Temporomandibular Joint Dysfunction (TMJ)
Many people suffer from Temporomandibular Joint (TMJ) disorders without realising that this is the source of their pain. Varied symptoms such as earaches, headaches and face and neck pain may be a result of Temporomandibular dysfunction. Other common symptoms which characterise the problem include:-
- Pain on chewing, yawning or opening the mouth widely.
- Clicking noises on opening and closing the mouth.
- Tenderness of the jaw muscles.
- Difficulty or inability to open the mouth fully.
- Locking of the jaw.
The most common cause of TMJ dysfunction is a breakdown in the complex system of the jaw muscles, ligaments and temporomandibular joints. This often results in spasm of the chewing muscles, leading to pain and further dysfunction in the system and therefore further damage i.e. a cycle of pain. The causes of the initial breakdown could be:-
- Oral habits (i.e. grinding or clenching the teeth), which can be stress related.
- A direct blow to the TMJ (e.g. car accident or sporting injury).
- Misaligned bite or poorly fitting teeth.
- Arthritic changes in the TMJ.
Treatment of TMJ dysfunction can take a number of forms and often will incorporate combinations of therapies:-
- Ice or heat to relieve jaw muscle spasm.
- Ultrasound to relieve muscle spasm and TMJ swelling and pain.
- An occlusal (bite) splint made by a dentist to stop teeth grinding and clenching.
- Retraining of the chewing muscles with an exercise program
- Relaxation training to help relieve stress.
- Surgery to repair TMJ damage in advanced cases.
WHAT TO DO
Temporomandibular Joint dysfunction can be successfully treated by your Physiotherapist, often in conjunction with a dentist, and Sports Physician. Persistent problems, which do not respond to conservative therapies, may need medical or dental specialist referral.
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Headaches Can Be A Pain In The Neck
Headaches are one of the most difficult conditions in general practice. They are often the most disabling and limiting of conditions most people experience.
Recent research released at an international conference in Perth offers answers for at least some of the many headache sufferers. Professor Gwen Jull of the University of Queensland released the findings of an Australia wide multi centre study carried out over two years. This trial compared a number of common treatments for headaches and the resulting improvements in the patient’s condition.
Two hundred subjects suffering from headaches for longer than six weeks were randomly assigned to four different groups. The control group received no specific treatment, and the other three groups received either
Specific physiotherapy mobilisation to the neck. A new form of specific low load exercises for the deep neck flexors. A combination of physiotherapy and low load exercises.
The results of this study showed that those clients receiving specific physiotherapy mobilisations, the low load exercise, or a combination of these two managements, all showed significant improvements in comparison to the control group. The combination of the two therapies was shown to be better than either of the treatments individually.
Not only this, but the improvements were shown to be lasting over a 12 month period.
In comparison it was found that the medication levels of clients undergoing these form of treatments dropped significantly, whereas the control group increased their medication intake over time.
The other interesting finding was that the majority of patients with cervicogenic headache reported that the headache pain was worse than the pain in their neck.
Significant benefits were still derived even if the symptoms have existed for many years prior to receiving this form of treatment.
This research is the first of its type in the world, and gives guidance to practitioners in dealing with this very difficult and disabling problem. It offers hope for those suffering from headaches no matter how long the problem has existed.
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Headaches: Research Into Treatment
Evidence Based Management of Cervicogenic Headaches shows that
Manual Therapy and Specific Exercises are beneficial for Cervicogenic Headaches.
In 2009 noted Researchers Bogduk and Govind, found that the treatment of cervicogenic headaches with;
- Manual therapy,
- Specific exercises, or
- Manual therapy plus exercises
Are “significantly more effective at reducing headache frequency and intensity than was no specific care”.
At 12 month follow up, about 76% of the patients treated with these approaches achieved more than a 50% decrease in their headache frequency.
Combination of Exercises and Manual therapy is Especially Beneficial for Cervicogenic Headaches.
Jull et al (2002) found that in treating patients with cervicogenic headaches, both manipulative therapy and specific exercise significantly reduced headache frequency and intensity.
With the combination of the manual therapy and the exercises, 10% more of the patients gained relief.
It was shown when using manipulative therapy alone, muscle performance of craniocervical flexion failed to improve.
Thus there is a need for a specific exercise intervention to target muscle control of the cervical region.
Too late? Too chronic?
Interestingly, Jull et al (2002) identified that the length of headache history was not a determinant of treatment effectiveness.
The subjects in the study had symptoms that were chronic in nature, with average length of symptoms 6.1 years. As identified above they still gained significant benefit from the treatment.
Physiotherapists at Physiotherapy4u would be happy to discuss any aspects of managing patients with cervicogenic headaches.
- N. Bogduk, J. Govind. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. The Lancet Neurology, 2009;8:959-968.
- Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D., Emberson, J., Marschner, I.C., Richardson, C. A randomised controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine, 2002; 27:1835-1843.
Most people would agree that headaches are some of the worst pains you can have. Yet apart from using medications, the only solutions offered are usually a cup of tea and a long lie down. Whether it be the hangover, the “Not tonight dear I’ve got a headache”, or the headache your boss gave you, headaches are a major problem.
There are a number of different types of headaches and a number of different treatments that can be useful in combating this common problem. A common type of headache is one that originates from the neck (cervical spine).
HOW CAN THE NECK CAUSE HEADACHES?
The nerves that supply much of the scalp and forehead originate from the upper part of the neck at the base of the skull. These nerves also supply us with sensation from the joints and tissues of the upper neck. If there is a problem in this part of the neck it can be felt as pain in the form of a headache.
These headaches may show signs to indicate that they originate from the neck. Limitations of neck movements, tenderness and soreness around the neck, and pain that feels like a tight band around the head and behind the eyes are commonly seen with these types of headaches.
They are frequently seen in drivers and in people who work on computers or sit for prolonged periods of time. These problems are also often associated with traumatic injuries to the neck especially car accidents and sporting incidents.
SO HOW DO WE GET RID OF THESE HEADACHES?
The most important thing to do is to have the pain properly assessed to find out if the headache is coming from the neck. If this is the problem, treatment aimed at relieving the stiff joints, stretching the stiff muscles, or strengthening the muscles can significantly reduce the problem. Correcting poor postures and addressing stress can also be vital in fixing this very painful and persistent problem. Special exercises, prescribed by your LifeCare physiotherapist, are often required to alleviate the pain and prevent a recurrence. If we find your headache is not related to your neck, we will communicate with your local doctor who will provide further medical assistance.
Physiotherapy4u’s physiotherapists are trained and experienced in the treatment of neck related headaches and will work with your doctor to overcome this painful condition.
There is widespread support in the literature that headaches are often multifactorial in their origins. If your assessment reveals poor posture, limited range of cervical spine movement, palpatory tightness or a reproduction of symptoms on cervical palpation you may consider referring to physiotherapy. Even a short trial period of treatment is often useful to help with differential diagnosis provided medical review is arranged if symptoms remain unchanged.
Treatment is guided by signs and symptoms but the literature supports a 2 phase programme:
1) Mobilisation of the upper cervical spine
Improvement in symptoms of cervicogenic headache have been shown with attention to pain provoking structures (Edeling 1994, Jull 1994b, Schoensee 1995). However, whilst improvements were gained in the short term there was a plateau after mobilization.
2) Muscle Re-Training
Specific exercises isolating the deep flexors and addressing postural dysfunction. In a study by Beeton and Jull(1994) it was found by incorporating these into a more comprehensive programme that improvements were maintained six weeks after treatment had ceased.
Edeling J (1994): Manual Therapy for Chronic Headache (2nd ed.) Oxford: Butterworth- Heinemann.*Jull GA(1994b): Headaches of cervical origin. In Grant R(Ed.): Physical Therapy of the Cervical and Thoracic Spine (2nd ed.) New York: Churchill Livingstone).
Schoensee SK, Jensen G, Nicholson G, Gossman M and Katholi C (1995): The effect of mobilization on cervical headaches. Journal of Orthopaedic and Sports Physical Therapy 21(4): 184-196.
In Physiotherapy4u Physiotherapists are involved in a comprehensive ongoing education programme including the management of acute and chronic headaches.
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WHAT IS IT?
Cervical headaches are one of the types of headaches people experience and between 15-20% of all headaches are thought be cervical in origin.
WHY A PAIN IN THE NECK?
Nerves that supply much of the scalp, forehead and base of the skull also supply the joints and tissues of the upper neck Therefore: a problem in the upper neck = a headache
WHAT DO I LOOK FOR?
- Limitations in neck movement.
- Tenderness and stiffness around the neck.
- Headache in the base of the neck, base of the skull or frontal head region.
WHAT CAUSES IT?
- Muscle tension in the neck head and jaw region Stress.
- Poor posture especially when working at a desk.
- Trauma such as a car accident.
- Poor sleeping position.
WHEN DO I SEE SOMEONE FOR HELP?
Your Physiotherapy4u Practitioner will be able to provide an accurate diagnosis and an appropriate management plan.
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Can Red Wine Cause A Headache And Can Physiotherapy Help?
Suffering a headache the morning after drinking Red Wine is a very common experience for many people in the community. But are these headaches part of a hangover? Why do some people suffer a headache even after as little as one glass of red Wine?
In particular Red Wines, which include Shiraz in their mixture, appear a potent source of headache the next day. A Shiraz Headache, may not in fact be caused by drinking to excess, but may be referred from the neck.
Headaches referred from the neck are “Cervicogenic” in origin and are now a well established cause of this form of pain. The referral of pain from the upper cervical spine is now well accepted in the literature, as well as clinical practice.
Common causes of these pain can be broadly describe in two groups according to their cause.
The headaches from acute trauma to the cervical spine such as that seen in motor vehicle accidents have an obvious mechanical cause. The damage to the structures of the cervical spine involved in motor vehicle accidents can be extensive, and reflect the significant forces involved in these accidents.
More commonly seen today is the referred pain caused by the lack of enough movement. People in sedentary work, and particularly those using computers for long periods of time, have a high incidence of headaches, associated with upper back and neck pain. The static sitting and stooping postures associated with desk bound work can cause significant problems over a long period of time.
So how can Red Wine cause a cervicogenic headache?
The inflammatory properties of red wines and particularly Shiraz are well known. There is also a tendency for people to sleep longer and move less at night after consuming some wine that evening. Add these factors to a history of long periods of sitting at a desk and you have enough of a problem to cause a headache.
So how can you stop this from occurring?
Certainly avoiding excess is the first step, and there is no doubt a large number of headaches following red wine are the result of a hang over. But, just as you should consume water as much as possible to lessen some of the effects of alcohol, you should also look after your neck to prevent headaches.
Prevention can include gentle slow stretches of the neck movements in all directions, and regular changes out of static postures. The same measures can be used to help alleviate the symptoms once they have occurred. Heat can also be of benefit, as can having a good supportive pillow (and not falling asleep on the couch).
However, if headaches are common
It is an indication that all is not well, and that there is potential for problems even without the help of the wine. Consulting a LifeCare Physiotherapist for an assessment and if required treatment will help determine if indeed the neck is contributing to the headaches. From here, the management of the condition can be addressed. Recent researches has conclusively shown that the appropriate treatment including mobilisations and specific exercises is highly effective in resolving headaches of cervicogenic origin. It has also shown that the improvements gained from this form treatment is usually long lasting.
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Benign Paroxysmal Positional Vertigo (BPPV)
Benign paroxysmal positional vertigo (BPPV) is the most common disorder of the inner ear in the adult population. The age of onset of BPPV is often from between the ages of 40 – 60 years old, with between 11 and 64 people per 100,000 being affected each year.
Females are more likely to get BPPV than males.
BPPV is a disorder of the inner ear which is characterised by episodes of vertigo that are position dependant. The name benign paroxysmal positional vertigo in itself describes the disorder. ‘Benign’ refers to the fact that this condition is not due to any serious pathology and that the prognosis for recovery is good. ‘Paroxysmal’ refers to the swift onset of the vertigo, and ‘positional vertigo’ refers to the spinning/dizzy sensations which patients complain of that occur when they are in certain positions.
The inner ear is home to the vestibular system, which monitors the head’s position and movement in space and relays this information to the brain. When information from this system is incorrect and conflicts with information from other sensory systems it can cause feelings of vertigo and nausea.
The semicircular canals within the vestibular system respond to movements of the head. The 3 canals are arranged at approximately right angles to each other, and are filled with fluid. When head movement occurs, the fluid causes the sensory hairs in the semicircular canals to bend and send off nerve impulses which give the person the sensation of movement.
The cause of BPPV is related to the presence of abnormal debris within the semicircular canals. The debris is usually small crystals which have dislodged from another part of the inner ear. This debris causes abnormal stimulation of the sensory hair cells in the semicircular canal and leads to the sensations of dizziness and vertigo experienced in BPPV.
BPPV is the most common vestibular disorder. Of patients presenting with vertigo, BPPV accounts for 42% of cases. However, BPPV can be under diagnosed or misdiagnosed. Other conditions which may cause similar symptoms to BPPV include Vestibular neuritis, Meniere’s disease, vascular disorders, and metabolic or autoimmune disorders (e.g. Diabetes, lupus). It is important to seek accurate diagnosis as this will affect the expected prognosis, treatment methods, and the potential for related serious medical problems.
Signs and symptoms
The main symptom that people with BPPV report is intermittent episodes of vertigo. Vertigo is an abnormal feeling that you or your surroundings are in motion. The vertigo is often reported to be brought on by changes in head position (e.g. rolling over in bed, looking upwards or bending forwards), and lasts less than one minute. Other symptoms that people with BPPV may experience include light-headedness, dizziness, nausea, and feeling off balance.
Although BPPV is not a serious condition, these symptoms can have a substantial impact on people suffering from them and severely impair their ability to function. In older patients particularly, BPPV may increase risk of falls which can then cause serious injury.
Physiotherapists are able to asses for and treat BPPV. Performing certain head movements according to semicircular canal positioning can work to remove the debris from them. This means that the stimulus that was causing the BPPV will no longer be present so symptoms are alleviated. Physiotherapists are able to asses which semicircular canal is affected and based on this assist patients to perform the appropriate head movements required to treat the condition. Physiotherapists may also prescribe home exercises and give home advice on management; which can be particularly important for decreasing rate of re-occurrence and minimising risk of falls. Although BPPV often responds well to treatment, there is a considerable rate of re-occurrence (around 15% per year), so follow up with your Physiotherapist is important.
If required your physiotherapist will be able to refer you onwards for specialist assessment and treatment.
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