Trigeminal Neuralgia (TN)

This post was originally published at TreatingTMJ.com

Trigeminal Neuralgia (TN), Fothergill’s Disease or “Tic douloureux” is characterized by sudden attacks of severe, sharp, stabbing, electric shock like pain affecting one side of face mainly along the second and third divisions of the Trigeminal Nerve.

TN is sometimes called “the worst pain known to mankind” and “the suicide disorder” by Medical Science. It is triggered by chewing, speaking, cold winds and touching a trigger spot. The disease, typically involves older females aged more than 35 years and usually involves the right half of the face. Most of the time the patients with TN who showed they are partially or temporarily responsive to drug therapy then underwent for surgery to relieve the pain. The International Headache Society (IHS) differentiates between classical trigeminal neuralgia, often caused by microvascular compression at the trigeminal root entry to the brainstem, and symptomatic trigeminal neuralgia, caused by a structural lesion other than vascular compression. The pain involves the second (maxillary) or third (mandible) divisions more often than the first (ophthalmic);

It rarely occurs bilaterally and never simultaneously on each side, occasionally more than one division is involved. Sudden attacks last for few seconds to minutes. Hardly any studies have reported the role of physiotherapy in Trigeminal Neuralgia. Dildip Khanal, physical therapist, completed his masters of physiotherapy in neurology. Presently he is working in BIKASH Nepal as a joint training coordinator and as a Clinical therapist in Metro City Hospital, Pokhara, Nepal. His area of interest is Physiotherapy and Neurophysiology.

In his article, Is there Any Role of Physiotherapy in Fothergill’s  Disease? (J Yoga Phys Ther 4: 162.), this pilot study emphasized the role of Physiotherapy in treatment of Fothergill’s Disease or Trigeminal Neuralia.  The results of the study showed that using continuous TENS, Relaxation technique, hot moist pack over the trapezius muscles, Isometric neck exercise, nerve desensitization and behavioral modification or advice on how to manage TN, reduces pain in patients suffering from TN.

Probably what I am personally most excited about is the work that has been done by Dr. Harry Von Piekartz, PHd, M.Sc., B.Sc, FT, MT, MDAMT, IMTA, NOI, ICMMO. In 2002, Dr Piekartz was one of the main initiators of the Cranial Facial Therapy Academy (CRAFTA). In 2004 he became  Fellow of the International College of CranioMandibular Orthopaedic (ICCMO) in Germany. He has written 2 books and has published several articles all relevant to head, neck and face problems.

I feel privileged to be one of the first and only 1 of about 15 Physical therapist and 1 occupational therapist in the USA to be trained by Dr. Harry Von Piekartz. In collaboration with Myopain Seminars, one of the educational bodies I teach for, Dr. Von Piekartz opened our minds up to an endless possibility of treatment options for patients suffering from head, neck and face pain. Just when you thought you had a pretty good handle on the treatment of TMD, face pain, etc.

Anyway, back to the physical therapy treatment of Trigeminal Neuralgia. Experience, empirical data and clinical evidence from micro-neurosurgery can give the physical therapist some ideas about how it may be possible to treat and try to change the pathodynamics caused by trigeminal neuralgia.

While it is too challenging to try and simplify the anatomy of the cranium (our skull) and the ways the trigeminal nerve and its blood supply may become mechanically entrapped, suffice it to say that Breig (1976) discovered that 75% of 9 groups of 24 patients with TN, demonstrated an impingement phenomenon in the foramen rotundum when you side bend your head to the opposite side. Jannetta(1976, 1990), Barba and Alksne (1984), and Jannetta and Bissonette (1985) confirmed this during neurosurgical procedures.

So what does all this mean, this means in the hands of a well-trained physical therapist (and training by Dr. Piekartz), it is possible with skilled, manual neck positioning, and jaw or mandibular positioning we can affect the trigeminal nerve, through something called Neurodynamics.

Let’s just say that our nerve tissue in our body, is like dental floss. Our nerves need the FREEDOM to move and glide and when they get restricted or stuck either by boney mechanical blocks or by soft tissue like muscle, it is imperative we restore that nerve tissue mobility and either reduce or eliminate the impingement that Breig talks about.  IF we can achieve this, it is possible to reduce or eliminate the symptoms that are caused by Trigeminal Neuralgia.

Once again, I want to remind you to seek medical care that is conservative, and reversible.