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Case report
Derangement of the temporomandibular joint; a case study using Mechanical
Diagnosis and Therapy
C. Krog a, S. May b,*
a Faculty IMDT, Denmarkb Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, 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
Classification
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 classifications 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-specific temporomandibular pain and reduced function, who had had lots of previous failed treat-
ment. Examination using repeated movements resulted in a classification 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 classification, 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 verygood 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-specific temporomandibular joint (TMJ)problem. This patient was classified 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
Symptoms had started during a tooth operation at the dentist in
May 1997, during which her mouth was held wide open for about* Corresponding author. Tel.: 44 (0)114 225 2370.
E-mail addresses: [email protected] (C. Krog), [email protected] (S. May).
Contents lists available at SciVerse ScienceDirect
Manual Therapy
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / m a t h
1356-689X/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2011.12.002
Manual Therapy 17 (2012) 483e486
mailto:[email protected]:[email protected]://www.sciencedirect.com/science/journal/1356689Xhttp://www.elsevier.com/mathhttp://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://www.elsevier.com/mathhttp://www.sciencedirect.com/science/journal/1356689Xmailto:[email protected]:[email protected]7/29/2019 1-s2.0-S1356689X1100230X-main
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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 chewedor 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 wors-
ening situation in 2004 her general practitioner referred her to anoral 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. Addi-
tionally, she suffered from extreme morning stiffness in the jaw.
A screening examination of the cervical spine, which consistedof 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 first 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. MDTuses non-specific measures
for loss of movement: minor, moderate, and major, which though
imprecise are meaningful to MDTclinicians 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 andpainful throughout the range. Right lateral deviation was unre-
stricted 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 demon-
strated 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 10e
15 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 feelingof subluxation returnedand 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 confirm 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 demon-
strated 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 clas-
sification of derangement was confirmed.
She was now shown to progress the force by applying over-
pressure to the movement by using her hands to support the upperleft 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.
C. Krog, S. May / Manual Therapy 17 (2012) 483e486484
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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 move-
ment 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 pain-
free in all directions. It was no longer possible to reproduce the
feelingof subluxation with right lateral deviation by repeating side-
gliding to the right or by chewing or repeating mouth opening. She
was discharged with instructions to return if there was any re-
appearance 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 func-
tional 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
Thiscase study describes the successful management throughtheuse of MDT principles of a patient with TMJproblems who hadfailed
numerous previous management strategies. MDT does not seek to
make specific patho-anatomical diagnoses, but rather is based on the
symptomatic and mechanical responses to repeated movements.
According to these responses this patient was classified with
derangement syndrome and then demonstrated rapid improve-
ments 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 discin the TMJ,and in deed internalderangement of the disc
is a commonly used classification 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 sufficient information to understand the problem and its effecton the patient, nor is it sufficient to justify the course of management
chosen.... of moreconcern is thatsolely tissue-basedreasoning tends
to promote inflexibility of management strategies. When therepeated
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
firstly considers the presence of one of the mechanical syndromes,
namely derangement, dysfunction,or postural syndrome. Becauseof
the nature of the patients presentation and response to repeated
movements derangement was the only mechanical syndrome that
was possible. Full operational definitions are available for all the
mechanical syndromes, so it is not the point of this case study to
describe them (McKenzie andMay 2003). Althoughonly considering
3 options could be said to promote infl
exibility of management
strategies,if a patient does notfit the operationaldefinitions of oneof
the mechanical syndromes a number of other optionsare 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 classifications can be commonly applied to many
extremity problems (May 2006). Identification 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 scientific methodology.
4. Conclusion
This case report details the history and assessment of a woman
who presented with typically chronic non-specific 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 classified as derangement under MDT principles. This is
the first 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.
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