BRIGHAM BRIGHAMAND ANDWOMENS WOMENSHOSPITAL HOSPITAL

Department Department of of Rehabilitation Rehabilitation Services Services

Physical PhysicalTherapy Therapy

Standard of Care: Temporomandibular Joint Disorder Case Type / Diagnosis: ICD9 codes 784 9!" 78# $
Temporomandibular Joint Disorder The temporomandibular joint (TMJ) is the articulation between the jaw and head.1 It is the most active joint in the body, opening and closing up to ,!!! times per day to account "or a "ull day#s worth o" chewing, tal$ing, breathing, swallowing, yawning, and snoring. ,% The jaw, cervical spine, and alignment o" the teeth are integrally related. &ys"unction in one o" these regions may lead to a TMJ disorder, which is a term used to describe a variety o" clinical disorders resulting in jaw pain or dys"unction. TMJ disorder is commonly viewed as a repetitive motion disorder o" the masticator structures.' (ain during "unction or at rest is usually the primary reason patients see$ treatment.' )eduction o" pain is the primary goal o" physical therapy "or patients with TMJ.' (atients also see$ physical therapy "or TMJ loc$ing, masticatory sti""ness, limited mandibular range o" motion, TMJ dislocation and une*plained change in mouth closing or opening. ' The etiology o" TMJ disorder is o"ten multi"actorial and may be due to stress, jaw malocclusion, habitual activities including bru*ism, postural dys"unction, in"lammatory conditions and trauma.+,, TMJ disorders are more commonly seen in "emales most speci"ically over the age o" ++.- .ome authors have suggested that there may be a connection between hormones and women and TMJ dys"unction. - It is suspected that +!/0-+/ o" the general population has e*perienced unilateral TMJ dys"unction on a minimum o" one occasion. It is also suspected that at least %%/ o" people have e*perienced a minimum o" one continuing persistent symptom. %natomy and biomec&anics of t&e T'J The TMJ is "ormed by the articulation o" the condyle o" the mandible with the articular eminence o" the temporal bone and an interposed articular dis$.1 It is a synovial joint with sur"aces that are covered by dense collagenous tissue that is considered to be "ibrocartilage.1 The mandible is the distal or moving segment o" the TMJ.1 The pro*imal or stable segment o" the TMJ is the temporal bone.1 The articular dis$ allows the sur"aces o" the TMJ to remain congruent throughout the motion available to the joint.1 The primary ligaments o" the TMJ are the temporomandibular ligament, stylomandibular ligament and the sphenomandicular ligament.1 The loose pac$ed position o" TMJ is with the mouth slightly open and the tongue resting on the hard palate. The close0pac$ed position is with the mouth closed with the teeth clenched.1 2ll motions o" the TMJ are limited by the temporomandibular ligaments in all directions, and the capsular pattern o" restriction is limitation o" mouth opening.3

Standard of Care: Temporomandibular Joint Disorder

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The joint articulation o" the TMJ consists o" two joint spaces divided by the dis$. The lower joint o" the TMJ is a hinge joint "ormed by the anterior sur"ace o" the condyle o" the mandible and the in"erior sur"ace o" the articular dis$. The upper joint o" the TMJ is a gliding joint "ormed by the articular eminence o" the temporal bone and the superior sur"ace o" the articular dis$. The dis$ provides three advantages to the TMJ: increased congruence o" the joint sur"aces, the shape o" the dis$ allows it to con"orm to the articular sur"aces, and sel" centers itsel" on the condyle.1 The motions available to the TMJ include mouth opening;mandibular depression, mouth elevation;mandibular elevation, jutting the chin "orward; mandibular protrusion, sliding the teeth bac$wards; mandibular retrusion and sliding the teeth to either side; lateral deviation o" the mandible.1 Mandibular elevation and depression occurs in two se<uential phases o" rotation and gliding. Mandibular protrusion and retrusion occurs when all points o" the mandible move "orward at the same amount. This motion is pure translation and occurs in the upper joint alone. &uring mandibular lateral deviation, one condyle spins around a vertical a*is while the other condyle translates "orward.1 The TMJ is one o" the most "re<uently used joints in the body. Most o" the TMJ motions are empty mouth movements, which occur with no resistance "rom "ood or contact between the upper and lower teeth. The associated musculature is designed to provide power and intricate control.1 'uscle &igastric Medial pterygoid >ateral pteryogid Temporalis Masseter %ction #" 8 (rimary muscle "or mandibular depression Mandibular elevation= 2ssists in protrusion Mandibular depression Mandibular elevation Mandibular protrusion

The TMJ and most o" the muscles o" mastication are innervated by the mandibular branch o" the trigeminal nerve, (cranial nerve ? @4A ?B). (ain may be re"erred to adjacent areas on the "ace in the distribution o" 4A ?.% The cervical spine and TMJ are connected via muscular attachments. Muscles that attach to the mandible also have attachments to the hyoid bone, cranium and clavicle. These muscles can act upon the mandible, atlanto0occipital joint or the cervical spine. (osition o" the head and nec$ can also a""ect tension o" the muscles and there"ore a""ect the position or "unction o" the mandible. It is important to remember to e*amine the cervical spine in conjunction with the TMJ due to these muscular connections.1

Standard of Care: Temporomandibular Joint Disorder

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(at&ology 6asic pathologies o" the TMJ involve in"lammation and degeneration in arthritic disorders and structural aberrations in growth disorders. Cverall, the etiology o" the most common types o" TMJ disorders is comple* and still largely unresolved.1 This list below includes some o" the main agreed upon categories o" TMJ disorders1!: a) 2rthritic: 4haracteriDed mainly by pain. 2s the disease progresses symptoms can lead to internal derangement and "acial de"ormity.1! (ain"ul crepitus or grating sounds is common in patients with TMJ osteoarthritis.1 Treatment is aimed at controlling ris$ "actors and in"lammatory response.1! b) Erowth disorders: 4haracteriDed mainly by "acial de"ormity. Treatment is aimed at removing the tumor and correcting the de"ormity 1! c) Aon0arthritic disorders: 4haracteriDed mainly by mechanical derangement, which can include lu*ation and acute (traumatic) disc dislocation.1! Myo"ascial pain and dys"unction are present due to a primary muscle disorder resulting "rom oral "unction habits. .ome o" the habits can be related to headache, chronic bac$ pain, irritable bowel syndrome, stress, an*iety and depression.1 Internal derangement re"ers to a problem with the articular disc with an abnormal position leading to mechanics inter"erence and restriction o" mandibular activity. 1 2 patient who presents with internal joint derangement will have continuous pain that will be e*acerbated by jaw movement. 4lic$ing and loc$ing will result in restricted mandibular opening or deviation o" mandibular movements during opening and closing.1 Treatment is aimed at reducing the mechanical obstruction.1! In !1! authors .tedenga et al developed a categoriDation "or TMJ disorder that "ocuses on intra0articular positional changes o" the disc (internal derangement). The authors noted that these internal derangements can e*plain most o" the mechanical mani"estations occurring in the joint.1! This newer classi"ication system seems to "urther describe the Fnon arthritic disordersG listed in the list noted above. a) &isc derangements, which e*plains clic$ing sounds and movement restriction because o" the obstruction o" condylar movement by the disc 1! b) .ublu*ation and lu*ation o" the disc0condyle comple*, which represents TMJ hypermobility disorders1! c) 2dherence, adhesion, and an$ylosis o" joint sur"aces, which results in TMJ hypomobility1!

Indications for Treatment:

1. . %. '. +. (ain 4lic$ing, crepitus or popping &ecreased )CM in mouth opening >oc$ing o" the jaw with mouth opening &i""iculty with "unctional activities o" the TMJ: chewing, tal$ing, yawning

Standard of Care: Temporomandibular Joint Disorder

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Contraindications / (recautions for Treatment:

(ost0operative patients may have surgeon speci"ic precautions regarding physical therapy progression. 4ontact the surgeon, as appropriate, to clari"y case0speci"ic precautions.

)*aluation:
'edical +istory: )eview computeriDed longitudinal medical record (>M)), review o" systems and inta$e health screening tool. +istory of (resent Illness: Aote course o" symptoms and presence o" trauma (M?2, assault), previous surgery (dental implants, C)IH), and;or repetitive trauma (see habitual activities below). .igns and symptoms o" TMJ dys"unction are o"ten unilateral but can be bilateral. 4lic$ing may or may not be present at the time o" the evaluation. Aote any history o" clic$ing and loc$ing. Aote current or past use o" mouth orthotics or splints, the results and the reason the patient stopped using the appliance, i" applicable. 2lso in<uire about nocturnal symptoms and daytime symptoms.' 2 patient may wa$e up with TMJ pain which lasts "or only minutes to hours, which suggest the nocturnal "actors are the primary contributors to the symptoms. Cther patients awa$e symptom "ree and the TMJ symptoms develop later in the day, suggesting that daytime "actors are the primary contributors.' .ome patients may have pain during the night and daytime, so both o" these symptoms producers need to be considered. ' Typically patient may have more pain in the morning and sore teeth due to clenching. There is o"ten a history o" stress and di""iculty in sleeping.1 Social +istory: Aote daily habitual activities such as smo$ing, bru*ism (clenching), chewing gum, snoring, leaning on chin, biting nails, lip biting, clenching teeth, etc. can all contribute to the presenting symptoms. 4onsider wor$, household responsibilities, hobbies and;or recreational activities that may involve repetitive stress and sustained postures, e.g. computer wor$. Imotional stress can trigger nervous habits or poor postural responses, which can lead to TMJ symptoms.% 'edications: Aote relevant medications including A.2I&., muscle rela*ants, and other analgesics. .ome patients may be ta$ing 2mitriptyline, Aortriptyline, or &iaDepam be"ore bedtime to reduce IME activity at the TMJ.' Diagnostic Imaging: (lain "ilm radiography is the gold standard to evaluate the TMJ. 2;( and lateral views are used to assess the normal shape and contours o" the condyles+, the position o" the condylar heads in open and closed mouth positions and to measure the amount o" movement available.+ (eriapical images can e*clude problems with the teeth., Magnetic resonance imaging (M)I) can be used to assess the dis$ position and shape and

Standard of Care: Temporomandibular Joint Disorder

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is used primarily when a nonreducing dis$ is suspected clinically. .ince dis$ displacement is common in assymptomatic subjects, M)I evidence o" dis$ displacement is not considered signi"icant unless )CM is restricted or a nonreducing dis$ is suspected clinically., 4omputed tomography (4T) and arthroscopy have been advocated but ordering these tests should be at the discretion o" the specialist oral and ma*illo"acial surgeons.1 ),amination
This section is intended to capture the most commonly used assessment tools "or this case type;diagnosis. It is not intended to be either inclusive or e*clusive o" assessment tools.

-bser*ation: Cpening and closing o" mouth: Inspect that the teeth normally close symmetrically and that the jaw is normally centered. 2lignment o" teeth: Ta$e note o" a cross bite, under or over bite. Identi"y any missing teeth.1 .ymmetry o" "acial structures (eyes, nose, mouth): Aote o" any "acial de"ormity which can range "rom very subtle to severe and readily visible de"ormation.1! I*amine both so"t tissue and bony contours between le"t and right halves.1- (ay special attention to muscular paralysis, such as ptosis o" the eyelid or drooping o" the mouth, which may be associated with 6ells (alsy. 12lso determine whether the upper and lower lip "renulums are properly aligned.1 (osture: Aote the presence o" "orward head posture, rounded shoulders and scapular protraction.11 2lso be aware o" scoliosis or cervical torticollis, which a""ect the length tension relationships o" the muscles attaching to both sides o" the mandible causing an uneven pull to one side.11 6reathing pattern: 2ssess i" diaphragmatic breathing occurs or i" there is an accessory pattern to breathing. Tongue: I*amine "or presence o" bite mar$s, scalloping (tongue resting between teeth) resulting "rom tongue not properly resting on the hard palate or "rom tongue being e*cessively wide. 2 dry or white appearance o" the tongue is an abnormality and may indicate bacterial in"ections, dys"unction o" salivary glands or adverse reaction to medications.1(ain: The main complaint may include oro"acial pain, joint noises, restricted mouth opening or a combination o" these.1 It is help"ul to evaluate pain in terms o" onset, nature, intensity, site, duration and aggravating and relieving "actors. 2lso consider how the pain relates to "eatures such as joint noise and restricted mandibular movement.1 &etermine which movements cause pain, including opening or closing o" mouth, eating, yawning, biting, chewing, swallowing, spea$ing, or shouting. The patient may also present with headaches and cervical pain. (ain may also be present in the distribution o" one o" the three branches o" the trigeminal nerve (4A ?).11 (ain is generally located with the masseter muscle, preauricular area, and anterior temporalis muscle regions. The pain is usually an

Standard of Care: Temporomandibular Joint Disorder

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ache, pressure, or a dull pain which may include a bac$ground burning sensation. There may also be episodes o" sharp pain and throbbing pain. This pain can be intensi"ied by stress, clenching and eating. (ain may be relieved by rela*ing, applying heat to the pain"ul area or ta$ing over the counter analgesics.' TMJ disorders are distinguished "rom other possible diseases by the location o" pain. TMJ pain is speci"ically centered in and around the preauricular region and may be accompanied by clic$ing or grating sounds with mandibular "unction and restricted mouth opening.1 Cer*ical spine and upper .uadrant screen: 2ssess cervical and shoulder 2;()CM, muscle length including deep cervical "le*ors, myotomes, dermatomes and re"le*es. (alpation: TMJ: (alpate the TMJ bilaterally while the patient opens and closes the mouth several times.11 2ssess "or joint integrity and structural deviations. The mandibular condyles on both sides should move smoothly and e<ually.11 I" the e*aminer "eels one side rotate be"ore the other or shi"t laterally while the mandible is moving, this may indicate TMJ dys"unction.11 Muscles o" mastication: (alpate and compare bilaterally, assess "or pain and;or muscle spasm o .ome o" the muscle to be palpated can include: lateral pterygoid (intraorally), insertion o" temporalis (intraorally), medial pterygoid (e*ternally), masseter (e*ternally) 1 o It is recommended that the masseter, anterior temporalis and TMJs be palpated to ensure that it intensi"ies or reproduces the patient#s pain in order to determine the primary source o" pain.' These areas can be palpated by having the patient clench the jaw and palpating the muscle over its origin and muscle belly.112reas o" tenderness, trigger points and patterns o" pain re"errals should be noted.1 Joint sounds and their location during opening, closing and lateral e*cursion may be palpated or detected with a stethoscope placed over the preauricular area.1 /-': 2)CM: )ange o" motion can be measured "rom top tooth edge to bottom tooth edge mar$ing on a tongue depressor and measuring the distance in millimeters.11 Cpening and closing o" mouth Aormal opening J %+0+! mm% Hunctional opening J +0%+ mm or at least two $nuc$les between teeth% (rotrusion o" mandible Aormal J + mm% >ateral deviation o" mandible Aormal J 101! mm%

Standard of Care: Temporomandibular Joint Disorder

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Aote asymmetrical movements, snapping, clic$ing, popping or jumps. Mechanical derangements account "or the common clinical signs o" clic$ing and loc$ing.1! )ecord deviations: lateral movements with return to midline )ecord de"lections: lateral movements without return to midline ()CM: 2pply overpressure at the end range o" 2)CM to assess end "eel

Strengt&: &eep cervical "le*ors and scapular stabiliDers should be assessed. )e"er to a manual muscle testing (MMT) te*t such as &aniels and 7orthingham#s Muscle Testing ! or Kendell and Kendell 1 "or complete description o" MMT techni<ues. )esisted opening, closing, lateral deviations and protrusion o" the jaw should also be tested. Lpon testing, the patient should have the mouth open one to two centimeters and therapist should place a stabiliDing hand on the "orehead.11 2 gradual onset o" "orce should be used so that the patient can resist the motion appropriately. 11 (ain and;or wea$ness with the resisted testing are positive "indings.11 Sensation: 2ssess upper <uadrant dermatomes, 41, 4 , 4%, cutaneous nerve supply o" the "ace, scalp and nec$, cranial nerves ? M NII.% Joint sounds: 4repitation: 2 sound that is continuous over a long period o" time o" jaw movement, li$e grating or grinding. 4lic$ing: 2 distinct, very brie" sound with a clear beginning and end. Joint mobility: 4audal traction, ventral glide (protrusion), medial;lateral glide. )e"er to joint mobiliDation te*ts "or appropriate techni<ues, e.g. Idmond3, Maitland1% Dynamic loading7: >oad contralateral TMJ 0 bite on cotton roll. 4ompression o" bilateral TMJ M Erasp the mandible bilaterally and tip the mandible down and bac$ to compress the joints. &istraction o" bilateral TMJ M Erasp the mandible bilaterally, distract both joints at the same time. 2 positive "inding to dynamic loading is pain. 0unctional %cti*ities: 2ssess chewing, swallowing, coughing, and tal$ing. Iither have patient demonstrate tas$ or as$ "or patient#s subjective report. Include changes the patient has made to their own diet to accommodate "or their pain and dys"unction.

Standard of Care: Temporomandibular Joint Disorder

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Differential Diagnosis: 2ppro*imately -!/ o" patients presenting with TMJ disorders also have cervical spine impairments according to )ocobado.13 It is important to screen the cervical spine and upper <uadrant as part o" the TMJ evaluation. Aon0musculos$eletal disorders may also cause "acial and jaw pain including in"ection, dental problems including malocclusion, trigeminal neuralgia, parotid gland disorder, or other lesions o" the "ace, mouth or jaw. I" non0musculos$eletal origin o" pain is suspected, re"er to the primary care physician "or "urther wor$0up. (atients who present with TMJ pain may also have symptoms related to tooth pain. Tooth related pain includes: pain that occurs or intensi"ies upon drin$ing hot or cold beverages, throbbing pain that occurs spontaneously, throbbing pain that awa$ens the patient "rom sleep. I" these symptoms are present, a re"erral to a &entist would be appropriate.' (atients with TMJ disorder may also report a "eeling o" "ullness o" the ear, tinnitus and;or vague diDDiness. These symptoms are seen in appro*imately %%0'!/ o" patients with TMJ dys"unction and usually resolve a"ter treatment.11

%ssessment:
Istablish &iagnosis and Aeed "or .$illed .ervices C"ten patients with TMJ dys"unction present with pain, "orward head posture, protracted shoulders, mouth and accessory muscle breathing patterns, abnormal resting position o" the tongue and mandible, and abnormal swallowing mechanism. (atients with these clinical signs will bene"it "rom s$illed physical therapy intervention to correct these upper <uarter muscle imbalances and to restore the normal biomechanics and motor control o" the TMJ.13 (roblem 1ist: (otential Impairments: Increased pain >imited 2;()CM Impaired posture Impaired motor control;strength &ecreased $nowledge o" habit modi"ication, rela*ation techni<ues (otential Hunctional limitations: Inability to chew, cough, sneeDe, swallow or tal$ without pain

Standard of Care: Temporomandibular Joint Disorder

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(rognosis: Medlicott and 9arris published a systematic review in (hysical Therapy July !!,, analyDing %! research studies that tested the e""ectiveness o" various physical therapy interventions "or temporomandibular joint disorder.1' The authors conclusions and recommendations are as "ollows: 1. 2ctive e*ercises and joint mobiliDations, either alone or in combination, may be help"ul "or mouth opening in patients with acute dis$ displacement, acute arthritis, or acute or chronic myo"ascial pain.1' . (ostural training may be used as an adjunct to other treatment techni<ues as it#s e""ectiveness alone is not $nown.1' %. The inclusion o" rela*ation techni<ues, bio"eedbac$, IME training, proprioception education may be more e""ective than placebo or occlusal splints in decreasing pain and mouth opening in patients with acute or chronic myo"ascial pain.1' '. 2 combination o" active e*ercises, manual therapy, postural training, and rela*ation training may decrease pain and increase mouth opening in patients with acute dis$ displacement, acute arthritis, or acute myo"ascial pain. It is not $nown, however, i" combination therapy is more e""ective than providing a single treatment intervention.1' 2 study by Kurita et al e*plored the natural course o" symptoms "or patients with internal dis$ displacement without reduction over a .+ year period.1+ They "ound that appro*imately '!/ o" patients were asymptomatic at the end o" the study period, %%/ o" patients had a reduction in symptoms and +/ o" patients did not improve. These "igures, which show a wide range o" results, were similar to another study loo$ing at TMJ outcomes over a one0year time "rame and were not dependent on splinting treatment.1, .ome studies suggest that patients with TMJ with cervical or widespread pain will not obtain the same degree o" improvement as other patients with TMJ who do not have these pains. ' 2oals .hort term ( 0' w$s) and long term (,01 w$s) goals may include but are not limited to: 1. )educe or independently sel" manage pain symptoms or joint noises . Aormal )CM and se<uence o" jaw movements %. Ma*imiDe strength and normaliDe motor control o" muscles o" mastication, cervical spine and periscapular region '. Ma*imiDe "le*ibility in related muscles as indicated +. Ma*imiDe postural correction in sitting and;or standing ,. 4orrect ergonomic set0up o" wor$stations at home and;or at wor$ -. Independence with home e*ercise program 1. Independence with rela*ation techni<ues

Standard of Care: Temporomandibular Joint Disorder

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%ge Specific Considerations Oounger women !0'! years o" age are most li$ely to report TMJ disorder symptoms. 2dolescents and elderly men are least li$ely to report TMJ dys"unction. -

Treatment (lanning / Inter*entions

Istablished (athway Istablished (rotocol PPP Oes, see attached. PPP Oes, see attached. PNP Ao PNP Ao

Inter*entions most commonly used for t&is case type/diagnosis

This section is intended to capture the most commonly used interventions "or this case type;diagnosis. It is not intended to be either inclusive or e*clusive o" appropriate interventions.

Aon0surgical treatments such as counseling, pharmacotherapy and occlusal splint therapy continue to be the most e""ective way o" managing over 1!/ o" patients. 1 Treatment strategies may include but are not limited to:

Modalities "or pain control: 9eat, ice, electrical stimulation, TIA., ultrasound, phonophoresis 2;22;()CM .tretching: active, assisted and passive stretching, can use tongue depressors or cor$ as needed. )e"er to physical therapy te*ts "or speci"ic techni<ues. Joint mobiliDation or manipulation: )estore normal joint mechanics o" the TMJ, cervical and;or thoracic spine as appropriate. )e"er to appropriate te*ts "or treatment techni<ues.3,13, 1 .o"t tissue mobiliDation, myo"ascial release and deep "riction massage Muscle energy techni<ues Aeuromuscular "acilitation: hold0rela*, contract0rela*, alternating isometrics. Hor speci"ic e*ercises re"er to physical therapy re"erences e.g. 9ertling and Kessler#s Management o" 4ommon Musculos$eletal &isorders.13 )ela*ation techni<ues: learning to rela* masticatory muscles and maintain this rela*ed state during the day= learning stress management and coping s$ills' 6io"eedbac$ and IME training to promote muscle control and rela*ation ' Therapeutic e*ercises: Including )ocobado , * , isometrics program. 4ervical stability e*ercises.

0re.uency 3 Duration: The "re<uency and duration o" "ollow up treatment sessions will be individualiDed based on the speci"ic impairments and "unctional limitations with which the patient presents during the initial evaluation. Cn average, the "re<uency may range "rom 10 times per wee$ "or '0, wee$s.

Standard of Care: Temporomandibular Joint Disorder

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(atient / family education: To stop or change poor habits including grinding or clenching teeth. 2n over0the0 counter mouthguard or an occlusal orthotic "rom the &entist may be help"ul "or nighttime use.' The occlusal orthotic can be help"ul "or masticatory muscle pain, TMJ pain, TMJ noises, restricted jaw mobility, and TMJ dislocation.' (ostural re0education and maintenance correct resting position o" the tongue and mandible &iaphragmatic breathing 6ody mechanics training 9ome e*ercise program instruction

/ecommendations and referrals to ot&er pro*iders .peech and >anguage (athologist "or assessment and treatment o" speech or swallowing dys"unction associated with the TMJ dys"unction )heumatologist (sychologist;(sychiatrist I" conservative measures do not alleviate the patient#s symptoms, surgical management may be considered. .urgical interventions may include dental implants, condylectomy, condylotomy, C)IH or surgical manipulation. It is beyond the scope o" this standard to discuss the speci"ics o" the above listed procedures. (otential surgical re"errals could include: 1. Ctolaryngologist (IAT) . &entist or oral surgeon %. Crthopedic surgeon

/e4e*aluation / assessment
)eassessment should be completed every thirty days in the outpatient setting unless warranted sooner. (ossible triggers "or an earlier reassessment include a signi"icant change in status or symptoms, new trauma, plateau in progress and;or "ailure to respond to therapy.

Disc&arge (lanning
Commonly e,pected outcomes at disc&arge: )esolution or independent management o" pain symptoms Hunctional, active motion o" mandible )esume normal "unctional activities with jaw, including chewing and tal$ing Modi"ications o" para"unctional or habitual activities that are associated with the cause o" the patient#s TMJ dys"unction 2bility to sel"0correct and maintain normal postural alignment o" the head, nec$ and trun$ 4orrect ergonomic set up o" wor$space Independent home e*ercise program and sel" progression o" program

Standard of Care: Temporomandibular Joint Disorder

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(atient5s disc&arge instructions 9ome e*ercise program )ela*ation techni<ues 9abit modi"ication %ut&ors: Karen 7eber, (T June, !!7pdated: 2lyssa 7eber, (T Aovember, !11 /e*ie6ed by: Joel Hallano, (T 2my 6utler, (T Janice McInnes, (T /e*ie6ed by: Ken .hannon, (T >ina (eni$as >amb, (T

Standard of Care: Temporomandibular Joint Disorder

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/)0)/)8C)S
1. 9elland, M. 2natomy and Hunction o" the Temporomandibular Joint. JC.(T: 131!. . 9oppen"eld .. (hysical I*amination o" the 4ervical .pine and Temporomandibular Joint. In: (hysical I*amination o" the .pine and I*tremities. Aorwal$, 4T: 2ppleton and >ange.13-,. 1!+01% . %. Magee &J. Temporomandibular Joint. In: Crthopedic (hysical 2ssessment, Magee ed. (hiladelphia: 76 .aunders 4o, 1333, 1+ 01-'. '. 7right, I and Aorth, .. Management and Treatment o" Temporomandibular &isorders: 2 4linical (erspective. J Man Manip Ther. !!3=1-('): '-0 +'. +. .ommer CJ et al. 4ross0sectional and "unctional imaging o" the temporomandibular joint: )adiology, pathology, and basic biomechanics o" the jaw. )adiographics online. !!%= %: e1'. ,. .heon1 )(. Temporomandibular joint dys"unction syndrome. LpTo&ate. !!,. -. )ene$er, J et. al. &iagnostic 2ccuracy o" clinical Tests and .igns o" Temporomandibular Joint &isorders: 2 .ystematic )eview o" the >iterature. JC.(T. !11= '1(,): '!10'1,. 1. >evangie, (. and Aor$in, 4. Joint .tructure and Hunction 2 4omprehansive 2naylsis, %rd edition. (hiladelphia: H2 &avis. !!1. 3. Idmond .>. Temporomandibular Joint. In: Manipulation and MobiliDation: I*tremity and .pinal Techni<ues. 133%: 6oston, Mosby. !%0 1!. 1!. .tegenga, 6. Aomenclature and classi"ication o" temporomandibular joint disorders. Journal o" Cral )ehabiliation. !1!= %-: -,!0-,+. 11. 9edge ?. 2 review o" the disorders o" the temperomandibular joint. JI(.: !!+= +( ): +,0 ,1. 1 . &imitroulis, E. Hortnightly review: Temporomandibular disorders: a clinical update. 6ritish Medical Journal. 1331= %1-(-1 +): 13!013'. 1%. Maitland. (eripheral MobiliDation and Manipulation 1'. Medlicott M., 9arris .) 2 systematic review o" the e""ectiveness o" e*ercise, manual therapy, electrotherapy, rela*ation training, and bio"eedbac$ in the management o" temporomandibular disorder. (hys Ther !!,: 1,(-): 3++03-% 1+. Kurita K et al. Aatural course o" untreated symptomatic temporomandibular joint disc displacement without reduction. J &ent )es 1331: --( ): %,10%,+. 1,. >undh 9 et al. Temporomandibular joint disc displacement without reduction. Treatment with "lat occlusal splint versus no treatment. Cral .urg Cral Med Cral (athol, 133 = -%: ,++0 ,+1. 1-. (almer, >. Hundamentals o" musculos$eletal assessment techni<ues. 1331. 11. .ailors, M. Ivaluation o" .ports0 )elated Temporomandibular &ys"unctions. Journal o" 2theltic Training. 133,:%1(')= %',0%+!. 13. 9ertling &. The Temporomandibular Joint. In: Management o" 4ommon Musculos$eletal &isorders: (hysical Therapy (rinciples and Methods, %rd edition. &arlene 9ertling and )andolph M Kessler, eds. Aew Oor$: >ippincott, 133,: '''0'11. !. &aniels and 7orthingham#s Muscle Testing: Techin<ues o" Manual I*amination, ,th Idition. 9elen J 9islop and Jac<ueline Montgomery eds. (hiladelphia: 76 .aunders 4o, 133+.

Standard of Care: Temporomandibular Joint Disorder

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1. Kendall H(, Mc4reary IK, (rovance (E. Hacial, Iye, and Aec$ Muscles= Muscles o" &eglutition= and )espiratory Muscles. In: Muscles Testing and Hunction. John ( 6ulter, editor. (hiladelphia: 7illiams and 7il$ins (133%), 330%%!. . Temporo0Mandibular Joint 4omple* I*ercise .uggestions. 2vailable at: http:;;itandb.com;pd";TMJI*ercises.pd". 2ccessed Cctober 1', !11.

Standard of Care: Temporomandibular Joint Disorder

4opyright 5 !11 The 6righam and 7omen8s 9ospital, Inc. &epartment o" )ehabilitation .ervices. 2ll rights reserved. 1'