Rub Out TMJ

Therapeutic massage holds out healing hope for sufferers of jaw joint disorders
By Vesna Vuynovich Kovach
In Anew magazine, Autumn 2005

He was graceful, lean but not quite lanky, with high, well-defined cheekbones, a broad, intelligent forehead, and a thoughtful, artistic intensity in his eyes. He pretty well fit the description of all my youthful crushes – like Fred Astaire and Ludwig Wittengstein (yes, the philosopher) – and also of – maybe you could guess it, but I was 30 before a girlfriend pointed it out to me – my father. My heart leapt. My blood rushed. My brain – scandalized – scolded and denied. I shouldn’t be feeling any of this.

It was my ex-boyfriend from L.A., whom I hadn’t seen for nearly a decade, come to visit. It hadn’t occurred to me that, after years of friendly correspondence, I’d be so primally attracted to him on sight, just like when we first met. I suddenly and painfully recalled that he dumped me. And what a fool of myself I’d made over it.

My body fairly vibrated as I accepted his warm hug. I watched as if from a great distance as he cordially shook hands with my husband. I tensed. I didn’t know what to say.

And then my jaw locked shut.

My jaw remained clenched, frustratingly, through the wonderful Chinese dinner we went out for. (Sucking Lo Mein wasn’t too bad, but oh, those big, juicy dumplings!) Long past that short-lived, but intense, jolt of first encounter. All through the perfectly normal and lovely week the three of us enjoyed together. And a few days thence.

This was one of the many episodes of TMJ (temporomandibular joint, or jaw joint) disorder (sometimes abbreviated as TMD) I’ve experienced over the course of my adult life. And I’m not alone. The National Institute of Dental and Craniofacial Research, one of the National Institutes of Health (www.nidcr.nih.gov), estimates 10.8 million Americans share my pain.

Recently I decided to find out more about TMJ, and explore the possibilities for a healing journey. I discovered some surprises along the way. And I came to the conclusion that the most promising avenue for treatment might be one that most of those millions will, unfortunately, probably never pursue: therapeutic massage.

TMJ problems can be difficult to diagnose, partly because there are so many possible symptoms: pain; impairment of motion; a jaw that’s locked in an open or closed position; clicking, popping and crunchy noises; headaches; eyelid twitching; sleep disturbance; dizziness; a changing bite; flu-like symptoms; bad wear on the teeth; even toothaches. For some, the symptoms are mild and/or infrequent; for unlucky others, persistent and/or excruciating. Episodes are often triggered by stress, as in my case, and are intermittent – and that also makes it hard to judge the effectiveness of therapy.

The cause of “TMJ syndrome,” as this cluster of conditions is often called, is unknown. There are plenty of theories: orthodontic work, malocclusion (bad bite), stress, chewing gum or ice, tooth grinding at night, injuries or trauma to the head or neck, posture, playing woodwind instruments, tooth extractions. But for just about each theory, there’s at least one scientific study that contradicts it.

Treatments include braces to correct jaw position, grinding down the teeth to change the bite, “splints” that can be inserted or else implanted surgically – an irreversible procedure – hot and cold packs, and rather dreary advice to subsist on soft foods for life. None of these are known to work terribly well, according to the NIDCR’s 1996 Management of Temporomandibular Disorders conference assessment statement.

Another wrinkle: 90% of folks seeking treatment are women in their childbearing years, according to the TMJ Association (tmj.org), a national non-profit advocacy, education and support group based in Milwaukee.

So here’s a condition that (1) is generally reported by women, (2) is associated with stress, (3) has no known cause, and (4) resists treatment. Put all that together and you shouldn’t be surprised that TMJ sufferers are too often told that their condition is merely psychological – all in our pretty little female heads, as it were. For many, the legacy of this invisible pain can be alienation from friends and family who have run out of patience, humiliation by condescending or unsympathetic doctors and dentists, frustration and despair.

Add to this the likelihood that the number of TMJ sufferers is far greater than statistics indicate. There’s reason to believe that many, if not most, do not report their condition to anyone. Or that when they do, it’s shrugged off and not referred for treatment, as happened with me some 23 years ago when I consulted a physician soon after first experiencing jaw locking. More recently, I told my dentist that my bite sometimes changes from day to day. He looked puzzled, then told me that was impossible and changed the subject.

This time, I decide to investigate massage therapy. I speak to Rebecca Massman, LMT, a massage therapist who specializes in site-specific, medically directed, therapeutic bodywork. Massman tells me she encounters plenty of TMJ troubles in her work; about one in eight of her clients report it. “I think it’s way more common than people think,” she says. But only rarely is it the reason for their visits.

Massman works at the UW Health Center for of Integrative Medicine, as well as in private practice. She is an instructor of soft tissue techniques and clinical anatomy at the East-West Healing Arts Institute, a local school for therapeutic massage. (“Soft tissue” refers to all sorts of features softer than bone, even though they may not seem squishy-soft to us layfolk.) The massage modalities she uses include myofascial release (the stretching and pulling of fascia, fibrous bands of connective tissue) and trigger point techniques (areas that, when touched, feel painful at that spot and in other “referred” places as well).

Massman is trained in TMJ massage. But having the opportunity to use it is another story. “Clients will usually come for something else, and the TMJ is secondary to other issues,” she says, but as “everything’s connected, everything’s related in the body,” these could be addressed holistically together with the TMJ. “It’s not well known that massage can help,” she says. “They don’t think we can treat it, or what to do. I let them know we can work on it, and they can get relief. They listen. I do a little jaw work to let them know. But then the numbers go way down, like one out of 50 says, yeah, go ahead, let’s do it.”

Why not? One reason is insurance. It’s rare to find coverage for TMJ massage – even though more invasive approaches that are far more expensive, like surgery, are readily covered. What’s more, Massman says TMJ is just one of many conditions that could be treated successfully with massage, but that few people get because of insurance. She lists Carpal Tunnel Syndrome, frozen shoulder and Thoracic Outlet Syndrome, which causes numbness, pain and pins-and-needles sensations along the arm.

Massman says that a full course of TMJ therapy can take anywhere from one to 10 hour-long sessions, “depending on the individual, what’s involved, how long it’s been an issue. Years, or months? The longer it’s been around, the more time and work it will take.” In south central Wisconsin, massage typically costs $60 to $70 per hour.

Another reason could be that physicians traditionally have referred TMJ cases to dentists and orthodontists, who are not usually experienced in soft tissue work in the same way that massage therapists are. These specialists do not ordinarily make referrals to massage therapists.

Another factor that keeps people from diving into TMJ massage treatment: pain. “It’s an ongoing series of treatments, and it can be really painful,” says Massman. “Probably the most painful area of the body to work on.”

I get a demo session from Massman, and I can attest to the pain – but also to the effectiveness. The experience transforms how I think and feel about my TMJ issues.

Massman begins by palpating my subocciptals, the muscles down at the back of my skull. As she presses on the trigger points that she finds there, I feel sensations shoot through my cranium and then subside as the muscle fibers relax. A classic trigger point response.

Next, she squeezes along the length of the sternocleidomastoid (SCM), the long, ropy muscle on the side of the neck that connects chest to collarbone to jaw. Not much pain there, in my case. “I would do the scalenes in further sessions,” she explains, with an explanatory nudge at the raft of muscles that run underneath and crosswise to the SCM. “You have a lot of work to be done there.” Ouch. Sounds right.

Finally Massman moves to the three key muscles of the TMJ assembly. She finds some tension and knotting in the medial pterygoid (poke upwards under your jaw toward the back and you’ll find it) and lateral pterygoid (under the cheekbone). But it’s in the masseter (reach inside your mouth for a tough, fin-like ridge) that she finds scores of trigger points. She methodically applies steady, firm pressure to individual spots. “It feels like a wad of tissue,” she explains, “Thick and hard. Then I can feel it release.” What I feel is exquisite pain during that release, as if she is pushing harder (she isn’t), and then nothing, as if she’s let go (when she hasn’t). Also classic trigger point behavior.

There are plenty more points to be resolved, she assures me, but they will have to wait for future sessions. “They’re deeper. It’s like peeling the layers of an onion,” she says. And it would be a mistake (besides unbearable) to attempt it all in one day: “Your jaw would probably seize up, go into shock.”

Massman explains that the patterns of tensions she has found are unique to me, and have developed over years in response to numerous factors and life events, probably including clenching when stressed, poor postural habits and the trauma to my jaw of wearing braces and then getting them removed. (That doesn’t mean that braces are bad – just that getting massage in conjunction with them is probably a good idea.)

Over the next several days, I feel increased mobility. My jaw feels markedly more open and relaxed – and it’s quieter during chewing. The familiar crunchy feeling is gone. Perhaps most important, my point of view is greatly expanded.

I’ve begun to appreciate the truly marvelous, complex system of muscles and other tissues that keep my jaw in place, allow movement for talking, provide force for chewing. I’ve learned that tensions and knots in some of these muscles have pulled my jaw out of kilter in a highly individualized way.

In other words, there’s a lot of stuff there, and all those parts work really hard, all day, every day. No wonder things go awry fairly frequently. Or that different bits go wacky in different ways for different people. In fact, the very term “TMJ syndrome” begins to sound silly to me. Would we say there is a “knee syndrome” because many people are susceptible to various injuries to that complex and heavily used part of the anatomy?

I’ve discovered that my TMJ tensions are responsible for more of my symptoms than I had dreamed. I’ve learned how far-reaching and variable TMJ effects can be, and how common. I am convinced that therapeutic bodywork, given time and in the hands of a properly trained practitioner, can resolve most, if not all, of these effects in my own case, and that the potential is great to help others, as well. I have a long way to go on my TMJ healing journey. But for the first time, I believe my path is clear.

To learn more about the TMJ and related areas, and for massage you can do yourself, check out The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, Second Edition, by David G., Md. Simons (New Harbinger Publications, 2004).

Rebecca Massman, LMT, can be reached at 608-222-7473.