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Empowering Patients to Resolve Head, Neck and TMJ Pain

This article was written by Jennifer Webster. It was originally published in MD News.

Active physical therapy and patient-learned manual therapies such as those practiced at Physicians’ Diagnostics & Rehabilitation (PDR) Clinics prove very effective for long-term pain management.

Family practice physicians, neurologists, orthopedists and otolaryngologists, among others, may hear patients complain of head or neck discomfort. Some patients may mention pain incidentally during normal checkups with primary care physicians or dentists, says William Ahlenius, MD, board-certified physical medicine and rehabilitation physician.

“Patients may complain of jaw pain or report headaches for days after a dental procedure,” Dr. Ahlenius says. “They may believe they are having a toothache but show no signs of dental problems.”

Whatever route patients travel, when they arrive at PDR, they learn an approach to pain treatment that yields proven results.

“Patients have typically been through three different programs for their pain before coming to us,” says Christy Dauner, OT, registered occupational therapist with PDR. “They may have tried injections, massage or chiropractic care – all primarily passive techniques. At PDR we take an active approach and teach them how to break out of the pain cycle and address pain when it returns.”

Adds Dr. Ahlenius, “We focus on nonsurgical treatment of head, neck and back pain. As a rehabilitative medicine physician, my training and philosophy are based on improving function by using physical, occupational and other forms of therapies to help patients participate in their daily activities.”

Cervicogenic headaches

PDR assists patients with many kinds of pain management and physical therapy needs, from pregnancy backache to whiplash injuries to TMJ dysfunction. However, people who have head and neck pain have often had particularly frustrating questions for a cure. In some cases this is because the diagnoses are relatively new, as with cervicogenic headaches. This term was coined in 1983 and formalized in the International Classification of Headache Disorders, 2nd Edition in 2004.

Caused by stress in the neck and spine, cervicogenic headaches result in steady pain at the skull base, neck or back. They may also involve pain in the forehead. The neck may become stiff, so that the person has difficulty moving it and quick, involuntary movement such as sneezing causes pain. The patient may experience dizziness, nausea and light sensitivity. Fatigue, tense muscles, poor posture, injuries and disc problems contribute to cervicogneic headaches.

While medical management – beginning with over-the-counter pain medications and including prescription opiates and injected nerve blocks – is the standard therapy for cervicogenic headaches, Dauner’s experience supports physical therapy as a resulting in superior outcomes. The International Journal of Sports and Physical Therapy suggests a multi modal approach, primarily based on analogy to research studies of other headache.

This is an image of a man with a weathered face standing on a beach.“The priamry goal of physical therapy is to reactivate the cervical extensors,” she says. “We also teach patients neuromuscular re-education techniques to essentially wake up their deep neck flexors, which often become inhibited. The resulting decrease in strain on the cervical spine leads to fewer headaches.”

If needed, therapists utilize MedX medical equipment to increase range of motion by breaking up myofascial adhesions, specifically adhesions around injured joints, and strengthen and stabilize the spine, Dauner says. Deep tissue massage to suboccipital muscles, cervical traction and kinesiotape may be helpful for some patients, too.

“I was part of a headache focus group two years ago that performed a literature review of cervicogenic headaches,” Dauner says. “We learned that the best evidence-based practice was deep flexor head nods. Now, we emphasize teaching that exercise early in the program.

Success rates with PDR’s program have been high, with 71 percent of patients citing a 50 to 100 percent reduction in headaches during 2013.

When chewing becomes a pain

The PDR team also sees many patients for temporomandibular disorders (TMD). Patients experience pain in the face, jaw and neck that interferes with daily activities such as chewing, talking or performing oral hygiene, Dr. Ahlenius says. Other symptoms include difficulty opening or closing the mouth, “locking” of the jaw in one position, and swelling.

“At Physicians’ Diagnostics & Rehabilitation, we try to see the potential every patient has for living a full life. Week by week, their faces become more open and expressive as patients grow more hopeful about the future. It’s great to see them learning to overcome their pain.” — William Ahlenius, MD, board-certified physical therapy medicine and rehabilitation physician.

A clicking jaw may indicate TMD treatment, Dauner says, but only when associated with pain. Since the condition may be experienced in the face and ear, rather than as jaw pain, patients may believe they have an ear infection. They may even experience stuffiness or congestion related to the condition.

Treatments for TMD are typically more passive than those for headaches, Dr. Ahlenius says. At PDR, it takes about seven visits to achieve resolution.

“The physician performs the initial physiatric evaluation, diagnosing and determining the cause of TMD, such as subluxation or myofascial pain,” hey says.

“Patients return for an hour twice weekly, often undergoing manual therapy to release the internal muscles of mastication. We teach them to perform these techniques at home so they can self-manage their pain if it recurs. We also educate them in posture and ergonomics and how they can modify activities such as sitting or eating to improve their condition.”

How PDR works

The PDR process begins with a medical evaluation performed by Dr. Ahlenius or one of four other medical providers on staff. Based on the examination, the provider creates a treatment plan that may include exercises, education, manual therapy and/ or other modalities.

PDR utilizes MedX cervical extension equipment to help isolate the cervical spine in ways hands-on therapies cannot. As patients increase strength and range of motion, they improve spinal function and blood flow. With the help of the appropriate equipment, therapists can help patients achieve extremely discrete movements and avoid compensation or substitutions from other muscles, Dr. Ahlenius says.

“We have a big toolbox of techniques at our disposal,” Dauner says. “If pain does not resolve in several weeks using one approach, we try another. We emphasize using active techniques to equip our patients with the tools they need for self pain management.”