Temporomandibular Joint Pain: Why, What, and How

The temporomandibular joint (TMJ) is a small joint that can be the source of major pain in patients. While some TMJ pain is directly from the joint itself, there are MANY other causes of pain in this region and there are many treatments available. This presentation was given to clinicians as a primer on fundamental anatomy of the joint and how to evaluate TMJ pain.

A Primer on Pain Neuroscience Education and Chronic Pain

Pain science is becoming an increasingly prominent and sometimes controversial topic in PT. This is a presentation I gave for clinicians on models of pain and how to integrate pain neuroscience education into clinical practice.

Some say that pain science is just the latest fad in PT. However, pain science is not a “new treatment method”. Rather it is an extension of a holistic view of pain that acknowledges that the experience of pain is related to much more than just tissue damage.

The Disconnect: Evidence and Physical Therapy Practice

As a student and clinician, I’ve often heard about “evidence based practice”. I even had a class on the topic in PT school. Yet during clinical rotations, I almost never heard discussion of research evidence among clinicians. In fact, some clinicians disparagingly said “Yeah I don’t have time to read research”. Some clinics had monthly journal clubs where clinicians would meet, chat about an interesting paper over lunch, and then go back to treating patients. There appears to be a disconnect between the supposed importance of evidence and how PT’s actually practice.

To help address that disconnect I’m sharing Steven Kamper’s 2018 series (https://pubmed.ncbi.nlm.nih.gov/29852833/)  on how to practically apply evidence to the clinic. I also include my own commentary in [brackets].

Why should PT’s use evidence?

-The public expects medical care to be based on science [Ideally. There will likely always be a market for “body workers”, faith-healing, and related practitioners of pseudoscience.]

-If PT wants to be considered a scientific, it must use evidence
[I would argue that being scientific is the ONLY way PT can differentiate itself from the pseudoscientific professions mentioned previously. If we aren’t scientific, we’ll have to compete by developing increasingly strange, “cutting edge” treatment methods.]

-Agencies like insurers and government are trending towards only paying for evidence based treatments

But why can’t we just rely on clinicians using experience?

As clinicians we are subject to biases. First, the confirmation bias. We overvalue information that supports our views, ignore/forget what contradicts our views, and interpret ambiguous information to support our views. Second, the recall bias. We tend to remember extreme events (like a patient who did really well or really badly). [For example, if a patient raved about how they were “cured” by dry needling, we will tend to remember that patient rather than those who had a mediocre response. A related issue is that some patients stop attending PT, but we tend to forget those or assume that they improved.] Third, in clinical observation there is a fundamental difference between change in outcome and treatment effect. That is a treatment’s theoretical effect may not be solely responsible for the patient’s improvement in symptoms.

Why might patients improve regardless of the treatment effect?

-Natural history. Many conditions resolve completely or mostly on their own, especially acute conditions. For example, after a mild ankle sprain a patient will see improvement simply due to the passage of time.

-Regression to the mean. Many conditions are episodic or fluctuating. Patients may visit us only at the peak of an episode, after which point the patient’s symptoms will mostly improve regardless of intervention, since the condition is episodic. For example, some types of back pain are episodic and have exacerbations that will abate, regardless of the intervention given.

-Placebo. Placebo effects are any effects that occur due to manipulation of patient expectations and/or conditioning. [For example, if a patient expects that a chiropractic adjustment will “fix” their back pain, they are likely to feel less pain simply because they expect the adjustment to work. The point is not to disregard any treatment that has a placebo element, but we must examine the research to try to determine how a treatment compares to placebo. This has real practical implications. For example, suppose research shows that a highly “scientific”, intricate kinesio-taping pattern is found to work no better than sham, placebo taping to reduce knee pain. This means that simply applying tape to a patient’s knee will likely give the same effect as using a highly “scientific”, intricate taping pattern. If that’s the case, is it really worth it to invest time and money into a course on taping? Or should we look for treatments that have more robust evidence? Now with the COVID-19 pandemic, is it ethical to tell a patient they “need” a treatment that is known to mostly be a placebo (putting their health at risk)? Is it ethical to knowingly sell a patient a placebo with lots of “scientific” explanations?].

-“Polite patients”. As clinicians we build relationships with patients and sometimes they don’t want to “disappoint” us, so they say they feel better. [I’ve noticed this in the clinic. As a patient, it is very awkward to tell your friendly PT that all their hard work didn’t help you. Even on questionnaires, many patients will state more improvement than has actually occurred.]

The next post will discuss how to identify evidence relevant for a real patient case. As always there are exceptions and nuance to this discussion. All constructive, good faith comments are welcome!

Is Daily Practice Important? Why We Need to “Load the System”

I broke my DuoLingo streak. While studying for the PT licensure exam, I used DuoLingo as part of my Spanish training. Every day, I would hop on the app and do the exercises to hit my daily XP requirements. I built up a 45 day streak. Yet I retained little to nothing from these exercises (despite accumulating almost 2 hours per week). So I deleted the app and broke the streak.

I had been fixated on this idea that I needed to practice every single day. DuoLingo states that “15 minutes a day can teach you a language”. And many people online stress the importance of daily training: exercise, mindfulness training (meditation), etc.

However, if we are overly focused on daily training, we can run into a few issues:

First, adherence can be difficult because there is usually a cost to switching tasks (i.e. to exercise you have to put on exercise clothes, warmup, etc.) Second, sometimes life happens and we don’t get to practice. So we may feel we are failing since we’re not keeping our daily streak. Lastly, certain types of training actually benefit from not being performed daily. For example, most often people lift weights intensely 2-4 days per week. Lifting weights daily can make it harder to bring the necessary level of intensity (i.e. due to motivation, fatigue etc). Training too often can be ineffective and/or impractical.

So what is the alternative to daily training? We need to “load the system” with deeper, more intense sessions. A basic principle of biological systems, like us humans, is that stressors (challenges) promote adaptations. When a person lifts a heavy load they feel tired Their muscles, bones, and tendons have been stressed. They have “loaded the system”. That load provokes an adaptation to get stronger. Now they can lift the same heavy load with less effort.

Similarly, with other types of training we need to “load system”. For example, in language learning we need to reach that point of being challenged in order to progress. When I went to Argentina for a short trip, I thought I would practice a lot of Spanish. I did. However, the conversations were mostly less than 10 minutes and therefore not challenging. When first meeting someone, the conversations are mostly small talk, “what do you do, where are you from, etc”. Only after the 10-15 minute mark do you really get to discuss more in depth topics. And that depth is challenging, which is where the growth happens.

All this being said, daily “low load” training is still beneficial. For example, in addition to lifting weights a few times per week, walking daily is excellent for your health. In language learning, daily immersion is useful in addition to having challenging conversations.

Note that there is a minimum frequency needed for training. For example, although lifting weights for 1 hour, 3 times a week is beneficial, it would be ineffective to lift weights for 3 hours straight, once per week.

In short, not all training needs to be done daily. Rather we need to ensure we “load the system” by working at our limits.