The notorious TMJ

I can still remember the feeling – after a quick scan of the medical history form, and a glance into the waiting room, it was becoming clear to me that my first experience working with someone with Temporomandibular Joint Dysfunction was going to be a disaster…

But first, allow me to digress.

A digression

Temporomandibular Joint Dysfunction (aka Temporomandibular Joint Disorder, TMJD TMD) is a catch-all term covering lateral facial pain and difficulty with chewing. However, Googling “Temporomandibular Joint Dysfunction” may give you the impression that it is a condition involving one’s hand being stuck to the side of one’s face, possibly combined with an unhealthy red glow. Have a look at my Google images result mashup below.

screen-shot-2017-02-27-at-11-13-55-am

TMD by Google Images

TMD can evoke a certain fear in physical therapists, but it’s an interesting kind of fear. It’s not the kind of fear and anxiety that I was feeling before that first evaluation. It’s a fear of doing a good job and having someone refer progressively more people with TMD to you.

Let’s face it, there is a stigma against those with TMD. I was once perusing the old lab book of a manual therapy guru. In it they were providing heuristic shortcuts to common presentations in the clinic;

Limited neck rotation on one side – think cervical manipulation.

Temporomandibular Joint Dysfunction – think neurosis.

If you do a good job with one person, the local dentist,  desperate for a useful place to send their patients, might get your name and continue to send you a whole caseload of “neurotic individuals” with TMD. As physical therapists we work hard to develop referral sources – seemingly not so in TMD.

Back to the clinic

I had all of these these warnings from more experienced clinicians running around my head on that fateful day as I faced my first TMD, and this person sitting in front of me seemed to fit the challenging mould. She reported an extensive psychological history (depression, anxiety, bipolar) and an involved past medical history (craniotomy, brain injury and a laundry list of mediations).

After the examination, things weren’t looking much better. She had 7-10/10 pain from her left shoulder, through her neck, up into her head, across the whole left side of her face and deep into her ear. Her mouth opening was less than 15 mm, she was on a liquid diet, and she was not sleeping.

Then she said…

“I’ve never heard of physical therapy for this and I don’t think you can help. I’m just here because the dentist sent me here.”

Back to basics

Faced with this situation on that day, I went back to basics. Without boring you with the all the details, I used some neurobiology of pain principles, I used some basic manual therapy techniques and I used some very basic exercises. And much to my surprise, she got quite a bit better and was as surprised as I was with the progress  that she made.

As a result, the referring dentist (a maxillofacial surgeon) got hold of my name and my schedule was quickly between 30% and 50% TMD. And I actually really enjoyed it.

Better together

I’ve found TMD and Explain Pain pair together quite nicely, even when I was still practicing (and frequently struggling with) Explaining Pain. People with TMD are used to being told that the pain is in their head. But they’ve typically been told this in a way that makes them feel like they have some kind of personality flaw.  I have found them more likely to embrace an alternate non-judgmental explanation that is based on solid biology.

As a result, I have found that they tend to embrace neurobiology of pain and undergo conceptual shifts without as much cognitive dissonance to work through. This was an ideal situation for me to gain experience and confidence as an Explain Pain newbie.

If you look at what is available for people with TMD, physical therapy has a strong research backing and doesn’t have the out of pocket costs associated with oral appliances, or the irreversible side effects of things like shaving teeth down or surgery. Despite this, the TMD population appears to be under-served by PT’s.

Keep it simple

I’ve found that TMD treatment doesn’t have to be complicated. A couple of basic exercises and a good background in neurobiology of pain can get you a long way. Some manual therapy techniques for the TMJ, surrounding muscles and the upper cervical spine can be quite helpful as well. There’s even some emerging evidence for a Graded Motor Imagery  approach. It’s probably not as easy as that, but it’s also  not as complicated, scary and unpleasant as it gets made out to be either.

I’d be curious to know of other physical therapists’ experiences with TMD and whether you have found those with TMD similarly receptive to neurobiology of pain education without having to break through as many barriers of cognitive dissonance? Thoughts and comments welcome below.

-Cody Weisbach

Cody is a Physical Therapist in Boulder Colorado, with a special interest in pain. Cody can be found on Twitter @CodyWeisbach

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4 Responses to “The notorious TMJ”

  1. davidbutler0noi

    Hi Cody,
    This is great story. I went through something like what you did 20+ years ago though we didn’t have the more modern treatment techniques now available. Wriggling the TMJ joint around and not much else didn’t do much and on reflection why should it? I was actually scared of the TMJ – with its disc, seemingly complex biomechanics and ‘locked jaw’ was terrifying. And it’s only when I realised that pain on the side of your face is not much different to pain on the side of the foot or in your gut that it became easier. The mechanisms are the same with the presentation sometimes altered by physical features of the target tissue and the person’s perception of it.
    Thanks for sharing this.

    David

    Reply
  2. Ori Bar Zeev

    Hey, i’m a physio with special interest in TMD. I totaly agree with what you are saying. The TMJ shouldn’t be treatet differently from other joints. We should keep it simple.
    Very nicely written!

    Ori Bar Zeev.

    Reply
    • Cody Weisbach (@CodyWeisbach)

      Thanks for the feedback Ori! That’s actually what one of my students said when he started feeling more comfortable with TMJ. “Oh, this is just like treating any other joint!”

      I think the wording of that statement of comforting is interesting. We PT’s tend to be most comfortable with joints, so I can see how labeling it as such can go a long way towards de-mystifying it. However, I like David’s example above is more complete. Not only is it just another joint, but it’s not much different from treating other pain states as well.

      Glad to hear that you are interested in serving this population. There’s a lot of need for it.

      Cody

      Reply
  3. Mary Duffy Zupkus

    Cody
    Well stated! Overcoming fear– both of the therapist and more importantly, that of the patient is fundamental to any successful treatment approach and often leads to new discoveries. Thank you for sharing your insights and encououraging me to explore the new science of pain.

    Reply

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