Learning with Laughter

According to Round Earth Publishing this will give the ‘coat hanger’ headache.

Red areas represent major pain areas. The ‘x’ marks the trigger points that are referring pain to those areas. They respond well to stretching with breath, improving posture and having assessment done of jaw and cranial shape.

The upper trapezius refers a ‘fish-hook’ pain pattern up the back side of the neck to the head, and around the temple to the eye. There may be goosebumps to upper arm and thigh possibly with nausea and visual disturbances. Problems often begin with heavy bags or purses, balancing phones between head and shoulder, or imbalances and strain by tight sternomastoid or scalene muscles.

The nauseating pain of a one-sided trapezius headache is commonly diagnosed as “migraine” although migraine medications often fail to relieve the pain. Bursitis and back pain may arise from the upper and lower fibres of the same muscle.

The suboccipital muscles are comprised of eight muscles total (one set of four on either side). They are not very well known to people, but after reading the following article you should get a better idea of their significance.   You can see by looking at the picture that these muscles form a triangle over the upper cervical spine.

The upper cervical spine has been shown to be the most concentrated area of mechano-receptors (joint position receptors) in the body. The suboccipital muscles have been also been shown to have a very dense number of muscle spindle cells and GTOs (Golgi tendon organs). Muscle spindles measure the rate of change in muscle length, monitoring joint position as it relates to the muscle. GTOs measure muscle tension.

When someone develops an upper cervical dysfunction and/or mis-alignment of the upper two neck vertebrae they can cause a very substantial alteration in the tone of these suboccipital muscles. It can lead to a tightening on one side or both, which often times can be the cause of tension headaches or cervicogenic headaches.

Temporalis: These are the ‘morning’ headaches felt at the side of your head after a night of clenching. If the bite is uneven which may not be noticed by your brain this can be unilateral. I was offered a “Temporal artery surgical investigation” for cause of headache when drugs did not help! Glad my intuition told me there must be further analysis!

Another fact: Tension / sinus headache, TMJ and toothache in upper teeth. Combine a head-forward position with long hours of playing a wind instrument or a violin and you can inflame the Scalene and Temporalis muscles, the cervical spine and occasionally a branch of the trigeminal nerve in the cheek area.

SUPPORTING CASE STUDIES

(Editor’s Note: Macy’s story in italics & quotations (”"), Cathy’s comments in brackets ([])

Macy’s real story:  “I was overdue by 10 days, and I had a difficult birth (I was in isolation for 3 days), I had digestive issues which were diagnosed as colic. I was breast fed.” (This promotes good jaw development)

[NOTE: In a study of 1250 babies there was visible trauma to head either before or during labour in 10% of the babies.  Membranous articular restrictions, which could be detected by the osteopathic physician, were present in 78%. Thus, nearly 9 of every 10 infants in the study had been affected.

In a study done of 100 children between 5-14 who were having learning or behavioural difficulties it was found that 79 had been born after a long or difficult labour and had one or more of the common symptoms of the neonatal period. (Difficulty sucking, vomiting, nervous tension and irregular respiration) Also the study noted that childhood allergies can be traced to musculoskeletal strains originating at the time of birth!)

KEY POINT: The Vagus nerve provides innervations to the gastrointestinal and cardiorespiratory system. Compression transmitted through the squama to the condylar part on one side may disturb the function of the Vagus and/or Hypoglossal nerve, causing vomiting, irregular respiration and difficulty speaking and sucking.]

“I have had stomach upset for years – since my childhood and it continues now, however is not as severe.”

[PERSONAL CLINICAL OBSERVATION: I notice clinically those patients who have colic as babies seem to suffer from gastric issues as adults in varying severity.]

“Orthodontic work was done to correct my bite and wore a retainer top and bottom for years.”

[Different medical perspective on neonatal period from Osteopathic Annals (5): 197-205 May 1976.

The hypoglossal nerve (cranial nerve)  which innervates the muscles of the tongue, pass out through the cranium between the base and the lateral mass, through interosseous cartilage join the space that will become the condylar canal. The occipital condyle which articulates with the atlas, spans the intraosseous cartilage: its anteromedial third is found on the base, the posterior thirds on the lateral mass. Immediately anterolateral to this condylar area is the jugular foramen, a space between the condylar part of occiput and the petrous portion of the temporal. This foramen gives passage not only to the jugular vein but also to cranial nerves 1X, X and X1 (Glossopharyngeal, Vagus and Accessorius, respectively]

“I was on the track & field team even though I had knee problems (diagnosed as patella femoral syndrome and was given orthotics).”

[Possible Explanation: Postural adaptation can occur because the brain tries to align, maximize & optimize the lower pharyngeal airway, with the bite and visual tracking. Facial and muscular restrictions at front of neck affect mandible (jaw) position: forward tip of pelvis follows shift of centre of gravity of head. This affects lower leg muscles, pelvis rotates backwards and moves body forward due to shortness of Dural sheath/fascia (see past newsletter): Hamstrings tighten to balance the pelvic shift, and often feet rotate outward in response to pelvic rotation. Patient then complains of IT band and hip issues.]

“I have had IT band tightness which leads to hip pain since becoming a runner a few years ago.

Age 10, I had a couple of traumas to the head which was the start of my headaches and migraines – they are above my eyebrows and temples. Neck and shoulder pain is aggravated by working at a computer every day. In my adult years, my sinuses have had infections, had a “stuffy feeling” giving me head pressure and plugged ears.”

[For causes see: Sternomastoid Trapezius, Masseter, Pterygoids]

“I have also experienced relief from seeing Cathy, and it has been helpful to learn about the musculoskeletal head to toe connections and how that affects how I feel day to day.”

FACIAL AND TEETH PAIN

1. Masseter > TMJ, tinnitus, “sinus”, and toothache. For its size and weight, the masseter is the strongest muscle in the body and its effects are not trivial. It refers pain to both upper and lower molar teeth, causes TMJ dysfunction, earache and a “sinus” pain over the eyebrow. Interesting that people who develop headaches from worrying may get depressed and are given. Prozac and related anti-depressants such as Paxil, specifically cause tightness in this muscle. If you’re grinding your teeth at night and waking with a headache, ask your doctor about taking the medication during the daytime when you can be more aware of clenching and tooth-grinding which tense the masseter but also strain the Temporalis.

2. PTERYGOIDS > TMJ and “sinus” pain. The lateral pterygoids (at right) help to open and protrude the jaw. These relatively weak muscles are easily strained in opposing the powerful masseter and temporalis muscles that close the jaw.

The pterygoids commonly develop trigger points which in turn cause pain and/or clicking in the TMJ joint. They may block drainage from the maxillary sinus causing more still more pain. They are also linked to tinnitis, and cause lateral deviation on opening the jaw. There may be entrapment of the buccal nerve causing numbness / tingling in the cheek (see buccinator, below). The masseter muscle and medial pterygoid support the jaw like a sling. Masseter is on the outside, medial pterygoid inside; together they close the jaw.

MEDIAL PTERYGOIDS produce diffuse pain in the mouth involving the floor of the nose, tongue, throat and hard palate; pain below and behind the TMJ joint, pain and/or stuffiness of the ear, difficulty swallowing, lateral deviation and possibly pain on opening the jaw. They can also entrap the lingual nerve producing the odd symptom of a bitter, metallic taste in the mouth (which the patient may not connect with other symptoms and may not report for fear of being thought “crazy.”)

3. BUCCINATOR

Cheek pain. This muscle forms the wall of cheek and mouth. It’s the part of the cheek that puffs out when playing the trumpet (for which it is named), blowing up balloons or stuffing one’s mouth too full. Buccinator pain may appear suddenly following dental/orthotic work or progressively after repetitive wind instrument playing.

There are no entrapments by the buccinator itself, but the lateral pterygoid can entrap the buccal nerve which supplies the skin and mucous membrane in this area. The muscle itself can cause local pain deep in the cheek while chewing, commonly misdiagnosed as TMJ dysfunction

4. DIGASTRIC > Neck pain and toothache in the lower incisors. The digastric assists the lateral pterygoid in opening the jaw against the counterforce of the far more powerful temporalis and masseter muscles. The upper portion can entrap the external carotid artery and auricular artery decreasing blood flow to the brain. Strained by retrusion of the jaw (as in playing the clarinet or similar wind instruments) or by holding a violin in place with the chin. Commonly damaged in whiplash injuries in concert with other neck muscles such as trapezius and splenius.

Dentally, trigger points in the anterior belly send pain to the four lower incisor teeth and the alveolar ridge. There may also be pain in the throat and tongue and difficulty swallowing because of the relationship to the hyoid bone.

Trigger points in the posterior belly refer pain to the upper sternocleidomastoid muscle, pain to the throat possibly as far back as the occiput. There may also be difficulty swallowing and a bothersome feeling of a persistent “lump” in the throat. That “lump” may be the hyoid bone which, again, is not moving properly.

About 45 million Americans suffer from chronic recurring headaches. Exact cause of migraines and other headaches are still not understood fully.

Over 20 muscles (primarily of the neck) refer pain to the head. Several refer pain specifically to the eye. At least three refer pain directly to the teeth for reasons that will never be relieved by fillings or repeated root canals. Teeth are extracted with no relief of symptoms!

How is a doctor or dentist who gets minimal or no education on this area ever meant to diagnose or understand sinus ear and facial pain? No wonder so many chronic pains have a psychogenic component with the sufferer feeling anxious, alone and worried.   Strangely, it is rarely applied to other chronic body pain. Even as a specialist in TMD I find on a daily basis there is always something new to learn

As mentioned before with very little education and high expectations that our medical professionals must know everything and have time to listen, patients are disappointed when treatment is often geared at symptom relief with drugs. Dental procedures, massage, acupuncture, chiropractic osteopathic and physiotherapy should all, in a perfect world, be recommended. The only constant in life is CHANGE therefore different perspective and beliefs for a cure have varied! In the old days they would drill a hole in your head! Clinically I have success treating headaches using cranial sacral osteopathy techniques, massage and encouraging patients to change poor lifestyle choices. This is not easy when most of us have invested a lifetime developing poor habits, which unknown to us keep layering on symptoms. Clinically I listen to a variety of lifetime symptoms and try to put the puzzle pieces together which forms an intriguing bigger picture.

Change in Habits

I find I tick off the same “causal” boxes. For example: If the child has a narrow face & palate, I can usually predict that they will have had some orthodontic work and what athletic endeavors (which are anaerobic) due to poor posture reducing airway efficiency, breathing and jaw position.

Ever take an ibuprofen or Tylenol for a headache? Ever think “I’d rather not take pills. I know they have side effects. Oh it’s easy what the heck!” As a physiotherapist treating chronic pain I notice that an overburdened health system often treat symptoms not the cause!

In the perfect scenario human ‘too busy doings” would take time and be paid to change lifestyle & poor work habits which might prevent problems happening in the first place. Humans do not stop poor habits until the body gets sick and then they want it to go away ‘yesterday’. This is tough on the practitioners.

Causes

Tension headaches, toothaches, facial pain & a stiff neck can be brought on by any number of factors such as cranium shapes from birth or in utero, malocclusion, (an undesirable relative positioning of the upper and lower teeth when the jaw is closed), whiplash, poor sleeping & sitting postures, pillows, heavy purses, cradling a phone between shoulder and neck, muscle fatigue, sinus infections, emotional turmoil, high blood pressure, food allergies and chemical sensitivities, or even due to repetitive motion activities. The list is endless, and eventually affects our physiology. Please note that headaches can be a sign of an underlying health condition, so if it is not a tension-type headache, seek professional medical help.

MUSCLES “trigger points” CAUSING HEADACHES (from Round Earth Publishing.) There are certain muscles on the head whose “trigger points” (see May’s newsletter) will give pain in specific areas. First let’s explore the Sternocleidomastoid. (SCM)

1. SYMPTOMS; Dizziness, nausea, “migraine” and sinus, motion sickness, and balance problems”. It has an intimate involvement with brain stem and the Vagus nerve. (see below.)
2. The SCM muscle of the neck produces a long list of neurological and pain symptoms which appear primarily in the head and face. These are commonly mistaken for migraine, sinus headache, inner-ear problems, trigeminal neuralgia — and so on. SCM has one of the most extensive patterns of pain and dysfunction, yet is one of the easiest muscles to self-treat.

As shown this is a two part muscle that connects the head/occiput to the front chest wall and can give a variety of “confusing” variety of symptoms to medical health professionals and patient. Note the red areas are where ache/pain is felt. The ‘x’ are the trigger points. No wonder a consultation is often sought to an ear nose and throat, & eye specialist. Often the symptom is treated not the source of the problem, then fear and anxiety raise the level of pain and people clench and grind their teeth and also have irrational thoughts! “I have a brain tumour! Eventually they develop insomnia and maybe depression worrying and are given sleeping pills and/or prozac. 70% of my clients are now on “Zoplicone’ –mild sleep sedative!

Other people self medicate with brown or red fluids! Whatever works!

True Story

I had a patient who complained of dizziness and thought her hearing had deteriorated. Of course she put that down to stress, a car accident (she had 3 months prior) and the aging process! She had consumed a variety of pills, consulted various medical professionals. I did some manual therapy on the neck joints and stretched & massaged sternomastoid muscle and her symptoms disappeared! In addition, education was given on changing her work /computer habits, posture and consult dentist about her bite.

Another True story

My daughter was about 6 months when she had her 1st ear infection and she complained of a sore head. Since birth she had difficulty nursing because her nose was congested. This led to a hungry cranky baby who was exhausted trying to nurse and could only feed for 5 minutes at a time and probably gulped as much air as milk! In those days most of my clothing had a “white stripe milk accessory” over one shoulder! Her sinus congestion and ear pain continued until she was 2 years old in which time she was on antibiotics constantly to treat nasal congestion and ear infections. I remember wondering why she cried when we would lay down on her right side to sleep…now I think her problem could have been a cranial strain from the birth trauma giving her a jaw and ear problem. Ear problems often occur while children are teething which puts undue forces on skull, jaw, TMJ, ears and Eustachian tubes. At age 2 she had ear tubes put in her ears and her pain disappeared.

I might mention that many of my patients have a variety of similar stories and the kids that suffer more, have a very narrow upper jaw- palate and cranium front to back. This often makes the teeth erupt in the mouth in what is called a dental crossbite. Depending what side this is, the jaw will shift towards it, compressing the jaw joint and ear. If the dentist can change the balance of the bite and stop the jaw shifting and/or widen the palate, the child has cranial /sacral treatment the ear /head pain will often disappear!

Many of my clients are not so lucky, and as adults are still on sinus and pain medication or having sinus surgery. This in my experience helps to start with, but often the symptoms return within the year, if body work is not done too

In addition to pain, do you know people who suffer from balance issues, runny & red eyes and swallowing /sinus congestion and nothing works…could be TP’s in this muscle.  See Cathy’s you tube video for stretching this muscle

Vagus Nerve -New Mums and grandparents read this if you are someone who wants to seek out another possible cause of sleepless nights!

Dr. Viola Frymann, who did research on babies believed that musculoskeletal strains on the newborn during delivery can cause problems throughout life …9 out of 10 babies are affected

Symptoms are difficulty sucking efficiently, vomit after feeding. Sadly, such symptoms are considered “normal”. At birth, the occiput (base of skull) is made of 4 bones united by an intraosseous developmental cartilage. It articulates with the atlas (1st cervical vertebra). Passing between the basi occiput and the atlas condyle is the 12th nerve which innervates the tongue. When this nerve is compromised by forward compression of the condylar part, the baby may fail to take hold of the nipple and suck effectively for a day or two or even days. These become the children with tongue thrusting, deviate swallowing speech problems and even malocclusion. This developmental articulation forms the posterior medial wall of the jugular foramen which not only gives passage to 95% of the venous drainage of the head but also to cranial nerves 9th, 10th and 11th. (This area has been researched with regard to cause of multiple sclerosis recently.)

The most common manifestation of condylar compression is vomiting due to dysfunction of the Vagus Nerve. Treatment is to decompress the condylar parts of the occiput and the vomiting stops! Think about the babies who are denied breast feeding or have changed from one formula to another when the real problem was condylar compression of the occiput.

Information is key! Unfortunately health professionals cover very little if anything about this, at university, hence the poor understanding and misdiagnosis.

A surprising number of localized and global problems come from tight hamstrings: locally it can contribute to knee pain under, below & behind the knee cap, pain climbing stairs, walking downhill, menisci tears, and of course, hamstring pulls and tears.

Do these words sound familiar?  “Stop slouching; keep your shoulders back and keep your head up!”  Perhaps your body was doing this to survive!

Note in the 1st and 3rd postures the head is forward and the curves have changed to displace the line of gravity forward. This results in tight hamstrings and shoulder muscles which in turn can be one of the factors causing neck and back pain, headaches, and poor respiration. Thus there is more serious consequence of poor posture namely enjoying “Living large.”

WHY? Headaches, neck and shoulder pain can occur because over time there is a minute ‘forward shearing’ of the 4th cervical vertebra in relation to the 5th cervical vertebra changing the normal curve in the neck. This is an X-ray of my neck showing a flattening of the cervical area. No wonder I had head and neck aches!
 
For me over time this alignment change affected the 5th and 6th cervical nerve and the soft tissue (muscles ligaments, and fascia) locally. I developed shoulder and elbow pathologies which improved when I had both the neck and shoulder treated locally but also paid attention to the lower body muscle asymmetries and how they interrelate.

Another interesting fact to think about is that the “Phrenic nerve” operating the diaphragm can also be affected by poor spinal alignment so clinically I believe, that these postures develop as the body’s way of ‘maximizing its airway’, optimizing blood chemistry and oxygen intake. Think how this could affect your physiology and quality of life ie: memory, mood and moving.

In summary, I have a ‘jingle’ to remember this neurological fact: “C (cervical nerve) 3, 4 & 5, keeps the diaphragm alive”. To everyone I say, “walk around ‘high beaming’ everyone!’ They will be dazzled with your sparkle. Not only is this forward line of gravity affecting the neck but also the lumbar spine because the same forward shearing can happen at L3 on 4 or L5th on the sacrum. Symptoms can then develop in the back, hip and/or knee.

In the May newsletter I talked about the number of neck muscles including the scalenes, upper trapezius, sternomastoid, splenii and suboccipitals muscles all referring pain to the head. Therefore are frequently responsible for Tension headaches. The masticatory muscles are likely then affected, causing head aches felt at the side of the head (often first thing in the morning), facial and jaw area.

In head forward posture the scalenes and sternomastoid muscles shorten and that reduces the ability to breathe deeply. The normal ratio of breathing in the chest is 20% in the upper area and 80% in the diaphragm. Tight neck muscles reverse this ratio therefore massage and stretching of these muscles helps promote easier oxygen intake.

As the upper back rounds (thoracic hyperkyphosis) respiration is compromised and often the patient will complain of exertional breathlessness or will choose anaerobic sport intuitively; ie: will not be a marathon runner.
Lower vertebral alignment is also affected which reduces expiration and diaphragmatic movement.

In summary the patient will automatically start to do rapid upper chest breathing and there will be reduced exercise tolerance. Many of my patients complain of exercise induced asthma, increased infection, and/or allergies, reduced exercise tolerance, mood swings and decreased overall health.

In some cases their minds take over and a wee voice says “You ought to be better, soldier on.” (Anyone who comes from Britain will understand that statement) They can do it, but at what cost to their physiology? They are in danger of stressing the heart and upper chest, jaw and neck muscles. If this is combined with an asymmetrical skull, narrow palate and sinus area in my experience they develop many health issues one of which is TMD and Chronic Hyperventilation Syndrome. Both I mentioned in previous newsletters.

To recap CHVS is a condition of the respiratory system in which the rate of breathing increases, venting off carbon dioxide that exceeds the rate at which cellular metabolism is producing carbon dioxide. The symptoms resulting from CHVS and can be widespread: they can be Cardiovascular – sharp or dull atypical chest pain, palpitations; Neurological – headaches, dizziness:  Respiratory – shortness of breath, irritable cough which becomes hyperactive when trying to slow breathing; Gastrointestinal – heart burn, difficulty swallowing; Muscular – pain especially occipital, neck, shoulders, in between shoulder blades, cramps, stiffness;  Psychic – anxiety, panic, out of body experience; General – weakness, exhaustion, disturbed sleep, woolly head, night sweating, emotional sweating in armpits and palms.

The most severe symptoms I’ve seen are in a patient who had open heart surgery at 27!

Stretching is Vital

Stretching should be a warm up, as a break during repetitive activities and as a cool down after activities.

Rules: Breathe deeply – slow and controlled – visually thinking about the muscle that is stretching – hold for 10-15 seconds – Repeat each stretch 2-3 times-pain free stretching.

Why is Stretching so important? As we age or are leading sedentary lives, muscles lose their flexibility. This can lead to muscle imbalance; ie: some muscles are weak and some are short and strong. As body tries to adapt to imbalances, we develop common overuse injuries such as tendonitis, plantar fasciitis, neck and back strain.

Over time tight muscles can compress nerves, resulting in tingling and numbness, muscle weakness and pain.  Example of this was mentioned in Scalene muscles article (see May 2010 newsletter).

Benefits of stretching:
·    Improve youthful appearance as posture improves
·    Muscles work more effectively
·    Reduce injuries
·    Muscles heal and strengthen easier because of increased blood flow and reduced muscle tension.

When and How to stretch:
·    To decrease risk of injury by stretching lightly after your warm up
·    Following workout. The muscles respond better to a stretch when body temperature is raised
·    2-3 times a day to improve flexibility and decrease to 3 times a week for maintenance
·    Don’t compare your self to others
·    No bouncing
·    Breathe deeply and stretch mindfully aware of the muscle you are targeting Stretch until feel tension or pulling. Hold this and breathe until feel the muscle relaxes – breathe and then stretch a little more. You should be pain free during and after stretching.

 
Remember keeping fit should be your number one priority so that you can enjoy life and retirement.

In non-technical terms, the fascial system is the body stocking under the skin or straight jacket holding us together.

The fascia of the body is the tough connective tissue orientated in longitudinal and transverse tubes which holds us together. It stops the heart and liver descending downwards into the pelvis and also prevents uncontrolled lateral expansion of the torso. The fascia envelopes every structure of the body. Even the tiniest nerve or a taste bud has its own fascial sheath or envelope. About half of the muscular attachments of the body are to fascia so that muscle tone or the state of contraction, have a lot to do with how tight or loose the fascial sheaths and envelopes are, in certain areas of the body.

An example of this fact was solving a patient’s back pain. I believe one must “think global and act local”.

Any one had their Jaw, neck and back treated for back pain? Probably not!

A patient came in with acute lower back pain. He had no history of any recent injury however he mentioned that his bite was “off”. I noticed the spine had a visible “s” curve sideways which was caused by muscle spasm and his head and neck had done a compensatory rotation so he could see where he was walking! Next day he visited the dentist who had fixed his high filling! Within 10 minutes he walked out pain free with a straight spine. Clinically I find treating a short leg, pelvis misalignment and body fascia helps the jaw.

Did you know that there is continuous line of fascia connecting the inside of your head to your big toe? Starting inside the head the fascia exits and forms the carotid sheath then the Pericardium in the chest ie: thorax. This in turn connects to the Respiratory diaphragm, Psoas or hip flexor and then down leg into bottom of the foot

“You are only as young as your spine”

A healthy flexible spine and Dural Tube is critical in treating TMD, headaches and back pain. This is because that Dural Tube connects the head to your upper neck and pelvis.

Anatomy: The Dural Tube situated within the spinal Vertebral canal is made of fascia and must have a reasonable degree of movement in relationship to the arachnoid membrane. According to Wikipedia this is “A delicate fibrous membrane forming the middle of the three coverings of the brain and spinal cord, closely attached to the dura mater, from which it is separated only by the subdural cleft, but separated from the pia mater by the subarachnoid space.

I found this article interesting from the CranioSacral Therapy by John Upledger and Jon.D. Vredevoogd:

“THE DURA MATER forms a tube which runs downwards through the vertebral canal. Within the canal its only bony attachments are to the posterior bodies of the second and third cervical (neck) vertebrae and to the posterior body of the second sacral segment. It exits the vertebral canal through the Sacral hiatus and blends with the periosteum of the coccyx (tailbone). The Dural Tube within the vertebral canal is also firmly attached to the Foramen Magnum of the Occiput. This dura mater connects with membranes inside the skull which line and form partitions in the skull cavity.”

I find, clinically, that stretching the fascial system together with mobilising joints in the neck and back makes a huge difference to help relieve headaches, TMD and improving flexibility.

1. Physiotherapy to mobilize fascial restrictions

2. Exercises to stretch out this structure

Video and pictures to follow every month: 1st tip Seated roll down  (as seen on YouTube) 

The arachnoid mater is one of the three meninges, the membranes that cover the brain and spinal cord (To read more follow the links).

Using the occiput (base of skull) to evaluate and mobilize the Dural tube.

I ask the client to lie on their back and place hands on the occiput and apply a very light traction towards the top of the head.

This is a picture of the 2nd Vault Hold

and the Occipital Base Release

Pictures reprinted from CranioSacral Therapy by John Upledger and Jon D. Vreevoogd with permission of Eastland Press.

TMD – Who to refer

• Key point “ TMD patients treated with conservative and reversible modalities on the whole responded as well as patients treated with more aggressive regimens, both short terms and long term assessment of outcomes”.

Reference: Greene CS p224 Chap14 “concepts of TMD etoliogy. Effects on Diagnosis and Treatment” in TMD’s an evidence-based Approach to Diagnosis and Treatment, Laskin, Green, and Hylander, eds Quitnessence 2006

• Early intervention is Key as passage of time is a major factor in development of chronic pain problems: any pain that lasts longer than 3-6 months is considered chronic. Patients tend to treat their symptoms after 6 months as if acute and this can lead to escalating psychosocial issues, for example (frustration, anxiety, depression, relationship conflicts),

TMD and occlusion

“…there is a relatively low association of occlusal factors in characterizing TMD. Skeletal anterior open bite, overjets greater than 6 to 7 mm, retruded cuspal position/intercuspal position slides greater than 4mm, unilateral lingual crossbite, and five or more missing posterior teeth are the five occlusal features that have been associated with specific diagnostic groups of TMD conditions.

Reference: Occlusion, Orthodontic treatment and TMJ disorders: a review. McNamara JA Jr, Seligman DA Okeson JP. J Orofac Pain 1995 Winter;9 (1) ; 73-90

• 70% of patients with TMD present with neck pain, more prevalent with myogenous than arthrogenous TMD 

• All patients with neck pain, headaches, ear aches, sinusitis and facial pain because with TMD often a central pain phenomenon-region of primary lesion excites neighbouring areas in Central Nervous System to produce heightened sensitivity

• Referred pain-pain arising from a trigger point, which refers pain to another area. Most common example would be when patient comes in complaining of upper tooth pain. This could be from a trigger points in Temporalis muscle.

Other contributing factors are behavioural, (forward head posture, parafunctional habits, muscle tension), and widespread pain like fibromyalgia. All these factors aggravate symptoms.

• All patients who have been in car accidents, any presumed innocuous hit on the head. Recent one I had patient had hit head on car roof /boom of a boat etc.

TMD SELF CARE

In our fast paced lifestyles and communications it is hard to make time for self. Meditate –take time for your self

Try to something you love every day –aim for greater heights, because time spent now will ensure healthy retirement

After 100 who cares!

Make time to have fun and be able to laugh at your self!

Laughter is best medicine and can improve perspectives of challenging situations in every day life

BASIC SELF CARE FOR PATIENTS

Awareness of habits or jaw use patterns

• Teeth should only make contact during eating and swallowing, otherwise they should be apart

- Bite… Restful jaw position is when tongue tip is behind the maxillary central incisors, lips together and the teeth slightly apart

DIET MODIFICATIONS

 Softer foods place less stress on the jaw muscles

   Cut foods into small bites-

 No hard food like nuts/carrots or chewy food

Do NOT chew gum

 Avoid wide jaw opening

 Support your jaw with your hand when yawning

 Do not sleep on your stomach or with your jaw resting on your hand or arm

 Avoid leaning on your chin or jaw

Apply moist heat on muscles for 15-20 minutes

 Apply “ice cube’ massage to joint /muscles for 5 minutes

-  Do not test jaw

 Jaw movement that elicits pain may prolong recovery

- Exercise to maintain good health –best exercise is one you love. Do 4 times a week for at least half hour.

- Mindful breath based exercise like Yoga

Pilates, tai chi, Qi gong are excellent for chronic pain sufferers

- Yoga Stretching Whatever works for you!

Why is it important? With aging and a sedentary lifestyle muscles lose their flexibility. This leads to muscle imbalances and adaptations causing some muscles to become strong and short and others muscles to become weak. These imbalances place abnormal forces around joints and can lead to common overuse injuries such as tendonitis, plantar fasciitis, jaw, neck and back pain.

Overtime tight muscles can compress nerves, resulting in tingling and numbness; muscle weakness and pain. When you improve your flexibility you improve posture, decrease tension and increase circulation in the muscles.

Alternate nostril breathing (see December newsletter)

As always I find when I tweak the ordinary extraordinary things happen. Try this version of the 12 Days of Christmas (Click for the ‘Original Version’)

This game is best played on a family you will be spending Christmas with or will see on Christmas day. My version of this is as follows:

Step 1: Make 12 individual cards with the following writing:

On the 1st day of Christmas OUR FAMILY GIVES TO YOURS… Some pears from the tree the partridge sat in

On the 2nd day of Christmas OUR FAMILY GIVES TO YOURS… Some turtles on a bar of Dove soap

On the 3rd day of Christmas OUR FAMILY GIVES TO YOURS… Some noodle soup compliments of the 3 The French Hens

On the 4th day of Christmas OUR FAMILY GIVES TO YOURS… A telephone message pad designed by the 4 calling birds

On the 5th day of Christmas OUR FAMILY GIVES TO YOURS… 5 gold rings

On the 6th day of Christmas OUR FAMILY GIVES TO YOURS… Some eggnog made from the eggs the 6 geese laid

On the 7th day of Christmas OUR FAMILY GIVES TO YOURS… A box of tissues that those silly swans needed after they caught a cold while swimming in the winter

On the 8th day of Christmas OUR FAMILY GIVES TO YOURS… The chocolate Milk we got from eight maids milking eight brown cows

On the 9th day of Christmas OUR FAMILY GIVES TO YOURS… Nine canes used by the nine dancing ladies(they needed them to get home)

On the 10th day of Christmas OUR FAMILY GIVES TO YOURS… Some “Ben Gay” recommended for use by 10 lords we saw out leaping

On the 11th day of Christmas OUR FAMILY GIVES TO YOURS… Some pickles since the pipers stopped piping and started picking a peck of pickles for us to give you

On the 12th day of Christmas OUR FAMILY GIVES TO YOURS… A dozen beers that the twelve drunk drummers left behind,

Step 2: The each night starting the 12th day before Christmas you leave the 1st note and appropriate gift on the doorstep. The 1st couple of nights you can try ringing door bell and running away… Go at different times because soon kids in house are taking shifts to watch the door and try and catch mystery person leaving gifts.  The whole idea is not to get caught or found out right up until Christmas day.

More exciting and difficult these days with motion detector security lights coming on!

Step 3: Now if singing this song you can ask people whose birthday is in January to stand up every time the first day of Christmas verse is sung those whose birthday is February stand up for 2nd verse and so on through 12 verses depending what month your birthday is.

The visual is quite funny as people look like “Happy Jack-in-a-boxes” getting up and down as song repeats itself!!

Tongue tips – The tip of tongue should always be on the roof of mouth. Test it by saying the letter “m” or “n”.  Ask your patients, “Where is your tongue rest in your mouth. “  Many TMD patients are unaware that their tongue is sitting the wrong place and in a low lingual position. The partial vacuum that exists when the tongue is sitting in the “n” position and the palate is critical in supporting the jaw.  Extra bonus it also facilitates deep diaphragmatic breathing.

Teeth grinders – In these tough economic times, people are taking it out on their teeth, and therefore jaws more and more.  Most people are unaware until they break a tooth or an implant, have morning headaches and have stuffy noses.  Some nocturnal grinders will grind up to 40 minutes and can exert up to as much as 200 pounds per square inch on their teeth.

As we enter the cold season it may be of interest to note a little known side effect of all this clenching, ie a sore throat or sinusitis or stuffiness in the ears.  If clients not feeling other cold like symptoms It may not be a virus. Instead could be due to over activity in the clenching muscles.

Side effects of Masseter overuse. Patient will complain of:

1.      Pain and restricted opening to two thirds. or less of normal aperture (at least 45mm for women and 55mm for men) Quick test -  ask patient if they can get three knuckles between teeth.  If two has restricted movement.

2.       Pain in upper molar teeth, adjacent gums and maxilla.

3.       Maxillary pain is often described as “sinusitis”

4.       Unilateral tinnitus. If tinnitus is bilateral suspect a systemic rather than myofascial cause. However deep layers of master can become involved bilaterally in this case unilaterally it can fluctuate in its intensity

Side effects of Temporalis overuse. Patient will complain of:

1.        Headache throughout the temples, along eyebrow, and behind the eye

2.        Hypersensitivity and aching of upper teeth

3.        Premature tooth contact

Side effect of the medial pterygoid (which can be can be palpated below the inner aspect of the angle of the jaw).

1.        Sore throat with no infection

Try to remind your patients that tongue should be on the roof of mouth, with teeth apart and lips together and breathe slow!