Case of the Week 6-11-12: Non-Textbook TMD | Modern Manual Therapy Blog

Case of the Week 6-11-12: Non-Textbook TMD

What does starburst have to do with a TMD patient? Follow the break to find out!


Textbook TMD case here.

History: Pt is a 26 yo female, textbook in appearance, protracted cervical spine, extended at subcranial, protracted scapula. She is extremely lax, previously ectomorphic, but has some thyroid issues and others causing gradual weight gain. Currently c/o bilateral facial and earache with TMJ pain starting insidiously 5 years ago, and have been worsening since. She also reported B cervical and thoracic pain, which she attributed to hypermobility.

The non-textbook part: Sx worse with heat. She is better with eating very chewy candy, eats up to 40 starbursts a day and experiences 100% relief of complaints only for the duration of chewing. Sx are also relieved with eating cold food, and antibiotics.

She consulted with two different ENTs who thought she may have a sinus infection and prescribed antibiotics. The first time on a z-pack, she experienced 100% relief of her complaints, but they returned after 2 weeks, she was then placed on a 10 day, which again gave her 100% relief, but Sx returned in less than 2 weeks. At time of eval, she was on her 6th round, but after the 5th, Sx returned after only 2 days. Sx on average are 5-7/10.

I told her I was at a loss for why that would help, when all other studies/signs showed no signs of infection from several different MDs. I have suggested on later visits that there was a central sensitization component and explained why.

Objective: (only listing deficits)

Cervical flexion: DP, min loss
Thoracic rotation right, DN, min loss

Mandible depression 42 mm, deflects 2 mm to right

Myofascia: mod restrictions in B masseter, temporalis, occiput bony contours lateral to medial, C2-4 in proximal to distal.
Corrected sitting posture centralized and abolished current cervical pain and occipital HA.

I explained the postural implications on the head, neck and mandible and she understood. Piece of cake.

Assessment: Signs and Sx consistent with chronic TMD with accompanying cervicogenic HA.

Treatment 1: IASTM to cervical paraspinals, subcranial shear distraction, STM to B masseter and temporalis.

Treatment 2: Pt just coming off of antibiotics so she had increased pain to 4/10. Treated as above, added TMJ mobilization in distraction.

Treatment 3: Pt Sx increased to 5-6/10, but she was now 4-5 days after stopping her antibiotics. Cervical and thoracic pain abolished, but still had bilateral facial and earache.

Treatment 4: She reports pain decreasing for the first time to 3-4/10 overall, but was still eating 40 starbursts (an entire bag) daily during a flare-up which occurred for no reason she could think of. I tried medial/lateral glides to replicate mastication which is not uniplanar like pac-man.

I told her to think about which part of mastication, compression into the sticky candy or pulling her teeth apart gave her the relief and she would note on next visit.

Treatment 5: Her complaints were 5/10, still better with starburst or ice cream. She stated pulling her teeth apart after chewing into the starburst gave her the temporary relief. I performed STM to masseter and temporalis, then tried TMJ distraction with anterior translation. This immediately relieved her complaints for the first time.

In speaking with the MDT Diplomats, they told me they are still searching for a DP for the TMJ. If anything it would be light anterior translation, but normally, postural correction would take care of the mandible repositioning. I cautioned them against repeated anterior translation because if the articular disc is subluxed anteriorly, it would potentially further sublux or disclocate it if joint space was not improved.

However, I went against my gut feeling and told patient to perform light mandible anterior translation 10 times/hour.

Treatment 6: She had to cancel 1 visit, and ended up following up well over 1 week later. She happily reported that the repeated anterior translation kept her facial pain and earache at a 1/10 at the most. No starburst was needed. She did have 1 minor exacerbation to 3/10, but she realized it was from lying out in the heat for hours (previously, a let me write a soap note and give you moist heat application aggravated her complaints). This was relieved by eating some italian ice.

Tone in bilateral mandible elevators were normalized. I concentrated on TMJ distractions with anterior glide. She reported performing them well to end range, which I only recommended a few millimeters. Like any other derangement reduction or reset exercise, end range was the key. She had a DP of mandible anterior translation!

She has 1 more follow up scheduled. Perhaps she will bring us all of her extra starburst.

Discussion: The antibiotics, who knows - hard to say placebo when she did not even think it would continue working, however, each round worked less and less. She had 9/9 hypermobility, probably one of the most lax I have seen. Most likely eating starburst could have moved her mandible anteriorly enough to reduce pressure on the bilaminar zone posteriorly, but not permanently. Postural correction may not have moved her mandible enough into anterior translation due to laxity. Repeated motion into her DP reduced the irritation posteriorly. Works for her, works for me!

2 comments:

  1. HarrisonvaughanptJune 18, 2012 at 2:20 PM

    E,
    Awesome case here. The fun side of PT is the non textbook patients! Makes you think outside the box.

    Cool thing is that I showed this case to my intern and the next patient arrived, we decided to look more into the TMJ. His case is the opposite (more ankylosis joint surfaces thanhyoermobility---actually worse joint mobility than I have ever seen!), ut helped her bring out a different thought process. I may write about his case soon, but will probably get your opinion since you have much more knowledge in TMD than myself if that is okay.

    Hv

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  2. Np HV! I see a ton of TMD, everything from very severe capsulitis with adhesions to hypermobility and subluxation, so fire away! Good luck!

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