Head Case

“I'm very brave generally, he went on in a low voice: only today I happen to have a headache.”

- Lewis Carroll

Jaw pain. Head ache. Toothache (but wait, the dentist said my teeth are fine). Clicking in the jaw. Yawning hurts. Chewing is Exhausting (or painful). Can’t open my mouth. Can’t close my mouth. Numbness in head or face. No pain. Weird noises. Jaw locks. Talking hurts my head. I wake up with headaches. Resting helps. I grind my teeth. I don’t grind my teeth. I clench my jaws. My ears hurt. My ears are “stuffy,” Flying gives me a head-ache. My neck hurts. My shoulders hurt. I get migraines. I don’t get head-aches.

What is going on here? The list of symptoms looks like a mixed bag of unrelated, even contradictory sensations. But, for people suffering with TMD, or TMJ syndromes, this list will look really familiar.

The TMJ (tempormandibular joint) is the joint that attaches your lower jaw to your head. Like the joints that connect your spine, the two sides work in tandem. Damage to one side, will cause dysfunction in the other. And the most debilitating symptoms may show up in the side with the least damage. The muscular attachments, nerve pathways and patterns of use are a complicated system that delivers a wide range of symptoms if things go awry. Most confusing is that the symptoms listed above may all be present in the same person at different times. This makes it very difficult to diagnose, and treat. There are as many treatment options available as there are symptoms, and the results vary just as widely.

The TMJ association has a new forum for patients that I found to be very interesting. This site is a wonderful place to share information and learn about TMJ dysfunction. The Forum is running a couple of polls on “what has helped you the least?” and “what has helped you the most?” At last count physical therapy was least helpful for 11.1% of those reporting, and most helpful for 33% of those reporting. Interesting. Unfortunately with many of the conditions I treat, nothing works for everyone. On the reverse, something works for everyone. People with chronic pain conditions have to be constantly on the watch for something that will work for them. I would also like to add that some things will work, even if they didn’t work the first time.

For someone in constant, everyday, debilitating agony, I am probably not the best front line of treatment. Having a team of good, supportive doctors on board is essential. Sometimes drug therapy is essential to help with the intense pain while we work on the mechanical imbalances that cause the problem. Having good, compassionate dental or orthodontal care is important. Be warned that some studies have shown bite therapy to be causative, not curative for TMJ. Other studies have shown that it is the best treatment. I have had many patients whose first symptoms came after orhtodontal or dental work to correct a bite, or repair teeth. I have had patients that swear their orthodontist cured them. Jaw surgery is another question mark for cure. I treat a lot of post-surgical patients. Many of them consider the implants to be a miracle cure. Many of them show up in my office 3-5 years later in the same (or worse) pain than they started with. At least the surgical interventions have improved over the years, 15 years ago some of the common practices bordered on barbaric. Be very cautious before undertaking a treatment plan that is very expensive, and irreversible.

As for physical therapy being least helpful (it pains me that we don’t help everybody – but I get it), it is also one of the least invasive. My practice focuses on improving musculoskeletal function, which means a lot of postural retraining, manual therapy and modalities to reduce muscular tensions, and a home program of stretching and strengthening to improve mechanics of the spine, jaw, and upper extremities. Even if it doesn’t help the TMJ, the program will prevent other postural problems in the future.

Please feel free to add a comment, tell us your story, or let us know what was most helpful for you!

Haven't Got a Chew

Temporomandibular Joint Dysfunction (TMJ, or, more accurately, TMD) is a syndrome that affects approximately 10,000,000 people in the United States. TMD is a poorly understood collection of symptoms that seem to originate from the temporomandibular (jaw) joint. For years it was bounced around like a hot potato between the dental and medical communities; in some ways, this still happens.

The presentation of symptoms does not necessarily include pain in the jaw, or even the classics: “popping” or “clicking” in the joint. This means that people who suffer from TMJ pain often are undiagnosed, or misdiagnosed. The most common symptom that is not directly related to joint dysfunction, is headache. TMD headaches can be ones sided (mimicking migraines); or two sided (complex migraines, tension headaches, or: we don’t know what is going on, and we need to run many inconclusive and scary tests to rule out the really bad stuff). These headaches are tension headaches, caused from clenching or grinding the teeth, building tension in the temporalis muscles (they are fan shaped muscles on your head; around, above and behind your ears). Tension headaches beginning at the base of your skull can contribute to TMD, and TMD can make these types of headaches worse. If you are prone to migraines, a TMD related tension headache can trigger a migraine. So if your major symptom is headache – you might want to discuss TMJ syndrome with your doctor or dentist. In an article from the Boston Globe: “If Doctors Can’t Help Your Headaches – Should You See a Dentist?” you will read about the benefits of seeking a dentist for help with chronic headaches.

How does Physical Therapy help? Well, in my practice, number one is: POSTURE. If we can’t fix your posture, everything else is palliative. There are many things we do to loosen the muscles, including electrical stimulation, ultrasound, heat, ice, and massage (massage is great, and proven effective for pain relief in TMJ). I have an earlier post on trigger points, which discusses how trigger points work, and mentions the benefits in the treatment of TMD. Trigger Trauma. Still; posture is key. By improving your posture, you take the stress off of the joints; not just off your jaw, it also relieves the stress on your neck and shoulders. Posture training and appropriate exercise also gives you more control of your health.

I was diagnosed with TMD 17 years ago. I am relatively symptom free unless I do something that I know is going to cause me pain, or throw me out of good posture – like wearing high heels. I do it very rarely, for very brief periods of time, and I know that I will pay, but it is a decision that I get to make. I also am in control of my diet. I have not chewed gum in 12 years – the pain that I will deal with for days after is not worth it to me. Carmel, on the other hand, is occasionally worth three days of ice-packs and begging my staff to treat me.

Stress (I mentioned that these are tension headaches, right?) is some what under our control. If you have a lot of stress and tension in your life, you have to get a handle on it. Learn to meditate, and make it a priority. If you are unable control your reactions to the stressors in your life (and yes, keeping your mouth closed, and pretending that things don’t bother you is a reaction,– clenching, remember?), please seek counseling. This is hugely important. Life happens, how you deal with it will determine how negatively it affects you. There is some basic information, and tips on how to deal with TMJ pain at my web-site: Slainte Physical Therapy .

There are factors that affect the joint that we don’t have a lot of control over. Changes in atmospheric pressure can worsen symptoms, especially if your temporamandibular joint has become arthritic. I live in Florida, hurricane season is hard on my jaw patients, and on me. Between the stress involved with the season, and the rapid weather changes, my office gets very busy. At that point it is just symptom relief, and trying to maintain as much of a positive attitude as possible. At least weather is not permanent.

Trigger Trauma

Trigger points - what are they? How do they effect me? what do I do about them?

Trigger points are small areas of tightness within connective tissue. They are typically found in muscles, but can be found just under the skin. Connective tissue is the "soft" support in your body, the tissue that surrounds muscle cells, muscle bundles and muscles. It makes up ligaments and tendons, and gives texture to skin. When it tightens it causes wrinkles superficially, and tight, inflexible muscles and joints in the deeper tissues. Anyway - not all tight spots in your muscles are trigger points. Some of those hard little knots you get in a tight muscle (go ahead, feel the muscles in your neck, I know you've got a few knots) are tender points. The difference between a tender point and trigger point is that when you press a tender point it hurts right where you are pressing, a trigger point will refer pain somewhere else.

It is still pretty unclear how trigger points are formed. Some theories are: micro-trauma (tiny tears) cause the connective tissue to tighten and scar; habitual tightening of the muscle causes them; we all have them latent in our bodies, and some trauma or pain response activates them. I believe it is a combination of these.
So what does all of this have to do with chronic pain? or pelvic pain? Well, if you have trigger points, your pain may not be where you think it is. For instance, I recently saw a patient that came to me with classic TMJ headaches and jaw pain. (TMJ - temporomandibular joint dysfunction, a painful condition of the jaw joint). This particular patient had no clinical findings to justify their pain. The dentist had cleared the bite; an oral surgeon found the jaw to be fine on an MRI, yet the patient still had pain. The patient also complained of toothache pain that was unfounded. We found trigger points in the neck that exactly mimicked the pain she was having. When the trigger points were cleared, the pain disappeared.

There are many trigger points (tp's) that effect pelvic pain syndromes. TP's in the muscles and skin of the abdomen, around the sacrum, in the muscles of the buttock, inner thigh and low back can refer into the pelvic region and pelvic floor. The muscles of the pelvic floor can contain tp's that refer to the bladder, the bowel or the labia. TP's have some pretty predictable referral patterns, but they are not obligated to conform to our textbooks, they can literally refer to any area of the body. Remember, if you have pain in an area caused from a tp, and you tighten the muscles to protect it, you may cause trigger points that refer somewhere else.

So, theoretically, if you develop trigger points in the abdomen after a surgical procedure years ago, that refers pain into your inner thigh muscles, you may not even notice either of these except a vague "gee - that's kind of tight, I should stretch or exercise more." These points refer to your pelvic floor, a place that most of us are completely unaware of unless there is a problem, here the muscles tighten, causing trigger points that refer to your bladder, which makes you think you have to go to the bathroom more often. Frequency may not be a huge problem for a lot of us, but if you are a school teacher, nurse, flight attendant, or any of the other 1,000's of people that can't go to the restroom every hour (or 1/2 hour, or 15 minutes) suddenly this is effecting your lively hood. So you try to hold it. Your pelvic floor tightens more. When you do finally get to go to the bathroom, you strain to urinate (stop that), and eventually you have a full blown, bonafide pelvic floor dysfunction with all of the pain associated. No one knows how it happened; it seems like a sudden onset, because you were functioning fine a couple of months ago.

So what do we do about it? Find a physical therapist. Someone trained in trigger point work, someone experienced with internal trigger point release.
There are a few different methods of trigger point release. They all seem to be pretty effective, and it depends on where your therapist was trained as to which method s/he will use. Some PT's will use a firm sustained pressure on the point for 30 seconds or more. Some will use a gentle pressure - just enough to elicit the referred response and hold for 8-12 seconds, until the referred pain diminishes. Remember these points did not happen over night, and often take several sessions to clear. For trigger points in the pelvic floor muscles, the therapist will work internally, either through the vagina or the rectum. Also, your therapist will work on posture, stretching and relaxation techniques to try to eliminate some of the mechanical problems that aggravate you trigger points.

There aren't a lot of PT's that do this type of work, and sometimes the travel involved is too great of an aggravating factor to justify several visits a week. Even if you are seeing a therapist 2-3 times per week, sometimes that isn't enough. Your therapist may have you work on your trigger points at home. When I send someone home with instructions for self administered trigger point work, I have them use a device to reach the internal trigger points (face it, we aren't built to do this on our own). My new favorite product is called "EZ-Magic" it is made out of medical grade glass, and has a smooth, rounded tip that won't damage the delicate lining of the vagina or rectum. It's important that you work with a therapist that will teach you how to use it properly, and of course, you should never try to self-treat until you discuss it with your health professionals.