Mar 3, 2014

Concussion, Cervical, TMJ/TMD or a Combination Thereof?

Myofascial Release of the Temporalis
Welcome readers! Today's post is about a very recent case of mine straight from the clinic! This is a mini case-study about a 22 year old male collegiate basketball player. This patient took direct blow via an elbow to the anterolateral aspect of the cranium during a basketball game on Saturday evening. After the game the athlete presented with several concussion symptoms as well as TMJ pain and a palpable and audible click with opening and closing of the mouth.

The patient presented with these findings during the assessment:
  • Cranial Nerve Testing all WNL
  • Dermatomes & Myotomes WNL
  • Concentration, Immediate Recall, Delayed Recall, Balance, and Orientation via the SCAT3 were all WNL
  • Patient Reported Concussion Symptoms
    • Headache, "pressure in head", "Not feeling right", Difficulty Concentration, and eventually added the symptom of difficulty sleeping the next morning.
  • Glasgow Coma Scale: 15/15 (WNL)
  • 1 Previous Concussion in the symptom prior where the patient suffered much more severely on the SCAT2 and had post-concussive symptoms for 2-3 weeks following initial injury.
Long before this case presented to myself I often wondered about possible connections between concussion symptoms, and temporomandibular joint(TMJ)/temporomandibular dysfunction(TMD)/ and cervicogenic headaches. I questioned whether a person could present with concussion symptoms due to potential muscle guarding/spasm and possible involvement of TMD/TMJ issues.

Obviously I still treated this patient as having a concussion and his symptoms had slightly increased the following morning(Sunday) as well. Nevertheless, despite the fact that I was treating him for a concussion and ordering complete neurocognitive rest (despite having perfectly acceptable objective test scores on the SCAT3) I decided to treat his TMJ and neck musculature using manual therapy. NOTE: Current policy with our team neurologist is to assume its a concussion and wait to imPACT test the patient with cessation of symptoms.

I only did a few minutes worth of manual therapy for this patient and they were done with very light pressure. I started with 1-2 minutes of light IASTM to the Masseter, and myofascial release of the Temporalis using my hands. (Both pictured in the above photos.) I followed these up with some light lateral mandibular glides bilaterally for about 30 seconds each.

Finally, I applied lateral-medial/posterior-anterior pressure with the pads of my second digit on both sides of the first palpable spinous process while the patient simultaneously performed an active cervical retraction or chin tuck, if you will. This was done in an alternating fashion with pressure on again/off again in 2-3 second cycles for about 30 seconds total.

The patient reported rapid improvement in their symptoms but not complete cessation and they started to slowly return about 40-50 minutes later...Which one might expect with a concussion...or with a rapid responding patient that wasn't given a HEP to perform after manual therapy. Which one is it? I can't be sure but I play on the safe side and assume the worst. Additionally, the click/pop of the TMJ was no longer present after treatment

The following day (Monday) the patient reported complete cessation of his symptoms and the TMJ issue had not returned. The patient underwent imPACT testing which came back normal and began the first step of a graduated return to play progression.

In conclusion, what does this all mean? I don't know. What if I wouldn't have chosen to treat the patient with manual therapy. Perhaps he would have awoken still with total cessation of symptoms and would have passed his imPACT as well. (This still doesn't even prove he didn't suffer a mild concussion!) Another potential alternative is that the patient could have continued to suffer from "concussion" symptoms for days at a time and perhaps this would have delayed his imPACT testing and subsequent return to play/activity/sport. 

This is not necessarily a bad thing because it is always best to play it safe. However, it also means that my patient/athlete would have had to suffer undue pain/discomfort related to his TMD/"concussion" symptoms. He also would potentially have to miss out on class/social activities/and experience a lot of undue psychological stress if I hadn't treated these findings. I am just curious if others if had these similar thoughts/case/experiences or what you all think of this? 


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