TMJ problems - an osteopathic guide.

How many times have you arrived at the end of a case history for a patient suffering with either headaches or neck pain and they say, there is one other thing, I also have a “clicky jaw” whenever I eat or open my mouth.

The jaw is an exciting joint to treat. Unlike treating patients suffering with a slipped disc or low back pain, the tempero-mandibular-joint (TMJ) is one which the osteopath can really get hold of and treat the soft tissue structures that support it.

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The jaw is quite a complex joint with some unique features. Take for example the articular disc of the TMJ. The TMJ has an inter-articular disc which separates the joint cavity into two. Not only is the disc's structure special being both concavo-convex superiorly whilst inferiorly it is only concave (thus fitting its joint surfaces exactly), it also is made of fibrocartilage allowing a certain degree of trauma and regeneration. The tempero mandibular joint functions for so many of our daily activities, the most significant of which is eating which requires tremendous leverage and strength

It is the disc that is often the bane of most peoples problems suffering with TMJ pain. It is the structure most likely to be giving the clicking sound that patients hear when chewing. This occurs as a result of disc displacement. The disc can be be displaced at various places along its length and this can interfere with the smooth gliding of the mandible on the articular surface of the temporal bone. The most common problem is for the disc to be displaced medially as a result of the action of the masseter muscle straining and lengthening the lateral TMJ ligaments and allowing excessive medial movement

The TMJ can move in 6 directions:
1)Up and down – the main movement used in biting and chewing
2)Protrusion and retraction – mainly used for tongue movements, talking and swallowing
3)Left and right – for grinding the food when chewing

The muscles that control these movements are:
1)Masseter – this muscle is the main chewing muscle and often becomes tight from emotional stress. It extends from the zygomatic arch to the outer surface of the ramus of the mandible
2)Temporalis muscle – supports the masseter muscle aiding it in chewing and it stabilizes the bite of the TMJ. It is a fan shaped muscle and extends from the surface of the temporal fossa, deep to the zygomatic arch and inserts on to the ramus of the mandible.
3)Lateral and Medial Pterygoid - these 2 muscles are found deep to the ramus of the mandible and they elevate and protrude the mandible.

Observation:
When assessing a patient with TMJ problems the osteopath begins with a standing postural assessment observing head-neck-spine relationships. The osteopath paying special attention to the position of the TMJ in relation to the skull, anterior and posterior cervical soft tissues and shoulder girdles all of which make up the closed kinetic chain of the gnathic system. The osteopath should observe areas of stress in around the TMJ itself including the scalenes, sternocleidomastoid and platysma. Obvious signs of tension or stretching should be noted by the osteopath as they will indicate a stress and potential imbalance of the TMJ and will need to be reassessed during the passive examination.

Active examination should focus on asking the patient to perform movements of the spine specifically the cervical spine noting restricting in movement in any direction which could be related either directly or indirectly to the TMJ via the cervical fascia, infra-hyoid muscles, anterior cervical muscles and posterior cervical muscles.

Active examination should also include examination of the gleno-humeral joints which have a soft-tissue connection to the somato-gnathic system.


Finally one can ask the patient to open the mouth in all directions paying attention to any adventitious movements.

Passive examination:
Palpation by the osteopath of all the structures previously mentioned, however this time the osteopath is able to put his hands directly on the TMJ and ask the patient to open her mouth. This allows the osteopath direct contact with the dysfunctional joint. The osteopath should simultaneously palpate the muscles around the TMJ gathering information about the hypertonia of the soft tissues and any inequality on either side that may be creating an imbalance of movement.

Gentle palpation along the anterior and posterior structures of the cervical spine should include articulation of the hyoid bone, glenoumeral joints, clavicles, menubrio-sternal joints and ribs, all of which have a role to play in the stability of the TMJ function.

Treatment
After a full assessment of the patient's condition the osteopath can start to design a treatment plan. Osteopathically I like to begin treatment distal to the area of pain. After doing a general osteopathic examination and treatment (where necessary) including working as far afield as the feet, ankles, knees and hips I eventually start to focus on structures directly related to the jaw.

Osteopathic treatment will most likely start with the dorsal spine removing any somatic dysfunction that may be reflecting in the cervical spine. Treatment may involve balancing the glenohumeral joints by treating the rotator cuff muscles and muscles of the scapulo-thoracic complex. Any tension in the scapula will be reflected in the cervical spine, anteriorly and posteriorly creating unilateral tension in the TMJ.

Osteopathic treatment of the cervical spine focuses strongly on the sub-occipital muscles and occipito-atalantal articulation onto which many TMJ-related muscles attach indirectly due to their close proximity.

The osteopathic work around the TMJ needs to address the local muscles directly using soft tissue massage to masseter and temporalis and indirectly to the pterygoids using articulation of the jaw or muscle energy.

The osteopath must try to be as clear as possible in which direction the jaw is being pulled so as to treat the appropriate muscles. The theory is that if during opening the mouth the jaw shifts to the right thereis tension in the muscles on that same side. It is important therefore treat the muscles on that side to allow some relaxation of the soft-tissues and for the TMJ to sit equally well in the condyles of both sides. Treatment to masseter can be quite painful so it it good to use gentle inhibition assessing the patients response and not working too aggressively.

The osteopath will most likely need to address the TMJ itself using techniques that temporarily “gap” or separate the two joint surfaces between the the condyle of the mandible and the base of the skull. This gapping allows the joint to reset itself comfortably and also may induce some movement that may have been lost due to excess tension on the restricted side.

At the end of treatment the osteopath should reassess how the movement in the TMJ has changed and whether there is any improved function. This is done by asking the patient to open her mouth and observing any adventitious movement. Often observation is done best when standing at the head of the table with the patient lying supine. Furthermore the osteopath can slide his finger over the joint with his little finger tucked in the joint under the ear lobe. This allows direct contact with the the TMJ as it opens and closes and dysfunction can be easily palpated.

Often patients go back to bad habits of chewing gum or experiencing emotional stress that influences the masseter but awareness of these factors as well as a management plan and gentle stretches can prevent the problem from reoccurring.

Spondylosis: Disease or Natural Response to Stress

Structural changes in the vertebrae may be considered as features which are related to disease. Changes which occur in the intervertebral disc are described as spondylosis. Changes in the facet joints are described as osteoarthritis.

When an osteopath examines an X-ray of a neck that has spondylosis the osteopath will notice osteophytes or bony spurs along the perimeter of the vertebral body i.e. at the junction between the two vertebral bodies and the disc. The osteopath could be forgiven for perceiving these osteophytic changes as part of an aggressive disease attacking the body, however, on closer examination the osteopath begins to understand that it is in fact part of the body's natural response to the mechanical stresses that are applied to the spine throughout life. In other words, it is an active purposeful process in the body, used to compensate for the natural, physiological changes occurring with age.

In a young healthy adult the vertebral disc in between each vertebrae adapts according to the stresses placed on the spine. It is able to do this due to its high water content. With age the disc loses water and hence flexibility – essentially it dries out, becomes less flexible and as a result the surrounding cartilage, the annulus, bears most of the weight.

Eventually, in cases of excess compression along the annulus, ossification starts to develop and can occur around the entire margin of a vertebral body. This can be viewed as if the vertebral body is trying to expand the surface area for articulation in order to distribute the load.

The osteopath must remember that spondylosis and osteoarthritis are not necessarily associated with pain; in fact spondylosis is just as common with people who have symptoms as those who do not have symptoms. Similarly, patients with pain may not have a single trace of spondylosis.

We could therefore conclude that there must be another cause for the pain in people with spondylosis and osteoarthritis and not necessarily the bony changes. As osteopaths this fact supports much of the work that we do. Osteopathy claims to help the body accommodate to changes. Osteopaths are regularly asked whether they treat arthritis. Well, osteopaths don't so much as treat arthritis as they do the patient's whole body – helping it to compensate for any changes that may put stress on the soft tissues.

Frozen Shoulder - Adhesive Capsulitis

Frozen shoulder can make an osteopath feel "disarmed" in terms of what treatment approach to take. However, a thorough knowledge of anatomy, a careful examination of the shoulder and reasonable expectations regarding prognosis are the key to helping the patient.

The diagnosis "Frozen shoulder" is often banded about as a diagnosis whenever there is shoulder limitation avoiding an accurate diagnosis. Much information is available on the internet for the diagnostic pointers of frozen shoulder but the most significant ones are reduced range of movement in external rotation, abduction, flexion and finally internal rotation in that order. Reduction in movement may not be associated with pain and there may not even have been a precipitating trauma.

Frozen shoulder is also known as adhesive capsulitis because the two surfaces of the capsule of the shoulder stick to one another. Instead of relying on the traditional diagnosis, for osteopaths it can be more helpful to develop a broader picture of the dysfunction of the shoulder and its associated joints and muscles and build a diagnostic story - whilst keeping the conventional diagnosis in mind.

The patient is observed standing and the relative positioning of both gleno-humeral joints is noted. The osteopath should analyse whether the problematic shoulder is retracted or protracted, superior or inferior relative to the healthy shoulder? Observation includes active movements - observing the ranges of movement in all direction and paying particular attention to the scapulothoracic rhythm - the relationship between movement of the scapula relative to the humerus.

Osteopaths emphasise the importance of the body's function as a unit and so osteopathic examination must extend to observation of the pelvis and of course beyond. At the risk of stating the obvious, the shoulder is attached to the dorsal spine via the dorsal erector spine and ribs, the dorsal spine sits on the lumber spine and the lumber spine rests on the sacral base which is firmly lodged in the pelvis. Furthermore, latisimus dorsi attaches from the pelvic rim onto the medial inferior border of the scapula and therefore the pelvis and spine must be examined and treated in order to treat the frozen shoulder comprehensively.

In my opinion, when treating frozen shoulder the osteopath approaches the treatment in 3 ways. Firstly, treatment of the local musculature of the shoulder to improve the scapulothoracic rhythm with special emphasis on teres minor. Next I like to work on the more distal areas; that is, treatment of the dorsal spine, lumber spine, neck, ribs and pelvis. Finally, once I feel I have prepared the body, I like to work directly into the capsule using a form of muscle-energy. I find this an especially affective technique assuming the patient is not so acute so as to be unable to tolerate it. With the patient side-lying and the osteopath standing at the head of the table the osteopath brings the patient's uppermost shoulder into flexion passively (sometimes the osteopath can add a little adduction by asking the patient to fully relax the shoulder – this increases the tension in the capsule and the arm drops towards the table slightly). At the end of range the osteopath asks the patient to try and bring the arm back to neutral (in the direction of extension in other words). The osteopath resists this movement until the osteopath requests that the patient gradually relax the shoulder (after about 5-10 seconds). The osteopath increases the stretch gently and repeats 2-3 times. The osteopath can apply this muscle-energy technique to any of the directions in which the patient is restricted.


The body's natural response to most shoulder injuries is for the surrounding muscles to contract in a protective manner. This is useful in terms of splinting the joint for protection but can interfere with the healing process by reducing the blood supply as the head of the humerus is pulled up into the glenoid fossa. Contraction of the rotator-cuff especially supraspinatus leads to the head of the humerus moving superiorly and buttressing the acromiom process of the scapula instead of sliding smoothly under it which can lead to further soft-tissue irritation. The osteopath should therefore encourage the head of the humerus to move inferiorly using techniques such as traction and distraction in concert with soft tissue massage to the rotator-cuff muscles. Any form of soft tissue contraction around the shoulder, clavicle, pectoral muscles and scapula may equally restrict lymphatic drainage from the shoulder into the thoracic duct as a result of compression between the clavicle and first rib, so due attention should be paid by the astute osteopath to these areas.

It is important for the osteopath explain 2 things from the outset. Firstly, frozen shoulder takes time, maybe even a few months but a better prognosis is expected than without treatment. Secondly, the patient may not see a change for the first 3-5 treatments and so should not be disheartened by this. It is worth using a gomiometer to show the patient the increased range of movement as the restricted shoulder is often forgotten once an improvement is achieved.