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Sunday, May 29, 2011

TMJ disorders, headaches and facial pain frequently involve cervical musculature. Acute pain relief is accomplished with cervical muscle injection

An article (pubmed abstract below) in the Journal of Orofacial Pain. "Treatment of acute orofacial pain with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 114 patients." dicusses the use of cevical intramuscular injections to turn off acute pain in the ER. The study showed that 94% of patients had complete of partial relief with injection of a long acting anaesthetic.

There is a connection between the jaw and the neck that is incredibly important in the treatment of muscular headaches, facial pain, migraines, chronic daily headaches and TMJ disorders (TMD). The jaw acts as a counter-balance to the head and allows maintenance of head posture minimal excessive muscle adaptation. This is well described mathematically in engineering terms in the "Quadrant Theorem of Guzay". The jaw position is vital to body posture and abberations in jaw position can act as a descending disorder that can effect the entire body.

Forward head posture is frequently seen in TMJ and Headache patients. This forward posture cause exponential increases in muscle work just to maintain head posture.

Rcobado estimated that it takes double the muscle work from cervical muscles to low back for every centimeter of forward head posture, Three centimeters forward head posture would increase chronic muscle adaptation 8 fold (2X2X2=8) while a 5 centimeter forward head posture would increase it 32 times (2X2X2X2X2=32). The reason muscular injections work so well in relieving acute and chronic headaches and facial pain is that these muscles are grossly overworked in TMD patients.

Treating the muscles can give relief of acute pain but returning the system to a more normal physiologic state can give long term relief to patients.

A diagnostic neuromuscular orthotic allows the jaw to function in an ideal physiologic position. This allows gradual restoration of normal head posture and a return to normal physiologic function of the neck. I work closely with Atlas Orthogonal and/or NUCCA Chiropracters to correct the first two vertebrae early in treatment. These areas are especially prone to problems in TMD patients. As the foward head posture occurs the patient must rotate their head on the Atlas and Axis (first to vertebrae) to maintain sight lines. This is well explained by the Quadrant Theorem of Guzay which shows that the actual center of rotation for the jaw when both rotation and traslation movements are calculated is on the odontoid process of the Axis (2nd vertebrae)

Patients with TMD who are in car accidents never recover fully if their jaw issues are not addressed.

Posturology is the study of whole body posture. Posturology recognizes the importance of the jaw position. The normal swallow is a neuromuscular resetting procedure but most TMD patients have deviant or reversed swallows and are not even aware they swallow wrong. This can lead to GI problems but is primarily a structural problems that makes long term successful treatment of pain impossible without correction of neuromuscular jaw issues. A diagnostic orthotic allows patients to experience relief of head and neck pain prior to and permenant occlusal alterations.

J Orofac Pain. 2008 Winter;22(1):57-64.
Treatment of acute orofacial pain with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 114 patients.
Mellick LB, Mellick GA.
Department of Emergency Medicine, Medical College of Georgia, Augusta, Georgia, USA. lmellick@mcg.edu
To describe 1 year's experience in treating orofacial pain with intramuscular injections of 0.5% bupivacaine bilateral to the spinous processes of the lower cervical vertebrae.

A retrospective review of 2,517 emergency department patients with discharge diagnoses of a variety of orofacial pain conditions and 771 patients who were coded as having had an anesthetic injection between June 30, 2003 and July 1, 2004 was performed. The records of all adult patients who had undergone paraspinous intramuscular injection with bupivacaine for the treatment of an orofacial pain condition were extracted from these 2 databases and included in this retrospective review. Pain relief was reported in 2 different ways: (1) patients (n = 114) were placed in 1 of 4 orofacial pain relief categories based on common clinical experience and face validity and (2) pain relief was calculated based on patients' (n = 71) ratings of their pain on a numerical descriptor scale before and after treatment.

Lower cervical paraspinous intramuscular injections with bupivacaine were performed in 118 adult patients. Four charts were excluded from review because of missing or inadequate documentation. Pain relief (complete or clinical) occurred in 75 patients (66%), and partial orofacial pain relief in 32 patients (28%). No significant relief was reported in 7 patients (6%). Overall, some therapeutic response was reported in 107 of 114 patients (94%). Orofacial pain relief was rapid, with many patients reporting complete relief within 5 to 15 minutes.

This is the first report of a large case series of emergency department patients whose orofacial pain conditions were treated with intramuscular injections of bupivacaine in the paraspinous muscles of the lower neck. The findings suggest that lower cervical paraspinous intramuscular injections with bupivacaine may prove to be a new therapeutic option for acute orofacial pain in the emergency department setting.

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posted by Dr Shapira at 12:44 AM

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