[Physio Explained] Assessment and treatment of the Temporomandibular joint with Lucy Butler

In this episode with Lucy Butler, we discuss the temporomandibular joint and temporomandibular dysfunction. We explore: 

• Assessment of TMJ Dysfunction
• Intra-articular dysfunction vs muscular based dysfunction
• Which subgroups may respond best to manual therapy
• The key elements of an effective rehab plan 
• Botox and it’s role in treatment within TMD

Want to learn more about temporomandibular dysfunction? Lucy Butler recently did a brilliant Masterclass with us called “Mastering the TMJ: Assessment and Management of Orofacial Pain” where they go into further depth on this topic. 

👉🏻 You can watch her class now with our 7-day free trial:
https://physio.network/masterclass-butler

Lucy Butler is an experienced physiotherapist with a Masters in Musculoskeletal Physiotherapy from La Trobe University, Melbourne. With over 10 years of expertise in Melbourne's public hospitals, she has worked as an Advanced Musculoskeletal Physiotherapist in the Emergency Department and neurosurgical clinics. Lucy has a special interest in managing Temporomandibular Disorders (TMD) and presents nationally for the Australian Physiotherapy Association on TMD- A Physiotherapists Perspective.  

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Our host is @Sarahyule from Physio Network

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Transcript

UNKNOWN: 0:00

Thank you.

SPEAKER_01: 0:05

Key components for me are always education first, so they understand what their diagnosis is and what we're trying to achieve with their rehab. And then I'm usually using manual therapy initially to show them how we can make a change to their symptoms. So I'm trying to get that short term, that immediate change in their symptoms, almost to get them on board with them doing their rehab. What are the most important steps in assessing TMJ dysfunction? When should we use manual therapy techniques like massage or joint mobilisation? And where do injections or surgery fit into the mix? These are just some of the questions we're diving into today with Lucy Butler, a musculoskeletal physiotherapist with over a decade of experience across private practice, emergency departments and multidisciplinary neurosurgical clinics. Lucy holds a Masters in Musculoskeletal Physiotherapy and has worked extensively in both post- I'm Sarah Ewell and this is Physio explained. Welcome, Lucy, to the podcast. Thank you so much for your time today. Thank you for having me, Sarah. So we'll start around the assessment and diagnosis component of TMJ dysfunction. What are the key steps that you might take when assessing a patient with suspected TMJ dysfunction? So one of the main things when a patient comes in and they're complaining of jaw pain is that we really need to differentiate between whether their symptoms are potentially a pain-related temporomandibular disorder versus an intraarticular temporomandibular disorder. For a lot of our patients, they will have a little bit of both going on, but it's really important to try and identify what is the most significant issue and what's the most significant diagnosis out of those two axes, if you will, when it comes to orofacial pain and temporomandibular disorders. And we go back to our TND or diagnostic criteria of TMD to differentiate those different disorders. And in terms of assessment, it really comes down to where their pain is when they are doing functional movements. That's of the chore in terms of opening, closing, lateral deviation, retraction, protraction, as well as what's happening when they are doing parafunctional activities, eating, chewing, biting, singing, talking, yawning, all those sorts of things. And so we know when we are assessing these patients that the location of pain is going to be quite different for a pain-related disorder, which is probably more likely to be myogenous or muscle-related pain, versus an intra-articular disorder where we know their pain will most commonly be right over that TMJ up around the ear joint and then going to usually have symptoms of clicking, locking or pain with wide opening at that specific location. So when we look at our assessment, we're really trying to hone in on those exact symptoms, where they are and what brings on their pain. And then if we go back to our diagnostic criteria, there's different assessments that we can do, whether it's looking at their opening and what happens with their opening, whether they're getting the clicking with opening and whether it's palpation of the muscles, whether that brings on the pain, to then be able to be specific. Is it a myogenous or a muscle-related pain-related TMD versus an intra-articular TMD? And that's really important for those patients in our assessment. Some great insights there, I think. So you've done your assessment and then manual therapy for some of those patients is an option. And in your mind, when is manual therapy, like soft tissue massage, or joint mobilizations most appropriate in the management of these TMD conditions? I would do manual therapy on almost every TMD-related patient that I see. So I think it does apply to both those pain-related diagnoses and also those intra-articular diagnoses. And you just have to work out in your assessment what are the main findings that might be contributing to their symptoms. So in the context of a myriad or a muscle-related TND. We're probably seeing that tension in their masseter and their temporalis muscles. And in that case, it's very appropriate to do soft tissue massage on those muscles to see if we can reduce that hypertrophy, that muscle tension and that pain. And equally, if we have a patient coming with an intra-articular disorder and they might be limited in how far they're opening or they've got pain in the joint with opening or any other trauma movements, we might be using our intra-articular accessory mobilizations. So some traction or some PA mobilizations or some lateral medial mobilizations of that joint, depending on where they're stiff or where their limitation is in the joint to try and give them a little bit of joint relief, if you will, opening up that joint, potentially traction, potentially increasing synovial fluid in the joint to reduce some of that intra-articular pain or arthralgia or inflammation. in that case. There's quite good evidence to support manual therapy for TMD-related pain and disorders, both intra-articular and pain-related conditions. When we look at the research, the thing to be aware of is that when they do the research, they don't differentiate between which condition they're looking at and which manual therapy technique is appropriate to use or is the best to use. So we don't know what manual therapy to use for what disorder But we do know that overall, the research tells us that manual therapy is quite effective for both pain-related and intra-articular-related disorders. Fantastic. It'll be interesting to see where the research goes in terms of the heterogeneity of the samples. Just anecdotally from you, are there particular subgroups that you've noticed of those patients who respond best to certain kinds of manual work, whether it's massage or mobilizations? With our manual work, therapy treatments as per all musculoskeletal injuries. If we're only doing manual treatments on someone that potentially has a lot of masseter or temporalis hypertrophy and tension because they're clenching and grinding, and we're just bringing them in for that manual treatment and sending them away, we're not getting anywhere with them. We're banging our head against a wall. So those patients, it can be really effective for reducing their pain, but they're just going back to doing exactly the same thing. Unless we change their activity and their habits. So whilst manual treatment is really effective for those patients, we need to make sure we're giving them the right exercises and the right things to do at home to support that manual therapy we're doing. Equally, we might use manual therapy really effectively in someone has reduced mouth opening from an intra-articular disorder. For example, someone who might have a disc displacement in the joint that is not reducing, so they're stiff in opening They're limited in how far they can opening. That's when we might get in there and use some of our intra-articular accessory traction or PA mobilizations to give them more mouth opening. But again, that's going to jump right back unless you're giving them the exercises and the stretches to do to maintain that opening between manual therapy sessions. But in both cases, I would always use manual therapy for those sorts of patients to try and help them to get the most out of the exercises in their home management

SPEAKER_00: 8:37

program as well. Want to take your physio skills to the next level? Look no further than our Masterclass video lectures from world-leading experts. With over 100 hours of video content and a new class added every month, Masterclass is the fastest way to build your clinical skills, provide better patient care, and tick off your CPD or CEUs. Click the link in the show notes to try Physio Network's Masterclasses for free today. And that's

SPEAKER_01: 9:06

probably the perfect segue into the rehab plan side of things. So what are the key elements that make up an effective rehab plan for TMD? For me, the most important thing before I give any rehab plan is to give a really good education because I think for a lot of people with orofacial pain, they actually don't understand where their pain is coming from or why they're getting their pain. And it's really hard for them to know how to do their rehab and what they're trying to achieve if we haven't done good education. And I think the face can be a little bit more abstract for people to understand than other parts of the body when we're talking rehab and that we actually need to do exercises for it. For some people that can seem a bit strange to do exercises for the face or the jaw joint and muscles. So key components for me are always education first so they understand what their diagnosis is and what we're trying to achieve with their rehab. And then then I'm usually using manual therapy initially to show them how we can make a change to their symptoms. So I'm trying to get that short-term, that immediate change in their symptoms, almost to get them on board with them doing their rehab. And then the rehab will differ or the exercise, home exercise program for these patients will differ depending on their diagnosis. So for our pain-related TMDs, those ones that have mostly muscular pain and hypertrophy and those clients quenching, grinding muscles. We're really focusing on a lot of relaxation techniques. We might be doing rotary opening, which is just tongue on the roof of the mouth, really relaxed opening and closing within comfortable limits. We might be doing a little lateral deviation, wiggle side to side exercise just to get them to switch off those quenching muscles. We're often doing deep breathing exercises to see if we can sort of reset the whole upper body and commonly we're putting in a couple of cervical or thoracic postural exercises for those patients as well because commonly we see that posture and cervical is playing a big part into those TMD pain-related disorders. And then on the other side, an intra-articular patient, we would be thinking more about stretching exercises for home, whether that is intra-articular, so them using their fingers to open their mouth, or using their hands on the side of their face to help them open as far as they comfortably can. And then they might be doing some stretching of muscles as well, or even some self-massage of those muscles to try and get some more range. And once we've got that initial phase of exercises where we're usually focusing on reducing pain and increasing range of motion of opening or lateral deviation movements, we might be moving on to strengthening exercises as a medium to long-term strategy to reduce further episodes of similar pain or continue to improve their function. So, that might be isometric exercises of opening, closing, lateral deviation. It might be biting down on a paddle pop stick exercises for strengthening those sort of clencher muscles or those biting muscles. And we might also be looking at proprioceptive exercises of the joint if we're feel like someone is struggling to coordinate their movements, but they have the movement. So it's not a matter of stiffness or limitation in the jaw. It's a matter of then trying to understand how to use their jaw in space, whether that's for eating, singing, or whatever it is, then we might be looking at proprioceptive exercises as well. So there's key parts of the rehab program that build on each other as we grow. Fantastic. And I suppose the other question is your adjunct treatments and your pharmacological management. Where do medications and things like Botox injections fit into the overall management and the scope of that rehab plan? I'm keen on working closely with my clients, GPs and doctors when it comes to pharmacological therapy for TMDs because the face is such a sensitive area. We're using it all day, every day. And for are a lot of people it can be quite overwhelming especially if it's a new injury or a new pain or a new problem to have facial pain or to have difficulty opening their mouth or eating so I like to work quite closely with our medical colleagues to use pharmacological therapy as an adjunct to what I'm doing and what that might look like is if someone came in and they were having trouble opening their mouth because they had a new episode of an intra-articular disc display and I thought they were quite irritable in the joint, they had quite a lot of inflammation, then I would definitely be suggesting that they talk to their pharmacist or a doctor about using an anti-inflammatory in that case to settle it down so that we can then start to use our manual therapy to increase their opening range and get them to do their exercises. Because if they're in a lot of pain, we're just not getting anywhere with those treatments and that could be weeks on end of this patient not being able to eat or not being being able to open their mouth. And the longer we leave it, often the harder it is to try and to actually achieve those functional goals if they've got a lot of pain. So, I do use pharmacological therapy when needed without too much hesitation. That might look like anti-inflammatories. It might just look like paracetamol for someone who has muscular pain. It might look like muscle relaxant medication or something a bit stronger like an anticonvulsant if I think that they've got some neuropathic pain or some referred pain as well. So when is Botox appropriate for these patients? Almost all my patients come in and ask about Botox. So if you're treating TMJ, you need to be across what Botox does and when it is appropriate. And we know that Botox can be quite useful for patients who have pain-related TMDs when we need to break the cycle. That's how I usually describe it to them. So our patients that might come in with many years of clenching, of grinding, and they're really, really hypertrophied in that masseter or temporalis muscle. And they've got very ingrained parafunctional habits that we may try to treat conservatively, but we're really not getting anywhere because there's years of ingrain. That's when Botox can be affected for those patients. But we do need to remember that Botox does over time have a negative effect on the muscles. So it will leave you in the long-term with weaker muscles. If anyone is getting Botox in the joy, we need to make sure that they're also doing a proper rehab program. And the Botox is really an adjunct to your rehab program, but it does create that nice circuit breaker so that then we can do the exercises so their pain is lower so that we maybe can then start to change the habits that they have day-to-day in those parafunctional activities with those exercises that we already talked about, both relaxation exercise those stretching of the jaw exercise, that rotary opening, to be able to do that effectively. Some of our patients might need Botox to lower their levels of pain and that's when it is effective. So it doesn't work for everyone, but every now and again, I will encourage a patient to potentially talk to their dentist or their doctor about it. Fantastic. I think that's a really nice takeaway tip for clinicians as well. It's in the bigger picture and it's an adjunct treatment as well on the background of a thorough assessment and structured rehab plan. Absolutely. Thank you so much for your time today, Lucy. I think we've covered a fair bit. For those listening, Lucy has done a fantastic masterclass with PhysioNetwork. So if you'd like to dive a lot deeper into this topic, feel free to click the link in the show notes to watch her masterclass for free with our seven-day trial. And Lucy, a big thank you to you for sharing your insights today. I've resisted from using a pun of sink our teeth into it. So Thank you so much for having me Sarah. It's been really lovely to chat with you about this topic. Thanks Lucy.