Physiotherapy in the Treatment of Craniomandibular, Craniofacial and Craniocervical Disorders with Krina Panchal

My name is Krina Panchal and I am a Biomedical Scientist, Physiotherapist and a Nutritional Therapist treating craniomandibular, craniofacial and craniocervical disorders.

My career began in 2007 when I graduated from Biomedical Science BSc (Hons). I realised that spending time in a lab wasn’t for me; I needed more patient contact and having enjoyed my experiences with physiotherapists I then went on to study Physiotherapy graduating in 2010. Since then I’ve never looked back.

Two years later I was introduced to Temporomandibular Joint Disorder (TMJD) by my husband who is a dentist. Physiotherapists in the UK are not taught the TMJ so this was new territory for me. Some evening reading became fascination and encouraged me to travel to the USA for advanced training. First stop Atlanta, to train with the renowned physiotherapist Steve Kraus and then onto Columbia University, New York and worked within an MDT which included a Neurologist, Oral & Maxillofacial Surgeon, Psychologist, Dentist and a Physiotherapist.

I have since completed the Masters module in Differential Diagnosis and Assessment of the Temporomandibular Joint at the University of Liverpool and continue to progress my knowledge and skills with recent completion of the Craniofacial Therapy Academy (CRAFTA) courses based in Germany. In addition I am an active committee member of the Association of Chartered Physiotherapists treating Temporomandibular Disorders (ACPTMD).

I currently work closely with Mr. Piet Haers OMFS (President of the International Association of Maxillofacial Surgeons in 2014-2015) as well as several London-based dentists.

Note: My preferred terminology for TMJD is in fact "Craniomandibular, Craniofacial, Craniocervical disorders". In the following paragraphs "TMJD" has been used as this was the term used in the studies own texts.

What is Physiotherapy?
Physiotherapists help people affected by injury, illness or disability through movement, exercise, manual therapy, education and advice. They help people of all ages maintain their health, helping patients to manage pain and prevent disease primarily but also alongside modes such as drugs or surgery.

Evidence for Physiotherapy in the Treatment of Craniomandibular, Craniofacial and Craniocervical Disorders
1) Ambrosina Michelotti graduated in Dentistry in 1984. In 1991 she qualified in Orthodontics and since she has been teaching undergraduate and postgraduate courses in Orthodontics and TMJD at the University of Naples Federico II as well as researching physiotherapy treatment for TMJD. She has found through her studies that physiotherapy should be the first port of call for TMJD patients. [1,2,3]

2) Harry van Piekartz is a physiotherapist based in Germany and has also completed several research articles on the effects of physiotherapy on TMJD. Harry has found that manual therapy is effective on craniomandibular, craniofacial and craniocervical disorders. [4,5,6]

3) Dr Mariano Rocobado is a Doctor of Physiotherapy from Chile who created the 6 x 6 x 6 TMJ exercise. He has also done many research articles on the effects of physiotherapy on TMJD where he believes these patients can be treated through exercise and manual therapy. In addition he advocates that physiotherapists and dentists should work alongside each other. [8,9,10]

4) There are also many studies which highlight when physiotherapy is used with splint therapy the outcomes are better than with splint alone or physiotherapy alone. However it should also be noted that there are also many studies that suggest splint therapy is better than physiotherapy. I think a lot more research needs to be done in this area to reach any conclusions. In my experience using both produces the best outcomes. [11, 12, 13]

5) A group of internationally recognised scientists, with expertise in epidemiology, pain mechanisms, TMJD diagnostics, functional genomics, statistical genetics, bioinformatics, and biostatistics, in collaboration with a highly recognized Data Coordinating Center (Battelle Memorial Institute) and the National Institutes of Dental and Craniofacial Research initiated a 7-year prospective cohort study titled: Orofacial Pain Prospective Risk Evaluation and Assessment Study (OPPERA). The primary goal of the OPPERA study was to identify the psychological and physiological risk factors, clinical characteristics and associated genetic mechanisms that influence the development of TMD as well as characterising the biological pathways through which these genetic variations causally influence TMD risk.

They found that about 4% of subjects developed TMJ each year, and that, of the 202 factors considered, several of these factors had a significant impact on the risk of developing TMD. They found that general health factors made the largest contribution to your risk, followed by psychological factors and characteristics of your head, neck, and mouth. Several genetic factors were also linked to developing TMJD, but future research is needed to determine their contribution. Another insight of the OPPERA study is that TMJD isn’t uniform for all people. There are many potential profiles of TMJ sufferers, and because of this, there are many TMJD treatments that can be employed to achieve optimal results that are also non-invasive and reversible. [14]

How Do I Assess Craniomandibular, Craniofacial and Craniocervical Disorders?
My initial assessment usually lasts 90 minutes. This is because I create a timeline of the patient’s full medical history from when they were a child to the present day as well as the present complaints and patterns of symptoms they are experiencing. I then go on to carry out an objective assessment which consists of an extra oral examination, an intraoral examination, palpation, conduction tests of the cranial nerves, neurodynamic testing, lymphatic system evaluation, biomechanics of the TMJ, accessory movements of the TMJ, cranium, cervical and shoulder evaluation. This gives me a full picture of the patients craniomandibular, craniofacial and craniocervical status. I always make sure that the patient is under the care of a dentist or a maxillofacial surgeon to make sure they are receiving treatment from both aspects.

It is also important to note that TMJD patients need to be treated from a biopsychosocial approach therefore if appropriate I will also refer to a range of allied practitioners including: Gynecologists, Endocrinologist, ENTs, Gastroenterologists, Clinical Psychologists, Cognitive Behavioural Therapists, Mindfulness Meditation practitioners, GPs, Rheumatologists and Sleep Specialists.

How do I treat Craniomandibular, Craniofacial, Craniocervical Disorders?

I treat patients with the following therapies:

• Low level laser therapy
• Dry needling
• TMJ manual therapy
• Cervical manual therapy
• Cranium manual therapy
• Massage
• Myofascial taping
• Dean Watson headache technique
• Pilates
• Full postural rehabilitation
• Nutritional assessment
• Laboratory Testing
• Behaviour modification techniques
• Nerve glides

Conditions I treat

• All TMJ Disorders
• Headaches
• Migraines
• Tinnitus
• Trigeminal Neuralgia
• Pre and Post Surgical head, neck and face
• Fibromyalgia
• Chronic Fatigue Syndrome
• Rheumatoid Arthritis
• Vertigo
• Neuropathic and Neurogenic Pathologies

Why use nutritional therapy for Pain and Inflammation?
in when I came across evidence that highlighted how certain food types alter the IgG, IgM, IgA, and IgE presence in the blood and therefore impact inflammatory processes in the body.

Elimination of these foods has been shown to reduce patients’ migraine occurrence [15, 16]. I decided to incorporate the conclusions of this evidence when treating a family member who suffered from migraines.

I had them adopt a highly tailored diet with specified supplements; he was migraine free within a week!! This is when my journey as nutritional therapist started and it is proving to be beneficial for my patients.

Why does Nutritional Therapy help when treating Pain?
1) Mitochondrial Dysfunction: Many studies results show that the five major mitochondrial functions (the mitochondrial energy generating system, reactive oxygen species generation, mitochondrial permeability transition pore, apoptotic pathways and intracellular calcium mobilisation) may play critical roles in neuropathic and inflammatory pain. Therefore, it would be common sense to preserve mitochondrial function to alleviate or prevent chronic pain [17]. A way we can optimise the “health” of the mitochondria is through nutrition i.e Magnesium deficiency leads to impaired cellular energy production in the mitochondrial electron chain complex therefore having magnesium rich foods or supplementing with magnesium can help chronic pain. [18,19]

2) Dysbiosis (“leaky gut”) has been linked in several studies with joint pain/chronic pain. [20, 21, 22, 23, 24]

3) (Hypothalamic-Pituitary-Adrenal): HPA axis dysregulation (adrenal fatigue): Those with TMJD have been shown to have altered cortisol rhythms indicative of HPA dysregulation. They have high levels of cortisol in the morning, and also exhibit an enhanced release of cortisol when stressed throughout the day. Pain itself is a stressor! When you are subject to chronic stress, your body becomes desensitized to the effects of cortisol. When this happens, inflammation is running rampant as the normal processes that keep it in under control do not function as they should. Inflammation and oxidative stress are also associated with TMJD, and therefore the inflammatory processes that take place at the TMJ may be the cause of the patient's pain experience. To decrease your inflammation, it is first crucial to get your HPA axis functioning normally. [25] [26].

4) Oestrogen and TMJD: more women than men experience temporomandibular disorders, subsequently researchers thought there might be a hormone-related connection to this disorder. According to recently published research [28], the connection between the contraceptive pill, decreased natural oestrogen and TMJD appears to be true. Changes in the bones of this joint have been seen. Also, the combined effect of the compression within the joint through parafunctional habits and low levels of natural oestrogen can lead to increased inflammation. In some individuals, this inflammation can result in osteoarthritis of the joint. [27] [29]

The four points above can all be managed nutritionally. Surprisingly many doctors, dentists and physiotherapists do not assess all of the human body systems.

Since adding nutritional therapy to my physiotherapy practice I am more able to assess all systems and give the patient the best outcome.

A typical nutritional assessment will be a detailed outline of the medical history from childhood to the present day resulting in appropriate lab tests and treating the patient with diet and supplementation. This process of assessment using lab tests are the principles of Functional Medicine which I am studying at the moment.

Conclusions
TMD is a multifactorial condition that can be complicated and difficult to treat. However, with new research we have a better understanding of the many factors that lead to its development.

Given this new research, it’s likely that treating the TMJ through dental and physiotherapeutic measures as well as assessing HPA axis dysregulation, controlling inflammation, analysing mitochondrial “health” and balancing hormones through nutritional assessment will bring relief to those that suffer from craniomandibular, craniofacial and craniocervical disorders.