learning with laughter cathy russell. dip pt (uk), mcpa, atm humor helps us relax… when we relax
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Learning with Laughter
Cathy Russell. Dip PT (UK), MCPA, ATM
www.cathymrussell.com
http://www.cathymrussell.com/blog/
Humor helps us relax…
When we relax we learn
SYMPTOMS of TMD
HeadachesChronic Neck / Shoulder
Pain Earaches
Facial /throat painSinusitis
ToothachesUndermining balance
against gravity
SYMPTOMS of TMD
HeadachesChronic Neck / Shoulder
Pain Earaches
Facial /throat painSinusitis
ToothachesUndermining balance
against gravity
1st HALF
WHAT IS PHYSIOTHERAPY?
ANATOMY
CERVICAL JOINTS & FASCIA
BIOMECHANICS
ETIOLOGY
DIAGNOSTIC CLASSIFICATION
1.MANAGEMENT OF PATIENT WITH COMPLEX TMD2. ROLE OF PHYSIOTHERAPIST3. ROLE OF DENTAL PROFESSIONAL4.TMD CHECKLIST FOR DENTAL PROFESSION 2nd HALF
TM and CV JOINTS
TM JOINT
TMD & VESTIBULAR SYSTEM
• The vestibular organs sense head motion: canals sense rotation; otoliths sense linear acceleration (including gravity).
• The central vestibular system distributes this signal to oculomotor, head movement, and postural systems for gaze, head, and limb stabilization..
• The visual system complements the vestibular system.• Visuo-vestibular conflict causes acute discomfort.• Peripheral and brainstem vestibular dysfunction causes
pathological sense of self-motion and visuo-vestibular conflict.
TMD & The Vestibular Organ
Horizontal canal
Anterior vertical canal
Posterior vertical canal
Vestibular Nerve
Facial Nerve
Vestibulocochlear(VIII) Nerve
Cochlea
Cochlear NerveCochlear Nerve
UtricleSaccule
There are 3 major vestibular reflexes
• Vestibulo-ocular reflex – keep the eyes still in space when the head moves
• Vestibulo-colic reflex – keeps the head still in space – or on a level plane when you walk
• Vestibular-spinal reflex – adjusts posture for rapid changes in position.
EMBRYOLOGY AND CRANIAL NERVE LINKS
Pharyngeal Arches- 5 & 20 weeks
Trigeminal Facial Glossopharyngeal Vagus
Art by Renee Peterson & John Chitty, based on Larsen, Human Embryology, p. 362
THE CHEWING MUSCLES
TEMPORALIS
MASSETER MUSCLE
PTERYGOIDS & EAR SYMPTOMS
Tensor velipalatini
Levator veli palantini
MOUTH OPENERS
From Gray’s anatomy
© 2012 Pearson Education, Inc.
Figure 11-7 Muscles of the Tongue
Styloid processPalatoglossus
Styloglossus
Genioglossus
Hyoglossus
Hyoid boneMandible
(cut)
EVERYTHING’S CONNECTEDphotos from Tom Meyers Anatomy trains
Cranium, Jaw, thorax connections
From grey’s anatomy
The Trigeminocervical nucleus.
TRIGEMINAL NERVE
Sensory -face, scalp, teeth, mouth and nasal cavity
Motor nerve to muscles of mastication
3 Nerve Branches
Opthalmic
Maxillary
Mandibular
SUMMARY OF BIOMECHANICS
ETIOLOGY
• Factors which may be involved in the onset of TMD/J:
Specific onset event or
No specific onset event
TMJ
SPECIFIC EVENT ONSET
MODEL OF TRAUMATIZATION FOR BRUXISM?
TRAUMA IN MVA / HEALTH PROFESSIONAL VISITS
• Meaning of event… in state of relative helplessness
• Life history of specific traumatic events especially from childhood “fans the flames”
Together may result in “Bruxism”which now becomes an unconscious activity incorporated into
muscle tension when triggered by memories
TMD
POSTURAL ABNORMALITIES/FORWARD HEAD POSTURE
SINUSITUS/PROLONGED MOUTH
BREATHING
PARKINSON’S
FIBROMYLAGIA
IBS
RIGHTING &
MOTOR REFLEX
CRANIUM SHAPESMALOCCLUSION
NARROW VAULTED PALATE
TENSION / STRESS BRUXISM
NO SPECIFIC ONSET EVENT
SLEEP DISORDERED BREATHING/APNEA
My Cranial base with C1 and rotation of C2
RIGHTING REFLEX
The proper alignment ofBipupillary, Otic plane, Occlusal plane
NORMAL C-SPINE ALIGNMENTX-RAY: LATERAL VIEW
• Schematic lateral view of a normal cervical spine. Note (A=anterior spinal line; B=posterior spinal line; C=spinolaminar line;
Forward Head PostureC1 encroaching on airway
Loss of Cervical spine stability
Weakened and lengthened hyoids- ABNORMAL SWALLOW
Spondylolisthesis
LOOK FOR NARROW PALATES
Blue triangle represents narrow airway
P = palatal height
Mx= maxillary intermolar distance
Mn=mandibular intermolar distance
OJ = over jet
NC = neck circumference
BMI = body mass index
Stanford Morphometric Model P + (Mx - Mn) = 3 x OJ+ 3x (BMI - 25) x (NC/BMI)
A Predictive Morphometric Model for the Obstructive Sleep Apnea Syndrome, Annals of Internal Medicine, Vol. 127, No. 8(Part1), Oct 15, 1997. Pages 581-587)
Cerebellum
From greys anatomy
RESEARCH DIAGNOSTIC CRITERIA
• Group1-Myofascial pain in face, neck and shoulders
Most common category
• Group 2-Internal derangement of the joint Disc Displacements ~ 3 types Injury to Condyle
• Group 3-Degenerative joint diseaseEg. Osteoarthritis, Pyogenic Arthritis, Rheumatoid Arthritis
Group TwoDisc Displacement With Reduction
Group 2-Disc Displacement without reduction, with limited
opening
<35mm (Less than 35mm)
GROUP 3
CERVICOGENIC HEADACHES
• Anatomical basis for these is the convergence of the afferent input of the upper cervical spine nerve roots(C1-3) and the afferent tracts of the trigeminal nerve in the trigeminocervical nucleus
Journal of manual & manipulative Therapy.
Vol 15 No 3 (2007),155-164
MANAGEMENT OF TMD
The Role of Health
Professionals &
Physiotherapist
The Role of the Dental Professional
THERE IS ALWAYS A WAY TO MANAGE A CHRONIC PROBLEM!
DIAGNOSTIC CRITERIA QUESTIONNAIRE FOR ALL HEALTH
PROFESSIONALS
If have TMD proceed to
INTAKE FORM
PHYSIOTHERAPY INTAKE FORM-QUESTIONS ARE KEY!
• HISTORY: MEDICAL –BIRTH, BREASTFEEDING HABITS, PARKINSONS, FIBROMYALGIA, IBS, LYME DISEASE, CONCUSSIONS
• DENTAL: ORTHODONTIC WORK, LONG DENTAL PROCEDURES, FACIAL TRAUMAS & SURGERY
• POSSIBLE CONTRIBUTING ETIOLOGY (MVA, Airway issues, Birth and childhood traumas)
• HISTORY OF PRESENT ILLNESS in own words
• SOCIAL HISTORY –HABITS AND WORK/HOUSEHOLD RESPOSIBILITIES• EMOTIONAL STRESS
• MEDICATIONS
• EPWORTH SLEEPINESS SCALE for OSA /CSA
• DIAGNOSTIC IMAGING-Plain film radiography; MRI- disc position only relevant when ROM restricted or non reducing disc is suspected
REFERRALS • PATIENTS WHO HAVE MANY SYMPTOMS ON THE
DIAGNOSTIC CRITERIA SCREEN
• DIFFERENTIAL DIAGNOSIS
• MVA PATIENTS
• TYPICAL TMD PROFILE PATIENT – FH POSTURE, ROUNDED SHOULDERS, MOUTH AND ACCESSORY MUSCLE BREATHING, ABNORMAL RESTING PLACE FOR TONGUE AND MANDIBLE, & ABNORMAL SWALLOWING PATTERN
• ACUTE TMD PATIENTS-SOONER THE BETTER.
• Please send to physiotherapy before making night guard- teeth
will change and patient needs educated
TREATMENT STRATEGIES
• EDUCATION ON HABIT MODIFICATIONS, CORRECT RESTING POSITION OF TONGUE
• ROCOBADO-THERAPEUTIC EXERCISES & DIAPHRAGMATIC BREATHING
• CRANIAL TECHNIQUES, HEAT, TENS, ULTRASOUND,
• STRETCHING: ACTIVE, ASSISTED & PASSIVE –USE OF TONGUE DEPRESSORS OR GAUZE PAD
• SOFT TISSUE MOBILIZATIONS: MYOFASCIAL MASSAGE TO 6 FASCIAL CENTRES OF FUSION & DEEP FRICTIONAL MASSAGE
• JOINT MOBILIZATIONS TO JAW AND NECK
ROCOBADO’S 6x6 PROGRAM
Involves Six components which are repeated six times each and performed six times/day
• Targets the craniocervical and craniomandibular systems
• Educate/instruct patient on proper breathing, tongue position & posture
AQUALIZER“THE BIOFEEDBACK TRAINING TOOL” ROCABADO TRAINING TOOL
DIAGNOSTIC CRITERIA FOR TMD
• Pain in jaw, temples, in or in front of ear?
• Headache
• Joint noises
• Closed or open lock
PAIN
1.EVER IN JAW, TEMPLE, Etc? IF YES CONTINUE. IF NO SKIP TO 9
2.HOW LONG in these areas?
3.DESCRIBE the DURATION-One response selected
4. IN LAST 30 DAYS: if No to 4 & 5 skip to 9• Describe BEHAVIOUR OF PAIN-one response
5. WHERE on awakening
6. What aggravates
7. HOW MANY DAYS PER MONTH?
8. On average, how long for single episode?
HEADACHE
9. In last 30 days: ANY HEADACHES? If No skip to 20
10. AREA? Did it include the Temples? If No skip to 20
11.DURATION
12. TEMPLE HEADACHE -1 response
13. SINGLE EPISODE DURATION?
14. INTENSITY-1 response
15-17. BEHAVIOUR
18. What AGGRAVATES?
19. LOCATIONS
JAW JOINT NOISES
In last 30 days:
20. NOISES
21. CLOSED LOCK? If No skip to 28
22-27. BEHAVIOUR OF LOCK
28-30 OPEN LOCK? If no skip to 31
29-30. BEHAVIOUR
THE ROLE OF DENTAL PROFESSIONAL
DIAGNOSTIC CRITERIA CHECKLIST & KEY QUESTIONS
Screening for TMJ(After: Epstein 1993)
• Variable onset and duration of jaw area pain• Night pain and bruxism• Pain with function, eating, wide opening• Joint noise variable, clicking, crepitus• Limited opening, deviation on opening• Associated symptoms: headaches, dizziness, tinnitus, fatigue,
chronic pain syndrome• Referred pain: neck, ears, face, upper ant chest, headaches• Sometimes general dysfunction state
PATIENT SYMPTOMS
TMJ EXAMINATION
• OBSERVATION
FACIAL VISUAL SCAN
PALATE SHAPE
TEETH
EMOTIONAL STATE
OBSERVE
FACIAL AND PALATE SCAN
Visual scan: Look for these
OMD - Orofacial Myofunctional Disorder
LOOK FOR THESE DENTAL SIGNS
• Skeletal anterior overbite
• Over jets < 6mm
• Retruded cuspal
• position/intercuspal position
• Slides < 4mm
• Unilateral lingual crossbite
• 5 or more missing posterior teeth
Reference: Occlusion, Orthodontic treatment and TMJ disorders: a review. McNamara JA Jr, Seligman DA Okeson JP. J Orofac Pain 1995 Winter;9 (1) ;73-90
3.PALPATE
Trigger points are an area of muscle characterized by local area of firm hypersensitive bands of muscle tissue
~~~ REFERRED PAIN ~~~
eg: in TMJ - tension type headache painful teeth
From Janet Travell
From Janet Travell
From Janet Travell
From Janet Travell
ACTIVE RANGE OF MOTION
Normal TM Joint ROM
• Active opening-35-50mm (3 fingers)
• Functional opening -25-35mm (2 knuckles)
• Protrusion- 5mm
• Lateral deviation- 8-10mm
CLICK –MORE THAN 3 IN SUCCESSION
HYPER MOBILITY SYNDROME “painful and possible end range
clicking/clunking TMJ”
On opening, the lateral deflection will be towards the Hypo mobile side
On opening, the lateral deflection will always be away from the Hypermobile / subluxing side
Inconsistent opening late click and early closing click
Right Left
Over 55mm opening
“S” Shaped Deviation
COULD BE bilateraldisc displacement or
poor muscle patterning
LeftRight
Dynamic Loading of TM joint
– Load contralateral TMJ - bite on cotton roll
– Compression of bilateral TMJ – Grasp the
mandible bilaterally and tip the mandible down and back to compress the joints
– Distraction of bilateral TMJ – Grasp the mandible bilaterally, distract both joints at the same time
EDUCATION KEY TO REDUCE HEALTHCARE COSTS AND SUFFERING
SELF CARE • Awareness of tension in
muscles, tongue position, habits
• BREATHING properly!
What are stressors • Techniques-breathing swaying,
forgiveness • TONGUE mobilization,
traction, yoga and myofascial release ball techniques
• Rocabado 6x6
PREVENTION start early!
• BREASTFEEDING • (TIGHT FRENUMS
INTERFERE with BF)• NEWBORNS SHOULD BE
EVALUATED FOR TIGHT FRENULUMS
• MALOCCLUSION
QUESTIONS
Learning with Laughter
Cathy Russell. Dip PT (UK), MCPA, ATM
www.cathymrussell.com
http://www.cathymrussell.com/blog/
Humor helps us relax…
When we relax we learn
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