The Missing Piece In TMJ TreatmentsPrint
The following review and article was published this month,
July 2011, in the online Journal of Massage Science:
Science of Medical Massage
In the July-August, September-October, and November-December
2010 issues of JMS we published a three part article on TMJ dysfunction and in Issue
#1 of 2011 we published a follow up on the same subject. We tried to
present to the readers comprehensive information as much as possible on the
subject of TMJ pathology as well as available massage and manual therapy
We did not discuss the critically important issue of
intra-oral treatment of the TMJ dysfunction in either article. Unfortunately,
from the legal point of view, the manual treatment in body cavities is outside
the scope of the massage profession, even if the practitioners have proper
training. In some states, it is even prohibited to be performed by
chiropractors and physical therapists. This was the reason we didn't include the
protocol of intra-oral treatment for TMJ dysfunction.
Mrs. Gail Falzon, RN noticed the absence of this important
information and contacted us offering an excellent answer to this problem. The
MyoFree® Self-Massage Tool which she developed allows the patient to conduct
self-treatment either learning on their own or under the practitioner's
guidance and supervision. In such cases the practitioner works on the outside
addressing the externally located masticatory and cervical muscles, while the
patient at home is able to address the inner masticatory muscles while
supporting the work of the practitioner on the external ones.
We are sure that her elegant solution is a very important
tool for everyone who works on patients with TMJ dysfunction, headaches and atypical
face pain. First of all, it allows those involved to avoid legal controversy.
Secondly, it involves the patient into the treatment process, which is a great
psychological tool. Thirdly, it allows individuals to avoid technical
difficulties that practitioners frequently face when they use intra-oral
treatment. These difficulties are the result of the inability of the patient to
open their mouth wide enough so that the practitioner is able to conduct
effective therapy or when the practitioner has large hands and fingers while
the patient's mouth is anatomically smaller.
Thus we see the MyoFree® Self-Massage Tool and instructional
video as a very important treatment system. This is why we would like our
readers to consider the article below as an important professional piece rather
than typical advertising.
Sincerely, Dr. Ross Turchaninov, Dr. Ali A. Bipar
CRANIOFACIAL PAIN SYNDROMES AND INTRA-ORAL TRIGGER POINTS
by Gail Falzon, RN
According to medical statistics, muscle dysfunction accounts
for 85% of all pain syndromes. This is especially true for those suffering from
craniofacial pain, including TMJD, headaches, atypical face pain (sometimes
diagnosed as neuralgias) and cervical pain. Patients presenting with head, neck
and jaw pain are sometimes challenging as there can be multiple components to
assess and treat.
According to the National Institute of Dental and
Craniofacial Research, the most common form of TMJD is myofascial pain, yet it
is not taught in dental schools. In addition to bite splints, dental
professionals use modalities such as biofeedback, external TENS and medications
to relax the muscles.
Attempts to relax the muscle simply cause an active trigger
point (TP) to become latent leaving the impression that all is well. It has
been an enormous challenge to educate the dental community on the difference
between "relaxing" muscle and "releasing" muscle
Because latent TPs (not causing an active pain complaint)
can still decrease the range of motion, weaken the muscle and pull on bony
attachments, it is important that we, as clinicians, not only correct the
myofascial component, but also teach the patient how to self-treat when TPs
become active again causing a myriad of painful symptoms and referred pain.
(See Figure 1).
There have been many scientific and clinical publications
pointing to TP infestation as either the central cause or significant
contributor to painful syndromes and myofascial disorders such as seen in TMJD
and other craniofacial pain (Simons et. al., ; Fricton, 1985; Fricton, 1999;
Mackley, 1999, Alverez et al., 2002).
In a study involving 300 patients who all had been involved
in a motor vehicle accident, the most common clinical findings indentified on
medical evaluation were the following; jaw pain, neck pain, post-traumatic
headache, jaw fatigue, and severe TMJ crepitus or clicking. The most common
diagnoses in order were: masseter muscle trigger points, closing jaw muscle
hyperactivity, and advanced disc derangement. (Friedman, et al., 2000).
Intra-oral TPs are often the underlying cause of headache
and face pain but our society is more versed in prescribing medications which
cover up the actual "source" of pain. Nothing is quite as gratifying
as watching a patient diagnosed with Trigeminal Nerve Neuralgia discover that
his or her pain is actually from a TP rather than true nerve damage. I've
witnessed several patients get off multiple anti-seizure medications prescribed
for nerve pain they didn't require in the first place. It is my personal goal
that intra-oral trigger points would be ruled out before giving a patient a
hopeless diagnosis of trigeminal neuralgia or tic doulourex.
INTRA-ORAL TRIGGER POINT RELEASE
Intra-oral TP work is slowly becoming more common in therapy
practice but is not the norm for therapy curriculum in our massage and PT
schools. There are five major muscle groups found inside the mouth, which also
include other surrounding muscles. For example the tensor veli palatini and
internal pterygoids located in the roof of the mouth can be the cause of
tension type headache, pain behind the eyes and sinus pressure. Dr. David G.
Simons, MD agreed with the referred pain patterns shown in Fig. 1 although this
particular one is not found in the current TPM
Fig. 1. Pain pattern for m. tensor veli palatini
TPs are palpable contraction knots (see Fig. 2) or taut
bands within the muscle/fascia that will ultimately change or alter muscle
tension which can lead to secondary problems of internal derangement,
arthritis, and/or faulty joint mechanics leading to ultimate joint erosion and
breakdown.(Peroz, et al., 2002) Whether primary or secondary, the presence of
TPs can perpetuate disability and worsen the prognosis if they are not
considered and treated. An intricate pathway of nerves and blood vessels run
through the muscles of mastication. Any disruption of normal function can lead
to severe pain.
Personally, after suffering a whiplash and closed head
injury in a MVA, it not only exacerbated a pre-existing TMJ disorder, but also
caused me to have headaches around the clock. There seemed to be no medication
or solution to help ease the pain and I was convinced by an oral surgeon that I
needed a complete reconstructive jaw surgery. Not only did the surgery not work,
it made the pain worse as I endured yet another two years of braces to correct
Desperate for help, I asked for a physical therapy referral
and was incredibly fortunate to find a PT well versed in treating TMJD and
headaches. She taught me how to self-treat using intra-oral TP release
techniques, and for the first time, I experienced true pain relief that
surprisingly was almost immediate. Because the treatment was so profound, I
began teaching and treating others while continuing research efforts. It soon
became evident that both reaching these muscle groups and following the release
response all the way through was near impossible with the fingers and thumbs
The MyoFree® SOLUTION
Based on years of research and product development, the patented
MyoFree® Solution was born. The self-help "kit" consists of the
easy-to-use MyoFree® Self-massage Tool (see Fig. 3) and the easy-to-learn,
Inside-Outside™ technique. The instructional DVD uses 3D animation of the
muscle groups to teach the location and treatment of intra-oral TPs using
ischemic pressure. A full-color Quick Start Guide is also included showing an
open mouth diagram and written instructions to compliment the video. A carrying
case is included for travel and safe storage. (Note* The MyoFree® Massage Tool
is for Patient Use Only!)
Fig. 3. MyoFree® Self-Massage Tool
Inactivating the TPs from both sides, if possible, renders much
more effective results. Also, a problem with most patients is the inability to
treat the tensor veli palatini and internal pterygoids found in the roof of the
mouth without eliciting a gag reflex. The MyoFree® massage tool (see Fig. 3) is
small in diameter which allows even those with severe hypomobility of the TMJ
to self-treat. One end of the device is shaped like a golf-tee and mimics the
thumb. The other end is a very small ball and was designed to treat the
attachment area of the lateral pterygoid which is located in a very small
anatomical notch. Practitioners often complain that they can't even reach this
area with their pinky finger as it is so small and hard to reach.
There are two video links that I would like to share with readers as
examples of clinical application of the MyoFree® Self-Massage Tool. The first
video link presents the intra-oral treatment of tension and active trigger points
developed in the medial pterygoid muscle. As readers know, this muscle is
accessible for the direct therapy only using an intra-oral approach. The
MyoFree® Self-Massage Tool eliminates necessity of intra-oral treatment
conducted by the practitioner to achieve stable clinical results while
involving the patient into the treatment process.
<iframe width="420" height="315" src="https://www.youtube.com/embed/EO6AyD2v0KU" frameborder="0" allowfullscreen></iframe>
The MyoFree® Self-Massage Tool has another important
benefit; its regular application by the patient between treatment sessions when
the practitioner concentrates on the external treatment and re-alignment of the
TMJ is very effective.
The second video link demonstrates self-application of the
MyoFree® Self-Massage Tool on the masseter muscle, which is usually targeted by
the practitioners during external therapy. The MyoFree® Self-Massage Tool
allows the patient to work on the masseter muscle combining external and
intra-oral approaches at the same time.
<iframe width="420" height="315" src="https://www.youtube.com/embed/o7b1tFtAiRo" frameborder="0" allowfullscreen></iframe>
An important advantage of the MyoFree® Self-Massage Tool is
its future re-application by the client to maintain pain and tension free
TMJ/headache symptoms after the entire treatment course is over.
Most therapists consider Dr. David G. Simons, MD to be the
"father" of TP therapy since he co-wrote the Trigger Point Manual
with Dr. Janet Travell. After watching the DVD and using the MyoFree® massage
tool on himself, Dr. Simons wrote a two page testimonial to the dental
profession on the importance of intra-oral TP release and why the MyoFree®
device is so effective. His testimonial and other resource materials can be
found at www.tmjpainsolutions.com
Anyone who has suffered a head injury, whiplash, has TMJD
and/or headaches should be made aware of these self-help techniques as part of
a comprehensive approach to the rehabilitation. We, as therapists, pride
ourselves on comprehensive home programs and providing knowledge that empowers
a patient to become involved in their own wellness. The presence of TPs can be
primary or secondary, but either way, can perpetuate disability and worsen the
prognosis and interfere with primary interventions if not considered and
treated. Left untreated, TMJD can become progressively worse and cause
permanent damage within the tissues.
Trigger points have a sensory component but can also
manifest as tension altering entities which, over time, can lead to uneven bite
mechanics and restrict mouth opening. (Djkstra, et al., 1999). Research shows
that TPs are a common component of diagnoses related to the head, neck and jaw.
Intra-oral TP release has a huge impact on not only the muscles of the face and
jaw, but also has a remarkable cervical component. Any therapy that can
eradicate or control TPs should eventually become a standard part of the total
treatment intervention for these difficult to treat conditions.
The MyoFree® Solution is a life-long, self-help, pain-relief
system that teaches a patient how to self-manage their muscle pain symptoms for
the rest of their life! The real beauty of the system is that anyone can easily
learn the techniques. If you would like to learn these techniques, you will add
a new important modality to your current practice and help desperate patients.
OTHER IMPORTANT FACTORS TO CONSIDER
There is never a single modality of treatment for these
complicated diagnoses, but because intra-oral trigger point release is such a
critical part of the pain puzzle, pairing it with existing treatments render
far more beneficial results. Also important, of course, is teaching stretch and
strengthening exercises, evaluating posture from the feet up, body mechanics,
pelvic tilt and other perpetuating factors that can lead to the formation of
TPs. Chemical imbalances and nutritional factors (Ferritin, Vitamin B1, Vitamin
B6, Vitamin B12, Vitamin D, Serum Folate, Calcium, TSH, and serum magnesium and
potassium) should also be considered in the overall evaluation of muscle pain
The MyoFree® Solution is available at www.pressurepositive.com
and retails for $59.00. Wholesale and health professional inquires are welcome.
Simons DG, Travell JG, and Simons LS. Myofascial Pain and
Dysfunction. The Trigger Point Manual. Volume 1, 2nd Edition, Lippincott
Williams and Wilkens.
Fricton JR. Masticatory myofascial pain: an explanatory model integrating
clinical, epidemiological and basic science research. Bull Group Int Rech Sci
Stomatol Odontol., 1999. Jan-Feb; 41 (1): 14-25.
Alverez DJ, Rockwell PG. Trigger Points: diagnosis and management. Am Fam
Physician, 2002. Feb 15; 65(4):653-660.
Mackley RJ. Role of trigger points in the management of head, neck and face
pain. Funct Orthod., 1990. Sept-Oct; 7(5):4-14.
Fricton JR, Kroening R, Haley et al. Myofascial pain syndrome of the head and
neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med
Oral Pathol., 1985. Dec; 60(6):615-623.
Peroz I, Tai S. Masticatory performance in patients with anterior disc
displacement without reduction in comparison with symptom free volunteers. Eur
J Oral Sci., 2002. Oct; 110(5):341-344.
Friedman MH, Weisberg J. The craniocervical connection: a retrospective
analysis of 300 whiplash patients with cervical and temporomandibular
disorders. Cranio, 2000. Jul; 18(3):163-167.
Djkstra PU, Hof AL, Stegenga B et al. Influence of mandibular
length on mouth opening. J Oral Rehab., 1999; 26:117-122.
Gail Falzon, RN is a myofascial practitioner who specializes in craniofacial
pain disorders. She treats patients in southeast Michigan, teaches other professionals and
speaks at national conferences for therapists and other medical/dental
clinicians who work with TMJD, headaches and atypical face pain. She is the
founder of TMJ Pain Solutions and the Inventor of the MyoFree® Solution. More
information can be found at www.tmjpainsolutions.com and www.facebook.com/tmjpainsolutions.
Her contact information:
TMJ Pain Solutions
7446 Lochmoor Dr.
Ypsilanti, MI 48197