DISCLAIMER WHY DIFFERENTIATE · Headache TMD Orofacial HANDOUTS 28 Feb 2013 Myotherapists Melbourne.ppt Author: Robert Granter Created Date: 20130224102139Z

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DIFFERENTIATION OF CERVICOGENIC AND TEMPEROMANDIBULAR

DISORDER RELATED HEADACHE

Peter Selvaratnam Ph.D (Medicine, Anatomy) FACP

Assoc Prof (Clinical) The University of Melbourne and The Melbourne Spinal and Sports Physiotherapy

Clinic Specialist in Musculoskeletal

© Peter Selvaratnam

•! 39 Authors, 66 reviewers •! Dr Guy Zito •! Ken Niere •! Maria Zuluaga •! Philip Gabel •! Prof Gwen Jull •! Dr Cathy Sloan •! Dr Iggy Soosay •! Kerrie Bolton •! Dr Mark Faragher •! Dr Janaka Seneviratne •! Dr Phil Tehan •! Dr Steve Friedmann •! Dr Ian Devlin •! Grant Shevlin •! Prof Keith Hill

Sponsored by Elsevier Australia Foreword by Prof Ed Byrne(Neurologist, Vice-Provost (Health) at University College London and Vice Chancellor, Monash University)


DISCLAIMER

•! DUE TO COPYRIGHT LAWS NOT ALL POWERPOINT’S ARE IN THE HANDOUTS

•! THE MAIN POINTS OF THE PRESENTATION ARE IN THE CONTENTS OF THE HANDOUTS

WHY DIFFERENTIATE

•! Both headaches can be referred to the temporal region

•! Cervical and/or temperomandibular signs may co-exist in patients with primary and secondary headache

•! Assess Primary or Secondary Headache

•! Assess Catastrophic or Sinister Headache © Peter Selvaratnam

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PRESENTATION

•! What are the differential features of Primary or Secondary Headache

•! What cues could be diagnostic of

Cervicogenic and TMDHA (Zito et al 2008)

•! Case vignette-Biomechanical analysis from Atlas to Talus

International Headache Society Classification (2004)

•! Primary headache is that which does not have a underlying medical pathology-migraine, tension type headache, cluster and exertional headaches

•! Secondary headache is that which has an underlying medical pathology- cervicogenic, TMD, infection, trauma, vascular, intracranial disorder, substance or its withdrawal, psychiatric or other sinister pathology



Secondary Headaches-Cervicogenic or

other pathology •! Chiari malformation •! 25 year old Ph.D

student

•! Dental abscess •! Cracked teeth •! Tonsilar tumour © Peter Selvaratnam

Sub-arachnoid haemorrhage, Benign Intracranial hypertension and Temporal arteritis can be catastrophic and when not diagnosed immediately may lead to permanent disability or death. Other headaches can be sinister; they may not be associated with serious underlying pathology

Catastrophic and Sinister Headaches

Faragher 2009, Seneviratne 2009 In: Headache Orofacial Pain and Bruxism, Selvaratnam PJ, Niere K, Zuluaga M (eds)

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“Worst Headache”

•! 57 year old •! Visited Hospital ED-

Twice •! Consulted Neurologist •! Headache moving

from supine to sitting •! Medication:


Aneurysm-Vertebral artery/internal carotid



•!Collective term for different musculoskeletal conditions •!involving temperomandibular joints (TMJs) and/or masticatory muscle disorders •!absence of other visceral pathology (Nitzan et al, 2008)

Temperomandibular disorders (TMD)


Temperomandibular disorder related headache (TMHA)

•! Temperomandibular disorders (TMD) may lead to pain or headaches in the temporal region, maxillary or mandibular region, the temperomandibular joint (TMJ), with associated pain in the teeth.

•! It is estimated that 25–33% of those with TMD may have pain or headache (Dworkin et al 1990, Gremillion et al, 2000).

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Quincy-Peritonsilar abscess

Peter Selvaratnam

Cervical /TMD/Both or Other?



Nerves of Head, Neck, Scalp and Orofacial region


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Trigeminal nerve


Omohyoid

© Peter Selvaratnam © Peter Selvaratnam

Characteristics TMD-related headache

Cervicogenic headache

AArreeaa ooff ssyymmppttoommss!!!!

•! UUnniillaatteerraall oorr bbiillaatteerraall tteemmppoorraall hheeaaddaacchhee ++//--TTMMJJ aanndd mmaassttiiccaattoorryy mmuussccllee ppaaiinn

•! PPaaiinn mmaayy rraaddiiaattee aanntteerriioorrllyy ffrroomm tthhee pprree--aauurriiccuullaarr rreeggiioonn oorr ssuuppeerriioorrllyy

•! UUnniillaatteerraall ffrroonnttoo--tteemmppoorraall,, oorr oorrbbiittaall !!

•! ccaann ooccccuurr bbiillaatteerraallllyy

•! PPaaiinn mmaayy rraaddiiaattee ssuuppeerriioorrllyy ffrroomm tthhee cceerrvviiccaall rreeggiioonn

Zito G, Morris M, Selvaratnam PJ 2008 Physical Therapy Reviews

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Zito G, Morris M, Selvaratnam PJ 2008 Physical Therapy Reviews

Characteristics TMD-related headache Cervicogenic headache

•! Associated

symptoms

•! Mandibular pain

•! Fullness in the ear

•! Sensitive teeth or periodontal structures

•! Tinnitus and dizziness

•! Pain in the occipital

or sub-occipital region or upper trapezius muscle.

•! Dizziness, dysphagia, lacrimation, nausea or vomiting

•! Phonophobia, photophobia, rhinorrhoea, shoulder or arm symptoms, visual disturbance


PPrreecciippiittaattiinngg mmeecchhaanniissmm!!

•!TTrraauummaa ttoo TTMM rreeggiioonn!!•!OOcccclluussaall ddiisshhaarrmmoonnyy""!!•!PPaarraaffuunnccttiioonnaall aaccttiivviittyy eegg##bbrruuxxiissmm !!

•!ssppoorrttss iinnjjuurryy !!

•!ddeennttaall pprroocceedduurree!!

•!PPhhyyssiiccaall oorr eemmoottiioonnaall ssttrreessss!!

PPrroovvookkeedd bbyy::!!•!NNeecckk mmoovveemmeennttss,, !!

•!SSuussttaaiinneedd ppoossttuurreess iinncclluuddiinngg !!•!ppoooorr sslleeeeppiinngg ppoossttuurree!!


SSlleeeepp ppaatttteerrnn •!WWookkeenn dduurriinngg sslleeeepp oorr oonn aawwaakkeenniinngg wwiitthh hheeaaddaacchhee,, mmaannddiibbuullaarr,, tteeeetthh oorr ppeerriiooddoonnttaall ssyymmppttoommss •!PPaattiieenntt oorr ppaarrttnneerr ccoommppllaaiinnss ooff ssnnoorriinngg

•!OOnn wwaakkiinngg aassssoocciiaatteedd wwiitthh cceerrvviiccaall ppaaiinn oorr rreessttrriiccttiioonn

•!NNoott aassssoocciiaatteedd wwiitthh ssnnoorriinngg



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Bruxism

•! Sleep studies indicate that tooth grinding occurs in 80% of young adults during Stages 1 and 2 of sleep and in about 5–10% during rapid eye movement (REM)

•! Laboratory studies also demonstrate that a large number of sleep bruxism episodes occur in the supine position similar to obstructive sleep apnea (Lavigne, 2005; Lavigne et al., 2006)


Bruxism •!Increase -autonomic cardiac activity 4 to 8 minutes preceding tooth grinding or phasic jaw muscle contractions •!Increase in cortical activity (alpha waves) 4 seconds before SB •!Increase in cardiac rhythm 1 second before SB •!Increase in suprahyoid muscle tone 0.8 seconds before SB •!Onset of activity of jaw-closer muscle with possible tooth grinding (Lavigne et al 2005a, Huynh et al 2006a)


Biomechanics

Assessment in Sitting •! Head –Neck posture

•! Facial symmetry •! The masseter muscles of

patients who brux may appear to be hypertrophied

•! Parotid Gland •! Position of transverse

process of atlas (Rocabado, 2012)


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Effect of Starting point /Biomechanics

•! Shoulder girdle and scapula posture

•! Thoracic and lumbar posture

•! Pelvic posture

•! Overpronation of feet © Peter Selvaratnam © Peter Selvaratnam

Characteristics TMD-related headache

Cervicogenic headache

AAccttiivvee mmoovveemmeennttss!!!!

AAccttiivvee TTMMJJ mmoovveemmeennttss mmaayy bbee rreessttrriicctteedd aanndd mmaayy rreepprroodduuccee hheeaaddaacchhee

AAccttiivvee cceerrvviiccaall mmoovveemmeennttss mmaayy bbee rreessttrriicctteedd aanndd rreepprroodduuccee oorr eeaassee hheeaaddaacchhee


SSppaattuullaa tteesstt!!!!Prof Harry Von Piekartz, (2000, 2009)

•!PPllaacciinngg ssppaattuullaa bbeettwweeeenn iinncciissoorrss// pprreemmoollaarrss mmaayy rreedduuccee hheeaaddaacchhee oorr TTMMJJ ppaaiinn.. •!EExxaammiinniinngg cceerrvviiccaall mmoovveemmeennttss rreedduucceess hheeaaddaacchhee

HHeeaaddaacchhee iiss uunnaalltteerreedd bbyy ppllaacciinngg ssppaattuullaa bbeettwweeeenn pprreemmoollaarrss aanndd rree--eexxaammiinniinngg cceerrvviiccaall mmoovveemmeennttss

Characteristics TMD-related headache Cervicogenic headache In Supine

•! Manual distraction of the upper/lower cervical region

•! Sustained palpation of sub-occipital region

•! Sustained postero-anterior palpation of the

C2, C3, C4 C5 region

•! Sustained palpation of Upper trapezius

•! Palpation of SCM

•! Assessment of TMJ

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Clicking of the TMJ - anterior displacement of the articular disc or ligamentous?


•! Masseter - Intra and Extra –Oral

•! Temporalis


Medial Pterygoid


Lateral Pterygoid


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OOddoonnttooggeenniicc ffaaccttoorrss

•!WWeeaarr ffaacceettss ooff ddeennttiittiioonn •!CCrraacckkeedd ttooootthh ssyynnddrroommee •!TToonngguuee ccrreennaattiioonnss aanndd lliinneeaa aallbbaa

DDeennttaall ssiiggnnss aarree nnoott aassssoocciiaatteedd wwiitthh cceerrvviiccooggeenniicc hheeaaddaacchhee


Sub-grouping of headaches

•! Primary or secondary •! Regions involved •! Cervical •! a. muscles, joints, neural or other

pathology •! b. directional preference •! TMD- Joint, muscle, neural, referred

from neck or other pathology


Management

•! Manual Therapy •! Cervical Programme •! Occlusal splint •! Orofacial rehabilitation programme •! Dry Needling/Acupuncture •! Cognitive Therapy •! Biomechanico-behavioural evaluation


What is EVIDENCE informed Medicine (Sackett 1996)

EVID

ENCE

PATI

ENT

S E

XPER

IEN

CE

PHYSIC

IAN

S WISD

OM

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Outcome measures

•! Functional Movements •! Self reported pain scale (VAS) •! Patient specific functional measure •! Headache Disability Questionnaire

(Niere 2009) •! Mandibular function impairment

questionnaire (Stegenga et al 1993)



Case Vignette •! 31 year old lady –Consultant/MBA •! Bilateral Pain –Ear, TMJ, mandible, Teeth,

anterior neck and occipital headache post wisdom tooth extraction in 1999

•! 1992-MCA- Neck pain •! 2008-Sinus infections •! May 2009 Sneezed- increased pain •! Pain –Talking at meetings •! VAS- 6/10


CASE VIGNETTE FROM ATLAS to TALUS

•! Manual Cervical Distraction (Supine)-Pain •! Upper cervical Flexion+ Distraction-No Pain •! Trapezius (Supine)- Pre- Auricular Pain •! C1, C2- Local pain, restricted movement •! T4- restricted movement •! Masseters- Intraorally hypertonic •! SCM

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© Peter Selvaratnam Interincisor opening:24mm © Peter Selvaratnam

© Peter Selvaratnam Interincisor opening: 29.5mm

© Peter Selvaratnam Interincisor opening: 31.5mm

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Interincisor opening: 34mm © Peter Selvaratnam

MIRROR THERAPY and fMRI

Somatosensory Cortex

Peter Selvaratnam © Peter Selvaratnam

Summary •! Both Headaches may be associated

with Primary and Secondary Headache

•! Cervicogenic Headache and TMD Related headache-can be differentiated and may coexist

•! Biomechanical evaluations may assist in targeting the region/s for treatment

•! Interventions can be measured with suitable outcome measures

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•! Ken Niere •! Maria Zuluaga •! Dr Guy Zito •! Philip Gabel •! Judy Waters •! Dr Jonathon Tversky •! Dr Cathy Sloan •! Prof Gwen Jull •! Kerrie Bolton •! Dr Iggy Soosay •! Dr Mark Faragher •! Dr Janaka Seneviratne •! Dr Phil Tehan •! Dr Steve Friedmann •! Grant Shevlin •! Dr Ian Devlin •! Prof Nik Bogduk •! Prof Keith Hill •! Prof Ed Byrne

Documents

DISCLAIMER WHY DIFFERENTIATE · Headache TMD Orofacial HANDOUTS 28 Feb 2013 Myotherapists Melbourne.ppt Author: Robert Granter Created Date: 20130224102139Z