#121 Fact Checking TMD/TMJ Treatments (Part 6) Physical Therapy and Dry Needling

When a patient presents to his physician, (MD) with complaints of constant, recurrent, or chronic neck and shoulder pain one of several treatments may be proposed.  Depending on which alternatives have already been prescribed and failed, including various categories of drugs, and referrals to orthopedic surgeons, and neuro surgeons, the PCP will likely refer their patient for physical therapy evaluation.  The PCP will almost always make the referral to other health care providers within the “medical system” and never considers that neck and shoulder pain is the second most common symptom of TMD/TMJ.  The surprising fact is that nationwide, 99% of PCP’s are not educated in TMD/TMJ and therefore only consider it in their differential diagnosis when it is brought to their attention by the efforts of dental providers who focus their practice on the devastating symptoms of this disease.   

Here in Middle Tennessee, we are fortunate there is a large and growing number of PCP’s, Family Practitioners, Physician Assistants and Nurse Practitioners, Neurologists, Orthopedic Surgeons and Neuro Surgeons who more easily recognize the symptoms of TMD/TMJ because of the information  originating from this practice. However, referrals to physical therapists for the treatment of neck and shoulder pain is one of the most common consequences of going to the physician or immediate care clinic. 

On arrival at the physical therapy facility, one of two possibilities will occur.  The physical therapist will recommend a program of repetitive exercises, or something called dry needling for symptom relief. Repetitive motions of the neck, shoulder, and arms is used to “work” the tension out of the affected muscles and is usually a combination of clinic and home exercises.  On the other hand, dry needling is a procedure performed by the physical therapist only in the clinic.  Both repetitive motion exercises and dry needling are intended to relax the muscles involved and relieve the “tension” which is causing the pain. When dry needling is used, very sharp, small needles are placed through the skin into the parts of the muscles that are “knotted”.  These knotted areas of the muscles are called trigger points. It is theorized that placing the needle into the trigger point will cause the muscle to twitch or contract and bring blood and nutrients to the area.  The muscle then becomes relaxed, and symptoms resolve.  In practice many studies have shown this is effective.  The problem is that relief is only temporary and needs to be repeated often like massage therapy for swollen and tight muscles.  Massage therapists and physical therapists have very successful businesses because of long standing returning clients. 

The temporary solution of repetitive muscle motion, dry needling and massage therapy ignores the CAUSE of muscle tightness. The medical literature uses the term muscle trismus instead of muscle tightness. The cause of muscle trismus is the constant and recurring nerve signals coming from the central nervous system that tell the muscles not to move that portion of the body. The nervous system tells the muscles to tighten up and don’t move the associated joints.  In the case of TMD/TMJ, when the jaw joints become damaged and inflamed, the nervous system sends signals first to the muscles of the jaw to tighten up limiting jaw motion and further damage.  Tightening the jaw muscles will usually elicit headaches and jaw pain, the first and third most common symptom of TMD/TMJ.  When tightening the jaw muscles does not limit the damage and inflammation within the jaw joints, the central nervous system sends additional signals to tighten up all the muscles of the neck and shoulder to hold the entire head motionless causing the second most common symptom of TMD/TMJ, neck and shoulder pain. 

Physical therapy and dry needling are very temporary solutions while reversing the inflammation within the joint itself creates permanent relief.  The best way to create long term TMD/TMJ relief is to consistently unload the jaw joint with a device and protocol that unloads the TMJ like a set of crutches unloads the knee, or a sling unloads the elbow to decrease inflammation.  When the inflammation is reversed and limited, the central nervous system no longer sends signals to muscles that move the jaws, head, neck, and shoulders. All the associated muscles relax and the symptoms gradually fade away and stay away.