Case Study: Temporomandibular Joint Dysfunction - A Painful Jaw Condition Not Always Presenting As A Physiotherapist Would Expect
Faye Smith, pictured on left, and Sarah Gilbertson, pictured on right, are both fans of using walking poles.
A 64-year-old Sheffield female patient attended our practice following a 10-year history of ear pain which was becoming more persistent. This was affecting her sleep and day-to day life due to the marked level of pain which was being managed with painkillers and anti-inflammatory medication. More recently, her GP had placed her on Amitriptyline to help alleviate chronic pain and insomnia.
It was only after a family member recommended trying the route of physiotherapy, that the patient found us through the ACPTMD (Association of Chartered Physiotherapists in Temporomandibular Joint Dysfunction).
The patient, on attendance, reported her pain to be predominantly in her left ear but with slight discomfort into the left side of her head. She also experienced neck stiffness with slight discomfort referring into the left side of her arm.
She did not experience added sounds such as tinnitus or clicking of the jaw, and there were no reports of locking or catching in the jaw (which is what we usually expect when a patient presents with TMJ dysfunction).
Now, it is worth mentioning here that the face and head accounts for 45% of the sensory cortex in the brain meaning that when we get issues here it shouts loudly to us that they may have the potential to impact significantly on a patient's health.
The patient was under the care of ENT consultants who requested an MRI scan which showed no issues with her ear, but signs of wear over the left temporomandibular joint. There was report of previous trauma in this area. The ENT consultant discharged the patient under the care of GP, dentist and physiotherapist.
However, no issues were identified with the patient's teeth at the last dental review, and the GP felt at a bit of a loss as to where to refer her next. So, it was time for a visit to our physiotherapy clinic.
On physiotherapy examination, there was tension discovered over the muscles to the side of the patient's head and jaw into the base of the skull and she experienced some tenderness over the small joints at the side of her neck.
Treatment consisted of advice and education with acupuncture for pain relief – both local to the cervical spine and systemic points. Ultrasound treatment was also administered to the upper cervical spine and temporomandibular joint.
A home exercise programme commenced, working on self-release of the patient's tight muscles, jaw relaxation positions and cervical stability work. She was then given some self-mobilisation to release both fascial tightness and ligament tightness of structures which span from her temporomandibular joint to her ear canal.
Throughout ongoing treatment, the patient reported significant improvement in symptoms, enjoying periods of no pain. Yet, during treatment there have also been some periods of exacerbation with other structures going into spasm. These have been released with soft tissue mobilisation and reassurance. Triggers for exacerbation vary, but it is expected that with further management, the symptoms can be managed long-term.
It is expected the patient will continue to improve by optimising the movement of the temporomandibular joint and the upper cervical spine, managing the length tension relationship of the muscles around the head and neck, and ligamentous mobility connecting to the ear canal.
Physiotherapy intervention within the analysis and treatment of TMJ dysfunction is a growing area, and work is being done to forge the relationships between dental, audiology, maxillofacial experts, GPs and pain management specialists.
TMJ dysfunction can present in 1 in 3 people at some point during their lives, and is mostly seen in the 20 to 40 years-old age group. Interestingly, there is a significant prevalence in females with a ratio of 10:1.
For more info on TMJ dysfunction, please visit the ACPTMD website:
