Presents the Evaluation, Treatment and Management Of

Presents

The Evaluation, Treatment and Management of Temporomandibular Disorders, Craniofacial Pain And Orofacial Pain

April 20, 2017

By Michael Karegeannes PT/MHSc/LAT/MTC/CFC/CCTT/CMTPT Jeff Verhagen PT/MBA/CMTPT Mike Verplancke DPT/CSCS/CMTPT

Freedompt.com Treatingtmj.com Michael Karegeannes, PT, MHSc, LAT, MTC, CFC, CCTT, CMTPT, is the owner of Freedom Physical Therapy Services , 4 clinics in WI, since 1997 and a practicing physical therapist since 1989. His specialties in the field of physical therapy include: TMD, spine and pelvic dysfunctions, myofascial pain, and orthopedic therapies. Michael graduated from the University of Wisconsin-Madison in 1989 with a Bachelor’s of Science Degree in Physical Therapy. After he graduated, he received his athletic training license from the University of Wisconsin-Milwaukee, and later, Michael completed his manual therapy certification and Masters of Health Science from the University of St. Augustine in Florida.

In 2005, Michael had the honor of being trained by Dr. Mariano Rocabado, (in conjunction with the University of St. Augustine) who is the leading national expert in the field of craniofacial therapies. Michael holds a Craniofacial Certification with the University of St. Augustine.

In addition, Michael has attended an orofacial pain and TMD residency with the University of Minnesota Dental School. He is a member of the American Academy of Orofacial Pain (AAOP), a board member with the Physical Therapy Board of Craniofacial and Cervical Therapeutics (PTBCCT) and is one of the few physical therapists in the United States recognized as a certified cervical and temporomandibular therapist with the AAOP.

In 2011, Michael received thorough and extensive training in the technique of intramuscular dry needling and is certified through Myopain Seminars, the premier post-graduate medical and physical therapy continuing education company in the United States with a focus on myofascial trigger points. Michael is also on faculty with Myopain Seminars. Michael is also one of the few PTs in the USA trained in the CRAFTA approach to TMD.

His diverse experience, knowledge, and manual skills allow Michael to be highly effective in the evaluation and treatment of his clientele.

Michael is a member of the APTA, WPTA, NATA, AAOP, PTBCCT, AES, PAMA and IMS.

Jeffrey Verhagen started his career as a Physical Therapist in 1990 after graduating from the University of Wisconsin -Madison. He furthered his breadth of knowledge by attending several post-graduate continuing education opportunities with a focus on manual therapy for orthopedic, spine and sports injuries. He soon learned that he enjoyed treating spine problems and patients with headaches.

In order to properly assess the etiology of headaches, he expanded his studies to include the evaluation and treatment of TMD/craniofacial pain and in 2013 completed a certification in Intramuscular Dry Needling through Myopain Seminars. Dry Needling treats myofascial trigger points and their affect on localized and referred pain. He soon learned that he could successfully treat TMD and craniofacial pain for patients that had tried other treatment approaches and still were left with pain and loss of function.

Jeff has attended several courses and has reviewed the literature to expand his ability to successfully treat this challenging population. Freedom Physical Therapy Services, commissioned Steve Kraus PT, a well known TMJ therapist and educator, to come to the Milwaukee area and teach the latest treatment techniques and research on TMD/craniofacial pain to our therapy staff. Jeff looks forward to continuing to expand his knowledge to better serve this patient population.

Jeff has been with Freedom Physical Therapy Service since July of 2000 and currently serves as the Clinical Operations Administrator for the practice. He earned his Master of Business Administration from Cardinal Stritch University in 1999. He also served 21 years in the Army Reserves and is a Desert Storm veteran.

Jeff resides in Brookfield with his wife and two children and enjoys many hobbies to include golf, fishing and reading.

Michael Verplancke left his roots of St. Louis, Missouri, to both attend and play ice hockey at St. Mary’s University of Minnesota, where Mike graduated in 1998 with a Bachelor of Arts degree in Biology. He then attended Finch University of Health Sciences/The Chicago Medical School in North Chicago, Illinois, to obtain his physical therapy degree. He graduated in 2001 with a Doctorate of Physical Therapy. Mike has participated in numerous continuing education seminars with a focus on manual therapy techniques, evaluation and treatment of the spine and TMJ/craniofacial pain, mobilization techniques, and intramuscular dry needling.

In 2002, Mike obtained his credentials as a Certified Strength and Conditioning Specialist (CSCS), which has assisted him with exercise prescription, as well as progression of overall health and wellness for patients.

In 2014, Mike completed his certification in Intramuscular Dry Needling through Myopain Seminars. This treatment approach has provided a technique that improves treatment of Myofascial Trigger Points and their affect on localized and referred pain, as well as muscle activation patterns throughout the body. In addition, Michael has attended an Orofacial Pain and TMD residency with the University of Minnesota Dental School.

Mike has been trained in Temporal Mandibular Disorders (TMD) and Craniofacial Pain (CFP) by Dr. Mariano Rocabado, a world renowned leader in the field of TMD and CFP. Mike is currently working towards his Craniofacial Certification in conjunction with Dr. Rocabado and the University of St. Augustine.

Mike has been an employee at Freedom Physical Therapy since July of 2005, and is currently the Lead Physical Therapist and clinic director of the Grafton location.

Mike has a wide range of hobbies and interests, which include playing ice hockey, softball, golf, and basketball. He also enjoys spending quality time with his wife, Marion, their three daughters, Sophia, Liliana, and Emilia, and their Golden Retriever, Stan.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 1 Time Ordered Agenda 4-20-2017

9:00 – 9:45am Introduction and TMJ Anatomy and TMJ Biomechanics

9:45 – 10:30am Pathomechanics, abnormal mechanics and parafunction, etiology, imaging

10:30 – 11:00pm Break

11:00 – 12:00pm Epidemiology, Lab Evaluation of ROM of TMJ, Lab Muscle Palpation, Hypermobility Screen, muscle treatment

12:00 – 2:00pm Lunch

2:00 - 2:45 pm TMJ Arthralgia and various Disc related TMJ Dysfunction

2:45pm – 3:30pm Lab Mobilization Techniques for the TMJ

3:00 - 3:45pm Break

3:45 – 4:15pm TMJ Exercise, Rocabado 6 x 6, self help

4:15 – 5:00pm Cervical spine as it relates to TMJ, Ergonomics, Lab C spine assessment/treatment, dry needling Demo to facial and selected neck muscles

5:00pm Adjourn, Thank you!

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 2 The Evaluation, Treatment and Management of Temporomandibular Disorders, Craniofacial Pain and Orofacial Pain

Michael Karegeannes PT/MHSc/LAT/MTC/CFC/CCTT/CMTPT

CRANIO-CERVICO-MANDIBULAR RELATIONSHIP

Cranio-Vertebral Cranio-Mandibular

ASSIMILATION

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 3 Tragus of the ear

Anatomical Video Clip

The condyle (anterior view). The medial pole (MP) is more prominent that the lateral pole (LP).

Medial and Lateral Discal Collateral Ligament (A) Lateral view and (B) diagram showing the anatomic components. RT, retrodiscal tissue, SRL, superior retrodiscal lamina (elastic); IRL, inferior retrodiscal lamina (collagenous); ACL, anterior capsular ligament (collagenous); SLP and ILP, superior and inferior lateral pterygoid muscles. AS, articular surface; SC and IC, superior and inferior joint cavity; the discal (collateral) ligament has not been drawn.

TMJ ( anterior or coronal view). AD, articular disc; CL, capsular ligament; LDL, lateral discal ligament; MDL, medial discal ligament; DC, superior joint cavity; IC, inferior joint cavity.

Courtesy of Per-Lennart Westeson, M.D., Rochester, NY.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 4 TMJ Mechanics/Disc TMJ pain primarily originates from tissues in the posterior and lateral aspect of the TMJ, ie capsule, TMJ ligament, Lateral collateral ligament , synovium and retrodiscal tissue.

Mandibular Biomechanics Osteokinematics

• Depression (opening) – 40 to 50mm normal- 36 mm for most dental procedures • Elevation (closing) • Protrusion- 5 to 7 mm from incisor to incisor • Retrusion to protrusion 10mm, be specific and consistent • Lateral excursion – 10 mm

4:1 Ratio For every 1mm of lateral excursion, 4mm of opening.

TMJ AUTOPSY SPECIMEN TMJ AUTOPSY SPECIMEN (Normal Joint) (Reducing Disc)

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 5 TMJ AUTOPSY SPECIMEN Mandibular Opening Patterns (Non-Reducing Disc)

• Deflection: Movement away from midline but it does NOT return to midline

Mandibular Opening Patterns (cont) Mandibular Opening Patterns (cont) Deviation: “S” Movement away from midline but returns to midline as it gets to end range. • Midline: Could be normal, or could be bilateral Disc dislocation without reduction, depends on??

A man with reducing disc displacement of the right joint. (a) On mouth opening, there is an early transient locking and a slight deflection of the mandibular midline to the right affected side. (b) When the condyle slides over the posterior edge of the disc, there is a rapid exaggeration of the mandibular shift, and the mandibular midline then returns to center. At further mouth opening, the mandibular movement is symmetrical. (c) Lateral excursion to the contralateral side is impaired before the click, but not necessarily after. (d) Lateral excursion to the ipsilateral or affected side is typically normal. (e) Protrusion there is a slight deflection of the mandible to the right affected side, after the “click” the mandible tends to track in the center.

Mandibular ROM (LAB) Hypermobility Screen Will Cover In Lab

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 6 Hypermobility

Beighton 9 Point Scoring System Revised 1998 Brighton Diagnostic Criteria For JHS

Generalized hypermobility is one of the most important etiological factors in the development of Chapter 2 Assessment of Hypermobility craniomandibular disorders. Professor Rocabado presented the following summary of etiological factors and we can see that clenching/bruxism and mobility rank much higher than history of trauma or orthodontics. P. Beighton et al., Hypermobility of Joints Springer-Verlag London Limited 2012

Rodney Grahame, CBE, MD, FRCP, Joint Hypermobility

Syndrome Pain, Current Pain and Headache Reports The importance of systemic hypermobility is evident when we consider the association between 2009, 13:427-433. parafunction and hypermobility. It has been found that 79% of patients with systemic hypermobility and clenching/grinding of teeth (or nail biting) go on to develop a TMJ problem. A control, with clenching/grinding of teeth but without systemic hypermobility, were found to have only 16% incidence. The implications seem to be that hypermobile individuals do not tolerate the added stress of parafunction. So most patients have hypermobility and parafunction going hand in hand.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 7 What other problems might a person with hypermobility have to suggest there is an underlying medical condition?

The things individuals might most often present with beyond joint problems include:

• Easy bruising, scarring that is stretched, thin and often wrinkled, and stretch marks that appeared at a young age and in many places across the body. The skin often feels soft and velvety;

• Weakness of the abdominal and pelvic wall muscles that presents as hernias (such as hiatus hernia) or prolapse of the pelvic floor causing problems with bowel and bladder function; http://hypermobility.org/ • Unexplained chest pains – perhaps the individual has been told they have This diagram illustrates that people with CWP, CFS and FM can be hypermobile or may have a heart murmur and mitral valve prolapse; JHS; that JHS and EDS may present in similar ways; and that the very complex systemic problems of the bowel, lungs, heart and blood vessels are features of conditions such as EDS • Blackouts or near blackouts that may be associated with low blood and MFS, and not JHS. pressure or fast heart rate, and often triggered by change in posture from CWP – Chronic Widespread Pain; FM - Fibromyalgia; CFS - Chronic Fatigue Syndrome; JHS - Joint Hypermobility Syndrome; EDS - Ehlers Danlos Syndrome; MFS – Marfan Syndrome lying/sitting to standing, or after standing in one position for even just a few minutes; http://hypermobility.org/

Cervical Spine Joint Hypermobility: a possible predisposing factor for new daily • Symptoms that sound like Irritable Bowel Syndrome with persistent headache, TD Rozen, JM Roth and bloating, constipation, and cramp-like abdominal pain; N. Deneberg, Michigan Head-Pain and • Shortness of breath, perhaps diagnosed as asthma because Neurological Institute, Ann Arbor, MI, USA the symptoms seem the same, but not responding to inhalers in the way the doctor might have expected, because it is not true asthma;

• Noticing that local anesthetics, used for example in dentistry, do not seem to be very effective or require much more than might be expected;

• Severe fatigue; Anxiety and phobias.

http://hypermobility.org/

History

• 1934 James Costen described a group of symptoms centering around the ear and TMJ, the term Costen Syndrome was developed.

• While much of what Costen had suggested has been disproved his interest certainly was a catalyst to foster more work and understanding in the area of TMD

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 8 “Temporomandibular Disorders”

Fast forward through various other terms over The term does not merely suggest problems that the years such as TMJ disturbances, TMJ are isolated to the TMJs, but includes all dysfunction syndrome, Functional TMJ disturbances associated with the function of the disturbances, occlusomadibular disturbance, masticatory system rather than a single myoarthropathy of the TMJ, Craniomandibular diagnosis: disorders, to what Bell in 1992 coined, • Arthrogenous • Myogenous “Temporomandibular Disorders” • Atrhrogenous and Myogenous

TMD Uncommon Classifications of TMDs

The American Dental Association adopted the • Ankylosis term TM disorders or Temporomandibular • Aplasia or hyperplasia Disorders. • Pathology such as an infection, fracture or neoplasm ( malignant or benign) In 1993 the AAOP collaborated with the International Headache Society (IHS) to integrate TMD into an already existing medical diagnostic classification system.

Common Classifications/ ICD 10 Coding of TMDs Common Symptoms/Signs of TMD

Myogeneous • Pain in the area of the TMJ and jaw muscles Masticatory Muscle Pain: • Pain with mouth opening, chew and /or yawn • Joint sounds with jaw movements Muscle Spasms ICD 10 # M79.1/ICD 9 # 728.85 • Intermittent locking closed or open Contracture of muscle, unspecified site ICD 10 #M62.40 • Limited mouth opening Adhesions and ankylosis of temporomandibular joint #M26.61 • Headache Artrhogeneous • Earache or pain Arthralgia: ICD 10 # M26.62/ICD 9 # 524.62 Primary osteoarthritis, unspecified site M19.91

Disc Displacements: ICD 10 #M26.62/ICD 9 # 524.63

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 9 Treatment – Insurance Issues and TMD Diagnosis other specified disorders of TMJ ICD 10 #M26.69  It is about 50/50 as far as which insurances will Dislocation of jaw, initial encounter ICD10 #S03.0XXA cover the diagnosis of TMJ/TMD. Cervicalgia ICD 10 #M54.2/ ICD 9 #723.1  If they do, sometimes small TMD cap applies (say only $1250), others fall into same coverage for other Myofascial Syndrome ICD 10 # M79.1/ICD 9 #729.1 MS issues

Headache ICD 10 #R51/ ICD 9 #784.0  Most patients have a combo of cervical and TMD sx’s, therefore it is not unreasonable to use a Chronic tension-type headache, intractable G44.221 cervical dx. /339.12 CTTH  For Medicare you will need a script from their medical doctor, not the dentist as Medicare does not cover TMD

This is a graphic model depicting the relationship between various factors that are associated with the onset of TMD. The model begins with a normally functioning masticatory system. There are five(6) major etiologic factors that may be associated with TMD. Whether these factors influence the onset of TMD is determined by the patient’s individual adaptability. When the significance of these factors is minimal and adaptability is great, the patient does not report any TMD symptoms. Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7th edition, 2013

Craniovertebral Junction Craniovertebral Junction

Copyright ©2013 by Mosby, an imprint of Elsevier Inc. Copyright ©2013 by Mosby, an imprint of Elsevier Inc. In this graphic model, the etiologic factor of occlusion is depicted as being significant (perhaps a newly placed poorly fitting crown). If this factor exceeds the patient’s adaptability, TMD symptoms may now be reported by the This graphic model depicts the concept that some patients may present with less patient. In this instance, improvement of the occlusal condition (adjustment of the crown) would reduce this adaptability or a reduction in adaptability. When this occurs, the various etiologic etiologic factor, thereby bringing the patient within adaptability and thus resolving the TMD symptoms. The same factors that did not originally create symptoms may now lead to symptoms. When effect can be associated with any of the five etiologic factors and helps explain why data show that treatment of adaptability is very limited, attempts at reducing any of the five factors may be any of these factors may reduce symptoms. ineffective.

Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7th edition, 2013 Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7th edition, 2013

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 10 Parafunctional Activity

Craniovertebral Junction

Managing this etiologic factors May no longer be adequate Copyright ©2013 by Mosby, an imprint of Elsevier Inc. This graphic model depicts a much more difficult management problem. As symptoms become Some clinical signs associated with parafunctional activity. A, Evidence of cheek biting during prolonged, the pain condition can move from acute to chronic. As pain becomes chronic, the sleep. B, Here the lateral borders of the tongue are scalloped, conforming to the lingual surfaces central nervous system can be altered, making management more complicated. Some of these of mandibular teeth. During sleep a combination of negative intraoral pressure and forcing of alterations may involve the hypothalamus-pituitary-adrenal axis, central sensitization, and/or a the tongue against the teeth produces this altered tongue shape. This is a form of reduction in descending inhibitory control. When this occurs, more chronic pain conditions may parafunctional activity. develop, which cannot be managed by addressing the five etiologic factors.

Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7th edition, 2013 Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7th edition, 2013

Masseter hyperplasia secondary to chronic bruxism

TMD Diagnostic Guidelines • For over 20 years it has been the most widely used and heavily cited publication of diagnostic • 1992- Research Diagnostic criteria for TMDs protocol in clinical and research settings – Dworkin SF, LeResche L., Research Diagnostic Criteria for Temporomandibular Disorder 1992; 6:301-355. • It was never intended to be a final document but – RDC is a landmark paper providing operational rather a work in progress definitions to distinguish TMD patients from controls and to diagnose, with reasonable reliable and valid tests and measurements, the most common subtypes • The Journal of Oralfacial Pain 2010, volume 24, of TMD Issue 1 offers several articles validating and recommending updates to the 1992 RDC paper – http://www.rdc-tmdinternational.org/Home.aspx

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 11 The new DC/TMD protocol is a necessary step toward the ultimate goal of developing a mechanism and etiology based DC/TMD that will more accurately direct clinicians in providing personalized care for their patients.

Steenks, M, De Wijer, A; Validity of the Research Diagnostic Criteria for Temporomandibular Disorders Axis in Clinical Research settings: Journal of Oralfacial Pain 2009;23:9-16.

Summary of RDC/TMD diagnostic Guidelines A. To diagnose all common subtypes of TMD involves taking a history and performing a physical examination that is reliable and valid. B. Does NOT require: 1. Electronic Equipment a) Sonograph b) EMG c) Jaw Tracking Devices

Panoramic X-Ray

2. Radiographs • Is a two-dimensional dental x-ray that can show the maxilla and mandible, all the teeth including the -Radiographs are indicated if recent trauma, "wisdom teeth," the frontal and maxillary sinuses, red flags are present, patient not responding to the nasal cavity and the temporomandibular joint and conservative care and surgery is being other near by head and neck anatomy. considered for disc replacement • Can determine bony changes of the condyle and fractures or severe dislocations of the condyle. Does not image soft tissue, so the position of the disc cannot be determined by this test.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 12 Computed Tomography

• The latest advancement in this technology is called Cone Beam tomography • It allows for viewing the condyle in multiple planes so that all surfaces can be visualized. Patient positioned in a cone beam CT scanner. • This technology is capable of reconstructing 3D images • Cone beam technology can image both hard and soft tissues, but MRI GOLD standard for soft tissue

Computed tomographic scan. A, A typical CT projection of the TMJ. Hard tissue (bone) is visualized better than soft tissue with this technique B, A three- dimensional CT reconstruction of an edentulous mouth.

From Wilkinson T, Maryniuk G. J Craniomandib Pract 1:37, 1983.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 13 MRI

• Gold Standard for evaluating the soft tissue of the TMJ, especially disc position • Major advantage of not introducing radiation • Disadvantages include: expensive, not typically available in a dental setting, quality of images may very from facility to facility • Cine or dynamic MRI on its way

A three-dimensional image reconstructed from a cone beam image. These three-dimensional images can be rotated on the computer screen so that the clinician can visualize the precise area of interest. (Courtesy of Dr. Allan Farmer and Dr. William Scarf, Louisville, KY.)

Magnetic resonance image (MRI). A, When the mouth is closed, the articular disc (dark) is dislocated anterior to the condyle (arrows).B, During opening, the disc is recaptured into its normal position on the condyle.

The clinician should note that the presence of a displaced disc in an MRI does not constitute a pathological finding. IT has been demonstrated that between 26% and 38% of normal, asymptomatic subjects are found to have disc position abnormality on MRI. Therefore the clinician should rely primarily on history and examination findings to establish the diagnosis and use imaging information only as contributing data.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 14 Although there was a 33% prevalence of disc This study suggests that disc displacement is relatively displacement in asymptomatic volunteers, there was a common (34%) in asymptomatic volunteers and is highly highly significant difference in the prevalence of internal associated with patients (86%) with TMD. derangement in symptomatic subjects. Bruxing was statistically linked to TMJ disc displacement and could explain the anatomic variation in abnormal disc position.

In conclusion, panoramic radiography had poor reliability and low sensitivity, compared with CT, for detecting TMJ-related osseous changes. These findings suggest that this imaging modality has limited utility for assessing the TMJ. Magnetic resonance imaging had fair reliability and marginal sensitivity in diagnosing osseous changes compared with CT. Therefore MRI is not an ideal imaging technique for detecting osseous changes, and CT remains the image of choice for assessing osseous tissues. Regarding soft tissue assessment, MRI had excellent reliability for assessing disc position and good reliability for detecting effusions. Overall, the criteria proposed in this study for image analysis covered all possible osseous and nonosseous conditions of TMJ in a large group of participants in the multisite RDC/TMD Validation Project.17 The image analysis criteria presented in this paper are reliable for diagnosing osseous and nonosseous components of TMJ using CT and MRI, respectively. We recommend that they be used in both clinical and research settings.

Sagittal CT views of condyles representing examples of nonosteoarthritic or indeterminate osseous changes observed. A-B. Rounded condylar head, and well-defined cortical margin. C. Rounded condylar head, and well-defined noncortical margin. D-E. Indeterminate for Axially corrected coronal CT views of condyles representing examples of osseous changes observed, and OA: slight flattening of anterior slope and well-defined cortical margin. F. Indeterminate for corresponding osteoarthritis (OA) diagnoses. A-B. Nonosteoarthritic condyles, rounded condylar head, and well-defined cortical margin. C. Nonosteoarthritic condyle, flattened superior margin, and well-defined OA: flattening of anterior slope and a pointed anterior tip that is not sclerosed, well-defined cortical margin. D. Nonosteoarthritic condyle, flattened lateral slope, and well-defined cortical margin. E. cortical margin, fossa is shallow. G. Well-defined cortical margin has a notch on the Indeterminate for OA: rounded condylar head and subcortical sclerosis. F. Indeterminate for OA: subcortical superior part, a deviation in form, fossa is shallow. H. Narrowed appearance of the condylar sclerosis. G. OA: subcortical sclerosis, surface erosion. H-I. OA: surface erosion. J. OA: generalized sclerosis, head near medial part, close position of the cortical plates gives the impression of sclerosis, and subcortical cysts. K. Nonosteoarthritic condyle, well-defined corticated margin, bifid appearance, a nonosteoarthritic condyle, deviation in form. L. Nonosteoarthritic condyle, subcortical sclerosis in nonarticulating surface, bifid appearance, deviation in form.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 15 Eagle’s Syndrome Epidemiology of TMDs

• Cross sectional epidemiologic studies of selected non-patient populations show that 40% to 75% of those populations have at least one sign of joint dysfunction ( eg, movement abnormalities, joint noise, tenderness on palpation)

Eagle’s syndrome. A, An extremely long and calcified styloid process seen in the panoramic • 33% of selected non-patient populations have projection. This patient was suffering from submandibular neck pain, especially with movement at least one symptom of dysfunction (eg, face of the head. B, A very large styloid process that has been fractured is seen in this panoramic projection. There is also a large radiolucency in the mandibular molar region secondary to a pain, joint pain) gunshot wound. (B courtesy of Dr. Jay Mackman, Radiology and Dental Imaging Center of Wisconsin, Milwaukee, WI.)

• Joint sounds or deviations on mouth opening occur in ~ 50% of non-patient samples • Only 3.6% to 7% of these individuals are estimated to be in need of treatment • Other signs are relatively rare, mouth opening limitations occur in less that 5% of • Only 7% of patient population with benign non-patient populations TMJ clicking showed progression to bothersome clicking status over a 1 to 7.5 year • Pain in the TM region is reported in ~10% of period the population older than 18 years, it is primarily a condition of young and middle • Most patients with clicking remained stable or aged adults showed less or no clicking throughout • Women:Men, 2:1 and as high as 9:1 evaluation period

Management of TMDs

• Management goals for patients with TMDs are similar to those for other orthopedic or rheumatologic disorders: – Decrease pain – Decrease adverse loading – Restore function – Resume normal daily activities

Orofacial Pain, Guidelines for Assessment, Diagnosis, and Management, 4th edition, AAOP, 2008.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 16 Conservative (reversible) Therapy Long term follow up of TMD patients shows that 50% to more than 90% of patients have few or no • Physical Therapy symptoms after conservative treatment. From a • Self Management/Patient Education retrospective study of 154 patients, it was concluded that most TMD patients have minimal recurrent • Behavioral modification symptoms 7 years after treatment. Furthermore, 85% • Medications To 90% of the patients in 3 longitudinal studies lasting • Orthopedic Appliances 2 to 10 years had relief of symptoms after conservative treatment, and stability was achieved in most cases between 6 and 12 months after start of treatment.

Orofacial Pain, Guidelines for Assessment, Diagnosis, and Management, 4th edition, AAOP, 2008.

Even a Monkey can do it☺ 3 Main TMD Categories

• Masticatory Muscle Disorders

• Arthralgia or Joint Disorders

• Disc Derangement Disorders

Masticatory Muscle Disorders

C, The digastric anterior refers only to the Referral of myofascial trigger-point pain to the B, The masseter refers only to the posterior mandibular incisors. teeth. A, The temporalis refers only to the teeth. maxillary teeth. The Trigger Point Manual, 2nd edition, Baltimore, Williams & Wilkins, 1999, pp. 331, 351, 398.) The Trigger Point Manual, 2nd edition, Baltimore, Williams & Wilkins, 1999, pp. 331, 351, 398.)

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 17 The medial pterygoid muscle refers pain in poorly circumscribed regions related to the The lateral pterygoid muscle refers pain deep mouth (tongue, pharynx, and hard palate), into the temporomandibular joint and to below and behind the temporomandibular the region of the maxillary sinus, can cause joint (TMJ), including deep in the ear, but not tinnitus as well. to the teeth. Stuffiness of the ear may be a symptom of medial pterygoid TrPs.

The Trigger Point Manual, 2nd edition, Baltimore, Williams & Wilkins, 1999, pp. 331, 351, 398.)

Symptoms related to Masticatory Ear Symptoms Muscle Disorders • Patients commonly report pain that is associated Ear Symptoms such as ringing/fullness in the with functional activities such as chewing, ears may be related to an increase in activity of: swallowing, and speaking – tensor typani • Patient reports pain in the face, jaw, temple, in – Tensor veli palatini front of the ear or in the ear in the past month – Levator veli palatini • Pain is aggravated by manual palpation of “it is understood that anatomically they are muscles muscle(s) of the middle ear although they are really muscles • Acute malocclusion (Lateral Pterygoid spasm) of mastication because they are modulated by • Pain can awaken them at night and/or is present motorneurons coming from the trigeminal motor in AM upon awakening nucleus”

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 18 “jaw muscular activity may cause ear symptoms resulting from the tensor typani and tensor veli palatine muscles participation”

RAMIREZ, A. L. M.; SANDOVAL, O. G. P. & BALLESTEROS, L. E.;Theories on Otic Symptoms in Temporomandibular Disorders:Past and Present; Int. J. Morphol., 23(2):141-156, 2005. Stuffiness of the ear may be a symptom of medial pterygoid TrPs. In order for the tensor veli palatini muscle to dilate the eustachian tube, it must push the adjacent medial pterygoid muscle and interposed fascia aside. In the resting state, the presence of the medial pterygoid helps to keep the eustachian tube closed. Tense myofascial TrP bands in the medial pterygoid muscle may block the opening action of the tensor veli palatini on the eustachian tube producing barohypoacusis (ear stuffiness). Medial pterygoid tenderness was confirmed in all 31 patients who were examined and who had this symptom.

The Trigger Point Manual, 2nd edition, Baltimore, Williams & Wilkins, 1999, pp. 331, 351, 398.) Drake: Gray’s Anatomy for Students, 2nd Edition. Copyright© 2009 by Churchill Livingstone, an imprint of Elsevier, Inc. All rights reserved.

Biting on a tongue blade is being used to determine whether the patient’s pain has its origin in the joint structures or the muscles. Biting on the tongue blade on the right side will reduce right intracapsular pain while biting on the tongue blade on the left side will increase the pain in the right joint.

This illustration shows that when a patient is biting on a tongue blade, It is concluded that the bite test is of significant the tongue blade become value for evaluation of TMJ disorders and can a fulcrum with muscles be useful for the indication of complementary on both sides. Therefore biting hard on the right radiological examinations side will reduce the pressure in the ipsilateral joint. If the tongue blade is moved to the left side Julsvoll EH, Vøllestad NK, Robinson HS. Validation of clinical tests for patients and the patient is asked with long-lasting painful temporomandibular disorders with anterior disc to bite, the pressure in displacement without reduction. Man Ther. 2016 Feb;21:109-19 If symptoms the right joint will increase on the Konan E, Boutault F, Wagner A, Lopez R, Roch Paoli JR. Clinical significance of side you are increase. the Krogh-Poulsen bite test in mandibular dysfunction. Rev Stomatol Chir biting on, may Maxillofac. 2003 Oct;104(5):253-9. incriminate muscle on that Copyright ©2013 by Mosby, an imprint of Elsevier Inc. side

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 19 Diagnosing Masticatory Muscle Pain Subjective Muscles of Mastication 1. Patient reports having pain in the face, jaw, temple, in front of the ear or in the ear in the past month. 2. Patient is asked if the pain; a. Increases during the day with chew, talk, yawn, and/or with parafunctional activities b. awakens them at night and /or present in AM upon awakening

Examiner confirms pain location is a muscle(s) Objective Finding Plus 1. During digital palpation, a minimum of one site is painful in the masseter muscle or temporalis and/or 2. Patient reports having pain with maximum unassisted opening and/or 3. Mouth opening is limited (may or may not be painful)

Pain that is reproduced or increased is familiar pain and is located in a muscle I (Mike) typically find ROM mechanics are normal, minimal or no joint noises I (Mike) like to assess temporalis insertion on coronoid for tendinitis

Muscle Palpation (LAB) TEMPORALIS

• Temporalis • Masseter • Medial Pterygoid • Temporalis Tendon • Vicinity of Lateral Pterygoid • Palatini Muscles • Anterior and Posterior Digastrics

Masseter Masseter

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 20 Medial Medial Pterygoid Pterygoid

Temporalis Tendon Vicinity of Lateral Pterygoid

I prefer to use my pinky finger vs. Index Using Pinky medial to coronoid process, press superiorly into recess and have patient open into your finger.

Palpation of the tendon of the temporalis. The clinician’s finger is moved up the anterior border of the ramus until the coronoid process and the attachment of the tendon of the temporalis are felt. Copyright ©2013 by Mosby, an imprint of Elsevier Inc.

Tensor and Levator Veli Palatini Palpation of the lateral pterygoid region in TMD-where is the evidence? J.C. Turp, S. Minagi, Journal of Dentistry, 29, 2001, 475-483

Conclusion: Considering the lack of validity and reliability associated with the palpation of the lateral pterygoid area, this diagnostic procedure should be discarded. Evidence - The intraoral palpability of the lateral pterygoid muscle – A prospective study. Stelzenmueller W, Umstadt H, Weber D, Goenner-Oezkan V, Kopp S, LissonJ.Ann Anat. 2015 Dec 17

The intraoral palpability of the inferior caput of the lateral pterygoid muscle is verified. The basic requirement for successfully palpating the lateral pterygoid muscle is the exact knowledge of muscle topography and the intraoral palpation pathway. After documented palpation of the muscle belly in cadaverous preparations, MRI and EMG also visualized palpation of the lateral pterygoid muscle in vivo. The palpation technique seems to be essential and nd basically feasible. Drake: Gray’s Anatomy for Students, 2 Edition. Copyright© 2009 by Churchill Livingstone, an imprint of Elsevier, Inc. All rights reserved.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 21 Anterior and Posterior Digastrics

I will also palpate digastrics intraorally

To treat the two palatini muscles, insert the index finger or little finger into the mouth and stay just lateral to the midline. Feel for the end of the hard palate and do not press upward until you fall off the hard palate. Press upward to affect the palatini muscles. Sweep laterally with your finger hooked on the posterior part of the soft palate and continue all the way out to the hamulus.

Treatment for Masticatory Muscle Pain Modalities (MMP) • US, US with ketoprofen rub or Dexamethasone • No Chew Diet • Behavioral Modification • Modify daily activities that may perpetuate MMP – Discontinue oral parafunctional activity Modalities Intraoral Massage Patient Self Massage • Iontophoresis Self Help – Schiffman, E. TMJ Iontophoresis: A double blind randomized clinical trial, JOP;1996 10:2

LLLT ESTIM

• LLLT (Low Level Laser Therapy) is the application • Rich-mar Unit of red and near infra-red light over injuries or • Pre Mod IF lesions to improve wound and soft tissue healing, • Estim on Surge, Ramp up reduce inflammation and give relief for both acute • and chronic pain. 10 secs on/10 off • 2x2 dual lead Petrucci, A., Effectiveness of LLLT in TMD: A Systematic Review and Meta-Analysis. J Orofac Pain, • 2 leads 1R, 1B 2011;25:298-307. • Purpose is to inhibit pain and to relax muscle

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 22 CONTROLLED MOUTH OPENING TEMPORALIS SELF MASSAGE MASSETER SELF MASSAGE --Place tongue in the “No” or “Never” position --Tip of tongue should be against the hard palate NOT pressing against the back of your teeth --This exercise focuses on the “rolling” movement occurring in the TMJ and is less traumatic --You should not hear or feel any clicking --This controlled amount of opening should dictate how wide you should open when you yawn and what size bite of food you should take --Perform this exercise in good postural alignment, tongue remains in contact Using index and thumb finger gently massage with the hard palate --Place heel of hands on temporal area the muscles used for chewing 2 to 3 minutes --Perform 10 reps, slow and controlled --Gently clench teeth and feel muscle contract several times a day to your tolerance --Every 2 hours during the day under the heel of your hands --massage using pressure to your tolerance for Experiment, move tongue further back to limit opening, or put tongue along upper 2 to 3 minutes, several times a day back right molars to promote more movement of left condylar head or vice versa, put tongue along left upper back molars to promote increase movement of right condylar head

Temporalis Tendon Ice Massage Occasional Muscle disorders • Lateral Pterygoid Spasm, patient is unable to I bring their back teeth together on the side of the pterygoid spasm( subjectively and objectively) • May occur after unexpected resistance when chewing food, yawning, wearing CPAP appliance, wearing ARA • Rx: dry needling, gentle sustained posterior glide of mandible, • Other causes of why a patient cannot bring back teeth together – TMJ Arthralgia – Prolong use of posterior coverage appliance

• Trismus- is a tonic contraction of the muscles of mastication. In the past, this word was often used to A common cause of trismus often seen in general practice is the limited mouth opening that occurs 2–5 days after a mandibular describe the effects of tetanus, also called “lock Jaw”. block has been administered. This is usually attributed to The term trismus is now used to describe significant inaccurate positioning of the needle when giving the inferior restriction to mouth opening, (<20mm) often related nerve block. Ideally, the needle should be placed in the to intraoral injections or trauma pterygoid space, which is bound by the internal oblique ridge of the mandible on the lateral side and pterygomandibular raphe • Subjective, severe limitation of mouth on the medial side. Occasionally, the medial pterygoid muscle is opening, an identifiable event accidentally penetrated or a vessel is punctured and a small bleed follows: a haematoma can occur in the muscle bed and • Objective MIO< 20mm, firm end feel with subsequently organize, causing a fibrosis. Trismus due to this passive overpressure cause can be protracted and quite severe.

https://www.youtube.com/watch?v=kmPqV-dMo98 Mandibular Anesthesia - Inferior Alveolar Nerve Block

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 23 Have patient read out loud 3 to 5 Trismus Treatment minutes daily with cork in mouth. Cut cork down to a size that applies some stretch, but patient is able to attempt to articulate

I have found if I cut down a tongue blade 1 to 2 mm less than the opening measurement I achieve Stretching exercises can often be used to regain normal opening movement. The after a session and give to patient, patient is instructed to apply stretching force gently and intermittently to the they come back each session elevator muscle with the fingers. Pain should not be elicited. If it is, then the force maintaining some of the motion we should be decreased or the exercises stopped completely. achieved at the prior session

Bakke M, Petersson A, Wiesel M, Svanholt P, Sonnesen L. J Oral Facial Pain Headache. 2014 Fall;28(4):331-7

A considerable portion, (47.6%) of OSA patients without ongoing pain and TMJ complaints had bony deviations with CBCT images. These bony changes were not associated with clinical diagnoses.

This specimen depicts significant osteoarthritic changes. Here the articular surface of the condyle and fossa is flattened and the disc (D) is anteriorly dislocated. CBCT images of a TMJ of a patient with a RDC/TMD diagnosis of OA and with osteoarthritic Courtesy of Dr. Frank Dolwick, University of Florida, Gainesville, FL. changes (erosions and osteophyte). (a) Sagittal, (b) Coronal

Symptoms related to TMD Arthralgia

• Patient reports having pain in face, jaw, temple, in front of the ear or in the ear the past month • Patient is asked if pain increases during the day with chew, talk and/or yawn. • Parafunctional activity may also increase pain • May follow typical arthritic pattern, less ROM

Radiographic evidence of osteoarthritis. A, Severely deformed condyle resulting from night. osteoarthritis (cone beam CT). B, A panoramic radiograph depicting left condylar changes. C, Significant osteoarthritic changes in the condyle and fossa. D, Lateral cone beam CT view revealing significant flattening, resulting in an osteophyte (arrow).

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 24 Objective Examination for TMD Steve Kraus recommends doing back teeth together and Arthralgia apart because some patients may say they have pain on opening and not with back teeth together. So if opening is painful, it only tells you of the possibility of three tissues Joint Palpation: that may be involved (later collateral, TMJ lig or capsule - pertaining to the joint only but it can also suggest muscle). • Lateral Pole with back teeth together pain: No ___ Yes ___ • Lateral Pole with mouth open (>11mm) pain: No ___ Yes ___ • Posterior attachment “inside ear” pain: No ___ Yes ___ Tests primarily provides a base line to reassess the effects of treatment and nothing else. In my opinion palpation here is assessing Lateral Collateral Ligament tenderness and assessing posterior disc attachments, informing you of One test tells you nothing, multiple tests (when using position of condyle as possibly being more Superior and Posterior in the Temporal fossa clinical reasoning) tells you more.

I tend to prefer lateral excursion to opposite side.

Biting on a tongue blade is being used to determine whether the patient’s pain has its Palpation of the TMJ. A, Lateral aspect of the joint with the mouth closed. B, Lateral origin in the joint structures or the muscles. Biting on the tongue blade on the right side aspect of the joint during opening and closing. C, With the patient’s mouth fully open, the will reduce right intracapsular pain while biting on the tongue blade on the left side will clinician moves a finger behind the condyle to palpate the posterior aspect of the joint. increase the pain in the right joint.

Joint Pain Map TMD Arthralgia ROM • Assess ROM as demonstrated earlier Synovial Spaces 1, 2, 5, 6 • Jaw dynamics may or may not be limited • I like to use a stethoscope to listen from crepitation type sounds, grating, grinding, vs. a discrete “click” • Here is where Condylar asymmetry is important to at least file away in your memory banks

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 25 Copyright 2013 by Mosby an imprint of Elsevier Inc. A, This radiograph reveals idiopathic condylar resorption of the left condyle. The majority of this bone loss occurred in a 3-month period. B, As a consequence of this significant and rapid bone A, Sometimes significant osteoarthritic changes occur in only one joint. When this happens rapidly, the affected condyle can loss, the mandible was shifted to the left side, where only the left second molars contact. C, As collapse, resulting in a shifting of the mandible to that side. This is referred to as idiopathic condylar resorption. B, In this patient there has been a midline shift to the patient’s right. This shift is evident even in the relationships of the posterior arches. This the left masseter and temporal muscles contract, the mandible is shifted to the left, so that only idiopathic condylar resorption was isolated to the patient’s right condyle. C, A cone beam CT of the right condyle showing the the second molars contact on the affected side. D, The heavy contact on the second molar degenerative changes. D, The loss of condylar support in the right condyle caused a shift to the right, so that only the right second accompanied by the elevator muscle activity has caused a posterior open bite on the patient’s molar is contacting. Copyright 2013 by Mosby an imprint of Elsevier Inc. right side.

LAB

Palpation of Lateral Poles, Bite Test

Rheumatoid arthritis commonly causes a significant and relatively rapid loss of the articular bone of both condyles. With this loss of posterior support to the mandible, the posterior teeth begin to contact heavily. These teeth act as fulcrums by which the mandible rotates, collapsing posteriorly and opening anteriorly. The result is an anterior open bite.

Treatment for Arthralgia Hypermobility • No Chew Diet • Gentle Mandibular Mobilizations to gate pain/flush • Patient will report the jaw “goes out” when joint opening wide • Treat Masticatory pain ( if diagnosed) • • Controlled mouth opening At the later stage of opening, the condyle will • Control Yawn jump forward leaving a small depression in the • Avoid elective dental work face behind it • Discuss with Dentist possible NSAIDs • A deviation can be present and greater and • Modalities much closer to the maximally open position – Heat or ice that that seen with Disc Derangement – US (phono) disorder – Ionto – LLLT

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 26 • An eminence click may or may not be felt or heard • In my opinion loading the mandible with opening brings out subluxation or eminence click so that it is more noticeable • S: jaw goes out when opening wide, joint noises end of mouth opening or beginning of mouth closing, jaw catches on closing from fully opened With unilateral hypermobility, the position mandibular midline shifts to the • O: A jutter is felt at end of mouth opening and contralateral side at the very end the beginning of mouth closing, eminence click of mouth opening, when the may or may not be felt or heard condyle passes the articulating eminence, and you end up with a deflection. DEFLECTION

Treatment for hypermobility

• Patient education • Control mouth opening – Eat smaller bites of food a b – Limit mouth opening with dental cleanings – No Jimmy John subs☺ Manipulation after TMJ dislocation: (a) The condyle is – Control yawning (tongue up against palate, far back if dislocated anterior to the articular eminence (red necessary) shadow). (b) During manipulation, the posterior part of the mandible is distinctly guided downwards-backwards – Controlled mouth opening to aid the condyle in passing the articulating eminence – Neuromuscular reed- hyperboloid training, deep and retrude into the articulating fossa. (c) After successful manipulation, the condyle is seated in the masseter and lateral pterygoid retraining articulating fossa behind the articulating eminence at intercuspal position. c

A, Clinical appearance of a spontaneous dislocation (open lock). The patient is unable to close the mouth. B, A panoramic radiograph of a patient experiencing a spontaneous dislocation. Here the condyles are bilaterally positioned anterior to the eminences.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 27 Normal Stable Disc/Condyle Disc Displacement Disc/Eminence An anterior or anterior medial disc displacement is the most common form of a disc displacement that potentially effects jaw range of motion

A, In the closed-joint position, the pull of the superior lateral pterygoid muscle is in an anteromedial direction (arrows). B, When the mandible translates forward into a protrusive position, the pull of the superior head is even more medially directed (arrows). Note that in this protruded position the major directional pull of the muscle is medial and not anterior. C, From a superior view, the entire disc may be displaced anteriorly medially. D, In some instances, the lateral portion of the disc may be more displaced than the medial portion. E, In still another instance, the medial portion of the disc may be more displaced than the lateral portion.

Parts A, B courtesy of Dr. Samuel J. Higdon, Portland OR.

A, Normal position of the disc on the condyle in the closed-joint position. B, Functional displacement of the disc. Its posterior border has been thinned and the discal and inferior retrodiscal ligaments are elongated, allowing activity of the superior lateral pterygoid to displace the disc anteriorly (and medially. C, In this specimen the condyle is articulating on the posterior band of the disc (PB) and not on the intermediate zone (IZ). This depicts an anterior displacement of the disc. (Part C courtesy of Dr. Julio Turell, University of Montevideo, Uruguay.)

Piper Classification Rocabado has 4 Phases of Disc Displacement Disorders

http://www.pipererc.com/tmj.asp

Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 28 • Phase I- the disc drops medially as the LCL elongates beyond 70% or 80% • With Phase 1 no joint sounds, and there is actually a medial subluxation in opening and a lateral reduction in closing (opposite from phase 2 and 3, in which the disc reduces with opening and subluxes with closing) • Causes could be occlusal fulcrum, cross bite, posterior rotation of cranium Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991. Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991

• Phase II- click will occur at about 10-20mm of opening, an early opening click, a late closing click • Pattern of dysfunction in Phase II is opposite I, In Phase II with opening the click is the disc reducing, and the click on closing is the disc subluxating again • So the disc is now more anterior and probably medial • Frequently accompanied by parafunction, i.e. nocturnal grinding or nail biting

Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991

• Phase III- there is significant LCL and posterior ligament overstretching • The shape of the disc can become distorted, more convex • Late opening click at 20-30mm, and a click upon closure • Can develop capsular tightness, and hence mobilizations are performed to address this

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 29 • Phase IV- The disc may be completely deformed Couple of key points in front of the condyle. • The further anteriorly the disc is on the temporal • The condyle will rotate deep within the eminence, the more displaced it is and the greater mandibular fossa, but cannot translate forward, opening (or protrusion according to the 4:1:1 rule) in the initial stages of disease, although later needed for the condyle to reduce into the disc normal motion may return • The disc can also displace laterally and (more commonly) medially. • There is no joint sound. • Note that the condyle and the disc luxate in opposite • Limitation of the translation phase of opening directions. may result in a loss of up to 50% of total opening, • A therapist who assesses a sound with 40-50mm of with a deflection of the mandible to the side with opening with loading is usually not subluxated. The limited motion sound is due to the condyle going over the anterior • This is called a posterior-superior condylar-disc border of the disc or temporal eminence- this is an luxation with an anterior disc-temporal luxation. over-rotation subluxation due to hypermobility (over- rotation because all the translation has been used up). • Disc is not reducible It is not a phase 4, but may lead to a phase 1 later on.

Classification of Disc Displacement Factors contributing to a disc displacement

Stage 1 • Trauma • Anteriorly displaced by muscles ( sup Lat Ptyer) Disc displacement with Reduction (DDWR) • Superior retrodiscal lamina becomes elongated Stage 2 • Tanaka identified a ligamentous attachment of the medial portion of the condyle-disc complex to the medial Disc Displacement without Reduction with wall of the fossa, if this ligament was bound down, limited opening (DDWoR WLO) forward movement of the condyle might create a Stage 3 tethering of the disc medially • LCL laxity Disc Displacement without Reduction – Repetitive without limited opening (DDWoR WoLO) – Sustained – Excessive joint loading Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation

DDWR- STAGE I DDWR • Subjective – patient reports having a click in their jaw(s) while opening their mouth – Patient may or may not have a prior experience of their jaw locking intermittently so that it would not open all the way • Definition- Click or a snap, pop or crack is a distinct sound, of brief and very limited Copyright ©2013 by Mosby, an imprint of Elsevier Inc. duration, with a clear beginning and end that

Reciprocal click. Between positions 2 and 3 a click is felt as the condyle moves across the posterior border of emanates from the TMJ the disc. Normal condyle-disc function occurs during the remaining opening and closing movement until the closed-joint position is approached. Then a second click is heard as the condyle once again moves from the intermediate zone to the posterior border of the disc (between 8 and 1). Management of Temoromandibular Disorders and Occlusion by Jeff Okeson, 7th edition, 2013

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 30 DDWR DDWoR WLO- STAGE II (close lock)

• Objective Findings – A palpable irregularity of a reciprocal clicking is felt and maybe heard – Opening click is louder that the closing click – Opening click at 5 to 10mm or greater of interincisal opening with the closing click less than 5mm – Clicking may occur during lateral excursion or protrusion

– Clicking is eliminated on protrusive opening and Copyright ©2013 by Mosby, an imprint of Elsevier closing Inc. Functional disc dislocation without reduction (Closed lock). The condyle never assumes a normal relationship on the disc but instead causes the disc to move forward ahead of it. This condition limits the distance it can translate forward.

DDWoR WLO- STAGE II DDWoR WLO- STAGE II

• Subjective- • Objective- – Limited opening that is severe enough to interfere – Maximum unassisted mouth opening <30mm with with eating, yawning, brushing of teeth, flossing, singing, etc. deflection to the side of the involved joint – History of clicking w/or w/o intermittent locking – Protrusion limited with deflection to the side of – Intermittent locking would be when a patient the involved joint experiences a sudden episode of limited mouth – Contralateral excursion is limited (assuming disc is opening. Mouth opening returns to normal with medially displaced vs. Just anteriorly displaced) spontaneous resolution or resolution in response to force or movement (lateral, protrusive and/or opening) exerted by patient

Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation

Courtesy of Dr. Per-Lennart Westesson, University of Rochester, Rochester, NY.

A, In this specimen there is a functionally anterior dislocated disc and the condyle is totally articulating in the retrodiscal tissues (RT).B, The specimen also has an anterior dislocated disc. The condyle has moved closer to the fossa as the joint space (JS) has narrowed. This disc dislocation is probably chronic.

What other view might help you determine if disc was medially or laterally displaced as well???

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 31 Do all DDWR progress to a DDWoR WLO? DDWoR WoLO –Stage III

• Some patients may never progress from Stage • Subjective- I to Stage II – May complain of limited opening but is not severe • Some patients may never have a history of a enough to interfere with eating, yawning, brushing clicking or reducing discs and go immediately teeth, flossing, singing, etc to a non reducing disc problem – History of clicking w/or w/o intermittent locking • Some patients may progress from a DDWR to • Objective Findings- a DDWoR WLO immediately after one click  Active unassisted mouth opening is >30mm of and others may click and make joint noises MIO and never progress  Palpable crepitus may or may not be identified during opening and closing

Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation

TMJ AUTOPSY SPECIMEN TMJ AUTOPSY SPECIMEN (Normal Joint) (Reducing Disc)

TMJ AUTOPSY SPECIMEN DDWR Subjective-clicking (Non-Reducing Disc) Objective –feel/hear a click during mandibular opening and closing --elimination of click on protrusive opening and closing

DDWoR WLO Subjective—limited function ---prior history of popping with or without intermittent locking Objective –mandibular opening< 30mm --limited mandibular movement with deflection towards the involved joint during opening and protrusion --a decrease in lateral excursion towards the opposite side of the involved joint

DDWoR WoLO Subjective– may complain of limited function --prior history of popping with or without locking, crepitus may or may not be present Objective—normal or near normal (>30mm) mouth opening --palpable irregularities of crepitus may or may not be identified during opening and closing

Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 32 Physical Therapy for DDWR without Lab Session—Diagnosing Stage I, II, III Pain • Explain and educate patient as to what is going on, popping may continue indefinitely, they may experience brief moments of locking, • Reassure what they have is common, their condition rarely deteriorates to the level of having chronic pain and loss of oral function • Try to ease their fears so as not to create anxiety or somatize their joint condition

Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation

Physical Therapy for DDWR with Physical Therapy for DDWR with Pain Intermittent locking • Treat other sources of symptoms that may be • Objective is to decrease joint loading which may: – Decrease intermittent locking and/or unrelated to the DDwR such as: – Decrease loudness of the pop and/or – Arthralgia – Increase mouth opening before the pop (in essence increasing translation, by probably moving the disc more – Muscle pain anterior) – Cervical spine pain – Improving opening, while decreasing loudness or intensity of pop, maybe eliminating click all together.

Decrease joint loading by – Decreasing jaw muscle tension – Decreasing neck muscle tension

Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation

Manual Techniques • Then I will follow up all mobilizations with controlled mouth opening • Intraoral/Extraoral Massage of muscles • Then I have patient perform lateral excursion identified on evaluation with 2 tongue depressors or hyperboloid – • Mobilization techniques to TMJ Active, active/assistive, passive – I do not do protrusive movements until pain and – Long axis distraction inflammation are significantly down. – Laterally mobilize condyle for medial joint – Protrusion, or translation is irritating to joint, if distraction you regain lateral excursion which is less irritating – Stabilize condyle and mobilize Cranium laterally to joint, protrusion will come, as will opening for lateral joint distraction (superior compartment ROM per Rocabado)

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 33 • I always finish Jaw techniques with a courtesy suboccipital distraction • I then proceed to slowly progress patient thru postural correction program • I will typically show the rest position of the jaw and add jaw wiggle • I will add chin nod to begin decompressing suboccipital area. • If necessary I will finish with modalities, laser, ice etc for pain relief • Over time add stabilization exercise with Hyperboloid, deep masseter (laterally) and Lateral Pterygoid (medially) to the disc

Physical Therapy for DDWoR WLO • Increase condyle/disc translation • Manual massage techniques • Mobilization techniques/ Mobilization with guided TMJ MOBILIZATION LAB movement into translation or lateral excursion – Gentle techniques – Min to no pain – Add cervical extension with mobilization techniques if needed • Controlled mouth opening (tongue on left or right maxillary molars) • Lateral excursions • Mandibular isometrics • Tongue depressor stretch • Cervical treatment • Modalities as needed

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 34 neutral left lateral excursion right lateral excrusion

Self Long Axis Distraction Technique

Finger Spread Technique

Protrusion Tongue depressor stretch

Home Program Physical Therapy for DDWoR WoLO

• Requires no treatment other than explain • Handouts what they are experiencing • Postural correction exercises • Crepitus may continue indefinitely if present • Measuring tongue depressor so patient knows • What they have is common what their opening was when they left treatment. Goal is to maintain opening between sessions, • If pain is present, then Treat: but not uncommon to lose a few mm between – Arthralgia sessions – Masticatory Muscle Pain • I like to gain 3 to 5mm each session, with the goal – Referred pain from Cervical spine being maintaining about 5 mm range each week. Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation

Concurrent diagnostic subsets identified in this study are similar to those of other studies, which show that a 1- category diagnostic subset of TMD is scarce in the clinical environment. The largest subset of TMD is myofascial pain, and the most common concurrent diagnostic subset identified in group II and group III is myofascial pain. The most prudent thing to do therefore in the clinical setting would be to manage myofascial pain. Managing myofascial pain often reduces pain and dysfunction associated with group II and III diagnoses. Treating only myofascial pain may work well for the majority of patients. For other patients, it may be necessary that their concurrent diagnostic subsets be dealt with simultaneously.

Characteristics of 511 patients with temporomandibular disorders referred for physical therapy Characteristics of 511 patients with temporomandibular disorders referred for physical therapy by Steven L. Kraus, PT by Steven L. Kraus, PT Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:432-439 Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:432-439

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 35 Hyperboloid Exercises for ROM and Neuromuscular Reeducation Rocabado 6 x 6

Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis Here is the group I like to work with. There are so many kids with headaches, Susan Armijo-Olivo, Laurent Pitance, Vandana Singh, Francisco Neto, parafunction, mouth breathers, poor Norman Thie, Ambra Michelotti posture. This is the group to me that we Phys Ther. 2016 Jan;96(1):9-25. have the greatest chance of helping and not allowing early degeneration of the TM joints and cervical spine! Although the overall level of evidence is low, exercises and MT are safe and simple interventions that could potentially be beneficial for patients with TMD. Active and passive exercise for the jaw, postural exercises, and neck exercises appear to have favorable effects for patients with TMD. Manual therapy alone or in combination with exercises shows promising effects. Exercises did not show clear superiority over other conservative treatments for TMD.

Cervical Spine Evaluation

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 36 Jules Hesse fysiotherapist☺ Amsterdam http://www.juleshesse.nl/

Characteristics of 511 patients with temporomandibular disorders referred for physical therapy by Steven L. Kraus, PT Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:432-439

A single blind examiner evaluated cervical range of motion (ROM) measures including axial rotation during the flexion-rotation test (FRT) and sagittal plane ROM. Twenty asymptomatic subjects were compared with 37 subjects with pain attributed to TMD, confirmed by the Revised Research Diagnostic Criteria. Subjects with TMD were divided according to the presence of headache (26 without headache TMDNHA, 11 with headache TMDHA). One-way analysis of variance and planned orthogonal comparisons were used to determine differences in cervical mobility between groups. All subjects with TMD were positive on the FRT with restricted ROM, while none were in the control group. Neck pain was the second most common symptom in the present study, reported by 68% of the 511 patients. The coexistence of neck pain and CONCLUSIONS: TMD has been reported previously and its clinical implications should Subjects with TMD had signs of upper cervical spine movement impairment, greater in those with headache. Only subjects with TMD and headache had impairment of cervical not be underestimated. spine sagittal plane mobility. This study provides evidence for the importance of examination of upper cervical mobility determined by the FRT in patients who suffer from TMD.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 37 POSTURE FACIAL ASSYMETRY

Cervical Spine Treatment

6.5 101 6.5

SAGITAL CRANIOCERVICAL from ROCABADO. C2-7V

PEDIATRIC ADULT.

DEGENERATION IS NOT A PROBLEM OF AGE.

Rocabado Rocabado

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 38 Convergence of the trigeminal and cervical nerves is an anatomic and physiologic explanation for referred pain from the cervical region to the trigeminal

The muscles of the jaw, tongue, face, throat, and neck work synergistically to execute multiple orofacial functions, but pain in these areas alters the movements. Neck or shoulder pain may result in impaired jaw movement and vice versa.

A, Injury to the trapezius muscle results in the tissue damage. Nociception arising in this cervical region is transmitted to the second-order neuron and relayed on to the higher centers for interruption. B, As this input becomes protracted, note that the adjacent converging neuron is also centrally excited, which relays additional nociception on to the higher centers. The sensory cortex now perceives two locations of pain. One area is the trapezius region, which represents a true source of nociception (primary pain). The second area of perceived pain is felt in the TMJ Metal Mayhem area, which is only a site of pain, not a source of it. This pain is heterotopic (referred). (Adapted from Okeson JP. Bell’s Orofacial Pains. 5th ed. Chicago: Quintessence; 1995:66.)

Perspective: The current study showed the existence of multiple active muscle TrPs in the masticatory and neck-shoulder muscles in women with myofascial TMD pain. The local and referred pain elicited from active TrPs reproduced pain complaints in these patients. Further, referred pain areas were larger in TMD pain patients than in healthy controls. The results are also in accordance with the notion of peripheral and central sensitization mechanisms in patients with myofascial TMD.

Combined treatment approach of Mobilization, Manipulation and Exercise provides relief!

Key Points ● Mechanical neck disorders are common, costly, and can be disabling. ● This systematic review of 33 trials did not favor mobilizations and/or manipulations done alone or combined with other treatments like heat for relieving acute or persistent pain and improving function when compared to no treatment. ● Mobilization and/or manipulation when used with exercise are effective for alleviating persistent neck pain and improving function when compared to those who received no treatment. When compared to one another, neither mobilization nor manipulation was superior. journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | ● There was insufficient evidence available to draw conclusions for mechanical neck disorder with radicular findings.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 39 Low to Moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term and cervicogenic headaches in the long term!

Individuals with neck pain who received a combination of thoracic spine thrust manipulation and cervical spine nonthrust manipulation plus exercise demonstrated better overall short-term outcomes on the numeric pain rating scale, the Neck Disability Index, and the global rating of change.

journal of orthopaedic & sports physical therapy | volume 43 | number 3 | march 2013

Functional and Structural Changes in Muscles related to pain (adapted by Falla and Farina 2007)

Treatment Approach Cervical Spine THE ROLE OF THE PHYSICAL THERAPIST IS TO BE A

Myofascial Mobilization “STUDENT OF MOTION, SCULPTOR OF STRUCTURE, Joint Manipulation & Mobilization AND FACILITATOR OF FUNCTION.” Patient directed exercises to maintain myofascial mobility, And Joint mobility

Neuromuscular reeducation and strengthening of supporting As quoted from a 1991 article musculature By Mannheimer and Rosenthal Ergonomics and Bad Habits Healing Hands by Joseph Ventura

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 40 Soft tissue massage

• Massage induces acute antinociceptive effects involving opioid and oxytocin interaction(hug) • Massage may alter the sensitization state of the trigeminocervical nucleus • Massage may influence the potential to change the neck muscle tone through alteration of the trigeminalreticular pathway

Dr. Kathleen C. Light, a professor at the University of North Carolina Department of Psychiatry

Effects of partner support on resting oxytocin, cortisol, norepinephrine, and blood pressure before and after warm partner contact. Psychosom Med. 2005 Jul- Aug;67(4):531-8. Grewen KM, Girdler SS, Amico J, Light KC.

ANTERIOR CRANIAL LUXATION, DENTAL CASE, LACK OF DIAGNOSIS. PT/OT RESPONSIBILTY.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 41 3 Primary Conditions That Could Contribute to Disruption of Strength 3 Quick Screens and Integrity of These Ligaments • Alar Odontoid Integrity Test • Down’s Syndrome • Transverse Ligament Test/Anterior Shear Test: • Rheumatoid Arthritis – S/C Flexion or chin nod – Sharp Purser Test • Cervical Spine Trauma, – MVA or CAD Injuries S3 Seminar manual by Stanley Paris, 2000 edition

S3 Seminar manual by Stanley Paris, 2000 edition Occult hypermobility of the craniocervical junction: a case report and review. Mathers KS, Schneider M, Timko M. J Orthop Sports Phys Ther. 2011 Jun;41(6):444-57. Occult hypermobility of the craniocervical junction: a case report and review. Mathers KS, Schneider M, Timko M. J Orthop Sports Phys Ther. 2011 Jun;41(6):444-57.

Suboccipital Release

More aggressive suboccipital release with head pinning Gentle Relaxation and Mobilization While Assessing

Distraction Downslide

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 42 I will palpate transverse Stabilize C2 with Distract base of lumbrical grip occiput with other process of Atlas C0-C2 Distraction hand and head not pincher pinning bilaterally either sitting or supine or both, to assess which one feels more prominent, which might suggest a rotational issue of C1, usually the one more prominent tends to be more tender. Then use FRT to confirm. If you have a hard time finding the TP of C1 have patient protruded their mandible to expose TPs.

ASSESSING C1C2 ROTATION RESTRICTIONS With Flexion-Rotation Test

MUSCLE ENERGY TECHNIQUE TO CORRECT Muscle Energy Technique for Restricted Rotation C1C2 ROTATION RESTRICTION to the Right at C1-2

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 43 Muscle Energy Technique for Restricted Rotation MANUAL TOWEL TRACTION to the Right at C1-2

1.The patient is supine, and the operator sits or stands at the patient's head. 2.With the palms of both hands (and/or belly), the operator supports the patient's head and flexes the neck as far as it easily goes, usually approximately 45 degrees or I will do chin to chest. 3. Monitoring on the posterior lateral aspect of C2, the operator turns the patient's head to the right, until C2 on the left just begins to move or you engage barrier, and then backs off the barrier by de-rotating slightly 4. The patient is asked to turn his or her head gently to the left (or don’t let me turn you right) or simply to move his or her eyes to the left. The effort is maintained for 3-5 seconds, while the operator resists any movement. 5. On relaxation, the operator rotates the patients head further to the right, and the patient is asked to look to the right to help facilitate further right rotation. 6. Steps 4 and 5 are repeated two or more times. 7. Retest to see if right rotation has been fully restored at this segment.

** Do the opposite for restricted rotation to the left at C1C2 **

P/A scooping OSTEOPATHIC MANIPULATION motion with your fingers to upper thoracic spine

Block cervical spine and • High Velocity/Low Amplitude occiput from going into too • Create a barrier much extension – A cumulative end of range vs. anatomical end of range – You “create” this barrier by combining many components: flexion, extension, sidebending, Lean back on back leg to use sideshifting, rotation and don’t forget your body vs. too compression! much arms

OA SIDEBENDING MANIPULATION Effects of manipulation

• Mechanical – Stretch out tight capsules – Stretch out adhesions – Snap adhesions “pop” – Alter positional relationships • Psychological – Laying on of intelligent and skilled hands provides confidence and assurance something good will happen – Hearing or feeling the “pop” • Neurophysiological – Firing type III inhibitory receptors reducing muscle holding • Chemical effects – Possible release of endorphins Healing Hands by Joseph Ventura

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 44 Trapezius

The present study shows that the dry needling treatment is effective in relieving the pain and in

improving the quality of life of patients with MPS. SCM Finger placement for photographic reasons

Anterior scalene

Levator Oblique Capitas Inferior directed towards opposite eye (fingers removed for photographic reasons)

Chin Nod

Start with back of head and spine against corner of wall

 Nod your chin down about 15 degrees  The back of your head should remain in contact with the wall  Your eyes should remain level-imagine a string at the top of your head pulling up

Do 15 reps x 5 secs each 5 times a day

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 45 CERVICAL JOINT LIBERATION (Rocabado)

Stabilize C2

The best available studies indicate that the C2/C3 zygapophysial joints are the most common source of cervicogenic headache

C1-C2 self-sustained natural apophyseal glide (SNAG) for cervical right rotation. Force is applied to the C1 level via horizontal

pressure from the strap. At the same time, the subject actively Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Medicine 2007; 8: 344–53.

turns his/her head to the right. Lord S, Barnsley L, Wallis B, Bogduk N. Third occipital headache: a prevalence study. J Neurol Neurosurg Psychiatr 1994; 57: 1187–90.

Bogduk N, Marsland A. On the concept of third occipital headache. J Neurol Neurosurg Psychiatr 1986; 49: 775–80.

Bogduk N, Marsland A. The cervical zygapophysial joints as a source of neck pain. Spine 1988; 13: 610–17.

Foam Roller Chest Stretch

 Sidebend your head to one side, slightly off the foam roller, gently grab your head to add in the sidebending component

 Place your arm in the position shown, experiment with arm straight or slightly bent  Make sure arms are just above 90 degrees  Elbows should be bent at 90 degrees  Now rotate your head up and back to  Hold position for 3 minutes, increase time feel stretch in area as shown below as tolerated Do each side twice, 2 reps x 30 to 60 Do exercise 1 to 2 times a day seconds,

Do 1 to 2 times a day. **To enhance stretch nod chin down and pull your navel into your spine

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 46 DIAGNOL THERABAND Thumb is up!! PRONE CHIN NOD SCAPULAR STRENGTHENING EXERCISE

Start position

 Sitting with excellent posture  Edge of table should be about mid chest  Nod chin in as in standing wall exercise  Arms at your side  Imagine string at top of head pulling you tall  Be sure to reach way back Finish Position  Perform 2 sets of 10-15 reps each arm Perform 15 reps x 5 secs each  Perform 3x a week Perform exercise 1 to 2 times a day

HORIZONTAL ABDUCTION LATISSIMUS THERABAND STRENGTHENING EXERCISE Thumb is pointing THERABAND SCAPULAR Start Position Finish Position back!! STRENGTHENING EXERCISE Lower only to shoulder height!! Palms Start Position facing out!!

Finish Position Theraband should  Sitting with excellent posture be behind head!!  Be sure to reach way back  Perform 2 sets of 10-15 reps  Sitting with excellent posture each arm  Be sure to reach way back  Perform 2 sets of 10-15 reps each arm Alternate View  Perform 3x a week  Perform 3x a week

ALL-IN-ONE SCAPULAR/NECK STABILIZATION EXERCISE Lower Trapezius

 Nod your chin down 15 degrees  Keep band pressed between your head and the wall  Straighten arms without your head leaving wall  Perform 2 sets x 10 reps each  3 to 4 times a week

Mid Trapezius

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 47 Rhomboid Latissimus Dorsi

Serratus Anterior

Magnetic resonance imaging study of the morphometry of Craniocervical Flexion cervical extensor muscles in chronic tension-type headache Start with pressure biofeedback inflated to 20 mmHg. Make sure your chin and forehead are lined up. Nod your head, keeping the large neck muscles soft and C Fernández-de-las-Peñas, A Bueno, J Ferrando, JM Elliott, ML Cuadrado & JA Pareja bringing the reading up to 22 mmHg. Work up to ten 10-second holds. Then progress to 24, 26, and 28 mmHg. 5 to 10 reps, 5 to10 second hold times, increase as tolerated.

Rectus capitis posterior minor, left side is image of control group, right side is image of CTTH group The Change in Deep Cervical Flexor Activity After Training Is Associated With the Degree of In conclusion, RCPmin and RCPmaj muscles showed reduced rCSA in CTTH patients compared Pain Reduction in Patients With Chronic Neck Pain, Deborah Falla, PhD, Shaun O’Leary, PhD, with healthy controls. Headache intensity, frequency and duration were greater in those CTTH Dario Farina, PhD, and Gwendolen Jull, PhD, (Clin J Pain 2012;28:628–634) patients with more reduced rCSA in both RCPmin and RCPmaj muscles.

YAMUNA BODY ROLLING

Supportive Therapies & Ergonomics

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 48 http://www.rapidforce-phs.com/

Correlations between Posture and Jaw Relations, Danner, Jakstat and Ahlers, Journal of Craniomandibular Function, 2009;1(2):149-163

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 49 Better Reading posture

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 50 LUMOback, the first posture sensor and mobile application to support healthy backs. Now introducing the LumoLift

www.varidesk.com www.lumobodytech.com

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 51 ERGONOMICS/BAD HABBITS

So even though there is vast evidence showing the functional coupling between the musculoskeletal structures of the cervical spine “POSTURE IS A REFLECTION and the masticatory system, there is only weak evidence for a direct biomechanical mechanism (such as the effect of poor head posture on the OF ONES ATTITUDE TO LIFE” masticatory system) as a cause for TMDs.

The association between head and cervical posture and temporomandibular disorders: a systematic review. Olivo SA1, Bravo J, Magee DJ, Thie NM, Major PW, Flores-Mir C. J Orofac Pain. 2006 Winter;20(1):9-23. Dr. Stanley Paris

The association between the cervical spine, the stomatognathic system, and craniofacial pain: a critical review. Armijo Olivo S1, Magee DJ, Parfitt M, Major P, Thie NM. J Orofac Pain. 2006 Fall;20(4):271-87.

Occlusal Appliance Therapy

• An occlusal appliance is a removable device, usually made of hard acrylic, which fits over the occlusal and incisal surfaces of the teeth in one arch. – Occlusal Splint – Bite guard – Night guard – Interocclusal appliance – Orthopedic device Maxillary Occlusal Appliance

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 52 Not enough evidence about whether stabilisation splints can reduce pain caused by painful temporomandibular (jaw) disorders. Pain dysfunction syndrome (PDS) is the most common TMD (temporomandibular disorder, from the joint between the lower jaw and base of the skull). PDS is also called facial arthromyalgia, myofacial pain dysfunction syndrome and craniomandibular dysfunction. One option is a splint (a type of bite plate) at night when people otherwise may grind their teeth more. The stabilisation splint (SS) is one type, also known as the Tanner appliance, the Fox appliance, the Michigan splint or the centric relation appliance. The review found there is not enough evidence from trials to show whether or not stabilisation splints can J Evid Base Dent Pract 2006;6:48-52 reduce PDS.

Conclusions that can be drawn from this evidence-based review include; Since occlusal treatments are typically irreversible treatments and the evidence 1. There is insufficient evidence to suggest that any occlusal treatment as reviewed here is more or less effective than on its therapeutic or preventive effects placebo in treating TMJD pain. on TMJD is insufficient, it is 2. There is also insufficient evidence to suggest that any recommended that reversible treatment occlusal treatment is as or more effective than other such as self-care, splints, physical rehabilitation treatments in treating TMJD pain. therapy, and cognitive-behavioral 3. There is also insufficient evidence to support the therapy be used to initially manage signs generalized preventive influence of occlusal adjustment and orthodontic correction of malocclusion on TMJD and symptoms of TMJD. development.

Indications for an oral appliance per Kraus

• To reduce AM jaw muscle pain and or HA if symptoms are triggered by sleep bruxism induced by mayalgia or arthralgia

• To protect occlusal surfaces of teeth and dental The nociceptive reflex is activated by unexpectedly biting on a hard object. The noxious stimulus is initiated when the tooth and periodontal ligament is stressed. Afferent nerve fibers carry the impulse restorations from sleep bruxism forces to the trigeminal spinal tract nucleus. The afferent neurons stimulate both excitatory and inhibitory interneurons. The interneurons synapse with the efferent neurons in the trigeminal motor nucleus. Inhibitory interneurons synapse with efferent fibers leading to the elevator muscles. The message Evaluation and Treatment of TMD by Steve Kraus, Jan 2013 course presentation carried is to discontinue contraction. The excitatory interneurons synapse with the efferent neurons that innervate the jaw, depressing muscles. The message sent is to contract, which brings the teeth away from the noxious stimulus.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 53 Bruxism vs. Clenching

• Bruxing is an oral parafunctional activity that can occur Diurnally or nocturnally. Bruxing is classified as a series of rhythmic contractions, tooth grinding. ~ 20 to 38% of children brux, and 25% to 50% of adults brux • Clenching is more of a single contraction

episode, and this can occur as well during the The purpose of an anterior positioning appliance is to temporarily bring the mandible forward in an attempt to improve the condyle-disc relationship. A, This specimen reveals day or night. a disc dislocation. B, The MRI shows the disc to be dislocated anterior to the condyle. C, When the mandible is brought forward, the condyle is repositioned on the disc. D, The MRI shows the disc in its normal position on the condyle. This is a temporary therapeutic position that will encourage adaptation of the retrodiscal tissues. (Courtesy of Dr. Per-Lennart Westesson, University of Rochester, Rochester, NY.)

What is the best occlusal appliance design? • All appliances have the potential to be • The best appliance design is one that causes therapeutic for reasons that are not known the least amount of adverse side effects while • All Appliances have the potential of causing providing for the most potential therapeutic adverse side effects: benefit: – Increase pain – Reduce AM muscle pain/HA – Movement of teeth, extrusion or intrusion – Reduce AM locking – Potentially could lead to orthognathic surgery – Protect occlusal surfaces

Appropriate features of an oral appliance • Even centric stops on the appliance- ask the patient if they hit evenly on the appliance, ask the patient to “tap-tap-tap” on the appliance and if they hit evenly on the appliance • Maxillary or mandibular full coverage, Maxillary is preferred when possible • Shallow inclines of the acrylic leading into the centric stops • Hard Acrylic vs. soft • Anterior guidance during protrusive and lateral excursions- anterior guidance is the relationship of any • of the lower anterior 6 teeth maintaining contact with Thin as possible, thickness of appliance is any of the upper 6 teeth during protrusive and lateral determined by looking at thickness of the excursions resulting in disclussion of the posterior appliance in the posterior molar region teeth during such movement

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 54 Why should a TMD specialist assess the design and understand the purpose of an oral appliance?

• Gain insight of the appropriateness of the oral

appliance design James Fricton, DDS, MS/John O. Look, DDS, PhD/Edward Wright, DDS, MS/Francisco G. P. Alencar, Jr, DDS, MS/Hong Chen, DDS, MS/Maureen Lang, DDS, MS/Wei Ouyang, DDS, PhD/Ana Miriam Velly, DDS, PhD, • Communicate to the dentist necessary changes in Summer 2010 Volume 24 , Issue 3,pages 237-254. oral appliance design-possibly as a result of your Conclusion: Hard stabilization appliances, when work on posture, cervical spine alignment, etc… adjusted properly, have good evidence of modest • Not uncommon for a dentist to ask for your efficacy in the treatment of TMJD pain compared to non-occluding appliances and no treatment. Other advise on design of an oral appliance types of appliances, including soft stabilization • Be satisfied that the patient has the best oral appliances, anterior positioning appliances, and anterior bite appliances, have some RCT evidence appliance design (according to the evidence) to of efficacy in reducing TMJD pain. However, the achieve the best possible outcomes potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use.

DDS PT

Management and Treatment of Temporomandibular Disorders: A Clinical Perspective EDWARD F. WRIGHT, DDS, MS; SARAH L. NORTH, PT, MPT; THE JOURNAL OF MANUAL & MANIPULATIVE THERAPY, VOLUME 17, NUMBER 4. pg. 247-254.

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 55 It’s not about the nail

THANK YOU! Michael Karegeannes--Owner PT, MHSc, LAT, MTC, CFC, CCTT, CMTPT Jeff Verhagen - PT, MBA, CMTPT Mike Verplancke – DPT, CSCS, CMTPT

4 locations: Fox Point, WI Brookfield, WI Grafton, WI Mukwonago, WI

414-352-2082 work 414-352-5279 fax

[email protected] [email protected] [email protected]

www.freedompt.com www.treatingtmj.com

Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 56 TMD EVALUATION FORM TMD HISTORY

Health Professionals seen for current symptom(s): ______

Diagnostic procedure(s) done: ______

Onset; trauma/insidious/surgery/other: ______

Previous treatment(s) ______Medications; anti-inflammatory/muscle relaxer/narcotic/anti-depressant/anti- anxiety

Progression of symptoms: better / worse / no change ______

Do you have jaw pain? No ___ Yes ___ R ___ L ___

Is your jaw pain: constant ___, daily ___, weekly ___

What increases your jaw pain? ______

What decreases your jaw pain? ______

Does your jaw click / pop / grind? No ___ Yes ___ R ___ L ___

Do you have limited mouth opening? No ___ Yes ___ R ___ L ___

Has your jaw ever locked open ___ or close ___ No ___ Yes ___ R ___ L ___

Do you clench ___ grind ___ brace ___ ? No ___ Yes ___ R ___ L ___

Do you have ear symptoms? No ___ Yes ___ R ___ L ___

Is your ear symptom (______) constant ___ daily ____ weekly ___

What increases your ear symptom? ______

What decreases your ear symptom? ______

Do you have headaches? No ___ Yes ___

Location: ______

Is your H/A: constant ___, daily ___, weekly ___

What decreases your H/A? ______

Do you have neck / shoulder pain? No ___ Yes ___ R ___ L ___

Is your N/S pain: constant ___, daily ___, weekly ___

What increases your N / S pain? ______

What decreases your N / S pain? ______

Other symptoms? ______

______

A. Mandibular Dynamics: Key: 1= Mild Pain 1. Vertical Opening 2 = Moderate Pain a. Opening w/o pain ___mm 3 = Sever Pain RIGHT LEFT b. Maximum opening w/pain ___mm 1 2 3 1 2 3 c. Opening Pattern w/mandibular loading: a. Straight: ______b. Deflection: R____ L____ c. Deviation: R to L ___ L to R____

2. Excursions: a. Right lateral Excursion: Right Left limited: No ___ Yes___ Pain: No___ Yes___ 1 2 3 1 2 3

b. Left lateral excursion limited: No ___ Yes ___ Pain: No ___ Yes ___ 1 2 3 1 2 3

c. Protrusion: limited: No ___ Yes ___ Deflection: No___ Yes ___ Pain: No ___ Yes ___ 1 2 3 1 2 3

© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 58 B. Muscle Palpation: Right Left 1. Temporalis pain/ tight No ___ Yes ___ 1 2 3 1 2 3 2. Masseter pain /tight No ___ Yes ___ 1 2 3 1 2 3 3. Medial Ptyergoid pain /tight No ___ Yes ___ 1 2 3 1 2 3 4. Temporalis Tendon pain/ tight No ___ Yes ___ 1 2 3 1 2 3 5. Vicinity of Lat Pty pain/ tight No ___ Yes ___ 1 2 3 1 2 3 6. Ant/Post Digastrics pain/ tight No ___ Yes ___ 1 2 3 1 2 3 7. SCM pain/tight No ___ Yes ___ 1 2 3 1 2 3 8. Subocc pain/tight No ___ Yes ___ 1 2 3 1 2 3 9. Levator pain/ tight No ___ Yes ___ 1 2 3 1 2 3 10. Trapezius pain/tight No ___ Yes ___ 1 2 3 1 2 3 C. Joint Palpation: 1. Lateral Pole with back teeth together pain: No ___ Yes ___ 1 2 3 1 2 3 2. Lateral Pole with mouth open (>11mm) pain: No ___ Yes ___ 1 2 3 1 2 3 3. Posterior attachment “inside ear” pain: No ___ Yes ___ 1 2 3 1 2 3

D. Pain Map

E. Joint Loading Right Left 1. Biting of fulcrum right molars pain: No ___ Yes ___ 1 2 3 1 2 3 If painful, response was joint (L) ___ muscle (R) ___ both ___ 2. Biting on fulcrum left molars pain: No ___ Yes ___ 1 2 3 1 2 3 If painful, response was joint(R) ___ muscle(L) ___ both ___ F. Patient can bring back teeth together: No ___ Yes ___ G. Hypermobile No ___ Yes ___ Identified by: “jutter” R/L and/or eminence click R/L H. Beighton Scale ___/9

© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 59 I. Stage I (Disc Displacement with Reduction) Summary: No __ Yes __: R __ L __ 1. Palpable opening click No ___ Yes ___: R___ L ___ 2. Late closing click No ___ Yes ___: R ___ L ___ Click too soft to ID ___ 3. Opening click eliminated on protrusive opening and closing No: R _ L _ Yes: R _ L _ 4. Patient reports having had intermittent locking No ___ Yes ___

J. Stage II (Disc Displacement without Reduction with Limited Mouth Opening) Summary: No __ Yes __: R _ L_ 1. Active Unassisted Mouth Opening is < 30mm (see mandibular dynamics) No _ Yes _ 2. Prior history of clicking with or without intermittent locking: No __ Yes __: R _ L _

K. Stage III (Disc Displacement without Reduction without Limited Mouth Opening) Summary: No_ Yes _: R _ L _ 1. Active Unassisted Mouth Opening is > 30mm (See mandibular mechanics) No __ Yes __ 2. Prior History of Clicking with or without Intermittent Locking: No __Yes __: R __ L __

L. Crepitus: No __ Yes __: R __ L __ M. Occlusion: Anterior Open Bite __ Posterior Open Bite __ Cross Bite Yes/No R or L N. Parafunctions Identified: No ___ Yes ___ nail biting, scalloped tongue, cheek biting, etc O. Lip or Tongue Frenulum tightness No____ Yes____

P. Cranial Nerve Tests: a. Trigeminal i. Jaw Reflex ii. Corneal Reflex iii. Sensory testing (light touch and pin prick) iv. Isometric tests: 1. Direction of movements: a. Depression b. Elevation c. Lateral excursion b. Facial i. Muscle testing ii. Corneal reflex iii. Sense of taste iv. Salivary gland v. Tear gland

1. Maxillary Full Coverage yes no Maxillary Anterior Coverage yes no Mandibular Anterior Coverage yes no Mandibular Full Coverage yes no Mandibular Posterior Coverage yes no Anterior Repositioning Appliance yes no

2. Hard_____ Soft____ 3. Thin_____ Thick___ 4. Centric Stops on a full coverage hard appliance ( tap/tap/tap) NA ___ even all around ___ front___back right___back left ___

5. Inclines leading into the centric stops Shallow ___ Steep ___

6. Anterior Guidance: ___ balancing interference(s) were not present during protrusive And lateral movements

___ balancing interference (s) were present during:

Protrusive movement R L no R lateral movement yes(left) no L lateral movement yes(right) no ______

Frequency in use of the oral appliance 24 hours a day yes no 24 hours a day except for eating yes no As needed during the day yes no At night yes no

Did your dentist tell you the purpose of the intraoral appliance yes no

If yes, what is the purpose: ______

______

The therapist should always implement a home treatment program to reinforce the clinical treatment plan of care and modify the patient's lifestyle and how the patient’s body functions in its working and home environment. As the craniomandibular and craniocervical environment is altered, it must be maintained. Exercises remove parafunctional habits and reinforce new postures and functions. The home program, the "6 x 6 program” is a sequence of exercises for the patient in dysfunction. This 6 x 6 exercise program complements the active clinical program performed by the therapist during the patient's acute and sub·acute dysfunctional stages. The home program exercises modify or reinforce the postural relationships of:

 the cranium to the upper cervical spine,  the cervical spine(anterior, posterior, and lateral aspects) to the shoulder girdle, and  the mandible to the maxilla. These inter-relationships make up the elements that impact on the orthostatic equilibrium of the entire upper body. Consequently, the practitioner must consider each of these components, the relationship of one component to another, and the impact of each component on the entire body. Therefore, the therapist treating temporomandibular pain must not restrict their evaluation and treatment to the structures or the face and jaw, but look at the entire body. The objectives of the home self-mobilization program are:

I. To learn a neutral postural position and rest position of the mandible

2. To fight the “soft tissue memory" of the old position

3. To restore the muscle to its original functional length

4. To restore normal joint play and mobility

5. To restore normal balance among the body parts

6. To give the patient an ongoing exercise program to incorporate into their life activities.

This program should be initiated as the patient's pain begins to diminish. At this point the exercises will not irritate an acute condition and a therapist-patient relationship is established to some degree. These factors will maximize effective patient compliance with the exercise program. Factors that promote patient compliance are:

© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 62 I. The exercises should not produce nor increase pain. 2. The patient should be taught the exercises gradually, one to two per session. 3. The exercises should not take more than a few minutes to perform. 4. The performance of the exercises should be performed regularly and often so they become a routine act that contributes to the consistent compliance of the patient to the program. 5. The exercise performance should be spaced through the day (every 2-3 hours). 6. Performance expectations should not exceed the what a patient can truly accomplish between work and home responsibilities. 7. Visual cues wilt help patients remember to perform the exercises, i.e., sticky note on computer, phone, desk, mirror in bathroom, a timer or any helpful reminder.

The 6 x 6 program is not meant to be a time consuming regime. These exercises should be able to be performed in any position and not last more than a few minutes. The program is termed "6 x6” because: 1. There should be no more than six instructions, 2. They should be repeated six times each, and 3. They should be performed six times a day.

Although each exercise program should be individually designed to the patient's complaints, there are six fundamental exercises commonly used in the treatment of head-neck-mandibular dysfunction for these patients. These components are as noted below.

1. Rest position of the tongue: To establish a correct position of the tongue during rest, it is necessary to teach the patient the correct position of the tongue against the hard palate. The practitioner asks the patient to place their tongue against the hard palate (never directly behind the upper incisors) and make a "cluck-like” sound, or say the word “no” or “never”. This action will position the tip of the tongue in the same position that it assumes during swallowing and the correct mandibular rest position. After identifying this position, the patient attempts to maintain the anterior one-third of their tongue against the palate with a slight pressure, key word is slight. This position will contribute to the creation of negative pressure in Donder's space to hold the tongue with little or no muscle action against the hard palate, the normal rest position of the tongue. With the tongue in this position, the patient should attempt to breathe through their nose and use the diaphragm muscles for respiration rather than the accessory respiratory muscle (i.e. pectoralis, scalenes, scm, and intercostals). The use of the accessory muscles promotes abnormal forward head and rounded shoulder posture and could lead to a host of other musculoskeletal problems.

© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 63 2. Control temporomandibular or joint rotation: The temporomandibular joint rotation exercise limits early translation of the temporomandibular joint and promotes the normal repositioning of the mandibular head in the fossa. Rotation also allows the disc to maintain a healthy position over the mandibular head, rotating anteriorly or posteriorly during opening and closing of the mandible. During the phase of rotation in opening, the upper head of the lateral pterygoid is relaxed and the lower head is contracted. This creates a pumping effect of the intracapsular musculature, which is necessary to maintain a healthy synovial joint. The practitioner instructs the patient to place and hold the anterior one-third of their tongue flat against the palate as the patient opens their mouth. This tongue position limits the range of opening to rotation and reduces the patient's tendency to protrude the mandible. In addition, this exercise will minimize joint sounds, and therefore reduce the abnormal wear on the structures of the temporomandibular joint. This can be done by the patient monitoring joint rotation by placing his/her finger over the temporomandibular joint, the anterior lateral capsule. After the patient is able to perform this exercise adequately, they should attempt to chew with limited translation. This amount of opening with minimal to no pain can also help limit or determine the bite size of food they are allowed to chew. The patient can more easily control translation if he practices chewing in front of a mirror while palpating the temporomandibular joint. The major emphasis of treatment of the hypermobile joints are to limit translation of the mandibular head, control rotation, stabilize and realign the connective tissue, ligaments, capsule and joint, and maintain the orthostatic head , neck, and shoulder girdle positions. As the patient learns to control temporomandibular rotation and implement rhythmic stabilization techniques, they will be treating the hypermobility of the TM joints.

© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 64 3. Mandibular rhythmic stabilization technique (RST) : This technique is adapted from proprioceptive neuromuscular facilitation techniques. It attempts to increase the individual's muscular control by stimulating the proprioceptive capabilities of the neuromuscular system. RST is a series of isometric contractions of the muscles of mastication to resist opening, closing, and lateral excursion - the three planes of motion. The patient should begin with their mandible in its rest position. They should not permit movement of the temporomandibular joint in response to the resistance applied. Excessive forces should not be used because only the force of one or two fingers is required to stimulate the muscles of mastication. Initially, the patient may palpate the specific muscle of mastication being stimulated to provide feedback that the exercise is being done correctly. Excessive force may induce mandibular motion and potentially damage or irritate the joint. These exercises re-educate the patient's neuromuscular system to avoid unconscious abnormal positioning or posturing of the structures of the maxillofacial region, while maintaining an orthostatic posture.

© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 65 4. Cervical joint liberation: This technique creates a distraction force on the upper cervical vertebrae and relieves mechanical compression by elongating the posterior and suboccipital cervical muscles. In the patient with maxillo-oral facial pain mechanical compressions occur between the occiput-atlas, atlas axis, and axis-C3 joints. The patient can distract their craniovertebral joints by holding both hands with fingers interlaced behind their neck to stabilize the C-2. to C-7 region. Then the patient nods their head forward six times while stabilizing the cervical spine in only 15 degrees of anterior cranial rotation. This controlled flexion relieves neurovascular compression in the upper cervical region. The application of this technique distracts the occiput from the atlas to counteract the dysfunctional effect of extension of the cervical spine produced by a forward head posture. The patient should recognize that this exercise does not include flexion of the neck but flexion of the head on the cervical spine.

Stabilize C2

© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 66 5. Axial extension of the cervical spine: This exercise improves the functional and mechanical relationship of the head to the cervical spine. Before learning axial extension, the patient must learn toposition their head forward to the level of the sternum, aligning the malar bone. The patient creates a distraction force on the cervical vertebrae as he combines flexion of the occiput on the upper cervical spine and extension of the lower cervical spine, relative to the thoracic region. These movements position the head in an ideal orthostatic position. In this ideal position the scm muscle shifts from its vertical relationship in the dysfunctional posture to its normal posterior angulation in a posterior direction in axial extension. The realignment of the scm limits the unnecessary cervical muscle activity required to maintain the abnormal forward head posture; the levator scapulae and trapezius relaxes by shortening. The practitioner may remind the patient that the muscles of the posterior cervical spine must work twice as hard 10 hold the head upright in the forward head posture than in the more normal head on neck posture.

Start with back of head and spine against corner of wall

--Nod your chin down about 15 degrees --The back of your head should remain in contact with the wall --Your eyes should remain level-imagine a string at the top of your head pulling up

© 2015 Freedom Physical Therapy Services S.C. Green Bay, WI April 20, 2017 Michael Karegeannes PT www.treatingtmj.com 67 6. Shoulder girdle retraction: These exercises restore the shoulder girdle to a more ideal and stable postural relationship of the head-neck- shoulder complex. The therapist instructs the patient to retract and depress the shoulder girdle relative to the rib cage. These actions correct the abnormal scapular abduction, reduce tension in the acromioclavicular joint, relieve compression in the sternoclavicular joint, and promote elevation of the sternum. The therapist, in time, must instruct the patient in exercises to strengthen the upper larger back muscles, i.e., rhomboids, mid trapezius and the inferior trapezius, to maintain the shoulder girdle in this corrected position and prevent postural relapse (Antoniotti and Rocabado).

Perform chin nod and roll shoulders back and downward

Reference: Musculoskeletal Approach to Maxillofacial Pain, by Rocabado and Iglarsh,1991

Move hyperboloid for 2 minutes from molar to molar 1 to 2 x a day

Laterally deviate your mandible right Laterally deviate your mandible left 10 reps 2 to 3 times a day 10 reps 2 to 3 times a day

Protrude Mandible forward teeth to teeth 10 reps 2 to 3 times a day

In general, avoid:  Large bites, “big” food  Repetitive chewing  Forceful bites  Using tongue to remove food from teeth

Specifically, avoid these foods:  Gum  Jaw breakers  Popcorn  Caramel  Steak  Pizza  Bagels  Chips  Nuts  Ice  Beef jerky  Crunchy fruits and vegetables  French bread  Hard cereal  Lettuce

Other things to avoid:  Resting chin on hand  Holding phone with shoulder  Sleeping on stomach  “Big” yawns  Singing  Yelling  Nail biting  Chewing on inside of cheek  Biting lip