Manual Therapy 17 (2012) 483e486

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Manual Therapy
journal homepage: www.elsevier.com/math

Case report

Derangement of the temporomandibular joint; a case study using Mechanical Diagnosis and Therapy
C. Krog a, S. May b, *
a b

Faculty IMDT, Denmark Faculty of Health and Wellbeing, Shefeld Hallam University, Shefeld, UK

a r t i c l e i n f o
Article history: Received 15 September 2011 Received in revised form 30 November 2011 Accepted 1 December 2011 Keywords: Temporomandibular pain Classication Mechanical Diagnosis and Therapy Derangement

a b s t r a c t
Mechanical Diagnosis and Therapy (MDT) is widely used for spinal problems, and more recently the principles and mechanical syndromes have been applied to extremity musculoskeletal problems. One of the most common classications is derangement syndrome, which describes a presentation in which repeated movements causes a decrease in symptoms and a restoration of restricted range of movement. The case study describes the application of repeated movements to a patient with a 7-year history of non-specic temporomandibular pain and reduced function, who had had lots of previous failed treatment. Examination using repeated movements resulted in a classication of derangement, and the patient rapidly responded in 4 treatment sessions, with an abolition of pain and full restoration of function, and remained improved after many years. The case study demonstrates the application of Mechanical Diagnosis and Therapy principles to a patient with a temporomandibular problem. 2011 Elsevier Ltd. All rights reserved.

1. Introduction Mechanical Diagnosis and Therapy (MDT) (McKenzie and May 2000, 2003, 2006) is well known and commonly applied in the management of musculoskeletal disorders worldwide, especially patients with spinal problems (Gracey et al., 2002; Hamm et al., 2003; Poitras et al., 2005; Byrne et al., 2006; Spoto and Collins, 2008). MDT uses a mechanical evaluation involving repeated movements performed to end range while symptoms and mechanical responses are monitored. The results of the repeated movements are then used to classify the patients into one of three mechanical syndromes: derangement, dysfunction or postural syndrome. Based on the classication, different exercises and postural concepts are employed to reduce derangement, remodel dysfunction, or correct adverse postural loads. The mechanical evaluation when used with spinal patients has demonstrated very good to excellent reliability between trained clinicians (Werneke et al., 1999; Razmjou et al., 2000; Fritz et al., 2000; Kilpikoski et al., 2002); and improved outcomes (Clare et al., 2004; Cook et al., 2005; Hettinga et al., 2007; Slade and Keating, 2007). Furthermore, centralisation, which is a core component of the approach, and describes the abolition of distal pain in response to

repeated movements, has demonstrated prognostic validity (Werneke and Hart, 2001; Aina et al., 2004; Chorti et al., 2009). When McKenzie (1981) described his original concept, he maintained that the method could be applied equally well to extremity problems, and an explicit description of how the MDT principles could be applied to extremity conditions was published more recently (McKenzie and May 2000). To date the relevant literature is mostly limited to case studies at the shoulder and thumb (Aina and May 2005; Littlewood and May 2007; Kaneko et al., 2009), but in addition there was a reliability study (May and Ross, 2009) that found good reliability, with kappa value of 0.83 amongst 97 therapists evaluating 25 case studies on McKenzie extremity assessment sheets. The purpose of this case report was to describe the assessment and management regime, using the principles of MDT, as applied to a patient with a non-specic temporomandibular joint (TMJ) problem. This patient was classied and treated as having a derangement according to MDT principles. The patient gave consent for the details of her case to be published in a medical journal anonymously. 2. Case report 2.1. Patient history

* Corresponding author. Tel.: 44 (0)114 225 2370. E-mail addresses: ck@mckenzie.dk (C. Krog), s.may@shu.ac.uk (S. May). 1356-689X/$ e see front matter 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2011.12.002

Symptoms had started during a tooth operation at the dentist in May 1997, during which her mouth was held wide open for about

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30 min by a dental wedge. During this time she felt a sharp pain in the left jaw. Symptoms continued for approximately 6 months. During this time she returned twice to the dentist who simply advised her to give it time. Subsequently the joint pain slowly abated but the jaw began to lock several times a day. If she opened her mouth she could not close it again, unless she helped with her hands. Chewing food, yawning and speaking loudly made the joint locking condition worse. In 1998, a second dentist began intra-oral splint therapy with a maxillary appliance for night-time wear. In 1999 she had 5 sessions of chiropractic for the jaw pain and then in 2000 she consulted another dentist. None of these interventions helped, but over time the stiffness and pain become worse and she felt at times her jaw coming out of place. She changed her eating habits, preferring foods that did not need to be chewed or cutting food into very small morsels. She also found that if she deviated the jaw to the left she could open the mouth wider, and that if the jaw locked she could unlock it by this same movement. For a number of years she just tried to live with the problem, but then it started to worsen, with pain radiating to her left ear, becoming constant again, and increasing in severity from 1/10 on a numeric pain rating scale to 8/10 at times. Because of the worsening situation in 2004 her general practitioner referred her to an oral and maxillofacial surgeon at the hospital. However, she was reluctant to contemplate further surgery, because of her previous experience, and instead elected to contact a physical therapy practice. 2.2. Physical examination The 30-year old female presented to the physiotherapy clinic with a complaint of left TMJ pain, which had been present for nearly 7 years. At times, pain radiated to the left ear. Currently, her functional ability was extremely limited and she was in constant pain. Her sleep was disturbed nightly because of joint pain. Additionally, she suffered from extreme morning stiffness in the jaw. A screening examination of the cervical spine, which consisted of single and repeated movements in sagittal and frontal planes, revealed no restrictions of movements and no symptomatic or mechanical responses. Involvement of the cervical spine was thought to be unlikely. An examination of single movements of the TMJ was conducted rst to gain a baseline understanding of her symptomatic and mechanical presentations. She reported an ache at the left TMJ at rest of 2/10 on a numeric pain rating scale. Opening the mouth demonstrated a moderate loss of movement that was very painful at end range. MDT uses non-specic measures for loss of movement: minor, moderate, and major, which though imprecise are meaningful to MDT clinicians and relevant in the case of individual patients. Both closing her mouth and clenching her teeth increased local left TMJ pain. Retraction of the jaw and return had no effect. Left lateral deviation was moderately limited and painful throughout the range. Right lateral deviation was unrestricted but painful during the entire motion and she had the feeling that the jaw would come out of place. Both deviations were painful, but as the right also caused the feeling of subluxation it was decided to explore this movement further with repeated movements. Clinical practice has demonstrated that the provocative movement can often be the most informative. One set of 10e15 repetitions increased her symptoms, made both the lateral movements more restricted, and made the feeling of subluxation worse, until she could barely repeat the movements. Given this negative response left lateral deviation was the next movement to be explored. Her baseline symptoms were recorded, with the numeric pain rating scale now at 6/10, and then she was asked to perform 10e15 repetitions. During the repetition

of left lateral deviation, she reported that the movement felt increasingly easier to do and less painful. After completion of two sets of repetitions, only end range pain remained, and she had no pain at rest. On re-checking her baseline mechanical response of mouth opening the range had increased to full range and was much less painful. On right lateral deviation, the feeling of subluxation was gone but pain was still present. When she repeated end range movements to the right, the feeling of subluxation returned and she developed an obstruction again in left lateral deviation. Thus through opposite lateral deviation movements, she was able to both improve and worsen her symptoms and mechanical presentation. 2.3. Initial clinical impression Provisional diagnosis from the assessment was derangement of the left TMJ, based on the rapid changes to symptoms and mechanical presentation. The self-treatment strategies for the next 24 h were 10e15 repetitions of left lateral deviation every 2 h and to try to avoid aggravating factors, such as chewing, speaking loudly or yawning. She was instructed to perform the movement as far to the end of range as possible on every repetition. 2.4. Visit 2 The patient was seen again the following day to conrm the diagnosis and the application of mechanical therapy. She reported she had performed her exercises regularly every 2 h while awake and demonstrated accurate performance of the exercises. Waking pain, pain on eating and joint stiffness was still present in the left TMJ, but about a quarter of what they had been. She now demonstrated minimal movement loss in all directions with end range pain only except right lateral deviation where the feeling of subluxation was still present. There was no pain at rest. The classication of derangement was conrmed. She was now shown to progress the force by applying overpressure to the movement by using her hands to support the upper left jaw and pushing with her right hand on the lower right jaw (see Fig. 1). As a result, end range pain increased in the left jaw but did not worsen as a result of repeated movements. She was instructed to perform this exercise 10e15 times every 2 h and limit chewing food. 2.5. Visit 3 The patient was seen again once more on the following day to ensure that overpressure was having the desired effect. She

Fig. 1. Model demonstrating left lateral deviation with overpressure to the TMJ, overpressure with right hand.

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reported she had performed the overpressure movement every 2 h, and demonstrated that she had been performing them correctly. In fact with each repetition she reported they had got easier and easier to do. She reported that she had slept through the night without waking due to the pain and had no pain on waking in the morning. Also, she had no pain when eating breakfast and lunch and no feeling of movement loss or stiffness as a result of eating. On re-assessment, the patient demonstrated full and pain-free movement in all directions except right lateral deviation where she felt a slight pain at end range but no feeling of subluxation. Based on the re-assessment, she was instructed to continue left lateral deviation with overpressure every 2 h for another 24 h. 2.6. Visit 4 A week later the patient returned with no complaints of pain. On examination, active ranges of all movements were full and painfree in all directions. It was no longer possible to reproduce the feeling of subluxation with right lateral deviation by repeating sidegliding to the right or by chewing or repeating mouth opening. She was discharged with instructions to return if there was any reappearance of symptoms or problems. 2.7. Long-term follow-up At follow-up by telephone one year later, the patient reported that her condition had remained pain-free. She reported no functional limitations and being able to freely chew food, sing, chew gum, and sleep through the night. By chance the patient was encountered on the street many years later. She reported no return of TMJ problems or symptoms and full return of function, with ability to eat anything she wanted, she could yawn fully, clench her teeth, and sing loudly without fear of further problems. 3. Discussion This case study describes the successful management through the use of MDT principles of a patient with TMJ problems who had failed numerous previous management strategies. MDT does not seek to make specic patho-anatomical diagnoses, but rather is based on the symptomatic and mechanical responses to repeated movements. According to these responses this patient was classied with derangement syndrome and then demonstrated rapid improvements in pain and function following regular application of active repeated movements and active movements with overpressure. It could be surmised that the source of the problem was related to the articular disc in the TMJ, and in deed internal derangement of the disc is a commonly used classication for TMJ problems (Cook, 2007). However according to Jones & Rivett (2004, pp 16e17) It is not satisfactory simply to identify structures involved, as this alone does not provide sufcient information to understand the problem and its effect on the patient, nor is it sufcient to justify the course of management chosen.... of more concern is that solely tissue-based reasoning tends to promote inexibility of management strategies. When the repeated movement abolished her symptoms and increased the range of motion, further examination was unnecessary as a treatment strategy had been concluded. The MDT clinical reasoning process rstly considers the presence of one of the mechanical syndromes, namely derangement, dysfunction, or postural syndrome. Because of the nature of the patients presentation and response to repeated movements derangement was the only mechanical syndrome that was possible. Full operational denitions are available for all the mechanical syndromes, so it is not the point of this case study to describe them (McKenzie and May 2003). Although only considering 3 options could be said to promote inexibility of management

strategies, if a patient does not t the operational denitions of one of the mechanical syndromes a number of other options are considered (McKenzie and May 2003). There are now several reports of the use of MDT principles being applied to extremity problems (Aina and May 2005; Littlewood and May 2007; Kaneko et al., 2009). A survey of 242 patients with a range of extremity problems demonstrated that mechanical syndrome classications can be commonly applied to many extremity problems (May 2006). Identication of the different mechanical syndromes through the use of case studies has also demonstrated very good levels of reliability amongst experienced MDT clinicians (May and Ross, 2009). Further research is necessary to demonstrate the effectiveness of MDT in extremity problems with more rigorous scientic methodology. 4. Conclusion This case report details the history and assessment of a woman who presented with typically chronic non-specic TMJ pain. During the physical examination the use of repeated movements, in line with MDT treatment principles was able to reduce and later abolish her symptoms and restore a full range of pain-free movement. Movements in the opposite direction reproduced her symptoms and caused a painful restriction in her range. Such a symptom response is classied as derangement under MDT principles. This is the rst documented evidence of the application of these principles being used as the only modality to assess and treat a patient with a chronic TMJ problem. Acknowledgement Thanks to Dr Betty Sindelar for comments on the initial draft. References
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