoughts on this?
May 23, 2020 at 10:22 am #8642helenrshepParticipant
Subjective – I think Anna and Taylor’s line of questioning is great. The only thing I would add is getting a better idea from her on big picture and daily timeline. Over the past 4 years has her pain been fluctuating? Is her pain different first thing in the morning compared to at the end of the day? Lastly, what has the dentist already done for her? It would be good to know if this is one of those situations where she’s been through 20 mouth guards with no relief.
Psychosocial – I definitely still struggle with this, but this patient is one that I would spend SO much time talking to and listening to. It sounds like she’s got a lot on her plate, and it may help her pain for the PT to just listen to her story and express empathy. I would also gently start to educate her on how pain works – my approach with someone like this would be to give her the basic science and then maybe use some examples involving kids. That way she hopefully feels less like we’re telling her it’s in her head or personally offending her. I think Anna’s point about asking her if she’s noticed a link between her jaw pain and stress is super valid. Sometimes just pointing that out is helpful. I also have no qualms about asking someone if they are seeing a mental health professional, so I’d ask her that. And then try to figure out some ways to incorporate things she likes doing/relaxation activities into her day.
Treatment – again, I agree with Anna and Taylor. I don’t really know if when the click happens matters a ton. I would for sure be looking at both sides to see if maybe a hypomobility on the “unaffected” side is contributing to issues on the affected side. I’d check her cervical spine out too since the two are usually linked and since she’s reporting headaches. It also seems like this is a patient who would do well with less frequent visits, and probably appreciate a solid HEP rather than having to come into the clinic. Depending on how the education is going, she may be one that I’d recommend Mosely’s book to. That way she can work through it on her on at home whenever she has time.
May 24, 2020 at 7:10 pm #8643Steven LagasseParticipant
Trying to dial into a pathology with only 1 to 2 questions is challenging. Adding the fact that this patient has obvious yellow flags makes the task even more challenging. Under these constraints, I would ask the following:
The first question I would ask is if she notices a reproduction in her symptoms with motions local to the cervical spine. This would begin to help rule-in or rule-out an upper cervical component.
Assuming the first question “ruled-out” the cervical spine, my next question would be to dive deeper into what specifically causes and/or reproduces her symptoms. I would want to know if it was the actual popping or the act of engaging the joint and adjacent musculature (without a pop) which reproduced her symptoms. This would allow me to begin differentiating between joint and/or myofascial pathology versus pathology of the disk.
Regarding management, I think yellow flags need to be addressed first. I would plan to start globally and, over time, become more narrow in my approach, focusing on the local impairments. The two patient’s I’ve treated with pain local to the TMJ benefited a great deal from education and reassurance. These individuals came in with poor beliefs. For example, one patient believed their jaw was disintegrating and breaking down the more they open/closed their mouths. With that, I believe education regarding the fact that movement, although currently painful, is overall safe, to be helpful. Secondly, it has also been my experience that many of these individuals went from living a normal lifestyle to becoming extremely sedentary due to the severity of their symptoms. Therefore, encouraging basic exercises such as returning to low-grade aerobic exercise and normal duties is helpful. I feel that would be the best/safest place to start given the limited information regarding this patient.
- This reply was modified 1 year, 4 months ago by Steven Lagasse.
May 26, 2020 at 12:14 pm #8645
Great discussion everyone.
I like how you focused on listening above throwing pain science out first.
Linking the stress, using analogies are great ideas.
The point I was trying to make about clicking is related to the hypomobility at end ranges vs motor control midway through the motion. If the diagnosis is off, you make be strengthening when the joint needs more mobility or mobilizing when motor control should be the focus.
Differential diagnosis is important and making sure you have a few for TMJ is important because it is not always the disc driving symptoms.
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