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We set out to talk with physical and occupational therapists, along with other healthcare providers about the state of healthcare, hot button topics, and treatment options in different healthcare segments.
Welcome back to another episode of the Freedom Talks Podcast everybody. This is your host, Joe Ogden. And today we're back with owner and physical therapist here at Freedom Physical Therapy, Mike Karegeannes, who also is one of the very few physical therapists in the world that have the education and credentialing that he does and he teaches all across the world as well now with how to effectively and efficiently treat TMD. So we're gonna pick his brain a little bit, and we're super excited and grateful that he took the time to sit down with us here on the Freedom Talks podcast to kind of go through some general TMJ and TMD symptoms, and some of the things that we see and some of the things that I think are important for people to know, about the capabilities of a highly skilled physical therapist to help treat these conditions. So again, thank you to Mike.
Joe:And without further ado, we'll get into our conversation with Mike Karegeannes. Welcome, Mike Karegeannes. Mike, good morning.
Mike:Good morning, Joe. How are you?
Joe:I'm fine. Excellent. It only took us I think we sat down last month.
Mike:Yeah. We're doing pretty good. We're on
Joe:the cool. Mike, I told people in the intro, that you are one of the few physical therapists in the world because you probably won't say it yourself. I'll probably have to set the stage a little bit, who have the TMD credentialing that you do and some of the education. Give Give us just a little background on your, kinda continuing education background and just what sets you apart from other physical therapists?
Mike:Okay. Gotcha. Great. No. A good question.
Mike:I mean, obviously, you know, right from a licensing perspective, you know, I'm a physical therapist. Back in the day, they did not have the DPT, Doctor of Physical Therapy. So it was a master's or, I'm sorry, a bachelor's degree back in 1989. So I'm dating myself when I went to Madison. But then I kinda quickly realized that, right, there's so much more to learn than just what's what we're taught at school.
Mike:So went on to through the University of Saint Augustine to get my master's of health science, just to kind of, you know, stay on par. It was a it was a very clinical based master's of health science, so I picked up a lot of great skills, as well as just better understanding of research and those things. And during my time at St. Augustine, doctor Stanley Paris is kind of a a a legend or a guru in the PT realm of things, certainly in the United States and frank quite frank frankly abroad. I said, alright.
Mike:What what should I do next? And, he, he said, well, do you know Mariano Roccobato? And I was like, nope. I'd never heard of him. He said, well, he's kind of a legend in the PT realm of of of really introducing and teaching physical therapists, how to evaluate and treat temporomandibular disorders and was also really working hard at that time to help educate communities at large about the benefit of PT and dentistry working together.
Mike:So, Saint Augustine had a craniofacial certification program. So it's really only one of 2, for lack of a better word, credentialing bodies in the US that actually has a specific educational niche in teaching PTs how to evaluate and treat TMD. So I went through that. I got that craniofacial certification, and then, also quickly, actually due to doctor Roccabado's recommendation, he said, you know, you should really join the American Academy of Oral Facial Pain. It's one of the few specific scientific organizations in the oral facial realm, that have PTs as members.
Mike:And went through their, you know, initial program, and they we also now I'm on the board of this program, and we have a certification program through that. So sort of what you're saying in the sense of, yes, I I think there's only 2 of us possibly, maybe 3 now. I'm not quite sure the exact number that have the dual credentials, you know, kind of certainly in the US and, yeah, abroad. There are more starting to take it, but you're right. Not not as much abroad.
Mike:So kind and 2, I think the message that's important is in PT school. Right? While they learn maybe a tiny bit about the jaw, there's certainly it's not gonna make you an expert. So like so many things in life, you have to go on. And same thing in dentistry, very few dentists really learn about TMD, but many of them go on to become board certified in in learning how to treat and evaluate TMD.
Mike:So long answer. I apologize.
Joe:What board are you on? Is that for the CCITT?
Mike:Yes. So the certified cervical and temporal mandibular therapist. It's it's the certification program we have. So we're independent from the American Academy of Oral Facial Pain, but we we play nice in the sandbox. So we're at every annual convention.
Mike:We bring in key speakers from around the world to do sort of a day pre conference for PTs and dentists. And then, like I said, our our board, we have put together like a certification exam, and then a credentialing application process. People have to meet very specific requirements before they can even sit for the exam.
Joe:And Mike also teaches now around the world your, treating TMJ level 1, level 2. Those the only 2? Am I missing 1 there?
Mike:Nope. For for right now, yep. Those are the 2. Yep. The the level 1 and the level 2 course for evaluation and treatment of temporomandibular disorders and craniofacial pain.
Mike:Periodically, right, working hard to bring in some really high quality guest lectures and speakers working through the program that sort of dovetail off of TMD. Like, you know, last 2 years, we've had Annie Strach from Australia come because she's an excellent, voice and vocal person. We've had Walt Fritz, who's out of Rochester, New York, come and educate. So really working hard to keep building on this platform and and just keep working with high quality people. And then literally last week, super excited to have finally gone, live with my first online 20 credit, course for evaluation and treatment of TMD.
Mike:So I'm really excited about that.
Joe:Where do you see it, you know, just because you mentioned, you know, you graduated in 1989, that's now 30. What are we at? 30 35 years?
Mike:35 years.
Joe:35 years. 35 years. Mhmm. You know, where I'm at the beginning of my career Yeah. Where do you see, like, in your career or where do you want kind of some of the things that you are involved with with TMD to go?
Joe:Yeah. Because I mean, we're overlapped a lot with, you know, we've talked with speech therapists as well. There's a ton of overlap there. Mhmm. We've treated dentists and that you and I have talked about treating dentists, working with them.
Joe:I think it's very interesting the overlap and how much we can really do together
Mike:Right.
Joe:On top of, you know, obviously working with with ortho orthopedic doctors. Where do you wanna see, you know, before your career is over? Mhmm. Where do you wanna see kind of the TMD realm kind of advance to?
Mike:Yeah. That's okay. That's a that's a great question. I mean, part of it is just continuing to raise the awareness in in sort of the right? The dental community, orthodontics, prosthodontists, endodontists, ear, nose, and throat docs that, you know, PT as a profession is certainly a a very wonderful conservative option for people suffering with oral facial pain, whether it's temporomandibular, trigeminal neuralgia, right, just muscular headaches.
Mike:Right? All the things that kind of fall sort of from the collarbone up, so to speak. So I guess, you know and and part of my mission has been as well, we've had the good opportunity to lecture, and help do lab at Marquette University. In the past, Mike Verblanc and I had an opportunity to, Rosalind Franklin University in North Chicago, and many of my other colleagues in this realm also some lecture at Columbia University and so and University of Minnesota. So I I think what's been nice is to also at least see the DPTs coming out of school getting some exposure so they can try to decide, you know, to what percent of your patient population do you wanna treat these people but recognizing you're gonna need to get more education.
Mike:My my pie in the sky, would be to have a PT in every dental office. I mean, I think that would be a pretty cool cool concept, you know, to, have PTs and dentists, because especially now with the overlap in, airway and sleep medicine, it really I mean, PTs too can be, if they want to be, very well positioned to be part of the the, process for people to to find answers, get better, you know, just overall health and wellness.
Joe:Does anyone do that that you know of?
Mike:I mean, I think there are some PTs I'm aware of that work, with dent you know, with dentists, some inside, I would say what I tend to find is it might be a a a a a couple's team. You know, one's a dentist and one's a PT. Yeah. And so they find themselves working together or or they might, take my class together, so that they're like, okay. This is a niche that we want to to go into.
Mike:So I would say it's it's not, very popular yet. I don't think, but I think, again, just there's so many avenues for a profession to go with. To me, this is just one amazing avenue for us to stay relevant and and we're gonna carve out our own mission. You know, yes, work fun in the sandbox in health care, but also work outside of health care, so to speak.
Joe:Yeah. Yeah. Yeah. Mhmm. Mike, let's backtrack a little bit because I think you and I talked before we started recording.
Joe:I feel like I see a lot of patients that are referred by their dentist and they really have no idea what a physical therapist can do for TMD or some of their symptoms. For you, I think it's probably different because obviously, Mike, again, will not say it, but I think you're kind of elite in the TMD, physical therapy world so people know what you do before coming in. What are some, you know, just kind of signs and symptoms that you see with, generally speaking, TMD patients and some of the basic things that for sure, physical therapy or a good physical therapist who treats TMD can do?
Mike:Yeah. No. It's a good question. So, like, on our website, you know, at,
Joe:treatingtmj.com.
Mike:You know, we have a TMD screener, so which is actually proven to be a very reliable and valid questionnaire. It's, a handful of questions, and it can give people a very simple answer. Yes or no. Like, yes, you probably do suffer from TMD or no, you don't. And some of the simple thing, you know, things we take for granted.
Mike:For example, right, do you have pain with chewing, talking, yawning, functional tasks of some sort? You know, do you wake up with facial pain and things like that, in the morning? You know, popping and clicking noises. Right? Sometimes they're painful for people, so sometimes they're not.
Mike:So so part of it is just, yeah, anything. And then, of course, what we also tend to find is a lot of these TMD people have headache and neck pain, but they may not necessarily think that the jaw could be contributing to those problems. So we also have a headache screener, on our website as well. And I would say, you know, again, when we're getting referrals from the dental community, right, if we keep in mind that dentistry like PT, and I I don't think I'll offend any dentist when I say this because many take my course, you know, their their training is really mostly about the teeth. You know, they don't get much exposure to the temporomandibular joint just like PT doesn't.
Mike:So it that's why you finally realize why they wouldn't even think of us sometimes as being one of their first choices. So I think what has really helped our profession, right, is by having direct access. So, right, we know patients are coming to us directly off the street with functional problems like chewing, talking, yawning, opening their mouth, right, that type of thing. And then that allows us a unique opportunity to find out who's their primary dentist and now start that communication back to, you know, just like we would do in our orthopedic role with the primary doc, now it's the primary dentist. And then opening that communication with the primary dentist and then educating them from that manner of what we do, but also learning more about their practice.
Joe:For the most part, in in general, like, symptom wise, what are what would you say are some of the biggest things that we see even at Freedom as far as, you know, patient presentation?
Mike:Mhmm. Obviously, the the things that are probably most, frustrating for people is when they can't open their mouth and they can't eat as well anymore. So, right, we would reference that. You know, the dentist might send a prescription for that called a closed lock, meaning they can't open their mouth wide. Right?
Mike:And it's very possible that that patient has now suffered what we call a a disc displacement, so the disc and the joint is not quite where it should be, and now it's blocking their normal mechanics and it's limiting their opening. And as a result, they can have not only just loss of function, but a significant amount of of pain that's associated with that. So I would say that's certainly one of the more common ones we see. And then, of course, you know, within that, we see a plethora of people that just are having more muscular related pain. So the joint always doesn't always have to be involved.
Mike:What I what I tend to say and when I teach is that when people tend to have joint related problems when it comes to the jaw, they almost always have some muscular component as well. But some people will come in just right. They're clenching too hard. They maybe have some type of pair of function like biting their nails, biting their cuticle, and that'll really cause a lot of over activation of the the muscles for chewing as well as any of the cranial and neck muscles. And so some of those people are just in need of really good muscle management.
Mike:And then I would say the other aspect of things we see is, one thing I think that Freedom is unique about is we do a really good job of screening for, like, systemic hypermobility issues. And I tend to find a lot of correlation with people with systemic hypermobility or, you know, Ehlers Danlos syndrome also have TMJ issues, headache issues, migraine issues in addition to other things below the collarbone. So I I would say, you know, we're we've positioned ourselves sort of uniquely to be a a you know, I hate to use the word like a primary, but a a very good primary point of contact to help lead these people to other providers, like other dentists, other TMD specialists, neurology, rheumatology that can help us really get these people better.
Joe:I feel like a lot of us and I can't speak for the other clinics, but I I would assume every clinic is the same. But here at Fox Point, I I feel like every therapist here has seen an EDS patient at some point. Right. Yes. And in my experience with patients that they say that they have it and that's about it.
Joe:They don't know who to see, where to go. Most doctors are so booked up. So I think the primary contact is is super important with us knowing how to manage it.
Mike:Right. Yep. I agree. No. I I think, the systemic hypermobility, I I think it's way more prevalent than we're aware of and probably that's even documented.
Mike:And, again, usually, what I after I've taught my class and I'm educating the participants about, you know, at least look for it. There's some very simple screens to look for. The UK has put out an amazing, EDS checklist which can be invaluable even for primary docs just to have a have a checklist as a screener once they get educated on how to do all the different testing and things. So, usually, I I will encourage them and say, I guarantee you these people are in your clinic right now, but you haven't looked for it. So you're right.
Mike:I I think they're in people's clinics. They might, unfortunately, tend to be people that have had a lot of chronic pain issues, everything from neck to low back to GI, irritable bowel syndrome, certainly headaches and migraines and that. So they're they're in their clinic, but, right, if you don't know to look for it or at least help tease that out, because those people usually need a nice team effect. You need multiple providers to help you really get, again, not a fix, but how to manage it really well.
Joe:I feel like since I've really started to use that, do I you know, when I first took your class, you know, I when you first take a a certificate or not certification, excuse me, just an instructional course, it seems overwhelming. You start treating patients. Okay. I just need to make sure I do the basics. Mhmm.
Joe:At first, I didn't do the Bryton Yep. Scale all the time because I just ran out of time.
Mike:Yep.
Joe:And now I feel like I do it, you know, pretty much with everybody. It's if and if they if they pass, it's quick. Just go through it. Yes. But I think it gives a ton of information as to what else may be causing some pain.
Joe:It may not just be the jaw itself. And I feel like that's one thing that you do incredibly well is like, okay. We need to make sure that every other system is functioning fine because there should be there could be a very deep, deep cause to what's going on. It's not just your jaw pain Correct. Which I feel like TMD patients.
Joe:I see that more and more that this is just where the pain's coming out. This is not really what's causing it. I don't know how you feel about that.
Mike:Yeah. No. I I think that's valid and and that's why too, like, even in our orthopedic world, even when I know that many people taking my class, maybe they only want TMD. Maybe they're only taking it because they wanna try to help their headache and their neck people and, you know, migraine people feel better. They maybe don't wanna totally have it be a a specialty, but I it's so relatable just to all of our orthopedics, you know, when it comes to getting an ACL repaired.
Mike:I think it's important, the surgeon even knows that this person, you know, has significant laxity. You know? Do we make this repair a little snug or a little tighter? Because we know they're they might have a tendency to loosen up quicker. And I agree with you.
Mike:I I think too what we often forget, especially in the PT realm is someone might come to us again because we're the TMD experts or whatever. It doesn't mean they think we know how to treat knees, hips, backs, and everything else. You have to educate them that, well, we we kind of are fortunate to have a pretty good understanding of the whole body, and then to your point. So putting all those little pieces together, that there's possibly a deeper underlying problem that's driving it. And then from there, you know, helping them manage this.
Mike:And and most people are you would think it's weird. You know, you never wanna head label someone. I hate to use the word labeling. But in some regards, they finally feel validated for because for 10 or 15 years, people kinda raise their hands. I don't know why you have all this chronic pain.
Mike:I don't know why your back hurts and you have headaches and you have migraines and and so they start to you know, psychologically, that messes with them. So we find a lot of our patients end up crying after we've had that initial session more out of, like, I'm finally feeling validated Yeah. And someone's listening to me. And I I you know what? To me, that's that's the problem right now we're at too.
Mike:Like, so many clinics don't have enough time to spend with patients. So, unfortunately, you you can't even get to know the person sometime, which is unfortunate.
Joe:Yeah. And I I think that's what I've appreciated a lot about, treating TMD patients and, or excuse me, patients that have TMD. And our setup here, every I think every clinic has a right to set up their appointment schedules, the what works best for them. But I think for some of this stuff, you have to spend a lot of time 1 on 1 with these people to really understand, okay, why is this going on? That other models just, I think, struggle to be able to facilitate that.
Mike:Mhmm. Nope. I I would agree and and, you know, there's something called the research diagnostic criteria, which came out in the early nineties, and it was a a vehicle to help dentists and oral facial pain specialists sort of, you know, ask a series of good subjective questions and then objective questions and to help put people in the categories for, you know, what we would call a musculoskeletal or orthopedic problem. But then there's this whole other access, it's called access to, and that's where then you kinda get in the realm of assessing for anxiety and depression and post traumatic stress. And and also, you know, the unfortunate part is so many of these people suffer from all those things as well.
Mike:Now the question is, did they become anxious and depressed because they've had all this facial pain for so long or or vice versa. And and that's where it's important we acknowledge those things as well. And then, right, we have to get into the right professionals that are capable of treating those aspects as well.
Joe:Yeah. Yeah. Mike, for your classes that you teach, who are they open to? Which providers are able to sign up and and benefit from your course?
Mike:Yeah. No. That's great. So, you know, physical therapy, of course, for sure. Physical therapy assistance because often, right, they're working under the supervision of a of a PT.
Mike:Dentists, by all means, of course. Orthodontists are always welcome. I think I've just had a few orthodontists actually take the class. But, you know, when you think of it, it it's to me, it would be really important for an orthodontist that's working on the teeth all the time to have a really good understanding of the very foundation of the jaw. It's certainly been open to primary docs.
Mike:I don't think I've ever had a primary doc take it. Nurse practitioners have taken it, dental hygienist. But, usually, they're coming with their dentist so that they have an understanding. It doesn't necessarily mean they're maybe gonna do the treatment, but I think they find it to be a really good educational view. They have a much better understanding of the patients that are in front of them.
Mike:Chiropractic, for sure, and then massage. And and the the biggest reason to me too with massage, massage people are already treating these patients. So why shouldn't they have an opportunity? I think the beauty is people can take from my class, and they come out with a better understanding, a better foundation, and they come out with tools that they can apply respective to their discipline. So, right, maybe they're not gonna be manipulating and mobilizing a joint because it's not in their scope of practice, but they're gonna learn the soft tissue skills that they can do.
Mike:So and in speech. Yeah. Can't neglect speech. I've had speech therapists take it because, there can be a nice symbiotic relationship for sure between dentistry, PT, and speech for these very complex orofacial pain patients.
Joe:OTs as well?
Mike:Yep. Thank you for reminding me. OTs as well. And we have had some, OTs, especially, you know, in other countries too where they're the OTs, sometimes have more latitude. They're treating a lot of cervical spine stuff, headache stuff, craniosacral stuff.
Mike:So yes. Yeah. OTs as well.
Joe:Okay. Mhmm. And you try and I know sometimes it depends. I feel like you've been teaching a ton in the past. Even since when I've started here in 2021 now Mhmm.
Joe:I feel like your classes have gotten busier and busier and busier. Do you try and have a class once a month on average?
Mike:On average now, I'm I'm teaching at least probably once a month, sometimes twice. You know, the uptake has been certainly by adding the level 2 course. You know, obviously, and, you know, we all only only have so many minutes and so much time in the day, but, kind of fortunate to be at a good point in my life right now where our kids are either taking care of themselves or they're in college. So, so it gives me some free time and for my wife and I to, you know, be able to travel and do some of these things and and spread the word.
Joe:And you do open classes, which we can find on treatingtmj.com. Correct?
Mike:Correct.
Joe:And closed courses as well?
Mike:Closed. And if clinicians or dentists are interested in hosting, sometimes, like you said, they'll be just pertinent to their group. Or, yep, we're we're a fully running machine to be able to accept, yeah, online registration and stuff like that for sure.
Joe:And the online, credentialing, what's the difference between the online course and the in person besides the obvious, in person skills?
Mike:I would say well, the one benefit with the online, is, you know, they'll they're gonna get about 4 more hours of content. It really gives me an opportunity to go more into the cervical spine that we you know, as as I think most people who've taken my course, while I give them a ton of information in 2 days, it's probably really a 3 day course. But trying to be respectful of people's time and finances and everything, I've just opted to continue to keep it at a 2 day course. So the online course, I think, offers just more time for more explanation, and and, more cervical spine stuff. And then, you know, as we would all say, I think we did the best we could through video to show the manual skills.
Mike:So I think the real plus is I think I find this tool as possibly being someone's first intro and then, like, okay. I really like this. I wanna see this guy in person to show me how to do the skills actually correctly, and vice versa. If you have taken my course, now you have a supplemental tool to because I don't know what the old adage is. Maybe we retain 10 to 15% of what we learn when we go somewhere.
Mike:So it will serve as a great reminder for them of, like, oh, yeah. Now that I've got these patients, now I'm gonna add in the biting or brighten test, or I'm gonna be more mindful of the EDS checklist from you you know? Because you just can't you can't implement it all day 1. It's too overwhelming.
Joe:That's what I think is nice too about the and I look at it because I graduated during the COVID Mhmm. Or at the beginning of the COVID era where everything is online.
Mike:Right.
Joe:To me, like and you've done it now too with the courses we've taken together here. The amount of video that you can get now and just the resources just to go back quickly go find a video of, like, okay. Yeah. That's how you do that. I think it's so beneficial.
Mike:Yes. I agree.
Joe:It's just a quick reminder.
Mike:Yep. And he can write pause, rewind, make sure you heard them correctly. So, no, I I think, yeah, I think that that that collaboration between online and live. I just, you know, I just hope we never lose the live because the piece that the participants online miss out on is also the collaboration of the group. No class is ever the same.
Mike:The dialogue changes. The content slightly changes depending on the skill level or lack of skill level of the participants. So and it just you know, it lends to and plus, you know, like, last time I when I was just teaching in Brooklyn, you know, I was I always love to ask people, what's your favorite pillow? You know, it's a random question, but sleep is important. Pillows are important for our neck pain, for our jaw pain.
Mike:And, one of the participants talked about something called Coop, c o o p. Apparently, it's a website, you know, that they sell pillows, but then you can, you can either take some of the product out or add product in so you can make it thinner or thicker. And I have to say, I got the pillow and so far I love it. So, I mean, I wouldn't know that if I you know, so while I'm also teaching, I'm learning. And I think that's I I mean, I've come out of every course learning something even I didn't know or it forces me to think more critically and different.
Joe:Yeah. So if anyone's interested in taking Mike's course, I've taken it. I've taken a ton of courses already. I think, again, it's working at Freedom. They're super supportive of continuing ed.
Joe:I would argue Mike's is one of the best where you get way more than what you signed up for, which Yep. For what you get out of it. Yep. Again, more information can be found out on treatingtmj.com. I think you're going to Ohio, California.
Mike:Yep. Back to Manhattan again, coming up.
Joe:York again. Level 2 and level 1.
Mike:City, Utah. Yep. And hope hopefully adding, DC, and Atlanta again coming up. We're just kinda finalizing some other things.
Joe:And just because we're local in the Fox Point, Milwaukee area, are you coming to I probably Fox Point anytime soon?
Mike:Late late winter yet. I have not finalized the December schedule or January, but you have a pretty good opportunity.
Joe:Probably a level 1?
Mike:Yeah. For sure level 1.
Joe:Level 1.
Mike:I think. Yeah.
Joe:Okay. Perfect. Mike, thank you for another podcast. This is really good. Again, we we do specialize our the very unique niche niche tomato tomato Exactly.
Joe:Of treating TMD patients here in Fox Point, Grafton, Brookfield, and Mukwonago. I think Mike has set us all up for success to really, treat this patient population effectively. So if anybody listening to what Mike has talked about thinks that they may have TMJ or, excuse me, TMD symptoms, or know for sure that you have them, definitely come and see us at one of our 4 locations. Mike, anything else?
Mike:That's it. Just appreciate you, Joe. You're doing a great job and and just, you know, appreciate you spreading the word. There's a lot of people that, could use, you know, our our attention to this problem, and we just wanna keep helping people. So appreciate the opportunity to share.
Joe:Just we enjoy spreading positivity for the health community.
Mike:Exactly.
Joe:We work better together
Mike:in a part. Love that.
Joe:Thanks for listening everybody to another episode of the Freedom Talks podcast. We'll see everybody in next week's episode.