Steigerwald D, "Headaches & Neck Pain...Symptoms of Whiplash Induced TMJ Injuries"
The personal injury field is demanding and evolving. New models for mechanism of injury, symptom complexes, projected outcome assessment, treatment options and diagnostic workup find their way into the literature on a regular basis. This creates opportunities and challenges.
The recognition of whiplash injuries as productive of temporomandibular disorders (TMD) has opened the door to a new understanding of post-whiplash head and neck symptom complexes. Some of these findings challenge incumbent models and call for a modification of our intake, exam, referral and treatment patterns.
Cervical whiplash injuries and temporomandibular disorders are each capable of producing a constellation of symptoms. These symptoms are known to include, but are not limited to, headache, neck pain, shoulder pain, dizziness and tinnitus. Doctors should be aware that the same event may cause cervical whiplash injury and injury to the temporomandibular joints with potential symptom overlap. This can and does lead to misdiagnosis and misdirected treatment. It should also be considered that the onset of or report of local signs and symptoms commonly associated with TMD, e.g. clicking, locking and jaw pain, may be delayed for weeks to months following the traumatic event. This lag in recognition and/or report of local TMD symptoms occurs because patients will report the dominant symptoms, e.g. headache and neck pain, first and because the articular surfaces of the temporomandibular joints are not pain sensitive. Scar formation and synovial proliferation which lead to local temporomandibular joint pain and destabilization take time to evolve. A patient with a whiplash induced TMJ injury may then present to you with headache and neck pain while not reporting jaw pain and/or dysfunction.
Developing an index of suspicion that specific symptoms emanate from a particular region or tissue is important in both acute and chronic patient presentations. Nowhere is this more evident then in the instance of an injury which produces damage to multiple body parts simultaneously such as whiplash. The neck, brain and temporomandibular joints are all known to be vulnerable to injury during whiplash and all may well be injured during the same event. The potential for symptom overlap is high in these cases and central neural pathways common to these regions may lead to a symptom complex produced by their combined central influence. This is not an uncommon scenario in whiplash injury cases.
One of the most problematic aspects of the whiplash induced TMJ injury is that the injured temporo-mandibular joints do NOT refer pain to the neck, rather, the injured temporomandibular joint will produce reactive muscular co-contraction of the cervical musculature. This confounds the issue as the patient not only complains of neck pain that may not be cervicogenic in origin but has signs, i.e. muscle hypertonicity and tenderness, that point falsely to a cervical origin as well. This reactive muscular co-contraction may also lead to trigger point formation in the involved muscles and produce tertiary symptom sites. The injured temporomandibular joint may cause contraction in the upper trapezius for example and this may lead to trigger points which produce temporal headache and referred neck pain. The same reaction may occur in the SCM musculature and cause dizziness and ear pain.
It is impossible to say how many whiplash patients have symptoms which emanate from injured temporo-mandibular joints although it appears to be far more prevalent than previously thought. It is important for the doctor of chiropractic to realize that they face these confounding presentations on a regular basis in their personal injury practice and that they can take simple steps to improve their diagnostic accuracy, treatment efficiency and documentation.
TM-joint trauma-induced pathology can lead to severe joint derangement if it goes undiagnosed and untreated and may eventually demand surgical intervention. Early diagnosis, appropriate home care and timely treatment may well intercept this process.
Specific examination, diagnosis, documentation, treatment and referral form the cornerstone of a successful personal injury practice. Expanding your whiplash workup and case management to include the potential for temporomandibular joint injury will only serve to improve treatment and help establish appropriate compensation. Expanding your diagnostic and treatment skills in this arena can result in interdisciplinary referrals as well and open the door to a world of patients you might otherwise never see. Patients who would be much the better for being exposed to your care.
In this vein I would refer you to a new website:
http://www.whiplashandtmj.com/ which contains scientific literature, medico-legal guidelines, references and other resources you can use to help your patients and expand your practice.
THANK YOU, DR. STEIGERWALD
Dr. Steigerwald has generously offered to donate $40 from the sale of each of his TMJ courses (text, workbook and video tape) to SOTO-USA. These monies will be used as part of the research fund from which honorarium payments are made to authors who publish SOT articles.