5 Things rehab specialists need to know when treating TMJ pain.

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This photo is from a Doctor's note documenting their treatment plan for Temporal-Mandibular-Joint pain or TMJ pain.  These are good general recommendations however most patients can find this type of treatment / advicewith a quick Google search.  When they make an appointment with a rehab specialist, they are looking for more than just general recommendations. 

They want to know:  a) why they have the pain, and b) how to fix it.Soft tissue work, passive modalities and eating soft foods can get them started but will it fix the underlying factor that caused the pain?

 TMJ pain is estimated to effect 22% of the population at one point in their lives.  Despite its common occurrence, it is one of the conditions that get put into the background with pre professional education and thus is met with anxiety.  But as Wayne Dyer said:  “When you change the way you look at things, the things you look at change.”  For me, this rings true for my journey learning to treat TMJ.  The person who got me and countless others to change the way I look at things was Nancy Adachi.  I took her weekend class in 2010 and still remember it and refer to my notes often.

Here are 5 things from Nancy Adachi's manuscript and class, that I feel everyone who treats TMJ should know.

Note:  (I know, I know…there are more than 5 but if you want more information, you can read her 76 page manuscript or, I highly recommend taking one of her classes)

 

1.     Treat the cervical spine:                                                                       

   Know how cervical posture relates to the TMJ.  Lengthened deep neck flexors combined with upper cervical extension can increase TMJ compression and pull it out of centration.  As the head sits with this forward head posture for prolonged time, the deep neck flexors can become lengthened leaving the jaw in a retruded position.  This can lead to trigger points and abnormal wear and tear in the TMJ.  Often we must treat the cause of this posture, which is often multifactorial: eyesight, lumbo-pelvic issues or ergonomics are common causes. 

 

2.  TMJ Disks, know when the disk is the issue and what treatment works best for this.

   Disk displacement without reduction is usually an anterior and medial displacement, which makes the posterior part of the disk the weight-bearing surface.  This can often lead to a clicking and if severe limited 25mm jaw opening.  Those with clicking and full range of motion have early stage disk displacement, which is labeled “with reduction.“  Sometimes this will be accompanied with a lateral deviation.  If translation of the TMJ is effected, manual therapy techniques can help here. 

                 

3.  Don’t forget to rule out muscle coordination deficits.

   If you place your fingers in front of your ear and then open your mouth, you may feel one side of your TMJ push into your thumb before the other.  I can’t tell you how many times patients are able to abolish their pain by syncing both sides to move simultaneously.  In this case the treatment would be coordinating opening and closing of the TMJ without clicking and simultaneous movement.  No pain and no clicking indicate they are performing the movement correctly.  Often this is the only home exercise they need.

                 

4.  Don’t forget about the emotional component.

  These patients are really suffering.  I mean how would you feel if you were unable to eat, yawn or talk without pain?  TMJ is linked to fibromyalgia (some studies report 75% of this patient population) and can be linked to high anxiety behaviors such as jaw clenching or teeth grinding.  For this reason I try to be especially understanding and reassuring when communicating with these patients.  I also make sure to spend extra time educating them on the condition and the plan of care.  Changing our language to reduce the threat of their TMJ pain is also a good idea.

 

5.  Know when to partner with the Dentist, know how to communicate with them.

Many times if there are structural issues with the teeth, rehab prognosis will be limited.  At times due to grinding at night and night guard may be indicated.  This is when collaboration with a dentist may be needed.Here are some definitions I have found useful when communicating with dentists:

occlusion– the bringing of the opposing surfaces of the teeth into contact.    

Anterior open bite– back teeth in contact while the front teeth aren’t touching.  

Cross bite– one side of the mandible larger than the other.                                                     

Posterior open bite– a bite when the front teeth are touching while the back teeth aren’t.         

Envelope of motion– a dental concept of extreme movement of the jaw in a sagittal plane.

 

This is just the tip of the iceberg as far as TMJ treatment considerations.  There is much, much more to learn about the TMJ beyond the scope of a blog posting.  If you are intrigued or need to, as Dyer says, “change the way you look at things” take a class from an expert such as Nancy Adachi.

I cannot recommend her class enough!

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 Update:  The class was a great success. 

below is a video from Nancy's class with Jetset Rehab Education.

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Nancy Adachi on the right with fellow student JoAnne in our spring class.

 

Randal Glaser PT, DPT, OCS, CEAS I, is currently working as a Physical Therapist in California as well as organizing classes for Jetset Rehab Education.  He is a published co-author in JOSPT and a graduate of the Kaiser Orthopedic residency and the Movement Science Fellowship.  

Networking in Physical Therapy classes, a Fight Club perspective.

 

Networking in a Physical Therapywhat Fight Club taught me.

Networking is one the core values of the JetSet experience. It is a value that can enhance course understanding and expand a therapist’s understanding of their profession via interactions with fellow participants. 

In the movie Fight Club, Edward Norton’s character, looked forward to his flights on an airplane. He realized of the countless hours spent on a trip, the most memorable involved networking with his “single serving friends” that sat next to him.  His character (albeit twisted and cynical) goes on to meet a specific friend, Tyler Durden whom transforms his life forever. If you are physical therapist like me, you have a little bit of Ed Norton’s character in you. You have spent countless hours in school learning your craft and then additional hours in continuing education courses refining your skills. However, you realize that like his character, the journey is only part of the experience; the interactions with your colleagues are clearly as important.

Attending various continuing education courses over the years, I have realized that part of what made course experiences valuable was my   interactions with colleagues. Attending a recent lecture on the DNS approach, I had questions about handholds that my classmates were able to critique and correct. Over the course of the one-day lecture, I found the interactions with my fellow colleagues bridged the gaps and made the class an even more meaningful experience. Additionally, networking with my colleagues during the course provided valuable clinical pearls that eventually lead to positive outcomes in the clinic. 

Learning from my colleagues enriched my experience of the course content. However, networking during breaks and lunches also gaveme a better understanding of my profession. At a prior course, I learned how newly passed direct access law were affecting clinicians with regards to care and payment. In prior courses, I’ve even had the opportunity to meet international PTs whom discussed their practice in their respective countries For example, back pain patients check into the hospital for their symptoms in certain European countries & ACL patients can spend months rehabbing in the hospital in Japan!Having networked with my colleagues showed me how diverse our profession is internationally. 

Networking has also illustrated how techniques can be utilized differently in specialties outside of orthopedics. In an MSIcourse I took a few years ago, I encountered therapists whom were utilizing the concepts learned on vestibular and neurologic patients.This brought to light how clinicians use“orthopedic” concepts in specialties not thought of as normally utilizing orthopedic skills. 

Networking and interacting with many of my colleagues over the years has provided me with unique experiences that have enriched course content and broadened my understanding of our profession as a whole. In understanding the effect these experiences have had over the course of my career, I truly feel as lucky as Edward Norton’s character did on his plane when he met his friends. Looking back, if I had avoided these opportunities to network, my growth as a professional and a person surely would have been hindered. At your next class, remember to embrace your inner Edward Norton and reach out to your fellow colleagues. You may find that your class experience may be that much more beneficial.

Jay Bhatt is a Physical Therapist whom is an OCS and Published in JOSPT. He is one of the founders of  JetSet Rehab Education. 

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