Contributed by Sandra K. Anderson, BA LMT ABT and Jolie Haun, PhD LMT
Have you ever wondered what inspires research in massage therapy and bodywork? Often, it starts from the work of practitioners who write case reports illustrating their experiences with clients and patients.
A case report is a detailed description of a practitioner's work with a client who has a condition which is addressed by a specific therapy or intervention. It also includes a review of published literature about research on issues similar to the client's. Both the practitioner's work with the client and the research literature can form the foundation for further scientific investigation.
This month, we at the Massage Therapy Foundation (MTF) are presenting a case report published in the International Journal of Therapeutic Massage & Bodywork in 2011. "Changes in Temporomandibular Joint Dysfunction Following Massage Therapy: A Case Report" was written by Melissa Joan Pierson, MT, and won a Silver Place Award in the Massage Therapy Foundation's Student Case Report Contest in 2010.
Most massage therapists have likely had clients with temporomandibular joint (TMJ) dysfunction as 65% to 85% of Americans experience symptoms during their lives. Symptoms include pain and muscle spasms in the head, mandible, neck and shoulder muscles; headaches; earaches; clicking noises or deviations when the mandible moves; limited ability to open the mouth; and dizziness. Causes of TMJ dysfunction include whiplash, bruxism, malocclusion, anxiety, stress, trigger points and postural dysfunction.
Treatments for TMJ disorder include splint therapy, analgesics, surgery, stress management, acupuncture, trigger point therapy, hydrotherapy and massage therapy. Data from focus groups and surveys of people with TMJ disorder suggest people experience frustration with conventional treatment, but are often satisfied with complementary and alternative medicine (CAM) treatments, especially massage therapy. However, literature regarding the effectiveness of massage therapy on TMJ disorder is limited and shows varying degrees of success, warranting more research on the topic. Pierson's case report is important because it shows the benefit of a treatment plan with detailed measurements of the outcomes associated with TMJ disorder.
Pierson's client was a 26 year-old female student who had TMJ disorder seven to ten years prior to the massage treatment series. There was no reported known cause of TMJ for this client. Her symptoms were pain, decreased range of motion, clicking and crepitus. She was a busy, stressed student who had sought treatment from a dentist and a TMJ specialist. Eating soft foods, stretching and following guidance on reducing stress decreased the majority of her symptoms, but when her stress levels increased, her symptoms returned. The client's goals from massage therapy were decreases in pain, muscle tension, stress and restrictions in the neck and facial muscles.
The treatment plan consisted of an initial assessment followed by ten treatments, with re-assessments midway through the series and afterward. Each assessment included a postural assessment using a plumb line and range of motion (ROM) and orthopedic assessments of the neck and TMJ. Pierson also conducted pre-treatment interviews which included questions about location of discomfort, duration, frequency, intensity and quality of pain, and aggravating and relieving factors.
The sessions lasted 45 to 50 minutes, and included intra-oral massage (with gloved hands) consisting of compression on the medial and lateral pterygoids to release trigger points and muscle tension and gentle stripping. Myofascial release was then performed on the neck muscles and pectoralis major to correct the client's rounded shoulder posture and release pressure on her jaw followed by stretching. The sternocleidomastoid was picked up and twisted to release trigger points and tension. Kneading, stripping and trigger point release through ischemic compression were also used on neck muscles. These techniques were done to relieve pain, increase blood flow to the muscles and elevate endorphin levels to further reduce the client's pain and stress. Shiatsu was performed on the client's scalp to restore and maintain the body's energy balance, prevent the buildup of stress and decrease pain.
Because studies have shown that 60% to 90% of patients with TMJ disorder have an improvement in symptoms after using only self-management techniques, self-care was essential to the client's treatment plan. The client performed daily exercises involving retraction to decrease forward head posture. To keep the jaw muscles from clenching, the client compressed and stretched masseter and temporalis musces, and performed self myofascial massage over pectoralis major. She also applied heat and ice alternately to painful areas. Starting three weeks prior to the treatment series, the client kept a daily journal recording her stress, pain and muscle tension levels; the amount and quality of her sleep; self-performed home care, daily activities and diet.
Overall, the treatment series was successful, yielding an increase in the client's ability to open her mouth maximally and range of motion in her neck and a decrease in muscle hypertonicity, pain and stress. Pierson states these results could be due to several factors - the client's compliance with home care, using evidence-based techniques and frequent sessions with no long breaks in between.
For greater accuracy in measurements, Pierson acknowledged that other tools could have been used. For example, a goniometer could have been used to measure the range of motion of the mandible. Instead of relying on the client's comments, valid and reliable measures could have been used to assess the client's mood, stress, concentration and patience. Also, during postural observation and resisted ROM assessment, more quantifiable measurements could have been used instead of the terms "mild, moderate, or severe."
This case report is valuable for several reasons. Because it details the techniques Pierson used on the client, massage therapists can use the information for their own clients with TMJ disorder. This case report warrants further study to investigate the benefits of massage therapy for TMJ disorder. And just as important, this case report may provide inspiration for other massage therapists to conduct and author case reports about their experiences using treatments with their clients.