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[MANAGEMENT FOCuS] Strengthening Referral Networks Targeted niche services help guarantee a steady flow of new patients to your practice. By Katherine Tan, PT, MPT, oCs, CCTT, and Monica vitenson, PT, MsPT, oCs, CCTT offering a range of specialty programs is a powerful strategy to keep new patients coming in to a physical therapy practice, regardless of what’s happening in the business and regulatory environments. At our practice, BodyFit Physical Therapy and Wellness in Manhattan, we’ve cultivated a strong network of referral sources by establishing niche services that meet the needs of our community. Spotlighting One Service In our practice, we treat a large number of patients who have been diagnosed with temporomandibular dysfunction (TMD). Often, these patients present with a long history of neck pain or headaches. They commonly report that they have previously had physical therapy and possibly other therapies such as chiropractic, massage and acupuncture for their cervical pain, and although these treatments were helpful, their symptoms never fully resolved. Clinically, we start by performing a cervical screen to rule out overlooked cervical involvement. For example, a restricted occipito-atlantal (OA) joint can be a common cause of lower cervical pain due to compensatory changes and stress to this neighboring region. Another frequently missed finding that can contribute to posterior neck strain is stiffness or tension in the anterior neck muscles especially sternocleidomastoid (SCM). If your patient’s chronic cervical symptoms persist despite having fully cleared the cervical spine, an assessment of the TMJ and surrounding musculature might offer some insight. Many physical therapists realize that a dysfunctional hip or ankle can cause knee pain but might forget that the TMJ has a similar relationship to the neck. Here are the questions to ask your patient. Do you have a history of TMJ problems? You may be surprised how many patients will answer yes but didn’t think it was relevant to mention to you earlier. Do you associate your neck pain with headaches? Does your neck pain or headache feel worse in the morning? These are common 8 ADVANCE for Physical Therapy & Rehab Medicine complaints of people who clench or grind their teeth at night. Some patients may reveal that they know that they clench and that their dentist has even made them an occlusal appliance or “nightguard.” However, don’t assume that a nightguard will help; not all occlusal appliances are created equal. For example, soft, pliable appliances, the kind most commonly made by general dentists, can actually exacerbate jaw and neck symptoms by prompting the patient to chew and clench on the appliance while they sleep as if they were chewing gum all night. Imagine the muscular fatigue and strain this would cause. Conversely, hard acrylic appliances, most often prescribed by TMD dental specialists, protect the teeth from wear without increasing muscular tension. Does biting down hard increase your neck pain? If your patient does not know the answer to this question, ask them to bite down and whether it increases their symptoms. A positive finding warrants further examination of their masticatory muscles. Do you have any parafunctional habits? These include nail biting, gum chewing, pen or pencil chewing, coffee cup or stirrer chewing, etc. and can cause excessive TMJ compression, ligamentous strain and muscular overload. Does your neck pain increase after yawning, talking or eating (especially chewy, crunchy or hard foods)? This finding suggests a direct link between jaw function and their neck pain. Areas to Examine At this point, you can move into more targeted diagnostic tests, such as the following. Mandibular ROM. Standard opening is 40-50 mm, or approximately 3 fingerwidths. A patient who can only comfortably fit two fingers or less in their mouth likely has decreased overall TMJ mobility. Also check for the ability to protrude the mandible 3-5 mm and glide laterally 10-14 mm in each direction. Look for the ability to open and protrude the jaw in midline. A deflection or deviation to one side with either motion is dysfunctional and suggests a TMJ disc pathology or a muscular imbalance. Is clicking in the joint associated with either opening or closing? Clicking is often a sign of disc pathology. Evidence of parafunctional habits. Check the teeth for signs of excessive wear due to grinding. Some patients might deny that they grind their teeth, but their teeth may tell a different story. Look at the sides of the tongue for “scalloping,” or a lasting impression of their teeth caused by sucking hard on their tongue. While sucking doesn’t cause tooth wear like grinding does, it can create just as much tension in the jaw muscles. Look at the inside of the cheeks for a “linea alba” or white line caused by the teeth when sucking and chewing on the inside of the cheek. Palpation. Some important masticatory muscles to assess for tenderness or hypertonicity include the temporalis, masseters, medial pterygoid (under the mandibular angle) and suprahyoids (under the chin). Full assessment of the masseters and temporalis requires intraoral palpation. One way to test the extensibility of the masseter muscle is to place your thumb inside the patient’s cheek and your fingers outside; gently squeeze the cheek and press your thumb out into the cheek simultaneously. This should be painless and pliable. To palpate the temporalis tendon for tenderness and extensibility near its attachment to the coracoid process, slide your finger along the upper gums between the maxilla and the coronoid process. Accessory joint motion. Like any other synovial joint, a healthy TMJ should have a springy and pain-free end feel. Since both TMJs move simultaneously, it’s important for both sides to have equal mobility. Otherwise, excessive torque or ligament strain can develop on one side. Each TMJ should be able to gap with distraction and glide anteriorly as well as have a JEFFREy lEESER
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