Hiro,
Sounds like you've got a difficult patient to work with. Is it normal for
most patients in Japan to be so noncompliant and difficult? Its
unfortunate that PT;s don't have more freedom in Japan, as patients need
and will/do benefit from cervical mobilizations. Why are they prohibited?
I would go ahead and mob the TMJ; though, be careful as it may cause
soreness (her jaw hasn't been stretched for some time because the patient
is afraid of pain) she needs to start moving her jaw more to keep what
function she has left! If she keeps limiting motion due to fear of pain,
she will continue to loose what she's got. Her neck pain is probably due
to the biomechanical changes that have been going on due to her altered use
of her TMJ adn due to postures when reading/sleeping etc like you suggest.
Her case is screaming for mobilizations of the cervical spine, but you can
use isometrics (muscle energy) to mobilize the spine. They are technically
isometrics and a secondary effect would be that the joint also moves when
performing isometrics; out of your control! Just either flex, extend, side
nbend or rotate teh cervisl spine to the level that you think is the
culprit adn have her pusr against your resistance for strenghtening and, of
course, a secondary effect of joint movement. One question, do Orthopedist
allow PROM of the c-spine? Mob's are no different adn less likely to cause
damage than PROM, as the total amount of actually less.
Best of luck to you!
Jason
----------
> From: Hiro Wood <[log in to unmask]>
> To: [log in to unmask]
> Subject: Re: Neck pain and TMJ dysfunction
> Date: Tuesday, October 06, 1998 9:50 AM
>
> 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.
> >
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