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HAND-CRAFTED PHYSICAL THERAPY IN MIAMI
Bruce R. Wilk, P.T., O.C.S. Director
8720 N. Kendall Dr. Ste. 206
Miami, FL 33176
tel. 305.595.9425
 fax. 305.595.8492
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By Bruce Wilk, PT, OCS

In the 1950s, physical therapy for TMJ patients consisted of heating packs, ultrasound, electrical stimulation, and very generalized, nonspecific' exercises because the etiology and pathology of the problems these patients experienced were not well understood. As arthroscopic techniques developed, surgeons were able to develop more specific diagnoses. As pathology was better understood, physical therapists devel­oped rehabilitation programs that were based on etiology and surgical intervention. These programs helped patients to regain mobility and strength while working to prevent injuries and other complications.

PRINCIPLES OF REHABILITATION

An important concept in physical therapy is the treatment of function versus the treatment of pain. In actuality, physical therapists have very few tools to treat pain. A great deal of time is wasted in physical therapy trying to treat pain, when as we all know the greatest modulator of pain is the patient's subjective response to pain. Therefore, physical therapy should treat function, which includes improving range of motion, improving muscle strength, educating the patient in daily and functional activities, neuromuscular relaxation, proper breathing and posture, and limiting muscular tension. Physical therapy is most effective when it is based on the treatment of function.

Another important concept in physical therapy is focusing on active rehabilitation versus passive intervention. All modalities that treat pain are very passive forms of intervention (i.e., heat, stimulation, massage, and so on). Passive intervention mayor may not work, but success is almost always achieved when patients are actively involved in the treatment program. Patients perform take-home exercises to strengthen muscles and to improve mobility. When patients are actively involved in changing their lifestyle, becoming more physically fit, and progressively clearing the underlying dysfunction or problem, success is virtually assured. Additionally, patients learn how to prevent further injury.

PREOPERATIVE WORKUP

The Team Approach

The team approach is vital in treating complex situations with patients. Generally, most TMJ patients present with many complex problems and complaints, at all levels, and each member of the team (the physical therapist, dentist, psychologist, and surgeon) has something to offer. All patients should be seen preoperatively by each member of the team as part of the initial workup.

Patient History
During the first visit, a detailed and subjective history of the patient, including a full musculoskeletal and general medical history, is obtained by the physical therapist. Patients describe how functional activities affect the pain; trigger their pain, and the quality and quantity of the pain. Their past history is critical, especially to their musculoskeletal system and previous surgical intervention. Based on this information, the physical therapist assesses the patient's condition and the results achieved by rehabilitative interventions.

Clearing the Upper Quarters
One of the most important functions of the physical therapist is to clear the upper-quarters, which consists of eliminating other aspects of pain that joint surgery would not be expected to alleviate or directly affect. Ideally, the upper­ quarters should be cleared preoperatively, but may be cleared postoperatively.
The physical therapist is the only member of the team that performs a thorough upper-quarter examination. Muscular trigger points in the shoulders, neck, facial, and masticatory musculature can reproduce headaches or trigger referred pain. Patients have come to us from other surgeons after successful surgery, but their pain was not alleviated because it was actually referred pain from the upper quarter, Pain in the jaw can be referred from many structures in the upper back, neck, head, or shoulders.

The physical therapist performs an objective examination, which includes the following:

  • Observation of how patients hold their heads in relation to their necks, how they are moving their jaws, and whether there are any guarded or abnormal movement patterns

  • Palpation of the entire soft-tissue system for quality, quantity, and location of pain, and for crepitation and joint noise

  • Evaluation of range of motion and end-feels in the entire upper-quarter system and quality and quantity of joint motion

  • Measurement of all active movements, including the neck and shoulders

  • Assessment of postural deficits, breathing patterns, head positioning, gait, upper-quarter function and tendencies toward compensatory use of accessory muscles

  • Assessment of muscle strength and muscle pain with isometric contraction

  • Evaluation of the patient neurologically, assessing any deficits

  • Provocation of pain by loading the various joints of the TMJ, upper quarters, and cervical spine

Sometimes the physical therapist may see the patient pre­ operatively for several weeks in an attempt to clear the upper-quarter system. Other patients may have upper-quarter problems, but require surgery very quickly. In these cases, preoperative exercise programs are initiated, and the postoperative rehabilitative process is explained to the patient.

Patient Selection

The physical therapist also assesses whether the patient is a good surgical candidate. The major complaint of all patients is pain and limited jaw motion. However, some type of limited neck motion and upper-quarter motion, or cervical trigger points which reproduce their headaches may also exist, and currently, this patient may not be a good surgical candidate because of these factors.
The next factor to assess is the complexity of the patient's situation. Will there be a few physical therapy sessions, or is this a very complex situation in which the problem has over­ taken the patient's entire life? What is the patient's motivation? Does the patient prefer passive treatment? Is the patient willing to become actively involved in the treatment plan? The treatment plan must be based on the problems presented by the patient and these objective findings. Patients must comprehend their role in the rehabilitative process.

Preoperative Review
Depending on the team's perception of the underlying eti­ ology, patients are informed of what to expect during surgery and what physical therapy will be performed. If continuous passive motion (CPM) will be used after surgery, patients are instructed in its use before surgery. Patients are also informed of postoperative management (i.e., rest, ice, diet compromise, and so on). Rehabilitative goals are established, realizing that these goals also may change. As a result of this visit, patients have an understanding of the expected duration of therapy and their role in the rehabilitation program.


POSTOPERATIVE REHABILITATION


Rehabilitation of surgical TMJ patients is divided into four stages, with specific goals and exercises for each stage (Table 17-1).

Stage I
The goal of Stage I physical therapy is to maintain mobility and strength without compromising healing structures. After surgical intervention, patients should maintain as much mobility and muscle strength as possible. Patients are followed by the physical therapist to ensure compliance with postoperative instructions.

Table 17-1. Rehabilitation stages, goals, and exercises

Stage Goal Exercises
I Maintain mobility and strength 1. Limited active vertical opening, right and left excursion and protrusion
2. Isometrics in neutral
II Increase range of motion 1. Active assisted exercises (guided by hand) to opening
2. Left and/or right side excursion
3. Protrusion
III Smooth active range of motion without deviation or asymmetry l.  Feel for deviation in rotation, translation, and protrusion
2.  Correct deviations in rotation, translation, and protrusion through isotonic 
     resistance
3.  Create smooth movement through isometrics
4.  Create smooth motion with resistance throughout the range through active
     correction
IV Progressively load 1.  Opening and closing
2.  Side excursion
3.  Protrusion

The physical therapist sees all patients on their first post­ operative day. At this time, the physical therapist has reviewed the surgical report consisting of the postoperative diagnosis and the surgical intervention. Generally, patients begin at Stage I, unless a significant loss in range of motion has occurred, and stretching must be started immediately, in which case patients are started in Stage II. Patients are not allowed to rest completely and risk formation of scar tissue. In Stage I, the therapist concentrates on reducing pain, spasms, and swelling. Gentle soft-tissue work may also be used to promote healing.

To achieve the goals of Stage I, the physical therapist pre­ scribes take-home exercises consisting of limited range of motion exercises and gentle isometrics. All exercises are to be performed slowly and comfortably, not causing any sharp pain.
Patients are instructed to place their tongue on the roof of the mouth, as illustrated in
Fig. l7-1, and to vertically open as much as their tongue will allow. Tongue placement limits opening to two finger widths. Patients are also taught to feel the rotation of the joint and to feel that it is not translating excessively. Generally, patients can open to only one finger width after surgery. In Stage I, patients will not open more than two finger widths.

Right and left excursion is performed by placing a finger on the incisor teeth and moving only tooth to tooth, first right and then left as shown in Fig. 17-2. Some patients progress postoperatively very quickly with this exercise and others experience a great deal of pain.

Protrusion exercises are performed by bringing the lower jaw forward (Fig. l7-3, A) until the lower teeth line up with the upper teeth (Fig. 17-3, B).

Isometrics are accomplished with the tongue on the roof of the mouth and the teeth slightly apart. Patients are taught to gently resist the muscles that open and close the jaw and to resist the jaw laterally and to protrusion. In this exercise, patients resist the muscular actions, but do not allow the jaw to move.

Depending on the patient's individual needs, the next appointment is scheduled in a few days, or in a week or two.

Stage II

In Stage II, the goal is to increase range of motion. In the office, hands-on stretching exercises are performed. In a bilateral case, both sides of the joint are stretched using intra­ oral manipulation. The joint is stretched into rotation, translation, protrusion, lateral excursion, and longitudinal distraction. All exercises are intended to stretch the soft tissues that could be restricting movement and to prevent the development of adhesions. In-office stretching is followed by take­ home exercises.
After surgery it is very important that patients perform the take-home exercises that move and exercise the jaw. These exercises should be done gently and easily. Patients should feel a slight stretching and some discomfort, not a sharp or ripping sensation.

Three types of opening exercises are prescribed: the con­ tract-relax, the hook-pull, and the pry-bar exercises. The con­ tract-relax exercise consists of opening the mouth as far as possible while using a hand to resist opening and closing iso­metrically and then opening a little farther. The hook-pull exercise is performed by hooking the index finger around the chin, opening as wide as possible, and then giving a gentle pull. The pry-bar exercise consists of placing both thumbs on the top teeth and the index or middle fingers on the bottom teeth, illustrated in Fig. 17-4, and then gently prying the mouth open. These are time-tested physical therapy exercises that allow the patient to maintain and then progress range of motion gains made in the office.

Lateral excursion exercises stretch the jaw to one side. To assist left deviation, the right hand is used to push the jaw to the left and vice versa for right deviation.
Protrusion stretching is assisted with the hands being used as guides, while moving the jaw forward as far as possible.

In a unilateral case, care must be taken to stretch the surgical intervention site, or a bilateral joint problem will develop. Patients must be taught to open to the point of restriction and to stretch the joint at this restriction. For example, after surgery on the right joint, patients are able to move laterally to the right, but not to the left. Therefore, lateral stretching exercises are performed to the left.

Stage III

Stage III consists of muscle reeducation. The physical therapist assesses the patient for any evidence of asymmetry or glitches in movement, possibility of overstretching, and/orinappropriate movement patterns. All of these issues are addressed and treated in Stage III. The joint was stretched in Stage II, so good joint mobility is already present. Patients continue to perform earlier stage exercises as they progress neuromuscularly to ensure maintenance of range of motion.
In-office techniques consist of teaching patients to resist the muscle of mastication, to permit smooth symmetrical mobility patterns, and to be aware of internal cues. Patients are taught to correct vertical opening, protrusion, lateral excursion movements. The goal of Stage III therapy is to teach patients to reeducate the jaw muscles to foster proper function.
In Stage III, patients are taught take-home exercises to correct asymmetries. Patients are instructed to feel for restrictions and deviations in their range and to correct these deviations through feeling, using their fingers and tongue as guides. Patients are not taught to perform exercises in front of the mirror, which relies on visual input.Patients should feel the movement and learn to rely on internal cues.

To correct an opening deviation, patients are instructed to open to the point of deviation or excessive translation and to use their hand to resist the muscles opposite the deviation at this point in the range as illustrated in Fig. 17-5. Once they have practiced offering resistance throughout the range at each point of deviation, the next step is to practice placing their tongue on the roof of the mouth and once again opening and closing without deviation.
In bilateral cases where patients have not been moving well for an extended period of time or there exists a movement deficit status post-surgery with hesitations and glitches in movement, patients are taught to perform isometrics at the point of hesitation in opening, closing, and lateral excursion.

Then, patients are progressively loaded in the restriction to accomplish smooth movement.
In unilateral cases, deviation and limitation in the muscular function exists on the more involved side. After right­ sided surgery, patients typically open and deviate to the right. During protrusion, patients also deviate to the right and have limitations when attempting to move to the left. Isometric and isotonic exercises performed opposite the deviation at the point in the range where the deviation occurs help to correct these situations.


Stage IV

The goal of Stage IV is to progressively strengthen the masticatory muscles until patients return to a full functional range of motion and a premorbid diet.

In Stage IV, resistive manual exercises, illustrated in Fig. 17-6 (e.g., opening, closing, lateral excursion, and protrusion), are taught throughout the entire range of motion. Patients are monitored closely to prevent development of synovitis and myositis. Patients are further instructed in injury prevention and warned against loading in extremes of motion. Harder and more chewy foods are introduced into the diet, and the diet is monitored to ensure that it is appropriate and not being progressed too quickly. Postoperative rehabilitation is completed with an individualized exercise or injury prevention program.

PHYSICAL THERAPIST INTERVENTION BY ETIOLOGY TYPE

Type 1: Myofacial Pain Dysfunction (MPD)

The type 1 etiology is frequent in occurrence. The physical therapist must clear the entire upper-quarter system, both pre- and postoperatively, followed by Stage I-IV protocols Goals consist of regaining full pain-free range of motion and diminishing trigger points. Patients receive instruction in injury prevention, neuromuscular relaxation, body mechanics, and stress management to reduce the abnormal mechanical forces to the myofacial system. The physical therapist works closely with the entire team to ensure that proper functioning of the masticatory muscular system is restored.

Type 2: Jaw Deformity

Type 2 patients are progressed through all four stages of physical therapy. Intervention is kept very simple and involves treating any existing myositis and joint dysfunction. Again, the focus remains on restoring normal jaw function as rapidly as possible.

Type 3: Direct Macrotrauma

Type 3 etiology involves direct trauma to the jaw with or without fracture. Patients are progressed through all four stages to restore full range of motion, to decrease pain, and to limit scarring and fibrotic changes.

Type 4: Indirect Macrotrauma

Indirect macrotrauma results when the force from an impact to another area of the body is translated to the joint. Physical therapy includes Stage I-IV protocols with the same goals as described for the type 1 (MPD) patient.

 Type 5: Systemic Disease

In patients with systemic disease, physical therapy progresses through the four stages, working with the upper­ quarter system as indicated. Arthroscopic procedures are more beneficial when accompanied by Stage I-IV protocols.

PHYSICAL THERAPIST INTERVENTION BY SURGICAL DIAGNOSIS

Hypomobility and Fibrosis

Patients are mechanically stretched under anesthesia, and adhesions are surgically released. In Stage I, CPM is started immediately. CPM is not for stretching, but a device that works to maintain range of motion and mobility. Stage II requires aggressive management. Using hands-on intervention and exercises, patients are stretched vigorously, but not to the point of causing severe pain. In Stage ill, muscle reeducation exercises are performed in the office and by the patient at home. During Stage IV, patients progress to normal function by performing strengthening exercises.

Hypermobility
Arthroscopic intervention consists of tightening the posterior ligaments. Patients begin with Stage I therapy and remain in this stage for 2 to 3 weeks. Patients are warned to avoid overstretching the surgically repaired structures. Gradually, patients progress to Stage II, performing stretching, while avoiding overstretching. In Stage III, patients are _ taught how to move within, but not beyond, their functional range of motion. In Stage IV, muscles are strengthened and the joint is progressively loaded, thus enabling patients to return to their premorbid diet.

Myositis
Physical therapists have treated muscle dysfunction in every part of the body. The jaw is no different. Myositis is treated using soft-tissue manipulation and antiinflammatory modalities. Cryotherapy is also used to reduce inflammation and to relieve discomfort.

Synovitis
Synovitis has also been treated by physical therapists for years. Postoperative management consists of Stage I-IV protocols with incorporation of antiinflammatory modalities.

Chondromalacia and Osteoarthritis
After arthroscopic intervention to minimize further fibrillar degeneration and to provide a smoother articulating surface, Stage I-IV protocols are strictly followed. In addition, CPM is used extensively to promote articular healing and regeneration.

Anterior Disk Displacement
Arthroscopic intervention for anterior disk displacement includes lysis and lavage or disk repositioning. In the case of lysis and lavage, patients require a short Stage I protocol. When disk repositioning is involved, patients remain in Stage I for approximately 2 weeks to allow healing of the surgically-repaired tissues. Then Stage II-IV protocols are followed.

CASE STUDIES

Three case studies typical of patients seen by the TMJ team have been selected for discussion.

Case no. 1

The first case is a 45-year-old female with a 2 Ih-year history of bilateral joint dysfunction. The patient had undergone open surgery with implants, and then the implants were subsequently removed. When seen by the TMJ team, the patient presented with progressive loss in oral range of motion, diminishing function, and severe pain. The patient was having difficulty inserting a spoon into her mouth to eat.

Previous postoperative physical therapy involved very aggressive in-office stretching, which was intolerable to the patient, and passive modalities (i.e., heating packs, ultra­ sound, electrical stimulation). The patient felt that physical therapy was useless, and she was unable to demonstrate any take-home exercises.

The patient underwent an arthroscopic procedure with lysis and lavage for fibrosis and manipulation under anesthesia.
Physical therapy was initiated with immediate CPM to ensure the maintenance of the joint mobility that was gained in the operating room. The first postoperative day, the patient was in the physical therapy office, and aggressive Stage II hands-on stretching exercises were initiated along with a take-home exercise program to maintain her new range of motion.

Stage II and III protocols were completed very quickly; the patient was motivated to learn how to perform these exercises. The Stage IV protocol was aggressively performed, while maintaining the gains achieved in Stage II. The patient continued stretching exercises while being monitored for development of synovitis and myositis as return to a normal diet was achieved.

At 2-year follow-up, the patient was maintaining range of motion. She was using over-the-counter medication only sporadically and was on a fairly normal diet.

Case no. 2

The second case is a 25-year-old male who was involved in a bar fight that resulted in direct macrotrauma to the jaw. The patient complained of worsening facial pain and dysfunction with limited range of motion.
The arthroscopic procedure consisted of lysis and lavage for synovitis.

Stage I postoperative physical therapy lasted for 1 week.
Stretching did not begin immediately, because the patient exhibited more inflammation rather than restrictions. Stage II progressed very quickly, and the patient regained full range of motion after two sessions of in-office stretching and home exercises. In Stage III, the patient was taught how to move his jaw correctly and how to perform the take-home exercises. In Stage IV, the joint was progressively loaded and a full range strengthening process was instituted. This patient completed physical therapy in six visits.
At 4-year follow-up, the patient presented with no further problems; he was completely functional and was not experiencing pain.

Case no. 3

The last case is a 35-year-old female who was involved in a motor vehicle accident 2 years previously. The patient complained of neck pain and progressive jaw and head pain. This patient had undergone passive physical therapy for 1 year. At the time of our initial evaluation, the patient could not demonstrate a home-exercise program. The patient's neck, shoulders, and back were stiff, with trigger points throughout her upper quarters, muscular dysfunction, myositis and synovitis, and joint dysfunction with a unilateral opening deviation.

Preoperative physical therapy consisted of IIf2 months of aggressive rehabilitation to the upper-quarter system. Hands­ on stretching exercises for the bilateral upper quarters and the cervical spine were initiated, followed by take-home exercises. The patient was instructed in injury prevention, while progressively loading and strengthening her upper­ quarter musculature.
Arthroscopically, the patient was diagnosed as having an anterior disk displacement that did not reduce. The joint was surgically treated with an AP repair.

Stage I therapy lasted 2 weeks to allow the structures to heal and to maintain the goals already achieved in the upper­ quarter system. During this time, the patient was seen on a regular basis to ensure maintenance of preoperative gains. Stage II consisted of 3 weeks of hands-on stretching and take-home exercises until functional range of motion was regained. Stage III took several weeks and required significant instruction for the patient to be able to perform the protocol independently. She had been opening with a deviation for months, so she had to relearn how to move symmetrically. Stage IV was on-going and progressive. Overall, the patient and the physical therapist worked for several months to resolve many of her problems.
At 2-year follow-up, the patient was able to work, had improved function, and was eating a more normal diet.

SUMMARY

The physical therapist is an important member of the surgical team. A progressive rehabilitation program helps to ensure a good surgical result. The physical therapist helps to save the surgeon time and effort by helping with patient selection and progression. The patient is helped by close supervision and instructed in a self-management and prevention program.

REFERENCES

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