Pursuant to a lecture on “The Role of the Cervical Spine and Physical Therapy in the Management of Temporomandibular Disorders” that I presented at the recent meeting of the American Equilibration Society, I was invited to write a guest editorial for the Journal of Craniomandibular Practice (CRANIO). After much thought about the many previous clinical and scientific publications on this subject that I, as well as my colleagues, have published, I decided to focus on the evolution of physical therapy as it relates to the evaluation and management of patients with headaches, orofacial pain, and temporomandibular disorders, as well as to inform the readers of CRANIO about the development of the Physical Therapy Board of Craniofacial and Cervical Therapeutics (PTBCCT).
Comprehensive physical therapy necessitates the performance of an initial evaluation to determine the etiology and chronological nature of pain and dysfunction, assessment of subjective and objective data, as well as provocation testing. The evaluation findings, interpretation, intuition, and experience of the physical therapist must then be utilized to develop a comprehensive treatment program that is designed to relieve pain, restore function and prevent recurrence within guidelines that reflect the status of the patient’s neuromusculoskeletal system at that time. This composite process cannot be performed by the application of passive modalities, but via utilization of two essential components, namely manual skill and cerebral neurotransmission on the part of an experienced and knowledgeable physical therapist. Establishing a strong multidisciplinary professional relationship with the patient’s dentist, oral surgeon, and physician further enhances a successful outcome.
According to the American Physical Therapy Association (APTA) “specialization is the process by which a physical therapist builds on a broad base of professional education and practice to develop a greater depth of knowledge and skills related to a particular area of practice. Clinical specialization in physical therapy responds to a specific area of patient need and requires knowledge, skill, and experience exceeding that of the physical therapist at entry to the profession and unique to the specialized area of practice. The APTA specialist certification program was established to provide formal recognition for physical therapists with advanced clinical knowledge, experience, and skills in a special area of practice and to assist consumers and the health care community in identifying these physical therapists”.
Throughout my 44 years of clinical practice, teaching, research and publication, I have witnessed the profession of physical therapy mature into specialized fields in a manner similar to that of medicine and dentistry, with current APTA recognized specialty areas consisting of cardiovascular/pulmonary, pediatrics, geriatrics, orthopedics, sports, neurologic, women’s health, and clinical electrophysiology. However, unlike medicine (neurology) and dentistry (orofacial pain and temporomandibular disorders) there has been a void within physical therapy that is specific to the specialized field that encompasses the interrelationship of cervical spine disorders (CSD), cervicogenic headaches (CGH), orofacial pain (OFP) and temporomandibular disorders (TMD). Furthermore, the number of physical therapists with specialized training and advanced education in this composite field currently represent a very small fraction of the APTA that parallels that of the dental profession and has necessitated the creation of the PTBCCT in a manner similar to that of the American Board of Orofacial Pain (ABOP).
The majority of dentists, oral surgeons, and physicians who refer patients with cervical and craniofacial pain/dysfunction syndromes, as well as the public and insurance industry, have been unaware that there are physical therapists who specialize in the evaluation and treatment of these disorders. In order to fill this void, the PTBCCT was established in 1999 by an international group of physical therapists with advanced education and experience in the evaluation and treatment of patients with CSD, CGH, OFP and TMD. The majority of our board members have faculty appointments in dental and physical therapy schools and/or clinical, research, and textbook publications in this field. We are frequently invited to lecture and teach nationally and internationally at educational and scientific meetings that include the American Academy of Craniofacial Pain and the American Academy of Orofacial Pain (AAOP). Many of our board members should be well-known to those who read CRANIO as highly respected physical therapists who consistently contribute to the expanding body of knowledge and expertise that is indigenous to the interdisciplinary relationship of dentistry and physical therapy. Furthermore, since the advent of specialization in the health care field, insurance companies have been increasingly limiting their approval for specific medical and dental services to qualified clinicians and certified facilities.
The venue in which we have been able to develop and achieve our goals has been graciously provided to us by the AAOP, but it is important to state that the PTBCCT is a fully independent of the APTA and AAOP. In direct relationship, the PTBCCT has established goals and objectives that include the following:
• Assist in the disbursement of evidenced based practice and research to ultimately improve the delivery of patient care.
• Provide an annual venue and forum by which physical therapists can obtain the education needed to develop competency in this specialized field and be exposed to the cutting edge of scientific and clinical advances.
• Inform and educate the dental and medical profession about the evaluative and therapeutic areas in which an experienced physical therapist can enhance the management of their patients.
• Provide information to the public, professional organizations and healthcare agencies relative to certification in the field of craniofacial and cervical therapeutics.
• Create strict educational and clinical requirements to determine whether candidates meet the qualifying criteria to apply for and sit for our certification examination.
• Develop, administer and maintain annual certifying examinations to evaluate the knowledge and experience of such candidates.
• Maintain a directory on the AAOP website (www.aaop.org) of physical therapists that have achieved diplomate status and designation as a “Certified Cervical & Temporomandibular Therapist” (CCTT).
On the AAOP website, click on the link (Physical Therapist/PTBCCT) and then click on the subsequent link to access the directory.
The following clinical and educational requirements must be met and approved by our application committee in order for a physical therapist to sit for the certification examination:
Five years and 2000 hours of clinical physical therapy experience of which two years must include specialization in the evaluation and treatment of patients with CSD, CGH, OFP and TMD.
25% or 500 of the 2000 hours must have been obtained within the last 3 years.
100 hours of continuing education in the areas noted above during the past 5-10 years.
Two letters of recommendation: From a dentist/oral surgeon and physical therapist that is known and approved by a member of the examination committee.
Current copy of professional license.
Proof of membership in respective national physical therapy organization.
Apply for and successfully pass the certification examination.
In order to maintain certification each CCTT must obtain 25 hours of continuing education each year within the areas of CSD, CGH, OFP & TMD. Yearly submission and subsequent review of support documentation is required and performed by the board.
Development of the Examination:
In order to define the responsibilities, tasks and type of knowledge necessary to obtain minimal competency in our specialized field, an international practice analysis was initiated by the PTBCCT in 2002 and finalized in 2007. A pool of test items were obtained from a cross section of international physical therapists, dentists and oral surgeons who are experts in the field of cervical and craniofacial therapeutics and practice in clinical, research and academic environments. The information was used to determine the parameters of the examination including knowledge areas to be assessed and the percentage of questions allocated to each. The subject areas covered in the examination include: epidemiology of CSD, CGH, TMD and OFP, temporomandibular and cervical anatomy plus biomechanics, evaluation, differential diagnosis and management of CSD, CGH, TMD and OFP, dental and occlusal terminology, oral appliances, orthognathic and temporomandibular surgical procedures, as well as acute post-operative management.
The examination was subsequently created under the professional guidance and direction of an independent psychometric testing service for the medical and dental profession: Measurement Research Associates (MRA) of Chicago, Illinois. MRA continues to oversee the administration, scoring, statistical analysis, and progressive evolution of the examination.
In summary, CCTT’s have a thorough knowledge of the anatomical and physiological relationship between the cervical/shoulder girdle, temporomandibular and craniofacial regions. Optimal patient evaluation and treatment necessitates a complete assessment of the upper 1/4 and temporomandibular complex, in order to develop a comprehensive and logically sequential treatment paradigm and home program that is individually geared to the evaluative findings and patient status (acute, sub-acute, chronic, post-operative) at the time of the initial visit. The following points highlight a general overview of the nature of the comprehensive approach that we promote:
• Comprehensive evaluation and typed report on the first visit.
• Restoration of functional cervical/shoulder girdle and TMJ mobility.
• Therapeutic paradigms geared to eliminate or reduce causative and perpetuating factors of pain and dysfunction.
• Education and instruction in postural correction, ergonomics and proper sleep, plus driving positions.
• Individualized cervical/shoulder girdle and TMJ therapeutic exercise geared to the patient’s presentation with augmentation via a home program.
• Hands-on soft tissue release and joint mobilization techniques.
• Supine manual and/or mechanical sub-occipital traction techniques.
• Adjunctive nonmedicinal pain management techniques.
Jeffrey Mannheimer, P.T., Ph.D., C.C.T.T.
President: Physical Therapy Board of
Craniofacial & Cervical Therapeutics
Assistant Professor Columbia University:
Program in Physical Therapy
Private Practice: Delaware Valley Physical
Therapy Associates
Lawrenceville, New Jersey
Board of Directors of the PTBCCT
Jeffrey Mannheimer, PT, PhD, CCTT
Steven Kraus, PT, OCS, MTC, CCTT
John Dunn, PT, FAAOMPT, CCTT
Eveline Erni, MA, PT, CMA, CCTT
Jules Hesse, PT, Ph.D, MT, CCTT
Corine Visscher, PT, Ph.D, CCTT
Mariano Rocabado, PT, DPT, CCTT
Barbara Semmel, MA, PT, RCMT, CCTT
Meralee Guhl, PT, DPT, CCTT
Patricia Rudd, PT, DPT, CCTT
Dina Delgado, PT, LLCC, CCTT
Thomas Eggleton, PT, DPT, CCTT
Dennis Langton, PT, CCTT
James Schorsch, PT, DPT, CCTT
Debra Mackman, PT, CCTT
© 2009-2012: The Journal of Craniomandibular Practice. Site by Medium