Hiro Wood wrote:
>
> Dear physio
> Jason
> Yaap-san
> Ms.Melissa Heebner
> Ms.Robert Michie
> Thank you for all your help.
> Someone recommended accupuncture.Someone did exercise of retraction movement of
> mandible.Someone did the remedy of myofacial pain syndrome,of which I couldn't
> find references easily in Japan and I don't know well about it.
> Someone did a mobilization of TMJ and cervical spine,but I am a novice of
> cervical mobilization and it is prohibitted by most of orthopedists.
> I will be able to only do it under the supervision of understanding orthopedist
> whom I cannot find still now.I will study cervical mobilization with healty
> people according to your kind suggestions at first and continue to search for
> understanding orthopedists.But such an orthopedist are apt to do it by himself.
> So autonomy of PT in Japan is needed,I think.
> While Korean PTs held an demonstration wanting for a right to do private
> practice in front of the Diet Building,Japanese PTs are obedient to the Ministry
> of Welfare and lack a desire to acquire a right to do private practice.
> A PT from foreign country who works at Japanese clinic said that Japanese PT
> was like a slave who was restricted too much.
> I had a second visit of the patient last Friday.
> She asked me to make her get well without a treatment of TMJ,because her pain
> locates only in a neck and she had been pronounced that her TMJ was not a
> indication of surgery and could be never cured by dentist of university
> hospital and she had believed it for more than 10 years.
> And she said that she would take an important examination which related to
> her job at 24 Oct.At that time she must sit and lean forward for 2 hours
> 2 times.She asked me to cure the neck pain perfectly until the examination.
> I examined her more deeply than before this time.
> The result is as follow.
> 1.History
> At 12 years old she consulted a dentist for orthodontic appliance and it did
> not work well.Her tongue was apt to protract and be bited by the teeth and
> have a difficulty in pronouncing S-words and T-words.
> I guess this means a protraction of mandible.
> As her dentist avoided his responsibility,she went to the mouth surgery
> department of university hospital.she was then diagnosed that both disks
> disappeared and both head of mandible was destroyed and its shape became
> straight from round by friction.
> Since then she had restricted her movement of whole body and mandible for more
> than 10 years.Last November she changed a way of chewing at dentist's
> suggestion and neck pain occurred.After that she entered a hospital for 1
> week owing to other disease.
> --she intended not to tell me what kind of disease it was.she had a unique
> atmosphere that ruled a place as if I was manipulated psychologically.---
> During admission she was always reading a book.
> After discharge she slept in a wrong posture in December and she had a neck
> pain.She consulted an orthopedist and was prescribed stup and medicine.
> The pain healed in 1 month.The symptom had got well and bad alternately after
> that.She had been rather well for 3 months from this June.
> Last nigt(24 Sept.)she had a severe neck pain when she raised a right hand
> toward front left and cold not sleep at night.
> She again consulted orthopedist and then referred to me.
> She said she had worn a mouthpiece every night for bruxism.
> 2.Main complaint --neck pain
> She cannot sleep well and she cannot work as a psychologist who needs nodding
> with client talk and using word-processor for a long time.
> 3.Present symptom
> There exists neck pain but get better only a little than the first visit.
> 4.Pain
> No pain in TMJ.There was a neck pain when she hold a heavy thing in right hand
> and she protracted a right hand toward front half left to take something and
> she shook a dressing strongly to mix it.
> 5.Observation
> (1)Breath -- through mouth.Her nose was stuffed up.
> (2)Toothache
> When she chew hard food or vegetable for a long time,there existed a
> pain of
> molar.I was taught a TMJ patient must not eat peanut,but I did not prohibit
> to do it because she had no pain in TMJ.
> (3)ear symptom -- no
> (4)There was an experience of locking of TMJ only at the first stage ten years
> ago but wasn't a click sound.
> (5)Habit of chewing gum,hair,nail --- no
> (6)Dizziness --- no
> (7)Activity
> Her action of putting on and off shoes was very quick and smooth but she
> was afraid of and refused to lie on back in my examination.
> Actually she made a great effort to lie for sleep every night.She must
> arrange cushions very carefully before lying.
> 6.Inspection
> (1)Posture of the whole body
> shoulder -- The right side was lower than the left.
> ASIS -- The right was higher than the left.
> PSIS -- The right was posterior than the left.
> There seemed to be a scoliosis at upper lumber spine.
> There was a protraction of left lower rib.
> There was not a difference of the length of both legs.
> There was not a forward head position in static status,but I did not check
> it in chewing.
> (2)There was no inclination of eyes line,nosal cavity line and mouse line.
> They were all horizontal.
> Face was symmetrical in right and left side.There was not a face palsy.
> (3)Occlusion
> There was a malocclusion.When she bited,only right molars touched and
> there was a retraction of lower teeth.The distance between the upper and the
> lower was 3 mm sagitally.Recently she had been recommended to protract
> lower teeth(mandible) by her dentist.The dentist intended to make her bite
> at frontal teeth,she said.
> (4)The distance between the upper and the lower when opening was three fingers
> and the distance of protraction was 7 mm.
> She had never experienced a lateral deviation for 10 years and the movement
> of it was difficult to do.
> She had been trying not to move mandible largely.There was an atrophy of
> masticatory muscles.
> (5)Movement of tongue was good.
> 7.Physical examination
> (1)When she opened the mouth there was not a C-curve or S-curve or deviation
> at a end point.
> (2)The length of mandible was same at the both side.
> (3)Chvostek sign was negative.
> (4)Auscultation of TMJ was normal.
> (5)Reflexion of mandible -- She was reluctant to do it,so the result was
> questionable.
> (6)Passive joint play movements of TMJ
> She refused to do it because she was afraid of occurrence of TMJ pain,in
> addition to present neck pain.
> (7)Palpation
> a)There was a tendeness of condylar heads in opening and right deviation.
> b)When I palpated through the external auditory meatus with the palpating
> finger,there was a tenderness when opening mouth.
> Both TMJ moved symmetrically and smoothly.
> c)There was not a tenderness of masticatory muscles.Parotis could not be
> palpated.
> 8.Questions to be remained.
> For what purpose and in what way did she chang a way of chewing last
> November?She said that she had been recommended to protract mandible by
> her dentist.Does this mean above thing?Does it relate to neck pain?
> Why cannot she chew only with right molar?Why have it been left as it is
> for ten years?What treatments has she received for 10 years by dentist of
> university hospital?
> Is there any difference in the deformation of mandibular head between right
> and left?But there is neither C-curve nor S-curve nor lateral deviation
> when opening mouth.
> 9.Pathological hypothesis
> (1)Primary cause may be changing a way of chewing.
> After that she entered a hospital and spent in reading books all day long.
> Owing to this admission the function of her body mechanism -muscle power and
> elasticity would be reduced and joint dysfunction(stiffness) would occure.
> She had already had poor body mechanism before admission.
> (2)Dental problem may also be a impotant cause.
> I think a co-operation with dentist is needed.I have ever heard there is a
> department of dental and TMJ proplem in Holland hospital,where PTs works in
> co-operation with dentist.
> My patient is going to bring X-ray and mouthpiece at next Friday.
> 10.My treatment plan
> (1)General conditioning --- walking for more than 1 hours a day.
> (2)Stretch Ex. --- shoulder,neck,lumber muscles
> (3)How about TMJ?I don't know whether I may mobilize it or not.
> How about strengthen the masticatory muscle?
>
> Thanks for reading long sentence.
> Would someone give me any comments?
>
> Best regards
> HIRO
> Japan
>
> At 8:20 PM 98.9.29 +0900, Hiro Wood wrote:
> >Dear physio
> >Would you teach me the treatment of patient with neck pain and
> >temporomandibular
> >join dysfunction?
> >
> >1.Patient profile
> > 25 years old female.She has been suffered from TMJ dysfunction for 10 years
> >and been treated by a dentist.She has never undergone a surgery.
> >
> >2.Diagnosis and treatment by a dentist
> > From patient's information diagnosis is bi-lateral TMJ dysfunction with fused
> >joint,rather severer in right side.
> >She has been wearing mouth piece,orthotic device at night.
> >
Dear Hiro
Excellent advice from Jason regarding mobilising the TMJ.
As she has had the TMJ problem for so long it is likely that she has
adopted abnormal postures as a guarding process and you are no longer
treating the TMJ problem alone.
What is her 'head posture' like, does she have a 'poking' chin?
I don't thnk you mentioned her C/spine ROM in your letter. Is it
reduced?
As the C/spine would appear a no go area for hands on, have you
considered McKenzie type exercises, retraction, retraction with
extension, ret with ext and patient over-pressure etc. Taking into
consideration the 'traffic light' principle of progression of forces, of
course.
Just a thought.
Hope it helps.
Regards
Pete Purslow
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