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A joint approach

Robert Millett meets a successful multidisciplinary team running a holistic clinic for temporomandibular joint problems

People with jaw joint discomfort often have to endure frequent referrals – to dentists and to ear, nose and throat specialists, for example – before they receive the treatment they need.

But now a pioneering multidisciplinary service is providing an answer through a holistic, patient-focused approach.

Clinical lead physiotherapists Helen Cowgill and Nicola Pugh are key members of the innovative temporomandibular joint (TMJ) team based at King’s College Hospital, south London.

The team also includes a consultant maxillofacial surgeon, a prosthetist, a pain management consultant and a psychiatrist.

The service was set up three years ago and early analysis of the clinical data has revealed outstanding outcomes and strikingly positive feedback.

So much so that data from the clinic were presented at this year’s British Association of Oral and Maxillofacial Surgeons conference in London, and the World Congress of Pain Clinicians conference in Granada, Spain.

A paper has also been submitted to the prestigious British Journal of Oral and Maxillofacial Surgery.

The success of the service is seemingly down to two key factors – a multi-disciplinary mindset, which promotes constructive cooperation and knowledge sharing, and a decision-making process that includes the patient as an active participant.

‘At the moment most TMJ patients are treated in separate departments and not in a collective setting like this,’ says Shaun Matthews, consultant maxillofacial surgeon.

‘We offer a holistic approach where we can all discuss the best modality that may be available for the patient.

Our outcomes so far are extremely promising and seem to suggest this helps patients in the long-term.’

Impressive outcomes

The clinic offers a ‘one stop’ multidisciplinary environment.

Each patient is assessed by all the specialists at once and the team adopts a combined approach to management.

Preliminary results show that 94 per cent of patients coming through the clinic have reported improvements in their quality of life.

Patients come from London and south east England and have often exhausted what is available locally.

‘They are the ones who others have been trying to treat for a specific period of time and have been unsuccessful so the symptoms have got worse and they are then referred on to us,’ says Mr Matthews.

‘They’ve been through other disciplines and other departments and they’ve had all the bog standard, conservative treatment options that haven’t worked.’

The service opens just one day a month and sees around four patients.

The relatively small number means each patient receives an unprecedented degree of attention.

For a start there is an initial 45 minute consultation, which is attended by all team members and is highly collaborative in nature.

‘On a standard clinic I would only be allocated a 10 minute slot to see each patient,’ says Mr Matthews.

‘But here the patients get a lot of time spent on them and we often get letters and cards which say: “Thank you – I feel like for the first time someone has actually been prepared to listen to my problem” and that’s  because we’ve devoted that time to them.’

Inspired by visit to Austrian clinic

The first of its kind in the UK, the clinic was inspired by the patient-focused approach of a service in Vienna, Austria, that Mr Matthews, Ms Cowgill and Cristina Nacher, a consultant maxillofacial prosthetist, visited.

The lessons they learned  influenced the development of the King’s service.

‘I had the idea of setting up a clinic where all the disciplines would gather together in the same room and – even more importantly – the patient would also be there,’ says Mr Matthews.

‘So we could  all see, speak to, examine and take a history together at the same time and come up with a collective treatment plan that we all feel is appropriate.’

The central idea is that staff conduct an open discussion in front of the patient about what they feel will be beneficial for him or her and strive to involve the patient in their own care.

The patient-group discussion empowers the individual and also has advantages for the staff as well as the patient.

‘From a physiotherapy point of view we know exactly what the entire treatment plan is going to be and don’t have to wait for clinic letters to tell us what will be happening from a surgical or pain management perspective,’ says Ms Cowgill.

‘It’s really good because you‘re given a clear picture of exactly where you’re going with the patient for each discipline, which is something that you don’t get in a normal clinic.’

The treatment plan might involve physiotherapy, medication or surgical treatment – or a combination of approaches.

Although not present at the group consultation, consultant psychiatrist Lisa Page provides psychological aid when needed.

‘The main reason people come to us is because of pain,’ says Tim Poate, pain management consultant.

‘There may be other factors such as clicking or noise from the joint, or an inability to open the mouth wide which may affect their ability to eat, but the main reason that they come to us is pain from the joint.’

Mr Poate explains that many patients with facial pain experience associated depression or anxiety.

This can create a damaging ‘see-saw’ of suffering, because chronic pain not only causes depression and anxiety but, conversely, anxiety and depression actually worsen chronic pain.

In these cases, pain-killing medication is often necessary, but psychiatric counselling can also reap huge benefits.

Physiotherapy input

When physiotherapy will be beneficial, the initial stage of assessment involves observation, with attention paid to both the problem area and the general positioning of the body.

‘The first thing we do is to look at posture – because that has a huge impact on jaw position and the different muscles around the jaw,’ says Ms Cowgill.

‘Then we make observations around the jaw to look at the active range of motion, the passive range of motion and to access movements of the joint.’

Once the problem has been assessed, the physiotherapists primarily reply on manual therapy techniques. These include specific joint mobilisation methods and soft tissue manipulation.

‘We also have acupuncture as an adjunct to treatment which is really beneficial for dealing with the soft tissues and dealing with the pain as well,’ says Ms Pugh.

‘We needle the actual soft tissue of the area but there are other points on the body where you can access the pain gates.’

The majority of patients respond well to manual therapy, acupuncture, soft tissue release and being given appropriate exercises to follow.

There is also access to a low intensity laser therapy.

Most jaw joint patients respond well to conservative management and surgery is usually a last resort.

But people with severe osteoarthritis or rheumatoid arthritis of the jaw joint may have been unable to eat or chew and have intractable pain. If extreme surgery is required, patients may need their entire jaw joint replaced with an artificial one.

Following surgery, patients usually start physiotherapy relatively quickly.

At first, the rehabilitation consists of using a functional mechanical jaw exerciser machine, which encourages movement in the jaw joint.

Later, patients can be offered a range of motion exercises, strengthening exercises and mobility exercises for the joints.

After any course of treatment various outcome measures are used to monitor progress, such as checking whether pain has reduced and whether the patient’s function has improved.

Patients complete regular feedback forms and questionnaires.

‘We see them as many times as they need to be seen,’ says Ms Cowgill.

‘And we re-evaluate them to see that they are making progress with the objectives that we’ve set with the patient. If the patient is happy and we’re happy then we discharge them.’

Planning for the future

Given the success of their clinical outcomes the team hopes the clinic will open more frequently.

The number of referrals we get is enormous,’ says Mr Matthews.

‘Jaw joint problems are the second most common referral to dental school after wisdom teeth.

That’s because 25 per cent of the population will, at some point in their lives, have problems with their jaw joints – that’s one person in four.’

Yet, although TMJ disorders are common, most physios don’t know how to respond. ‘With regards to physiotherapy the problem we have is that TMJ is not routinely taught at undergraduate level,’ says Ms Cowgill.

‘It’s considered more of a specialist subject and is only taught at post-graduate level, so a lot of physios come through their training without even seeing a jaw joint patient.’

Ms Cowgill and Ms Pugh are keen to raise awareness of the treatment and management of TMJ disorders among physios and bridge the ‘knowledge gap’.

Ms Pugh is writing an educational research paper, while Ms Cowgill helped to set up the Association of Chartered Physiotherapists in TMJ Management.

For further information, email: Helen@TMJphysio.co.uk or Helen.Cowgill@outlook.com or visit www.TMJphysio.co.uk fl

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