Learning with Laughter Cathy Russell. Dip PT (UK), MCPA, ATM Humor helps us relax… When we relax we learn

THE GREAT MIMIC COQUITLAM STUDY CLUB

1 st HALF WHAT IS PHYSIOTHERAPY? ANATOMY CERVICAL JOINTS & FASCIA BIOMECHANICS ETIOLOGY DIAGNOSTIC CLASSIFICATION

1. MANAGEMENT OF PATIENT WITH COMPLEX TMD 2. ROLE OF PHYSIOTHERAPIST 3. ROLE OF DENTAL PROFESSIONAL 4.TMD CHECKLIST FOR DENTAL PROFESSION 2 nd 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 Nerve Utricle Saccule

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 Glossopharyn geal Vagus Art by Renee Peterson & John Chitty, based on Larsen, Human Embryology, p. 362

THE CHEWING MUSCLES

TEMPORALIS

MASSETER MUSCLE

PTERYGOIDS & EAR SYMPTOMS Tensor veli palatini Levator veli palantini

MOUTH OPENERS From Gray’s anatomy

© 2012 Pearson Education, Inc. Figure 11-7 Muscles of the Tongue Styloid process Palatoglossus Styloglossus Genioglossus Hyoglossus Hyoid bone Mandible (cut)

EVERYTHING’S CONNECTED photos 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 SHAPES MALOCCLUSION 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 of Bipupillary, Otic plane, Occlusal plane

NORMAL C-SPINE ALIGNMENT X-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 Posture C1 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, Pages )

Cerebellu m 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 disease Eg. Osteoarthritis, Pyogenic Arthritis, Rheumatoid Arthritis

Group Two Disc 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),

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 AREA? Did it include the Temples? If No skip to DURATION 12. TEMPLE HEADACHE -1 response 13. SINGLE EPISODE DURATION? 14. INTENSITY-1 response BEHAVIOUR 18. What AGGRAVATES? 19. LOCATIONS

JAW JOINT NOISES In last 30 days: 20. NOISES 21. CLOSED LOCK? If No skip to BEHAVIOUR OF LOCK OPEN LOCK? If no skip to 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

ACTIVE RANGE OF MOTION

Normal TM Joint ROM Active opening-35-50mm (3 fingers) Functional opening mm (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 bilateral disc 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 Humor helps us relax… When we relax we learn