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.  

How We Learn Best

How should Physical Therapists learn?  It may not be a classroom setting.

I am a Physical Therapist in a primary care setting.  I work next to and co-treat patients with Doctors throughout the day.  Because of 

this, I am able to see a lot of the differences in how we have been educated, how we think, and how we clinically reason.  This difference has 

extended to how continuing classes have been designed.

 As I was talking with one of my Dr. colleagues he mentioned that he was going on a cruise to the Bahamas with his family.  He was 

taking a continuing education course and was planning on getting out of class early to enjoy the sun, family time and simply not being 

in his office.  “I bet there won’t be a lot of learning over there, right?” I quipped.  “Actually, I went last year and I learned a lot!” “I still 

remember a lot from those classes, something about short classes and having more time to discuss with my classmates afterwards just 

helped it stick.” He explained.  

This I found, is not only a common theme in Doctor classes but across our lives as well.  If I think back to lessons I learned both in rehab and 

out of it, I can point to many instances where the “a-ha” moment was achieved outside of the classroom.  This is backed by other 

reports as well.  In a Rasmussen poll 81% of respondents reported learning more outside of the classroom than in the classroom.  

According to Paul Hudson, writer for Elite Daily, the classroom/school setting is set up for short term goals:  semesters, grades, report 

cards.  Life doesn’t always work this way.  His article further explains that In real life networking and long-term goals are most often 

what helps someone progress professionally.

There are countless examples of people who suffer great pains to learn Algebra in school only to thrive when asked to do the same 

problem as it applies to their job.  Examples include a chef who has to triple a recipe or a carpenter asked to calculate area, volume, 

and circumference when building cabinets.  As a Physical Therapist, my key moments came with mentorship in the clinic, not the 

classroom.  In addition, most PTs will tell you that they have learned far more after they graduated as a clinician, than from school. 

I don’t want to conclude that the classroom is a bad way to learn, in fact, I do not see any other way to teach valuable information to a 

large amount of people.  What I do see however is that we have fallen into a rut as far as teaching in most continuing education 

classes.  My question:  Is there a better way?  Can we make information “stick” if we change the environment?  Is the Doctor’s class in 

the Bahama cruise onto something?  

Many other professions have already started vacation / education classes.  The reason for this seems to be more complex than improving attendance.  There is 

the additional benefits that come with travel. These lead to networking opportunities and participation in activities after the class.  These

lead to professional connections, more access to instructors, and even friendships.  Consider this quote from the U.S. Ambassador for 

the Asia-Pacific Economic Cooperation on why he held his most notable meetings at a vacation spot in Hawaii, “When people are 

relaxed, they think more clearly, and when they think more clearly, they’re more likely to come to conclusions that result in 

agreements.” 

 I may be biased but I can’t think of a profession that could benefit more from this than Physical Therapists.

 

 

Randal Glaser PT, DPT, OCS is a Physical Therapist in California and is currently working on developing continuing education courses for 

JetSetRehabEd.com.

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