Case of the Week 10-10-11: TMD and Lumbar Derangement: Pain Explained! | Modern Manual Therapy Blog

Case of the Week 10-10-11: TMD and Lumbar Derangement: Pain Explained!

History: Pt is a 45 yo female that was involved in a MVA 6 months ago. She had onset of right greater than left LE pain to above the knees, facial pain, earache, cervical pain, and bilateral UE pain to above the elbows. Since then, her complaints have been worsening. She had stopped most her regular exercise routine. Her Sx were worse in the morning, at night, with sitting, chewing, cervical and lumbar flexion, and use of her UEs. She was previously very active and was quite upset at how long it was taking her complaints to resolve.



  • flexion: mod loss, PDM
  • extension: sev loss, PDM
  • SB Left mod loss, ERP, right sev loss, PDM
  • rot Left min loss, ERP, right mod loss, PDM
  • flexion: mod loss, PDM
  • extension: sev loss, PDM
Mandible ROM
  • depression 28, PDM, deflects 1 mm to right
  • lateral excursion Left 5 mm Right 8 mm, no clicking noted
Myofascia: severe restrictions in right > left masseter, cervical paraspinals, scalenes, SCM, lumbar paraspinals

PIVM: severe loss of bilateral OA FB, mod loss of C2-4 right > left in downglide, bilateral 1st rib inferior glide, L5-S1 P/A glide

Repeated motions:
  • cervical retraction: decreases cervical pain, better as a result
  • lumbar extension in standing: mod loss, increases lumbar pain and LE pain, worse as a result
Assessment: Signs and Sx consistent with chronic TMD, cervical and lumbar derangements.

Treatment: Day 1, TASTM to cervical paraspinals, STM to masseter, postural correction, use of lumbar roll, HEP of cervical retraction.

Day 2: Pt unchanged, still frustrated. STM to masseter, added 1st rib mobs, subcranial shear distraction which enabled pt to perform cervical retraction with much less pain. Reviewed HEP.

Day 3: Pt reports not being any better. Normally, my deal is some change, ANY change within 4-6 visits or it's back to the referring doc. After some discussion, she stated the frequency of her complaints was less in the cervical spine. We had been focusing on this as per her evaluation, her complaints were upper > lower quarter. I added TMJ mobilizations bilaterally in distraction, lateral glide on right and medial glide on left to improve the slight capsular pattern. She left feeling a bit better about her condition.

Day 4: I added lumbar TASTM and P/A glides to her lower lumbar spine. Afterward, she was able to extend with much less pain, her ROM improved to moderate loss, which continued to improve with reps. Extension in standing was added to her HEP.

On days 5-6: The pt reported no change, and she was getting more frustrated. She stated the TMD specialist recently told her in the best case scenario, she would be wearing her orthotic nightly for the rest of her life. She was "tired of telling everyone she is in pain." She was considering going to a TMD specialist in out of state and a neurosurgeon in another state. 

Here is my David Butler, Explain Pain, moment. 

I told her in my 13 years of practice, even if patients get to be 100%, they ALL wore their orthotic at night. I told her that her condition was the "average" TMD and lumbar condition that I saw daily in my clinic. We needed more time than 3 weeks for 6 months of symptoms. The best specialists in the world could only offer her surgery, which she never wanted, or just another shot and pill regimen. She wasn't interested in that either. 

I then told her that if she gets to be 100%, the orthotic would only be worn when she was sleeping in bed, that she should think "This thing is great! It helps keep my jaw aligned and my symptoms away." It was a small price to pay to get and stay better. She stated that was a good shift in thinking because she was previously very upset she would have to wear it nightly for the rest of her life. When she said she was tired of telling everyone how bad she was doing. I told her, you stated you are feeling better in the face and cervical spine. We have identified a motion for your lower back that helps. From now on, when someone asks, "How are you,"" you tell them, "I'm doing great!"

Something clicked.... she stated she would tell everyone she was doing great from now on. She also felt better about wearing the orthotic and it would be only when she was sleeping anyway. This 10 minutes of discussion probably did more than all my STM, JM, and postural correction combined! It successfully reduced the perceived threat and prevented her catastrophization. I haven't seen her yet for the next visit, but I have no doubt she'll tell me she is doing "GREAT!"


  1. Hi Dr.E

    I just recently discovered your blog and I'm loving it!

    I study phsyiotherapy (or physical therapy as you call it over there!) in the united kingdom and i have some difficulties to figure out some of the abbreviations you use on here eg PDM, SCM. if you could please kindly comment back on what these abbreviations are that would be fantastic.

    Best wishes,

  2. Some of the abbrevations are MDT or McKenzie Mechanical Diagnosis and Therapy. PDM means pain during movement, typically seen in the Derangement Syndrome. SCM means sternocleidomastoid. Any other ?'s ask away!