Physical Therapist's Guide to TMJ

Physical Therapist's Guide to Temporomandibular Joint Disorder

Temporomandibular joint disorder (or "dysfunction") (TMD) is very common; more than 10 million people in the United States have it.

Jaw pain is one of the symptoms of TMD. It's important for you to know that jaw pain also can be a symptom of heart attack. Seek medical care immediately if jaw pain is accompanied by:

o    Chest pain

o    Shortness of breath

o    Dizziness

o    Left arm pain

o    Numbness in your left arm

o    Nausea. 

What Is Temporomandibular Joint Disorder?

The temporomandibular joint (TMJ) guides jaw movement. Problems with the TMJ are known as temporomandibular joint disorder or dysfunction (TMD). TMD is very common; more than 10 million people in the United States have it. TMD can be caused by:

o    Bad posture habits. One of the reasons TMD is so common is because many of us spend a great deal of time sitting at a desk, where we often hold our head too far forward as we work. But there are many other kinds of bad posture. Sitting in the car for a long commute, working at a checkout station, cradling a telephone receiver against the same shoulder for long periods of time, always carrying your child on the same hip—all can place the head in an awkward position and cause jaw problems. The "forward head position" puts a strain on the muscles, disk, and ligaments of the TMJ. The jaw is forced to "rest" in an opened position, and the chewing muscles become overused.

o    Chronic jaw clenching at night("bruxism"). Many people clench their jaws at night while they sleep, usually because of stress. This puts a strain on the TMJ because of the constant strain on the joint and surrounding muscles.

o    Problems with teeth alignment("malocclusion"). If your teeth come together in an unusual way, greater stress is placed on your TMJ.

o    Fracture. In a traumatic accident involving the face or head, a fracture to the lower jaw may result, and even when the fracture is fully healed, TMJ stiffness and pain may remain.

o    Surgery. Following surgery to the face and jaw, there may be a loss in mobility and function of the TMJ. 

o    Trismus ("lockjaw"). This condition—where jaw muscles spasm and the jaw cannot be fully opened—can be both a cause and a symptom of TMD. Other causes of trismus include trauma to the jaw, tetanus, and radiation therapy to the face and neck. 

How Does it Feel?

TMD symptoms include:

o    Jaw pain

o    Jaw fatigue

o    Difficulty opening your mouth to eat or talk

o    Ringing in your ears

o    Dizziness

o    Headache

o    Popping sounds in your jaw

o    Neck pain

o    Locking jaw 

How Is It Diagnosed?

To identify the cause of the symptoms, your physical therapist will first:

o    Review your medical history, and discuss any previous surgery, fractures, or other injuries to your head, neck, or jaw.

o    Conduct a physical examination of your jaw and neck.

The physical therapist will evaluate your posture and how your cervical spine—your neck—moves. The therapist will examine the TMJ to find out how well it can open and whether there are any abnormalities in jaw motion. The therapist might place his or her hand in your mouth in order to examine your jaw movement.

If, after the examination, the physical therapist suspects that your pain is a result of the position ("alignment") of your teeth, the therapist will refer you to your dentist for further examination.

How Can a Physical Therapist Help?

Your physical therapist can help restore the natural movement of your jaw and decrease your pain. If the therapist determines that your jaw pain is not related to teeth alignment, the therapist will select treatments that will work best for you. Treatments used by physical therapists for TMD include:

Posture education. If your therapist finds that you sit with your head in an increased forward position, this means that you are placing greater strain on the muscles beneath your chin, causing the lower jaw to pull back and the mouth to be in an open position even when resting, and increasing stress on the TMJ. You also might be overworking the jaw muscles to force the jaw closed so your mouth isn't open all the time. Your therapist will teach you to be aware of your posture so that you can improve the resting position of your jaw, head, neck, breastbone, and shoulder blades when you're sitting and walking. 

Improve jaw movement. Physical therapists use skilled hand movements called manual therapy to increase movement and relieve pain in tissues and joints. Your therapist also might use manual therapy to stretch the jaw in order to restore normal joint and muscle flexibility (how supple your muscles are) or break up scar tissues ("adhesions") that sometimes develop when there is constant injury.

Your physical therapist will teach you special "low-load" exercises—exercises that don't exert a lot of pressure on your TMJ but that can strengthen the muscles of the jaw and restore a more natural, pain-free motion.

Special pain treatments. In addition to manual therapy, if your pain is severe, your physical therapist may decide to use treatments such as electrical stimulation or ultrasound to reduce pain.

If your TMD is caused by teeth alignment problems, your physical therapist can refer you to a dentist who specializes in TMD who can correct your teeth alignment with special appliances, such as "bit guards," that create a natural resting position of the jaw to relax the TMJ, relieve pain, and improve jaw function. 

Can this Injury or Condition be Prevented?

Maintaining good sitting posture is key to preventing TMJ problems. Your physical therapist will show you how to maintain good sitting posture to prevent future episodes of TMD.

General Tips:

o    Avoid repetitive chewing, such as gum chewing

o    Avoid smoking

o    Avoid opening the jaw too wide

o    Avoid eating hard or chewy foods

o    Maintain good oral hygiene and tooth health

o    Avoid sleeping on your stomach, which forces the neck to rotate to one direction in order to maintain an open airway, increasing stress on the TMJ

At work:

o    Your work should be directly in front of you and not off to the side where you are forced to look in one direction for long periods of time.

o    Are you on the phone for long periods of time? Use a headset that allows the neck and jaw to remain in a restful("neutral") position. 

Real Life Experiences

You're attending your daughter's state championship volleyball match. Her team is ahead by one point, she sets up for the winning point, and she scores! Her team wins the state title, but after the celebration, you realize that your jaw is sore—and over the next week, it keeps getting worse.

You make an appointment with your physical therapist, who examines you and determines that your pain is related to postural habits and not to the alignment of your teeth. All season long, you've been cheering and yelling hard when her team was winning and nervously grinding your teeth when her team was trailing. You've also been sitting on bleachers without back support. Your physical therapist will provide a thorough examination of your neck and jaw to determine the true cause of your pain complaints and select treatments that will relieve your pain and help you use good posture so that you don't have more episodes of jaw pain.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case. 

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:

o    A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with a craniofacial focus, meaning that they focus on movement disorders related to the skull and facial structures.

o    A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopaedics physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

o    Get recommendations from family and friends or from other health care providers.

o    When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with TMD.

o    During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
APTA has determined that the following articles provide the best scientific evidence for how to treat TMD. The articles report recent research and give an overview of the standards of practice for treatment of TMD both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio. 2006;24:283–291. Article Summary.
Carmeli E, Sheklow S, Bloomenfeld I. Comparative study of repositioning splint therapy and passive manual range of motion techniques for anterior displaced temporomandibular discs with unstable excursive reduction. Physiotherapy. 2001;87:26–36. Article summary not available.
Nicolakis P, Burak EC, Kollmitzer J, et al. An investigation of the effectiveness of exercise and manual therapy in treating symptoms of TMJ osteoarthritis. Cranio. 2001;19:26–32. Article Summary.
Cleland J, Palmer J. Effectiveness of manual physical therapy, therapeutic exercise, and patient education on bilateral disc displacement without reduction of the temporomandibular joint: a single-case design. J Orthop Sports Phys Ther. 2004;34:535–548. Article Summary.
Wilk BR, Stenback JT, McCain JP. Postarthroscopy physical therapy management of a patient with temporomandibular joint dysfunction. J Orthop Sports Phys Ther. 1993;18:473–478. Article Summary.
Komiyama O, Kawara M, Arai M, et al. Posture correction as part of behavioural therapy in treatment of myofascial pain with limited opening. J Oral Rehabil. 1999;26:428–435. Article Summary.
Michelotti A, de Wijer A, Steenks M, Farella M. Home exercise regimes for the management of non-specific temporomandibular disorders. J Oral Rehabil. 2005;32:779–785. Article Summary.

Acknowledgments: Eric S. Furto, PT, DPT, MTC, FAAOMPT.  Article originally appeared on http://www.apta.org/.

A Guide to Understanding Knee Pain...How PT can help!

Physical Therapist's Guide to Knee Pain

Knee pain can be caused by disease or injury. The most common disease affecting the knee is osteoarthritis. Knee injuries can occur as the result of a direct blow or sudden movement that strains the knee beyond its normal range of movement. Knee pain caused by an injury is most often associated with knee cartilage tears, such as meniscal tears, or ligament tears, such as anterior cruciate ligament tears.

What is Knee Pain?

Knee pain can be caused by disease or injury. Knee pain can restrict movement, affect muscle control in the sore leg, and reduce the strength and endurance of the muscles that support the knee.

The most common disease affecting the knee is osteoarthritis, which is caused by the cartilage in the knee gradually wearing away, resulting in pain and swelling.

Knee injuries can occur as the result of a direct blow or sudden movement that strains the knee beyond its normal range of motion, as can happen in sports, recreational activities, a fall, or a motor vehicle accident. Knee pain caused by an injury often is associated with tears in the knee cartilage or ligaments. Knee pain also can be the result of repeated stress, as often occurs with the kneecap, also known as patellofemoral pain syndrome. Very rarely, with extreme trauma, a bone may break at the knee.

How Does it Feel?

You may feel knee pain in different parts of your knee joint, depending on the problem affecting you. Identifying the location of your pain can help your physical therapist determine its cause.

How Is It Diagnosed?

Your physical therapist will make a diagnosis based on your symptoms, medical history, and a thorough examination. X-ray and magnetic resonance imaging (MRI) results may also be used to complete the diagnosis.

To help diagnose your condition, your physical therapist may ask you questions like these:

o    Where exactly on your knee is the pain?

o    Did you twist your knee?

o    Did you feel a "tearing" sensation at the time of injury?

o    Do you notice swelling?

o    Have you ever felt like your knee joint is "catching," or "locking," or will give way?

o    Do you have difficulty walking up and down stairs?

o    Do you have difficulty sitting with your knee bent for long periods, as on an airplane or at the movies?

o    Does your pain increase when you straighten or bend your knee?

o    Does your knee hurt if you have to twist or turn quickly?

The physical therapist will perform tests to find out whether you have:

o    Pain or discomfort with bending or straightening your knee

o    Tenderness at the knee joint

o    Limited motion in your knee

o    Weakness in the muscles around your knee

o    Difficulty putting weight on your knee when standing or walking

The physical therapist also is concerned about how well you are able to use your injured knee in daily life. To assess this, the therapist may use such tests as a single-limb hop test, a 6-minute walk test, or a timed up and go test.

How Can a Physical Therapist Help?

Based on the evaluation, your physical therapist will develop a customized rehabilitation program, including a specific set of knee exercises, for you.

If you already have knee problems, your physical therapist can help with a plan of exercise that will strengthen your knee without increasing the risk of injury or further damage. As a general rule, you should choose gentle exercises such as swimming, aquatic exercise, or walking rather than jarring exercises such as jogging or high-impact aerobics.

Consult your physical therapist about specific ways to maintain your knee health following injury or surgery. Your physical therapist has the relevant educational background and expertise to evaluate your knee health and to refer you to another health care provider if necessary.

Depending on the severity of your knee problem, your age, and your lifestyle, the therapist may select such treatments as:

Strength training and functional exercises, which are designed to increase strength, endurance, and function of your leg muscles (quadriceps and hamstrings). This in turn helps support the knee and reduce stress to the knee joint.

Electrical stimulation of the knee, which further increases leg muscle strength and can help reduce knee pain. To increase strength, electrical impulses are generated by a device and delivered through electrodes to stimulate the primary muscle that supports the knee, the quadriceps femoris. To reduce your knee pain, the electrodes are placed on the skin to gently stimulate the nerves around the knee.

Your physical therapist can determine just how much you may need to limit physical activity involving the affected knee. He or she also can gauge your knee’s progress in function during your rehabilitation.

How Can a Physical Therapist Help Before & After Surgery?

Your physical therapist, in consultation with your surgeon, will be able to tell you how much activity you can do depending on the type of knee surgery (such as total knee replacement) you undergo. Your therapist and surgeon also might have you participate in physical therapy prior to surgery to increase your strength and motion. This can sometimes help with recovery after surgery.

Following surgery, your physical therapist will design a personalized rehabilitation program for you and help you gain the strength, movement, and endurance you need to return to performing the daily activities you did before.

Can this Injury or Condition be Prevented?

Ideally, everyone should regularly get 3 types of exercise to prevent injury to all parts of the body, including the knees:

o    Range-of-motion exercises to help maintain normal joint movement and relieve stiffness.

o    Strengthening exercises to keep or increase muscle strength.

o    Aerobic or endurance exercises (such as walking or swimming) to improve function of the heart and circulation and to help control weight. Weight control can be important to people who have arthritis because extra weight puts pressure on many joints, including the knee.

To keep knee pain and other musculoskeletal pain at bay, it’s important to maintain an overall healthy lifestyle, exercise, get adequate rest, and eat healthy foods. It’s also important for runners and other athletes to perform physical therapist-approved stretching and warm-up exercises on a daily basis—especially before beginning physical activity. 

Real Life Experiences

At age 56, Monica was in very good health—eating right, maintaining her weight, and exercising daily at home. One day she fell off her exercise equipment and twisted her knee. The pain was excruciating. Even though she could walk short distances, using her sore leg during her daily activities soon became impossible. Monica made an appointment with her physical therapist. The therapist reviewed her medical history, conducted a thorough examination, and consulted with Monica’s physician regarding the need for a series of X-rays to ensure no bones were broken in the fall.

Consultation with an orthopedic surgeon confirmed that there were no broken bones and no need for surgery. Monica's physical therapist developed a program of strength training and functional exercises to increase her hip, knee, and ankle muscle strength and endurance. The physical therapist also recommended electrical stimulation of the knee to increase her quadriceps (thigh) muscle strength.

By following the physical therapist's regimen, Monica decreased her knee pain, and her mobility improved dramatically. Regular ongoing strength-training knee exercises—and more careful use of her exercise equipment—have helped Monica remain free of knee pain.

What Kind of Physical Therapist Do I Need?

Although all physical therapists are prepared through education and experience to treat people with knee pain, you may want to consider:

o    A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems

o    A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopedic physical therapy, giving the therapist advanced knowledge, experience, and skills that may apply to your condition

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist:

o    Get recommendations from family and friends or from other health care providers.

o    When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with TKR.

During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Article originally appeared on http://www.apta.org/, click the following link to read the original article: http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=b92021cb-a1ec-4f20-8b7e-37d62bc1a52e

Physical Therapists Help You Get Fit!

This was a news release from last year by the American Physical Therapy Association (APTA) but is very applicable in the beginning of this new year with everyone's resolutions to get fit.  Read more to learn how to stay safe in your new endeavors of physical fitness...

New to the Gym? Physical Therapists Help You Get Fit – Safely – in 2011

ALEXANDRIA, VA, January 7, 2011 — New Years’ resolutions have an 80 percent rate of failure

by Valentine’s Day, but Americans can increase their success by sharing their commitment with

others. The American Physical Therapy Association’s (APTA’s) Move Forward campaign is

helping individuals keep commitments by starting the conversation online and providing fitness

tips for those who are heading to the gym.

For new, potential, and even returning gym members, APTA launched 12 instructional videos

featuring physical therapist and APTA member Robert Gillanders, PT, DPT. Dr. Gillanders

demonstrates correct posture and form for selected core, leg, shoulder and arm exercises. These

exercises, in conjunction with a regular cardiovascular routine, will help individuals strengthen

target areas. Gillanders’ advice will also help individuals exercise with less risk of injury.

“One of the most important things to remember is the overall form of the exercise,” Gillanders

said. “It’s going to help you be less vulnerable to injury. Physical therapists have extensive

knowledge of the way the body moves and are also able to adjust workouts for pre-existing

conditions, and these videos will help get Americans off to a good start in 2011.”

To help individuals stick to their New Years’ fitness resolutions, @MoveForwardPT invites people

to share their progress every Friday in January on Facebook and on Twitter via #MovePT. Join

the Move Forward PT community on Facebook, YouTube and Twitter via @MoveForwardPT. For

more information on how a physical therapist can help individuals achieve their fitness goals, visit

MoveForwardPT.com and read more about the benefits of physical activity.

About APTA

The American Physical Therapy Association (APTA) represents more than 74,000 physical

therapists, physical therapist assistants, and students of physical therapy nationwide. Learn more

about conditions physical therapists can treat and find a physical therapist in your area.

Consumers are encouraged to follow us on Twitter (@moveforwardpt) and Facebook.