Looking forward

For twenty years, the Journal of Manual and Manipulative Therapy has sought to inform the instruction and clinical practice of manual therapy across a wide array of clinically relevant topics. As evidenced by our journal’s growth and breadth of distribution, it is impacting its readers in a meaningful way. As we look forward to 2014, I would like to offer a reminder and an announcement about what lies ahead for JMMT.

I am very excited to announce that we will have a special issue leading off the New Year devoted to head pain and tempromandibular joint dysfunction that is guest edited by Drs. Carol Courtney and Cesar Fernandez-de-las-Peñas. All articles are invited manuscripts and will cover topics ranging from basic to clinical science, as well as examination, diagnosis and intervention for disorders of the head, face and TMJ. In addition to contributions by our guest editors, the issue will feature articles by Dr. Ruth Defrin on post-concussive headaches, Dr. Harry von Piekartz on facial pain, and a two-part series on TMD by Dr. Stephen Shaffer and colleagues. This promises to be one of the outstanding contributions to the literature regarding head and facial pain disorders. Here are some reasons why we need this focused issue now.

In 2011, approximately 49,000 patients visited physicians in the United States with a diagnosis of migraines/severe headaches (37,904) or jaw/facial pain (11,436).¹ These numbers don’t exactly pale to the number of patients with whom most of us are more accustomed to seeing; i.e., those with cervical spine (36,798) or lower back (66,917) pain.¹ Worldwide, headaches have been reported to affect 47% of the population.² Meanwhile, the prevalence of tempromandibular joint disorders has been reported as 6·3% for women and 2·8% for men.^3,4 A momentary reflection on those numbers should inspire every manual therapist to consider how he/she might prepare to best manage patients with these disorders. No doubt that not all patients with facial, jaw, or head pain require the services of a manual therapist. However, that should not diminish our preparation for recognizing, at the very least, those patients who do and which need referral to another specialist. Moreover, the need to provide quality service is evident for those patients who would benefit from our interventions. Are we there?

When was the last time that you asked a patient with cervical spine pain and/or headaches to show you how well they could open their mouth, move it side-to-side, and/or show you his/her bite? Did you inquire or examine for missing teeth or dental appliances? What about bruxism? Hopefully, most of us nod in considering those questions, but I can imagine that I have some readers scratching their heads right now trying to come up with an answer.

In 1978, I had been in practice for one year, or something less. I’ll never forget my first encounter with a patient [Sylvia] who had tempromandibular joint dysfunction (TMD). My students (current and past) know this story well because I share it with them to drive home the point that we too readily overlook the contributions of the TMJ since it is oft perceived as a problem for our colleagues in the dental profession to contend with. Or, perhaps, we just don’t think about the relationship between the TMJ and cervical spine when we see a patient with cervicalgia or headaches. As a backdrop to this story, I “defend” my oversight with this tidbit: I ran a topical search on Medline with “physical therapy” and “TMJ” spanning the years 1950-the present. I came up with 152 articles. I ran the same search over the time span from 1950–1978 (about the time I saw Sylvia in the clinic); I came up with 9 articles.

Sylvia came into the clinic upon referral from one of the general surgeons in the small town where I practiced at the time. She had headaches and neck pain that I am confident that she scored at 10/10 on the Visual Analogue Scale, because she was in so much pain. Following my examination, I was certain that I had a good grasp on the source of her pain. The musculoskeletal-related findings in her cervical spine were abundant- increased tension, loss of range of motion, atrocious posture, local tenderness, and weakness.

I am reasonably certain that we touched on the TMJ in PT school, but I suppose I missed class that day. Interestingly, one of my current colleagues still has the musculoskeletal examination textbook that we used in 1976, so I looked this up: Hoppenfeld⁵ actually had 5 pages devoted to examination of the TMJ! I would have bet a paycheck that he had none; credit to Dr. Hoppenfeld. Our other source at that time, for patients presenting with neck pain, by Cailliet,⁶ which I still have (!), had no references to the TMJ.

Following my examination of Sylvia, I offered her a combination of modalities, exercise instruction, and soft tissue treatment, as I recall. But the unfortunate decision was to treat her with mechanical cervical traction, which was, at that time, administered exclusively by a collar that included a chinstrap. It was not until the next day that Sylvia showed me her limited capacity for opening her mouth; less than the width of her index finger. The traction had exacerbated a previously minor issue. It was a cruel initiation to the realization of the influence of the TMJ in patients with neck pain and headaches. I’ve never forgotten that lesson. In an attempt to get her on the right track, I immediately sought help from a dentist who specialized in treatment of TMD; there was one in the entire state of South Carolina.

My current impression is that we have come a long way in our readiness to treat patients with headaches and TMD. After all, we have at least 152 relevant articles now, compared to nine. My current class textbook, by David Magee,⁷ offers an entire chapter on the topic. Yet, I think that it would be relatively easy to convince me that we are still overlooking the contributions of the TMJ to upper quarter pain presentations and that our entry-level graduates, at least, might not be aptly prepared to manage patients with a chief complaint of headaches. While this lack of expertise and preparation is probably not universal, it is a challenge for me to come up with many “experts” in management of TMD and/or headaches in the handful of cities that I have lived in in my professional career. I believe that we are, on the whole, in need of enhanced preparation and understanding of how to best manage patients with diagnoses related to these areas. As a point of reflection, ask yourself whether or not you are as well prepared to engage a dental colleague as you are a physician. I imagine that most of us engage medical colleagues almost daily, but dentists only about every six months, i.e., at our own appointment!

When patients come with neck, head, and/or facial pain, we cannot assume that relevant dental pathologies have been ruled out. Craniofacial pain can create significant physical and psychological stress. Establishing a presence in this area of practice would be of immeasurable benefit to our patients and create, perhaps, for many, an entirely new cadre of potential patients and referral sources. Let’s enhance our readiness to step into this realm. I hope that you will start by wholly consuming what our experts will present in JMMT 22 (1), 2014. It may open intellectual and practice doors that you may not have envisioned. Please join me in thanking our guest editors and the invited authors for their part in this important contribution to the literature.

As a reminder footnote, please remember that, in 2014, we will begin requiring registration of all clinical trials published in JMMT. If a manuscript was accepted early in 2013, but not published until the new year, then that manuscript will be exempt from this requirement. However, as published in JMMT 21 (1) earlier this year, we will henceforth be requiring that all clinical trials be registered. The rationale and means for registering clinical trials is fully presented in the joint editorial presented in our first issue of 2013. The process is simple, yet important. It adds a measure of integrity to research and publication. We join a very select group of journals in establishing this requirement and are pleased to do so.