Case of the Week 2-20-12: Textbook TMD | Modern Manual Therapy Blog

Case of the Week 2-20-12: Textbook TMD

ouch!
As I'm preparing for my webinar tomorrow, I don't have time to write a really detailed case, so I thought I'd write about a simply successful one in just 6 visits.


History: Pt is a 42 yo male who c/o left TMJ and ear pain, facial pain, cervical pain bilaterally and HA. His main complaint is for over 5 years, his malocclusion, causing no contact of his rear molars bilaterally. This made it very difficult for him to masticate.

Q: What's the first thing you should do after taking your history with any patient who has a spine?
A: Sit up straight as you're reading this, and correct the patient's posture!!!!

Upon postural correction, with increasing his lumbar lordosis, and placing his head and neck over his shoulders, his occlusion was perfect. We had him slouch again... malocclusion... sit upright... normal occlusion. Naturally, in a textbook case, his cervical pain also improved.

Objective: mandible shorter side on left (Rocabado indicates this is a sign of greater dysfunction), also proven to be sign of unilateral HA

  • ROM
    • mod loss of cervical extension
    • cervical SB mod loss bilaterally, rotation, min loss bilaterally
    • flexion WNL
    • mandible depression, 33 mm, deflecting to the left 3 mm (capsular pattern)
    • mandible lateral excursion left 9 mm, painful, right 4 mm, painful
  • myofascia
    • mod restrictions in left > right masseter proximally to distally
    • mod restrictions along occiput laterally to medially
    • mod restrictions in left > right cervical paraspinals C2-4 proximally to distally
  • PIVM
    • grade 1 left > right bilateral OA forward bending
    • grade 2 C2-4 downglide bilaterally, left C6-7 downglide, left 1st rib inferior glide
Assessment: Signs and Sx consistent with chronic TMD with upper cervical dysfunction causing cervicogenic HA

Treatment:
  • visit 1
    • STM to masseter bilaterally
    • IASTM to occiput and posterior cervical spine
    • instruction on use of a lumbar roll, cervical retractions to be performed hourly
  • visit 2 - pt 75% better in terms of left TMJ pain, HA abolished, very pleased
    • same treatment as above
    • added TMJ mobilizations, distraction bilaterally, lateral glide on the left, medial glide on the right (improves lateral excursion to the right)
    • skull-crushers added (subcranial shear distraction)
  • visit 3 - pt unchanged, treatment unchanged
  • visit 4 - pt reports being worse at night and in the morning, slept mainly on left side, instructed on supine and right sidelying and told to buy a cervical pillow
  • visit 5 - use of cervical pillow and supported sleeping as instructed here now made sleeping and waking completely pain free, added retraction overpressure to maxilla
    • I NEVER use overpressure force on the mandible, even the MDT Dips state they do not have great outcomes with the TMJ - because it cannot be treated only with repeated motions if not a simple postural problem (like this case partially was)
    • mandible retraction is one of the main reasons why the TMJ posterior bilaminar zone become irritated and the discs often sublux anteriorly, so why would you instruct a patient to overpressure their mandible?
    • manual treatment as above
  • visit 6, completely Sx free, very pleased, back to eating normal foods
  • visit 7, cancelled because he was feeling well.
Remember to fix posture, RIGHT after the subjective, show cause and effect and cross your fingers and hope it works. It often reduces cervical, upper trap, lumbar, shoulder, and mandible, tenderness, pain, and if lucky, centralizes lumbar and cervical radiating complaints. It can even change ROM, strength, and DTRs. 
Hope you found the case useful!


6 comments:

  1. Glad to see a "textbook" case of TMD managed with rehabilitation. No surprise that there was significant sagittal stability impairment from pelvis to occiput. The unfortunate fact is that many cases like this (5 yrs of pain) have already involved significant orthodontic intervention.
    Thanks for sharing.

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  2. Thanks Brad! Yeah, sad that it took 5 years for him to find his way into my clinic. I mainly treat spinal and 70% TMD in my practice. With some education to local docs, I'm seeing them sooner and sooner. It's can be a combo of the pt not thinking there can be anything done and PCP telling them so.

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  3. Erson, thanks for the post. I also find the interesting relationship between posture and occlusion, very intriguing. I had a hard time finding a solid textbook on TMD from PT perspective, do you have one to recommend? I know you are a St. Augustine grad and likely had exposure to Rocabado's teaching? For a non St. Augustine grad, do you have any suggestions on courses to attend on the matter? Thanks so much for your time. By the way, I enjoyed the 5 things you didn't know about me post you made. The path to excellence can be quite bumpy and takes some unexpected turns doesn't it.

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  4. I highly recommend taking all of Rocabado's courses through the USA. I finished them and also got certified from the man himself. It also makes you much better at treating upper quarter conditions in general.

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  5. Any textbooks or online courses? The 2014 schedule is quite full!

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  6. I'll look around for online courses and get back to you!

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