Temporomandibular Dysfunction: Physical Therapy Management

Transcription

1 Faculty Disclosure Jessica Turner, PT, DPT, OCS Ms. Turner has listed no financial interest/arrangement that would be considered a conflict of interest. Temporomandibular Dysfunction: Physical Therapy Management Jessica Turner, PT, DPT Board Certified Orthopedic Specialist Fellow in Training, EIM s Fellowship in Orthopedic Manual Physical Therapy 1

2 Who We Are Physical therapists are evidence-based health care professionals who offer cost-effective treatment that improves mobility and relieves pain, reduces the need for surgery and prescription drugs, and allows patients to participate in a recovery plan designed for their specific needs. 1 Physical therapists are now graduating with a Doctor of Physical Therapy (DPT) degree. 2 Why us? TMD is common condition that limits the natural function of the jaw, such as talking or chewing, and major cause of non-dental orofacial region pain. 3 Describes pathologies or disorders effecting the temporomandibular joint (TMJ), masticatory muscles, and related structures. Neuromuscular system has a central role. 4 Physical therapists help people with TMD ease pain, regain normal jaw movement, and decrease daily stress on the jaw. 2

3 Who gets it? 35% of the population report symptoms (all ages) Women > Men 5-10% actually seek care Age Okeson et al 5 Classification Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) 4,6,7,8 Classification system based on an integration of impairments and symptoms. Updated in 2010 by an inter-professional consortium DC/TMD 3

4 Masticatory Muscle Disorder Temporalis, Massester, Lateral pterygoid, and Medial pterygoid Overuse or tensile Strain Trigger Point pain referral 4

5 Disc Dislocation with Reduction Normal: DDxR: Disc Dislocation with OUT Reduction DDwoR: 5

6 Joint Disorder Arthralgia, Osteoarthritis, Osteoarthrosis Treatment guided by symptoms not diagnosis It is important to note that the TMJ does demonstrate normal age-related changes such as slight flattening of the condyle, but age-related adaptive processes do not predispose one to pain or dysfunction in this region. Special Questions Key Questions to rule in TMD: Have you had pain or stiffness in the face, jaw, temple, in front of the ear, or in the ear in the past month? If yes, Are symptoms altered by any of the following jaw activities: chewing, talking, singing, yawning, kissing, moving the jaw? Key Questions indicating disc disorder: Have you ever had your jaw lock or catch so that it would not open all the way? If so, Is this limitation in jaw opening severe enough to interfere with your ability to eat? Have you ever noticed clicking, popping, or other sounds in your joint? 6

7 Special Questions Recent dental behaviors? Headache present? If so, how does it relate to symptoms Parafunctional activities? (eg, clenching, chewing pencils, chewing gum, chewing fingernails, or grinding teeth) Red Flags 7

8 Objective Exam Neuro Exam + Cranial Nerve Exam (Trigeminal and Facial) Cervical and Thoracic spine assessment Palpation: comparable sign? Range of motion: 2 knuckle quick test Muscle Testing: Resisted jaw motions. Bite or loading. Accessory mobility testing: Raise hand or grunt if painful. Cervical Spine 70% of patients have TMD and neck pain 9 Patients with chronic neck pain have greater masseter EMG activity bilaterally 10 Patients with TMD have increased fatigability of cervical extensors 11,12 Bio-mechanical, neurophysiological, and functional association between trigeminal and cervical systems 13 8

9 Treatment Evidence indicates physical therapy is effective! 14,15,16,17,18,19,20,21,22,23 Multi-modal approach is best Manual therapy, Range of Motion, Posture, Neuromuscular Re- Education, Therapeutic Exercise, Cognitive Behavioral Therapy Manual therapy Techniques: TMJ distraction mobilization TMJ Anterior glide mobilizations Soft tissue mobilization (extra and intra-oral) Regional manual therapy(neck, periscapula, thoracic spine) Kraus et al 9 9

10 Kraus et al 9 Kraus et al 9 10

11 Yellow Flags DC/TMD Axis II 4 Pain behavior, psychological status, and psychosocial functioning If present, early management improves symptoms and disability May reduce the risk of patients developing persistent or chronic pain Outcome measures: Patient Health Questionnaire-4 (PHQ-4), Graded Chronic Pain Scale (GCPS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire- 15 (PHQ-15), Temporomandibular Disorder Disability Index (not validated), FABQ, Depression Screen, Tampa Scale Kinesiophobia, Pain Catastrophizing Scale, Fear of Activities Scale, Psychosocial Considerations Chronic TMDs are physiologically overreactive to their environment and tend to have substantial psychosocial stressors compared to people without TMDs. 4 Cognitive Behavior Therapy 23,24 Either alone or with conservative management is effective for chronic TMD Improvements in pain, function, beliefs and behaviors. A conservative approach involving counseling and physical therapy resulted in significant improvement in parameters of pain and jaw function in patients with myofascial pain

12 Team Approach Psychologist, Psychiatrist, LMPH Dentist Dental Physical Therapist Psychosocial Musculoskeletal References d8cb18e0b91e 4. Harrison AL, Thorp JN, Ritzline PD. A Proposed Diagnostic Classification of Patients With Temporomandibular Disorders: Implications for Physical Therapists. J Orthop Sport Phys Ther. 2014;44(3): Okeson JP. Management of Temporomandibular Disorders and Occlusion. 7th ed. St Louis, MO: Mosby/Elsevier; Schiffman, Eric, et al. "Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group." Journal of oral & facial pain and headache 28.1 (2014): Schiffman EL, Ohrbach R, Truelove EL, et al. The Research Diagnostic Criteria for Temporomandibular Disorders. V: methods used to establish and validate revised Axis I diagnostic algorithms. J Orofac Pain. 2010;24: Schiffman EL, Truelove EL, Ohrbach R, et al. The Research Diagnostic Criteria for Temporomandibular Disorders. I: overview and methodology for assessment of validity. J Orofac Pain. 2010;24:

13 References 9. Kraus, Steven L. "Temporomandibular Disorders, Head and Orofacial Pain* Cervical Spine Considerations." Orthopaedic Physical Therapy (2009): Testa M, Geri T, Gizzi L, Petzke F, Falla D. Alterations in Masticatory Muscle Activation in People with Persistent Neck Pain Despite the Absence of Orofacial Pain or Temporomandibular Disorders. Journal of oral & facial pain and headache. Fall 2015;29(4): ) 11.Manfredini D, Guarda-Nardini L, Winocur E, Piccotti F, Ahlberg J, Lobbezoo F. Research diagnostic criteria for temporomandibular disorders: a systematic review of axis I epidemiologic findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(4): doi: /j.tripleo Armijo-Olivo S, Magee D. Cervical musculoskeletal impairments and temporomandibular disorders. Journal of oral & maxillofacial research. 2012;3(4). Furto ES, Cleland J a, Whitman JM, Olson K a. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio. 2006;24(4): doi: /crn Vernon H, Vernon H, Sun K, Zhang Y, Yu X, Sessle BJ. Central sensitization induced in trigeminal and upper cervical dorsal horn neurons by noxious stimulation of deep cervical paraspinal tissues in rats with minimal surgical trauma. 14.Kalamir A, Pollard H, Vitiello A, Bonello R. Intra-oral myofascial therapy for chronic myogenous temporomandibular disorders: a randomized, controlled pilot study. J Man Manip Ther. 2010;18(3): doi: / x Nicolakis P, Erdogmus B, Kopf a, Djaber-Ansari a, Piehslinger E, Fialka-Moser V. Exercise therapy for craniomandibular disorders. Arch Phys Med Rehabil. 2000;81(9): doi: /apmr Mcneely ML, Olivo SA, Magee DJ. A Systematic Review of the Effectiveness of Physical. 2006;86(5): References 17.Aggarwal VR, Tickle M, Javidi H, Peters S. Reviewing the evidence: can cognitive behavioral therapy improve outcomes for patients with chronic orofacial pain? J Orofac Pain. 2010;24: Calixtre LB, Moreira RFC, Franchini GH, Alburquerque-Sendín F, Oliveira a. B. Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials. J Oral Rehabil. 2015;(2):n/a n/a. doi: /joor Dworkin SF, Turner J a, Mancl L, et al. A randomized clinical trial of a tailored comprehensive care treatment program for temporomandibular disorders. J Orofac Pain. 2002;16(4): Available at: 20.Bennett AC, Fritz JM. A Manual Physical Therapy Approach to the Management of Patients with Temperomandibular Disorders. 7310: Martins, Wagner Rodrigues, et al. "Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis." Manual therapy 21 (2016): Tuncer, Aysenur Besler, et al. "Effectiveness of manual therapy and home physical therapy in patients with temporomandibular disorders: A randomized controlled trial." Journal of bodywork and movement therapies 17.3 (2013): Stappaerts, Karel, Sven Papy, and Antoon De Laat. "Counseling and physical therapy as treatment for myofascial pain of the masticatory system." J Orofac Pain 17 (2003): Turner J a, Mancl L, Aaron L a. Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: a randomized, controlled trial. Pain. 2006;121(3): doi: /j.pain