Treatment of Myofascial Pain Dysfunction (MPD) at the Temporomandibular and Cervical Spine Regions with a Systems Approach using Integrative Manual Therapy: A Case Report
Author: Regina Rosenthal MA, PT
Abstract: This is a single subject case report documenting the effectivity and efficiency of using a Systems Approach with Integrative Manual Therapy (developed by Dr. Sharon W. Giammatteo, Dialogues in Contemporary Rehabilitation, Bloomfield, Connecticut) to assess and treat myofascial pain dysfunction of the temporomandibular and cervical spine regions.
Key Words: Temporamandibular Joint (TMJ), Cervical Spine, Jaw Pain
Discussion
This is a single subject case report documenting the efficacy and efficiency of using a Systems Approach with Integrative Manual Therapy (developed by Dr. Sharon W. Giammatteo, Dialogues in Contemporary Rehabilitation, Bloomfield, Connecticut) to assess and treat myofascial pain dysfunction (MPD) of the temporomandibular and cervical spine regions.
Temporomandibular disorders include a span of related disorders which may encompass problems with:
Chief presenting complaints may include:
The craniomandibular, CS, and shoulder girdle region make up the upper quarter, which consists of several skeletal structures interconnected by joint articulations, muscular/ligamentous/fascial connections, as well as neural tissue and circulatory vessels (arteries, veins, lymphatic vessels). The skeletal structures include: cranium, mandible, hyoid bone, TMJs, dentition, suboccipital spine, mid-lower CS, cervico-thoracic junction, upper thoracic spine, first and second ribs, sternum, and shoulder girdle. The TMJ is a connecting link between the cranium and the dentition. The mandible connects with the hyoid bone via the suprahyoid musculature and the hyoid bone connects with the clavicle via the infrahyoid musculature. The clavicle then connects with the sternum and rib cage (1, 2).
"The suboccipital spine (occiput, atlas, and axis) contains dense neural and vascular components. The facet joints and capsules of the atlas and axis, as well as their related ligamental stabilization, contain a significant degree of mechanoreceptors that contribute to the control of balance and equilibrium through proprioceptive input (3, 4). Normal craniocervical posture provides a means of non-nociceptive afferent input to the central nervous system (CNS)… The interaction within the vestibular system between visual and vestibular signals with those of proprioception contributes to stabilization of vision during normal head motion… The prime muscular source of proprioceptive input relative to the orientation of the head in space is the SCM. Innervation of the SCM is via the C2-3 cervical nerve roots and the spinal accessory nerve. Innervation of the upper trapezius muscle is via the C3 and C4 roots as well as the spinal accessory nerve" (5).
"The spinal tract of the trigeminal nerve (CN V) descends to the level of at least C3 and possibly C4… The facial (CN VII), glossopharyngeal (CN IX), and vagus (CN X) nerves course with the trigeminal spinal tract to synapse in the dorsal horn of C1-4. Thus innervation of all the facial and masticatory musculature as well as the TMJ can be influenced at this region. Other anatomic connections also exist between the ventral ramus of C2 to the hypoglossal and vagus nerves which continue to innervate the lateral walls of the posterior cranial fossa. A spinal accessory branch communicates with the vagus and hypoglossal (CN XII) with additional anastamoses at the C2-4 and C5-6 spinal segments. The hypoglossal nerve communicates with the inferior ganglion of the vagus and both share a dense connective tissue binding at OA.
Hypoglossal efferents innervate the hyoid and tongue musculature with the glossopharyngeal innervating the soft palate and base of the tongue. Besides providing efferent and afferent visceral innervation, a superior laryngeal branch of the vagus provides sensory and motor fibers to the larynx, vocal cords, soft palate, lateral pharynx, posterior tongue, and superior surface of the epiglottis. Other vagal branches innervate the posterior cranial dura, dorsal wall of the external auditory meatus (EAM), and concha. . .
The entire trigeminocervical complex may thus encompass spinal nerves C1-4 and cranial nerves 5,7,9,10,11, and 12… Cutaneous innervation of the head is via the trigeminal nerve. However, the skin overlying the occiput, up to and including the vertex of the head, as well as the inferior and submandibular region is innervated by the occipital nerves from C1-3" (6).
"The vertebral artery represents the prime source of circulatory input to the cranial region… The vertebral artery courses along a groove on the posterior surface of atlas before ascending into the foramen magnum. This distribution allows for impingement to occur from abnormal suboccipital posture" (7). The vertebral artery becomes the basilar artery within the cranium and then branches into the Circle of Willis which provides blood supply for the posterior, middle, and anterior aspects of the brain. In addition to the vertebral artery, circulatory input to the internal and external cranium occurs via the internal and external carotid arteries.
Venous drainage in the head, neck, and upper quarter is provided primarily via the cranial venous sinuses, veins for the posterior cranial fossa, internal cerebral vein, Great Cerebral Vein of Galen and its branches, cerebral veins and branches, internal jugular vein, brachiocephalic vein, subclavian vein, and trunks of jugular vein into face, retromandibular, lingual, facial, superficial temporal, occipital region and branches within these veins.
Lymphatic drainage for the head, neck, and upper quadrant is via lymph nodes into the right and left thoracic ducts. The left thoracic duct receives drainage from 75% of the body, the right from 25% of the body. Congestion in the thoracic ducts can occur via trauma, musculoskeletal compression/myospasm, problems at the nodes, vessels, or capillaries, protective guarding in the region, or systemic conditions causing either impaired drainage, increased lymph viscosity, or back-up within the system (8).
Vascular compromise and/or constriction may occur as a protective mechanism due to dural restrictions, pressure changes in the region or body, trauma, infection, inflammation, membrane wall disruptions—all which may result in the development of compression syndromes in the region(s) involved. Integrative Manual Therapy has recognized that reflexes at the brain stem level can and do potentiate / produce compression syndromes in the body as a protective mechanism. These are not under conscious control and may develop at any place in the body where protection is needed. At times this protection may last beyond the time of healing as a result of sustained neuro-reflexogenic modes. Self-protection modes include:
Compression syndromes may initially be a secondary problem in relation to trauma, but continued post-healing they can become a primary problem. Areas commonly requiring protection include: arteries, veins, nerves, lymphatics, viscera, bone bruises, and disruptions of membranes (i.e. leaky gut, leaky vessel) (9).
Disease has been defined as, "a failure of the adaptive mechanisms of an organism to counteract adequately the stimuli and stresses to which it is subject, resulting in a disturbance in function or structure of any part, organ, or system of the body" (10). When considering the upper quarter and specifically the TMJ and CS regions, any problem related to one segment can impact on any or all adjacent components, affecting both structure and function. IMT © uses a Systems Approach which works with both the structural and functional elements of healing and rehabilitation. It is a basic premise of osteopathy that structure governs function. Structural rehabilitation, through a Systems Approach, assists clients with attaining potential and functional rehabilitation then assists the client with maintaining and optimizing potential (11). IMT © uses a Systems Approach to address the often multiple signs and symptoms which frequently present for health-care intervention. When evaluating and comprehensively treating TMJ and CS problems, the role of the therapist becomes vital for assessing and identifying primary etiologies and contributing factors in an interconnected system. The ultimate goal is optimizing structure and function as well as educating clients to: 1) enhance their body-mind self-awareness and 2) enable them to actively participate in their health-care process and growth and development as individuals.
This case study will follow the evaluation, re-evaluation, discharge (within 8 visits), and treatment protocol followed for a client presenting with myofascial pain dysfunction of the masticatory and cervical regions using a Systems Approach with IMT.
History
The Patient was a 50-year-old, female, school teacher with initial onset of complaints December, 1999 with gradual onset of limited range of motion in the jaw and pain over right masseter and inferior mandibular angle. There was a history of root canal work October, 1999 involving upper left molar #15 with no complaints of limited VDO status post. Also accompanying these complaints was tinnitus in the right ear with no ear fullness or pain and no tooth pain.
The patient’s initial goals including the following: decreasing pain, increasing active range of motion at the CS and VDO TMJ; normalizing spinal, sacral, and TMJ mechanics; reducing myospasms; enhancing function of the TMJ and CS; and independence in a home program.
Evaluation
At initial evaluation, the client reported increased VDO, to current status, since onset of complaints. Pain was noted at the end of full opening. A late opening and early closing click was reported and observed right TMJ. There were no CS pain complaints except for "pulling" over left lower CS into upper trapezius region noted while driving and rotating CS to the left. There had been some pain and limited VDO noted in the mornings. A soft diet was being followed and a soft full-coverage mandibular appliance was being used at night and during her commute to work. Current complaints were aggravated with laughing and prolonged talking (especially while teaching), especially at the end of the day, with "fatigue" felt in the right TMJ region also at the end of the day. No complaints of headaches were reported except for a headache mid-January, 2000 over the vertex of client’s head described as pressure, "as if it were on the verge of a migraine", which she had a history of experiencing approximately every five years. General health was otherwise unremarkable and current medications included Premphase (hormone replacement therapy) and Etodolac (anti-inflammatory).
During a postural evaluation, the following was observed: Moderate forward head posture with swayback, flattened cervical, thoracic, and lumbar curvatures; right shoulder and iliac crest high, right A/PSIS high; CS in right head tilt with left rotation, pronation noted right more than left foot, right shoulder and left hip anterior comparable to contralateral sides. Active range of motion (ROM) of the Cervical Spine was as follows: Limitations noted – forward bending 25%, backward bending 25%, right rotation 25%, right sidebending 25%, left sidebending 50%. There was hypomobility noted at the right upper CS with sideglide and left upper CS with rotation.
In an upper quarter screen, the following was noted:
In a lower quarter screen, the following was noted:
A craniomandibular evaluation revealed the following:
Palpation produced complaints over right lateral condylar pole with open/closed occlusion and AROM as well as protrusion and left lateral excursion. Muscle palpation produced complaints over right temporalis tendon intraorally, right superficial and deep masseter, right medial pterygoid with intra and extraoral palpation. Provocation testing produced complaints right TMJ with left TMJ loading as well as right masseter with clenching. Intraoral mobilization revealed firm capsular endfeel with distraction bilateral TMJ, with rotation limited right TMJ. Isometric testing was without complaints over masticatory musculature. Normal sensation to light touch was noted throughout facial vault with AROM revealing decreased lip raising left with smiling.
Treatment
The patient was treated with Integrative Manual Therapy utilizing the following techniques:
The patient was put on a home program consisting of Neurofascial Process (24) and Feldenkrais © TMJ exercises (25).
Outcome
The patient was seen for 8 visits in total. After the second visit, deflection was reduced 75% after TMJ /sphenoid biomechanics were treated. At 6 weeks, re-evaluation showed that VDO was normalized to 41 mm, lateral excursion was 3 mm right and 5 mm left, with no maxillo-mandibular deviation, and protrusion 2 mm. CS active ROM had improved showing limitations in forward bending 15%, backward bending 25%, right rotation 20%, right sidebending 20%, and left sidebending 35%. Minimal complaints of pain were reported, and when present, they were localized over the right masseter. No medications were necessary for inflammation as at onset of care. Appliance usage was required only intermittently with stress/driving. No complaints were noted with prolonged talking and chewing, and client was able to chew firmer foods. Intermittent click was noted at the right TMJ with wide VDO, of decreased frequency from prior. The patient was discharged with a home program after 8 visits with no complaints of pain or limitations during daily activities involving the CS and TMJ regions.
Conclusion
In 1969 Laskin wrote, "There are two aspects to the successful management of any disease process: one is the establishment of an accurate diagnosis, and the other is an understanding of its etiology so that a rational treatment plan can be formulated. Unfortunately, in the management of many problems involving the temporomandibular joint, we have not been highly successful in either of these areas" (26). It has been the experience of this therapist that through the use of IMT and the Systems Approach treatment to this region can be both efficient and effective. This would reduce the incidence of developing a chronic condition, more systemic involvement and psychosocial complications, and, in addition, would save time and money for the individual and the health-care system. Use of medications could also be lessened, which would enable the client to heal more quickly, eliminate waste products more efficiently, and maximize structural integrity which would enhance more rapid return to normal function for the individual. The use of IMT proved most successful with this client. Using the IMT procedures outlined above, structure and function in the TMJ and CS regions were restored in a timely manner.
References
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6. Ibid.
7. Ibid.
8. Netter, Frank, MD. Atlas of Human Anatomy
9. "Upper Extremity Compression Syndromes." Dialogues in Contemporary Rehabilitation (DCR). Connecticut: 1998.
10. Jonas, S. Health Care Delivery in the United States. New York: Springer Publishing Co., l986. p. 13.
11. Weiselfish, Sharon, Ph.D, Manual Therapy with Muscle Energy Techniques for the Pelvis, Sacrum, Cervical, Thoracic, and Lumbar Spine, ANA Publishing, Connecticut, 1994.
12. Ibid.
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14. "Myofascial Release." Dialogues in Contemporary Rehabilitation. Connecticut: 1998.
15. Giammatteo, Thomas, DC, Weiselfish-Giammatteo, Sharon, Ph.D. Integrative Manual Therapy for the Autonomic Nervous System and Related Disorders.California: North Atlantic Books, 1999.
16. "Cranial Therapy Series." Dialogues in Contemporary Rehabilitation. Connecticut: 1998.
17. "Upper Extremity Compression Syndromes." Dialogues in Contemporary Rehabilitation. Connecticut: 1999.
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19.. "Advanced Assessment and Treatment of Neural Tissue Tension Techniques." Dialogues in Contemporary Rehabilitation Connecticut: 1997.
20. "Diaphragm Compression Syndromes." Dialogues in Contemporary Rehabilitation. Connecticut: 1998.
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23. "Personal Communication."Dialogues in Contemporary Rehabilitation.
24. "Integrative Diagnostics Series." Dialogues in Contemporary Rehabilitation. Connecticut: 1998.
25. Phillips, Lawrence, Feldenkrais © Practitioner, Personal lessons
26. Laskin, D, "Etiology of the pain-dysfunction syndrome." J Am Dent Assoc, 79:147, 1969.