Case Hx
- 48 y.o.
- Stiff neck & upper back pain
- Painful R jaw |
Jaw
- 0/10 at rest
- 7/10 when chewing
- 4/10 after chewing
- Onset after tooth removal 12 years ago
- Has OA of jaw (fears this will worsen)
- RF: massaging jaw when it locks
- AF: grinding teeth & chewing |
Neck & upper Tx
- 0/10 - 5/10
- 10-12 years ago
- AF: running, standing too long & neck extension |
Physical Exam Findings
Upper crossed syndrome: muscle imbalance in two sets of opposing muscles
- Tight: upper traps, elevator scapulae, & pectoralis major & minor → responsible for elevating & protracting the shoulders & rounding the upper back
- Weak: lower traps, serratus anterior, & the deep Cx flexors → responsible for stabilising the shoulder blades & supporting the neck & upper back |
ROM
- Can fit 2 fingers between teeth
- Palpable click-over R TMJ
- Centric relation test is painful on R
- Masseter, temporals, digastric, lateral pterygoid tight bilaterally
- Cx PROM all directions moderately restricted + flexion caused L upper traps pain |
Deep neck flexor endurance: shacking after 5 seconds |
Wall angel: unable to flatten back against wall or stretch arms towards wall |
Clinical tests
Wall angel:
- Purpose: assess Tx mobility
- Findings: Unable to flatten back against wall or stretch arms towards wall |
Beighton score:
- Purpose: screen for hyper-mobility
- Findings: 0 |
TOS tests:
- Purpose: Identifies compression of neuromuscular structures as they exit through the Tx outlet
- Findings: Didn't reproduce any pain aka. -ve |
Name 4 TOS tests:
- Adson's
- Reversed Adson's
- Roo's
- Hyperabduction |
Discussion
Working diagnosis:
- Chronic TMD (temporomandibular dysfunction) w/ knownTMJ OA
- Chronic non-specific mechanical neck & Tx pain w/ associated upper crossed posture |
Subdivisions of pain-related TMDs:
1. Myalgia / myofascial pain
2. Arthralgia (joint pain)
3. Intra-articular disorders (within joint)
4. Headache (typically confines to the temporal region) |
Correlation:
- Some neck muscle pain has been found to be correlated with TMD, doesn't completely account for rest of pt's presentations
- Non-specific mechanical neck & thoracic spine pain is very common (∴ high probability), links w/ the pt's posture & explains some of the other examination findings in the Tx & upper quarter
- Poor neck flexor endurancehas been linked w/ chronic TMD & chronic neck pain & poor posture (especially a forward head posture) |
What's the pt trying to tell me:
- Pt has identified stress (grinding teeth, unhappy at home, use of the Headspace app) → will aggravate both the TMD & neck/upper Tx symptoms
→ Pt should try to identify sources of stress & DC can offer to help them access further support |
Address the pt's expectations for having tech x-rays → they're not indicated, & would need to explain theist the pt |
Learning outcomes
Temporomandibular disorder (TMD) diagnosis & management:
⏺ Signs & symptoms:
- Jaw pain: located in jaw joint, surrounding muscles or both
- Jaw clicking or popping: may be duet the displacement of the jaw joint or the movement of the cartilage disc within the joint
- Jaw stiffness: may make it difficult to eat, speak, or jawn
- Headaches: especially in the temples or behind the eyes
- Ear pain or fullness: feeling of fullness in the ear, even though there's no infection
- Neck & shoulder pain: may become sore or painful as a result of compensating for the jaw
- Teeth grinding or clenching: (especially during sleep), can lead to tooth damage, headaches, & jaw pain
⏺ Imaging:
- X-rays: help identify any bony abnormalities or damage to the jaw joint
- MRI: jaw joint, surrounding tissues, muscle, ligaments, & cartilage
- CT: Jaw joint, surrounding structures, including bones & soft tissues
- Cone beam CT: 3D images of the jaw joint
⏺ Management:
- Lifestyle changes: soft foods, not gum chewing, stress management to reduce jaw tension
- Medications
- Manual therapy
- Oral appliances: (e.g. splint or mouthguard) to relieve jaw pain & reduce teeth grinding & clenching
- Injections
- Surgery |
Consider the impact of stress on the pt's prognosis:
- Can have significant impact on prognosis, especially for pts w/ chronic illnesses or conditions; chronic stress is linked to a range of -ve health outcomes (↑ inflammation, impaired immune function, & heightened risk of heart disease, diabetes, etc)
- Impaired immune function: can lead to a longer recovery time & more severe symptoms for pts with chronic illnesses
- Increased inflammation: can exacerbate symptoms of chronic illnesses & lead to further damage to organs & tissues
- Worsening of symptoms: (e.g. pain, fatigue, & digestive issues), can impact a pt's quality of life & ability to manage their condition
- Delayed healing: can lead to longer recovery & ↑ risk of complications
- Poor treatment adherence: pts may have harder time following treatment plans, can lead to poorer outcomes & slower recovery |
Indications for Cx spine x-rays:
⏺ SEE DIAGRAM BELOW
- Pt has no HIGH RSIK factors to warrant Cx x-ray immediately
- Pt has NO LOW risk factors + ROM rotation is not below 45° (PROM tested only, no AROM detailed [preffered]) |
Management of chronic non-specific neck & Tx pain:
- Chronic pain: consider referral to psych-management / pain clinic
- Home exercises to maintain movement between treatments
- Non-specific neck pain:
- Short term: Tx manipulation w/electrothermal therapy
- Long term: Cx manipulation, exercises ± manual therapies
- Encourage activity & ADLs
- NSAIDs
- Stretching & strengthening exercises, ROM exercises, manual therapy
- Non-specific Tx pain:
- Tx manual therapy: massage, trigger point therapy (TPT), stretches, traction, manipulation & mobilisation |
Functional management for this pt:
⏺ Jaw:
- Stabilisation exercises
⏺ Neck / upper Tx:
- Wall angel
- Prayer stretch
- Upper traps stretch
- Lev. scap. stretch
- Wall chin tucks |
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