Category Archives: pain

Massage therapy can help with TMJ dysfunction

by Nik Panagos, RMT

What is Temporomandibular joint (TMJ) dysfunction?

(1) TMJ dysfunction is a disorder of the muscles of mastication (chewing), the temporomandibular joints, and associated structures. This disorder also presents with pain, discomfort, or limitations whilst at rest or movement.

(1) Image above depicts TMJ location and each part of the moving area.

How do I tell if I have issues with my TMJ?

TMJ dysfunction may present with a combination of the following symptoms:

  • Pain in the TMJ at rest or with movement
  • A clicking feel or sound with pain
  • Movements impaired such as chewing/swallowing/opening the mouth/closing the mouth/moving the mouth side to side
  • Headaches
  • Sinus congestion with pain
  • Ear pain
  • Poor posture

I have clicking or popping in my jaw when I chew or yawn, is that normal?
Clicking or popping sound in the jaw is normal as long as no pain occurs or no movements of the jaw are impaired. If none of the listed symptoms occur,then it is not TMJ dysfunction.

Are there different types of TMJ Dysfunction?

The three main types of dysfunctions are:

  1. Internal derangement of the joint: Dislocation, displaced discs, trauma to the lower jaw
  2. Degenerative joint disease: overuse or aging of joint, osteoarthrosis, rheumatoid arthritis, or perforation (puncture) of disc
  3. Myofascial Pain: Muscles surrounding the joint in a hypertensive state (high tension). Usually caused from overuse of clenching of the muscles of mastication (chewing muscles)

What are some common representations of TMJ dysfunction?

(2) Up to 70% of TMJ dysfunction patients suffer from pathology or malposition of the TMJ disc (disc displacement).

Normal movement of the jaw function: the lower jaw opens as the disc slides with the lower portion of the jaw (condyle) allowing for normal opening and closing without pain or dysfunction

Anterior disc displacement with reduction (ADDWR): The disc is displaced slightly forward causing a clicking and potentially some pain as the lower portion of the jaw (condyle) slides over the condyle ending in the proper open position

Anterior disc displacement without reduction (ADDWOR): The disc is displaced so far forward it prevents thejaw from opening fully.

(2) Image above illustrates some common anterior disc displacement of the TMJ

How do TMJ dysfunctions occur?

There are many different factors that can lead to TMJ dysfunction. Some common reasons why it occurs include:

  • Excessive use of mastication (chewing) muscles (I.e. chewing gum, chewing tobacco)
  • Careers with repetitive strain on muscles around the TMJ often due to prolonged seated posture (I.e. call centers, receptionist, instructors)
  • Accidents involving neck/upper back/shoulder trauma (I.e. Moter vehicle accident, contact sports)
  • Dental issues (I.e. missing teeth, uneven overbite or underbite, deviation of jaw)
  • Stress grinding during sleep

How can Massage Therapy help with TMJ dysfunction?

Massage therapy will help with TMJ dysfunction by physically manipulating restricted muscles, ligaments, and joint capsules surrounding the TMJ. Reducing the restricted muscle tissues will allow for movement to resume without pain or limitation. Mobilizing the joint ligaments and stretching will allow for proper function of the joint space to resume. Stretching the joint capsule will reduce pain, improve function, and reduce clicking if present. Manipulation of these structures will also help improve the overall function of the jaw.

What can I do at home to help prevent or reduce symptoms of TMJ dysfunction?

There are many different ways to help with TMJ dysfunction at home; some of the following ways you can help at home are:

  • Self-massage to the muscles of mastication (chewing muscles)
  • Reducing the use of chewing gum or chewing tobacco products
  • Keeping overall dental hygiene in good standing as tooth decay or wear can cause alignment issues that can put extra strain on muscles surrounding the TMJ
  • Follow a prescribed home exercise program to improve the strength and motor control of the muscles that influence the TMJ as well as postural strengthening exercises for the neck and upper back.

Do you treat inside the mouth as well? Is this the only way it can be treated?

Due to the nature of where the TMJ is located, treating within the mouth is usually the best way to access the joint itself for manipulation. However, the TMJ can also be treated without internal mouth manipulation.

In summary, the TMJ is an overlooked area for treatment unless it advances to a point of dysfunction or severe pain. Physical manipulation of TMJ dysfunction is an effective method of treatment for the condition.

Text References

1 Clinical Massage Therapy, Fiona Rattray, Linda Ludwig, Jan, 2005 Pg 597 (Citation 2021-07-13)

2  Meghan K Murphy, BE, Regina F, MacBarb, BS, Mark E. Wong, DDS, and kyracos A. Athanasiou, PhD, PE. November/December 2013. Temporomandibular joint disorders: A review of etiology, Clinical management, and tissues engineering strategies Volume 28, Issue 6 (Citation 2021-07-13)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4349514/

Image References

1 Depiction of temporomandibular joint and associating structures, (Citation 2021-07-13), motionspecficrelease.com. http://bodytechphysio.files.wordpress.com/2021/11/5a1f7-4a037c_398c46d6c03c45e0bf0fe91839b2fc33mv2.webp2 A schematic representation of the position of the TMJ disc in three different conditions, (Citation 2021-07-13), researchgate.net.
https://www.researchgate.net/profile/Tarun-Goswami-3/publication/24147487/figure/fig6/AS:668687967195141@1536439043532/A-schematic-representation-of-the-position-of-the-TMJ-disc-in-three-different-conditions.png

Management of Osteoarthritis

What is Osteoarthritis (OA)?

Osteoarthritis is the most common form of arthritis and occurs when the protective cartilage that provides cushion and support at the ends of bones gradually wears down. This is a degenerative disease that can worsen over time, often resulting in chronic pain affecting your day-to-day activities. Eventually if the cartilage wears down completely, the bones in the joint will rub directly on each other exacerbating the symptoms.

Common Symptoms of OA

  1. Pain and Tenderness
  2. Joint Stiffness
  3. Muscle Weakness and Loss of Flexibility
  4. Grating Sensation
  5. Bone Spurs- not a symptom but a sign
  6. Swelling

Most Common Risk Factors

  1. Old Age
    • Articular surfaces on the end of bones can wear down over time due to the natural aging process that occurs to muscles, joints, and bones.
  2. Obesity
    • Excess weight puts more stress on the joints (commonly occurs to weight bearing joints such as the hip and knee).
  3. Repeated Stress on the Joint
    • Over time this will cause the articular surfaces to wear down.
  4. Joint Injuries
    • A break or tear can lead to the development of OA over time.
  5. Genetics and Certain Metabolic Diseases
    • People with a family history of OA are at a greater risk.

Treatment for OA

An effective approach is seeking physiotherapy treatment at earlier stages, accompanied with an exercise program specific to you. You may feel some discomfort during exercising, but this feeling is normal and should calm down. If it is unbearable then do not continue with the exercise. Of course with any exercise, there are always risks associated, therefore consult your doctor prior to beginning any new exercise program.

                Exercise has many benefits for ALL people including improved health, fitness, and mood. Many people believe that exercising with OA could harm your joints and cause more pain, but research shows that people can and should exercise when they have OA. It is considered the most effective, non-drug treatment for reducing pain and improving movement in those with OA.

Recommended Types of Exercise

So now we know that exercise can ease symptoms of arthritis, but what is best for you? Well that varies from person to person so here are a few main categories of exercises to include in your program:

  1. Flexibility

                This category includes exercises that will help to improve or maintain the range of motion of the affected joint(s). By relieving stiffness in the joint and increasing the ability for the joint to move through its full range, you will decrease the risk of further damage, improve the function of the limb and joint, and decrease overall pain. There are two main categories of stretching to consider:

  • Dynamic Stretching: these are movement-based stretches that involve multiple joints. They should be performed prior to activity to prepare the body.
  • Static Stretching: these are stretches that take the muscle to its end range before holding that position for a minimum of 30 seconds. These stretches should be performed after activity when the muscle is already warmed up.

2. Strengthening

                These exercises work to build stronger muscles to help support and protect the joints. This allows for offloading of the affected joint which has the potential to relieve many symptoms. It is recommended to engage in strengthening exercises 2-3 days/week. Examples of strengthening exercises include lifting a limb against gravity, using free weights or elastic bands, or weight machines requiring you to push or pull against resistance.

3. Aerobic / Endurance

                These exercises help with overall fitness and improve your cardiovascular health. They typically involve the use of large muscle groups in the body in a repetitive and rhythmic manner. Canada’s guidelines for adults are to achieve 150 minutes of moderate- to vigorous-intensity aerobic physical activity per week. This intensity typically involves you to breathe a little harder and sweat but not be out of breath. Activities falling under this category include walking, biking, dancing, or even everyday activities such as mowing the lawn or shoveling as long as you are achieving a moderate- to vigorous-intensity.

4. Balance

                This is a fourth, less recognized category that is very important to consider in your exercise plan. These exercises will target smaller groups of muscles to decrease your risk of falling and can help improve your ability to do other exercises. Balance exercises include anything with a smaller or unstable base of support such as performing activities on a foam pad or single legged exercises.

Summary

                Arthritis doesn’t have to keep you from living your life and participating in your everyday activities. Exercise and arthritis should coexist! Research has shown that people with osteoarthritis who exercise regularly have less pain, more energy, improved sleep and a better day-to-day function. Work with your Physiotherapist to create an exercise program that is right for you and kick start your road to a healthier life!

BodyTech Physiotherapy

Let’s Talk About the Complexity of Pain

What is Pain?

Pain is an unpleasant complex experience that occurs in response to a potential threat to our body’s tissues. No one really wants to have pain and if you do get pain you typically want to get rid of if ASAP. What we need to remember is that pain is normal and necessary to our survival as it is our body’s alarm system. The alarm system is there to help bring our attention to potential threats and to change our behaviour to avoid the threats if necessary. 

Everyone experiences pain differently. The way we experience pain depends on many factors such as the following: the severity of tissue injury, our emotional responses, previous experiences with pain, cultural experiences, the social and physical environment, our sensory inputs from receptors in our body, beliefs and knowledge about pain and our expectations about the consequences of pain.

For example: A person who is a major league soccer player that fractures their ankle will feel the pain very differently compared to a 65 year old person who is relatively sedentary because the soccer player may feel anxious about how is he going to make money if he can’t play soccer, whereas the 65 year old who generally is not very active will not have much change in their day. 

How Do We Experience Pain?  

When your body is injured in some way whether it be from stubbing your toe, repetitive use of you shoulder or appendicitis, the receptors and nerves in your body send this information to your brain and it is your brain that decides whether or not you feel pain. These receptors in your body are called nociceptors and they respond to thermal, chemical or mechanical changes on the tissues. For example, when you place your hand on a hot stove top the receptors in your fingers and hand sense that the temperature has changed. They then send messages to your brain about the temperature change and your brain decides if this change in temperature is a threat and if you should feel pain to make you take your hand away from the potential threat of a burn.

The signals from the nociceptors do not create pain. It is the brain decides that receives the signals from the nociceptors and other information such as your memories of pain, your beliefs about pain, your emotions at the time of the signal, your expectations and the information about the environment and uses all the information to decide whether or not there is a threat of damage and whether we should feel pain. The brain may decide that a nociception signal is not important and that we do not need to feel pain, so we ignore it. An example of this is when we are sitting in a chair the receptors in our bottom notice the change in pressure an send this signal to the brain. The brain then takes the information from the signal, and the environment and decides that sitting in the chair is not harmful so therefore we do not feel pain.

An analogy that can be helpful understand pain is to think of pain like a ship that is sailing in the ocean. The receptors are the lookouts on the ship, and they notice lights in the distance (these are the potential danger signals). The brain is the captain of the ship and makes all the decisions about how to sail.

The lookouts notice lights in the distance and tell the captain about them. The captain then considers his memories about these waters and takes in information about the environment. Maybe the captain knows these waters well and knows that these waters are safe and pirate free. He would then decide that the information was good to know but not very important, he may tell the crew members not to worry about it and they continue to sail as normal. This is like the when you sit in the chair and the brain decides that it is not a threat, so you continue sitting as normal without pain.

But if the captain is concerned by the information because he has never sailed these waters before and thinks that the lights may be pirates coming to rob the ship, he may tell the other crew members to stay on high alert. This is like when you place your hand on the hot burner and the brain creates a pain experience to make sure you are aware of the potential threat. He may even change the way he was sailing to avoid the pirates. This is like when pull your hand away from the burner because of the pain to avoid the threat of a burn.

Types of Pain

Pain can be either acute or chronic.

We tend to consider acute pain as pain that has a “mechanism of injury” such as a fall, motor vehicle accident, slamming your finger in a door etc. Acute pain typically is short lived, most times is not present past 3 months (BUT not always) and usually follows the stages of tissue healing (which are outlined in the picture below).

Chronic pain is when the pain is occurring for a longer period of time. It is often disproportionate to the stages of tissue healing and may or may not have a mechanism of injury that explains why the pain is there. Chronic pain can be very complex and is not fully understood. Chronic pain is usually pain that is present past the usual tissue healing process. Meaning that the tissues have likely healed, and no more damage is likely being done. But a reason we may still get pain is because our tissues have become more sensitized. If you think of the body as a ship again. Sometimes even through the ship has long since cleared the pirate-infested waters the captain and the crew remain hypervigilant to be sure they are safe. This means that now, even normal and helpful signals such as lighthouses, and ship horns may be perceived as threats. This can be the same as if we are in pain for a long time the entire system including the nociceptors and the brain become hypersensitive to all the information that even the normal signals that the brain usually ignores will be considered threats and you feel pain even though there is no tissue damage occurring.

Management of Pain

Management of pain can be complex because of all the factors that contribute to pain. Therefore, management of pain may have to be individualized. Pain management can include many things such as resting the area of injury, use of modalities such as ice or heat, education by a health professional about exercises, work or activity modifications, education about what to expect, healing duration as well as management strategies of stress or anxiety.

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