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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 1  |  Issue : 1  |  Page : 59-62

Effectiveness of physiotherapy rehabilitation on hysterical trismus


1 Department of Neurophysiotherapy, AquaCentric Therapy Private Limited, Mumbai, Maharashtra, India
2 Department of Neurophysiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission13-Nov-2018
Date of Acceptance09-Apr-2019
Date of Web Publication3-Jul-2019

Correspondence Address:
Mr. Suchit S Shetty
Department of Neurophysiotherapy, AquaCentric Therapy Private Limited, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_16_19

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  Abstract 


Trismus, known as difficulty in mouth opening, commonly occurs due to disturbances in the trigeminal nerve resulting in spasm of masticatory muscles. With a literature review on rehabilitation of hysterical trismus, it was observed that there were different electrotherapeutic modalities and exercises which have their individual benefits for trismus. However, there is a lack of a set structured exercise and electrotherapy protocol for the rehabilitation of this condition which may help for better and faster prognosis. A 62-year-old female with hysterical trismus was assessed using dial caliper for mouth opening and was treated using physiotherapeutic approaches. Pre- and postintervention values were recorded. Physiotherapy interventions included hot moist pack therapy, myofascial release, goldfish exercises for the temporomandibular joint (TMJ), TMJ mobilization with distraction, ultrasound, and maintenance of mouth opening using ice cream sticks. Aerospace 200-mm dial caliper was used to measure mouth opening. The present report emphasis on the effect of 2 weeks of physiotherapy intervention using a combination of electrotherapy and exercise has benefited the patient in improving the mouth opening and overall quality of life.

Keywords: Dial caliper, Maximal interincisal distance, Trismus


How to cite this article:
Shetty SS, Kumar S, Fernandes J. Effectiveness of physiotherapy rehabilitation on hysterical trismus. Indian J Phys Ther Res 2019;1:59-62

How to cite this URL:
Shetty SS, Kumar S, Fernandes J. Effectiveness of physiotherapy rehabilitation on hysterical trismus. Indian J Phys Ther Res [serial online] 2019 [cited 2019 Aug 21];1:59-62. Available from: http://www.ijptr.org/text.asp?2019/1/1/59/261991




  Introduction Top


According to the Dorland's medical dictionary, “trismus is a motor disturbance of the trigeminal nerve, leading to spasm of the masticatory muscles, with difficulty in opening the mouth and is a characteristic early symptom of tetanus”.[1] It is also called as false ankylosis of the temporomandibular joint (TMJ)since it has the pathology of the extra-articular joint structures which leads to the restriction of the joint.[1]

Trismus is the most common problem encountered by dentists. It occurs due to marked spasm of the pterygoid, masseter, and temporalis muscles of mastication leading to difficulty in mouth opening. The most common causes of painless trismus are encephalitis, rabies, tetany, tumor and oral cancers, radiotherapy and chemotherapy, drugs, infection, and myopathies, especially polymyositis which leads to fibrosis of the masseter muscles.[2] It can also occur due to congenital hypertrophy of the coronoid process causing interference of the coronoids against the anteromedial margin of the zygomatic arch.[3] Trismus pseudocamptodactyly syndrome is a rare combination of hand, foot, and mouth abnormalities and trismus.[4] Trismus can be hysterical [2] which is a miscellaneous disorder with an unknown cause but assumed that it could be due to mechanism of the conversion of emotional conflict into physical symptoms.[5] The patient's ability to eat, to communicate, and to have active social life is disturbed due to the reduced mouth opening.

The normal range of mouth opening is 40–60 mm, i.e., 2–3 finger breadth mouth opening is considered normal.[1] Maximal interincisal distance (MID) is the measurement done using caliper between the maxillary and mandibular ridges to assess the mouth opening. If MID value is <40–45 mm, then it is diagnosed as trismus.[6]

Physiotherapy rehabilitation is considered as an important line of management for trismus. Various electrotherapy modalities used for the treatment include therapeutic ultrasound,[7] iontophoresis,[7] neuromuscular electrical stimulation,[8] and hot moist pack. Furthermore, different exercise techniques used are massage,[6] active range of motion exercises, hold relax techniques, manual stretching, and joint distraction.[8] Certain modalities such as dynamic splints,[6] spring-loaded device,[9] TheraBite,[10] and dynamic bite opener are also used to maintain the range of motion of the TMJ. According to previous literature review on rehabilitation of hysterical trismus, it was observed that there were various electrotherapeutic modalities and exercises which had helped individuals with trismus. However, there is a lack of structured exercise and electrotherapy protocol for the rehabilitation of this condition which may help in better and faster prognosis. Hence, the present case report intends to evaluate the effect of a structured 2-week physiotherapy intervention on the mouth opening of the patient suffering from hysterical trismus.


  Case Report Top


A 62-year-old female (body mass index: 18 kg/m 2) was referred to the neurophysiotherapy department of a tertiary care center, with a complaint of inability in opening her mouth for 2 weeks. The complaints started after a spontaneous episode of vomiting due to indigestion 1 day before she reported to the physiotherapy outpatient department (OPD). There were no associated complaints of headache, fever, or pain. The following morning, the patient noted that she had difficulty in mouth opening without pain or paresthesia. The patient was admitted to the tertiary care center by her relatives for medical management, and after 13 days of medical treatment, the patient was referred to the physiotherapy department. On observation, there was edema present on the zygomatic area, and no redness or deviations in the jaw were noted. On palpation, there was Grade 2 tenderness present over the bilateral temporomandibular joint spasm of the masseter muscles. The MID score was recorded using a dial caliper, and the value was 18 mm. The patient presented with a significant challenge in eating and was on liquid diet for 20 days. She also had difficulty in speech due to restricted mouth opening. All the medical and radiological investigations such as X-ray and complete blood count that were advised by the doctors did not have any significant finding.

Intervention

Hot moist pack was administered at the bilateral mandibular region for 15 min. Myofascial release (MFR) for bilateral masseter and temporalis muscles was given. For masseter muscle, MFR was given placing one thumb fixed over the zygomatic arch and another thumb moving from fixed thumb to angle of the mandible (proximal to distal) and for temporalis (anterior) muscle from lateral aspect of the forehead to anterior area of the ear lobe (proximal to distal) [Figure 1]. TMJ mobilization with distraction, lateral glide, and medial glide (Grade 3) with 6–10 repetition each was also administered. Goldfish exercises for the TMJ within the available range were done for 5 repetitions. Therapeutic ultrasound was given with following dosage; pulse mode – 1:4, frequency- 3 MHz, intensity- 0.8 watt/cm2 and duration of 5 min [Figure 2]. After the treatment protocol was given, the patient was advised to maintain mouth opening with ice-cream sticks for 40 min. It was observed that initially patient complained of pain but once habituated she got relieved from that pain. The patient was treated for 15 days, twice a day. Each session was extended for 30–40 min.
Figure 1: Myofascial release for the temporomandibular joint

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Figure 2: Therapeutic ultrasound for the temporomandibular joint

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Outcome measures

Aerospace 200-mm dial caliper was used to assess the mouth opening, i.e., MID score [Figure 3]. At the end of 15 days of treatment with two sessions daily, the MID score demonstrated an increase to 50 mm [Table 1]. Tenderness over the bilateral TMJ and spasm of the affected muscles also showed a reduction. Functionally, the patient was able to consume soft diet such as rice and porridge, the articulation of the speech could be heard clearly, and she had improved with her communication difficulties. The patient got discharged after 2 weeks. She was advised for follow-up twice a week at physiotherapy OPD due to logistic problems.
Figure 3: Aerospace 200-mm dial caliper to assess the mouth opening

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Table 1: Pre- and postintervention value using dial caliper

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  Discussion Top


The purpose of the present study was to evaluate the effect of a structured 2-week intervention using a combination of structured exercise and electrotherapy for hysterical trismus without using expensive mechanical devices such as ultrasound and transcutaneous electrical neuromuscular stimulator.

Heat therapy increases the extensibility of collagen tissues and the blood flow resulting in the reduction of joint stiffness and muscle spasm. Previous literature supports the present case study in which oral surgeons have managed muscle spasm in a trismus patient using hot moist pack for 15–20 min.[1] MFR for the masseter and temporalis muscles improved the flexibility by directly affecting the stress–strain curve principle of the muscle resulting in further elongation of the muscle tissue [Figure 2]. Literature mainly suggests massage therapy for muscle,[11] but in the present study, MFR technique was used which might have helped to specifically relax the affected muscle (masseter and temporalis). This relaxation may be explained by applying a gentle pressure applied slowly Which activates viscoelastic property of fascia results in elongation of muscles.[12] MFR has also shown to help in alleviating the muscle stiffness, reducing pain, and improving the joint range of motion.[12]

Mobilization of the TMJ, especially distraction and lateral and medial movement of the jaw with Grade 3, has shown to improve the range of motion by breaking the fibrosis along with the goldfish exercises of TMJ to maintain the range. This may explain the reason that such exercises may help to break fibrosis in condition like trismus resulting in opening of the mouth.[11] Furthermore, along with jaw opening, lateral excursion of the jaw is mainly focused.[1]

Low-intensity pulsed ultrasound given over the surrounding area of TMJ using concentric circular method had effectively increased the flow of blood over the affected area which explains the reason for healing and relieving spasm [Figure 3], since low-intensity ultrasound has good biological effect, nondestructive, and promotes tissue healing.[13] Ice cream sticks were used posttreatment for 40 min to maintain the jaw opening. A number of sticks used daily were noted to keep a count on improvement. The patient was on soft liquid diet initially but later was able to regain normal soft diet. Prior to discharge, Improvement was noted using dial caliper in the range of motion of temporo mandibular joint. The overall quality of life of the patient has improved.


  Conclusion Top


The present report emphasis on the effect of structured physiotherapy intervention with the use of electrotherapy for 2 weeks in patients suffering from hysterical trismus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dhanrajani PJ, Jonaidel O. Trismus: Aetiology, differential diagnosis and treatment. Dent Update 2002;29:88-92, 94.  Back to cited text no. 1
    
2.
Campbell WW, DeJong RN. DeJong's the Neurologic Examination. 7th ed. 2012: Lippincott Williams & Wilkins; 2005.  Back to cited text no. 2
    
3.
Daniele A. Trismus due to hypertrophy of the coronoid processes. A clinical case report. Minerva Stomatol 1994;43:185-9.  Back to cited text no. 3
    
4.
Teng RJ, Ho MM, Wang PJ, Hwang KC. Trismus-pseudocamptodctyly syndrome: Report of one case. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi 1994;35:144-7.  Back to cited text no. 4
    
5.
World of Dentistry; 2012. Available from: http://www.worldofdent.blogspot.in/2012/12/trismus.html. [Last updated on 2012 Dec 22; Last accessed on 2016 Jun 28].  Back to cited text no. 5
    
6.
Shulman DH, Shipman B, Willis FB. Treating trismus with dynamic splinting: A cohort, case series. Adv Ther 2008;25:9-16.  Back to cited text no. 6
    
7.
Kahn J. Iontophoresis and ultrasound for postsurgical temporomandibular trismus and paresthesia. Phys Ther 1980;60:307-8.  Back to cited text no. 7
    
8.
Dijkstra PU, Sterken MW, Pater R, Spijkervet FK, Roodenburg JL. Exercise therapy for trismus in head and neck cancer. Oral Oncol 2007;43:389-94.  Back to cited text no. 8
    
9.
Kaban LB, Swanson LT, Murray JE, Sheridan W. Postoperative physiotherapy device for mandibular hypomobility. Oral Surg Oral Med Oral Pathol 1977;43:513-6.  Back to cited text no. 9
    
10.
Melchers LJ, Van Weert E, Beurskens CH, Reintsema H, Slagter AP, Roodenburg JL, et al. Exercise adherence in patients with trismus due to head and neck oncology: A qualitative study into the use of the therabite. Int J Oral Maxillofac Surg 2009;38:947-54.  Back to cited text no. 10
    
11.
Balasubramanian T. Trismus an Overview: Scholar Work Spaces. Stanley Medical College; 20 June, 2014. p. 1-13.  Back to cited text no. 11
    
12.
John FB. Myofascial Release Traetmentcenters & Seminars. No date. Available from: https://www.myofascialrelease.com/about/definition.aspx. [Last accessed on 2016 Jun 28]  Back to cited text no. 12
    
13.
Kaur S, Narain A, Kapoor V, Singh J. Comparative effect of ultrasound therapy and laser therapy for relief of pain, swelling and trismus following third molar surgeries. IOSR J Dent Med Sci 2014;13:63-72.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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