Originally we planned to finish the discussion about TMJ dysfunction in the November-December issue of Journal of Massage Science. The article on a completely different topic was planned for the publication in the Medical Massage Section of this issue. However, after the publication of Part III of our article in the previous issue of JMS we received a letter from a reader from Australia and we think that his concerns must be addressed. Other readers may have the same issues, and we would like completely clarify the necessity of the approach to the treatment of TMJ dysfunction we have advocated. We also think this letter has a broader meaning for the practitioners who engaged in the clinical aspects of massage therapy. Here is the original letter from the our Australian reader:
“Your article on TMJ dysfunction and treatment was very disappointing. Not once in the article did you refer to the treatment needed on the body below the neck and head to create a stable foundation for the neck and jaw.
The scientific approach of treating the symptoms and local area only is way out of date. Dysfunction in the neck is first started in the pelvis and spine and any localized treatment will provide short term relief at best.”
The reader was absolutely right: the medical massage protocol discussed in Part III didn’t contain any references concerning addressing the imbalance of feet, pelvis, lower back or middle back. We did it on purpose for several reasons, and after careful analysis of this matter in the medical literature and many clinical cases in our clinic.
We are perfectly aware that from textbook to textbook or from seminar to seminar the practitioners are exposed to the concept of necessity to restore any imbalance on the lower parts of the body in order to eliminate TMJ dysfunction. To some degree it becomes a standard clinical approach in many chiropractic, physical therapy or massage therapy clinics. Some practitioners were taught to address postural imbalance first and later, when it was corrected, work on TMJ itself. Some were taught to work on postural imbalance and TMJ at the same time.
What concerned us about this approach is the time and number of sessions needed to normalize TMJ dysfunction. However, as the reader was correct, the stability of the obtained clinical results is an even more important factor. This is why we decided to examine the modern scientific literature and put the concept of postural abnormalities and their impact on the TMJ dysfunction to the test in our clinic.
Initially we didn’t intend to conduct any scientific study or publication. We did it simply out of professional curiosity and for the our patient’s benefits. However, the results of our own pilot study were so convincing that we are currently working on the design of a randomized double-blinded study. Thus, the protocol we shared with our readers was based on an analysis of the scientific literature and our results.
At the very beginning we asked two very simple questions:’ Where did the idea of postural imbalance as a initial trigger of TMJ dysfunction came from?’ and ‘How exactly are postural abnormalities linked to TMJ dysfunction?’
The answer to the first question we traced back to an original paper published by Travel and Rinzler in 1952. As we discussed in Part I, Dr. J. Travel was among the first scientists who firmly established the muscular origin of TMJ dysfunction and its clinical correlation with facial pain and headache. Indeed, in her publications including Trigger Points Manual Dr. Travel mentioned the necessity of addressing active trigger points in other parts of the body if they were associated with TMJ dysfunction. She mentioned this information in ‘Other Measures’ in her main publication Trigger Point Manual.
However, in her publications there is no mention that postural imbalance is the actual cause of the TMJ dysfunction, and it is obvious that she considered the postural changes as one of possible contributing factors. Travel’s publications were always very respected by anyone who was involved in somatic rehabilitation.
The idea of postural imbalance as an initial trigger in the development of TMJ dysfunction was originated in the chiropractic community in the 1970s and it made sense at that time. This is an approximate date we came up with after conversations with a number of chiropractors and dentists. The logical outcome was that restoring postural balance will eliminate TMJ abnormalities. As a result, countless chiropractic clinics started to offer patients the chance to get rid of TMJ problems through slow restoration of postural balance. We had many stories from our patients who went through 15 and even 30 sessions of such treatments without any major improvement in the clinical picture of TMJ dysfunction. From the chiropractic community this concept bridged to the massage community where it was already accepted as an established scientific fact. The massage educators immediately incorporated this idea into their various protocols and it became a widespread belief.
In fact, the massage practitioners had better luck with this concept (compared to the chiropractic therapy) because they spent more time on working on the TMJ itself. However, what continued to bother us was the commonly accepted view that without restoring postural balance, it is impossible to achieve stable clinical results. This is the exact view which our Australian reader mentioned in his letter.
In general we think that it is against the practitioners and patients interests to spend time on unnecessary treatments for the sake of established views. It is bad for the patient because he or she loses time, money and faith in somatic rehabilitation, and it is bad for the practitioner who joins the army of somatic therapists who require a multi-session treatment routine instead of relying on the quick and effective techniques and approaches. As a matter of fact, unsuccessfully treated clinical cases of TMJ dysfunction where patients went through many sessions of postural balance therapies by chiropractors and massage practitioners were the first driving force which convinced us to look on the already accepted concept with a fresh look.
Now we would like to address the second question: How exactly are postural abnormalities, especially in the lower parts of the body, linked with TMJ dysfunction? Yes, there is a number of scientific papers which convincingly showed that the patients with TMJ dysfunction exhibited various postural abnormalities (Santoro, et al. 1989; Zonnenberg et al. 1996. Fischer et al. 2009). The health news and media also helped in spreading this information among the general population.
However, if we will discharge the media articles as well as personal opinions of the various educators and rely strictly on an analysis of credible scientific publications we will find that even strongest proponents of the idea that postural abnormalcies are the cause of TMJ dysfunction carefully avoided any categorization.
For example, the authors of one of the widely cited study (Zonnenberg et al. 1996) on this subject tried to examined if the body posture could be an etiologic factor of abnormalities in temporomandibular joint. After examining data the authors concluded that:
“The results suggest a somatic basis for the observed postural imbalances in patients with temporomandibular disorders. These results, however, must be interpreted with reservation (bold by JMS)”.
If you read this passage carefully it is obvious that the authors don’t interpreted their findings as a blank pass to use study results as a clinical justification of the treatment of postural abnormalities as a cause of TMJ dysfunction. Unfortunately many authors and educators did exactly that.
However, so far we haven’t answered one reasonable question: How do we explain the presence of postural abnormalities in the patients with TMJ dysfunction? The answer to this hypothetical question consists of three parts.
1. Some patients are simply misdiagnosed.
The most common mistake which health practitioners do is to diagnose TMJ dysfunction on the ground that the patient has a combination of headache and clicking in the TMJ. If the Three Knuckle Test is negative and mouth opening is painless while clicking noise or sensation are there the patents headache is a result of other cause.
Let’s consider for a second that the practitioner treats this patient with medical massage protocol, which of course is not indicated in this case and of course, the patient doesn’t get the expected headache relief. The practitioner and the patient are desperate for the results and this is where the idea of postural imbalance looks as a possible solution. However the correction of the postural balance for this patient will simply delay the point when the patient stops to see the practitioner. Thus, this is the category of patients who don’t have TMJ dysfunction to start with. Please read Part II of the initial article in the September-October issue of Journal of Massage Science.
2. In the minority of patients the postural changes may directly contribute to TMJ dysfunction.
Usually these patients have significant deformities for some extended period of time. For example, the patient with scoliosis or leg shortening develops TMJ dysfunction later in life. However, those patients are supposed to have these abnormalities for a long period of time and these pathological conditions are not guarantee TMJ dysfucntion. We see many patients with scoliosis in our clinic but this group of patients has only slight prevalence of the TMJ dysfunction.
3. The majority of patients with TMJ dysfunction have postural changes developed as a consequence of chronic pain in the TMJ.
We would like the readers to fully understand the meaning of this sentence. It is not postural changes which are causing TMJ dysfunction (which many practitioners were forced to believe) and require immediate treatment, but it is completely the opposite way around.
If postural changes is a cause of TMJ dysfunction then this problem should be already solved by chiropractors and massage therapists. However, in real life the facial pain caused by TMJ tension remains as elusive as before. From this point of view there is something wrong with initial theory of postural changes as a cause of TMJ dysfunction.
There is a growing number of studies which have questioned established views and showed that a careful analysis of data didn’t find a statistically valuable proof that postural changes in the middle and lower segments of the body are a cause of TMJ dysfunction (Hagberg, 1991; Michelotti et al. 1999, Munhoz and Marques, 2009). As it was stated by Michelotti et al. (1999):
“…it’s not advisable to treat postural imbalance by means of occlusal (i.e., TMJ by JMS) treatment or vice versa.”
Let’s put everything into a logical perspective. The patient was correctly(!) diagnosed with TMJ dysfunction. In such case he or she suffers from chronic facial pain and headache (see Part II of our article in September-October issue of JMS). Any activation of pain analyzing system changes the body posture. This is a clinical fact. Observe the gait of patient with simple tooth ache and you will see how much his or her body posture changed. The longer time the patient suffers from pain of any origin more pronounced and more habitual the postural changes become.
These changes are not under the patient’s voluntary control, but they are rather the reflex reaction of the motor cortex to the chronic pain stimuli. This reflex reaction has only one goal: to adjust the entire body to diminish the constant flow of pain stimuli to the brain. Overall this is self-protective action of the brain to cut its overstimulation.
For this patient the key to restoring health is to eliminate the initial source of the pain stimuli (i.e. TMJ dysfunction) rather than address his or her pelvis tilt which is a consequence of the initial TMJ problem. By addressing TMJ itself the practitioner cuts the gas line which supplies the fire.
Let’s consider that this patient now tries to get help from the practitioner who believes that postural disbalance is the key to TMJ dysfunction. In such case ideas of pelvis realignment, shoe inserts, lower rib adjustments etc. become the prominent target of the therapy. At the beginning the patient will go with this treatment because he or she has already researched the Internet and has been prepared by the media and system of established believes. If the practitioner is experienced enough and works equally on the TMJ itself he or she will get positive clinical results with only one exception: longer treatment course and larger number of sessions. Very frequently the frustrated patients stop to see the practitioner and he or she is sure that the treatment has worked. We saw many cases like that.
The last issue is what to do with those postural changes which have formed in the patient’s body as a response to the TMJ dysfunction? First of all the practitioner must fix TMJ dysfunction and realign the affected joint. This isn’t even a matter for discussion. The practitioner must do whatever it takes to control pain-analyzing system. The medical massage protocol we discussed in the Part III of our article (see November-December issue of JMS) usually takes 4-5 sessions to relieve tension in TMJ. After the practitioner has succeeded and the TMJ function is properly restored give the patient a 2-3 week break and ask him or her to combine daily self-treatments (see Part III of November-December issue of JMS) with daily light repetitive exercises: for example low impact cardio on the elliptical type machines or water aerobics. This period will be enough to address the residual postural abnormalities. After 2-3 weeks re-evaluate the patient and if the additional treatment needed to address, the let’s say, pelvis imbalance inform the patient and give him or her this option.
A couple of final thoughts. There are many textbooks, DVDs, seminars which tell the practitioners to do this or to do that for TMJ dysfunction or any other somatic abnormalities. However, the majority of practitioners don’t realize that even the best recommendations or protocols (including our Video Library) are just frameworks for the clinical application. If the practitioner would like to be clinically effective in the majority cases he or she must see outside of these frameworks incorporating various clinical tools which fit the patients needs. This is why the practitioner should use educational materials wisely and not be afraid of challenging the system of established beliefs. It is especially accurate for massage therapy where there are no unified views on the treatment of various pathological conditions, and such an unscientific approach to medical aspects of massage therapy additionally confuses the practitioners in the field.
Fischer MJ, Riedlinger K, Gutenbrunner C, Bernateck M. Influence of the temporomandibular joint on range of motion of the hip joint in patients with complex regional pain syndrome. J Manipulative Physiol Ther., Jun; 32(5):364-71, 2009.
Hagberg C. General musculoskeletal complaints in a group of patients with craniomandibular disorders (CMD). A case control study. Swed Dent J., 15(4):179-85 1991.
Michelotti A, Manzo P, Farella M, Martina R. Occlusion and posture: is there evidence of correlation? Minerva Stomatol., Nov; 48(11):525-34 1999.
Munhoz WC, Marques AP. Body posture evaluations in subjects with internal temporomandibular joint derangement. Cranio, Oct; 27(4):231-42 2009.
Santoro F, Maiorana C, Geirola R. Neuromuscular relaxation and CCMDP. Rolfing and applied kinesiology. Dent Cadmos, Nov 15;57(17):76-80, 1989.
Travel, J., Rinzler, S.H. The myofascial genesis of Pain. Postgrad Med, 11:425-434, 1952.
Travel, J., Simmons D.G. Myofascial Pain and Dysfunction. The Trigger Point Manual. Williams&Wilkins, 1983.
Zonnenberg AJ, Van Maanen CJ, Oostendorp RA, Elvers JW. Body posture photographs as a diagnostic aid for musculoskeletal disorders related to temporomandibular disorders (TMD). Cranio, Jul;14(3):225-32 1996.
Category: Medical Massage