Temporomandibular Disorders (TMJ) and Physical Therapy
TMJ disorders affect 5 out of every hundred people and it can be quiet debilitating. One in five people of TMJ typically tend to get help. The treatment of TMJ can have quiet an socio-economic burden on the individual and can be very expensive. The treatments range from physical therapy, chiropractic to splint therapy. Tempero-mandibular disorders (TMD) can cause a range of different symptoms ranging from headaches, ringing in the ears (tinnitus), facial pain and neck pain. TMD can cause significant functional limitations ranging from inability to eat hard food, yawn comfortably to chronic intractable pain. TMD can be classified into different categories depending on the pathology, the common diagnosis are TMJ pain of myofascial origin, Intraarticular dics subluxation with relocation, Intraarticular disc subluxation without relocation, Arthritis, Capsultis and sprain/strain. The treatment options to patients can be quiet confusing and be expensive for patients. Physical therapy can be inexpensive and effective treatment with patients with TMD. Often research has compared physical therapy to splint therapy and has found splint therapy to be more effective than physical therapy. In these studies, physical therapy has been limited to ultrasound and exercises. Physical therapist does a lot more than just providing US and exercises. A physical therapist specialized in treating TMJ have a range of techniques in their tool belt ranging from manual therapy, manipulation, postural retraining, iontophoresis, ASTYM, soft tissue mobilization techniques and guided relaxation. The aim of this bog is to inform patients on the effectiveness on different techniques physical therapists use and some tips on self management techniques
Anatomy of the TMJ, with the related muscles.Exercise therapy:
Exercises are commonly prescribed by PT’s for self management, to create a balance/ relax the muscles of mastication, to improve neuro muscular coordination, mobility and exercises to counter joint clicking. In a systematic review of 7 studies that investigated therapeutic exercises for TMD, which included stretching, relaxation, coordination, strengthening and endurance, Moraes et al. found exercises to be effective for the treatment of ‘muscular TMD’.
Soft tissue mobilization:
Intra-oral techniques have to be performed by a skilled and trained TMJ therapist. It is extremely hard to localize and treat the Lateral ptergoiyd, which is often a source of pain for patients. It has been shown to be difficult to locate and treat the lateral ptergoiyd. But with proper training in intra-oral finger placement, its possible to identify and treat the trigger point. Most studies have shown limited effectiveness of soft tissue mobilization as a stand alone treatment in the management of jaw pain.
Manual physical therapists use many different joint mobilization and high velocity thrust techniques in the management of TMD. A few studies have shown significant improvement in jaw mobility and reduction in pain in combination with a home exercise program. These studies are quiet encouraging as joint mobilization can possibly address the deep muscles of the jaw compared to soft tissue mobilization techniques.
Joint manipulations of the jaw and the upper neck have shown to be quiet effective in improving jaw mobility and pain reduction in the management of jaw pain. While spinal manipulation targeting the upper cervical spine has been shown to improve pain and motor performance in patients with TMD, the longevity of the changes is presently unknown. However, given that Dunning et al. reported a significant improvement in neck pain, disability and motor performance of the deep cervical neck flexors 48-h following spinal manipulation at C1-C2 and T1-T2 compared to grade IV mobilization, the changes are likely not transient.
Dryneedling and acupuncture:
Dryneedlng and acupuncture can be of some benefit to patients to control pain and to improve mobility. Few studies have shown dryneedling on a regular basis have decreased pain, improved mobility in patients with TMD. The chart is an illustration of the different points typically used in dryneedling. ST7, is an important point as it targets the inferior bundle of lateral ptergoiyd. Masseter and temporalis is often involved in patients with TMD and treating them could yield good results. Traditional acupuncture has been shown to be effective in patients with osteoarthritis of the jaw. A number of studies have shown improved blood flow to joints secondary to acupuncture may facilitate the recruitment of opioid producing immune cells required to reduce the level of inflammatory cytokines. There is also limited evidence suggesting that acupuncture may stimulate an increase in hyaluronic acid, allowing the synovial fluid to better lubricate the joint. Given Scully’s mechanism of TMD, it may therefore be particularly advantageous to target traditional acupoints GB2 and SI19, as they are anatomically positioned directly over the TMJ posterior capsule.
Often PT’s use different modalities like TENS, US, iontophoresis and Interferential therapy. Physiotherapists also use ultrasound and laser to treat TMD. Even though there are no significant research to back up the use of these eletrotherapeutic modalities, PT’s never use these modalities as a stand-alone treatment.
Even though PT’s are not part of the PT’s treatment plan, we feel its important for patients to understand the benefits of splint therapy. In a 2004 Cochrane review, Al-Ani et al. found insufficient evidence to support the use of splint therapy for the treatment of TMD. After treating 80 consecutive patients with TMD, Niemela reported that splint treatment, counseling and masticatory muscle exercises were not more beneficial than counseling and masticatory muscle exercises alone. Similarly Nagata et al. found no added short-term benefit of splint therapy in TMD patients receiving multi-modal therapy, including selfexercise, cognitive therapy, self-management education and manipulation. Quintus et al. further evaluated the long-term effect of splint therapy. After 1 year, 27.6% of TMD patients that received splint treatment and 37.5% of TMD patients that received counseling and instructions for increasing masticatory muscles exercises, respectively, reported ‘very good’ treatment effects. Even though 16/40 patients in the counseling and exercise group were switched to the splint therapy group because of painful symptoms associated with TMD, both groups experienced only a modest reduction in pain. Moreover, splint therapy did not outperform counseling and instructions for self-exercise.
Based on this information provided there is little evidence in the use of splint therapy, strengthening exercises, electro-therapy and massage in the management of TMD. Based on the available research a combination of mobilization and manipulation of the neck and jaw, dryneedling and combination of acupuncture or electro-acupuncture can be useful in the management of TMD.
At Revive Spine and Sport Physiotherapy Clinic in Edmonton, we have therapists, chiropractors and massage therapists who are trained in the management of TMD. All therapists treating TMD are trained in spinal/ TMJ mobilizations/manipulations.
Please check in later for further resources and self-help videos in the management of TMD.