Guest Case: Difficult TMD Pt s/p Bilateral Disc Replacements

I currently have a patient with cervicogenic headaches/migraines ongoing for 2 years. Here is the full case study:
Pt is a 37 y/o female with h/o headaches past 2 years with migraines occurring 10-15 times per month with light sensitivity and nausea. In 2003, she had bilateral TMJ prosthetics implanted, however she continues to experience pain and pressure in the L>R TMJ. She has a h/o of trigeminal neuralgia, optic neuritis. She has received PT prior to surgery with no pain relief, she has received several trials of chiropractics with no relief, biofeedback/injections/medications without any significant relief. Her occupation is a parole officer - primarily desk, computer work.
After learning a masseter release and subcranial shear distraction (roughly one week ago), integrating a lumbar roll with c/s retraction 10 reps once per hour, and work place set up modifications she has had one migraine with less intensity and duration as previously.
The problem is now - her TMJ opening is roughly 30mm and she is unable to actively R lateraly deviate. She continues with severe muscle spasm in L>R masseter, proximal scalenes and SCM. (I have been doing TMJ mobs to the best of my abilities and her tolerance).
I'm unsure where to progress her program from here. I"m looking for any advice or additional direction to help solve this patients migraine and TMD problem.
Feel free to comment!!!!!!
Thanks in advance
(ablack@cptrehab.net)
Amanda M. Black MPT,DPT 


Discussion


When Dr. Black first contacted me via my blog, I suggested she practice the subcranial shear distraction and integrate that into her treatment along with masseter STM. She should use the lumbar roll and integrate the cervical retractions hourly. Looks like that improved the pt's HA. What we need to know now is, does the pt have the ability to have lateral excursion, or did the surgeon make the joints hinge type? This is an unfortunately common solution of surgeons to replace the TMJ with a hinge joint, which makes mastication very difficult as you need lateral excursion bilaterally to chew. 


I suggest instructing the pt on self masseter release proximal to distal, repeated heat application for 10-15 minutes several times/day. She should also perform self mandible depressions isometrically at minimal opening to reciprocally inhibit the mandible elevators. The member can also try holding a cervical retraction over heat in supine for up to three minutes to see if this alleviates the cervicogenic HA. Get back to us Dr. Black and let us know if these suggestions help! Anyone else who wants to chime in would be appreciated!


Update 9/7/11 via discussions I have had with Dr. Black on FB


Last followup from the prior week


Dr. Black: I have not attempted those activities yet. I will see her tomorrow afternoon and I'll try them. 2 questions: 1) when you instruct a pt in self masseter release, how much pressure do you recommend? Is it per tolerance? 2) Mandible depression isometrically? Is that opening with the tongue at the roof of the mouth or just self resisted with the hands?

Myself: The pressure is light repeated stroking starting very superficial and progressing in depth. It is to tolerance. The mandible isometrics are with mouth barely open, tongue at roof self resisted with fist under chin. They should only open into the fist but not push superior into the chin if that makes sense. It can be held for four to six seconds repeatedly throughout the day

Dr. Black 9/7: Update.....she came in for her appt today. I taught her self masseter release, mandible depressions, retractions with the heat. I did the "skull crusher" and an OA nod. She ended up with a severe headache and what she described as neck swelling post treatment. Do you ever find this happens??? She did admit to having 3 migraines in 5 days with the "weather changes" and she felt a headache coming on before PT this afternoon. I just don't want to hurt her and I'm so anxious for some success with her that I'm feeling frustrated. Any thoughts???


Myself: The weather changes seem to affect people's complaints despite what the literature says (it says inconclusive). The OA nod was probably too aggressive and may have irritated the cervicogenic HA. I have flared up people with that technique. I would recommended performing some STM after moist heat application to the area on next treatment. The pattern of restriction in the occiput I most commonly see is restriction lateral to medial and proximal to distal. Meaning, you direct the repeated strokes to release the adhesions in those directions, starting from lateral and progressing to medial, same goes for proximal to distal. This is contrary to the popular suboccipital release, which while relaxing, seems to compress the area more than open it up. How does she respond to Mulligan HA Snags?