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c. e rst click happens during closing of the mouth fol-
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lowed by a second click during opening of the mouth.
d.
e rst click happens during opening of the mouth
followed by a second click during closing of the mouth.
e correct answer is d. e rst click happens during
opening of the mouth followed by a second click during
closing of the mouth.
4. Which of the following statements is correct?
a.
If ADDwR is left untreated, it may progress to ADDwoR.
In the case of ADDwoR, the patient’s mouth will deect
b.
to the contralateral side at the end of opening.
c.
Reciprocal clicks are one of the signs of ADDwoR.
d.
e closing click is usually louder than the opening click.
e correct answer is a. If ADDwR is left untreated, it
may progress to ADDwoR. Clinically, patients with ADDwoR
usually have a history of reciprocal clicks before they have limited mouth opening without joint noise.
Case Scenario 2
ML is a 50-year-old female executive who has had migraine
headaches and TMD for almost 20 years. She has been treated
by a dentist, internist, neurologist, and rheumatologist. However, her symptoms have continued to uctuate throughout the
years. ML’s chief complaints are frequent headaches, primarily
over the right side of her head, and pain in her right TMJ area.
She reports that her symptoms are worse when she is under
stress with her work, or when she rst wakes up in the morning.
She is currently on Topamax after trying many other medications (eg, Darvocet, Pamelor, Imitrex, etc) without long-lasting eect. Objective assessment reveals palpable sensitivity in
her right masseter and suprahyoid muscle areas, suboccipital
tightness, trigger points in the right para-cervical spine muscles, limited TMJ opening (37 mm) without deviation or any
joint noise, equal lateral excursion to 10 mm for both sides, and
hypomobility of the upper cervical segments. Fear avoidance
behavior is also noted during movement analysis.
Which of the following areas is most challenging in the man-
2.
agement of ML’s case?
a.
e adherence to her home exercise program.
b.
e body mechanic and work ergonomics.
e chronic pain aspect, which includes stress manage-
c.
ment.
d.
e relief of her symptoms.
e correct answer is c. e chronic pain aspect, which
includes stress management. With the long history of the condition and the uctuating property of the symptoms, it is clear
that ML has a chronic component in her TMD. Physical therapy can provide relief of her symptoms; a home exercise program
and ergonomics can also support the outcome of the physical
therapy intervention. However, chronic pain management is
important and most challenging for this patient to ensure longterm success.
3. Choose the evidence-based combination that you would in-
clude in your treatment program.
a. Education, heat, TENS, soft tissue mobilization, joint
mobilization, home exercise program, and stress management.
b. Education, joint manipulation, home exercise program.
Postural correction, body mechanics instruction, home
c.
exercise program.
d. Stress management, education, home exercise program.
e correct answer is a. Education, heat, TENS, soft
tissue mobilization, joint mobilization, home exercise program, and stress management. is is a more comprehensive
approach for the condition, especially at the initial stage.
4. What exercise program is suitable for this patient?
a.
e condylar remodeling exercise program.
b.
e horizontal tongue depressor exercise.
e tongue-controlled mouth opening exercise.
c.
d. erapeutic exercise for clicking due to anterior disk
displacement.
1. Which American Academy of Orofacial Pain (AAOP) diagnosis category ts ML’s condition?
a. Arthritides.
b. Articular disorders.
c. Cervicalgia.
d.
Masticatory muscle disorders.
e correct answer is d. Masticatory muscle disorders.
ML’s condition best ts in the diagnosis of myofascial pain disorder syndrome, which is a subgroup in the masticatory muscle
disorders category. ere is no sign of articular disorders or arthritides in the information obtained.
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.
e correct answer is c. e tongue-controlled mouth
opening exercise. ML demonstrates tightness of her mastica-
tory muscles, which will benet from the tongue-controlled
mouth opening exercise. ere is no indication of anterior disk
displacement or limited lateral excursion, therefore, a, b, or c are
not suitable choices for this patient.
Case Scenario 3
AB is a 48-year-old male who has had a history of TMD
for more than 20 years. He is accustomed to “re-adjust” himself
when his TMJ is “out of alignment.” AB had a dental procedure to extract his 2 mandibular wisdom teeth about 3 weeks
47
ago, which resulted in ADDwoR (pain, limited opening) on
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his left side. He subsequently received arthrocentesis of his left
TMJ about 2 weeks ago. His pain is nally better; yet, he is still
unable to chew due to pain and limited mouth opening. AB is
taking 1800 mg Advil daily (TID), and 20 mg Flexeril at night.
He reports that he has sleep disturbance, is unable to sleep on
his left side now, and is wearing a night splint due to bruxism.
1.
Do you think this patient is appropriate for physical therapy
just 2 weeks post-arthrocentesis?
a. No, because the patient is still symptomatic and physi-
cal therapy may aggravate his symptoms at such an early
stage.
b. No, because there is no literature to support the benet
of post-arthrocentesis physical therapy.
c. Yes, because physical therapy will be benecial in provid-
ing education to the patient.
d. Yes, because a post-arthrocentesis physical therapy pro-
gram will provide relief of symptoms and improvement
of patient’s oral function.
e correct answer is d. Yes, because a post-arthrocente-
sis physical therapy program will provide relief of symptoms
and improvement of patient’s oral function. At the initial
evaluation, the patient reports constant 6/10 pain intensity in
his left TMJ with limited mouth opening. e patient is unable
to open his mouth to chew properly and is currently on a liquid
diet.
Measurements obtained are as follows:
Cervical spine ROM: within normal limits in all direc-
•
tions.
• TMJ mouth opening: 15 mm without deection, he is
fearful in opening his mouth.
• Overbite: 1 mm
• Overjet: 2 mm
• TMJ lateral excursion: 4 mm in both directions and pa-
tient demonstrates fear avoidance behavior.
• Palpation: sensitivity with tightness palpable over both
masseter muscles, left greater than right. Tightness palpable over both upper trapezius muscles.
Patient appears anxious about his condition.
2. What is the most preferable and important initial step of
your treatment for this patient?
Education regarding the physical therapy program the
a.
patient will receive.
b. Electrophysical agents to relieve his pain.
c. Instruction in postural correction and body mechanics.
d. Manual therapy to increase mouth opening.
e correct answer is a. Education regarding the physical
therapy program the patient will receive. e patient exhibits
fear avoidance behavior and is anxious about his condition, it is
important to explain to the patient the treatment approach and
the goals of physical therapy because explanations have been
shown to have positive impacts on patient outcomes.
After the second visit using electrophysical agents and
manual therapy, the patient was able to open his mouth to 27
mm. However, he reported that he felt instability in his jaw
while lying supine on his back.
3. e ideal recommendation to address this problem at this
time would be:
a. Avoid sleeping on his back.
b. Isometric exercises for the TMJ and cervical spine.
c. Reassure the patient that this is a normal condition after
arthrocentesis.
d. Return to the surgeon for further assessment and recom-
mendation.
e correct answer is b. Isometric exercises for the TMJ
and cervical spine. It is important to introduce isometric exercises at this time to improve stability of the region.
e ultimate goal of physical therapy management for this
4.
patient (status post arthrocentesis) is to:
a. Increase mouth opening.
b. Relieve pain.
Restore normal kinematics of the TMJ.
c.
d. Return to normal diet.
e correct answer is c. Restore normal kinematics of the
TMJ. While all the other choices are also appropriate goals of
this condition, the ultimate goal after arthrocentesis should be
to restore the normal kinematics of the TMJ.
Case Scenario 4
GK is a 56-year-old male entrepreneur who has had tinnitus in his right ear for almost 10 years. e patient has been seeking diagnosis and treatment from a specialty clinic, in addition
to many other specialists. e diagnosis given by the specialty
clinic was degeneration of ear follicles and inammation. GK
has received dierent management for his symptoms including
medication, acupuncture, natural herbal treatment, detox with
electrical energy approach, etc. However, his symptoms remain
unchanged. In the recent 2 months, GK noticed increased intensity of his tinnitus in the right ear, as well as the beginning of
a faint tinnitus in his left ear. After consulting with a new ENT
doctor, he was referred for evaluation and treatment.
GK reported that he has been under a great deal of stress
lately, and he also received some adjustment to his brace to
straighten his teeth. His tinnitus is unrelenting, with uctuating severity throughout the day. He is unaware of clenching or
bruxing at night; therefore, he doesn’t think a night splint is
indicated.
48
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For personal use only. No other uses without permission.
1. After this history intake and interview, do you think this
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patient is appropriate for physical therapy? Why or why not?
a. No, this patient’s tinnitus is a chronic condition, which is
not appropriate for physical therapy management.
b. No, treating ear symptoms is not within the scope of
physical therapy practice.
c. Not sure, this patient needs to have further imaging
studies.
d. Yes, ear symptoms may improve with treatment to the
TMJ and cervical spine area.
either treating cervical spine alone or treating TMJ alone is the
preferable choice for management.
Examination of GK revealed a forward head posture,
parafunctional behavior (sucking on his right cheek when not
talking), 40 mm mouth opening with “S” curve movement of
the jaw, lateral excursion 12 mm on right side as compared to 8
mm on left side, and hypomobility of right TMJ, atlanto-occipital, and atlanto-axial joints. ere was palpable tightness and
tenderness noted in his right masseter and suprahyoid muscles.
Joint noise evaluation was negative.
e correct answer is d. Yes, ear symptoms may improve
with treatment to the TMJ and cervical spine area. Ear symptoms are closely connected to TMD and cervical spine dysfunction. erefore, a physical therapy assessment is indicated to
determine if intervention is appropriate. A physical therapist
trained in managing TMD, should have the knowledge and
skill for managing non-otological tinnitus.
2. Is there a connection pathway between TMD and ear symp-
toms? What’s the explanation?
a. No, TMJ and ear are innervated by 2 independent com-
ponents of the nervous system.
b. No, TMJ and ear are 2 independent structures.
Yes, the greater occipital nerve.
c.
d. Yes, the trigeminocervical nucleus.
e correct answer is d. Yes, the trigeminocervical nucle-
us. e trigeminal nerve, which innervates the TMJ, lies within
the trigeminocervical nucleus, along with other central nervous
system components and the cervical spinal nerves 1, 2, and 3.
e close proximity of the dierent neurons will aect each other’s function. In addition, the auriculotemporal nerve, which
is a branch of the trigeminal nerve, innervates the tympanic
membrane that may produce ear symptoms.
In addition to education, which choice is preferred for the
management of GK’s condition?
Electrophysical agents, myofascial release, TMJ mobiliza-
a.
tion, mid-cervical mobilization, stress management, and
home exercise program.
b.
Electrophysical agents, myofascial release, TMJ mobilization, upper cervical mobilization, stress management,
and home exercise program.
c. Stress management and home exercise program.
TMJ mobilization, upper cervical mobilization, and home
d.
exercise program.
e correct answer is b. Electrophysical agents, myofas-
cial release, TMJ mobilization, upper cervical mobilization,
stress management, and home exercise program. is is the
most comprehensive program that a physical therapist can provide to address the patient’s soft tissue impairment and joint
limitation (especially upper cervical spine), coupled with stress
management and a home exercise program to improve patient’s
functional status.
3.
Which of the following statements is correct?
a. Physical therapists should not be involved in the treatment
of patients with ear symptoms.
b. ere is a low incidence rate of ear symptoms in the pop-
ulation with TMD.
c. Treating TMJ alone is a superior approach to treating
cervical spine alone in the management of non-otological
tinnitus.
d. Upper cervical spine mobilization is important in the
management of non-otological tinnitus.
e correct answer is d. Upper cervical spine mobiliza-
tion is important in the management of non-otological tinnitus. Because C1, C2, and C3 nerves are located in the tri-
geminocervical nucleus, upper cervical mobilization to restore
normal kinematics of the upper cervical spine is crucial in relieving non-otological tinnitus. ere is no evidence indicating
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.
49
Appendix.
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Reprinted with permission from Ohrbach R. e Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) English
Assessment Instrument, International Network for Orofacial Pain and Related Disorder Methodology (INfORM). Copyright
241
2013.
50
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.
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