“Relationship between Restricted Breathing Mechanics on Airway and

Posture”

Dr. Jennifer Flage Hobson, PT, DPT, MTC, CMTPT

jhobson@ptrenaissance.com ptrenaissance.com

25 E Washington, Suite 1319 Chicago, IL 60602

Airway

Neck Posture

Evaluate Posture in standing and sitting Beighton scale systemic hypermobility Evaluate mouth opening mechanics for disc displacement and

muscular control Assess ROM; rotation to translation ratio, (should be 4:1:1 and

50/50). Centric Relation Provocation Test Palpation test: Using the Rocabado 8 point pain provocation map. Perform intra-oral joint/muscle and facial assessment. Hyoid Mobility test. Cervical spine ROM, joint testing, strength and stability Myofunctional Assessment (tongue tie, mallampati, swallow, chew) Breathing assessment; capnometer: CO2 levels, breath rate Review of C. S. X-rays: Lateral Ceph, flexion/extension, Open

mouth

Evaluation of the CS/TMJ and breathing dysfunction

Centric Relation Provocation Test Palpation test: Using the Rocabado 8 point

pain provocation map

Evaluate the TMJ for dysfunction.

Beighton Scale of Systemic Hypermobility 9 out of 9 points

Normal Atlas-Axis position

Right rotation of Atlas, R inclined occlusal plane.

Left Rotation of Atlas on Axis, Left inclined occlusal plane

Observe the spine of this patient. Straight neck causing neck pain, headaches, and bruxism

L. Motta, M. Matins, teal Craniocervical posture and bruxism in children, Physiotherapy Research International, Vol 16 Issue 1 pg. 57-61, March 2011 C. Restrepo, Y. Quintero, etal. Effect of Physiotherapy on Bruxism and Head Posture TMD/orofacial pain epidemiology and treatment Instituto de Ciencias de la Salud, Medellín, Colombia  Y. Quintero, C. Restrepo, etal. Effects of awareness through movement of the head posture of bruxist children. CES-LPH Research Group, CES University, Medellín, Colombia.

Interactions Between Head and Mandibular Position

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

Forward Head Posture to Military

Cervical Flexion to Cervical Extension

Mandibular Retrusion to Protrusion Teeth contact more post to ant

Mandibular Retrusion to Protrusion Teeth contact more ant to post

Weakness of the anterior neck flexorsChin tucks, Chin tuck and lift exercise.

Jull, G, Kristjansson, E & Dall'alba, P 2004. Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Man Ther, 9, 89-94.

Superior and inferior airway

Effects of neck flexion and extension on airway. Cervical flexion decreases airway

Cervical extension increases airway

Capnometer: ETCO2 40-45mmHG, Breath rate: 8-10 at rest

Dysfunctional shallow chest breathing found in 90% of my head and neck patients, including myself!

(CO2: 26mmHG, Breath rate 22bpm)

Dr. Kevin Boyd, Pediatric cases effects of posture and airway.

Is it a coincidence that the majority of my head and neck patients have dysfunctional breathing?

!• In my practice, all of my patients are getting

tested and treated for breathing dysfunction. • They are now also getting Myofunctional

therapy along with the manual therapy/dry needling/postural strengthening to restore proper joint mechanics of the upper quarter/spine balanced stance.

• Buteyko breathing method. (Proper breathing mechanics, volume, breath rate)

Dr. John Mew

Crooked or Straight Front Teeth

Crowding caused by incorrect tongue position and function

Crooked or Straight Front Teeth

Correct tongue position and function gives correct arch form

Permission by Dr. Boyd

Patient I.H 4.yo

• Nursed for 6 months, milk supply faded. Mom return to work.

• Swollen adenoids and tonsils. • Snoring at night. • Mouth breathing during the day and night. • Forward head posture. • Hyperactivity. • Nail biter.

Physical Therapy Examination

• Mallampati score: Between 3-4, • Hyoid bone moderate restriction of mobility • Tongue evaluation: short anterior frenulum;

mouth breather; high narrow palate. • Scapular weakness. • Sub-cranial stiffness, posterior rotation of the

cranium. Increased tone posterior cervical muscles. Forward head posture.

• Decreased diaphragmatic breathing

Female 4 year old patient, ponticulus posticus grade 2; Small bridge of bone resulting from complete ossification of the Atlanto-Occipital

membrane reaching the posterior notch of C1.

Enlarged Adenoids & TonsilsLimited airway

I. H. Front view pics

Note facial asymmetry

Retro-inclined Profile

Weakness of the scapular stabilizers and upper quarter; winging noted.

Mandible to the Left

Frontal view occlusion mandibular midline 2 mm to left

Tongue thrust swallow, poor position of tongue

• Tongue thrust swallow

I.H. frenulum anterior and lateral view

Suction upward of the tongue Cave exercise

Jenny’s anterior and lateral view of lingual frenulum

Swollen tonsils and adenoids Pediatric ENT recommend

Tonsilloadenoidectomy

Importance of proper nutrition

• Met with Dr. Lois Laynee, Developmental airway specialist. Recommended the following…

• Eliminate gluten and dairy (well known foods to cause inflammation to the body)

• Eliminate process foods. Anything packaged.

• Reduce sugar intake.

Biobloc palatal expander, Dr.Mew/Dr. K. Boyd, began Sept.2013

Intraoral swelling reduced to normal 12/2013 to present 6/2014

• No need for a adenoidectomy or tonsillectomy • No longer hyperactive. • No longer had dark circles under her eyes. • She is still in Myofunctional/speech therapy. • We 3M Micropore tape on lips every night. • She is in swimming for scapular strengthening. • Still in phase 1 of the Biobloc expander with Dr. Kevin

Boyd. • Capnometer: CO2: 40mmHG, Breath rate 14bpm. • In each of my Children’s Buteyko clinics I offer. • Scheduled to have anterior tongue tie frenectomy with Dr. Larry Kotlow 7/22/14

C.H. 3-year old boy

• Delivered 5 weeks early VBAC • Difficulty with milk supply from mom. Nursed yet

had to supplement after 2 months. • Weaker immune system, longer to recover from

illness’. • Hospitalized for pneumonia at Children’s Hospital

at age 1; 2nd 3day hospitalization Corona virus effecting breathing (CO2 levels in hospital 18mmHG).

• Swollen adenoids and tonsils, recommended SX • Speech delay, speech therapy 1 year.

Examination: C. H.

• Mallampati score: Between 3-4. • Hyoid bone moderate restriction of mobility. • Tongue evaluation: short posterior frenulum;

mouth breather; high narrow palate. • Firm, tight floor of mouth under mandibular

symphysis. • Decreased diaphragmatic breathing, over-

breathing. • Mouth breathing.

C.H. Frontal View Pics

No smile smile

C.H. profile

C.H.posterior tongue tie4 opinions First 3 said no to tongue tie

Last opinion, Dr. Larry Kotlow

Performed Posterior tongue tie frenectomy on 1/29/14

Albany, NY.

C.H. Post frenectomy tongue flexibility

CH Intraoral swelling reduced to normal 2/2014 to present 6/2014

• No need for a adenoidectomy or tonsillectomy • No longer hyperactive. • She is still in Myofunctional/speech therapy/PT

manual therapy. • We 3M Micropore tape on lips every night. • He is in swimming for scapular strengthening. • Planning to start Biobloc expander with Dr. Kevin

Boyd at age 4 (Oct 2014). • Capnometer: CO2: 30mmHG, Breath rate 27bpm.

Still needs more work. Can’t do Children’s Buteyko breathing clinics due to attention span yet.

• Lingual posterior tongue tie revision Frenectomy scheduled 7/22/14 with Dr. Larry Kotlow

Why is OMT Important?

• Lack of a Lip Seal may lead to Occlusal dysfunction (Harari, et al,2010)

• Low, forward tongue rest may be linked to psychological, cosmetic, structural issues, (Peltomaki, 2007)

• Failure to masticate food properly (Straub, 1962)

• Incorrect swallowing may be linked to GERD, (Phua, et al., 2005)

• OSA: Mouth Exercises May Reduce AHI numbers by 39% (Guimaraes, 2010)

Mallampati scores 1-4

Throat musculature1. Tensor veli palatini 2. Levator veli palatini 3. Salpingopharyngeus

4. Musculus uvulae

5. Aponeurosis of tensor veli palatini

6. Pterygoid hamulus

7. Palatopharyngeus

8. Palatoglossus

9. Tonsil 10.Tongue

References• Danner H., Jakstat H., Ahlers M. Correlations between posture and jaw

relations Zeitschrift fu kraniomandibulare Funktion 2009; 1(2):149-163. • Cesar G. Tosato J, et al. Correlation between Occlusion and Cervical Posture in

Patients with Bruxism. Parkell Online Learning Center. • Ciancaglini R, Testa M, Radaelli G. Association of Neck Pain with symptoms of

Temporomandibular Dysfunction in the general adult population. Sand J Rehab Med 31, pg. 17-22, 1999

• Visscher C. , Lobbezoo R, et al. Clinical test in distinguishing between persons with or without craniomandibular or cervical spinal pain complaints. Eur J Oral Sciences

• McNeely M, Olivo A., Magee D. A systematic Review of the Effectiveness of Physical Therapy Interventions for Temporomandibular Disorders. Physical Therapy J o APTA 2006; 86:710-725

• Armijo-Olivo A., Jara X. et al. A Comparison of the head and cervical posture between the self-balanced position and the Frankfurt Method.

• Carra M., Huynh N. , Lavigne G. Sleep bruxism and sleep-disordered breathing in pediatrics: an overview for clinicians. Zeitschrift fur Kraniomandibulare Funktion 2011; 3(3):205-220

References• Olivo, S.A., Bravo, J et al. The Association Between Head and Cervical Posture and

Temporomandibular Disorders: A Systematic Review. J Orofac Pain Vol 20, Number 1, pg 9-23, 2006

• Olivo, S. A., Mages, D. et al. The Association Between the Cervical Spine, the Stomatognathic System, and Craniofacial Pain: A Critical Review. J Orofac Pain Vol 20, Number 4, 2006 Pg. 271-287

• Lee, W. Y., Okeson, J. et al. The Relationship Between Forward Head Posture and Temporomandibular Disorders. J Orofac Pain Vol Number 2, 1995 Pg. 161-167

• Moniaco, A., Cozzolino. V. et al. Osteopathic manipulative treatment (OMT) effects on mandibular kinetics: kinesiographic study. Euro J or Paediatric Dentistry 1/2008, pt. 37-42.

• Olmos. S, Kritz-Silverstein. D, et al. Effect of Condyle Fossa Relationships on Head posture. J of Craniomandibular practice Jan 2005 Vol 23., No. 1 pg. 48-52

• Pradham. N, White, G. et al. Mandibular deviations in TMD and non-TMD groups related to eye dominance and head posture. J of Clinical Pediatric Dentistry Vol 25, Number 2/200 pg. 147-154

• Wright. E, North. S. Management and Treatment of Temporomandibular Disorders: A Clinical Perspective. J of Manual & Manip Therapy Vol 17 Number 4pg 247-254.

References continued

• L. Motta, M. Matins, teal Craniocervical posture and bruxism in children, Physiotherapy Research International, Vol 16 Issue 1 pg. 57-61, March 2011

• C. Restrepo, Y. Quintero, etal. Effect of Physiotherapy on Bruxism and Head Posture TMD/orofacial pain epidemiology and treatment Instituto de Ciencias de la Salud, Medellín, Colombia

•  Y. Quintero, C. Restrepo, etal. Effects of awareness through movement of the head posture of bruxism children. CES-LPH Research Group, CES University, Medellín, Colombia.

• Jull, G, Kristjansson, E & Dall'alba, P 2004. Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Man Ther, 9, 89-94.

!• Dr. Mariano Rocabado, PT, DPT, CFC, MTC • Michael Karegeannes, PT, MHSc, LAT, MTC,

CFC, CCTT, CMTPT • Dr. Larry Kotlow • Dr. Kevin Boyd • Joy Moeller, RDH, • Patrick McKeown, Buteyko Mentor

Special Thanks