Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_138_библиотеки_им_акад_М_И_Перельмана
.pdf
malalignment of the cervical spine, interfering with the tonic
https://t.me/med1917
neck reex, can also aect the vestibular nuclei.
16
Swallowing and speech diculty
Swallowing and speech diculty in patients with TMD
is due to the trigeminocervical nucleus connection of cranial
nerves V, VII, IX, X, XI. e input of the TMJ through the
cranial nerve V will aect other cranial nerve distribution to the
tongue and pharynx area.
Psychological aect
Anxiety, depression, or chronic pain is often associated
with TMD. Patients tend to clench their jaws under stressful
situations, which triggers the vicious cycle of spasm and pain.
e psychological issue can be a biproduct of TMD or can be
a precipitating and perpetuating factor of the TMD. is area
will be discussed further in the management section.
Trigeminal neuralgia (tic douloureux)
Trigeminal neuralgia is a paroxysmal, unilateral, electric-like, stabbing pain that occurs intermittently and abates
within seconds or minutes. is is a neurogenic type of pain
that involves the maxillary and mandibular divisions of the trigeminal nerve. Temporomandibular joint pain and other orofacial pain may mimic the symptoms of trigeminal neuralgia. A
complete and conclusive diagnosis can be done by a neurologist, who also guides the proper management procedures.
Temporal arteritis
Temporal arteritis is a condition caused by subacute inammation of the supercial temporal artery and the vertebral
artery. Its clinical presentation includes severe unilateral or
bilateral headache over the scalp-temporal artery region. Jaw
claudication with pain or stiness during chewing is highly
suggestive of this condition due to ischemia of the muscles of
mastication. Ophthalmologic evaluation is vital because of the
danger of vision loss associated with this condition.
Atypical odontalgia (phantom tooth pain)
Atypical odontalgia or phantom tooth pain is a constant,
burning or pressure-like pain, that occurs after endodontic procedures and dental extraction. is condition is caused by the
disruption of neural pathways to the alveolar or pulp.
Post-herpetic neuralgia (herpes zoster)
Post-herpetic neuralgia or herpes zoster is a constant, severe, burning, or stabbing pain over the distribution of the rst
division of the trigeminal nerve. is condition is associated
with shingles (herpes zoster), a reactivation of the varicella-zoster virus in individuals with a history of varicella infection. Pain
associated with this condition may be severe and disproportionate to the extent of skin irritation.
Ménière disease
Ménière disease is dened as a combination of vertigo, tin-
86,87
nitus, aural fullness, and facial-TMJ pain. Bjorne et al
reported that a coordinated treatment of TMD and cervical spine
disorder was eective in relieving symptoms of Ménière disease,
even after a 3-year follow- up.
Cervical or postural cause
e pattern of referred pain to the facial or TMJ area from
a cervical origin, and vice versa, has been acknowledged both
clinically and scientically. Many studies have reported that patients with TMD often report neck symptoms, and patients with
cervical spine-related symptoms often complain of TMD.
29,79,88
Neck pain is the rst comorbidity of TMD followed by head-
89,90
ache, low back pain, and joint pain.
von Piekartz et al91
performed a cross-sectional study and concluded that TMD is
strongly related to cervical spine musculoskeletal impairments;
therefore, treatment of the cervical spine is recommended for
92
the management of TMD. Hong et al
conducted a study to
investigate the relationship among cervical spine degeneration,
head and neck postures, and myofascial pain in older individuals with TMD. ey concluded that in this particular population, degenerative changes in the cervical spine were related
to altered head posture and the development of active trigger
points in the masticatory and cervical muscles.
A forward head posture typically causes the mouth to open
93
wider, which in turn may result in TMJ hypermobility.
e
increased tightness of the suboccipital muscles resulting from
the forward head posture would exert undesirable pressure on
the greater occipital nerve, which in turn may cause symptoms
radiating into the head, face, ear, neck, and even scapular ar-
31,32,40,44
eas.
e relationship between head posture and dental occlusion has also been documented. When the head is side bent
and rotated away, the occlusal contact is stronger on the ipsilateral side. When the head extends, the occlusal contact is
more posterior; while when the head exes, the occlusal contact
31
becomes more anterior.
erefore, when assessing a patient’s
TMJ symptoms, the physical therapist must make sure the patient stays in a neutral head position. e same guideline applies
to the dentist for occlusal adjustment.
Patients also brux more in response to neck pain. is be-
havior increases the tension of the masticatory musculature and
94
can trigger joint and myofascial symptoms. Clark et al
used
electromyography (EMG) on 12 males to study the connection
between masseter muscle contraction and the activation of the
SCM. ey reported that there was a progressive development
of SCM coactivation that paralleled masseter muscle activation.
45
De Laat et al
studied the correlation between the cervical spine
and TMD for 30 patients with TMD and 30 control participants. ey reported that segmental limitations (especially
at the Occiput-C3 levels) and tender points (especially in the
SCM and upper trapezius muscles) were signicantly more
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
27
present in those with TMD. In contrast, Visscher et al95 did not
https://t.me/med1917
nd a signicant dierence in head posture between individuals
with and without TMD. erefore, they did not support the
theory that TMD is related to head posture.
2
Armijo Olivo et al
and Olivo et al96 conducted systematic
reviews to assess the association between head and cervical posture and TMD. Neither review was able to make conclusions
due to the poor methodological quality of most research. ey
recommended that future studies should include a larger sample
size, better classication in TMD diagnoses, and more objective
methods for posture evaluation.
97
La Touche et al
applied manual mobilization to the cervical spine and provided deep cervical exor muscle exercises to
19 patients with myofascial TMD for a total of 10 treatment
sessions over a 5-week period. ey concluded that the application of these treatments targeted at the cervical spine were
benecial in decreasing pain intensity, increasing pressure pain
threshold (PPT) over the masticatory muscles, and increasing
pain-free mouth opening in patients with myofascial TMD.
98
La Touche et al
further studied the inuence of 3 dierent cranio-cervical postures, neutral, forward, and retracted, on
maximal mouth opening and PPT in patients with myofascial
temporomandibular pain disorders. ey concluded that there
was a biomechanical relationship and interaction within the
trigeminocervical complex as well as nociceptive processing in
dierent cranio-cervical postures.
Chronic pain, psychosocial factors, stress factors
Myogenous TMD is signicantly aected by the level of
stress experienced by the patient on a daily basis. Studies have
shown that patients with TMD demonstrate increased somatization, stress, anxiety, and depression compared to healthy indi-
99
viduals.
If these psychological factors are not addressed in the
early phase of the condition, chronic pain will develop and can
100
perpetuate and maintain the TMD.
Physical therapists play
an important role in recognizing predisposing factors for chronic pain (eg, fear avoidance, symptom catastrophizing, etc) so
that proper overall management of the patient can be designed
to avoid the development of chronic pain. Timely referral to
psychotherapy or behavioral therapy should be made as needed.
PHYSICAL THERAPY MANAGEMENT FOR
TEMPOROMANDIBULAR JOINT DISORDERS
Non-surgical treatment is now recommended as the rst
option for managing TMDs. Options include physical therapy
as well as medication, occlusal adjustment, splint therapy, chiropractic care, osteopathic care, and cognitive behavioral therapy, provided in isolation or in combination. Physical therapy
intervention plays an important role in assisting patients with
TMD to control symptoms, restore normal kinematics, and optimize oral function.
Patient Education
e rst step of physical therapy management is to explain
to the patient the etiology, epidemiology, natural course of the
disorder, prognosis, treatment goals, and predicted outcome of
treatment. Research has shown that when patients have a good
understanding about their condition, the treatment outcomes
are more favorable.
30
Physical therapists play a vital role in preventing patients from developing a chronic condition. Prevention is accomplished in part by using appropriate pain neuroscience education (PNE) to decrease fear and anxiety.
Sleep hygiene is another important area that needs to be
included in patient education. Sleeping posture, relaxation,
comfortable environment, dim light, removal of electronic devices, and avoidance of large meals, caeine, and alcohol before
bedtime are some of the instructions that can be helpful for a
more restful sleep. Nocturnal bruxism has been proven to be
related to TMD.
101
erefore, stress management and the use of
a night splint (if indicated) is recommended.
Relaxation, Postural Correction,
and Body Mechanics Instruction
Relaxation training is critical to reduce muscle hyperactivity; in essence, teaching patients to decrease their cervical and
mandibular muscle activity to the “least measurable activity” at
rest. is is accomplished by performing diaphragmatic breathing, imagery, and progressive relaxation exercises. Ferendiuk et
102
al
recommended using Jacobson’s progressive relaxation tech-
nique as a supportive therapy for patients with TMD.
Proper alignment of the head, neck, and spine is of utmost
importance in the management of TMD. Komiyama et al
and Wright et al
104
studied the eectiveness of postural correc-
103
tion for patients with myofascial TMD and concluded that postural training was benecial in relieving symptoms, increasing
mouth opening, and decreasing disruption of ADLs.
Body mechanics principles for working, computer use, sitting, standing, transferring, lifting, driving, and sports activities
should be reviewed with the patient. Sleeping posture should be
analyzed as well. Prone sleep positions that put extra pressure
on the jaw and excessive stretching of the cervical musculature
should be avoided. Proper sleeping posture appears to have a
positive eect on nocturnal parafunctions.
30
Physical therapists
also have the ability to recommend the appropriate type of pillow for each patient.
Oral Habits Modication
Proper tongue resting position is necessary for a relaxed jaw.
e patient is instructed to gently keep the tip of the tongue on
the palate, resting slightly posterior to the maxillary central incisors; keep the back molars apart, lips together, while breathing
normally; and maintain the jaw and surrounding muscles in a
relaxed manner at all times. When a patient has diculty keeping the tongue on the palate, the general relaxation techniques
mentioned in the previous section are reinforced. e patient is
28
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
then instructed to just relax the tongue and make sure the back
https://t.me/med1917
molars are apart while lips are kept together. For a patient with
a hypermobile TMJ, keeping the tongue on the palate while
yawning is advisable to prevent subluxation or dislocation of
the jaw. Patients should avoid any undesirable oral habits (eg,
clenching, biting on cheek or pen, biting on nails, sucking on
lips, supporting or resting the jaw or head on hand(s), playing
with jaw and mouth, etc). Overcoming parafunctional oral habits will provide the TMJ and its related structures with a more
balanced environment.
permeability. Sei et al
112
and Rezazadeh et al
113
conducted
studies to compare the eectiveness of TENS and LLL. Both
groups reported that TENS, as well as LLL, were eective in
relieving pain and muscle tenderness in patients with TMD,
113
with Rezazadeh et al
than LLL. Chellappa et al
nding that TENS was more eective
114
also studied the ecacy of LLL
and TENS for the relief of TMD symptoms using a RCT. ey
reported that both methods produced substantial improvement
in ROM and pain relief, with the LLL group exhibiting statistically signicant better improvement than the TENS group.
114
Soft Diet
For acute or postoperative conditions, a complete soft or
semi-solid diet is recommended until the patient’s pain symptoms subside. Some suggestions include soup, pasta, mashed
potatoes, sh, chicken, and cooked vegetables. Crunchy and
chewy food such as chips, salads, bagels, nuts, etc, should be
avoided. To relax the muscles of mastication, an increase of uid
intake is suggested. e patient is advised to chew on the uninvolved side at the beginning, and progress to bilateral chewing
when symptoms have improved. Eventually, chewing on the
involved side is permitted when normal function has returned.
Electrophysical Agents
Heat, ice, transcutaneous electrical nerve stimulation
(TENS), microcurrent electrical nerve stimulation (MENS),
ultrasound, phonophoresis, iontophoresis, light therapy, cold
laser, etc can be provided on an as needed basis to help with
pain control and recovery.
59,105-108
Amongst the published research articles on the eective-
109
ness of TENS in TMD management, Ferreira et al,
based on
their randomized control trial (RCT), concluded that TENS is
superior to placebo to reduce pain intensity and muscular ac-
110
tivity. Awan et al,
based on their literature review on the use
of TENS in the management of patients with TMD, concluded
that TENS could play a signicant role in pain control for the
masticatory musculature.
Microcurrent electric nerve stimulation is another type of
electrophysical agent used for pain management. It has been
postulated that this subthreshold stimulation can realign the
111
electrical properties of the injured tissues. Saranya et al
compared the eect of TENS and MENS in acute and chronic
masticatory muscle pain. ey concluded that both approaches were equally eective in pain reduction and mouth opening
improvement; yet, MENS showed better and more immediate
eects in pain relief, and less negative eects such as post-procedure paresthesia.
Low-level laser (LLL) light therapy has gained attention in
recent years for its analgesic and anti-inammatory eects. It
has been postulated that the infrared radiation wavelength can
increase the release of endogenous epions, improve microcirculation, increase lymphatic drainage, increase the production of
adenosine triphosphate (ATP), and reduce nerve cell membrane
Soft Tissue Mobilization
Myofascial release, soft tissue mobilization, and massage
can decrease edema, improve circulation, and restore tissue extensibility. Massage therapy has been proven to be one of the
eective interventions for the management of patients with
TMD. Soft tissue mobilization also should be applied to the
cervical area.
Manual Lymphatic Drainage
Manual lymphatic drainage is an eective method to mobilize the lymphatic system and to decrease edema and restore
circulatory eciency. is method is especially eective in the
management of postoperative conditions involving the head,
neck, and TMJ regions.
Joint Mobilization
Joint mobilization is used to increase mobility of the TMJ
and cervical spine and to restore normal kinematics of the involved joints. Mobilization of the TMJ also can be used for patients with anterior disk displacement with and without reduction. Long axis distraction, anteromedial translation, anterior
or posterior rotation, medial glide, and lateral glide joint mobilizations can be applied to the TMJ while the patient is supine
or sitting. Muscle energy technique (MET) can be added at the
end of long axis distraction to elicit reexive relaxation of the
15,115
masticatory muscles.
A cadaveric study by Ho et al
116
showed that the mandibular condylar head rotates anteriorly and translates anteriorly
and inferiorly during passive mouth opening. eir work further suggested that a unilateral inferior glide with anteromedial
translation (UIGAT) or a bilateral inferior glide with anterior
translation (BIGAT) can be applied if anterior or inferior movement of the condyle or jaw opening is limited. Also, the UIGAT
or a lateral glide can be applied if the lateral movement of the
condyle is limited. To our knowledge, this is the only study in
this eld to justify the eectiveness and desired direction of
TMJ mobilization.
Upper cervical spine distraction and mobilization is of
great importance because of the close connection of the cervical
spine to the TMJ and the ear. e use of mid-lower cervical
spine mobilization, when indicated based on the examination
of the patient, is also an important intervention to ensure opti-
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
29
mal patient management. Patients can also be instructed on the
https://t.me/med1917
use of sustained natural apophyseal glide (SNAG) to be used as
a self-help home program.
117
Joint Manipulation
Joint manipulation in the management of TMD is used
for ADDwoR, a dislocated condyle, and the cervical spine. In
many research articles, the “manipulation technique” that was
used was not clearly described. Most of the time, it appeared to
refer to a manual skill more like a mobilization technique, in
contrast to a thrust-manipulation technique. For the consistency of reporting the evidence in this area, we will keep the word
“manipulation” as used by the authors of the original papers,
while acknowledging the dierent uses of the term.
Temporomandibular joint manipulation is indicated for
acute closed lock (ADDwoR) or acute dislocation. ese conditions may be caused by prolonged dental procedures or acute
trauma. Sometimes, the TMJ manipulation (reduction) for disk
displacement is performed by a medical doctor or dentist while
118
the patient is under general anesthesia.
For acute non-traumatic TMJ dislocation, which is usually caused by chewing or
yawning, a manipulation (reduction) without anesthesia by a
skilled clinician can be eective.
119
Gonai et al
120
described an
extraoral autoreduction technique for patients with recurrent
119
dislocation of the TMJ and Gorchynski et al
described a “syringe technique” to reduce an acute nontraumatic TMJ dislocation in the emergency department. Performing these reduction
techniques requires advanced training. Please refer to the relevant references for detailed descriptions.
121
Nagata et al,
in their RCT, studied the ecacy of mandibular manipulation on patients with limited mouth opening
(<35 mm) caused by ADDwoR. e authors reported that the
manipulated group showed improvement in mouth opening
after the rst visit, while the therapeutic exercise group exhibited a similar eect for mouth opening, pain, and joint sound.
However, the “manipulation techniques” described in this article appeared similar to extraoral and intraoral TMJ mobilization techniques, as opposed to high velocity, small amplitude
“thrust” techniques.
rust manipulation of the cervical spine has been recommended and shown eective in some studies for the overall
management of individuals with TMD.
122,123
Adelizzi et al
124
conducted a systematic literature review on the eectiveness
of thrust-manipulation of the cervical spine for TMD. Based
on the review of 6 articles, the authors concluded that cervical
spine manipulation along with other non-surgical interventions
may be benecial in achieving positive eects in patients with
TMD.
Mansilla-Ferragut et al
122
and Oliveira-Campelo et al
123
both reported positive immediate eects of atlanto-occipital
joint thrust-manipulation on mouth opening and PPT. Many
orthopaedic physical therapists have the skills to perform
thrust-manipulation techniques for the upper cervical spine.
125
Reynolds et al
conducted an RCT on the eectiveness
of cervical spine manipulation added to behavioral education,
soft tissue mobilization, and exercise for people with TMD
with myalgia. ey reported that both experimental and comparator groups improved over time with only small dierences
measured by the Jaw Functional Limitation Scale, Tampa Scale
of Kinesiophobia for TMD, and global rating of change, and
that the additive clinical eect of cervical spine manipulation to
standard care for treating TMD remains unclear.
Therapeutic Exercises
One often used exercise approach is to instruct the patient
on cervical spine ROM and TMJ controlled-opening exercises, 6 repetitions of each exercise, to be performed 6 times a
day (6x6). Controlled mouth opening exercise is performed by
keeping the tip of the tongue on the palate and opening the
mouth slowly without excessive protrusion. e 6x6 exercise
program is performed on a time-contingent basis, to be done
approximately every 2 hours throughout the day, regardless of
symptoms. e purpose is to remind the patient of good posture and to provide timely stretching of the tissues involved.
Diaphragmatic breathing is encouraged at all time for general
relaxation. Isometric TMJ exercises to relax the elevators and
provide stabilization for the masticatory system are also important. Cervical spine isometric and deep neck exors activation
exercises are often added for patients who demonstrate weakness or poor endurance of the cervical musculature.
126
Lindfors et al
used a postal questionnaire to study patients’ experiences of jaw exercise in the treatment of masticatory myofascial pain. e majority of participants (73% of 109
patients) reported that the jaw exercises not only reduced their
symptoms but also provided condence in self-management.
127
Storm Mienna et al
also studied experiences of supervised
jaw-neck exercise among patients with localized TMD pain or
TMD pain associated with generalized pain. A 10-session supervised exercise program, which included relaxation, coordination, and resistance training of the jaw, neck, and shoulders,
was given to the study group. e authors found that an individualized, progressive, graded exercise program was benecial
in reducing pain and providing self-ecacy for these patients
128
with either localized or generalized pain. Lindfors et al,
international modied Delphi study, concluded that jaw exer-
in an
cises were an eective treatment for myalgia of the jaw muscles,
restricted mouth opening, and disk displacement without reduction. is point of view is consistent with the international
consensus of TMD experts.
129
Dickerson et al
conducted a systematic review and meta-analysis of the eectiveness of exercise therapy for TMD.
Based on the 6 included articles, they concluded that exercise
therapy had moderate treatment eects in the short-term and
varying amounts of long-term treatment eects for patients
with TMD. ere was no consensus of exercise dosage, other
than a range of repetitions from 5 to 10, and daily sets from 5 to
30
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
10. Future research with a larger sample size to study the adher-
https://t.me/med1917
ence to home exercises and the proper dosing of exercises would
be benecial in providing better guidance for dosage of exercise.
Spray and Stretch
61
Travell and Simons
have indicated that trigger points in
the temporalis and masseter muscles can refer pain to the maxillary teeth and mandibular teeth, respectively. Patients with the
complaint of a toothache should be examined carefully to rule
out a trigger point as a potential cause before an irreversible
dental procedure is performed. To relieve trigger points and
promote normalcy of soft tissues for patients with myofascial
complaints, the method of spray and stretch with Ethyl-Chloride or Fluori-Methane has proven eective. is approach will
be described briey in the special technique section while a
detailed description is provided in the textbook by Travell and
Simons.
61
Dry Needling
Dry needling performed by physical therapists has gained
increasing recognition across the United States in the past several years. Dry needling is the practice of inserting acupuncture
needles into the trigger point of a muscle. e goal is to deactivate the trigger points and provide pain relief. In 2012, Gon-
130
zalez-Perez et al
reported the positive eect (pain reduction
and ROM improvement) of dry needling in the trigger points
of the lateral pterygoid muscle of patients with TMJ myofascial
pain. ey further reported in 2015 that dry needling in the
lateral pterygoid muscle showed better ecacy than oral medication for patients with chronic myofascial pain, for outcomes
of mouth opening, lateral excursion, protrusion, and pain intensity.
131
Fernandez-Carnero et al
132
investigated the eects of
dry needling of active trigger points in the masseter muscle in
patients with TMD. ey concluded that the application of dry
needling signicantly improved PPT and maximal jaw opening
in the participants in the experimental group as compared to
those who received sham dry needling. Blasco-Bonora et al
133
applied dry needling to the myofascial trigger points of patients
with sleep bruxism and TMD. ey reported an immediate
and 1-week improvement in pain, sensitivity, jaw opening, and
TMD-related disability.
134
Vier et al
conducted a systematic review and meta-analysis to study the eectiveness of dry needling for patients with
orofacial pain associated with TMD. Despite some studies suggesting that dry needling is better than sham therapy for improvement in PPT and some other interventions for improvement in pain intensity, they were not able to draw denitive
conclusions due to the low quality of the research designs, including small sample sizes, of the studies included in the review.
135
Similarly, Machado et al
conducted a systematic review of
dierent substance injections and dry needling for treatment
of TMJ myofascial pain. ey found that dry needling and local anesthetic injections seemed promising, but better research
designs and longer follow-ups were needed to draw denitive
conclusions.
Dry needling has attracted increasing interest in the eld of
physical therapy. However, the widespread use of dry needling
for TMD management still needs to be guided by better quality
research.
Kinesio Taping
e speculated purpose of applying Kinesio tape is to provide lymphatic drainage, increase circulation, and take advantage of natural self-healing processes. A few studies have been
conducted in recent years to examine the eects of Kinesio
taping on individuals with TMD. Coskun Benlidayi et al,
136
based on their single-blind RCT, reported that Kinesio taping
in conjunction with counseling and exercise was more eective
than counseling and exercise alone in improving disability and
increasing mouth opening in a group of patients with TMD.
Lietz-Kijak et al
137
assessed the short-term eectiveness of Kinesio taping and trigger point release in patients with masticatory
muscle disorders. ey found both methods were benecial in
relieving latent trigger points through the analgesic eects. A
more favorable outcome was observed in the Kinesio taping
group.
Kinesio taping is a relatively inexpensive and simple method of treatment. It can be considered as an adjunct intervention
for managing TMD. However, its clinical use needs to be supported by further well-designed clinical trials.
Home Programs
Self-care programs include awareness of posture and
tongue resting position, progression from a soft diet to a normal
diet, chewing on both sides of the mouth at the same time or
alternating sides to minimize excessive muscle tension, avoiding parafunctions, applying heat or ice as indicated, performing
time-contingent cervical spine and TMJ exercises, practicing
general relaxation (with relaxation tapes or music), participating
in a daily cardiovascular exercise program (30 minutes treadmill
or stationary bike), and managing stress for control of chronic
pain.
SPECIAL PHYSICAL THERAPY TECHNIQUES
Soft Tissue Mobilization and Myofascial Release
Extraorally, gentle pressure can be applied over the masseter, temporalis, frontalis, suprahyoid, and infrahyoid muscles,
according to the patient’s tolerance. Massage over the masseter
muscles can follow the direction of the bers, or be cross-sectional, with mouth closed or open (which places the masseter
muscle under stretch). Addressing the upper trapezius, levator
scapulae, and suboccipital musculature with appropriate techniques is also important. Acupressure points along the zygomatic arch, temple area, and medial corners of the orbital groove
are eective locations for headache relief. One can apply a rm
pressure or use circular motion of the ngertips (bilaterally) for
30 seconds on each location.
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
31
For intraoral techniques, therapists must wear latex-free
https://t.me/med1917
gloves on their hands for protection and to avoid unwanted allergic reactions of the patients. To start the intraoral approach,
the clinician rst uses the index nger or thumb to gently
stretch the buccal tissue and the orbicularis oris. is will relax
the mouth area. en, with the index nger, follow the mandibular arch to pass the posterior molar, move superiorly towards
the maxilla, and ask the patient to gently elevate the mandible.
e clinician will feel tension under their index nger that is
caused by contraction of the medial pterygoid muscle. is is
a very tender spot. If it is tolerated by the patient, the clinician
may exert static pressure for 30 seconds to release the tension in
this area. e clinician may also use the tip of the small nger
to follow the maxillary arch to the lateral-superior aspect of the
back molar, which is the “lateral pterygoid muscle region,” and
apply either gentle pressure or oscillation to provide release of
tension. Again, this is a very sensitive area, and palpation may
not be tolerated well by all patients.
Joint Mobilization
Joint mobilization for the TMJ includes longitudinal distraction, anteromedial translation, medial glide, and lateral
glide. It is an eective intervention for restoration of kinematics
of the TMJ.
Figure 13.
Unilateral Longitudinal Distraction Mo-
bilization of the Temporomandibular Joint - Supine
Longitudinal distraction
e patient is supine with neck supported by a thin pillow. e physical therapist stands at the head of the table, on
the contralateral side (right side) of the treated joint (left TMJ),
facing the patient’s head diagonally. e patient should be informed that you will put your thumb into their mouth to gently
mobilize the jaw. e patient is also instructed in using a hand
signal to indicate any discomfort. e physical therapist starts
by palpating the patient’s left TMJ extraorally with the left index nger and then places the right thumb intraorally over the
patient’s left posterior mandibular molar. e mobilizing force
is in the caudal direction along the vertical axis of the mandibular ramus. e mandible is supported gently at the mandibular
angle by the rest of the ngers of the right hand (Figure 13).
After applying longitudinal distraction for the desired amount
of time, the force is released and the mandibular condyle is returned to the initial resting position. If specic joint play is desired, the physical therapist may add tilting of the condylar head
either posteriorly (with ulnar deviation of the mobilizing hand
for “recapturing” the displaced disk) or anteriorly (with radial
deviation of the mobilizing hand for increased opening through
a kinematic path) before distracting the joint longitudinally.
Muscle energy technique can be added at the end of longitudinal distraction to elicit reexive relaxation of the mastica-
15,115
tory muscles.
is technique is accomplished by asking the
patient to contract the masseter muscle against the therapist’s
thumb at the end of longitudinal distraction, and then to relax
after 7-10 seconds to permit further stretching of the masseter
muscle by the therapist.
Anteromedial translation
After the longitudinal distraction is performed as described
previously, the physical therapist can then translate the mandible anteromedially along the horizontal axis of the mandibular
ramus. After reaching the end of the translation range, the condyle is then moved back posteriorly and superiorly to return to
the original position.
Anteromedial translation can also be performed bilaterally
at the same time while the physical therapist stands at the head
of the treatment table and translates the condyles caudally and
anteriorly with both hands (Figure 14). Again, subsequent to
the anterior translation, both condyles are moved posteriorly
and superiorly back to their original position. Attention is given
to any dierence in range, mobility, or joint play between sides.
e unilateral (Figure 15) and bilateral (Figure 16) mo-
bilizations should also be performed with the patient seated,
which is a more functional position. e patient’s cervical spine
needs to be maintained in a neutral posture at all time during
the mobilization techniques.
Lateral glide
A lateral glide technique is accomplished by using the intraorally placed thumb as a fulcrum, and lightly grasping the
32
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Figure 14.
https://t.me/med1917
Bilateral Anteromedial Translation Mo-
bilization of the Temporomandibular Joint - Supine
Figure 15.
Unilateral Anteromedial Translation Mo-
bilization of the Temporomandibular Joint - Sitting
mandibular angle with the other 4 ngers. en, move the condylar head laterally with the thumb. is technique can be performed with the patient either supine or seated.
Medial glide
A medial glide can be accomplished by moving the mandibular angle laterally with the thumb
placed intraorally (hooking the metacarpophalangeal [MCP] joint on the mandibular teeth) and trans-
Figure 16.
Temporomandibular Joint - Sitting
lating the condylar head medially with the second
and third ngers placed extraorally. eoretically, a
medial glide can also be accomplished by performing lateral glide of the contralateral TMJ. e medial glide is rarely done or indicated; however, it may
be used for the purpose of evaluating or improving
joint play.
Tongue-Controlled Mouth Opening Exercise
e tongue-controlled mouth opening exercise can be used for hypomobility, hypermobility,
incoordination, and inammatory conditions. e
patient is asked to keep the tongue on the palate,
and then open the mouth slowly in a controlled
manner. is exercise will keep the condylar head
in its rotation range and restrict its anterior trans-
lation. Repetitive movements in this manner can re-educate a
hypermobile joint to return to its normal kinematics, provide
mobility to a hypomobile joint, decrease inammation through
restrictions of anterior condylar translation, and guide an unco-
Bilateral Anteromedial Translation Mobilization of the
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
33
ordinated muscular system to regain its control. e patient is
https://t.me/med1917
instructed to perform 3 sets of 6 repetitions of this exercise, 6
times during the day. As control of this exercise improves, the
speed of the exercise can be increased (similar to oscillation)
for further neuromuscular re-education.
30
In addition, when the
opening pattern no longer shows deviation or deection, the
patient may practice wider opening without keeping the tongue
on the palate for a more comfortable stretch.
Additional tongue-specic exercises can also be introduced
to increase the exibility of the tongue and relax the masticatory system. is may include sticking the tongue out of the
mouth; retracting the tongue back toward the throat; moving
the tongue inside the mouth to touch the cheeks on either sides;
and circling the tongue around the cheek and in front of the
maxillary and mandibular teeth. In addition, puckering the
cheek and other facial muscle exercises can promote the general
relaxation of the orofacial area.
Isometric Temporomandibular Joint Exercise
is exercise is performed for the purpose of stabilizing the
TMJ, not for strengthening the masticatory musculature. Once
patients have mastered the skill of controlled opening, they may
progress to isometric stabilization. e patient is asked to keep
the tongue on top of the roof of the mouth, open the mouth
slightly, then apply a rm but gentle force with the index nger
(or index and long ngers) on the chin in dierent directions
(ie, left, right, superior, inferior, forward, backward, and diagonally). e exercise consists of maintaining the mandible in its
original position while resisting the externally applied force. Applying quick external forces to the mandible in a randomly chosen direction sequence can be used for the purpose of rhythmic
stabilization (Figure 17). Isometric contraction for the depressors of the TMJ can be introduced by asking the patient to open
their mouth against the resistance exerted by the dorsal aspect
of the hand that is resting under the chin. e recommended
hold time is 10 seconds, 6 repetitions each session. is maneuver can reexively inhibit the hyperactive mandibular elevators,
often the case with TMD (Figure 18).
Figure 17.
Rhythmic Stabilization of the Temporo-
mandibular Joint
Figure 18.
Isometric Exercise of Mandibular
Depressors for Relaxation of Mandibular Elevators
(Masseter, Medial Pterygoid, Temporalis Muscles)
Horizontal Tongue Depressor Exercise
is exercise is designed to assist the patient with increasing lateral excursion and anterior translation of the condyles for
improved joint play. A stack of tongue depressors (the number
of tongue depressors varies according to the patient’s amount
of mouth opening), with a rubber band on each end, is placed
between the patient’s maxillary and mandibular teeth. e patient is then asked to translate the mandible forward, backward,
and from side to side. is exercise is eective for improving
postoperative hypomobility. It also is often used to regain lateral
excursion (hence mouth opening), protrusion, and retrusion of
the TMJ (Figure 19).
Spray and Stretch
A ne stream of Ethyl-Chloride or Fluori-Methane vapocoolant spray is applied directly over the aected muscle with
trigger points. e muscle is put under stretch rst (for exam-
Academy of Orthopaedic Physical erapy, APTA.
34
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Figure 19.
https://t.me/med1917
Horizontal Tongue Depressor Exercise to
Improve Lateral Excursion
ple, keeping the mouth open to stretch the masseter muscle)
and then the spray is applied from approximately 24 cm away,
at a rate of 10 cm per second, for about 4 times. At the end of
the spray, the physical therapist warms the muscle with hand
strokes and applies further stretching to the muscle. e theory
proposed by Travell and Simons
61
is that the coolant can abolish
the supercial stretch reex of the fascia, which allows further
stretching of the underlying muscles. By doing so, TMJ ROM
can be increased and pain decreased.
60,61
For the treatment of
TMD, this approach can be applied to the masseter, temporalis,
and all cervical muscles.
SPECIFIC PHYSICAL THERAPY
INTERVENTIONS FOR SELECTED DISORDERS
Anterior Disk Displacement
Physical therapy should focus primarily on patient education regarding proper head, neck, and jaw positioning, avoidance of parafunctions and clicking or popping of the joint, and
an explanation of precipitating and perpetuating factors. Manual therapy with soft tissue mobilization and joint mobilization
are also important interventions for the management of anterior
disk displacement. e use of electrophysical agents and exercise
principles for restoring normal head, neck, and TMJ alignment
is eective in relieving the symptoms caused by both ADDwR
and ADDwoR. Often, these basic physical therapy management techniques can eectively improve the patient’s functional status. e goals of physical therapy in the management of
TMJ disk displacement are to relieve symptoms, increase and
normalize mouth opening, restore normal kinematics of the
TMJ, and promote oral function. Researchers disagree about
whether a displaced TMJ disk can be “recaptured.” However,
joint mobilizations of the TMJ with longitudinal distraction,
anteromedial translation, and lateral glide are eective clinically
in repositioning the disk for patients with an ADDwR. During
mobilization, the clinician may add a small amount of posterior
rotation of the condylar head with ulnar deviation of the wrist
before anterior translation. is maneuver may provide additional space for the disk to be relocated. In the case of acute and
subacute ADDwoR, the goal of physical therapy is to relieve
pain and unlock the TMJ. e same mobilization techniques
can be used, and the eect is often favorable.
140
Mongini et al
reported that using “their special manipulation technique” successfully decreased the symptoms of
ADDwoR (increase mouth opening and decrease pain), during
142
a long-term follow-up. Yabe et al
used a “manipulative technique” similar to the mobilization technique described earlier:
longitudinal distraction performed on the involved joint with
the patient in a supine position. ey reported that this was an
eective reduction technique for disk displacement.
Some osteopathic energy techniques have been described
121
by researchers as “manipulation of the TMJ.” Nagata et al
reported that the Jog-type jaw manipulation technique plus conventional treatment was not more eective than conventional
treatment alone in pain relief and restoring maximal mouth
opening.
Again, readers should access each cited reference for a detailed description of the specic “manipulation” (manual) technique used in each study.
143
Alajbeg et al
provided evidence that during 6 months
of treatment for ADDwoR, simultaneous use of physical therapy and a stabilization splint was more eective in reducing
deviations and improving mouth opening than was the use of
144
a stabilization splint alone. Stiesch-Scholz et al
studied the
eects of medical treatment and physical therapy for ADDwoR.
ey concluded that medical treatment (with pharmacological
agents) and physical therapy (mobilization, exercises, and massage), along with splint therapy, were eective in reducing pain
and increasing jaw opening.
145
Kraus and Prodoehl
conducted a cross-sectional study
and reported outcomes and patient satisfaction following individualized physical therapy treatment for ADDwoR. ey provided patient education, behavioral modications, therapeutic
exercises, neuromuscular re-education, manual therapy, and
electrophysical agents as indicated, and tailored the program
according to each patient’s condition. e authors concluded
that individualized physical therapy treatment was eective in
improving mouth opening, reducing pain, and providing patient satisfaction.
115
Alves et al
found only 2 studies examining the eectiveness of mandibular “manipulation” for ADDwoR. ey did not
nd sucient evidence to support the procedure and recom-
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
35
mended that future studies of high methodological quality be
https://t.me/med1917
performed.
e specic exercise program for internal derangement of
the disk is presented below. When physical therapy treatment is
not successful in relieving the patient’s symptoms, further surgical consultation should be recommended.
Figure 20.
Condylar Remodeling Exercise
Condylar remodeling exercise program
146
is exercise program was designed by Rocabado
for
neuromuscular re-education of the TMJ. With a 1 cm (0.5
inch) piece of surgical tubing resting between the maxillary and
mandibular central incisors, the patient is asked to move the jaw
laterally to the contralateral side of the symptomatic joint. (If
both joints are involved, then use the more symptomatic side as
the ipsilateral joint). If the movement is pain-free, then “gentle
biting” is incorporated at the end of the movement. e patient
is then instructed to release the contraction before returning to
the midline. e next phase is to perform the same routine, but
to maintain the bite as the jaw is moved back to midline. If no
symptom is reported, then the patient is instructed to perform
the same procedure but with protrusion instead of lateral excursion. After this phase, isometric contractions with tubing in
place can be introduced via mandibular stabilization or tubing
40,146,147
distraction (Figure 20).
eoretically, this exercise can
recruit the muscles of mastication to stabilize the disk via the
compression force, and result in improved condyle-disk-emi-
40
nence congruency. Furto et al
used this exercise program in
conjunction with other physical therapy techniques, such as
mobilization, iontophoresis, and exercises, and found favorable
improvement in disability and overall perceived change. Further
research is recommended to justify the usage of this exercise
program.
erapeutic exercise for clicking due to
anterior disk displacement with reduction
Another therapeutic exercise was designed by Yoda et al
148
to reduce the clicking caused by ADDwR. e patient is instructed to open their mouth maximally, causing the opening
click, and then close the mouth along a protruded path (closing
the mouth as if trying to contact the tips of the front teeth).
Maintaining this protruded position during closing is thought
to keep the disk on top of the condyle. At this point, the patient
carefully retrudes the condyle just before the closing click occurs. is is called the disk repositioning mandibular position.
Lastly, the patient is asked to open the mouth maximally again
without an opening click. e above procedure is repeated 5
minutes after each meal and the patient is asked to maintain
the disk repositioning position all day. Based on an RCT comparing this exercise approach to a control group, Yoda et al
148
demonstrated positive eects in reducing joint clicking with
their exercise program. Even though “recapturing of the disk”
could not be proven with MRI, they believed that the decrease
in joint noise may be due to an increase in joint space to al-
A, patient lightly bites the rubber tubing with incisors. B, patient translates rubber tubing to contralateral side (away from side of pain), then returns to
middle position. If no pain is experienced, then patient is asked to bite down after lateral translation and
maintains the bite until returning to middle position.
Same procedure may be performed with protrusion.
148
low smoother condylar translation.
Also, improvement of the
clicking leads to reduction of interference in daily life. Further
research is needed to study the long-term eects of this exercise
program.
Posterior Disk Displacement
A patient with posterior displacement of the disk usually
describes the condition as a sudden painful inability to close
the mouth (open-lock). A closing click may also be reported.
Management of the posteriorly displaced disk can be through
the same interventions used for an anteriorly displaced disk and
mobilization with longitudinal distraction. Most importantly, avoid maximal mouth opening, and work on submaximal
ROM exercises.
Myofascial Pain Disorder Syndrome
In addition to the traditional physical therapy management for TMD (eg, electrophysical agents, exercises, joint
mobilization, postural correction, and body mechanic instructions), treatment of MPDS also focuses on elimination of trigger points, reduction of precipitating factors, and elimination
of perpetuating factors. Trigger points can be treated by vapor
coolant spray and trigger point injection. Physical therapists
trained in the spray and stretch approach can often disrupt the
trigger point and reduce tautness and pain in the involved muscles. As discussed before, dry needling techniques have also been
adopted by physical therapists in recent years to provide trigger
point release in TMD management. Trigger point injection is
36
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Соседние файлы в папке Библиотека им академика М.И. Перельмана