Thanks to a reader who found me through Craig Libenson for asking a question that lead me to write this blog post. Here are 5 things I make sure to focus on for TMD patients.
The question specifically was other than light tissue work around the TMJ, how do you lock in the improvements?
1) Education
- locking the improvements with any manual technique has to be done with education
- letting the patient know the effects of your treatments are transient
- avoiding hard, crunchy, chewy foods for a few weeks similar to avoidance of hard ADLs after spraining an ankle
- education of the head/neck posture influencing mandible position, and possibly contributing to neck pain/headaches which leads to point...
- I look at every TMD patient as 90% cervical, 10% TMJ and only tweaks in the educational pieces are needed
- get a symptom baseline, start with postural correction and see if there are any changes
- ask them if different head positions change their bite or occlusion
- here is a vid I made explaining how I go about this with a patient interaction
3) STM to the mandible elevators
- the pattern of greatest resistance that seems to offer the best relief and decrease tone is light and slow stroking of the mandible elevators (temporalis and masseter) in a proximal to distal direction
- start very lightly and stroke slowly to reduce tone
- use reciprocal inhibition of the mandible depressors to assist with this
- teach the same reciprocal inhibition techniques to keep the tone reduced throughout the day - make sure to keep them in neutral, it's easy to protract the head and retract the mandible doing this!
4) Light TMJ mobilizations
- patients who have dysfunctional clenching, capsular or movement dysfunction or small subluxations often benefit from light TMJ distractions along with lateral greater than medial glides
- too often providers just focus on restoring mandible depression, but you cannot forget about lateral excursion
- mastication is a circular motion, we do not eat like pac man, so we need to restore medial and lateral glides to improve mandible lateral excursion, which assists with eating
- this is a small joint so you can get grade 3 or 4 oscillations very easily, Rocabado says "Finesse" - sounds a lot better with a Chilean accent!
5) Lock it in!
- cervical retractions to restore craniomandibular position
- education on bringing the food to you while sitting mostly upright as opposed to bringing your head to the food often helps
- lingual re-education, tongue at the rest position (like saying "nnnnnn" or clucking), clucking - snapping the tongue off of the palate just behind the two upper middle incisors and leave it there
- tongue in rest position should reflexively decrease mandible elevator tone
- scapular retractions (90% down, 10% back to inhibit upper traps by firing lower traps
- diaphragmatic breathing should be looked at as well if the above are not locking in improvements
- occasionally a patient may also need to be cued on repeated mandible protrusion, but not to end range, just a few millimeters to counter the inferior posterior pull of a forward head
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