HEADACHES & TMJ

Ari Sudarsono
 Headaches-overview

 Primary headaches
 -Migraine
 -tension type
 -cluster headache/
cephalgias
 -Others
Headache classification

 Secondary headaches-
 Trauma
 Cranial/ cervical vascular disorder
 Substance or its withdrawl
 Infection
 Homeostasis related
 Neck , sinuses,eyes,nose, teeth
 Anxiety/somatisation
Headache classification

 Neuralgias/other headaches
 Eg cranial neralgias, trigeminal neuralgia,
atypical facial pain
Headaches

 Affect 40% of UK population

 Migraine- 15% of population.
 Females:males 3:1
 Tension headaches- 80% of population
 Cluster headache 1 in 200
MIGRAINE
Migraine
Migraine management

 Look at predisposing factors

 -stress,
fatigue,depression,anxiety,menstruation,
menopause, head/neck trauma.
 -trigger factors-dietary (20%), relaxation,
travel, missing meals/sleep, bright lights,
noise, strenuous exercise, mensruation.
Migraine

 Duration (hours3 days)

 Without aura in 2/3rd -unilateral, pulsating,
moderate/severe intensity, aggravated by
exercise, nausea/vomiting.
Photophonophobia
 With aura in 1/3rd- spreading scintillating
scotoma, unilateral paraesthesia, dysphasia
Migraine-drug intervention

Step one- simple analgesic+/- antiemetic

Eg aspirin 600-900mg +buccastem 3-6mgbd

Step two – rectal analgesic +/- antiemetic

Eg diclofenac suppositaries+domperidone
suppositaries
Step three – triptans-use at onset of pain, not
aura. Some rebound of symptoms in 20-50%
of patients within 48 hours.
Triptans

 Sumatriptan 50-100mg
 Zolmitriptan 2.5mg then rpt after 2 hours (not
children)
 Rizatriptan 10mg (equiv sumatriptan 100mg)
 Almotritan 12.5mg-HIGH EFFICACY. COST
EFFECTIVE
Migraine prophylaxis

 Ineffective for medication overuse headaches

 Use for 4-6 months-taper off over 2-3 weeks.
 Agents: betablockers, TCAD, pizotifen,
gabapentin, lisinopril
 Other agents-topiramate, sodium valproate,
clonidine
 Non drug therapies
Tension headache
Tension headaches

 Chronic tension type headache:-

-more than 15 days per month
- often daily
-often stress/lifestyle related
Tension headaches

 Episodic tension-type headache-

-may be unilateral but tend to be generalised
- pressure/tightness
- often spreads from neck
-stress related or related to cervical/cranial
musculoskeletal anomalies
Tension headache management

 Lifestyle changes
 Regular exercise
 Drug treatments-acute-aspirin 600-900mg,
ibuprofen 600mg, naproxen 250-500mg,
paracetamol 500mg-1g
 Prophylaxis-amitriptyline, nortriptyline,
propranolol, SSRIs
Medication overuse headaches

 Affects 1 in 50 adults
 Females:males 5:1
 First noted with phenacetin/ergotamine
 More common with aspirin/
NSAIDs/paracetamol/codeine/DF118
 Can take several weeks to resolve after
medication withdrawl
 Key feature-pre-emptive use of analgesia
Medication overuse headaches-cont.

 Low doses daily carry larger risk than higher

doses weekly
 Esp common if using simple analgesia more
days than not per month
 Using triptans, codeine >10days per month
 Worse on awakening in the morning
 Worse after physical exertion
Medication withdrawl headache-treatment

 Stage one-abrupt withdrawl most effective-Sx

will worsen in days 3-7.
 Stage 2-recovery from MOH
 Stage 3- review and assess the underlying
primary headache disorder
 Stage 4- prevent relapse
 Failure to withdraw- naproxen
250mgtds/500mg bd, tcad.
References

 Mentor/GP notebook
 BASH (British Association for the Study of
Headaches)-guidelines. www.bash.org.uk
 Neurological Differential diagnoses. Batten, J.
2nd edition.
FISIOTERAPI PADA HEADACHE

 TTH
 MIGRAINE
 SINUS
 CERVICOGENIC
TTH
Treatment

 Minimize Stress
 Stress management
 Medication
 Acupuncture
 Healthy living and
eating
Physiotherapy Treatment
 Massage
 Stretching
 Manual Cervical
Traction
 Postural correction
 Muscle strengthening
 Acupuncture
 Heat
 Home exercise program
Muscles connecting Occiput, Cervical
spine & Scapula
Muscles and landmarks
Muscles
Muscles

 Levator scapulae  Splenius capitus

Trapezius & Rhomboids
Muscles

 Scalenus posterior and medius

Soft tissue therapy
Stretches

 Upper Trapezius
 Levator Scapulae
 Pectoralis Major
 Upper cervical extensors
 Scalenes
Stretches – Trapezius & Levator Scapulae
Stretches – Upper Cx spine & Pectoralis
Major
Chin Retraction
Posture
Strengthening Exercises

 Deep neck flexors

 Scapula retractors
 Lower Trapezius
 Rotator cuff
 Thoracic extensors
SINUSITIS & PHYSIOTHERAPY

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Anatomy

 Paranasal Sinuses

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 Lateral View of Sinuses

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What are the sinuses?

 Thesinuses are hollow air-filled sacs lined

by mucous membrane.

 Each sinus has an opening into the nose for

the free exchange of air and mucus, and
each is joined with the nasal passages by a
continuous mucous membrane lining.

 The ethmoid and maxillary sinuses are

present at birth. The frontal sinus develops
during the 2nd year and the sphenoid sinus
develops during the 3rd year.
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 Four pairs of paranasal sinuses
 Frontal-above eyes in forehead bone
 Maxillary-in cheekbones, under eyes
 Ethmoid-between eyes and nose
 Sphenoid-in center of skull, behind nose and
eyes

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 Sinuses have small orifices (ostia) which
open into recesses (meati) of the nasal
cavities.
 Meati are covered by turbinates
(conchae).
 Turbinates consist of bony shelves
surrounded by erectile soft tissue.
 There are 3 turbinates and 3 meati in
each nasal cavity (superior, middle, and
inferior).
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Considerations for Pediatrics

 At birth, the ethmoid, sphenoid and

maxillary sinuses are tiny and cause
problems in infants and toddlers.
 Frontal sinuses develop between 4-7
years of age, causing problems in school
aged children and adolescents.

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Sinusitis

 Inflammation of paranasal sinuses

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What is sinusitis?

 An inflammatory process or infection

involving one or more of the paranasal
sinuses.
 A complication of 5%-10% of URIs in
children.
 Maxillary and ethmoid sinuses are most
frequently involved.

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pathophysiology

1-sinuses are normally sterile, but their

proximity to nasopharyngeal flora allows
bacterial and viral inoculation following
rhinitis.
2-Diseases that obstruct drainage can
result in a reduced ability of the
paranasal sinuses to function normally.
The sinus ostia become occluded,
leading to mucosal congestion.
3-The mucociliary transport system
becomes impaired, leading to stagnation
of secretions and epithelial damage,
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sooooooooooooooooo

Anything that causes a swelling in the nose—an infection, an

allergic reaction, or an inflammatory reaction to a chemical to
which you may get exposed--can affect your sinuses/ also
abrupt pressure changes (air planes, diving) or dental
extractions or infections.

This result in 
a-Inflammation and edema of mucous membranes lining the
sinuses cause obstruction.
b-This provides for an opportunistic bacterial invasion.
C-Postnasal drainage causes obstruction of nasal passages and
an inflamed throat.
D-If the sinus orifices are blocked by swollen mucosal lining, the
pus cannot enter the nose and builds up pressure inside the
sinus cavities.

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E-Air trapped within a blocked sinus,
along with pus or other secretions may
cause pressure on the sinus wall that
can cause the intense pain of a sinus
attack. Similarly, when air is prevented
from entering a paranasal sinus by a
swollen membrane at the opening, a
vacuum can be created that also
causes pain

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classification

 Acute, which last up to 4 weeks

 Subacute, which last 4 to 12 weeks
 Chronic, which last more than 12
weeks and can continue for months or
even years
 Recurrent, with several acute attacks
within a year

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Predisposing Factors

 Allergies, nasal deformities, cystic

fibrosis, nasal polyps, and HIV infection.
 Cold weather
 High pollen counts
 Day care attendance
 Smoking in the home
 Reinfection from siblings

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1- ACUTE SINUSITIS

A- Most cases of acute sinusitis start with a common cold (acute

rhinitis), which is caused by a virus. Colds can inflame your
sinuses (damage to cells) and cause symptoms of sinusitis.
Both the cold and the sinus inflammation usually go away
without treatment within 2 weeks. However, In about 0.5-2%
of cases, viral sinusitis can progress to acute bacterial
sinusitis

The most common culprits in acute viral rhinosinusitis are

rhinovirus, influenza virus, and parainfluenza virus.

The inflammation caused by the cold results in swelling of the

mucous membranes (linings) of your sinuses, trapping air and
mucus behind the narrowed sinus openings. When mucus
stays inside your sinuses and is unable to drain into your
nose, it can become the source of nutrients for bacteria,
which then can multiply.

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Most healthy people harbor bacteria, such
as Streptococcus pneumoniae and
Haemophilus influenzae, in their noses
and throats.
Usually, these bacteria cause no problems.
But when sniff or blow your nose when you
have a cold, these actions create pressure
changes that can send typically harmless
bacteria inside the sinuses.
If your sinuses then stop draining properly,
bacteria can begin to multiply in your
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B- People who have allergies or other chronic problems that
affect the nose are also prone to episodes of acute sinusitis.
Chronic nasal problems cause the nasal membranes to swell
and the sinus passages to become blocked. The normally
harmless bacteria in your nose and throat again lead to acute
sinusitis.

C- In general, people who have reduced immune function, such

as those with primary immune deficiencys or HIV infection, or
abnormalities in mucus secretion or mucus movement, such
as those with cystic fibrosis, are more likely to suffer from
sinusitis

D- mechanical obstruction as seen secondary to foreign bodies,

intranasal cocaine use

E- Fungal infections very rarely cause acute sinusitis because

the human body has a natural resistance to fungi. However, in
people whose immune systems are not functioning properly,
fungi can cause acute sinusitis.
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BACTERIAL SINUSITIS

70% of bacterial sinusitis is caused by:

 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella catarrhalis

Other causative organisms are:

 Staphylococcus aureus
 Streptococcus pyogenes,
 Gram-negative bacilli
 Respiratory viruses

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Signs

 Sinusitis has 4 main signs

-Mucopurulent rhinorrhea

-Nasal congestion

-Facial pain, pressure, or fullness

-Decreased sense of smell

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Subjective Symptoms of Sinusitis

 History of URI or allergic rhinitis

 History of pressure change
 Pressure, pain, or tenderness over sinuses
 Increased pain in the morning, subsiding in the afternoon
 Malaise
 Low-grade temperature
 Persistent nasal discharge, often purulent
 Postnasal drip : thick nasal secretions that are yellow, green,
or blood-tinged drain in the back of the throat and are difficult
to clear
 Cough, worsens at night
 Mouthing breathing, snoring
 History of previous episodes of sinusitis
 Sore throat, bad breath
 Headache

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Signs and symptoms of acute sinusitis
 Ethmoid sinusitis (behind the eyes)

 Nasal congestion with discharge or postnasal drip (mucus

drips down the throat behind the nose)

 loss of smell, and tenderness when you touch the sides of

your nose

 Pain or pressure around the inner corner of the eye or down

one side of the nose

 Headache in the temple or surrounding the eye

 Pain or pressure symptoms worse when coughing, straining,

or lying on the back and better when the head is upright

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 Maxillary sinusitis (behind the cheek bones)

 Pain across the cheekbone, under or around the eye, or around

the upper teeth

 Pain or pressure on one side or both

 Tender, red, or swollen cheekbone

 Pain and pressure symptoms worse with the head upright and
better by reclining

 Nasal discharge or postnasal drip

 Fever common
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 Frontalsinusitis (behind forehead, one or
both sides)

 Severe headaches in the forehead

 Fever common

 Pain worse when reclining and better with the head upright

 Nasal discharge or postnasal drip

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 Sphenoid sinusitis (behind the eyes)

 Deep headache with pain behind and on top of the head,

across the forehead, and behind the eye

 Fever common

 Pain worse when lying on the back or bending forward

 Double vision or vision disturbances if pressure extends

into the brain

 Nasal discharge or postnasal drip

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2- CHRONIC SINUSITIS

A-In chronic sinusitis, the membranes of

both the paranasal sinuses and the nose
are thickened because they are
constantly inflamed. Most experts now
use the term chronic rhinosinusitis to
describe this condition.

B-nasal polyps. (Polyps are grape-size

growths of the sinus membranes that
protrude into the sinuses or into the
nasal passages,more commonly seen in
patients with aspirin sensitivity and
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D- An allergic reaction to certain fungi may be
responsible for some cases of chronic
rhinosinusitis; this condition is called allergic
fungal sinusitis. However, at least half of all
people with chronic rhinosinusitis do not
have allergies/ or exaggerated immune
response to fungi

E- Acute bacterial sinusitis that does not

completely resolve can progress to chronic
sinusitis, the infecting organisms vary, and a
higher incidence of anaerobic organisms is
seen (eg, Bacteroides, Peptostreptococcus,
and Fusobacterium species
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G-As with acute sinusitis, other causes of
chronic rhinosinusitis may be an immune
deficiency disorder

E-Another group of people who may

develop chronic rhinosinusitis are those
with significant variations in the
anatomical structure inside the nose that
lead to blockage of mucus (septal
deviation).

F-Diseases such as cystic fibrosis, primary

ciliary dyskinesia, Wegener
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Signs and symptoms of chronic sinusitis
 Ethmoid sinusitis

- Chronic nasal discharge, obstruction, and

low-grade discomfort across the bridge of
the nose
- Pain worse in the late morning or when
wearing glasses
- Chronic sore throat and bad breath
- Usually recurs in other sinuses

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 Maxillary sinusitis

- Discomfort or pressure below the eye

- Chronic toothache

- Pain possibly worse with colds, flu, or allergies

- Increased discomfort throughout the day with

increased cough at night

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 Frontal sinusitis

- Persistent, low-grade headache in the

forehead

- History of trauma or damage to the

sinus area

 Sphenoid sinusitis
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?????????

 However, most people with sinusitis have

pain or tenderness in several locations, and
their symptoms usually do not clearly point
out which sinuses are inflamed.
 Pain is not as common in chronic
rhinosinusitis as it is in acute sinusitis.
 Also, acute and chronic rhinosinusitis are
strongly associated with a stuffy nose, as
well as with a general feeling of fullness
over the entire face.
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DIAGNOSIS

1- physical exams, signs and symptoms

2- imaging study (x-ray,CT, MRI, ULTRASOUND)
3- laboratory tests
4-ENT can directly visualize the nasal passages
and the OMC (passage into the sinuses) with a
nasopharyngoscope. This is a fiberoptic,
flexible tube that is insertable through the nose
and enables the doctor to view the
passageways and see if the OMC is open and
draining right. Anatomical causes of breathing
difficulties may also be found, such as a
deviated nasal septum, nasal polyps, and
enlarged adenoids and tonsils
5- drain the affected sinus to test for organisms (
culture)
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History, physical

Sinusitis usually a clinical diagnosis

Because your nose can get stuffy when you
have a condition like the common cold,
you may confuse simple nasal congestion
with sinusitis.
A cold, however, usually lasts about 7 to 14
days and goes away without treatment.
Acute sinusitis often lasts longer and
typically causes more symptoms than a
cold
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Imaging study ( X-ray)

 In the past, doctors relied on x-ray films for

diagnosis because the symptoms of acute
sinusitis are very similar to those of an acute
upper respiratory tract infection. In fact,
most of the time, a viral infection is required
to promote sinusitis.
 However, these films are not specific and
depend on a good technique by the
technician.
 According to one study, sinusitis is not
visible on x-ray films about 55% of the time.
 If symptoms continue beyond 7-10 days and
are associated with a simple cold, a
diagnosis of sinusitis may be possible.
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Imaging study ( CT, MRI, ultrasound )
 A CT scan may indicate a sinus infection if any of these
conditions is present:

1-Air-fluid levels in 1 or more sinuses

2-Total blockage in 1 or more sinuses

3-Thickening of the inner lining (mucosa) of the sinuses

 Mucosal thickening can occur in people without symptoms of

sinusitis. Therefore, CT scan findings must be correlated with
a person's symptoms and physical examination findings to
diagnose a sinus infection.

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Laboratory tests

 Laboratory tests your healthcare provider may

use to assess possible causes of chronic
sinusitis include

1- Blood tests to rule out conditions associated

with sinusitis, like an immune deficiency
disorder
2- A sweat test or a blood test to rule out cystic
fibrosis
3- Tests on the material that is inside your
sinuses to look for bacterial or fungal infection
4- Biopsy (taking a small sample) of the
membranes (linings) of the nose or sinuses
to find out the health of the cells lining these
cavities
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Physiotherapy Management

 The physiotherapist has certain options for

therapy.

 Use can be made of nebulisation, laser

therapy, ultrasound therapy, short-wave
diathermy, and rinoflow therapy, to mention
but a few of the treatment modalities.

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 Perhaps the present best known form of
therapy is nebulisation.
 Use can be made of a compressor type or
ultrasonic nebuliser.
 Physiological saline solutions are
nebulised, which has a hydrating effect on
the mucous in the sinus cavities.
 Nasal cannulae can be used, or in the case
of an ultrasonic nebuliser, the rate of flow is
set at 'high'.
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 Laser therapy is used directly over the
sinus cavities to reduce inflammation of the
mucosal lining of the sinus.

 Alternatively, ultrasound therapy makes use

of sound waves conducted through a
hypoallergenic gel to reduce inflammation
of the mucosal lining as well as to loosen
the accumulated mucous.

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 A fairly new option is called rinoflow
therapy, which is basically a micronised
endonasotracheal wash.

 Rinoflow is a specific compressor

microniser chamber system used for the
treatment of diseases of the upper
respiratory tract where catarrh, mucous and
purulent and crusty secretions are present.

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 Besides use in treatment of sinusitis, it can
be used to treat rhinitis, pharyngitis,
laryngitis, chronic rhino-sinusitis, chronic
purulent rhinitis, adenoidism and secretory
otitis media.

 Physiologicalsaline or medicated saline is

used to hydrate the mucosal lining of the
nasal cavities, rhino-pharynx and the
paranasal sinuses, which assists with
drainage of the sinus cavities.
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 Excellent results are normally achieved
in two to three treatments with the
abovementioned physiotherapy
techniques.

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 Bear in mind, however, that results depend
on the state of the sinusitis (i.e. acute or
chronic), patient compliance (i.e. whether
cutting down on smoking, attending
treatment) and most importantly, early
referral achieves quicker results which
inevitably saves on medical costs.

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CERVICOGENIC
HEADACHE
Primary or secondary headache?

Primary:
 no other causative disorder

Secondary
(ie, caused by another disorder):
 new headache occurring in close temporal
relation to another disorder that is a known
cause of headache
 coded as attributed to that disorder
What is a cervicogenic headache?

 A cervicogenic headache is simply another

name for a headache which originates from
the neck and is one of the most common
types of headache.
 The International Headache Society (IHS)
has validated cervicogenic headache as a
secondary headache type that is
hypothesized to originate due to nociception
in the cervical area.
Superficial Cervical Muscle

Anterolateral View Posterior View

Intermediate cervical muscles

Anterior View Posterior View

Deep cervical muscles

Anterior View Posterior View

 The spine (neck) comprises of many bones
known as vertebrae. Each vertebra connects
with the vertebra above and below via two
types of joints: the facet joints on either side
of the spine and the disc centrally
Kinesiology and Biomechanic
 Mechanism

 Force of neck movement or sustained

posture, stretching or compression placed at
joint, muscle, ligaments, and nerves of the
neck  damage  pain referred to the head
and causing a headache  cervicogenic
headache
How is the pain occur?
Causes
Cervicogenic headache typically occurs due
to activities placing excessive stress on the
upper joints of the neck.
 traumatically due to a specific incident (whiplash or
heavy lifting)
 prolonged slouching
 poor posture
 lifting or carrying
 excessive bending or twisting of the neck,
 working at a computer
 activities using the arms in front of the body
Contributing factors to the development of
cervicogenic headache
 muscle imbalances  inappropriate pillow or
 muscle weakness sleeping postures
 muscle tightness  a sedentary lifestyle
 previous neck trauma  a lifestyle comprising
(e.g. whiplash) excessive slouching,
 inappropriate desk bending forwards or
setup shoulders forwards
activities.
 stress
Diagnostic Criteria
International Headache Society (IHS)

1. Pain localized in the neck and occiput, which

can spread to other areas in the head, such as
forehead, temples, orbital region, or ears,
usually unilateral.

2. Pain is precipitated or aggravated by specific

neck movements or sustained posture.
Cont.
3. At least one of the following:
i. Resistance to or limitation of passive neck
movements.
ii. Changes in neck muscle contour, texture, tone, or
response to active and passive stretching and
contraction.
iii. Abnormal tenderness of neck musculature.

4. Radiological examination reveals at least one of the

following:
i. Movement abnormalities in flexion/extension.
ii. Abnormal posture.
iii. Fractures, congenital abnormalities, bone tumors,
RA, or other distinct pathology (not spondylosis or
osteochondrosis).
 Detailed history Physical
examination

Is the headache possibly caused by another disorder?

NO YES
Primary Secondary

Cervicogenic Headache
Tension type • Pain referred from a source in the neck and
Migraine
headache perceived in one or more regions of the head
and/or face.
• Clinical, laboratory and/or imaging
evidence of a disorders within the cervical
spine or soft tissues of the neck known to
cause headache
• Clinical sign that implicate a source of pain
in the neck
• When myofascial tender sports are the
only cause, the headache should be
diagnosed as tension-type headache not
cervicogenic headache
Other type headache NO
Findings consistent with
Physical therapist Treatment YES cervicogenic headache
Prognosis for cervicogenic headache

 Most patients with this condition heal quickly

and have a full recovery with appropriate
physiotherapy treatment.
 Recovery time:
 minor cases of cervicogenic headache may be
pain free in as little as a couple of days, although
sometimes it may take 2 – 3 weeks.
 severe or chronic cases a full recovery may take
weeks to months.
Treatment

 Manual therapy  Education

 the use of a lumbar
 joint mobilization
roll for sitting
 joint manipulation
 the use of an
 traction appropriate pillow for
 soft tissue massage sleeping
 Exercise  ergonomic advice

 improve flexibility,  activity modification

strength (particularly advice

the deep cervical  Electrotherapy
flexors) and posture  US

 Pilates exercise  Postural taping

 Postural bracing
Exercise Program

 Chin tucks;
This exercise can stretch and strengthen the upper neck muscles
and reduce forward head posture.
To perform:
1. Sit with your head facing forward
2. Place your index finger and middle finger on your chin and guide
your head into a “double chin” position
3. The motion should be directed straight back and you should
continue to look straight ahead
4. Hold this position for up to 10 seconds. Do 1-3 sets of 10
repetitions.
 Do not let your head tilt up or down during the exercise.
 Neck rotations;
This exercise can help to improve neck range of motion.
To perform:
1. Sit with your head facing forward
2. Keeping your back straight, slowly turn your head to the right until
pain, stiffness, or end of motion occurs. Do not go past the point of
pain
3. Now slowly turn your head to the left
4. Do 1-3 sets of 10 repetitions
5. Attempt to go further with each repetition as your pain and motion
improve.
 Do not let your head tilt or your chin drop while rotating your
head.
 Neck Strengthening;
This exercise strengthens the deep anterior neck muscles and
improves neck stabilization.
To perform:
1. Lie on your back with your head relaxed
2. Perform a chin tuck, bringing your chin straight back to create a
“double chin.”
3. Keeping the chin tucked, raise your head off the floor and hold this
position for 5-10 seconds
4. Slowly lower your head to the floor and relax your chin tuck
5. Progress up to 10 repetitions. As you strengthen these muscles,
increase your hold time up to 30 seconds.
 Do not allow your chin to protrude as you fatigue. Keep your
chin tucked throughout the exercise.
Shoulder Blade Squeezes

Begin this exercise by

sitting or standing tall
with your back
straight. Squeeze
your shoulder blades
together as hard and
far as possible pain-
free. Hold for 5
seconds and repeat
10 times provided
there is no increase in
symptoms. Repeat 3
Cervical spine mobilization techniques

 Cervical central & unilateral anterior

glide
 Cervical upglide (opening)

 Cervical downglide (closing)

 Cervical forward bending w/ finger

block
 Cervical side bending w/ finger block

 Cervical rotation w/ finger block

Cervical central & unilateral anterior glide
Cervical upglide (opening)
Cervical downglide (closing)
Cervical forward bending w/ finger
block
Cervical side bending w/ finger block
Cervical rotation w/ finger block
Education
(posture)

6 kg 16 kg 21 kg
Education
(lumbar roll)
Education
(ergonomic workstation)
 THANKS
FOR
YOUR
ATTENTION


 References
1. Headache classification subcommittee of the International Headache Society.
The international classification of headache disorders: 2nd edition. Cephaligia.
2004;24 Suppl 1:9-160.
2. Hall T, Robinson K. The flexion-rotation test and active cervical mobility: A
comparative measurement study in cervicogenic headache. Manual Ther.
2004;9:197-202.
3. Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunction in the
diagnosis of cervicogenic headache. Manual Ther. 2006;11:118-129.
4. Smedmark V, Wallin M, Arvidsson I. Inter-examiner reliability in assessing
passive intervertebral motion of the cervical spine. Manual Ther. 2000;5(2):97-
101.
5. Hoppenfeld S, Murthy VL. Treatment and rehabilitation of fractures. 1st ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 1999:515.
6. Aprill C, Axinn MJ, Bogduk N. Occipital headaches stemming from the lateral
atlanto-axial (C1-2) joint. Cephaligia. 2002;22:15-22.
7. University of St. Augustine for Health Sciences. S3: Advanced evaluation &
manipulation of cranio facial, cervical & upper thoracic spine. St. Augustine, FL.
8. Gonnella C, Paris SV, Kutner. Reliability in evaluating passive intervertebral
motion. Phys Ther. 1982;62(4):436-444.
9. Van Duijn J, Van Duijn AJ, Nitsch W. Orthopaedic manual physical therapy
including thrust manipulation and exercise in the management of a patient with
cervicogenic headache: A case report. J Manual Manipulative Ther.
2007;15(1):10-24.
10. Hoving JA, Koes BW, de Vet HCW, et al. Manual therapy, physical therapy or
continued care by a general practitioner for patients with neck pain. Ann Intern
Med. 2002;136:713:722.
Temporomandibular Disorders and
Physical Therapy Interventions
Temporomandibular Disorders
(TMDs)
 Different pathologies
affecting the
masticatory muscles,
the temporomandibular
joint (TMJ), and related
structures
 Affects more than 25%
of the population
 90% of those seeking
treatment are women
Signs/Symptoms

 Facial pains/Muscle
spasms
 Pain/tenderness in the  Uncomfortable “off” bite
muscles of mastication  Inability to comfortably
and joint open/close mouth
 Joint sounds (popping,  Dizziness/vertigo
clicking)  Ringing in the ears
 Limited jaw motion  Visual disturbances
 Jaw locking open or  Insomnia
closed  Tingling in
 Headaches hands/fingers
 Teeth grinding  Deviation of jaw to one
 Abnormal swallowing side
Additional Symptoms

 People with temporomandibular dysfunctions

frequently report symptoms of depression,
affected sleep quality, and a decrease in
energy.
 It may also interfere with personal
relationships and normal social activities.
Causes

 Trauma  Bruxism
 Excessive stress  (teeth grinding)
 Arthritis of the TMJ  Unaligned teeth
 Whiplash injury  Congenital
 Postural abnormality  Jaw abnormalities
 Ligamentous laxity  Prolonged mouth
 Psychosocial distress breathing
(stresses)  Thumb sucking
TMJ Anatomy

 Osseous Anatomy
 The articulation between the condyles of the mandible
and the temporal bone, which is part of the cranium.
 The articular surface of the condyle is convex and the
articular eminence of the temporal bone is concave.
TMJ Anatomy

 Meniscal Anatomy
 Oval-shaped fibrocartilaginous articular disk (meniscus) between
the osseous components of the joint.
 The central, intermediate portion of the disk is thin while the
anterior and posterior aspects, or bands, are thicker.
 The bilaminar zone attaches to the posterior disc assists the head
of the condyle in moving forward.

 Ligaments
 Temporomandibular ligament
 Stylomandibular ligament
 Sphenomandibular ligament
TMJ Musculature

 Four muscles of
mastication that
move the mandible:
 Masseter
 Temporalis
 Medial Pterygoid
 Lateral Pterygoid
TMJ Biomechanics

 Two motions:
 First 20mm of motion is
rotation. The mandible
and meniscus move
anteriorly together
beneath the articular
eminence while opening
or closing.

 Second motion is
translation, which slides
the jaw further forward or
from side to side.
Normal TMJ

 The TMJ allows the jaw to open, close,

protrude, retract, and deviate laterally.
 Mainly used for chewing and speaking
 Normal opening 35-40”
 2 to 3 knuckles
TMD Treatment

 Working together:
 Dentists
 Orthodontists
 Psychologists
 Physical Therapists
 Ear, Nose, Throat Doctor
 Physicians
 Alternative Medicine
TMD Examination

 MRI
 X-Ray
 Dental examination for bite alignment
Physical Therapy Treatment

 Physical Therapy is an
important aspect in the
treatment for TMD to:
 Relieve musculoskeletal
pain
 Decrease inflammation
 Restore normal
joint/muscular movements
for oral motor function
 Correct poor posture
TMJ Evaluation
 History
 Posture
 Watch, feel, listen to jaw with AROM
 Opening between 40-50mm

 Protrusion/retraction between 8-10mm

 Lateral deviation while opening (S or C curve)

 Lateral excursion 8-10mm

 Ligamentous Laxity testing

 Transverse Ligament

 Alar Ligament

 Cervical ROM testing

 Palpate joints/muscles for tenderness
Postural Examination

Forward head
Thoracic kyphosis
Soft tissue
dysfunctions

ADLs/Occupational
activities
Types of Treatment

 Therapeutic
Exercises
 Manual Therapy
 Modalities
 Electromyographic
(EMG) Biofeedback
 Dental Splint
Therapeutic Exercise

 Improve muscular  Muscles of

coordination mastication
 Increase muscular  Cervical spine
strength muscles
 Postural exercises  General mobility
 Active ROM exercises
Techniques: Tongue Proprioception
and Control
 Make a “clicking” sound  Place tip of tongue on
with the tongue on the palate behind teeth and
roof of the mouth. This draw small circles.
slightly opens the jaw
with the tongue on the  Place tip of tongue on
palate behind the front hard palate and blow air
teeth, which is the resting out, rolling the tongue, or
position of the jaw and making a “r r r r” sound.
the first portion of
relaxation exercises.
Techniques: Control of
Jaw Muscles
 Begin with proper resting position of the jaw. Teach the
patient control while elevating and depressing the
mandible throughout the first half of the ROM.
 Keeping the tongue on the roof of the mouth, the patient
opens the mouth while trying to keep the chin in midline.
Use a mirror for visual reinforcement.
 If the jaw deviates to one side, teach the patient to
practice lateral deviation to the opposite side without
creating pain or excessive motion.
Strengthening Exercises

 Periscapular mm
 Trunk Extensors
 Shoulder External Rotators
Rocabado’s 6x6 Program

 Six components
 Repeat six times each
 Perform six times/day

 Targets the craniocervical and

craniomandibular systems
 Educate/instruct patient during treatment,
then issue for HEP
Rocabado’s Program
1) Tongue Rest Position
• Lips together, teeth slightly apart. Anterior 1/3 of tongue
against roof of mouth with slight pressure.
• Breathe through nostrils, and use diaphragm for deep
breathing.
2) Control TMJ Rotation
• While opening jaw, keep anterior 1/3 of tongue on roof of
mouth to limit movement to rotation only, no protrusion.
• Instruct patient to chew in this manner- without
translation/protrusion.
3) Rhythmic Stabilization Technique
• Lightly resisted motions: opening, closing, lateral deviations
Rocabado’s Program
4) Cervical Joint Liberation
• Distract the upper cervical vertebrae by clasping hands behind
neck to stablize C2-C7, and flex head 15 degrees for
distraction.
• Not neck flexion exercise, but flexion of the head on the
cervical spine.
5) Axial Extension of Cervical Spine
• Push posteriorly on the upper jaw into lower cervical spine
extension and slight flexion of the occiput.
• This reduces unnecessary cervical mm. activity and improves
the functional relationship between the head and cervical
spine.
6) Shoulder Girdle Retraction
• Draw shoulders back and down.
• Restores shoulders to normal postural position to reduce tension and
increase stability.
Manual Therapy

 Massage Reduce pain

 Joint Mobilizations Increase mobility
 Muscle stretching Restore oral range of motion
(passive and active)
 Myofascial Release
 Manual Traction
 Trigger Points
 Relaxation techniques
Massage

 Masseter mm
 Thumb inside mouth, fingers on cheek- sweeping motion to angle
of jaw
 Cross-friction massage parallel to inner and outer fibers of mm.

 If trigger point, focus there

 Temporalis
 Circular motions
 Sternocleidomastoid
 “Corn Cob” technique
 Postural mm.
 Face, shoulders, back of neck

 Pressure on sensitive points, massage with hard, slow, short

strokes
Stretching Tissues

 If the jaw is restricted from opening,

determine if the cause is:
 A dislocated meniscus, which can be repositioned
by joint mobilizations, or
 Hypomobile tissues, which can be passively
lengthened with stretching as well as joint
mobilizations.
Stretching

 Passively increase  Also focus on:

jaw opening by  Upper and Lower
Trapezius
placing thumbs on  Sternocleidomastoid
last molars of lower  Masseter
jaw and adding  Temporalis
slight caudal  Suboccipital/Posterior
Cervical mm
pressure until the
 Scalenes
patient can insert  Rotator Cuff mm.
the knuckles of the  Pectorals
index and middle
fingers.
Resisted Stretching

 Mandibular Opening  Lateral Mandibular

 Open to widest point Movement
 Mouth slightly open
 Place both thumbs
inside mouth on molar  Move mandible

surface laterally
 Resist light closure for  Resist medial

6 seconds movement for 6

 Relax 6 seconds seconds
 Relax 6 seconds
 Open further, repeat 3-
5x  Laterally deviate
further, repeat 3-5x
Joint Mobilizations

 Long Axis Distraction:  Anterior Glide

 Sitting/Supine
 PT positioned opposite of
 Same hand placement
affected side  Slightly distract using
 Use hand opposite of DIP of thumb while
affected jt. side
gliding anteriorly
 Thumb in mouth on last
molar  Oscillate for 30
 Apply gentle downward seconds
pressure with thumb
 Hold for ~30 seconds 2-
3x/session
 Bilaterally
Joint Mobilizations

 Lateral Glide
 Thumb on tongue side of last molar
 Use whole hand to oscillate laterally
 Medial Glide
 Stand on affected side
 Thumb on lateral side of last molar
 Glide medially
Electrophysical Modalities

 Increase blood flow to  Moist Hot Pack

the area  Cold Pack
 Relax tense muscles  Ultrasound
 Reduce inflammation  Transcutaneous
 Reduce pain Electrical Nerve
Stimulation (TENS)
 Increase range of
 Laser
motion for joint
opening and lateral  Shortwave Diathermy
deviation
Preventing TMD

 Avoid:  Relaxation techniques

 Large bites to reduce
 Excessive chewing
stress/muscle tension
 Removing food from teeth
with tongue  Maintain good
 Gum chewing posture
 Chewy foods: bagels,
sandwiches, steak, ice,
crunchy fruits/vegetables,
caramel, nuts etc.
Bibliography
 McNeely, Margeret L., Susan Armijo Olivo, and David J. Magee. "A Systematic Review of the
Effectiveness of Physical Therapy Interventions for Temporomandibular Disorders." PT Journal 86
(May 2006): 710-25. Physical Therapy. 27 Jan. 2009
<http://www.ptjournal.org/cgi/content/full/86/5/710?maxtoshow=&HITS=10&hits=10&RESULTFOR
MAT=1&title=temporomandibular&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltex
t=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT>.

 Medlicott, Marega S., and Susan R. Harris. "A Systematic Review of the Effectiveness of
Exercise, Manual Therapy, Electrotherapy, Relaxation, and Biofeedback in the Management of
Temporomandibular Disorder." PT Journal 86 (July 2006): 955-73. Physical Therapy. 27 Jan.
2009 <http://www.ptjournal.org/cgi/content/full/86/7/955#T3>.
 Kisner, Carolyn; Lynn Allen Colby. Therapeutic Exercise, Foundations and Techniques. 2002

 http://www.nismat.org/ptcor/tmj
 http://uwmsk.org/tmj/anatomy.html
 http://www.nlm.nih.gov/medlineplus/ency/article/001227.htm
 http://udel.edu/~spetter/TMJWebsite/anatomy.htm