When the Pieces Donít Fit

Finding Appropriate Providers is Critical

By Douglas Nelson
[Table Lessons]

I have always enjoyed seeing my client B.K. She possesses the perfect combination of compassion, insight, and intelligence, all of which make her a very successful psychotherapist and a delight to be around. This session was to address orofacial pain on the left side.

“Show me where you are feeling pain,” I began. 

B.K. pointed to the left side of her face in a rather broad sweeping motion, so broad I couldn’t really tell what she was pointing to. This made me wonder if she was unaware of the exact source, or if the pain presentation was that diffuse. While she was seated, I palpated her tissue for further clarification.

“How about this muscle?” I asked, pressing on her masseter. 

“I think so,” she said. 

“And this?” I asked while exploring her temporalis. 

“There, too, I think,” she answered. 

Given the presentation of her pain, both of these muscles were prime suspects. I measured her interincisal range of motion with three successive readings: 41, 44, and 47 millimeters respectively. For B.K.’s petite size, these readings were not indicative of notable restriction. In addition, the readings improved each time, something that research endeavors have told us is a good sign. If the masseter and/or the temporalis are involved, why is the range of motion so unremarkable? Thinking about this more, I remembered other presentations where muscle length tests out fine, but contraction reveals the problem. 

“Do you have trouble with sustained chewing of foods, such as a bagel or a piece of steak?” I asked. “Do you find your jaw tired or painful afterward?”

“No, I can’t say that I do. I chew gum occasionally, and that never bothers me. I have never noticed the pain in my jaw or face being worse after chewing, but maybe I am just not paying enough attention to when it happens.”

Somehow, deep inside, I found her answer to be unsatisfying. Perplexed, I had her lie supine on my table and proceeded to explore the orofacial musculature.

I began with the fanlike temporalis, carefully palpating every millimeter. Starting first with the posterior section, I soon found areas where the tissue felt restricted. 

“That’s pretty tender,” B.K. remarked. 

“Now we are onto something,” I thought. “Do you feel it here, too?” I asked, moving a few millimeters anteriorly. 

“Yes, there, too,” she replied. 

And so it continued throughout most of the temporalis. I found many tender spots, but none of them replicated her pain exactly. Again, at a deep level, I found this unsettling. Curious, I decided to explore the right temporalis for comparison. It, too, had many sensitive areas, not much different than the left. If her pain is only on the left, why is there no substantial difference between the left and right side? 

I proceeded to explore the masseter on the left, starting first externally and then intraorally.1 As with the temporalis, I found numerous tender areas, none of which replicated her pain. The right masseter was just as tender as the left. I expanded the search to other orofacial muscles, each muscle having the same result.

“What do you think?” B.K. asked. 

“I don’t have the sense that we found the cause of your pain. I feel like I am missing something,” I admitted. “Would you be willing to keep a little journal about this pain for me for a couple weeks? Writing down when you feel discomfort might pinpoint something for us.”

“Would you write that instruction down for me?” B.K. asked. 

She responded sheepishly to my quizzical glance. Writing down such a simple request seemed overkill, but I felt terrible seeing the embarrassment on her face. 

“I know it seems strange,” she admitted. “I have been having so many senior moments lately that I do not trust myself anymore. Everyone thinks that they struggle with memory, but this is serious. I often find myself in a room not knowing why, and a couple of times I have gotten lost driving home from my office.” 

Suddenly a chill went through me. I suggested foregoing the pain journal and instructed her to see a physician as soon as possible. 

B.K. did see her doctor and unfortunately received the worst possible diagnosis—a very aggressive form of brain cancer. She passed away about five months after our visit. 

Besides the tragic loss of a wonderful person, there is a deep lesson in this experience. When the pieces of the puzzle do not fit, do not force them. Those pieces belong to a different puzzle. If muscles are involved, muscle length or strength is almost always affected. Local tissue tenderness may be present, yet clinically irrelevant. Most importantly, recognizing that the problem isn’t muscular will facilitate seeking the appropriate provider more quickly. In B.K.’s case, I couldn’t have done anything to save her. With someone else, it may be a lifesaving decision. 


1. Massage therapists and bodyworkers may only perform intraoral massage after completing specific training and only when following the proper protocol. Follow up with your state licensing board for regulation in your locale.  


  Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com or email him at doug@nmtmidwest.com.