PDR TMJ EVALUATION
Name: _______________________________________ Date:____________________
History & Symptoms: History______________________________________________________
_________________________________________________________________________________
Hx of blow to head or face ____________________________________________________________
Head & Jaw Symptoms: Jaw Pain (0-10) ___________ Right / Left / Bilateral: _______________ Frequency ______________________________
TMJ Noise: None / Clicking / Popping / Grinding / Cracking / Other:________ TMJ Locking: None / Open / Closed / Tightness: __________________
HA: Yes No Frequency: _________________________________ Neck Pain right/Left ________________________________________________
Ear Pain/Stuffiness Right/Left
Dizziness/vertigo _______________________ Teeth Pain _____________Other:_____________ ___________
Symptoms relieved with: Heat / Ice / Rest / Soft diet / Massage / Relaxation / Exercise / Medication / Other: ___________________________________
Previous Treatment: ____________________________ Current Medications __________________ Appliance Yes No Type: ________________
Pertinent Medical History / Surgeries / Contraindications ____________________________________________________________________________
Contributing Factors: Clenching / Bruxism / Gum / Leaning on Chin / Sleep Position / Phone / Biting Habits / Jaw Thrust / Tongue Thrust/ Chewing
Functional Limitations Sleep is reduced by none / ¼ / ½ / ¾ of pre-injury level. Hours __________ Waking _________ Pain level _______
Sleep Position: prone / sup / side (R/L) Surface & Pillow support: ______________________________________ Sx in am: ____________________
Sitting Tolerance:
NA / 1 hr / ½ hr / 10 min / avoids ______________________ Pain Level____________________ Required: _______________
Sustained Head Position Tolerance: NA / 10 min / ½ hr / 1 hr/ 2 hr / avoids_________Pain Level____________________ Required: _______________
Jaw Activities: Talking Tolerance _____________________ P level:________
Dental Tolerance: ______________________ P level:________
Oral Hygiene Tolerance _____________________ P level:________
Yawning Tolerance: ______________________ P level:________
Laughing Tolerance ________________________ P level:________
Chewing Tolerance_______________________ P level:________
Work / Other Functional Limitations:___________________________________________________________________________________________
Current overall ability to perform self-cares and HH tasks < 3/10: _______% Current ability to perform job tasks < 3/10 : __________%
Systems Review:
General Behavior & Affect: flat / calm / acute distress / cooperative / non-cooperative / other: ______________________
Communication & Cognition: normal / impaired / difficulty staying on task / symptom magnification / neurological issues / ESL / Translator Present
Anxiety / Stress ____________________________________________ General Health: _________________________________________________
Postural: FHP / FSP
Lips:Open / Closed / Tense
Tongue: Up / Down / Thrust
Breathing Pattern: Mouth / Nose / Shallow/ Diaphramatic
Tests, Measures,& Palpation
AROM:
Active Incisal Opening ___________mm (Normal 40-60mm)
Lateral Excursion Right _________ mm Left __________ mm
(Normal > 7mm)
Passive Incisal Opening ____________mm (Normal 42-62mm)
Protrusion ___________ mm
(Normal > 7mm)
R__________________________L
Quality of Motion: Smooth / Rigid / Jerky / Guarded / Fasciculation / Thrusting ______________
TMJ Translation:
R=L
R<L
R > L __________________________________________________________
TMJ Noise: Right: Opening Click / Closing Click / Reproducible / None Quality: Soft / Loud Crepitus: Fine / Course
Left: Opening Click / Closing Click / Reproducible / None Quality: Soft / Loud Crepitus: Fine / Course
PDR TMJ EVALUATION
Name: _______________________________________
Palpation:
+ Pain, -- Pain Free, * Duplicates Pain
Right
_________
_________
_________
_________
_________
_________
_________
_________
_________
Left
Temporalis
________
Masseter
________
Medial Pterygoid
________
Anterior Digastric
________
Internal Lateral Pterygoid ________
Internal Medial Pterygoid ________
Internal Temporalis Tendon________
Internal Anterior Masseter ________
Capsule
________
Cervical Screen:
Forward Flexion _________________________________________
Protrusion
_________________________________________
Left Sidebend _________________________________________
Left Rotation _________________________________________
Examiner/Date:_________________
Special Tests:
Max Clench (30 sec) R: ________ L: ________
S=Same side O=Opposite side -- Pain Free
Weight Bearing –loading joint
+ Pain, -- Pain Free, *Duplicates Click
Opening
R: _______ L: _______
Deviation
R: _______ L: _______
Protrusion
R: _______ L: _______
Joint Distraction
Anterior/Medial Glide
R=L
R=L
R>L
R>L
R < L _________________
R < L _________________
Extension
___________________________________________________
Retraction
____________________________________________________
Right Sidebend ___________________________________________________
Right Rotation ____________________________________________________
Palpation: (tender/spasm): Right: SO, CEXT, SCAL, UT, LS, SCM, PECMAJ, PECMIN
Left: SO, CEXT, SCAL, UT, LS, SCM, PECMAJ, PECMIN
Other: ______________________________________
__________________________________
Evaluation Summary:
_______ Subjective Impairments
_______ Severe/ Moderate/ Mild Pain in ________________________________________________________________________
_______ Headaches / Dizziness ______________________________________________________________________________
_______ Extremity Sx _______________________________________________________________________________________
_______ Objective Impairments
_______ Pain Medication Reliance _____________________________________________________________________________
_______ Postural Dysfunctions: _______________________________________________________________________________
_______ TMJ Dysfunction:
_____ Myofascial Pain (R / L ) _____ Disc Disorder ( R / L ) _____ Subluxation/Hypermobility ( R / L )
______Arthritis (R / L )
_____ Capsulitis (R / L )
_______ Vertebral Mobility Dysfunction (MET): ___________________________________________________________________
_______ Myofascial / Palpatory Dysfunction: _____________________________________________________________________
_______ Fair / Poor AROM in R / L Upper Extremity / JAW ________________________________________________________
_______ Fair / Poor MMT strength in R / L SCAP/ Upper Extremity __________________________________________________
Functional Limitations / Impairments:
_____ SLEEP: Inability to achieve quality sleep. Limited due to pain; sleep reduced by > 25%, waking several > 3 x night, and/or waking in > 3/10 P.
_____ SITTING: Inability to sit normal duration ( 1- 2 hours) to complete educational, desk, and/ or dining activities.
_____ HEAD POSITIONS: Prolonged head positions (30 min – 2 hrs) creates fatigue and / or >3/10 pain with reading, and/or overhead activities.
_____ JAW ACTIVITIES: _____ Inability to tolerate conversation due to jaw pain > 3/10 _____ Inability to tolerate dental work due to jaw pain >3/10
______Inability to tolerate oral hygiene due to jaw pain > 3/10 _____ Inability to tolerate yawning due to jaw pain > 3/10
______Inability to tolerate laughing due to jaw pain > 3/10
_____ Inability to tolerate opening mouth to eat or chew due to jaw pain > 3/10
_____ SELF CARES: Inability to complete self cares and oral hygiene efficiently independently, and/or due to pain > 3/10, currently __________% able
_____ WORK: Inability to complete following work and / or specific daily requirements: currently __________% able
_____ Inability to sit required duration of ________________________________________________________________________
_____ Inability to perform: ___________________________________________________________________________________
_____ HEALTH:Inability to engage in physical exercise due to pain > 3-5/10, putting patient at risk for medical issues associated with sedentary lifestyle.
_____ SOCIAL: Inability to engage in wellness, family, or social activities due to fatigue and exhaustion created from pain interference in daily life.
_____ FLARE UPS: Patient does not demonstrate any measurable functional limitations as of today; however suffers from periodic, recurrent flare-ups
that significantly impair functional levels on a regular basis & demonstrates objective impairments
______Others:_____________________________________________________________________________________________________________
Prognosis: Patient demonstrates EXCELLENT/ GOOD/ FAIR/ POOR motivation to improve functional status and reach established goals.
Prognosis for this patient is EXCELLENT/ GOOD/ FAIR/ POOR based upon above orthopedic and functional problems, chronicity of symptoms, and/or
co-morbidities, to achieve program goals.
TMJ REHABILITATION PLAN OF CARE
Name: _______________________________________
Examiner/Date:_________________
Rehabilitation Goals: (circle those that apply)
1.
2.
RECOVERY: Pt will report a total recovery (0-10) rating of >7/10; and reduction of all pain, HA and jaw symptoms by 75%
PAIN/MEDS: Pt will demonstrate knowledge in pain management strategies (icing, self treatment techniques) as instructed by therapists;
decreasing pain levels by >75%, and/or decreasing reliance for pain medications by >75%.
3. HEADACHES: Pt will report > 75% reduction in headaches and demonstrate indep in headache pain management / therapeutic ex program.
4. SLEEP: Pt will be educated in good sleep postures & report that their typical duration of sleep is restored, sleep is uninterrupted by pain,
and/or pt is waking with pain < 3/10
5. POSTURE: Pt will improve posture and postural habits, and postural strength to:
a. ______ SITTING: ability to sustain improved postural habits in sitting and standing to improve sitting & standing tolerance by 75%
b. ______ HEAD POSITIONS: tolerate prolonged reading and/or overhead activ (30 min– 2 hrs), with mild fatigue and/or P < 3/10
c. ______ OTHER: ___________________________________________________________________________________________
6. JAW ROM: Pt will improve jaw AROM to WNL (40-60mm) of opening and (7mm) of lateral excursion with pain level < 3/10.
7. JAW FUNCTION: Pt will demonstrate WNL / mild / moderate dysfunction in AROM / strength impairments to allow
a. ______ ability to tolerate conversation with < 2/10 pain
b. ______ ability to tolerate pain free yawning with < 2/10 pain
c. ______ ability to tolerate pain free laughing with < 2/10 pain
d. ______ reduce jaw pain with chewing, with < 2/10 pain after prolonged use
e. ______ reduced jaw pain with oral hygiene and/or dental work activities with < 2/10 pain
f. ______ other: _____________________________________________________________________________________________
8. SELF CARES/HH: Return to >85% ability to do all self and household requirements at tolerable level of <3/10 pain.
9. WORK: Return to >85% ability to do all work related requirements at tolerable level of <3/10 pain.
10. HEALTH/HEP: Demonstrate independence with home exercise program (stretching, CV, and strengthening exercise) prescribed by therapists
with good technique and without verbal cues, engaging in regular exercise with pain < 3/10 to promote active lifestyle, and continued wellness.
11. HABITS: Pt will demonstrate understanding of contributing factors to dysfunction and make lifestyle modifications to prevent flare-ups.
12. OTHER:__________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Duration & Frequency: __________ X WEEK FOR __________ VISITS ________________________________________
Treatments & Interventions:
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


Interventions & Treatments provided by PT, OT, PTA, or COTA in accordance to practice acts & scope of practice
MedX equipment strength & AROM therapeutic exercise in-clinic; goal resistance set to body weight comparisons IF ORDERED & INDICATED
Stretching & Mobility Home Exercise Prescription (see PLAN OF CARE FLOW SHEET)
Patient Education (see PLAN OF CARE FLOW SHEET)
Strength & Stability Home Exercise Prescription (see PLAN OF CARE FLOW SHEET)
Exercise & Education Perscription:
SEE TMJ/TMD PROGRAM PLAN OF CARE FLOW SHEET
Discharge Planning
PT, OT, and doctor will formally re-assess patient at least every 8 visits to establish progress, re-evaluate subjective and objective goals, and make
appropriate changes to the rehab plan. These changes will be indicated in the Doctor PT/OT Order Form, daily SOAP note, Internal Progress Note, and
on the Protocol Flow Sheet. Patient will undergo formal discharge evaluations by PT, OT, and Doctor at the completion of their treatment program.
Please refer to this documentation in the patient chart as the complete medical record.
I certify that this treatment plan’s nature, scope, and duration, is medically necessary & reasonable to reach the therapy goals for patient’s illness/injury.
_______________________________________
Physical/Occupational Therapist Signature & Date
PER MEDICARE GUIDELINES:
Per Medicare guidelines, as a supervising physician, please sign that you have certified that this plan of care is medically necessary and will reasonably
diagnose or improve the functioning of the patient.
Supervising Physician Signature: ______________________________________________________________________________________________