Gentle Treatment for TMJ Dysfunction

Posted on: Sun, 09/15/2013 - 3:28pm By: Alice

When people say, “I have TMJ,” they usually mean that they have temporomandibular joint dysfunction, a condition that can cause jaw pain that can be difficult to treat. Chewing may be painful and it can lead to headaches and neck, shoulder, and upper back pain. They may experience popping, clicking, and shifting when they open and close their jaw and their mouth may even get stuck in an open position if they yawn or open their mouth too far.

Six months ago, a young woman who had been suffering with TMJ dysfunction for 12 years came to my office. She filled out the intake form and I asked about her history. One of the things that pain science research has reinforced is not just the importance of the treatment but also the quality of the therapeutic encounter. How the therapist interacts with the client may be just as important as the treatment itself. I think that this is one place where massage therapists have a lot to offer. Most massage therapists are caring people and truly want to help their clients. In addition, we often have the time to listen to clients in a way that other health care practitioners may not. One of the most frequent complaints of patients with chronic pain is that they do not feel listened to.

How we listen is important.

Successful therapy begins the moment we meet the client, when we welcome them into our office and give them a safe environment in which to tell their story. When I listen to a client tell their history, I am paying attention to many things. Of course, I want to know when the pain started, how it started, how has it progressed, when is it worse, what seems to aggravate it? Sharp pain, dull pain, constant or intermittent? I want to know what doctors they have seen, what have they been told, what therapies have been tried? I want to know the usual objective details. But that is only one part of the picture. Just as importantly, I want to know about the client’s own personal experience. How does this affect their sleep, their ability to do what they want to do, their job, their relationships? How does it affect them emotionally? As they tell their story, I am listening to how they describe their experience. Do they seem depressed? Hopeless? I observe how they talk, what language they use. Is their face contorted with distress and tension? How do they move? Guarded? Does it seem like the pain is in control of their lives? Is there room for cautious optimism? What are their beliefs?What do they think is perpetuating their pain? What do they think needs to change? Clients have a lot to tell us about their pain if we are willing to listen to more than just their medical history and physical symptoms.

Living with chronic pain is a frustrating and fatiguing experience. It is very, very difficult and affects a person in many ways. I lived with chronic pain for ten years so I understand the physical and emotional drain, the feeling sometimes that the people around you don't understand. You don’t want to complain all the time but the pain is a constant weight that others can’t see that you are carrying.

In this client’s case, she had a heartbreaking history and it made me feel sad that she was so young and had been suffering so much for so long. Just giving her a safe place to tell her story, to be listened to and understood and believed, is a start.

Education is essential.

After she finished telling her story, I took some time to tell the client my story – not my personal story, but the story that I wanted to tell her. I started out with a very honest statement. “I don’t know exactly why you hurt. I don’t know if there’s anything I can do to help you. However, there are some things I’d like to tell you that might help and some things I can do with my hands that might help. I think there’s a good chance that we can at least reduce your pain. If you are willing to experiment, so am I.”

I proceeded to give her some pain education. I use Explain Pain by Butler and Moseley as a model. I explained what is known about how pain works, about how it is the brain’s alarm system, that it’s a protective mechanism in response to perceived threat. That this alarm system can sometimes become hypersensitive. I emphasized that this does not mean that pain is “all in your head” in the sense that it is imaginary. The experience of pain is very real! However, it is not directly related to tissue damage. Knowing this is not a magic bullet to make it go away but it can help to take the fear and anxiety out of the experience and that can start shifting the experience of pain.

Pain education also helps put the client back in control. Often people with chronic pain feel out of control, feel as if they have no power. They feel as if the pain, the doctor, the therapist are in control. Understanding pain can help restore the locus of control back to the client. 

Gentle manual therapy can help.

The client got on the table. I turned down the lights, put on soothing music. Creating an environment where the client can relax and feel safe is important, especially to a client who has carried so much tension from so much pain for so long. I took my time. In a face down position, I did some very slow, very gentle skin stretching on her back, neck, shoulders. No rough stuff, no heavy pressure, just very gentle handling designed to help her body begin to relax and convince her brain that it was safe and no longer needed to protect itself. Skin stretching is very calming to the central nervous system, which controls the level of tension in the body and controls the experience of pain, and feels very good. I could feel the client’s body gradually relax and, over time, slide into a deep state of relaxation.

The client turned over, face up. I put my hands, very gently, on her face, her head, her neck. The approach that I used is based on a modality called Dermoneuromodulation (DNM), an approach developed by a Canadian physiotherapist, Diane Jacobs, based on what we know about how the nervous system works. It is gentle, uninvasive, and I have found it to be very effective in a variety of situations. I took my time and tried to do my best to create a safe space where my client’s body and mind could relax, turn down the volume on the tension and pain, and return to more normal function.  I left the room and allowed the client to take her time getting up.

When I reentered the room, she said that was nice, she felt relaxed, more so than she had in a long time. I encouraged her to pay attention to how it felt to be in that state and to remember it. I showed her some things she could try doing for herself at home, encouraged her to get a copy of Explain Pain and read it, and she made an appointment to return.

I few days later I had reason to email her and asked how she felt in the aftermath of our session. She said it was interesting. She didn’t feel any marked difference for the first two days and then on the third day she sneezed. When she sneezed, she felt her jaw shift and her pain levels dropped 90%. She was surprised. A day or so later, she felt her jaw shift back into the old painful place but she was able to get it back to where it felt right and not painful. Other annoying sensations she had been experiencing had also decreased dramatically.

When the client returned for her next session, she told me she had read Explain Pain. She was surprised that it was easier to understand than she expected and she thought it was helpful. “Why didn’t anyone ever tell me this before?” she asked. After all, she’d seen quite a variety of doctors and physical therapists. “They didn’t know,” I told her. “But now you know and you will know this for the rest of your life.”

I saw her two more times. I email her occasionally and the last time I heard from her, she was still doing well. It’s been six months since our first encounter. I asked her if she would allow me to share her story.

How did this happen?

I don’t get that dramatic of a response every day and I don’t assume I could do that again with another client. People are complex. They are not like machines where you can turn a dial and get a predictable output. Even the same person is different from one day to the next. At every moment there are a complex array of factors – physical, emotional, social – that are constantly changing. It’s important for the therapist to understand this.

What happened? Exactly how did that change come about after twelve years of unsuccessful treatment? There is no way for us to know for sure. This is what I think: The client was willing to do what it took and found the right thing at the right time. She had realistic expectations. She was hopeful that massage therapy might help but also said she didn’t expect miracles. She was willing to listen to new information that made sense and to think about it. She was willing to put forth the effort to get a book and read it. She was willing to put herself on the table and engage in the therapeutic process.

Gentle, skilled handling gave her brain something new and different to pay attention to, something it found pleasant and soothing. We were able to turn an area that was associated with pain into an area of good sensations. We managed to convince her brain, by providing some soothing exteroception (stimulation from the outside) that it was safe, it could relax, it could release the tension it was creating and stop generating the sensation of pain. It could let go and let things return to normal function. And when it did return, briefly, to an uncomfortable state, she did not panic. She now understood better what was happening and was not trapped by fear. She was able to return to a functional state.

That’s my story. Maybe it was pure coincidence? That’s always a possibility. But my story is compatible with what we know about how pain and the brain work.

I can never guarantee anything to anyone. However, focused and caring attention, pain education, and skilled, gentle manual therapy can help many people begin to live with less pain.

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