Case of the Week 9-12-11: Chatty Cathy with TMD

I am often reminded of this case from several years back when I speak with my TMD patients about avoiding aggravating activities. She was a mid 40s housewife who could talk your ears off. During the history, I had to practice my fine art of politely cutting the patient off to get back to the point.

History: Insidious onset of left > right facial pain 2 year prior. She had been seeing a TMD specialist (dentist) who I get most of my cases from. He prescribed soft food diet, which she was still on, full time use of an intraoral appliance that protracted her mandible, and use of heat application to her face several times/day. This was helpful to reduce her complaints, but only by about 20%. She also had temporal and frontal headaches, facial and TMJ pain left > right and cervical pain radiating to her left upper trap.

Objective: fair sitting posture, forward head, left scapula elevated compared to right

cervical ROM: WNL for flexion, extension moderate loss, SB to left painful, moderate loss, hard end feel, SB to right minimal loss with end range pain

mandible ROM: depression 28 mm, with 2 mm deflection to the left, indicating capsular pattern (deflects toward the restricted side, with right side being hypermobile in anterior translation)
mandible lat exc left 6 mm right 2 mm, right more painful than left, no clicking palpated

myofascia: moderately restricted left great than right masseter in proximal to distal direction and along bony contours of angle of mandible in posterior to anterior direction, left > right scalenes, SCM, cervical paraspinals, upper trap and levator scapula

PIVM: grade 2 restrictions in bilateral OA FB, C2-4 downglide left > right and C6-7 downglide on left, left 1st rib inferior glide

Assessment: Signs and Sx consistent with chronic TMD, with accompanying subcranial dysfunction and upper quarter muscle imbalances

Treatment:

Day 1: STM to the occiput, masseter, instruction on use of a lumbar roll in sitting and cervical retractions for HEP

Day 2: Pt reports headaches and cervical pain 30% improved, facial pain and TMJ pain no change. Treatment included previous techniques and added subcranial shear distraction and first rib non-thrust manip. Exercises were reviewed and added "w" for scapula setting/postural reset to be performed hourly.

Day 3: Pt reports 40-50% improved in HA and cervical pain. Cervical ROM improved to minimal loss in SB to left, right was WNL, extension also minimal loss now. Mandible ROM 30 mm, deflecting 2 mm to left. TMJ distraction, lateral glide on left, medial glide on right were added. Afterward, improved to 34 with less pain. Instructed on mandible minimal protrusion with lateral excursion to right to stretch left TMJ capsule. She was to perform 6 reps/6 sets/6 times/day. Why 6? Because Rocabado likes the number. Who am I to argue with the only physio in the world I know of who works in a dental school? Also, it works and is easy to remember.

Days 4-6: no real changes in Tx or HEP, steady improvements in mandible ROM to 33 consistently with end range pain. HA and cervical pain almost 100% better. Still had moderate facial pain rated 5-7/10. Better in the morning and worse as the day progressed.

Day 7: Everything WNL except facial pain, which was still 5-6/10. She was getting frustrated, and forgetting how much better everything else was. This was understandable because facial/cranial pain is very limiting, possibly even hurting to smile. Very emotional... I reassured her she was doing better. The patient stated she would make 1 more visit and then return to the referring specialist if there were no more changes.

Day 8-9: It had been a 3 day weekend with a Monday holiday. The patient's husband went out of town. She came back in and was ecstatic! She had not spoken to ANYONE the entire weekend. Before this, I was quick to identify common things to avoid like chewing hard, crunchy or chewy foods, yawning, WB through the mandible when thinking, and of course posture! I didn't think that her actually only opening her mouth the bare minimum would be enough to let her TMJ rest for several days. This got the inflammation down and she was now 100% pain free. Her mandible ROM was 35, with minor deflection to the left. After one more session, I showed her self mandible distractions on the left. She returned to the specialist very pleased, and he started her weaning from her appliance. She was also progressed from a soft chew diet. She called me two weeks later and was very thankful for my help! She felt like she could manage the rest of the treatments on her own and did not schedule further visits.