Theoretical Case Studies

            The case presented involves a 32-year-old mother of 3 young children who presented to the clinic with chronic head and jaw pain. The patient characteristics include the weight of 88 kg, 152 cm. Long, is married, lives in the city, and works as a child care center manager where she does a lot of computer work. A close observation of her medical history reveals that she was diagnosed with an adolescent migraine and polycystic ovary disease. 

She has had a surgical history of three caesarean sections in 2006, 2008, and 2010. The patient explained that she had had stress over the past six months before her presentation to the clinic as a result of her work and family issues. Regarding the history of pain, the lady explained that she had menstrual cycle migraine for several years that was treated using contraceptive pills. She experienced a headache and jaw pain frequently for the past two years that became worse when under stress.

            Since the lady presented to the clinic with complaints of chronic pain in the head and jaws, it is important to lay emphasis on the pain issue. During her presentation, she reported of pain mainly in the suboccipital region that spread out around the side of the head to the temple. She also felt pain over the eye and on the right side. She woke up in pain and usually enhanced by her computer work, staff, parents, and children management. Her jaw pain presented severely in the joint, cheeks, and behind the ear and in some instances experience challenges in opening her mouth fully. She was initially diagnosed with bruxism, hence has to wear a mouth guard as she slept. The condition involves teeth grinding and clenching the jaw which can be a cause of jaw pain, discomfort and wear down teeth. It can also result to severe headaches as well as earaches. The patient’s headaches are associated with dizziness, ear ache, and tinnitus. Postural examination of the patient showed that she could sit with the head slightly forward and squinting eyes. She had forward head posture and increased weight around the abdomen with increased anterior pelvic tilt. For her range of movement, all the active ROM’s (range of motion) were normal but tight to the EOR. Her passive ROM and active ROM were similar, and there was no limitation to shoulder ROM movements. She had slight winging of the scapula on the functional movements of the GHJ bilaterally as well as the slight limitation to mandible depression and mandible deviates to the right. The mandibular movement was not associated with any pain. Her soft tissue examination showed the upper trapezius being hypertrophic to touch and was tender on palpation. The scapula bilateral had a slight winging, and the posterior cervical musculature was tender to palpation and felt ropey to touch. The lady was tender on palpation of the frontalis, temporalis, and scalene muscles. An examination of the reflexes and neurological characteristics showed no changes to reflexes or temperature in the head and upper extremities.

Differential Diagnosis

            The patient has a likelihood of suffering from a migraine headache or temporomandibular joint (TMJ) disorders. A migraine is a complex disorder that has characteristics of recurring experiences of a headache and usually unilateral (Lipton, 2011). It can be associated with visual ad sensory symptoms that are caused by the head pain (Mayo Clinic, 2016). The condition is more common in women and is also genetically motivated. The major signs include a headache and moderate to severe pain that increases with physical activity. Other signs include unilateral pain in the front temporal which may be felt around the head or neck. A headache may last for more than four to 72 hours, and patients have light-headedness effect (Kabbouche & Gilman, 2008). The physical findings when patient experiences migraine headaches include cranial muscle tenderness, hypertension, bradycardia, and hemi sensory and hemiparetic neurologic deficits. Patients usually experience extreme pain in the normal physical activity (Gilmore & Michael, 2011). The patient may be suffering from a migraine due to her clinical presentation with chronic head and jaw pain though some of her examination findings are not consistent with the condition. Pathophysiology of a migraine reveals that patients with the condition are likely to experience throbbing pain as well as nausea and vomiting which were not evident to the patient. The patient’s earlier diagnosis with bruxism could be the cause of the chronic pain since it is likely to cause jaw pain and headaches. Regarding epidemiology, Migraine is a serious, prevalent neurological disease that affects approximately 38 million men, women, and pediatrics in the United States and 1 billion worldwide (Manack, Buse & Lipton, 2011). It is the 3rd most prevalent disease condition in the world and nearly one in every 4 U.S households have someone with a migraine. Statistics from the Migraine Research Foundation show that 18% of the American women, 6 % of men, and 10% of children suffer from migraines (Bigal & Lipton, 2009). However, it is most common among individuals aged between 25 and 55 and tends to run in families with a history of the same. The condition disproportionately affects women of which 85 % of the chronic type sufferers are women (Ibid, 2009). The figures reveal of the high prevalence of women to A migraine which increases the likelihood of the patient in the case study having the condition.

            Temporomandibular joint (TMJ) disorders involve the problems related to TMJ which is a joint located in front of the ears on either side of the head (Müller, et al., 2009). The joints function as the hinges for the movement of the jaws when chewing and talking. The disorders associated with the joint can affect any part of the neuromuscular system of the jaw and results to jaw pain, spasms, clenching, teeth grinding, ear pain, and unevenly worn teeth. The problems associated with the temporomandibular joint disorder (TMD) can lead to headaches as the most common effect. The signs and symptoms of jaw misalignment include headaches, tinnitus, jaw pain, neck and pain shoulder, clicking jaw, feelings of dizziness, ear pain, eye pain and stuffy ears feeling like the water of pressure (Tanaka, Detamore & Mercuri, 2008). In some instances, the symptoms and issues arising from TMD do not have an association with jaw disorder and thus left untreated. The clinical presentation of the patient revealed some of the signs and symptoms related to TMD which could be a probable differential diagnosis. In the U.S, TMJ disorders affect an estimated 10 million people, and 25% of the population has the related symptoms at some point (Cunha, 2016). The morbidity of the disorder has a significant relation to pain as well as the movement of the jaw. Some patients’ symptoms may resolve after few weeks, but others have chronic symptoms that remain despite having extensive therapy. The disorder is highly associated with women having a female to the male ration of 4:1. The highest incidence of the disorder is observed in adults aged 20 to 40 years and is infrequently found in Pediatrics (Cunha, 2016).  From the epidemiological data, it is likely that the patient presented in the case suffered from temporomandibular joint disorder due to her gender, age, and symptoms conforming to the high-risk population.

Perpetuating and aggravating factors

            There are several aggravating factors and flags identified in the patient case study that relates to the biopsychosocial model, medical history, and pharmacological status that have implications for treatment and recovery. The biopsychosocial model states that health and illness are established by the interaction between biological, psychological, and social factors (Ghaemi, 2009). From the patient data presented, the lady suffered from bruxism, which is partly genetically motivated and suggests that her condition was biologic. It was also psychological following the observed signs and symptoms that affected her behavior. They include occasional challenges when opening her mouth, earlier diagnosis of bruxism which involves teeth grinding, and her work of using a computer frequently. The patient’s condition was also influenced by the social factors that include past medical history of an adolescent migraine, polycystic ovary disease, bruxism, ear ache, and tinnitus. All the aspects of the biopsychosocial model interact to contribute to the condition of the patient presented in the case study.

            The patient’s medical history shows that she suffered from an adolescent migraine and polycystic ovary disease. She experienced a headache and jaw pain frequently that worsened when she was stressed up.  Her computer work aggravated her pain as well as the challenges of managing staff, parents, and children. Her pharmacological status shows that she is not under medication. The factors discussed have an impact the treatment and recovery process since they require to be addressed in designing a management plan.  The purpose of using the biopsychosocial model, medical history, and pharmacological status in a case analysis is to offer a basis to understand and treat an illness, the patient’s sense of suffering, and the meaning of the diagnostics. The identification of the various signs and symptoms, the past medical history, emotional state, pain history, as well as reflexes and neurological findings is to ensure that the probable cause of a patient headache and jaw pain is established and appropriate treatment modalities are given. The recovery of a patient depends on the ability to have an accurate diagnosis and treatment plan. The patient ought to be fully evaluated for any cause of her pain to ensure that every recommendation given is appropriate.

Relevant Diagnostic investigations

            The patient presented in the case study had a complaint of chronic head and jaw pain. She was stressed up by her work and family issues, and an examination of the history revealed that she had had on and off cases of a headache and jaw pain over the last two years that is worsened by stress. She had pain in the region around the side of the head and top of the eye. She woke up with pain that was aggravated by computer work and other work issues. Her jaw pain was deep in the joint and cheeks and behind the ear and experienced pain when opening the mouth. An earlier diagnosis of bruxism was a confirmation of the pain experienced in the jaws. The postural, range and soft tissue presentations clearly show the effect of her condition. The soft tissue tenderness to palpation is an indication of pain certain parts of the jaw and the joints. The patient experienced occasional tinnitus which could have been caused by the problems in the jaws and joints in the target regions. From the available information on the patient, it is evident that she is likely to suffer from a temporomandibular joint disorder which overrules a migraine. TMJ disorders can pain in the jaw joint and also the muscles that regulate jaw movement. The exact cause is challenging to determine since pain could be a combination of factors such as genetics, people with arthritis, or jaw injury. The disorders can also be due to teeth or jaw injury, teeth grinding, misalignment of teeth and jaw, poor posture, stress, and gum chewing (Tanaka, Detamore & Mercuri, 2008). The causes are consistent with the patient presented since she had bruxism (from teeth grinding), posture problems due to her computer work, and stress from her work and family. Thus, the temporomandibular joint (TMJ) disorder is the most probable diagnosis for her.

Patient management program   

            Several therapies for TMD have been advanced that help to improve TMD symptoms. The most cost-effective therapy methods include self-management therapies (Wright & North, 2009). The patients suffering from TMD can undergo occlusal orthotics for masticatory muscle pain, noises, pain, restricted jaw movements, and dislocation (Luther, Layton & McDonald, 2010).

            There are various theories for the treatment of TMD and none is perfect, but tend to reduce the symptoms. They include relaxation and controlling stress, orthotic processes, and use of medication such as tricyclic antidepressant (desipramine (25 mg, one tab in the morning and afternoon). The management of TMDs for both awakening and daytime symptoms involves the use of medications (NSAIDS or steroids), performing physiotherapy modalities (such as ultrasound and heat), performing the jaw-stretching exercise, head, and neck posture exercises, as well as cervical therapies. The various therapy methods should be modulated by symptom severity, compliance, the ability of the provider, cost, and the impact on the patient’s choice of lifestyle (List & Axelsson, 2010).      

 References

Bigal, M. E., & Lipton, R. B. (2009). The epidemiology, burden, and comorbidities of a migraine: Neurologic Clinics, 27(2), 321-334.

Ghaemi, S. N. (2009). The rise and fall of the biopsychosocial model: The British Journal of Psychiatry, 195(1), 3-4.

Gilmore, B., & Michael, M. (2011). Treatment of an acute migraine headache: Am Fam Physician, 83(3), 271-280.

Kabbouche, M. A., & Gilman, D. K. (2008). Management of a migraine in adolescents: Neuropsychiatric Disease and Treatment, 4(3), 535–548.

Lipton, R. B. (2011). A chronic migraine, classification, differential diagnosis, and epidemiology, Headache: The Journal of Head and Face Pain, 51(s2), 77-83.

List, T., & Axelsson, S. (2010). Management of TMD: evidence from systematic reviews and meta‐analyses. Journal of oral rehabilitation, 37(6), 430-451

Luther, F., Layton, S., & McDonald, F. (2010). Orthodontics for treating temporomandibular joint (TMJ) disorders, The Cochrane Library

Manack, A. N., Buse, D. C., & Lipton, R. B. (2011). Chronic migraine: epidemiology and disease burden. Current pain and headache reports, 15(1), 70-78

Müller, L., Kellenberger, C. J., Cannizzaro, E., Ettlin, D., Schraner, T., Bolt, I. B., ... & Saurenmann, R. K. (2009). Early diagnosis of temporomandibular joint involvement in juvenile idiopathic arthritis: a pilot study comparing clinical examination and ultrasound to magnetic resonance imaging. Rheumatology, kep068

Tanaka, E., Detamore, M. S., & Mercuri, L. G. (2008). Degenerative disorders of the temporomandibular joint: etiology, diagnosis, and treatment. Journal of dental research, 87(4), 296-307.

Wright, E. F., & North, S. L. (2009). Management and Treatment of Temporomandibular Disorders: A Clinical Perspective. The Journal of Manual & Manipulative Therapy, 17(4), 247–254.

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