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TMJ Dysfunction Case Study

Temporomandibular Joint Dysfunction Case Study

14 year old male baseball player presented to Vertex with a chief complaint of left sided jaw pain that occurred after being hit on the chin by a ground ball at practice.  Additionally, he complains of his jaw “locking” and “clicking” with end range mouth opening, specifically while eating.

Clinical Exam:

Palpable Click with opening and 25mm left mandibular deviation (ipsilateral)

Apical breathing pattern

Decreased left upper cervical rotation (+ left cervical flexion rotation test)

Tenderness to palpation left masseter and left medial pterygoid with patient reported familiar pain

 

Treatment:

HVLAT directed to bilateral C1/C2 with + cavitations.

Upper and mid thoracic HVLAT

DN with electrical stimulation to left masseter, medial pterygoid, and joint capsule.

Manual TMJ distraction

Home Exercise Program:

Cervical SNAGs, cervical retraction with over-pressure applied to maxilla, postural resets, diaphragmatic breathing

Patient Education:

Postural considerations; specifically with school and smart phone use consisting of spending less time in forward head posture in order to minimize mandibular retraction.

Result:

Chief complaint of “click” and “locking” resolved within session. 25mm deviation reduced to <5mm.  Patient followed up 6 weeks later and maintained treatment effect.

Four Exercises to Improve Dance Technique and Strength

 

1. Hip Flexor Pulse
a. Purpose: Improves strength in hip flexors, especially Iliopsoas, to increase leg height. This exercise works best in combination with stretching the hamstrings to allow greater mobility and active range of motion.
b. How to do: start sitting with legs extended and leaning back on hands. Perform a posterior pelvic tilt and lift one leg with the knee bent. Pulse the leg closer to your body for about 4 reps while concentrating on using the Iliopsoas. Repeat 4-6 times.

2. Attitude Raises
a. Purpose: To increase turn out (external rotation of hips) and leg height in second position (to the side).
b. How to do: Start lying on one side. Raise top leg (both knees facing forward and knee bent). Turn out the leg into attitude al second (to the side with knee facing ceiling). Repeat this while bringing the leg closer to the trunk with each rep. Repeat 4 reps 4-6 times.

3. Hip Flexor Stretch
a. Purpose: To stretch hip flexors more efficiently
b. How to do: Start in lunge with both knees at 90 degrees. Perform strong posterior pelvic tilt. Add more of a stretch by bending the trunk to the same side as the front leg. Hold for at least 30 seconds.

4. Calf Raises with ball
a. Purpose: To improve strength and control of plantar flexion in heel raises without inverting at the ankles.
b. How to do: Place small ball in between the ankles. Raise heels off the ground while squeezing the ball. The goal is to not let the ball fall to the ground. This helps train the muscles to not invert, but to remain neutral in plantar flexion.

 

-Lauren Rowell

Words that Harm

How many times have you been given a phrase by a physician that, perhaps, wasn’t phrased as well as it could be? “You’ve got a time bomb in your chest” or “I don’t know how you’re walking around with that spine!” As I venture through all the information that’s required in my Orthopedic Residency, this is the one subject that I wish more healthcare providers understood.

 

Too often, I hear a new patient tell me that their referring physician told them their spine is “riddled with bulging discs” to the point that they “shouldn’t be able to move.” Put yourself in that patient’s shoes. In that moment, how would you feel? You’ve been in pain for a long time, you’ve maybe had failed alternative treatments, perhaps you’re on pain medication that you don’t like taking. And the medical professional you’ve been sent to says they can’t even fathom how you’re able to move based on what they’ve seen on your images. There’s no way in that moment you feel great about your situation. And likely you have no hope for a more conservative treatment to finally get some relief.

 

Why would a medical professional say such words to their patients, if there were the possibility of being more supportive or hopeful? It’s suggested that possibly we no longer hear the words we say; we’ve become desensitized to the anxiety or fear that they cause. Perhaps we don’t have time to think of better phrases or words to say; with the way healthcare has gone in recent years, doctors don’t have a ton of time to spend with each patient. Physical therapists, who would typically have the most time with their patients, in many clinics are seeing multiple patients at a time. So instead of explaining how MRIs have shown bulging discs in patients who are asymptomatic or how patients with debilitating pain have no significant findings on MRI, they rush through the exercises for the day and hope that patient doesn’t have any questions. It was further suggested that maybe we use fear-evoking words as a method of getting compliance out of the patient. If we tell the patient that the only way to make sure “this heartbeat isn’t the last” is if they start exercising or begin taking their medication, the fear becomes helpful to that professional. But none of these reasons are acceptable for using language that has been shown to cause undue anxiety and poor results in our patients.

What we’re learning now is how important the brain is in how we perceive pain. Many new approaches in physical therapy seek to retrain the brain and our thoughts about pain.  One of the best ways I think we can seek to provide that re-training is through better use of language. Instead of getting stuck in these negative connotation words or phrases that cause fear, I think we should seek to determine words that evoke inspiration in our patients.

So, what words should be used by healthcare professionals? Words that allow patients to feel comfortable enough to ask questions are a good place to start. Miscommunication between healthcare professionals and patients due to the patient being afraid to ask a question about their condition is unacceptable. Clear, precise language that helps the patient understand exactly what is going on in their body, while taking into consideration the patient’s understanding and educational level. Metaphors that don’t cause negative emotional reactions can be helpful, too – as the car alarm analogy that is used to explain chronic pain situations (Neuroscience Pain Education). Healthcare professionals should seek to find and use words that will boost a patient’s self-confidence in their ability to control their situation and to inspire hope for recovery or rehabilitation.

As a physical therapist, I hope to never lose the humility that allows me to talk to a patient on their level. I hope to be able to always inspire patients to take control of their situations (within their means) and to be able to manage their symptoms without dependence on me. I hope to never get caught up on medical jargon that evokes fear in my patients, and instead build a trusting relationship where all questions can be asked and answered comfortably.

Bedell, S., Graboys, T., Bedell, E., Lown, B. Words that Harm, Words that Heal. Archive of Internal Medicine, 2004; 164:1365-1368.

Louw, A., Zimney, K., O’Hotto, C., Hilton, S. The clinical application of teaching people about pain. Physiotherapy Theory and Practice, 2016. http://dx.doi.org/10.1080/09593985.2016.1194652

Dr. Tristan Faile, PT, DPT
tristan@vertexpt.com

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Concussion Nutrition (Part 2)

Patients with concussions or Mild traumatic brain injury often complain of stress and have been shown to possess higher plasma cortisol levels. Vitamin C supplementation has been shown to decrease cortisol which is commonly known as the “stress hormone”. A 1500mg daily dose of oral Vitamin C may decrease the production of the the adrenal hormones, cortisol and adrenaline, which are immunosuppressive at high levels.

Be sure to consult with your physician before taking dietary supplements.

Peters, E. M., Anderson, R., Nieman, D. C., Fickle, H., & Jogessar, V. (2001). Vitamin C supplementation attenuates the increases in circulating cortisol, adrenaline and anti-inflammatory polypeptides following ultramarathon running. International journal of sports medicine, 22(07), 537-543.

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Concussion Nutrition (Part 1)

Omega 3-6-9 and docosahexaenoic acid (DHA) may be beneficial in patients with concussions by serving not only as a vascular and neuroprotectant but by enhancing the repair process of damaged brain cells. In fact, dietary supplementation with DHA increases serum levels and, if given prior to concussion or Mild TBI, it may reduce the injury response by mitigating permanent brain cell death.

Be sure to consult with your physician before taking dietary supplements.

Hasadsri, L., Wang, B. H., Lee, J. V., Erdman, J. W., Llano, D. A., Barbey, A. K., … & Wang, H. (2013). Omega-3 fatty acids as a putative treatment for traumatic brain injury. Journal of neurotrauma, 30(11), 897-906.
Mills, J. D., Hadley, K., & Bailes, J. E. (2011). Dietary supplementation with the omega-3 fatty acid docosahexaenoic acid in traumatic brain injury. Neurosurgery, 68(2), 474-481.
Wu, A., Ying, Z., & Gomez-Pinilla, F. (2007). Omega-3 fatty acids supplementation restores mechanisms that maintain brain homeostasis in traumatic brain injury. Journal of neurotrauma, 24(10), 1587-1595.

EIM Orthopaedic Residency

We are pleased to announce that Vertex PT Specialists is now an Evidence In Motion (EIM)preferred host site for Orthopaedic Physical Therapy Residency.
You can apply here:

www.evidenceinmotion.com/educational-offerings/course/orthopaedic-physical-therapy-residency/

Assess your Mortality with the Sitting-Rising Test (SRT) AKA Brazilian Get Up Test

The Sitting Rising Test (SRT), originally developed in Brazil, is a simple measure of flexibility, strength, and balance that can predict who will live longer and whose lives will be cut short.
 
To perform:
 
1. Stand in comfortable clothes, with your shoes off, and plenty clear space around you.
 
2. Without leaning on anything, lower yourself to a sitting position on the floor.
 
3. Now stand back up, trying not to use your hands, knees, forearms or sides of your legs.
 
(If you have joint pain or may be at risk of falling, DO NOT PERFORM this without the supervision of a physical therapist).
 
Everyone starts with a score of 10 (as Darryl demonstrates in the video), 1 point is deducted each time a hand, arm, knee, or side of the leg is used for support and half a point is deducted for any loss of balance.
 
In a study published in the European Journal of Cardiology, researchers had more than 2,000 patients ages 51 to 80, take the SRT. People who scored fewer than eight points on the test were twice as likely to die within the next six years compared with those who scored higher; those who scored three or fewer points were more than five times as likely to die within the same period compared with those who scored more than eight points.
 
Overall, each point increase in the SRT score was associated with a 21 percent decrease in mortality from all causes.
 
We hope this information can help get more people walking through the doors of a gym rather than rolling into an emergency room.
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Blood Flow Restriction (BFR) Biceps and Triceps

This is a sample super-set that I use as a finisher using the Occlusion Cuff for biceps and triceps hypertrophy.

2017 CrossFit Open

Good Luck to all of our friends and patients who are competing in the Open starting this week!