NEUROSTRUCTURAL INTEGRATION TECHNIQUE IMPACT OF TMJ ON BODY FUNCTION Presented by Ron Phelan NST Practitioner and Instructor Remedial Massage Therapist Assessment and treatment guide for soft tissue therapists: the NST approach Copyright Ron Phelan 2015
Table of contents Introduction 2 Workshop outcomes 2 Overview of TMJ 3 - Physical 3 - Neurological 4 - Hormonal 4 Muscle testing 4 NST approach to treatment 5 - Assessment 5 - Muscle testing for the TMJ a) Latissimus Dorsi 6 b) Iliopsoas c) Omura ring test - Treatment 7 - Post treatment assessment 8 - Stabilisation 8 - Referral 9 Other considerations 9 References 9 TMJ procedure diagram 10 1
Introduction IMPACT OF A DYSFUNCTIONAL TEMPORO MANDIBULAR JOINT (TMJ) UPON BODY FUNCTION Presented by Ron Phelan, Remedial Therapist, Bowen (NST) Instructor/Practitioner Temporomandibular Joint (TMJ) disorder is referred to as the hidden imposter because it mimics the symptoms of many other musculoskeletal problems. Dysfunction of the TMJ typically affects around 30 percent of the population, with symptoms such as neck pain, back pain, headaches, migraines, clicking jaw and bruxism being the most common problems. The TMJ has many functions, involved in chewing, swallowing and talking. To gain a fuller understanding of the implications of TMJ disorder, its relationship within the context of a broader system, the Stomatognathic system (SGS) must be considered. The SGS consists of the cranial, spinal and pelvic structures and is considered a closed loop feedback network. Hence imbalances in the TMJ locally are reflected not only locally but also to the pelvis via the dura mater. The imbalances can also be distributed: mechanically (causing distortions in the cranial area, spinal and pelvic regions resulting in irregular muscular tensions anywhere in the body), hormonally (by affecting the regulation of the pituitary gland), and neurologically (through pressure on cranial nerves). In most cases, TMJ disorder can be effectively treated using NST technique in isolation or in conjunction with other supportive modalities. These techniques involve a comprehensive assessment protocol to isolate the source of the problem, followed by NST treatment. Workshop outcomes: Understanding of TMJ relationship to the body Assess the impact of dysfunctional TMJ Diagnostic protocol for fault isolation Observe/experience the effect of an NST move. 2
Overview of TMJ Overview of the TMJ: (An edited and updated version taken from the newsletter, The straight news ) -reproduced with the kind permission of Brendan Stack D.D.S., M.S There are a number of factors that make the TMJ unique in the whole body, as it has two joints in one. The two joints, one in front of each ear and are connected by the jawbone. One joint may influence the function of the other joint. Because they are connected, by the jawbone this means that you cannot move one joint without moving the other. The two temporomandibular joints can differ from one side to the other in size, shape, and function. It is frequently possible to have a problem in one joint but have the symptoms expressed in the other joint. You could also have pain that starts on one side of the head and migrates to the other side simply because of the relationship of these joints. The second factor making this joint unique is that another structure dictates its function. The other structure is the teeth. The teeth are passive members of the upper and lower jaws, but they have a specific way they must fit together and interrelate. As far as the brain is concerned, tooth position has priority over joint position. This means that the TMJ is forced by the muscles to move so that the teeth will fit together properly. This can potentially cause misalignment within one or both joint capsules. If that happens, the muscles are put in a compromising situation, causing them to spasm and resulting in pain. Many of the problems experienced are a result of muscle spasm, but the cause is not a muscle problem. The muscles are simply caught between two positions: the tooth position and the jaw position. The third factor making this joint unique is that it has an articular disc located between the condular head of the mandible and the glenoid fossa of the mandible. The disc has a muscle attached to the front of it that pulls the disc forward as the condyle moves forward in the glenoid fossa. The disc is also attached in the back by elastic connective tissue that is much like a rubber band, and pulls the disk back as the condyle moves backward in the glenoid fossa. In other words, this attachment can stretch and recoil as the jaw opens and closes. Since the disc is a separate structure and may move independently from the condyle, it can be displaced and damaged causing many problems. This disorder is called an internal derangement of the TM joint. Internal derangement of the TM joint can cause a distressing syndrome of pain, limited jaw movement, clicking, popping and crepitus in the joint. This derangement may be caused by genetic pathological changes in the joint or acquired pathological changes as a result of trauma. Often, internal derangement of the TMJ is preceded by myofascial pain dysfunction that can involve severe spasms of the muscles of the 3
head, neck, shoulder and/or back. A wide range of local symptoms may occur, such as headache, muscle pain, ear pain, dizziness, stiffness and ringing in the ears. Distally, because of the connection via the dura mater, the effects of the misalignment can be observed in pelvic and sacral area as well as causing unresolved sacral, coccyx, lumbar and thoracic problems. Neurologically, local effects of TMJ disorder can be experienced by entrapment of the Vagus, Hypoglossal and Trigeminal nerves. Distally due to muscular imbalances between the cranium and pelvic region, spinal nerves may become compromised and the individual may experience many seemingly unrelated symptoms such as digestive, respiratory, urinary and bowel disorders, etc. Respiration involves flexion/expansion of the sacral-iliac joint. This movement is likewise mimicked at the sphenobasilar junction in the cranium. At the centre of the sphenoid bone lies the Sella Turcica, or Turkish Saddle. This houses the pituitary gland. The pituitary gland requires consistent rhythmical motion at that joint to regulate the glands function. Irregular movement can cause variations in hormonal output, thus affecting growth, pancreas function, fertility and more. Muscle Testing Reference: NST Update and Expansion Manual 2001, by Michael J. Nixon-Livy Manual muscle testing was originally developed to evaluate muscle function for the assessment of insurance claims by Kendall, Kendall and Wadsworth in the late 1940 s and early 1950 s. It was a specific diagnostic technique in the broader developing field of kinesiology, which basically refers to the study of motion of the human body, and subsequent movement of related muscles, joints and limbs. The tests were designed to isolate a single muscle or group of muscles, in the most contracted state, to determine if a manually applied force from the tester could be resisted. The test itself is not intended as an absolute measure of strength (which relates to muscle size), but rather a dynamic test of the muscles neurological integrity, or ability to lock. Therefore, a strong muscle will quickly and firmly resist an increasing test pressure, while a weak muscle will be slow to respond, feel indecisive and mushy, or may even give way altogether. This is called unlocking. Generally speaking a strong muscle (locking) will reflect a positive state, while a weak muscle (unlocking) will reflect a negative state, of the subject being tested. 4
Muscle testing has evolved and developed over the decades to the extent, that these days it is used as a very accurate diagnostic methodology for evaluating not only for neurological integrity of the muscles, but emotional states, nutritional imbalance, allergies, postural disorders, physiological dysfunction and more. NST approach to TMJ treatment 1) Assessment 2) Treatment 3) Stabilisation 4) Referral Assessment TMJ integrity can be assessed by: Symptomatic Headaches, neck pain, balance problems, recurring back pain, tinnitus, etc Observation Clicking and/or joint deviation on opening and closing the jaw. Palpation - Temporalis, Lateral Pterygoid, Masseter, Sternocleidomastoid, Trapezius TMJ s Muscle testing typically Latissimus Dorsi, Iliopsoas and Omura ring test. Muscle Testing for the TMJ TMJ integrity is quite easily and simply tested using appropriate muscle. Typically latissimus dorsi or Iliopsoas muscle tests provide concise testing results for both pre and post test assessments. Latissimus Dorsi: Shoulder Because of the connections of latissimus dorsi to the iliac crest, thoracic, lumbar and sacrum, this muscle gives good proprioceptive feedback to any imbalances in the cranial area due to the dural attachments. Actions: Extension, adduction (prime mover) Internal rotation, horizontal extension (assistant mover) 5
Typically the muscle is tested with the client holding the slightly extended and internally rotated arm thus bringing the back of their hand to their hip area. Switch point - Spleen 1. Iliopsoas: Hip Actions: Flexion (prime mover) Abduction, external Rotation (Assistant mover) Due to the relationship of iliopsoas and the pelvic girdle, its attachments to the last thoracic and Lumbar transverse processes, (fascial and dural), any imbalance between the TMJ and pelvic girdle is quickly and accurately assessed using this muscle. Typically the muscle is tested with the client in supine position, hip flexed, externally rotated and slightly abducted. Switch point - Kidney 1. Forearm flexor : Omura ring test The Omura ring muscle test, developed by Dr Yoshiaki Omura from Japan in the 1970's, found that finger muscles were more appropriate than large muscles in determining functional relationships in the body. The test uses the flexors of the thumb (flexor pollicus longus and brevis) in conjunction with the flexors of the hand and fingers (flexor digitorum). Switch point Pericardium 6. Actions : flexion of the fingers and hand. Typically the client will hold the thumb and one of the other fingers together and the therapist would apply a force to try and separate these. Typically the ring finger provides an accurate test result, however other fingers may be required to facilitate the test procedure. a) The therapist tests the muscle in a resisted test so as to ascertain the neural locking ability of the hip. Neural integrity is noted. Retest with switch point held and muscle should unlock. If muscle does not unlock, then recipient most likely dehydrated. b) The client is asked to swallow and open their mouth. Whilst their mouth is open, the test (a) is then repeated. The neural integrity is then compared against that measured in (a). c) No difference in strength means that the TMJ complex is potentially sound. d) A difference in strength means the TMJ complex is most likely compromised. 6
Treatment Recipient Supine (Refer to diagram on page 10) 1 Perform the muscle test as discussed on pages 5 and 6, noting the results. 2 Place your fingers over both TMJ s and observe any deviations/clicking or other sounds during the opening and closing phases. 3 Using the left thumb make a rolling movement over the Levator Scapulae muscle in a superior/oblique direction and release the thumb. Immediately repeat this sequence on the right side of the body using the right thumb. 4 Standing at the head of the recipient, place the middle finger of the left hand on the lateral margin of the upper Trapezius muscle in line level with spinal vertebrae C4, and roll over the upper Trapezius muscle in a medial direction. Immediately repeat this movement on the right side of the neck. 5 Without delay place the left thumb on the medial border of the left Sternocleidomastoid muscle slightly superior to its sternal origin and roll over the muscle in a lateral direction. (abc) Repeat this action three more times, moving superiorly onto the Mastoid process, and making a final lateral move over the insertion of the muscle. Immediately repeat this sequence on the right side of the neck using the right thumb. 6 Without delay using the thumb and index finger wiggle the Hyoid bone as instructed. 7 Place index and middle fingers bilaterally over the TMJ. Ask recipient to swallow and then open mouth wide an then close. 8 Ask recipient to partially open their mouth, inset their index finger and gently bite on it until the remainder of the procedure is completed. 9 Place the left thumb on the Condular head of the Mandible. Draw the skin superiorly over the TMJ and then move inferiorly crossing the joint. Without 7
removing thumb draw the skin anteriorly over the lateral ligament and then move posteriorly crossing the joint, and then release the thumb. Immediately repeat this sequence on the right side of the Mandible. 10 Without delay place the left thumb on the anterior margin of the Masseter muscle on top of the Coronoid process. Roll across the Masseter muscle into the depression (created by the open position of the jaw) and apply digital pressure to the Lateral Pterygoid muscle for five seconds. Release thumb. Immediately repeat this sequence on the right side of the face. Ask recipient to remove finger from mouth and ensure they are warm and comfortable whilst leaving them rest for 2-5 minutes. Post treatment Assessment Typically after having completed the treatment procedure, the recipient can be tested once again using either Latissimus Dorsi, Psoas or Omura ring testing protocols. A positive response will be indicated by the test being strong with both positions of the mouth, (open and shut) holding a similar strength in either Latissimus Dorsi or Psoas tests. Under certain situations, the adjustment may not hold, this weakness indicates that there may in fact be another structural weakness, such as degeneration of the disk or wear of any of the components within the TMJ/Cranial system. In this case stabilization of the joint is imperative. Other situations, upon becoming weight bearing, the weakness will return, indicating the need for additional pelvic/sacral re-alignment to create the required pelvic stability. Stabilisation Further stabilization therapy may be included at this point by way of the TMJ supportive appliance. The appliance allows gapping between the condular head of the mandible and the temporal fossa. This allows relaxing of the muscles locally and in the neck region, relieves the pressure on the TMJ, thus allowing the disk to regenerate and finally reduces the effect of bruxing and grinding. 8
Referral A small number of clients will require additional work to help relieve the symptoms of TMJ disorder. In these cases, referral to an experienced TMJ orthodontist will be the only solution to the problem. As such, the structure underlying the TMJ/cranial system is typically worn to such an extent that adjustment and stabilization techniques as outlined are unable to correct the situation. Typically the orthodontist will insert a number of different types of splints to stablise the TMJ complex. Pivot Appliance - increases the freeway space by increasing the vertical dimension only. Indications for Pivotal Appliance; no superior joint space, unilateral closed lock and bilateral closed lock. Repositional Appliance - moves the jaw in an anterior/posterior direction. Indications for Repositioning appliance; adequate superior joint space, myofascial pain, unilateral and bilateral clicks, unilateral and bilateral internal locks, unilateral and bilateral joint surgery and after manipulation of the joint. Other considerations Emotional conditions can also be the root cause of the TMJ disorder and as such, referral to the appropriate health practitioner should also be considered. References: The straight news (newsletter) Spring 2004, Brendan Stack. DDS. MS. Self published Brendan Stack course notes 2008 Brendan Stack. DDS. MS. Self published The TMJ Appliance (brochure) Myofunctional Research Co. Self published Applied Kinesiology; A synopsis. Vol 1+2. David S Walther. Systems DC, Pueblo, Colorado 1988. Head and face pain, edition 1 Rene Cailliet, MD. Published by F.A. Davis The Heart of Listening - Hugh Milne - Volume 2, A Visionary Approach to Craniosacral Work, North Atlantic Books. NST Introductory course workshop manual Michael J. Nixon-Livy. Self published. NST Basic course workshop manual Michael J. Nixon-Livy. Self published. NST Update and Expansion course notes Michael J.Nixon-Livy. Self published. For more information regarding the NST approach, refer to the NST website: at www.nsthealth.com or contact Ron at bowenst@iprimus.com.au. 0419380443 9
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