01 96-601 1 /82/0304-0193$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright 0 1982 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

The Evaluation of Facial, Head, Neck, and Temporomandibular Joint Pain Patients TERESA A. ATKINSON, BS, PT, SARAH VOSSLER, BS, PT,* DENNIS L. HART, MPA, PTf

The purposes of this paper are 1) to present an evaluation procedure for patients with signs and symptoms of temporomandibular joint (TMJ) pain dysfunction syndrome (PDS) and 2) to describe the findings of the evaluation procedure on 12 patients with TMJ PDS. The evaluation emphasizes the collection of subjective and objective data. Records from 12 patients with facial, head, and neck pain were reviewed. The most frequent symptoms were: headache (1 00%), neckache (83.3%), and ear pain (58.3%). The most frequent signs were: muscle tenderness (100%) and mandibular deviation on opening (66.7%). Subjects with lateral pterygoid muscle tenderness had digastric muscle tenderness as well. Subjects with medial pterygoid muscle tenderness had masseter and hyoid muscle tenderness. Masseter muscle tenderness was strongly related to sternocleidomastoid and mylohyoid muscle tenderness and neckache.

Temporomandibular joint (TM J) pain dysfunc- tion syndrome (PDS)4' is a nonorganic disorder of the complex stomatognathic system including the bilateral TMJs, the articulating maxillary and mandibular teeth, the periodontium, and the muscles of ma~tication.~' The four cardinal elements of the syndrome are pain, joint sounds (clicking or crepitus), dysfunction of jaw movements, and tenderness of the muscles of mastication.7. 17,20,22.33,34,41.44 According to S~hwartz,~' the pain patterns commonly include a unilateral dull ache in the TMJ, ear, and jaw with radiation to the head, neck, and shoulder. Clinical studies tend to relate signs of muscle tenderness to particular referred pain patterns.6323 However, specific pathologies for patients with facial, head, and neck pain fre- quently elude the ~ l i n i c i an . ' ~~ l7

To organize the clinical approach to patients with facial, head, and neck pain, a thorough musculoskeletal evaluation is required. The eval- uation should include an examination of the TMJ, the muscles of ma~tication,'~ and the entire spine, including the sacroiliac joints.' The ex-

* Staff Physical Therapist. Gracewood State School and Hospital. Gracewood, GA 3081 2. t Assistant Professor, Division of Physical Therapy, West Virginia University Medical Center, Morgantown, WV 26506.

amination of the sacroiliac joints is presented elsewherei2. " and will not be included here. The purposes of this paper are 1) to present an evaluation procedure for patients with signs and symptoms of TMJ PDS and 2) to describe the findings of the evaluation procedure on 12 pa- tients with TMJ PDS.

REVIEW OF LITERATURE

The theories of TMJ PDS etiology have been classified by De Boever." The first classification is the mechanical displacement theory. This the- ory states that the posterior displacement of the mandibular condyle results in pain in the poste- rior joint structure^.^ Malocclusion or loss of posterior teeth may be the etiological factors of this condylar di~placement.~ Second, the mus- cular theory emphasizes the myofascial source Of 15, 25,47 The muscular pain may be in- duced by the stimulation of hypersensitive trig- ger areas, leading to muscle shortening, painful spasms,5i and possible contractions. Patterns of referred pain and concomitant symptoms also have been des~ r i bed .~ ,~ ' Similar patterns of muscle tenderness have been described in "normals."23

The third classification is the neuromuscular concept. This concept stresses the influence of

194 ATKINSON ET AL JOSPT Vol. 3, No. 4

inhibitory and facilitatory impulses from peri- odontal proprioceptors, muscle spindles, and joint receptors."* 55 Major etiological factors re- lated to the neuromuscular concept are para- functional oral movements, such as bruxism and clenching. These oral habits may be caused by occlusal interference^,^' especially when cou- pled with emotional 49. 58 Fourth, the psychophysiological theory emphasizes the role of emotional tension in producing parafunctional oral habits. Occlusal disharmony is considered to be a sequela of the chronic muscle spasms associated with tension-relieving habits.26136 Last, the psychological theory examines person- ality profiles of patients with TMJ PDS to deter- mine the possibility of psychological predisposi- tion.", 31

In light of the debate concerning the etiology of TMJ PDS, several authors warned against the rigid acceptance of one con~ept ' . '~~ 277 42 Thus, a broad approach to the evaluation of a patient with head, neck, and facial pain is recom- mended.

Review of the physical therapy literature in- cludes several studies describing the manage- ment of oral problems'~ ', ', 38' 5 3 3 56 but did not reveal a specific evaluation procedure that ad- dresses subjective and objective information. In a clinical research study, Trott and G O S S ~ ~ eval- uated and treated 34 patients with myofascial PDS using physiotherapy techniques. The phys- ical therapy evaluation consisted of: three tests for the muscles of mastication, three tests for the TMJ, and two tests for the cervical spine. Trott and Goss did not report a collection of subjective information which is essential for the manage- ment of any pain problem. Thus, there is a need for a thorough physical therapy evaluation format which will serve the following purposes: deter- mine the specific acute signs and symptoms and chronic structural problems of patients with TMJ PDS; provide individualized baseline data on which to judge the effectiveness of treatment; and provide data for clinical research.

PHYSICAL THERAPY INITIAL EVALUATIONS

An outline of the physical therapist's evalua- tion is seen in Table 1. The first step of the physical therapy evaluation was to ask th'e pa- tient to complete a self-administered question- naire to determine information concerning the

$ Based on the work of R o ~ a b a d o , ~ ' ~ ~ Gelb,16-l8 and E v e r ~ a u I . ' ~ . ' ~

chief complaint, medical and dental history, and other subjective data.37 After reviewing the ques- tionnaire, the therapist conducted an interview to clarify the patient's answers. During the inter- view, the therapist observed the patient's gen- eral posture, state of health, affective qualities, and signs of orofacial dysfunction such as vol- untary or involuntary facial habits or speech defects.

Facial measurements were performed to de- termine any decrease in vertical dimension and to check for developmental problems such as micrognathia or ma~rognathia.~' Hypertrophy of the facial muscles, redness, or swelling were also checked.40

An active range of motion test was then per- formed. The patient was asked to move the man- dible in elevation, depression, protrusion, retrac- tion, and lateral movement to each side. During active range of motion, the therapist checked for limited movement, hypermobility, incoordination, or evidence of pain. At maximal opening, the midline interincisal distance was measured. The normal value for this distance is 35-40 millime- t e r ~ . ~ ~ During jaw opening and closing, mandib- ular and maxillary midlines were observed to determine lateral or zigzag deviations.

The occlusion was then checked. Overbite, crossbite, presence of orthodontic appliances, dentures, or missing teeth were noted and re- corded.

The TMJs were palpated both on the lateral surface and with the therapist's fingers in each external auditory meatus. The patient was asked again to open and close his mouth several times so that clicking on opening or closing or crepitus could be noted.

The muscles of mastication were palpated bi- laterally both extraorally and intraorally. The de- grees of tenderness were graded subjectively as follows: 0 = normal; 1 = tender; 2 = painful.

METHOD OF SURVEY

Twelve records of patients from the office of Physiotherapy Associates, Augusta, GA, were selected nonrandomly for the study. The selec- tion of the records was based on the following criteria: 1) a complete history questionnaire; 2) a chief complaint of head, neck, or facial pain; 3) no history of recent trauma or surgery of the face or head; 4) no history of an organic disorder of the TMJ; and 5) the same therapist (T. A. A,) performed all initial evaluations.

Following the acquisition of a written informed

JOSPT Spring 1982 EVALUATION OF TMJ PATIENTS

TABLE 1 Outline of physical therapy evaluation of the patient with facial, head, or TMJ pain

I. Self-administered questionnaire* A. Chief complaint B. Past treatments to correct the problem and success C. Patient's opinion of a solution to the problem D. Symptoms and history

1. Location(s) 2. Onset (time and circumstances) 3. Duration 4. Aggravating or relieving factors 5. Consultations, diagnoses, medications 6. Specific symptoms

a. Jaw dysfunctions b. Signs of inflammation c. Symptoms of autonomic nervous system involvement or endocrine problem d. Parafunctional oral habits e. Dental signs and symptoms f. Headaches and neckaches g. Ear symptoms h. Pain

1) Type 2) Intensity 3) Frequency

II. Patient interview A. Dietary history B. Dental history

Ill. Examination A. General posture evaluation B. Inspection of the head and face

1. Anterior view 2. Profile

C. Mandibular movements 1. Active range of motion 2. lnterincisal distance on maximal opening

D. Lip closure39 E. Lingual position3' F. Occlusion G. Bony palpation

1. Lateral joint surface 2. External auditory meatus

H. TMJ auscultation I. Palpation of the muscles of mastication and of the neck J. Respiration (mouth or nasal breather)16 K. Phonetics (his house, church, judge, zebra)I6

* Summarized from George EversaulO, P.O. Box 19476, Las Vegas. NV 891 19.

consent, each patient's chart was reviewed to obtain subjective and objective data from the initial physical therapy evaluation. The data were analyzed for means, standard deviations, and Pearson product-moment correlation coeffi- cients for each pair of signs and symptoms. The signs and symptoms were totaled to determine the ranked order of frequency of occurrence.

RESULTS

Two men and 10 women, ages 35 to 77 with a mean age of 50.5 years (median of 48 years),

consented to participate in the retrospective study. Eight patients were referred from otolar- yngology, one from cardiology, one from internal medicine, and two from dentistry.

Tables 2 and 3 present the raw data from the survey. The most frequent symptom was pain: headache (1 00%), neckache (83.3%), and ear pain (58.3%). The most frequent signs were: muscle tenderness (1 00%) and mandibular de- viation on opening (66.7%).

Significant correlations of r 2 0.70 (P 5 0.05) for various signs and symptoms are presented in Table 4. Subjects with lateral pterygoid

196 ATKINSON ET AL JOSPT Vol. 3, No. 4

TABLE 2 Sians and svmDtoms of TMJ ~atients

- -

Patients Total

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2

Age 40 77 35 37 68 50 36 60 65 52 46 40 Sex F F F M F F F F F M F F Oral

TMJ pain X X X X X X 6 Limited mouth opening X X X 3 Deviation X X X X X X X X 8 TMJ noise X X X Bruxism X Clenching X X 2

Ear symptoms Tinnitus X X X X 4 Popping X X X 3 Stuffiness X X X 3 Pain X X X X X X X 7 Itching X 1 Hearing loss X X 2 Hearing sensitivity X X 2

Concomitant symptoms Headaches X X X X X X X X X X X X 12 Neckache X X X X X X X X X X X 11 Dizziness X X X X X X X X 8

TABLE 3 Results of muscle palpation *

Patients

1 2 3 4 5 6 7 8 9 . 1 0

External palpation Temporalis 2 0 0 2 1 2 2 2 1 1 Masseter 2 2 2 2 0 2 2 2 1 1 Medial pterygoid 2 2 2 2 0 1 2 1 2 0 Digastric 2 2 0 2 2 2 2 2 2 2 Sternocleidomastoid 2 2 2 2 0 2 2 2 0 2 Hyoid 2 0 2 2 0 1 2 2 0 0

Internal palpation Masseter 2 0 2 2 0 2 2 2 0 0 0 0 Medial pterygoid 2 0 2 2 0 2 2 2 0 0 0 0 Temporalis tendon 2 0 0 2 0 0 2 1 0 1 0 0 Lateral pterygoid 2 2 1 2 2 2 2 2 2 2 2 1

* Muscle palpation values: 0 = normal; 1 = tender; 2 = painful.

tenderness also had digastric muscle tender- TABLE 4 ness. Subjects with medial pterygoid muscle Correlations of signs and symptoms

tenderness also had masseter and hyoid muscle Variables r * P

tenderness. Masseter muscle tenderness was Lateral pterygoid-digastric 1 .oo 0.001 strongly related to sternocleidomastoid and Medial pterygoid-masseter 1.00 0.001

mylohyoid muscle tenderness and neckache. Medial pterygoid-hyoid 0.96 0.001 Masseter-sternocleidomastoid 0.95 0.001 Masseter-neckache 0.93 0.001

DlSCUSSlON Masseter-mylohyoid 0.85 0.001 Sternocleidomastoid-neckache 0.77 0.003

An evaluation procedure for patients with TMJ Mylohyoid-temporalis tendon 0.73 0.007

PDS was presented, and the records of 12 non- bledial pterygoid-dizziness 0.72 0.008

randomly selected patients with histories of TMJ tendon-c1enching teeth 0.70 0.01

PDS were reviewed. The clinical findings were * r = Pearson product-moment correlation coefficient.

JOSPT Spring 1982 EVALUATION OF TMJ PATIENTS 197

TABLE 5 Comparison of surveys of the symptomatology of TMJ PDS with percentage of occurrence

Investigators

Signs and symptoms Atkinson Greene Sheppard and Gelb et al. et a1." Shepparda5 et al." Ne133

Pain Joint sounds Muscle tenderness Limited motion TMJ pain Ear symptoms Headache Tinnitus Dizziness Muscle palpation tenderness

Lateral pterygoid Masseter Temporalis Medial pterygoid

Ratio of women to men Total N

similar to previous studiesi8* "3 339 43, 44* 4 5 3 57

(Table 5) even though the total number of sub- jects was much smaller. One hundred percent of the patients in the present study reported tender- ness in at least one muscle. All subjects had a history of headaches which was a higher inci- dence than previously r e p ~ r t e d . ' ~ . ~ ~ However, since headache is such a difficult symptom to quantitate, headache data should be cautiously compared among studies. The relationship be- tween tension headaches and tenderness of the muscles of mastication have been reported else- where."

The incidence of ear symptoms in the pres- ent study was high in comparison to the other StUdieS5. 18.30.32.33.45 and may be attributed to the fact that the majority of subjects (67%) were referred by otolaryngologists. Myrhaug3' postu- lated that, since the innervation of the muscles of mastication, tensor tympani, and tensor pala- tini was the same, a generalized condition of muscle spasms involving all of these muscles may be present in patients with TMJ PDS. The sustained contractions of the tensor muscles may lead to tinnitus, hearing sensitivity, tempo- rary deafness, and ear stuffiness or fullness. In an EMG study, Block4 identified a relationship between spasm of the medial pterygoid muscle and ear stuffiness.

In the present study, a correlation of r = 0.72 (P = 0.008) was found between medial ptery- goid tenderness and dizziness. Some authors have reported an association between dizziness and tenderness on palpation of the sternoclei-

domastoid muscle,44. 50. 54 but no explanation of either of these phenomena has been offered. Mryhaug3' suggested that dizziness may be as- sociated with TMJ dysfunction because of the myospasm of the tensor muscles.

The high incidence of muscle tenderness and low incidence of oral habits in the symptom survey appears to contradict the concept of the neuromuscu~ar~ 1,35,48,49,55.58 and psychophys-

theories of etiology. However, further studies of more than 12 subjects are necessary to clarify any discrepancies or corre- lations.

The common symptoms found among patients with TMJ .PDS have been described. Since many patients with TMJ PDS are referred to physical therapy with other diagnoses, commonly acute or chronic neck and head pain syndromes, a thorough examination of the stomatognathic sys- tem is necessary to determine the appropriate approach to treatment. If a diagnosis of TMJ PDS is suspected following an accurate evalua- tion, the patient should be referred to a dental- occlusion specialist for necessary intraoral sup- port. In our experience, the combination of den- tal splinting ;therapy and physical therapy has successfully alleviated many chronic pain com- plaints and permitted patients to return to normal function.

SUMMARY

A physical therapy evaluation procedure for patients with signs and symptoms of TMJ PDS

198 ATKINSON ET AL JOSPT Vol. 3, No. 4

has been presented. The clinical profiles of 12 patients presenting with head, face, or TMJ pain were compiled from their physical therapy eval- uations. The clinical findings were descriptively analyzed to determine the most frequently ob- served signs and symptoms and any possible correlations between these signs and symptoms. Additional research is required to determine the effectiveness of the physical therapy evaluation format presented in this report.

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