Assessment

 Personal Data:
Name: J.Q
Date of birth: 1-1-1968 (53)
Date of assessment: 7-8-2021
Gender: Female
Marital status: Married.
Occupation: Nurse
Address: Beitsahour
Phone N.: 000-0000000

Chief Complain: pain and inflammation in the

Temporomandibular joint (TMJ) and pain in the neck.

 History:
Present history:
From 10 years ago, she suffered from joint pain, and she went for
treatment, the pain was disappearing for a while and then returning
again.
About a week ago, the pain returned to her, because she went to
the dentist and kept her mouth open for a long time, and she went
to the doctor Thaer on 7-31-2021, he gave her medicines, and he
referred her to physical therapy on 7-8-2021, and she also
complains of Neck pain associated with TMJ pain.

Medication:
Analgesic and NSAIDs

Pain history:
Severity: 10/10
Nature: inflammatory
Irritability: Pain increases suddenly and when moving the mouth,
Pain decreases when pressure is applied to the joint or head
Time: all of the time 24 hour.
 Past history:
She started having a TMJ problem ten years ago because she
opened her mouth for a long time at the dentist. She went to many
doctors and went to a mandible doctor, she gave her exercises and
she took physical therapy and dry needles for the neck and back
every 6 months and she had neck pain.

Family history: free

Social history:
She married and she has 4 daughters and one son and she lives
with them.
Personal history:
She play sport sometime.

 Observation:
General Condition of patient: average to good
Swelling: around the shoulders (Because of muscle spasm)
Left eye twitching (sometimes)
Posture: normal
Gait: normal

 Palpation:
Spasm: around neck and shoulders (in trapezius,
sternocleidomastoid and scalene muscles)
Temperature of skin: normal
Type of skin: normal
Tenderness: around TMJ and neck and shoulders.

 Examination:
ROM:
For TMJ:
 Elevates (Opening) 25 mm
Right lateral 4mm
deviation
Left lateral 4mm
deviation
Protrusion 3mm
For neck:
Active Passive
Flexion 40 50
Extension 50 60
Right lateral flexion 30 45
Left lateral flexion 30 45
Right rotation 65 80
Left rotation 70 80
End feel: spasm.

Muscle power:
For TMJ:
Elevates 3
Lateral deviation 3
Protrusion 3

For neck:
Flexor 3
Extensor 3
Lateral flexor 3
Rotator 3

Special test:
1. Tongue blade test: negative.
2. TMJ Mobility Test: positive.
3. Oral Behaviors checklist (OBC): (behind the paper)
 Treatment Goals:
 Short goals:
1. Relieve pain: around TMJ and neck and shoulder in
2week.
2. Decrease swelling around shoulder (lower fiber of
trapezius) in 1 week.
3. Decrease muscle spasm for (trapezius,
sternocleidomastoid and scalene muscles) in 2week.
4. Increase ROM for the TMJ and cervical in 2 week.
5. Decrease eye twitching in left eye in 1 week.
6. Increase muscle power for neck and TMJ muscle in 2
week.

 Long goals:
1. Improve flexibility for TMJ in 3 week.
2. Return function in TMJ (chewing, Opening the mouth,
Sucking, Swallowing) in 4 week

 Treatment plan:
 Ice therapy to reduce swelling and relieve pain (in acute)
 Electrotherapy stimulation: to stimulate facial nerve and reduce
eye twitching.
 Ultrasound: to reduce pain and swelling and improve
circulation.
 Jaw ROM and strengthen exercises: to strengthen muscles and
improve flexibility and range of motion.
 ROM exercises for neck.
 Dry needling: to decrease muscle spasm.
 TMJ mobilization technique.
 chiropractic techniques for neck
 Massage.
 Home ex.