At the initial assessment, the client described her pain as an achy, tired feeling in front of her ears, throughout the temples, occipital region, directly in the TMJ and sometimes down her neck and shoulders. To the client, this pain felt like a headache. She expressed that when her pain was at its peak, she did not want to talk or even turn her neck. When pain levels were low, an achy uncomfortable sensation still remained. The symptoms interfered with her daily living by decreasing concentration and patience.
Following the treatment series, self-reported pain decreased from 7/10 to 3/10 (see ).
At the final assessment, the client remarked that her activities of daily living were no longer affected to the same extent, “just my concentration if the pain gets bad”. She also noted that the achy uncomfortable sensation that was consistent prior to the treatment series, regardless of pain levels, “now comes and goes”. Other comments on effectiveness of the treatment series overall were, “I feel a lot better”, “treatment went really well”, and “my jaw feels better”.
At the initial and midway assessments, forward head posture and anterior rounding of the shoulders were rated as moderate, and at the final assessment, both were rated as mild. Initially, the client’s right shoulder appeared approximately 2 cm higher than the left. By the mid-way assessment, the shoulders appeared to be of a more equal height and remained so at the final assessment.
Range of Motion Assessment
Maximal TMJ depression was evaluated during assessments and an increase was noted during each measurement (see ). At the initial assessment, active ROM of the TMJ revealed that in depression, the jaw deviated to the left and clicked on the left side and the movement was restricted. During active elevation of the jaw, deviation was noted to the right. During active bilateral lateral deviation, crepitus (a grinding or grating sound) was noted on the right side. Passive ROM of TMJ depression was slightly greater than active, and remained so until the final assessment. Resisted ROM of TMJ depression and lateral deviation were uncomfortable. Resisted elevation was stronger than normal. All other TMJ ROM findings were normal and remained so until the final assessment. At the mid-way assessment, active ROM of TMJ depression remained the same. During active elevation, no deviation was noted and remained so until the final assessment. During lateral deviation, no crepitus was noted and remained so until the final assessment. Resisted ROM of depression was uncomfortable and lateral deviation was normal. Resisted elevation was stronger than normal. At the final assessment, active ROM of TMJ depression was no longer restricted but revealed a slight deviation to the left, then the right, then vertical. The click on the left side remained. Resisted ROM of all TMJ motions was normal.
Active ROM of the neck is shown to increase over time (see ). At the initial assessment, the client felt bilateral “crackling” in the TMJ during active rotation to either side. This resolved by the mid-way assessment. Passive ROM of the neck was around 5 degrees greater for each motion than active ROM at the initial, mid-way, and final assessments, and therefore also increased over time. Resisted ROM of the neck at the initial assessment showed weakness in extension, flexion, and bilateral lateral flexion. At the mid-way assessment, these weaknesses remained, with the exception of flexion. At the final assessment, only extension was found to be weak.
At the initial assessment, during the ‘Three Knuckle Test’, the client could fit two knuckles in with no extra room; therefore, this test was negative, but did provide a measurement to monitor progress. The results improved to 2½ knuckles at the mid-way assessment and 2¾ at the final assessment.
Using the WNS, hypertonicity was evaluated by the massage therapist in the muscles of mastication. Tension was observed to decrease throughout the treatment series (see ).
Hypertonicity Changes in the Muscles of Mastication*
Upon examining the client’s daily journal, correlations are noted between stress and pain, as noted in . The way in which treatment days and weekends corresponded with stress and pain is also noted. Stress is shown to decrease from 9/10 at the first journal entry to 5/10 at the last. While observing stress on each treatment day and the following day, it is seen to decrease seven times and remain consistent two times. Pain observed in the same manner is seen to decrease four times, remain consistent two times and increase three times.
Correlation between stress levels and pain intensity in relation to weekends and massage treatments.
Data gathered from the daily journals also shows occurrences of “severe” grinding/clenching, “more than normal” joint clicking/popping, and severe pain (8/10 or higher) per week. The four weeks following the onset of the treatment series shows an overall decrease in occurrence for all three variables ().
Occurrence of “severe” grinding/clenching, “more than normal” joint clicking/popping, and “severe” pain per week.