1. 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

2. THE GREAT MIMIC www.cathymrussell.com 2015 COQUITLAM STUDY CLUB

4. 1 st HALF WHAT IS PHYSIOTHERAPY? ANATOMY CERVICAL JOINTS & FASCIA BIOMECHANICS ETIOLOGY DIAGNOSTIC CLASSIFICATION

5. 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

6. TM and CV JOINTS

7. TM JOINT

8. 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.

9. TMD & The Vestibular Organ Horizontal canal Anterior vertical canal Posterior vertical canal Vestibular Nerve Facial Nerve Vestibulocochlear (VIII) Nerve Cochlea Cochlear Nerve Utricle Saccule

10. 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.

11. 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

12. THE CHEWING MUSCLES

13. TEMPORALIS

14. MASSETER MUSCLE

15. PTERYGOIDS & EAR SYMPTOMS Tensor veli palatini Levator veli palantini

16. MOUTH OPENERS From Gray’s anatomy

17. © 2012 Pearson Education, Inc. Figure 11-7 Muscles of the Tongue Styloid process Palatoglossus Styloglossus Genioglossus Hyoglossus Hyoid bone Mandible (cut)

18. EVERYTHING’S CONNECTED photos from Tom Meyers Anatomy trains

19. Cranium, Jaw, thorax connections

20. From grey’s anatomy

21. The Trigeminocervical nucleus.

22. TRIGEMINAL NERVE Sensory - face, scalp, teeth, mouth and nasal cavity Motor nerve to muscles of mastication 3 Nerve Branches Opthalmic Maxillary Mandibular

23. SUMMARY OF BIOMECHANICS

24. ETIOLOGY Factors which may be involved in the onset of TMD/J: Specific onset event or No specific onset event

25. TMJ SPECIFIC EVENT ONSET

26. 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

27. 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

28. My Cranial base with C1 and rotation of C2

29. RIGHTING REFLEX The proper alignment of Bipupillary, Otic plane, Occlusal plane

30. 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;

31. Forward Head Posture C1 encroaching on airway Loss of Cervical spine stability Weakened and lengthened hyoids- ABNORMAL SWALLOW Spondylolisthesis

32. LOOK FOR NARROW PALATES Blue triangle represents narrow airway

33. 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)

34. Cerebellu m From greys anatomy

35. 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

36. Group Two Disc Displacement With Reduction

37. Group 2-Disc Displacement without reduction, with limited opening <35mm (Less than 35mm)

38. GROUP 3

39. 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

41. MANAGEMENT OF TMD The Role of Health Professionals & Physiotherapist The Role of the Dental Professional

42. THERE IS ALWAYS A WAY TO MANAGE A CHRONIC PROBLEM!

43. DIAGNOSTIC CRITERIA QUESTIONNAIRE FOR ALL HEALTH PROFESSIONALS If have TMD proceed to INTAKE FORM

44. 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

45. 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

46. 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

47. 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

48. AQUALIZER “THE BIOFEEDBACK TRAINING TOOL” ROCABADO TRAINING TOOL

49. DIAGNOSTIC CRITERIA FOR TMD Pain in jaw, temples, in or in front of ear? Headache Joint noises Closed or open lock

50. 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?

51. 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

52. 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

53. THE ROLE OF DENTAL PROFESSIONAL DIAGNOSTIC CRITERIA CHECKLIST & KEY QUESTIONS

54. 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

55. TMJ EXAMINATION OBSERVATION FACIAL VISUAL SCAN PALATE SHAPE TEETH EMOTIONAL STATE

56. OBSERVE FACIAL AND PALATE SCAN

57. Visual scan: Look for these

58. OMD - Orofacial Myofunctional Disorder

59. LOOK FOR THESE DENTAL SIGNS

60. 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

61. 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

62. From Janet Travell

66. ACTIVE RANGE OF MOTION

67. Normal TM Joint ROM Active opening-35-50mm (3 fingers) Functional opening -25-35mm (2 knuckles) Protrusion- 5mm Lateral deviation- 8-10mm

68. CLICK –MORE THAN 3 IN SUCCESSION

69. 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

70. “S” Shaped Deviation COULD BE bilateral disc displacement or poor muscle patterning LeftRight

71. 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

72. 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

73. QUESTIONS

74. 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