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Physical therapy as an adjunct to temporomandibular joint therapy
TEMPOROMANDIBULAR
JOINT
l
OCCLUSION
SECTION EDITOR
GEORGE A. ZARB
Physical therapy as an adjunct to temporomandibular joint therapy William N. Danzig, D.D.S.,* and Arlyn R. Van Dyke** University of California, School of Dentistry, San Francisco, Calif., and Walnut Creek, Calif.
T
he increased use of the automobile and the stress and tension produced by a modern society are increasing the incidence of musculoskeletal complaints from patients. An example of this is cervical and myofascial pain. It is our observation that patients referred to physical therapy for cervical muscle pain had a high incidence of temporomandibular joint (TM J) symptoms. Coincidentally, patients referred to the dentist for TMJ therapy had a high incidence of neck and shoulder pain. Treatment of either cervical or TM J pain rather than treatment of both regions simultaneously will frequently result in only partial success. At the University of California an attempt at using a physical therapy program along with TMJ therapy was instituted. The end result of this alliance has hastened resolution of the TM J symptoms. The use of physical therapy has emphasized the relationship of cervical pain and its radiation to the muscles and joints of the head.
DIAGNOSTIC
TREE
At the University of California TMJ Clinic, a Diagnostic and Treatment Tree that has been previously described is used (Fig. l).’ This article will further describe dentists’ use of a physical therapy program for the treatment of TMJ syndrome.
CLINICAL
OBSERVATIONS
When physical therapy was first used by the authors for the treatment of TMJ problems, the patient was referred without any previous splint therapy. Physical therapy used in this manner was not as effective as
Presented at the Articulationand Occlusion Study Group, University of California, San Francisco, Calif., and the American Academy of Craniomandibular Disorders, New York, N.Y. *Assistant Director of Articulation and Occlusion Study Groups. **Registered Physical Therapist.
96
JANUARY
1983
VOLUME
49
NUMBER
1
when splint therapy was initiated prior to or simultaneously with physical therapy. During the 8 years prior to associating with a physical therapist there were mixed results at a slower rate of improvement, especially in the neck and shoulder regions. If the neck and shoulders remain symptomatic, they continue to refer pain to the TMJ area and its associated structures. Bonica2 has written that people over the age of 35 are more predisposed to developing trigger points in the musculoskeletal system. A trigger point is a small circumscribed hypersensitive region in muscles or in connective tissues from which impulses arise and bombard the central nervous system to produce referred pain. Albng with localized physical therapy the patient is instructed to increase daily physical exercise. Vigorous walking or jogging maintains joint and muscle flexibility as well as increases muscle strength. The increased cardiovascular activity brings more blood to ischemic tissues and therefore aids in the reduction of muscle pain symptoms. The reduction in muscle tension is seen clinically as patients appear to have less head and neck pain when sedentary habits are converted to physical activity.
CONCEPTS OF PHYSICAL ACTIVITY The purpose of physical therapy is to reduce musculoskeletal pain through the modalities listed in Table I. Each of the modalities is used from the initiation of treatment with the exception of electrical muscle stimulation, which is not used until excessive acute pain has diminished. In order to have high quality physical therapy, it is important to maintain effective communication between the physical therapist and the dentist. If the therapeutic armamentarium does not quiet a trigger point, the dentist (or physician) should be consulted. At this time muscle injections of Xylocaine (Astra Pharmaceutical Products, Inc., Worcester, Mass.) and/or
0022-3913/83/010096
+ 04$00.40/O b 1983 The C. V. Mosby Co.
PHYSICAL
THERAPY
AND
TMJ THERAPY
1
BASE ‘“i
RECORDS 1
Fig. 1. University of California TMJ Clinic Diagnostic and Treatment Tree. Note that physical therapy in schematic is part of a patient’s total evaluation and treatment program. (From McNeill, C.: Modern oral preventive techniques. J PROSTHET DENT 30: 571, 1973.)
Table I. Temporomandibular
joint treatment
program
Ultrasound
Stimulates
Hot packs
Decreases Provides Increases muscle Stimulate
circulatory
system
inflammation deep heating elasticity in tendon, capsule, and tissue circulatory system
Provide a soothing effect to painful Stimulates circulatory system
Electrical muscle stimulation (AC current only)
Provides a mild stretch of muscle tissue Passive: increases TMJ range of motion Active: strengthens and reeducates muscles Hot showers 3 times a day Use of hot compresses Soft diet Checking and maintenance of proper mouth posture Ice massage to painful areas Active and passive exercises when indicated Massage to painful muscles Use of proper pillow for resting Avoidance of strenuous activities
Exercise
Home program
OF PROSTHETIC
DENTISTRY
1 W/sq cm for 5 minutes to each TMJ 1.3 W/sq cm for 7 minutes to cervical area
20 minutes to cervical and masticatory muscles
muscles
Decreases muscle spasm Provides a surge impulse at 1 impulse/set Provides a soothing effect to painful muscles
Massage
THE JOURNAL
Time and area
Effect
Modality
6 minutes to masseter muscles
10 to 15 minutes to cervical and masticatory muscles Varies for each treatment
97
DANZIG
AND
VAN
DYKE
Zero chin force
0
0
Incorrect
Fig. 2. A, Supine cervical traction results in a zero force to mandible. B, Cervical traction with a vertical force causes a mechanical stress to teeth and temporomandibular joint.
steroids are used to aid in the elimination of the pain. When musculoskeletal pain has dissipated adequately, range of motion exercises can be initiated. These exercises are implemented to increase flexibility of muscles and joints (reduce contracture) and diminish pain further. A patient without a normal range of motion will experience pain in the joints and muscles when attempting normal function.
CERVICAL TRACTION
AND TMJ
Dyer* recognized 14 years ago the high incidence of patients with TMJ problems following cervical traction. Patients described an increase in pain of the TMJ, facial muscles, and teeth following cervical traction. Physical therapists who treat acute injuries associate 50% to 75% of their work with spinal musculoskeletal injuries. Of this group approximately 50% are cervical related. The standard treatments consist of heat, ice, exercise, and, quite often, traction. Traction is an important procedure of cervical treatment, but the method of application by the therapist can help or hinder progress.
*Dyer, E.: Personal communication, 1969.
98
Methods of application
of cervical traction
There are three major situations in which the methods of traction application can irritate or cause facial pain symptoms. The skeletal outline in Fig. 2, A, demonstrates the supine position and zero chin force. The condyle is not stressed when the force is applied at a 45- to 60-degree angle from the horizontal. Fig. 2, B, is an example of traction applied in the sitting position. The conventional “home care” cervical apparatus produces greater forces to the TMJ and its muscles than to the desired occipital region. First, the angle of pull of the head halter on the patient’s head should be from 45 to 60 degrees from the horizontal ,to give the major pulling force to the occipital area of the head and zero chin pull. Any significantly lesser degree of pull on the halter creates a pulling force on the chin strap that in turn forces the teeth together and a pressure on the disk of the TMJ. The chin strap stimulates the masticatory muscles to contract by forcing the dentition together firmly. These two factors carry the potential conditions for setting up spasm and pain in the muscles involving the TMJ. Second, the supine position during cervical traction seemsmost advantageous to maintain zero chin pull. In the supine position the 45- to 60-degree angle of pull is easily attained when compared to the sitting position so often used. Most important, in the supine position the righting reflexes are less likely to be stimulated,
JANUARY
1983
VOLUME
49
NUMBER
1
PHYSICAL
THERAPY
AND
TMJ THERAPY
producing a more relaxed position for the cervical muscles. To keep the skeleton in an upright position, a righting reflex exists to regulate muscle tone throughout the body and to maintain posture and equilibrium. These reflexes are stimulated by sensory end organs in the TMJ and muscles during movement and/or erect body position. Slight changes in position will create increased muscle tone to compensate for and correct that change. It seemslogical that muscle tone should be minimized when treating cervical spasm, and the best position available to minimize muscle tone is the supine position. Third, the standard traction equipment available to patients for home care is inadequate. The patient is required to assume the sitting position, making zero chin force difficult to attain. The halter used in home care makes it difficult to eliminate chin force, in contrast to the halter used in the supine position, which allows for the elimination of chin force. When patients state that they are receiving home traction, the dentist can reasonably assume that a high percent of them may be traumatizing the TM J and its muscles. Many patients being treated for cervical pain
only may develop acute TMJ symptoms following improper cervical traction. In many patients this pain may remain long after the cervical pain has diminished. SUMMARY Physical therapy should be used to enhance and expedite the recovery of TMJ patients. When coordinated with dental corrective procedures, a more profound and corrective result ensues. It i:j important to remember that the detection of improper cervical traction by the dentist can prevent exacerbation of the TM J syndrome. REFERENCES 1. McNeill,
C.: Modern oral preventive techniques. J PROSTHET
DENT 30~567, 1973.
2.
Bonica, J. J.: Management of myofascial pain syndromes in general practice. JAMA, June 15, 1957.
Rqmnt
requesti to:
DR. WILLIAM N. DANZIG 2021 YGNACIOVALLEY RD., BLDG. B-4 WALNUT CREEK, CA 94598
Extra text pages added to the
JOURNAL
In recent months the backlog of articles awaiting publication in the JOURNAL
OF PROSTHETIC DENTISTRY has steadily increased. To reduce the publication delay for authors and to provide more scientific and practical information for our readers, the JOUPNAL will publish 16 additional text pages in each issue beginning in September. In January 1983, another 16 text pages will be added for a total increase of 32 pages per issue. This will allow an additional six articles to be published each month. To underwrite these 384 pages (approximately 72 more articles), the subscription rate for individual subscribers will be increased $3.00 effective January 1, 1983.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
99
JOINT
l
OCCLUSION
SECTION EDITOR
GEORGE A. ZARB
Physical therapy as an adjunct to temporomandibular joint therapy William N. Danzig, D.D.S.,* and Arlyn R. Van Dyke** University of California, School of Dentistry, San Francisco, Calif., and Walnut Creek, Calif.
T
he increased use of the automobile and the stress and tension produced by a modern society are increasing the incidence of musculoskeletal complaints from patients. An example of this is cervical and myofascial pain. It is our observation that patients referred to physical therapy for cervical muscle pain had a high incidence of temporomandibular joint (TM J) symptoms. Coincidentally, patients referred to the dentist for TMJ therapy had a high incidence of neck and shoulder pain. Treatment of either cervical or TM J pain rather than treatment of both regions simultaneously will frequently result in only partial success. At the University of California an attempt at using a physical therapy program along with TMJ therapy was instituted. The end result of this alliance has hastened resolution of the TM J symptoms. The use of physical therapy has emphasized the relationship of cervical pain and its radiation to the muscles and joints of the head.
DIAGNOSTIC
TREE
At the University of California TMJ Clinic, a Diagnostic and Treatment Tree that has been previously described is used (Fig. l).’ This article will further describe dentists’ use of a physical therapy program for the treatment of TMJ syndrome.
CLINICAL
OBSERVATIONS
When physical therapy was first used by the authors for the treatment of TMJ problems, the patient was referred without any previous splint therapy. Physical therapy used in this manner was not as effective as
Presented at the Articulationand Occlusion Study Group, University of California, San Francisco, Calif., and the American Academy of Craniomandibular Disorders, New York, N.Y. *Assistant Director of Articulation and Occlusion Study Groups. **Registered Physical Therapist.
96
JANUARY
1983
VOLUME
49
NUMBER
1
when splint therapy was initiated prior to or simultaneously with physical therapy. During the 8 years prior to associating with a physical therapist there were mixed results at a slower rate of improvement, especially in the neck and shoulder regions. If the neck and shoulders remain symptomatic, they continue to refer pain to the TMJ area and its associated structures. Bonica2 has written that people over the age of 35 are more predisposed to developing trigger points in the musculoskeletal system. A trigger point is a small circumscribed hypersensitive region in muscles or in connective tissues from which impulses arise and bombard the central nervous system to produce referred pain. Albng with localized physical therapy the patient is instructed to increase daily physical exercise. Vigorous walking or jogging maintains joint and muscle flexibility as well as increases muscle strength. The increased cardiovascular activity brings more blood to ischemic tissues and therefore aids in the reduction of muscle pain symptoms. The reduction in muscle tension is seen clinically as patients appear to have less head and neck pain when sedentary habits are converted to physical activity.
CONCEPTS OF PHYSICAL ACTIVITY The purpose of physical therapy is to reduce musculoskeletal pain through the modalities listed in Table I. Each of the modalities is used from the initiation of treatment with the exception of electrical muscle stimulation, which is not used until excessive acute pain has diminished. In order to have high quality physical therapy, it is important to maintain effective communication between the physical therapist and the dentist. If the therapeutic armamentarium does not quiet a trigger point, the dentist (or physician) should be consulted. At this time muscle injections of Xylocaine (Astra Pharmaceutical Products, Inc., Worcester, Mass.) and/or
0022-3913/83/010096
+ 04$00.40/O b 1983 The C. V. Mosby Co.
PHYSICAL
THERAPY
AND
TMJ THERAPY
1
BASE ‘“i
RECORDS 1
Fig. 1. University of California TMJ Clinic Diagnostic and Treatment Tree. Note that physical therapy in schematic is part of a patient’s total evaluation and treatment program. (From McNeill, C.: Modern oral preventive techniques. J PROSTHET DENT 30: 571, 1973.)
Table I. Temporomandibular
joint treatment
program
Ultrasound
Stimulates
Hot packs
Decreases Provides Increases muscle Stimulate
circulatory
system
inflammation deep heating elasticity in tendon, capsule, and tissue circulatory system
Provide a soothing effect to painful Stimulates circulatory system
Electrical muscle stimulation (AC current only)
Provides a mild stretch of muscle tissue Passive: increases TMJ range of motion Active: strengthens and reeducates muscles Hot showers 3 times a day Use of hot compresses Soft diet Checking and maintenance of proper mouth posture Ice massage to painful areas Active and passive exercises when indicated Massage to painful muscles Use of proper pillow for resting Avoidance of strenuous activities
Exercise
Home program
OF PROSTHETIC
DENTISTRY
1 W/sq cm for 5 minutes to each TMJ 1.3 W/sq cm for 7 minutes to cervical area
20 minutes to cervical and masticatory muscles
muscles
Decreases muscle spasm Provides a surge impulse at 1 impulse/set Provides a soothing effect to painful muscles
Massage
THE JOURNAL
Time and area
Effect
Modality
6 minutes to masseter muscles
10 to 15 minutes to cervical and masticatory muscles Varies for each treatment
97
DANZIG
AND
VAN
DYKE
Zero chin force
0
0
Incorrect
Fig. 2. A, Supine cervical traction results in a zero force to mandible. B, Cervical traction with a vertical force causes a mechanical stress to teeth and temporomandibular joint.
steroids are used to aid in the elimination of the pain. When musculoskeletal pain has dissipated adequately, range of motion exercises can be initiated. These exercises are implemented to increase flexibility of muscles and joints (reduce contracture) and diminish pain further. A patient without a normal range of motion will experience pain in the joints and muscles when attempting normal function.
CERVICAL TRACTION
AND TMJ
Dyer* recognized 14 years ago the high incidence of patients with TMJ problems following cervical traction. Patients described an increase in pain of the TMJ, facial muscles, and teeth following cervical traction. Physical therapists who treat acute injuries associate 50% to 75% of their work with spinal musculoskeletal injuries. Of this group approximately 50% are cervical related. The standard treatments consist of heat, ice, exercise, and, quite often, traction. Traction is an important procedure of cervical treatment, but the method of application by the therapist can help or hinder progress.
*Dyer, E.: Personal communication, 1969.
98
Methods of application
of cervical traction
There are three major situations in which the methods of traction application can irritate or cause facial pain symptoms. The skeletal outline in Fig. 2, A, demonstrates the supine position and zero chin force. The condyle is not stressed when the force is applied at a 45- to 60-degree angle from the horizontal. Fig. 2, B, is an example of traction applied in the sitting position. The conventional “home care” cervical apparatus produces greater forces to the TMJ and its muscles than to the desired occipital region. First, the angle of pull of the head halter on the patient’s head should be from 45 to 60 degrees from the horizontal ,to give the major pulling force to the occipital area of the head and zero chin pull. Any significantly lesser degree of pull on the halter creates a pulling force on the chin strap that in turn forces the teeth together and a pressure on the disk of the TMJ. The chin strap stimulates the masticatory muscles to contract by forcing the dentition together firmly. These two factors carry the potential conditions for setting up spasm and pain in the muscles involving the TMJ. Second, the supine position during cervical traction seemsmost advantageous to maintain zero chin pull. In the supine position the 45- to 60-degree angle of pull is easily attained when compared to the sitting position so often used. Most important, in the supine position the righting reflexes are less likely to be stimulated,
JANUARY
1983
VOLUME
49
NUMBER
1
PHYSICAL
THERAPY
AND
TMJ THERAPY
producing a more relaxed position for the cervical muscles. To keep the skeleton in an upright position, a righting reflex exists to regulate muscle tone throughout the body and to maintain posture and equilibrium. These reflexes are stimulated by sensory end organs in the TMJ and muscles during movement and/or erect body position. Slight changes in position will create increased muscle tone to compensate for and correct that change. It seemslogical that muscle tone should be minimized when treating cervical spasm, and the best position available to minimize muscle tone is the supine position. Third, the standard traction equipment available to patients for home care is inadequate. The patient is required to assume the sitting position, making zero chin force difficult to attain. The halter used in home care makes it difficult to eliminate chin force, in contrast to the halter used in the supine position, which allows for the elimination of chin force. When patients state that they are receiving home traction, the dentist can reasonably assume that a high percent of them may be traumatizing the TM J and its muscles. Many patients being treated for cervical pain
only may develop acute TMJ symptoms following improper cervical traction. In many patients this pain may remain long after the cervical pain has diminished. SUMMARY Physical therapy should be used to enhance and expedite the recovery of TMJ patients. When coordinated with dental corrective procedures, a more profound and corrective result ensues. It i:j important to remember that the detection of improper cervical traction by the dentist can prevent exacerbation of the TM J syndrome. REFERENCES 1. McNeill,
C.: Modern oral preventive techniques. J PROSTHET
DENT 30~567, 1973.
2.
Bonica, J. J.: Management of myofascial pain syndromes in general practice. JAMA, June 15, 1957.
Rqmnt
requesti to:
DR. WILLIAM N. DANZIG 2021 YGNACIOVALLEY RD., BLDG. B-4 WALNUT CREEK, CA 94598
Extra text pages added to the
JOURNAL
In recent months the backlog of articles awaiting publication in the JOURNAL
OF PROSTHETIC DENTISTRY has steadily increased. To reduce the publication delay for authors and to provide more scientific and practical information for our readers, the JOUPNAL will publish 16 additional text pages in each issue beginning in September. In January 1983, another 16 text pages will be added for a total increase of 32 pages per issue. This will allow an additional six articles to be published each month. To underwrite these 384 pages (approximately 72 more articles), the subscription rate for individual subscribers will be increased $3.00 effective January 1, 1983.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
99