presents - wpta.org evaluation, treatment and...michael karegeannes, pt, mhsc, lat, mtc, cfc, cctt,...

Presents

The Evaluation Treatment and Management of Temporomandibular Disorders Craniofacial Pain

And Orofacial Pain

April 20 2017

By Michael Karegeannes

PTMHScLATMTCCFCCCTTCMTPT

Jeff Verhagen PTMBACMTPT

Mike Verplancke DPTCSCSCMTPT

Freedomptcom Treatingtmjcom

Michael Karegeannes PT MHSc LAT MTC CFC CCTT CMTPT is the owner of Freedom Physical Therapy Services 4 clinics in WI since 1997 and a practicing physical therapist since 1989 His specialties in the field of physical therapy include TMD spine and pelvic dysfunctions myofascial pain and orthopedic therapies Michael graduated from the University of Wisconsin-Madison in 1989 with a Bachelorrsquos of Science Degree in Physical Therapy After he graduated he received his athletic training license from the University of Wisconsin-Milwaukee and later Michael completed his manual therapy certification and Masters of Health Science from the University of St Augustine in Florida

In 2005 Michael had the honor of being trained by Dr Mariano Rocabado (in conjunction with the University of St Augustine) who is the leading national expert in the field of craniofacial therapies Michael holds a Craniofacial Certification with the University of St Augustine

In addition Michael has attended an orofacial pain and TMD residency with the University of Minnesota Dental School He is a member of the American Academy of Orofacial Pain (AAOP) a board member with the Physical Therapy Board of Craniofacial and Cervical Therapeutics (PTBCCT) and is one of the few physical therapists in the United States recognized as a certified cervical and temporomandibular therapist with the AAOP

In 2011 Michael received thorough and extensive training in the technique of intramuscular dry needling and is certified through Myopain Seminars the premier post-graduate medical and physical therapy continuing education company in the United States with a focus on myofascial trigger points Michael is also on faculty with Myopain Seminars Michael is also one of the few PTs in the USA trained in the CRAFTA approach to TMD

His diverse experience knowledge and manual skills allow Michael to be highly effective in the evaluation and treatment of his clientele

Michael is a member of the APTA WPTA NATA AAOP PTBCCT AES PAMA and IMS

Jeffrey Verhagen started his career as a Physical Therapist in 1990 after graduating from the University of Wisconsin -Madison He furthered his breadth of knowledge by attending several post-graduate continuing education opportunities with a focus on manual therapy for orthopedic spine and sports injuries He soon learned that he enjoyed treating spine problems and patients with headaches

In order to properly assess the etiology of headaches he expanded his studies to include the evaluation and treatment of TMDcraniofacial pain and in 2013 completed a certification in Intramuscular Dry Needling through Myopain Seminars Dry Needling treats myofascial trigger points and their affect on localized and referred pain He soon learned that he could successfully treat TMD and craniofacial pain for patients that had tried other treatment approaches and still were left with pain and loss of function

Jeff has attended several courses and has reviewed the literature to expand his ability to successfully treat this challenging population Freedom Physical Therapy Services commissioned Steve Kraus PT a well known TMJ therapist and educator to come to the Milwaukee area and teach the latest treatment techniques and research on TMDcraniofacial pain to our therapy staff Jeff looks forward to continuing to expand his knowledge to better serve this patient population

Jeff has been with Freedom Physical Therapy Service since July of 2000 and currently serves as the Clinical Operations Administrator for the practice He earned his Master of Business Administration from Cardinal Stritch University in 1999 He also served 21 years in the Army Reserves and is a Desert Storm veteran

Jeff resides in Brookfield with his wife and two children and enjoys many hobbies to include golf fishing and reading

Michael Verplancke left his roots of St Louis Missouri to both attend and play ice hockey at St Maryrsquos University of Minnesota where Mike graduated in 1998 with a Bachelor of Arts degree in Biology He then attended Finch University of Health SciencesThe Chicago Medical School in North Chicago Illinois to obtain his physical therapy degree He graduated in 2001 with a Doctorate of Physical Therapy Mike has participated in numerous continuing education seminars with a focus on manual therapy techniques evaluation and treatment of the spine and TMJcraniofacial pain mobilization techniques and intramuscular dry needling

In 2002 Mike obtained his credentials as a Certified Strength and Conditioning Specialist (CSCS) which has assisted him with exercise prescription as well as progression of overall health and wellness for patients

In 2014 Mike completed his certification in Intramuscular Dry Needling through Myopain Seminars This treatment approach has provided a technique that improves treatment of Myofascial Trigger Points and their affect on localized and referred pain as well as muscle activation patterns throughout the body In addition Michael has attended an Orofacial Pain and TMD residency with the University of Minnesota Dental School

Mike has been trained in Temporal Mandibular Disorders (TMD) and Craniofacial Pain (CFP) by Dr Mariano Rocabado a world renowned leader in the field of TMD and CFP Mike is currently working towards his Craniofacial Certification in conjunction with Dr Rocabado and the University of St Augustine

Mike has been an employee at Freedom Physical Therapy since July of 2005 and is currently the Lead Physical Therapist and clinic director of the Grafton location

Mike has a wide range of hobbies and interests which include playing ice hockey softball golf and basketball He also enjoys spending quality time with his wife Marion their three daughters Sophia Liliana and Emilia and their Golden Retriever Stan

Green Bay WI April 20 2017 Michael Karegeannes PT wwwtreatingtmjcom 1

Time Ordered Agenda 4-20-2017

900 ndash 945am Introduction and TMJ Anatomy and TMJ Biomechanics

945 ndash 1030am Pathomechanics abnormal mechanics and parafunction etiology imaging

1030 ndash 1100pm Break

1100 ndash 1200pm Epidemiology Lab Evaluation of ROM of TMJ Lab Muscle Palpation Hypermobility Screen muscle treatment

1200 ndash 200pm Lunch

200 - 245 pm TMJ Arthralgia and various Disc related TMJ Dysfunction

245pm ndash 330pm Lab Mobilization Techniques for the TMJ

300 - 345pm Break

345 ndash 415pm TMJ Exercise Rocabado 6 x 6 self help

415 ndash 500pm Cervical spine as it relates to TMJ Ergonomics Lab C spine assessmenttreatment dry needling Demo to facial and selected neck muscles

500pm Adjourn Thank you


The Evaluation Treatment and Management of Temporomandibular

Disorders Craniofacial Pain and Orofacial Pain

By

Michael KaregeannesPTMHScLATMTCCFCCCTTCMTPT

CRANIO-CERVICO-MANDIBULAR RELATIONSHIP

Cranio-MandibularCranio-Vertebral

ASSIMILATION


Tragus of the ear

Anatomical Video Clip

The condyle (anterior view) The medial pole (MP) is more prominent that the lateral pole (LP)

Copyright copy2013 by Mosby an imprint of Elsevier Inc

(A) Lateral view and (B) diagram showing the anatomic

components RT retrodiscal tissue SRL superior retrodiscal lamina (elastic) IRL inferior retrodiscal

lamina (collagenous) ACL anterior capsular ligament (collagenous) SLP and ILP superior and inferior

lateral pterygoid muscles AS articular surface SC and IC

superior and inferior joint cavity the discal (collateral) ligament has

not been drawn

Courtesy of Per-Lennart Westeson MD Rochester NY

TMJ ( anterior or coronal view) AD articular disc CL capsular ligament LDL lateral discal ligament MDL medial discal ligament DC superior joint cavity IC inferior joint cavity

Medial and Lateral Discal Collateral Ligament


TMJ MechanicsDiscTMJ pain primarily originates from tissues in the posterior and lateral aspect of the TMJ ie capsule TMJ ligament Lateral collateral ligament synovium and retrodiscal tissue

Mandibular Biomechanics Osteokinematics

bull Depression (opening) ndash 40 to 50mm normal- 36 mm for most dental procedures

bull Elevation (closing)bull Protrusion- 5 to 7 mm from incisor to incisorbull Retrusion to protrusion 10mm be specific and

consistentbull Lateral excursion ndash 10 mm

41 RatioFor every 1mm of lateral excursion 4mm of opening

TMJ AUTOPSY SPECIMEN(Normal Joint)

TMJ AUTOPSY SPECIMEN(Reducing Disc)


TMJ AUTOPSY SPECIMEN(Non-Reducing Disc)

Mandibular Opening Patterns

bull Deflection Movement away from midline but it does NOT return to midline

A man with reducing disc displacement of the right joint (a) On mouth opening there is an early transient locking and a slight deflection of the mandibular midline to the right affected side (b) When the condyle slides over the posterior edge of the disc there is a rapid exaggeration of the mandibular shift and the mandibular midline then returns to center At further mouth opening the mandibular movement is symmetrical (c) Lateral excursion to the contralateral side is impaired before the click but not necessarily after (d) Lateral excursion to the ipsilateral or affected side is typically normal (e) Protrusion there is a slight deflection of the mandible to the right affected side after the ldquoclickrdquo the mandible tends to track in the center

Mandibular Opening Patterns (cont)Deviation ldquoSrdquo Movement away from midline but

returns to midline as it gets to end range

Mandibular Opening Patterns (cont)

bull Midline Could be normal or could be bilateral Disc dislocation without reduction depends on

Mandibular ROM (LAB)

Will Cover In Lab

Hypermobility Screen


Hypermobility

Beighton 9 Point Scoring System Revised 1998 Brighton Diagnostic Criteria For JHS

Chapter 2 Assessment of HypermobilityP Beighton et al Hypermobility of Joints

Springer-Verlag London Limited 2012

Rodney Grahame CBE MD FRCP Joint Hypermobility Syndrome Pain Current Pain and Headache Reports

2009 13427-433

Generalized hypermobility is one of the most important etiological factors in the development of craniomandibular disorders Professor Rocabado presented the following summary of etiological factors and

we can see that clenchingbruxism and mobility rank much higher than history of trauma or orthodontics

The importance of systemic hypermobility is evident when we consider the association between parafunction and hypermobility It has been found that 79 of patients with systemic hypermobility and

clenchinggrinding of teeth (or nail biting) go on to develop a TMJ problem A control with clenchinggrinding of teeth but without systemic hypermobility were found to have only 16 incidence The

implications seem to be that hypermobile individuals do not tolerate the added stress of parafunction So most patients have hypermobility and parafunction going hand in hand


CWP ndash Chronic Widespread Pain FM - Fibromyalgia CFS - Chronic Fatigue SyndromeJHS - Joint Hypermobility Syndrome EDS - Ehlers Danlos Syndrome MFS ndash Marfan Syndrome

This diagram illustrates that people with CWP CFS and FM can be hypermobile or may have JHS that JHS and EDS may present in similar ways and that the very complex systemic

problems of the bowel lungs heart and blood vessels are features of conditions such as EDS and MFS and not JHS

httphypermobilityorg

What other problems might a person with hypermobility have to suggest there is an underlying medical condition

The things individuals might most often present with beyond joint problems include

bull Easy bruising scarring that is stretched thin and often wrinkled andstretch marks that appeared at a young age and in many places across the body The skin often feels soft and velvety

bull Weakness of the abdominal and pelvic wall muscles that presents as hernias (such as hiatus hernia) or prolapse of the pelvic floor causing problems with bowel and bladder function

bull Unexplained chest pains ndash perhaps the individual has been told they have a heart murmur and mitral valve prolapse

bull Blackouts or near blackouts that may be associated with low bloodpressure or fast heart rate and often triggered by change in posture from lyingsitting to standing or after standing in one position for even just a few minutes httphypermobilityorg

bull Symptoms that sound like Irritable Bowel Syndrome with bloating constipation and cramp-like abdominal pain

bull Shortness of breath perhaps diagnosed as asthma because the symptoms seem the same but not responding to inhalers in the way the doctor might have expected because it is not true asthma

bull Noticing that local anesthetics used for example in dentistrydo not seem to be very effective or require much more than might be expected

bull Severe fatigue Anxiety and phobias


Cervical Spine Joint Hypermobility a possible predisposing factor for new daily

persistent headache TD Rozen JM Roth and N Deneberg Michigan Head-Pain and

Neurological Institute Ann Arbor MI USA

History

bull 1934 James Costen described a group ofsymptoms centering around the ear and TMJthe term Costen Syndrome was developed

bull While much of what Costen had suggested hasbeen disproved his interest certainly was acatalyst to foster more work andunderstanding in the area of TMD


Fast forward through various other terms over the years such as TMJ disturbances TMJ dysfunction syndrome Functional TMJ disturbances occlusomadibular disturbance myoarthropathy of the TMJ Craniomandibular disorders to what Bell in 1992 coined

ldquoTemporomandibular Disordersrdquo


The term does not merely suggest problems that are isolated to the TMJs but includes all disturbances associated with the function of the masticatory system rather than a single diagnosis

bull Arthrogenous

bull Myogenous

bull Atrhrogenous and Myogenous

The American Dental Association adopted the term TM disorders or Temporomandibular Disorders

In 1993 the AAOP collaborated with the International Headache Society (IHS) to integrate TMD into an already existing medical diagnostic classification system

TMDUncommon Classifications of TMDs

bull Ankylosis

bull Aplasia or hyperplasia

bull Pathology such as an infection fracture or neoplasm ( malignant or benign)

Common SymptomsSigns of TMD

bull Pain in the area of the TMJ and jaw muscles

bull Pain with mouth opening chew and or yawn

bull Joint sounds with jaw movements

bull Intermittent locking closed or open

bull Limited mouth opening

bull Headache

bull Earache or pain

Myogeneous

Masticatory Muscle Pain

Muscle Spasms ICD 10 M791ICD 9 72885

Contracture of muscle unspecified site ICD 10 M6240

Adhesions and ankylosis of temporomandibular joint M2661

Artrhogeneous

Arthralgia ICD 10 M2662ICD 9 52462

Primary osteoarthritis unspecified site M1991

Disc Displacements ICD 10 M2662ICD 9 52463

Common Classifications ICD 10 Coding of TMDs


other specified disorders of TMJ ICD 10 M2669

Dislocation of jaw initial encounter ICD10 S030XXA

Cervicalgia ICD 10 M542 ICD 9 7231

Myofascial Syndrome ICD 10 M791ICD 9 7291

Headache ICD 10 R51 ICD 9 7840

Chronic tension-type headache intractable G4422133912 CTTH

Treatment ndash Insurance Issues and TMD

Diagnosis

It is about 5050 as far as which insurances will

cover the diagnosis of TMJTMD

If they do sometimes small TMD cap applies (say

only $1250) others fall into same coverage for other

MS issues

Most patients have a combo of cervical and TMD

sxrsquos therefore it is not unreasonable to use a

cervical dx

For Medicare you will need a script from their

medical doctor not the dentist as Medicare does

not cover TMD

This is a graphic model depicting the relationship between various factors that are associated with the onset of TMD The model begins with a normally functioning masticatory system There are five(6) major etiologic factors that may be associated with TMD Whether these factors influence the onset of TMD is determined by the patientrsquos individual adaptability When the significance of these factors is minimal and adaptability is great the patient does not report any TMD symptoms

Per Rocabado must have

centric relation or balance of CV

joints

Craniovertebral Junction

Management of Temoromandibular Disorders and Occlusion by Jeff Okeson 7th edition 2013


In this graphic model the etiologic factor of occlusion is depicted as being significant (perhaps a newly placed poorly fitting crown) If this factor exceeds the patientrsquos adaptability TMD symptoms may now be reported by the

patient In this instance improvement of the occlusal condition (adjustment of the crown) would reduce this etiologic factor thereby bringing the patient within adaptability and thus resolving the TMD symptoms The same effect can be associated with any of the five etiologic factors and helps explain why data show that treatment of any of these factors may reduce symptoms




This graphic model depicts the concept that some patients may present with less adaptability or a reduction in adaptability When this occurs the various etiologic factors that did not originally create symptoms may now lead to symptoms When

adaptability is very limited attempts at reducing any of the five factors may be ineffective






Managing this etiologic factorsMay no longer be adequate

This graphic model depicts a much more difficult management problem As symptoms become prolonged the pain condition can move from acute to chronic As pain becomes chronic the central nervous system can be altered making management more complicated Some of these alterations may involve the hypothalamus-pituitary-adrenal axis central sensitization andor a reduction in descending inhibitory control When this occurs more chronic pain conditions may develop which cannot be managed by addressing the five etiologic factors



Parafunctional Activity

Some clinical signs associated with parafunctional activity A Evidence of cheek biting during sleep B Here the lateral borders of the tongue are scalloped conforming to the lingual surfaces of mandibular teeth During sleep a combination of negative intraoral pressure and forcing of the tongue against the teeth produces this altered tongue shape This is a form of parafunctional activity



Masseter hyperplasia secondary to chronic bruxism

TMD Diagnostic Guidelines

bull 1992- Research Diagnostic criteria for TMDs

ndash Dworkin SF LeResche L Research Diagnostic Criteria for Temporomandibular Disorder 1992 6301-355

ndash RDC is a landmark paper providing operational definitions to distinguish TMD patients from controls and to diagnose with reasonable reliable and valid tests and measurements the most common subtypes of TMD

ndash httpwwwrdc-tmdinternationalorgHomeaspx

bull For over 20 years it has been the most widely used and heavily cited publication of diagnostic protocol in clinical and research settings

bull It was never intended to be a final document but rather a work in progress

bull The Journal of Oralfacial Pain 2010 volume 24 Issue 1 offers several articles validating and recommending updates to the 1992 RDC paper


The new DCTMD protocol is a necessary step toward the ultimate

goal of developing a mechanism and etiology based DCTMD that will more accurately direct clinicians in providing

personalized care for their patients

Steenks M De Wijer A Validity of the Research Diagnostic Criteria for Temporomandibular Disorders Axis in Clinical Research settings Journal of Oralfacial Pain 2009239-16

Summary of RDCTMD diagnostic Guidelines

A To diagnose all common subtypes of TMD involves taking a history and performing a physical examination that is reliable and valid

B Does NOT require

1 Electronic Equipment

a) Sonograph

b) EMG

c) Jaw Tracking Devices

2 Radiographs

-Radiographs are indicated if recent trauma red flags are present patient not responding to conservative care and surgery is being considered for disc replacement

Panoramic X-Raybull Is a two-dimensional dental x-ray that can show the

maxilla and mandible all the teeth including the wisdom teeth the frontal and maxillary sinuses the nasal cavity and the temporomandibular joint and other near by head and neck anatomy

bull Can determine bony changes of the condyle and fractures or severe dislocations of the condyle Does not image soft tissue so the position of the disc cannot be determined by this test


Computed Tomography

bull The latest advancement in this technology iscalled Cone Beam tomography

bull It allows for viewing the condyle in multipleplanes so that all surfaces can be visualized

bull This technology is capable of reconstructing3D images

bull Cone beam technology can image both hardand soft tissues but MRI GOLD standard forsoft tissue

Patient positioned in a cone beam CT scanner

Computed tomographic scan A A typical CT projection of the TMJ Hard tissue (bone) is visualized better than soft tissue with this technique B A three-

dimensional CT reconstruction of an edentulous mouth

From Wilkinson T Maryniuk G J Craniomandib Pract 137 1983


A three-dimensional image reconstructed from a cone beam image These three-dimensional images can be rotated on the computer screen so that the clinician can visualize the precise area of interest (Courtesy of Dr Allan Farmer and Dr William Scarf Louisville KY)

MRI

bull Gold Standard for evaluating the soft tissue of the TMJ especially disc position

bull Major advantage of not introducing radiation

bull Disadvantages include expensive not typically available in a dental setting quality of images may very from facility to facility

bull Cine or dynamic MRI on its way

Magnetic resonance image (MRI) A When the mouth is closed the articular disc (dark) is dislocated anterior to

the condyle (arrows)B During opening the disc is recaptured into its normal position on the condyle


The clinician should note that the presence of a displaced disc in an MRI does not constitute a

pathological finding IT has been demonstrated that between 26 and 38 of normal asymptomatic

subjects are found to have disc position abnormality on MRI Therefore the clinician should rely primarily on history and examination findings to establish the

diagnosis and use imaging information only as contributing data


This study suggests that disc displacement is relatively common (34) in asymptomatic volunteers and is highly

associated with patients (86) with TMD

Although there was a 33 prevalence of disc displacement in asymptomatic volunteers there was a

highly significant difference in the prevalence of internal derangement in symptomatic subjects Bruxing was

statistically linked to TMJ disc displacement and could explain the anatomic variation in abnormal disc position

In conclusion panoramic radiography had poor reliability and low sensitivity compared with CT for detecting TMJ-related osseous changes These findings suggest that this imaging modality has

limited utility for assessing the TMJ Magnetic resonance imaging had fair reliability and marginal sensitivity in diagnosing osseous

changes compared with CT Therefore MRI is not an ideal imaging technique for detecting osseous changes and CT remains the image

of choice for assessing osseous tissues Regarding soft tissue assessment MRI had excellent reliability for assessing disc position

and good reliability for detecting effusions Overall the criteria proposed in this study for image analysis covered all possible osseous and nonosseous conditions of TMJ in a large group of

participants in the multisite RDCTMD Validation Project17 The image analysis criteria presented in this paper are reliable for

diagnosing osseous and nonosseous components of TMJ using CT and MRI respectively We recommend that they be used in both

clinical and research settings

Sagittal CT views of condyles representing examples of nonosteoarthritic or indeterminateosseous changes observed A-B Rounded condylar head and well-defined cortical margin

C Rounded condylar head and well-defined noncortical margin D-E Indeterminate forOA slight flattening of anterior slope and well-defined cortical margin F Indeterminate forOA flattening of anterior slope and a pointed anterior tip that is not sclerosed well-defined

cortical margin fossa is shallow G Well-defined cortical margin has a notch on thesuperior part a deviation in form fossa is shallow H Narrowed appearance of the condylarhead near medial part close position of the cortical plates gives the impression of sclerosis

a nonosteoarthritic condyle

Axially corrected coronal CT views of condyles representing examples of osseous changes observed and corresponding osteoarthritis (OA) diagnoses A-B Nonosteoarthritic condyles rounded condylar head and well-defined cortical margin C Nonosteoarthritic condyle flattened superior margin and well-defined cortical margin D Nonosteoarthritic condyle flattened lateral slope and well-defined cortical margin E Indeterminate for OA rounded condylar head and subcortical sclerosis F Indeterminate for OA subcortical sclerosis G OA subcortical sclerosis surface erosion H-I OA surface erosion J OA generalized sclerosis and subcortical cysts K Nonosteoarthritic condyle well-defined corticated margin bifid appearance deviation in form L Nonosteoarthritic condyle subcortical sclerosis in nonarticulating surface bifid appearance deviation in form


Eaglersquos Syndrome

Eaglersquos syndrome A An extremely long and calcified styloid process seen in the panoramic projection This patient was suffering from submandibular neck pain especially with movement

of the head B A very large styloid process that has been fractured is seen in this panoramic projection There is also a large radiolucency in the mandibular molar region secondary to a

gunshot wound (B courtesy of Dr Jay Mackman Radiology and Dental Imaging Center of Wisconsin Milwaukee WI)

Epidemiology of TMDs

bull Cross sectional epidemiologic studies of selected non-patient populations show that 40 to 75 of those populations have at least one sign of joint dysfunction ( eg movement abnormalities joint noise tenderness on palpation)

bull 33 of selected non-patient populations have at least one symptom of dysfunction (eg face pain joint pain)

bull Joint sounds or deviations on mouth opening occur in ~ 50 of non-patient samples

bull Other signs are relatively rare mouth opening limitations occur in less that 5 of non-patient populations

bull Pain in the TM region is reported in ~10 of the population older than 18 years it is primarily a condition of young and middle aged adults

bull WomenMen 21 and as high as 91

bull Only 36 to 7 of these individuals are estimated to be in need of treatment

bull Only 7 of patient population with benign TMJ clicking showed progression to bothersome clicking status over a 1 to 75 year period

bull Most patients with clicking remained stable or showed less or no clicking throughout evaluation period

Management of TMDs

bull Management goals for patients with TMDs are similar to those for other orthopedic or rheumatologic disorders

ndash Decrease pain

ndash Decrease adverse loading

ndash Restore function

ndash Resume normal daily activities

Orofacial Pain Guidelines for Assessment Diagnosis and Management 4th edition AAOP 2008


Conservative (reversible) Therapy

bull Physical Therapy

bull Self ManagementPatient Education

bull Behavioral modification

bull Medications

bull Orthopedic Appliances

Long term follow up of TMD patients shows that 50 to more than 90 of patients have few or no symptoms after conservative treatment From a retrospective study of 154 patients it was concluded that most TMD patients have minimal recurrent symptoms 7 years after treatment Furthermore 85 To 90 of the patients in 3 longitudinal studies lasting 2 to 10 years had relief of symptoms after conservative treatment and stability was achieved in most cases between 6 and 12 months after start of treatment


Even a Monkey can do it 3 Main TMD Categories

bull Masticatory Muscle Disorders

bull Arthralgia or Joint Disorders

bull Disc Derangement Disorders

Masticatory Muscle Disorders

Referral of myofascial trigger-point pain to the teeth A The temporalis refers only to the maxillary teeth

The Trigger Point Manual 2nd edition Baltimore Williams amp Wilkins 1999 pp 331 351 398)

B The masseter refers only to the posterior teeth

C The digastric anterior refers only to the mandibular incisors



The lateral pterygoid muscle refers pain deep into the temporomandibular joint and to the region of the maxillary sinus can cause tinnitus as well

The medial pterygoid muscle refers pain in poorly circumscribed regions related to the mouth (tongue pharynx and hard palate) below and behind the temporomandibular joint (TMJ) including deep in the ear but not to the teeth Stuffiness of the ear may be a symptom of medial pterygoid TrPs


Symptoms related to Masticatory Muscle Disorders

bull Patients commonly report pain that is associated with functional activities such as chewing swallowing and speaking

bull Patient reports pain in the face jaw temple in front of the ear or in the ear in the past month

bull Pain is aggravated by manual palpation of muscle(s)

bull Acute malocclusion (Lateral Pterygoid spasm)

bull Pain can awaken them at night andor is present in AM upon awakening

Ear Symptoms

Ear Symptoms such as ringingfullness in the ears may be related to an increase in activity of

ndash tensor typani

ndash Tensor veli palatini

ndash Levator veli palatini

ldquoit is understood that anatomically they are muscles of the middle ear although they are really muscles of mastication because they are modulated by motorneurons coming from the trigeminal motor nucleusrdquo


ldquojaw muscular activity may cause ear symptoms resulting from the tensor typani and tensor veli

palatine muscles participationrdquo

RAMIREZ A L M SANDOVAL O G P amp BALLESTEROS L ETheories on Otic Symptoms in Temporomandibular DisordersPast and Present Int J Morphol 23(2)141-156 2005

Stuffiness of the ear may be a symptom of medial pterygoid TrPs In order for the tensor veli palatini muscle to dilate the eustachian tube it must push the adjacent medial pterygoid muscle and interposed fascia

aside In the resting state the presence of the medial pterygoid helps to keep the eustachian tube closed Tense myofascial TrP bands in the

medial pterygoid muscle may block the opening action of the tensor velipalatini on the eustachian tube producing barohypoacusis (ear

stuffiness) Medial pterygoid tenderness was confirmed in all 31 patients who were examined and who had this symptom

The Trigger Point Manual 2nd edition Baltimore Williams amp Wilkins 1999 pp 331 351 398)Drake Grayrsquos Anatomy for Students 2nd Edition

Copyrightcopy 2009 by Churchill Livingstone an imprint of Elsevier Inc All rights reserved

Biting on a tongue blade is being used to determine whether the patientrsquos pain has its

origin in the joint structures or the muscles Biting on the tongue blade on the right side will reduce right intracapsular pain while biting on the tongue blade on the left side will

increase the pain in the right joint


If symptoms increase on the

side you are biting on may

incriminate muscle on that

side

This illustration shows that when a patient is biting on a tongue blade the tongue blade become a fulcrum with muscles on both sides Therefore biting hard on the right side will reduce the pressure in the ipsilateral joint If the tongue blade is moved to the left side and the patient is asked to bite the pressure in the right joint will increase


It is concluded that the bite test is of significantvalue for evaluation of TMJ disorders and canbe useful for the indication of complementary

radiological examinations

Konan E Boutault F Wagner A Lopez R Roch Paoli JR Clinical significance of

the Krogh-Poulsen bite test in mandibular dysfunction Rev Stomatol ChirMaxillofac 2003 Oct104(5)253-9

Julsvoll EH Voslashllestad NK Robinson HS Validation of clinical tests for patients

with long-lasting painful temporomandibular disorders with anterior disc

displacement without reduction Man Ther 2016 Feb21109-19


Diagnosing Masticatory Muscle Pain

Subjective

1 Patient reports having pain in the face jaw temple in front of the ear or in the ear in the past month

2 Patient is asked if the pain

a Increases during the day with chew talk yawn andor with parafunctional activities

b awakens them at night and or present in AM upon awakening

Examiner confirms pain location is a muscle(s)

Objective Finding Plus

1 During digital palpation a minimum of one site is painful in the masseter muscle ortemporalis andor

2 Patient reports having pain with maximum unassisted opening andor

3 Mouth opening is limited (may or may not be painful)

Pain that is reproduced or increased is familiar pain and is located in a muscle

I (Mike) typically find ROM mechanics are normal minimal or no joint noises

I (Mike) like to assess temporalis insertion on coronoid for tendinitis

Muscles of Mastication

Muscle Palpation (LAB)

bull Temporalis

bull Masseter

bull Medial Pterygoid

bull Temporalis Tendon

bull Vicinity of Lateral Pterygoid

bull Palatini Muscles

bull Anterior and Posterior Digastrics

TEMPORALIS

Palpation of the anterior (A) middle (B) and posterior regions (C) of the temporal muscles Copyright copy2013 by Mosby an imprint of Elsevier Inc

MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon

I prefer to use my pinky finger vs Index

Palpation of the tendon of the temporalis The clinicianrsquos finger is moved up the anterior border of the ramus until the coronoid process and the attachment of the tendon of the temporalis are felt Copyright copy2013 by Mosby an imprint of Elsevier Inc

Vicinity of Lateral Pterygoid

Using Pinky medial to coronoid process press superiorly into recess and have patient open into your finger

The intraoral palpability of the inferior caput of the lateral pterygoid muscle is verified The basic requirement for successfully palpating the lateral pterygoid

muscle is the exact knowledge of muscle topography and the intraoral palpation pathway After documented palpation of the muscle belly in

cadaverous preparations MRI and EMG also visualized palpation of the lateral pterygoid muscle in vivo The palpation technique seems to be essential and

basically feasible

Conclusion Considering the lack of validity and reliability associated with the palpation of the lateral pterygoid area

this diagnostic procedure should be discarded

Palpation of the lateral pterygoid region in TMD-where is the

evidence JC Turp S Minagi Journal of Dentistry 29 2001 475-483

Evidence - The intraoral palpability of the lateral pterygoid muscle

ndash A prospective study

Stelzenmueller W Umstadt H Weber D Goenner-Oezkan V Kopp S LissonJAnn Anat 2015 Dec 17

Drake Grayrsquos Anatomy for Students 2nd Edition Copyrightcopy 2009 by Churchill Livingstone an imprint of Elsevier Inc All rights reserved

Tensor and Levator Veli Palatini


To treat the two palatini muscles insert the index finger or little finger into the mouth and stay just lateral to the midline Feel for the end of the hard palate and do not press upward until you fall off the hard palate Press upward to affect the palatini muscles Sweep laterally with your finger hooked on the posterior part of the soft

palate and continue all the way out to the hamulus

Anterior and Posterior Digastrics

I will also palpate digastrics intraorally

Treatment for Masticatory Muscle Pain (MMP)

bull No Chew Diet

bull Behavioral Modification

bull Modify daily activities that may perpetuate MMP

ndash Discontinue oral parafunctional activity

Modalities

Intraoral Massage

Patient Self Massage

Self Help

Modalities

bull US US with ketoprofen rub or Dexamethasone

bull Iontophoresis

ndash Schiffman E TMJ Iontophoresis A double blind randomized clinical trial JOP1996 102

LLLT

bull LLLT (Low Level Laser Therapy) is the application of red and near infra-red light over injuries or lesions to improve wound and soft tissue healing reduce inflammation and give relief for both acute and chronic pain

Petrucci A Effectiveness of LLLT in TMD A Systematic Review and Meta-Analysis J Orofac Pain 201125298-307

ESTIM

bull Rich-mar Unit

bull Pre Mod IF

bull Estim on Surge Ramp up

bull 10 secs on10 off

bull 2x2 dual lead

bull 2 leads 1R 1B

bull Purpose is to inhibit pain and to relax muscle


TEMPORALIS SELF MASSAGE

--Place heel of hands on temporal area

--Gently clench teeth and feel muscle contract

under the heel of your hands

--massage using pressure to your tolerance for

2 to 3 minutes several times a day

MASSETER SELF MASSAGE

Using index and thumb finger gently massage

the muscles used for chewing 2 to 3 minutes

several times a day to your tolerance

CONTROLLED MOUTH OPENING

--Place tongue in the ldquoNordquo or ldquoNeverrdquo

position--Tip of tongue should be against the

hard palate NOT pressing against theback of your teeth

--This exercise focuses on the ldquorollingrdquo

movement occurring in the TMJ and isless traumatic

--You should not hear or feel anyclicking

--This controlled amount of openingshould dictate how wide you shouldopen when you yawn and what size bite of food you should take

--Perform this exercise in good posturalalignment tongue remains in contactwith the hard palate

--Perform 10 reps slow and controlled--Every 2 hours during the day

Experiment move tongue further back to limit opening or put tongue along upper back right molars to promote more movement of left condylar head or vice versa put tongue along left upper back molars to promote increase movement of right

condylar head

Temporalis Tendon Ice Massage

I

Occasional Muscle disordersbull Lateral Pterygoid Spasm patient is unable to

bring their back teeth together on the side of the pterygoid spasm( subjectively and objectively)

bull May occur after unexpected resistance when chewing food yawning wearing CPAP appliance wearing ARA

bull Rx dry needling gentle sustained posterior glide of mandible

bull Other causes of why a patient cannot bring back teeth togetherndash TMJ Arthralgia

ndash Prolong use of posterior coverage appliance

bull Trismus- is a tonic contraction of the muscles of mastication In the past this word was often used to describe the effects of tetanus also called ldquolock Jawrdquo The term trismus is now used to describe significant restriction to mouth opening (lt20mm) often related to intraoral injections or trauma

bull Subjective severe limitation of mouth opening an identifiable event

bull Objective MIOlt 20mm firm end feel with passive overpressure

A common cause of trismus often seen in general practice is the limited mouth opening that occurs 2ndash5 days after a mandibular

block has been administered This is usually attributed to inaccurate positioning of the needle when giving the inferior

nerve block Ideally the needle should be placed in the pterygoid space which is bound by the internal oblique ridge of the mandible on the lateral side and pterygomandibular raphe

on the medial side Occasionally the medial pterygoid muscle is accidentally penetrated or a vessel is punctured and a small

bleed follows a haematoma can occur in the muscle bed and subsequently organize causing a fibrosis Trismus due to this

cause can be protracted and quite severe

httpswwwyoutubecomwatchv=kmPqV-dMo98Mandibular Anesthesia - Inferior Alveolar Nerve Block


Trismus Treatment

Stretching exercises can often be used to regain normal opening movement The patient is instructed to apply stretching force gently and intermittently to the

elevator muscle with the fingers Pain should not be elicited If it is then the force should be decreased or the exercises stopped completely

Have patient read out loud 3 to 5 minutes daily with cork in mouth Cut cork down to a size that applies some stretch but patient is able to attempt to articulate

I have found if I cut down a tongue blade 1 to 2 mm less than the opening measurement I achieve after a session and give to patient they come back each session maintaining some of the motion we achieved at the prior session

This specimen depicts significant osteoarthritic changes Here the articular surface of the condyle and fossa is flattened and the disc (D) is anteriorly dislocated

Courtesy of Dr Frank Dolwick University of Florida Gainesville FL

Bakke M Petersson A Wiesel M Svanholt P Sonnesen LJ Oral Facial Pain Headache 2014 Fall28(4)331-7

A considerable portion (476) of OSA patients without ongoing pain and TMJ complaints had bony deviations with CBCT images These bony changes were not

associated with clinical diagnoses

CBCT images of a TMJ of a patient with a RDCTMD diagnosis of OA and with osteoarthritic changes (erosions and osteophyte) (a) Sagittal (b) Coronal

Radiographic evidence of osteoarthritis A Severely deformed condyle resulting from osteoarthritis (cone beam CT) B A panoramic radiograph depicting left condylar

changes C Significant osteoarthritic changes in the condyle and fossa D Lateral cone beam CT view revealing significant flattening resulting in an osteophyte (arrow)


Symptoms related to TMD Arthralgia

bull Patient reports having pain in face jaw temple in front of the ear or in the ear the past month

bull Patient is asked if pain increases during the day with chew talk andor yawn

bull Parafunctional activity may also increase pain

bull May follow typical arthritic pattern less ROM in am more during day tightening again at night


Objective Examination for TMD Arthralgia

Joint Palpation

bull Lateral Pole with back teeth together pain No ___ Yes ___

bull Lateral Pole with mouth open (gt11mm) pain No ___ Yes ___

bull Posterior attachment ldquoinside earrdquo pain No ___ Yes ___

In my opinion palpation here is assessing Lateral Collateral Ligament tenderness and assessing posterior disc attachments informing you of position of condyle as possibly being more Superior and Posterior in the Temporal fossa

Steve Kraus recommends doing back teeth together and apart because some patients may say they have pain on opening and not with back teeth together So if opening is painful it only tells you of the possibility of three tissues that may be involved (later collateral TMJ lig or capsule -pertaining to the joint only but it can also suggest muscle)

Tests primarily provides a base line to reassess the effects of treatment and nothing else

One test tells you nothing multiple tests (when using clinical reasoning) tells you more

Palpation of the TMJ A Lateral aspect of the joint with the mouth closed B Lateral aspect of the joint during opening and closing C With the patientrsquos mouth fully open the clinician moves a finger behind the condyle to palpate the posterior aspect of the joint

I tend to prefer lateral excursion to opposite side



origin in the joint structures or the muscles Biting on the tongue blade on the right side will reduce right intracapsular pain while biting on the tongue blade on the left side will increase the pain in the right joint


Joint Pain Map

Synovial Spaces 1 2 5 6

TMD Arthralgia ROMbull Assess ROM as demonstrated earlier

bull Jaw dynamics may or may not be limited

bull I like to use a stethoscope to listen from crepitation type sounds grating grinding vs a discrete ldquoclickrdquo

bull Here is where Condylar asymmetry is important to at least file away in your memory banks


A Sometimes significant osteoarthritic changes occur in only one joint When this happens rapidly the affected condyle can

collapse resulting in a shifting of the mandible to that side This is referred to as idiopathic condylar resorption B In this patient

there has been a midline shift to the patientrsquos right This shift is evident even in the relationships of the posterior arches This

idiopathic condylar resorption was isolated to the patientrsquos right condyle C A cone beam CT of the right condyle showing the

degenerative changes D The loss of condylar support in the right condyle caused a shift to the right so that only the right second

molar is contacting Copyright 2013 by Mosby an imprint of Elsevier Inc

A This radiograph reveals idiopathic condylar resorption of the left condyle The majority of this bone loss occurred in a 3-month period B As a consequence of this significant and rapid bone loss the mandible was shifted to the left side where only the left second molars contact C As the left masseter and temporal muscles contract the mandible is shifted to the left so that only the second molars contact on the affected side D The heavy contact on the second molar accompanied by the elevator muscle activity has caused a posterior open bite on the patientrsquos right side

Copyright 2013 by Mosby an imprint of Elsevier Inc

Rheumatoid arthritis commonly causes a significant and relatively rapid loss of the articular bone of both condyles With this loss of posterior support to the mandible the posterior teeth begin to contact heavily These teeth act as fulcrums by which the mandible rotates collapsing posteriorly and opening anteriorly The result is an anterior open bite


LAB

Palpation of Lateral Poles

Bite Test

Pain Map ndash we will not cover

Treatment for Arthralgia

bull No Chew Dietbull Gentle Mandibular Mobilizations to gate painflush

jointbull Treat Masticatory pain ( if diagnosed)bull Controlled mouth opening bull Control Yawnbull Avoid elective dental workbull Discuss with Dentist possible NSAIDsbull Modalities

ndash Heat or icendash US (phono)ndash Iontondash LLLT

Hypermobility

bull Patient will report the jaw ldquogoes outrdquo when opening wide

bull At the later stage of opening the condyle will jump forward leaving a small depression in the face behind it

bull A deviation can be present and greater and much closer to the maximally open position that that seen with Disc Derangement disorder


bull An eminence click may or may not be felt or heard

bull In my opinion loading the mandible with opening brings out subluxation or eminence click so that it is more noticeable

bull S jaw goes out when opening wide joint noises end of mouth opening or beginning of mouth closing jaw catches on closing from fully opened position

bull O A jutter is felt at end of mouth opening and the beginning of mouth closing eminence click may or may not be felt or heard

DEFLECTION

With unilateral hypermobility the mandibular midline shifts to the contralateral side at the very end

of mouth opening when the condyle passes the articulating

eminence and you end up with a deflection

Treatment for hypermobility

bull Patient education

bull Control mouth openingndash Eat smaller bites of food

ndash Limit mouth opening with dental cleanings

ndash No Jimmy John subs

ndash Control yawning (tongue up against palate far back if necessary)

ndash Controlled mouth opening

ndash Neuromuscular reed- hyperboloid training deep masseter and lateral pterygoid retraining

Manipulation after TMJ dislocation (a) The condyle is dislocated anterior to the articular eminence (red

shadow) (b) During manipulation the posterior part of the mandible is distinctly guided downwards-backwards to aid the condyle in passing the articulating eminence

and retrude into the articulating fossa (c) After successful manipulation the condyle is seated in the articulating fossa behind the articulating eminence at

intercuspal position

a b

c

A Clinical appearance of a spontaneous dislocation (open lock) The patient is unable to close the mouth B A panoramic radiograph of a patient experiencing a spontaneous dislocation Here the condyles are bilaterally positioned anterior to the eminences


Normal Stable DiscCondyle DiscEminence

Disc DisplacementAn anterior or anterior medial disc displacement is the most common form of a disc displacement that potentially effects jaw

range of motion

A In the closed-joint position the pull of the superior lateral pterygoid muscle is in an anteromedial direction (arrows) B When the mandible translates forward into a protrusive position the pull of the superior head is even more medially directed (arrows) Note that in this protruded position the major directional pull of the muscle is medial and not anterior C From a superior view the entire disc may be displaced anteriorly medially D In some instances the lateral portion of the disc may be more displaced than the medial portion E In still another instance the medial portion of the disc may be more displaced than the lateral portion

Parts A B courtesy of Dr Samuel J Higdon Portland OR

A Normal position of the disc on the condyle in the closed-joint position B Functional displacement of the disc Its posterior border has been thinned and the discal and inferior

retrodiscal ligaments are elongated allowing activity of the superior lateral pterygoid to displace the disc anteriorly (and medially C In this specimen the condyle is articulating on the posterior

band of the disc (PB) and not on the intermediate zone (IZ) This depicts an anterior displacement of the disc (Part C courtesy of Dr Julio Turell University of Montevideo Uruguay)

httpwwwpipererccomtmjasp

Piper Classification Rocabado has 4 Phases of Disc Displacement Disorders

Musculoskeletal Approach to Maxillofacial Pain by Rocabado and Iglarsh1991


bull Phase I- the disc drops medially as the LCL elongates beyond 70 or 80

bull With Phase 1 no joint sounds and there is actually a medial subluxation in opening and a lateral reduction in closing (opposite from phase 2 and 3 in which the disc reduces with opening and subluxes with closing)

bull Causes could be occlusal fulcrum cross bite posterior rotation of cranium

Musculoskeletal Approach to Maxillofacial Pain by Rocabado and Iglarsh1991 Musculoskeletal Approach to Maxillofacial Pain by Rocabado and Iglarsh1991

bull Phase II- click will occur at about 10-20mm of opening an early opening click a late closing click

bull Pattern of dysfunction in Phase II is opposite I In Phase II with opening the click is the disc reducing and the click on closing is the disc subluxating again

bull So the disc is now more anterior and probably medial

bull Frequently accompanied by parafunction ie nocturnal grinding or nail biting


bull Phase III- there is significant LCL and posterior ligament overstretching

bull The shape of the disc can become distorted more convex

bull Late opening click at 20-30mm and a click upon closure

bull Can develop capsular tightness and hence mobilizations are performed to address this


bull Phase IV- The disc may be completely deformed in front of the condyle

bull The condyle will rotate deep within the mandibular fossa but cannot translate forward in the initial stages of disease although later normal motion may return

bull There is no joint sound bull Limitation of the translation phase of opening

may result in a loss of up to 50 of total opening with a deflection of the mandible to the side with limited motion

bull This is called a posterior-superior condylar-disc luxation with an anterior disc-temporal luxation

bull Disc is not reducible

Couple of key pointsbull The further anteriorly the disc is on the temporal

eminence the more displaced it is and the greater opening (or protrusion according to the 411 rule) needed for the condyle to reduce into the disc

bull The disc can also displace laterally and (more commonly) medially

bull Note that the condyle and the disc luxate in opposite directions

bull A therapist who assesses a sound with 40-50mm of opening with loading is usually not subluxated The sound is due to the condyle going over the anterior border of the disc or temporal eminence- this is an over-rotation subluxation due to hypermobility (over-rotation because all the translation has been used up) It is not a phase 4 but may lead to a phase 1 later on

Classification of Disc Displacement

Stage 1

Disc displacement with Reduction (DDWR)

Stage 2

Disc Displacement without Reduction with limited opening (DDWoR WLO)

Stage 3

Disc Displacement without Reduction without limited opening (DDWoR WoLO)

Evaluation and Treatment of TMD by Steve Kraus Jan 2013 course presentation

Factors contributing to a disc displacement

bull Trauma

bull Anteriorly displaced by muscles ( sup Lat Ptyer)

bull Superior retrodiscal lamina becomes elongated

bull Tanaka identified a ligamentous attachment of the medial portion of the condyle-disc complex to the medial wall of the fossa if this ligament was bound down forward movement of the condyle might create a tethering of the disc medially

bull LCL laxityndash Repetitive

ndash Sustained

ndash Excessive joint loading

DDWR- STAGE I


Reciprocal click Between positions 2 and 3 a click is felt as the condyle moves across the posterior border of the disc Normal condyle-disc function occurs during the remaining opening and closing movement until the closed-joint position is approached Then a second click is heard as the condyle once again moves from the intermediate zone to the posterior border of the disc (between 8 and 1)


DDWRbull Subjective

ndash patient reports having a click in their jaw(s) while opening their mouth

ndash Patient may or may not have a prior experience of their jaw locking intermittently so that it would not open all the way

bull Definition- Click or a snap pop or crack is a distinct sound of brief and very limited duration with a clear beginning and end that emanates from the TMJ


DDWR

bull Objective Findings

ndash A palpable irregularity of a reciprocal clicking is felt and maybe heard

ndash Opening click is louder that the closing click

ndash Opening click at 5 to 10mm or greater of interincisal opening with the closing click less than 5mm

ndash Clicking may occur during lateral excursion or protrusion

ndash Clicking is eliminated on protrusive opening and closing

DDWoR WLO- STAGE II (close lock)

Functional disc dislocation without reduction (Closed lock) The condyle never assumes a normal relationship on the disc but instead causes the disc to move forward ahead of it This condition limits the distance it can translate forward


DDWoR WLO- STAGE II

bull Subjective-ndash Limited opening that is severe enough to interfere

with eating yawning brushing of teeth flossing singing etc

ndash History of clicking wor wo intermittent locking

ndash Intermittent locking would be when a patient experiences a sudden episode of limited mouth opening Mouth opening returns to normal with spontaneous resolution or resolution in response to force or movement (lateral protrusive andor opening) exerted by patient


DDWoR WLO- STAGE II

bull Objective-

ndash Maximum unassisted mouth opening lt30mm with deflection to the side of the involved joint

ndash Protrusion limited with deflection to the side of the involved joint

ndash Contralateral excursion is limited (assuming disc is medially displaced vs Just anteriorly displaced)


A In this specimen there is a functionally anterior dislocated disc and the condyle is totally articulating in the retrodiscal tissues (RT)B The specimen also has an anterior dislocated disc The condyle has moved closer to the fossa as the joint space (JS) has narrowed This disc dislocation is probably chronic

What other view might help you determine if disc was medially or laterally displaced as well

Courtesy of Dr Per-Lennart Westesson University of Rochester Rochester NY


Do all DDWR progress to a DDWoR WLO

bull Some patients may never progress from Stage I to Stage II

bull Some patients may never have a history of a clicking or reducing discs and go immediately to a non reducing disc problem

bull Some patients may progress from a DDWR to a DDWoR WLO immediately after one click and others may click and make joint noises and never progress

DDWoR WoLO ndashStage III

bull Subjective-

ndash May complain of limited opening but is not severe enough to interfere with eating yawning brushing teeth flossing singing etc

ndash History of clicking wor wo intermittent lockingbull Objective Findings- Active unassisted mouth opening is gt30mm of

MIO Palpable crepitus may or may not be identified

during opening and closing





DDWRSubjective-clickingObjective ndashfeelhear a click during mandibular opening and closing

--elimination of click on protrusive opening and closing

DDWoR WLOSubjectivemdashlimited function

---prior history of popping with or without intermittent lockingObjective ndashmandibular openinglt 30mm

--limited mandibular movement with deflection towards the involved joint during opening and protrusion--a decrease in lateral excursion towards the opposite side of the involved joint

DDWoR WoLOSubjectivendash may complain of limited function

--prior history of popping with or without locking crepitus may or may not be present

Objectivemdashnormal or near normal (gt30mm) mouth opening--palpable irregularities of crepitus may or may not be identified during opening and closing



Lab SessionmdashDiagnosing Stage I II IIIPhysical Therapy for DDWR without

Pain

bull Explain and educate patient as to what is going on popping may continue indefinitely they may experience brief moments of locking

bull Reassure what they have is common their condition rarely deteriorates to the level of having chronic pain and loss of oral function

bull Try to ease their fears so as not to create anxiety or somatize their joint condition


Physical Therapy for DDWR with Pain

bull Treat other sources of symptoms that may be unrelated to the DDwR such as

ndash Arthralgia

ndash Muscle pain

ndash Cervical spine pain

Physical Therapy for DDWR with Intermittent locking

bull Objective is to decrease joint loading which mayndash Decrease intermittent locking andorndash Decrease loudness of the pop andorndash Increase mouth opening before the pop (in essence

increasing translation by probably moving the disc more anterior)

ndash Improving opening while decreasing loudness or intensity of pop maybe eliminating click all together

Decrease joint loading by ndash Decreasing jaw muscle tensionndash Decreasing neck muscle tension


Manual Techniques

bull IntraoralExtraoral Massage of muscles identified on evaluation

bull Mobilization techniques to TMJ

ndash Long axis distraction

ndash Laterally mobilize condyle for medial joint distraction

ndash Stabilize condyle and mobilize Cranium laterally for lateral joint distraction (superior compartment per Rocabado)

bull Then I will follow up all mobilizations with controlled mouth opening

bull Then I have patient perform lateral excursion with 2 tongue depressors or hyperboloid

ndash Active activeassistive passive

ndash I do not do protrusive movements until pain and inflammation are significantly down

ndash Protrusion or translation is irritating to joint if you regain lateral excursion which is less irritating to joint protrusion will come as will opening ROM


bull I always finish Jaw techniques with a courtesy suboccipital distraction

bull I then proceed to slowly progress patient thru postural correction program

bull I will typically show the rest position of the jaw and add jaw wiggle

bull I will add chin nod to begin decompressing suboccipital area

bull If necessary I will finish with modalities laser ice etc for pain relief

bull Over time add stabilization exercise with Hyperboloid deep masseter (laterally) and Lateral Pterygoid (medially) to the disc

TMJ MOBILIZATION LAB

Physical Therapy for DDWoR WLObull Increase condyledisc translation

bull Manual massage techniques

bull Mobilization techniques Mobilization with guided movement into translation or lateral excursion

ndash Gentle techniques

ndash Min to no pain

ndash Add cervical extension with mobilization techniques if needed

bull Controlled mouth opening (tongue on left or right maxillary molars)

bull Lateral excursions

bull Mandibular isometrics

bull Tongue depressor stretch

bull Cervical treatment

bull Modalities as needed


neutral left lateral excursion right lateral excrusion

Protrusion Tongue depressor stretch

Finger Spread Technique

Self Long Axis Distraction Technique

Home Program

bull Handouts

bull Postural correction exercises

bull Measuring tongue depressor so patient knows what their opening was when they left treatment Goal is to maintain opening between sessions but not uncommon to lose a few mm between sessions

bull I like to gain 3 to 5mm each session with the goal being maintaining about 5 mm range each week

Physical Therapy for DDWoR WoLO

bull Requires no treatment other than explain what they are experiencing

bull Crepitus may continue indefinitely if present

bull What they have is common

bull If pain is present then Treatndash Arthralgia

ndash Masticatory Muscle Pain

ndash Referred pain from Cervical spine


Characteristics of 511 patients with temporomandibular disorders referred for physical therapyby Steven L Kraus PT

Oral Surg Oral Med Oral Pathol Oral Radiol 2014118432-439

Concurrent diagnostic subsets identified in this study are similar to those of other studies which show that a 1-

category diagnostic subset of TMD is scarce in the clinical environment The largest subset of TMD is myofascial pain

and the most common concurrent diagnostic subset identified in group II and group III is myofascial pain The most prudent thing to do therefore in the clinical setting would be

to manage myofascial pain Managing myofascial painoften reduces pain and dysfunction associated with group II

and III diagnoses Treating only myofascial pain may work well for the majority of patients For other patients it may be

necessary that their concurrent diagnostic subsets be dealt with simultaneously




Rocabado 6 x 6

Hyperboloid Exercises for ROM and Neuromuscular Reeducation

Effectiveness of Manual Therapy and Therapeutic Exercise for

Temporomandibular Disorders

Systematic Review and Meta-AnalysisSusan Armijo-Olivo Laurent Pitance Vandana Singh Francisco Neto

Norman Thie Ambra MichelottiPhys Ther 2016 Jan96(1)9-25

Although the overall level of evidence is low exercises and MT are safe and simple interventions that could potentially be beneficial for patients with

TMD Active and passive exercise for the jaw postural exercises and neck exercises appear to have

favorable effects for patients with TMD Manual therapy alone or in combination with exercises shows

promising effects Exercises did not show clear superiority over other conservative treatments for TMD

Here is the group I like to work with There are so many kids with headaches

parafunction mouth breathers poor posture This is the group to me that we have the greatest chance of helping and

not allowing early degeneration of the TM joints and cervical spine

Cervical Spine Evaluation


Jules Hesse fysiotherapistAmsterdamhttpwwwjuleshessenl

Characteristics of 511 patients with temporomandibular disorders referred for physical therapy

by Steven L Kraus PTOral Surg Oral Med Oral Pathol Oral Radiol 2014118432-439

Neck pain was the second most common symptom in the present study reported by 68 of the 511 patients The coexistence of neck pain and TMD has been reported previously and its clinical implications should

not be underestimated

CONCLUSIONSSubjects with TMD had signs of upper cervical spine movement impairment greater in those with headache Only subjects with TMD and headache had impairment of cervical spine sagittal plane mobility This study provides evidence for the importance of examination of upper cervical mobility determined by the FRT in patients who suffer from TMD

A single blind examiner evaluated cervical range of motion (ROM) measures including axial rotation during the flexion-rotation test (FRT) and sagittal plane ROM Twenty asymptomatic subjects were compared with 37 subjects with pain attributed to TMD confirmed by the Revised Research Diagnostic Criteria Subjects with TMD were divided according to the presence of headache (26 without headache TMDNHA 11 with headache TMDHA) One-way analysis of variance and planned orthogonal comparisons were used to determine differences in cervical mobility between groups All subjects with TMD were positive on the FRT with restricted ROM while none were in the control group


POSTURE FACIAL ASSYMETRY

Cervical Spine Treatment

101

C2-7V

65

65

5

SAGITAL CRANIOCERVICAL from ROCABADO

Rocabado

DEGENERATION ISNOT A PROBLEM

OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem

Convergence of the trigeminal and cervical nerves is an anatomic and

physiologic explanation for referred pain from the cervical

region to the trigeminal

The muscles of the jaw tongue face throat and neck work

synergistically to execute multiple orofacial functions but pain in

these areas alters the movementsNeck or shoulder pain may result in impaired jaw movement and

vice versa

A Injury to the trapezius muscle results in the tissue damage Nociception arising in this cervical region is transmitted to the second-order neuron and relayed on to the higher centers for interruption B As this input becomes protracted note that the adjacent converging neuron is also centrally excited which relays additional nociception on to the higher centers The sensory cortex now perceives two locations of pain One area is the trapezius region which represents a true source of nociception (primary pain) The second area of perceived pain is felt in the TMJ area which is only a site of pain not a source of it This pain is heterotopic (referred) (Adapted from Okeson JP Bellrsquos Orofacial Pains 5th ed Chicago Quintessence 199566)

Perspective The current study showed the existence of multiple active muscle TrPsin the masticatory and neck-shoulder muscles in women with myofascial TMD pain The local and referred pain elicited from active TrPs reproduced pain complaints in these patients Further referred pain areas were larger in TMD pain patients than in healthy controls The results are also in accordance with the notion of peripheral and central sensitization mechanisms in patients with myofascial TMD

Combined treatment approach of Mobilization Manipulation and

Exercise provides relief

journal of orthopaedic amp sports physical therapy | volume 39 | number 5 | may 2009 |

Key Points

Mechanical neck disorders are common costly and can be disabling This systematic review of 33 trials did not favor mobilizations andor manipulations done alone or combined with other treatments like heat for relieving acute or persistent pain and improving function when compared to no treatment Mobilization andor manipulation when used with exercise are effective for alleviating persistent neck pain and improving function when compared to those who received no treatment When compared to one another neither mobilization nor manipulation was superior There was insufficient evidence available to draw conclusions for mechanical neck disorder with radicular findings


Individuals with neck pain who received a combination of thoracic spine thrust manipulation and cervical spine nonthrust manipulation plus exercise demonstrated better overall short-term outcomes on

the numeric pain rating scale the Neck Disability Index and the global rating of change

journal of orthopaedic amp sports physical therapy | volume 43 | number 3 | march 2013

Low to Moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain

immediately post treatment and intermediate term and

cervicogenic headaches in the long term

Functional and Structural Changes in Muscles related to pain(adapted by Falla and Farina 2007)

THE ROLE OF THE PHYSICAL THERAPIST IS TO BE A

ldquoSTUDENT OF MOTION SCULPTOR OF STRUCTURE

AND FACILITATOR OF FUNCTIONrdquo

As quoted from a 1991 article

By

Mannheimer and Rosenthal

Treatment Approach Cervical Spine

Myofascial Mobilization

Joint Manipulationamp

Mobilization

Patient directed exercises to maintain myofascial mobility

And Joint mobility

Neuromuscular reeducation and strengthening of supporting

musculature

Ergonomics and Bad Habits Healing Hands by Joseph Ventura


Soft tissue massage

bull Massage induces acute antinociceptive effects involving opioid and oxytocin interaction(hug)

bull Massage may alter the sensitization state of the trigeminocervical nucleus

bull Massage may influence the potential to change the neck muscle tone through alteration of the trigeminalreticular pathway

Dr Kathleen C Light a professor at the University of North Carolina

Department of Psychiatry

Effects of partner support on resting oxytocin cortisol norepinephrine and blood pressure before and after warm partner contact Psychosom Med 2005 Jul-

Aug67(4)531-8 Grewen KM Girdler SS Amico J Light KC

ANTERIOR CRANIAL LUXATIONDENTAL CASE LACK OF DIAGNOSIS

PTOT RESPONSIBILTY


3 Primary Conditions That Could Contribute to Disruption of Strength

and Integrity of These Ligaments

bull Downrsquos Syndrome

bull Rheumatoid Arthritis

bull Cervical Spine Trauma

ndash MVA or CAD Injuries

S3 Seminar manual by Stanley Paris 2000 edition

Occult hypermobility of the craniocervical junction a case report and reviewMathers KS Schneider M Timko M J Orthop Sports Phys Ther 2011 Jun41(6)444-57

3 Quick Screens

bull Alar Odontoid Integrity Test

bull Transverse Ligament TestAnterior Shear Test

ndash SC Flexion or chin nod

ndash Sharp Purser Test



Suboccipital Release

More aggressive suboccipital release with head pinning

DownslideDistraction

Gentle Relaxation and Mobilization While Assessing


C0-C2 DistractionStabilize C2 with

lumbrical grip not pincher

Distract base of occiput with other

hand and head pinning

I will palpate transverse process of Atlas bilaterally either sitting or supine or both to assess which one feels more prominent which might suggest a rotational issue of C1 usually the one more prominent tends to be more tender Then use FRT to confirm If you have a hard time finding the TP of C1 have patient protruded their mandible to expose TPs

ASSESSING C1C2 ROTATION RESTRICTIONSWith Flexion-Rotation Test

MUSCLE ENERGY TECHNIQUE TO CORRECT C1C2 ROTATION RESTRICTION

Muscle Energy Technique for Restricted Rotation to the Right at C1-2



1The patient is supine and the operator sits or stands at the patients head2With the palms of both hands (andor belly) the operator supports the patients head and flexes the neck as far as it easily goes usually approximately 45 degrees or I will do chin to chest3 Monitoring on the posterior lateral aspect of C2 the operator turns the patients head to the right until C2 on the left just begins to move or you engage barrier and then backs off the barrier by de-rotating slightly4 The patient is asked to turn his or her head gently to the left (or donrsquot let me

turn you right) or simply to move his or her eyes to the left The effort is maintained for 3-5 seconds while the operator resists any movement 5 On relaxation the operator rotates the patients head further to the right and the patient is asked to look to the right to help facilitate further right rotation 6 Steps 4 and 5 are repeated two or more times7 Retest to see if right rotation has been fully restored at this segment

Do the opposite for restricted rotation to the left at C1C2

MANUAL TOWEL TRACTION

Block cervical spine and

occiput from going into too

much extension

Lean back on back leg to use

your body vs too much arms

PA scooping motion with your fingers to upper thoracic spine

OSTEOPATHIC MANIPULATION

bull High VelocityLow Amplitude

bull Create a barrier

ndash A cumulative end of range vs anatomical end of range

ndash You ldquocreaterdquo this barrier by combining many components flexion extension sidebending sideshifting rotation and donrsquot forget compression

Effects of manipulation

bull Mechanicalndash Stretch out tight capsulesndash Stretch out adhesionsndash Snap adhesions ldquopoprdquondash Alter positional relationships

bull Psychologicalndash Laying on of intelligent and

skilled hands provides confidence and assurance something good will happen

ndash Hearing or feeling the ldquopoprdquo

bull Neurophysiologicalndash Firing type III inhibitory

receptors reducing muscle holding

bull Chemical effectsndash Possible release of endorphins

Healing Hands by Joseph Ventura

OA SIDEBENDING MANIPULATION


The present study shows that the dry needling

treatment is effective in relieving the pain and in

improving the quality of life of patients with MPS

Trapezius

SCMFinger placement for photographic reasons

Levator

Anterior scalene

Oblique Capitas Inferior directed towards opposite eye (fingers removed for photographic reasons)

Start with back of head and spine against corner of wall

Nod your chin down about 15 degrees The back of your head should remain in

contact with the wall Your eyes should remain level-imagine a

string at the top of your head pulling up

Do 15 reps x 5 secs each5 times a day

Chin Nod


CERVICAL JOINT LIBERATION (Rocabado)

Stabilize C2

C1-C2 self-sustained natural apophyseal glide (SNAG) for cervical right rotation Force is applied to the C1 level via horizontal

pressure from the strap At the same time the subject actively turns hisher head to the right

The best available studies indicate that the C2C3 zygapophysial joints are the most common source of

cervicogenic headache

Cooper G Bailey B Bogduk N Cervical zygapophysial joint pain maps Pain Medicine 2007 8 344ndash53

Lord S Barnsley L Wallis B Bogduk N Third occipital headache a prevalence study J Neurol Neurosurg Psychiatr 1994 57 1187ndash90

Bogduk N Marsland A On the concept of third occipital headache J Neurol Neurosurg Psychiatr 1986 49 775ndash80

Bogduk N Marsland A The cervical zygapophysial joints as a source of neck pain Spine 1988 13 610ndash17

Make sure arms are just above 90 degrees Elbows should be bent at 90 degrees Hold position for 3 minutes increase time

as tolerated

Do exercise 1 to 2 times a day

To enhance stretch nod chin down and pullyour navel into your spine

Foam Roller Chest Stretch

Sidebend your head to one side slightly off the foam roller gently grab your head to add in the sidebendingcomponent

Place your arm in the position shown experiment with arm straight or slightly bent

Now rotate your head up and back to feel stretch in area as shown below

Do each side twice 2 reps x 30 to 60 seconds

Do 1 to 2 times a day


Edge of table should be about mid chest Arms at your side

PRONE CHIN NOD

Nod chin in as in standing wall exercise Imagine string at top of head pulling you tall

Perform 15 reps x 5 secs eachPerform exercise 1 to 2 times a day

Thumb is up

Start position

Finish Position

Sitting with excellent posture Be sure to reach way back Perform 2 sets of 10-15 reps

each arm Perform 3x a week

DIAGNOL THERABAND SCAPULAR STRENGTHENING

EXERCISE

Thumb is pointing

back

Start Position

Finish Position



HORIZONTAL ABDUCTION THERABAND SCAPULAR

STRENGTHENING EXERCISE

LATISSIMUS THERABAND STRENGTHENING EXERCISE

Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head

Sitting with excellent posture Be sure to reach way back Perform 2 sets of 10-15 reps each arm Perform 3x a week

Start Position Finish Position

Alternate View

ALL-IN-ONE SCAPULARNECK STABILIZATION EXERCISE

Nod your chin down 15 degrees Keep band pressed between your head and

the wall Straighten arms without your head leaving

wall Perform 2 sets x 10 reps each 3 to 4 times a week

Lower Trapezius

Mid Trapezius


Rhomboid Latissimus Dorsi

Serratus Anterior

Magnetic resonance imaging study of the morphometry ofcervical extensor muscles in chronic tension-type headache

C Fernaacutendez-de-las-Pentildeas A Bueno J Ferrando JM Elliott ML Cuadrado amp JA Pareja

Rectus capitis posterior minor left side is image of control group right side is image of CTTH group

In conclusion RCPmin and RCPmaj muscles showed reduced rCSA in CTTH patients comparedwith healthy controls Headache intensity frequency and duration were greater in those CTTH

patients with more reduced rCSA in both RCPmin and RCPmaj muscles

Craniocervical FlexionStart with pressure biofeedback inflated to 20 mmHg Make sure your chin and forehead are lined up Nod your head keeping the large neck muscles soft and

bringing the reading up to 22 mmHg Work up to ten 10-second holds Then progress to 24 26 and 28 mmHg

5 to 10 reps 5 to10 second hold times increase as tolerated

The Change in Deep Cervical Flexor Activity After Training Is Associated With the Degree of Pain Reduction in Patients With Chronic Neck Pain Deborah Falla PhD Shaun OrsquoLeary PhD

Dario Farina PhD and Gwendolen Jull PhD (Clin J Pain 201228628ndash634)

YAMUNA BODY ROLLING

Supportive Therapiesamp

Ergonomics


httpwwwrapidforce-phscom

Correlations between Posture and Jaw Relations Danner Jakstat and Ahlers Journal of

Craniomandibular Function 20091(2)149-163


Better Reading posture


wwwlumobodytechcom

LUMOback the first posture sensor and mobile

application to support healthy backsNow introducing the LumoLift

wwwvarideskcom


ERGONOMICSBAD HABBITS

So even though there is vast evidence showing the functional coupling between the

musculoskeletal structures of the cervical spine and the masticatory system there is only weak evidence for a direct biomechanical mechanism (such as the effect of poor head posture on the

masticatory system) as a cause for TMDs

The association between the cervical spine the stomatognathic system and craniofacial pain a critical review Armijo Olivo S1 Magee DJ Parfitt M Major P Thie NM J Orofac Pain 2006 Fall20(4)271-87

The association between head and cervical posture and temporomandibular disorders a systematic review Olivo SA1 Bravo J Magee DJ Thie NM Major PW Flores-Mir C J Orofac Pain 2006 Winter20(1)9-23

ldquoPOSTURE IS A REFLECTION

OF ONES ATTITUDE TO LIFErdquo

Dr Stanley Paris

Occlusal Appliance Therapy

Maxillary Occlusal Appliance


bull An occlusal appliance is a removable device usually made of hard acrylic which fits over the occlusal and incisal surfaces of the teeth in one archndash Occlusal Splint

ndash Bite guard

ndash Night guard

ndash Interocclusal appliance

ndash Orthopedic device


Not enough evidence about whether stabilisation splints can reduce pain caused by painful temporomandibular (jaw) disorders Pain

dysfunction syndrome (PDS) is the most common TMD (temporomandibular disorder from the joint between the lower jaw

and base of the skull) PDS is also called facial arthromyalgia myofacialpain dysfunction syndrome and craniomandibular dysfunction One

option is a splint (a type of bite plate) at night when people otherwise may grind their teeth more The stabilisation splint (SS) is one type also known as the Tanner appliance the Fox appliance the Michigan splint or the centric relation appliance The review found there is not enough

evidence from trials to show whether or not stabilisation splints can reduce PDS

J Evid Base Dent Pract 2006648-52

Conclusions that can be drawn from this evidence-basedreview include

1 There is insufficient evidence to suggest that any occlusaltreatment as reviewed here is more or less effective thanplacebo in treating TMJD pain

2 There is also insufficient evidence to suggest that anyocclusal treatment is as or more effective than otherrehabilitation treatments in treating TMJD pain

3 There is also insufficient evidence to support thegeneralized preventive influence of occlusal adjustmentand orthodontic correction of malocclusion on TMJDdevelopment

Since occlusal treatments are typically irreversible treatments and the evidence on its therapeutic or preventive effects

on TMJD is insufficient it is recommended that reversible treatment

such as self-care splints physical therapy and cognitive-behavioral

therapy be used to initially manage signs and symptoms of TMJD

Indications for an oral appliance per Kraus

bull To reduce AM jaw muscle pain and or HA if symptoms are triggered by sleep bruxism induced by mayalgia or arthralgia

bull To reduce AM lockingcatching associated with a disc displacement related to nocturnal bruxism activity

bull To protect occlusal surfaces of teeth and dental restorations from sleep bruxism forces


The nociceptive reflex is activated by unexpectedly biting on a hard object The noxious stimulus is initiated when the tooth and periodontal ligament is stressed Afferent nerve fibers carry the impulse to the trigeminal spinal tract nucleus The afferent neurons stimulate both excitatory and inhibitory interneurons The interneurons synapse with the efferent neurons in the trigeminal motor nucleus Inhibitory interneurons synapse with efferent fibers leading to the elevator muscles The message carried is to discontinue contraction The excitatory interneurons synapse with the efferent neurons that innervate the jaw depressing muscles The message sent is to contract which brings the teeth away from the noxious stimulus



Bruxism vs Clenching

bull Bruxing is an oral parafunctional activity that can occur Diurnally or nocturnally Bruxing is classified as a series of rhythmic contractions tooth grinding ~ 20 to 38 of children brux and 25 to 50 of adults brux

bull Clenching is more of a single contraction episode and this can occur as well during the day or night

The purpose of an anterior positioning appliance is to temporarily bring the mandible forward in an attempt to improve the condyle-disc relationship A This specimen reveals

a disc dislocation B The MRI shows the disc to be dislocated anterior to the condyle C When the mandible is brought forward the condyle is repositioned on the

disc D The MRI shows the disc in its normal position on the condyle This is a temporary therapeutic position that will encourage adaptation of the retrodiscal tissues

(Courtesy of Dr Per-Lennart Westesson University of Rochester Rochester NY)

What is the best occlusal appliance design

bull All appliances have the potential to be therapeutic for reasons that are not known

bull All Appliances have the potential of causing adverse side effects

ndash Increase pain

ndash Movement of teeth extrusion or intrusion

ndash Potentially could lead to orthognathic surgery

bull The best appliance design is one that causes the least amount of adverse side effects while providing for the most potential therapeutic benefit

ndash Reduce AM muscle painHA

ndash Reduce AM locking

ndash Protect occlusal surfaces

Appropriate features of an oral appliance

bull Maxillary or mandibular full coverage Maxillary is preferred when possible

bull Hard Acrylic vs soft

bull Thin as possible thickness of appliance is determined by looking at thickness of the appliance in the posterior molar region

bull Even centric stops on the appliance- ask the patient if they hit evenly on the appliance ask the patient to ldquotap-tap-taprdquo on the appliance and if they hit evenly on the appliance

bull Shallow inclines of the acrylic leading into the centric stops

bull Anterior guidance during protrusive and lateral excursions- anterior guidance is the relationship of any of the lower anterior 6 teeth maintaining contact with any of the upper 6 teeth during protrusive and lateral excursions resulting in disclussion of the posterior teeth during such movement


Why should a TMD specialist assess the design and understand the purpose of an oral appliance

bull Gain insight of the appropriateness of the oralappliance design

bull Communicate to the dentist necessary changes in oral appliance design-possibly as a result of your work on posture cervical spine alignment etchellip

bull Not uncommon for a dentist to ask for your advise on design of an oral appliance

bull Be satisfied that the patient has the best oralappliance design (according to the evidence) toachieve the best possible outcomes

James Fricton DDS MSJohn O Look DDS PhDEdward Wright DDS MSFrancisco G P Alencar Jr DDS MSHong Chen DDS MSMaureen Lang DDS MSWei Ouyang DDS PhDAna Miriam Velly DDS PhD Summer 2010 Volume 24 Issue 3pages 237-254

Conclusion Hard stabilization appliances when adjusted properly have good evidence of modest efficacy in the treatment of TMJD pain compared to non-occluding appliances and no treatment Other types of appliances including soft stabilization appliances anterior positioning appliances and anterior bite appliances have some RCT evidence of efficacy in reducing TMJD pain However the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use

PTDDS

Management and Treatment of Temporomandibular Disorders A Clinical PerspectiveEDWARD F WRIGHT DDS MS SARAH L NORTH PT MPT THE JOURNAL OF MANUAL amp

MANIPULATIVE THERAPY VOLUME 17 NUMBER 4 pg 247-254


Itrsquos not about the nail

THANK YOU Michael Karegeannes--OwnerPT MHSc LAT MTC CFC CCTT CMTPT

Jeff Verhagen -PT MBA CMTPT

Mike Verplancke ndash

DPT CSCS CMTPT

4 locationsFox Point WIBrookfield WIGrafton WIMukwonago WI

414-352-2082 work414-352-5279 fax

mkaregeannesfreedomptcom jverhagenfreedomptcom mlverplanckefreedomptcom

wwwfreedomptcomwwwtreatingtmjcom


copy 2015 Freedom Physical Therapy Services SC

TMD EVALUATION FORM TMD HISTORY

Health Professionals seen for current symptom(s) ____________________________________

Diagnostic procedure(s) done _____________________________________________________

Onset traumainsidioussurgeryother _____________________________________________

Previous treatment(s) ____________________________________________________________ Medications anti-inflammatorymuscle relaxernarcoticanti-depressantanti-

anxiety

Progression of symptoms better worse no change ________________________________

Do you have jaw pain No ___ Yes ___ R ___ L ___

Is your jaw pain constant ___ daily ___ weekly ___

What increases your jaw pain ______________________________________________

What decreases your jaw pain ______________________________________________

Does your jaw click pop grind No ___ Yes ___ R ___ L ___

Do you have limited mouth opening No ___ Yes ___ R ___ L ___

Has your jaw ever locked open ___ or close ___ No ___ Yes ___ R ___ L ___

Do you clench ___ grind ___ brace ___ No ___ Yes ___ R ___ L ___

Do you have ear symptoms No ___ Yes ___ R ___ L ___

Is your ear symptom (_____________________) constant ___ daily ____ weekly ___

What increases your ear symptom __________________________________________

What decreases your ear symptom __________________________________________

Do you have headaches No ___ Yes ___

Location ________________________________________________________________

Is your HA constant ___ daily ___ weekly ___



Do you wake with Headaches No___ Yes___ What increases your HA __________________________________________________

What decreases your HA __________________________________________________

Do you have neck shoulder pain No ___ Yes ___ R ___ L ___

Is your NS pain constant ___ daily ___ weekly ___

What increases your N S pain _____________________________________________

What decreases your N S pain _____________________________________________

Other symptoms _______________________________________________________________

______________________________________________________________________________

A Mandibular Dynamics Key 1= Mild Pain 1 Vertical Opening 2 = Moderate Pain

a Opening wo pain ___mm 3 = Sever Pain RIGHT LEFT

b Maximum opening wpain ___mm 1 2 3 1 2 3 c Opening Pattern wmandibular loading a Straight _______

b Deflection R____ L____c Deviation R to L ___ L to R____

2 Excursionsa Right lateral Excursion Right Left

limited No ___ Yes___ Pain No___ Yes___ 1 2 3 1 2 3

b Left lateral excursionlimited No ___ Yes ___ Pain No ___ Yes ___ 1 2 3 1 2 3

c Protrusionlimited No ___ Yes ___ Deflection No___ Yes ___

Pain No ___ Yes ___ 1 2 3 1 2 3



B Muscle Palpation Right Left 1 Temporalis pain tight No ___ Yes ___ 1 2 3 1 2 3 2 Masseter pain tight No ___ Yes ___ 1 2 3 1 2 3 3 Medial Ptyergoid pain tight No ___ Yes ___ 1 2 3 1 2 3 4 Temporalis Tendon pain tight No ___ Yes ___ 1 2 3 1 2 3 5 Vicinity of Lat Pty pain tight No ___ Yes ___ 1 2 3 1 2 3 6 AntPost Digastrics pain tight No ___ Yes ___ 1 2 3 1 2 3 7 SCM paintight No ___ Yes ___ 1 2 3 1 2 3 8 Subocc paintight No ___ Yes ___ 1 2 3 1 2 3 9 Levator pain tight No ___ Yes ___ 1 2 3 1 2 3 10 Trapezius paintight No ___ Yes ___ 1 2 3 1 2 3

C Joint Palpation1 Lateral Pole with back teeth together pain No ___ Yes ___ 1 2 3 1 2 3 2 Lateral Pole with mouth open (gt11mm) pain No ___ Yes ___ 1 2 3 1 2 3 3 Posterior attachment ldquoinside earrdquo pain No ___ Yes ___ 1 2 3 1 2 3

D Pain Map

E Joint Loading Right Left 1 Biting of fulcrum right molars pain No ___ Yes ___ 1 2 3 1 2 3

If painful response was joint (L) ___ muscle (R) ___ both ___ 2 Biting on fulcrum left molars pain No ___ Yes ___ 1 2 3 1 2 3

If painful response was joint(R) ___ muscle(L) ___ both ___ F Patient can bring back teeth together No ___ Yes ___G Hypermobile No ___ Yes ___ Identified by ldquojutterrdquo RL andor eminence click RLH Beighton Scale ___9



I Stage I (Disc Displacement with Reduction) Summary No __ Yes __ R __ L __ 1 Palpable opening click No ___ Yes ___ R___ L ___2 Late closing click No ___ Yes ___ R ___ L ___ Click too soft to ID ___ 3 Opening click eliminated on protrusive opening and closing No R _ L _ Yes R _ L _4 Patient reports having had intermittent locking No ___ Yes ___

J Stage II (Disc Displacement without Reduction with Limited Mouth Opening) Summary No __Yes __ R _ L_

1 Active Unassisted Mouth Opening is lt 30mm (see mandibular dynamics) No _ Yes _2 Prior history of clicking with or without intermittent locking No __ Yes __ R _ L _

K Stage III (Disc Displacement without Reduction without Limited Mouth Opening) Summary No_Yes _ R _ L _

1 Active Unassisted Mouth Opening is gt 30mm (See mandibular mechanics) No __ Yes__

2 Prior History of Clicking with or without Intermittent Locking No __Yes __ R __ L __

L Crepitus No __ Yes __ R __ L __M Occlusion Anterior Open Bite __ Posterior Open Bite __ Cross Bite YesNo R or LN Parafunctions Identified No ___ Yes ___ nail biting scalloped tongue cheek biting etcO Lip or Tongue Frenulum tightness No____ Yes____

P Cranial Nerve Testsa Trigeminal

i Jaw Reflexii Corneal Reflex

iii Sensory testing (light touch and pin prick)iv Isometric tests

1 Direction of movementsa Depressionb Elevationc Lateral excursion

b Faciali Muscle testing

ii Corneal reflexiii Sense of tasteiv Salivary glandv Tear gland



Oral Appliance Evaluation

1 Maxillary Full Coverage yes no Maxillary Anterior Coverage yes no Mandibular Anterior Coverage yes no Mandibular Full Coverage yes no Mandibular Posterior Coverage yes no Anterior Repositioning Appliance yes no

2 Hard_____ Soft____ 3 Thin_____ Thick___ 4 Centric Stops on a full coverage hard appliance ( taptaptap)

NA ___ even all around ___ front___back right___back left ___

5 Inclines leading into the centric stops Shallow ___ Steep ___

6 Anterior Guidance ___ balancing interference(s) were not present during protrusiveAnd lateral movements

___ balancing interference (s) were present during

Protrusive movement R L no R lateral movement yes(left) no L lateral movement yes(right) no

_____________________________________________________________________________________

Frequency in use of the oral appliance 24 hours a day yes no 24 hours a day except for eating yes no As needed during the day yes no At night yes no

Did your dentist tell you the purpose of the intraoral appliance yes no

If yes what is the purpose _______________________________________________________

______________________________________________________________________________



ROCABADO 6 X 6

The therapist should always implement a home treatment program to reinforce the clinical treatment

plan of care and modify the patients lifestyle and how the patientrsquos body functions in its working and

home environment As the craniomandibular and craniocervical environment is altered it must be

maintained Exercises remove parafunctional habits and reinforce new postures and functions The

home program the 6 x 6 programrdquo is a sequence of exercises for the patient in dysfunction This 6 x 6

exercise program complements the active clinical program performed by the therapist during the

patients acute and submiddotacute dysfunctional stages The home program exercises modify or reinforce the

postural relationships of

the cranium to the upper cervical spine

the cervical spine(anterior posterior and lateral aspects) to the shoulder girdle and

the mandible to the maxilla

These inter-relationships make up the elements that impact on the orthostatic equilibrium of the entire

upper body Consequently the practitioner must consider each of these components the relationship of

one component to another and the impact of each component on the entire body Therefore the

therapist treating temporomandibular pain must not restrict their evaluation and treatment to the

structures or the face and jaw but look at the entire body The objectives of the home self-mobilization

program are

I To learn a neutral postural position and rest position of the mandible

2 To fight the ldquosoft tissue memory of the old position

3 To restore the muscle to its original functional length

4 To restore normal joint play and mobility

5 To restore normal balance among the body parts

6 To give the patient an ongoing exercise program to incorporate into their life activities

This program should be initiated as the patients pain begins to diminish At this point the exercises will not irritate an acute condition and a therapist-patient relationship is established to some degree These factors will maximize effective patient compliance with the exercise program Factors that promote patient compliance are



I The exercises should not produce nor increase pain2 The patient should be taught the exercises gradually one to two per session3 The exercises should not take more than a few minutes to perform4 The performance of the exercises should be performed regularly and often so they become aroutine act that contributes to the consistent compliance of the patient to the program5 The exercise performance should be spaced through the day (every 2-3 hours)6 Performance expectations should not exceed the what a patient can truly accomplishbetween work and home responsibilities7 Visual cues wilt help patients remember to perform the exercises ie sticky note oncomputer phone desk mirror in bathroom a timer or any helpful reminder

The 6 x 6 program is not meant to be a time consuming regime These exercises should be able to be performed in any position and not last more than a few minutes The program is termed 6 x6rdquo because

1 There should be no more than six instructions2 They should be repeated six times each and3 They should be performed six times a day

Although each exercise program should be individually designed to the patients complaints there are six fundamental exercises commonly used in the treatment of head-neck-mandibular dysfunction for these patients These components are as noted below

1 Rest position of the tongue To establish a correct position of the tongue during rest it isnecessary to teach the patient the correct position of the tongue against the hard palate The practitioner asks the patient to place their tongue against the hard palate (never directly behind the upper incisors) and make a cluck-likerdquo sound or say the word ldquonordquo or ldquoneverrdquo This action will position the tip of the tongue in the same position that it assumes during swallowing and the correct mandibular rest position After identifying this position the patient attempts to maintain the anterior one-third of their tongue against the palate with a slight pressure key word is slight This position will contribute to the creation of negative pressure in Donders space to hold the tongue with little or no muscle action against the hard palate the normal rest position of the tongue With the tongue in this position the patient should attempt to breathe through their nose and use the diaphragm muscles for respiration rather than the accessory respiratory muscle (ie pectoralis scalenes scm and intercostals) The use of the accessory muscles promotes abnormal forward head and rounded shoulder posture and could lead to a host of other musculoskeletal problems



2 Control temporomandibular or joint rotation The temporomandibular joint rotation exercise limitsearly translation of the temporomandibular joint and promotes the normal repositioning of themandibular head in the fossa Rotation also allows the disc to maintain a healthy position over themandibular head rotating anteriorly or posteriorly during opening and closing of the mandible Duringthe phase of rotation in opening the upper head of the lateral pterygoid is relaxed and the lower head iscontracted This creates a pumping effect of the intracapsular musculature which is necessary tomaintain a healthy synovial joint The practitioner instructs the patient to place and hold the anteriorone-third of their tongue flat against the palate as the patient opens their mouth This tongue positionlimits the range of opening to rotation and reduces the patients tendency to protrude the mandible Inaddition this exercise will minimize joint sounds and therefore reduce the abnormal wear on thestructures of the temporomandibular joint This can be done by the patient monitoring joint rotation byplacing hisher finger over the temporomandibular joint the anterior lateral capsule After the patient isable to perform this exercise adequately they should attempt to chew with limited translation Thisamount of opening with minimal to no pain can also help limit or determine the bite size of food theyare allowed to chew The patient can more easily control translation if he practices chewing in front of amirror while palpating the temporomandibular joint The major emphasis of treatment of thehypermobile joints are to limit translation of the mandibular head control rotation stabilize and realignthe connective tissue ligaments capsule and joint and maintain the orthostatic head neck andshoulder girdle positions As the patient learns to control temporomandibular rotation and implementrhythmic stabilization techniques they will be treating the hypermobility of the TM joints



3 Mandibular rhythmic stabilization technique (RST) This technique is adapted from proprioceptiveneuromuscular facilitation techniques It attempts to increase the individuals muscular control bystimulating the proprioceptive capabilities of the neuromuscular system RST is a series of isometriccontractions of the muscles of mastication to resist opening closing and lateral excursion - the threeplanes of motion The patient should begin with their mandible in its rest position They should notpermit movement of the temporomandibular joint in response to the resistance applied Excessiveforces should not be used because only the force of one or two fingers is required to stimulate themuscles of mastication Initially the patient may palpate the specific muscle of mastication beingstimulated to provide feedback that the exercise is being done correctly Excessive force may inducemandibular motion and potentially damage or irritate the joint These exercises re-educate the patientsneuromuscular system to avoid unconscious abnormal positioning or posturing of the structures of themaxillofacial region while maintaining an orthostatic posture



4 Cervical joint liberation This technique creates a distraction force on the upper cervical vertebraeand relieves mechanical compression by elongating the posterior and suboccipital cervical muscles Inthe patient with maxillo-oral facial pain mechanical compressions occur between the occiput-atlas atlasaxis and axis-C3 joints The patient can distract their craniovertebral joints by holding both hands withfingers interlaced behind their neck to stabilize the C-2 to C-7 region Then the patient nods their headforward six times while stabilizing the cervical spine in only 15 degrees of anterior cranial rotation Thiscontrolled flexion relieves neurovascular compression in the upper cervical region The application ofthis technique distracts the occiput from the atlas to counteract the dysfunctional effect of extension ofthe cervical spine produced by a forward head posture The patient should recognize that this exercisedoes not include flexion of the neck but flexion of the head on the cervical spine

Stabilize C2



5 Axial extension of the cervical spine This exercise improves the functional and mechanicalrelationship of the head to the cervical spine Before learning axial extension the patient must learntoposition their head forward to the level of the sternum aligning the malar bone The patient createsa distraction force on the cervical vertebrae as he combines flexion of the occiput on the upper cervicalspine and extension of the lower cervical spine relative to the thoracic region These movementsposition the head in an ideal orthostatic position In this ideal position the scm muscle shifts from itsvertical relationship in the dysfunctional posture to its normal posterior angulation in a posteriordirection in axial extension The realignment of the scm limits the unnecessary cervical muscle activityrequired to maintain the abnormal forward head posture the levator scapulae and trapezius relaxes byshortening The practitioner may remind the patient that the muscles of the posterior cervical spinemust work twice as hard 10 hold the head upright in the forward head posture than in the morenormal head on neck posture


--Nod your chin down about 15 degrees --The back of your head should remain in contact with the wall --Your eyes should remain level-imagine a string at the top of your head pulling up



6 Shoulder girdle retraction These exercises restore the shoulder girdle to a more ideal and stablepostural relationship of the head-neck- shoulder complex The therapist instructs the patient to retractand depress the shoulder girdle relative to the rib cage These actions correct the abnormal scapularabduction reduce tension in the acromioclavicular joint relieve compression in the sternoclavicularjoint and promote elevation of the sternum The therapist in time must instruct the patient inexercises to strengthen the upper larger back muscles ie rhomboids mid trapezius and the inferiortrapezius to maintain the shoulder girdle in this corrected position and prevent postural relapse(Antoniotti and Rocabado)

Perform chin nod and roll shoulders back and downward



Additional Scapular exercise per Rocabado

Reference Musculoskeletal Approach to Maxillofacial Pain by Rocabado and Iglarsh1991



HYPERBOLOID EXERCISES

Move hyperboloid for 2 minutes from molar to molar

1 to 2 x a day

Laterally deviate your mandible right Laterally deviate your mandible left

10 reps 2 to 3 times a day 10 reps 2 to 3 times a day

Protrude Mandible forward teeth to teeth

10 reps 2 to 3 times a day



Guidelines To Minimize TMJ Pain

In general avoid

Large bites ldquobigrdquo food

Repetitive chewing

Forceful bites

Using tongue to remove food from teeth

Specifically avoid these foods

Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky

Crunchy fruits and vegetables

French bread

Hard cereal

Lettuce

Other things to avoid

Resting chin on hand

Holding phone with shoulder

Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting

Chewing on inside of cheek

Biting lip


WPTA TMD coverpage final

Time ordered Agenda for WPTA conference

WPTA Spring conference TMD powerpoint for 3-31-17 final

WPTA handout for back of manual 3-31-17

Michael Karegeannes PT MHSc LAT MTC CFC CCTT CMTPT is the owner of Freedom Physical Therapy Services 4 clinics in WI since 1997 and a practicing physical therapist since 1989 His specialties in the field of physical therapy include TMD spine and pelvic dysfunctions myofascial pain and orthopedic therapies Michael graduated from the University of Wisconsin-Madison in 1989 with a Bachelorrsquos of Science Degree in Physical Therapy After he graduated he received his athletic training license from the University of Wisconsin-Milwaukee and later Michael completed his manual therapy certification and Masters of Health Science from the University of St Augustine in Florida

In 2005 Michael had the honor of being trained by Dr Mariano Rocabado (in conjunction with the University of St Augustine) who is the leading national expert in the field of craniofacial therapies Michael holds a Craniofacial Certification with the University of St Augustine

In addition Michael has attended an orofacial pain and TMD residency with the University of Minnesota Dental School He is a member of the American Academy of Orofacial Pain (AAOP) a board member with the Physical Therapy Board of Craniofacial and Cervical Therapeutics (PTBCCT) and is one of the few physical therapists in the United States recognized as a certified cervical and temporomandibular therapist with the AAOP

In 2011 Michael received thorough and extensive training in the technique of intramuscular dry needling and is certified through Myopain Seminars the premier post-graduate medical and physical therapy continuing education company in the United States with a focus on myofascial trigger points Michael is also on faculty with Myopain Seminars Michael is also one of the few PTs in the USA trained in the CRAFTA approach to TMD

His diverse experience knowledge and manual skills allow Michael to be highly effective in the evaluation and treatment of his clientele

Michael is a member of the APTA WPTA NATA AAOP PTBCCT AES PAMA and IMS

Jeffrey Verhagen started his career as a Physical Therapist in 1990 after graduating from the University of Wisconsin -Madison He furthered his breadth of knowledge by attending several post-graduate continuing education opportunities with a focus on manual therapy for orthopedic spine and sports injuries He soon learned that he enjoyed treating spine problems and patients with headaches

In order to properly assess the etiology of headaches he expanded his studies to include the evaluation and treatment of TMDcraniofacial pain and in 2013 completed a certification in Intramuscular Dry Needling through Myopain Seminars Dry Needling treats myofascial trigger points and their affect on localized and referred pain He soon learned that he could successfully treat TMD and craniofacial pain for patients that had tried other treatment approaches and still were left with pain and loss of function

Jeff has attended several courses and has reviewed the literature to expand his ability to successfully treat this challenging population Freedom Physical Therapy Services commissioned Steve Kraus PT a well known TMJ therapist and educator to come to the Milwaukee area and teach the latest treatment techniques and research on TMDcraniofacial pain to our therapy staff Jeff looks forward to continuing to expand his knowledge to better serve this patient population

Jeff has been with Freedom Physical Therapy Service since July of 2000 and currently serves as the Clinical Operations Administrator for the practice He earned his Master of Business Administration from Cardinal Stritch University in 1999 He also served 21 years in the Army Reserves and is a Desert Storm veteran

Jeff resides in Brookfield with his wife and two children and enjoys many hobbies to include golf fishing and reading

Michael Verplancke left his roots of St Louis Missouri to both attend and play ice hockey at St Maryrsquos University of Minnesota where Mike graduated in 1998 with a Bachelor of Arts degree in Biology He then attended Finch University of Health SciencesThe Chicago Medical School in North Chicago Illinois to obtain his physical therapy degree He graduated in 2001 with a Doctorate of Physical Therapy Mike has participated in numerous continuing education seminars with a focus on manual therapy techniques evaluation and treatment of the spine and TMJcraniofacial pain mobilization techniques and intramuscular dry needling

In 2002 Mike obtained his credentials as a Certified Strength and Conditioning Specialist (CSCS) which has assisted him with exercise prescription as well as progression of overall health and wellness for patients

In 2014 Mike completed his certification in Intramuscular Dry Needling through Myopain Seminars This treatment approach has provided a technique that improves treatment of Myofascial Trigger Points and their affect on localized and referred pain as well as muscle activation patterns throughout the body In addition Michael has attended an Orofacial Pain and TMD residency with the University of Minnesota Dental School

Mike has been trained in Temporal Mandibular Disorders (TMD) and Craniofacial Pain (CFP) by Dr Mariano Rocabado a world renowned leader in the field of TMD and CFP Mike is currently working towards his Craniofacial Certification in conjunction with Dr Rocabado and the University of St Augustine

Mike has been an employee at Freedom Physical Therapy since July of 2005 and is currently the Lead Physical Therapist and clinic director of the Grafton location

Mike has a wide range of hobbies and interests which include playing ice hockey softball golf and basketball He also enjoys spending quality time with his wife Marion their three daughters Sophia Liliana and Emilia and their Golden Retriever Stan










300 - 345pm Break







By




ASSIMILATION


Tragus of the ear









not been drawn























Will Cover In Lab



Hypermobility





2009 13427-433

























History








bull Arthrogenous

bull Myogenous





bull Ankylosis









bull Headache


Myogeneous





Artrhogeneous













Diagnosis





MS issues



cervical dx



not cover TMD




joints








































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip














300 - 345pm Break







By




ASSIMILATION


Tragus of the ear









not been drawn























Will Cover In Lab



Hypermobility





2009 13427-433

























History








bull Arthrogenous

bull Myogenous





bull Ankylosis









bull Headache


Myogeneous





Artrhogeneous













Diagnosis





MS issues



cervical dx



not cover TMD




joints








































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip








By




ASSIMILATION


Tragus of the ear









not been drawn























Will Cover In Lab



Hypermobility





2009 13427-433

























History








bull Arthrogenous

bull Myogenous





bull Ankylosis









bull Headache


Myogeneous





Artrhogeneous













Diagnosis





MS issues



cervical dx



not cover TMD




joints








































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






Tragus of the ear









not been drawn























Will Cover In Lab



Hypermobility





2009 13427-433

























History








bull Arthrogenous

bull Myogenous





bull Ankylosis









bull Headache


Myogeneous





Artrhogeneous













Diagnosis





MS issues



cervical dx



not cover TMD




joints








































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip
























Will Cover In Lab



Hypermobility





2009 13427-433

























History








bull Arthrogenous

bull Myogenous





bull Ankylosis









bull Headache


Myogeneous





Artrhogeneous













Diagnosis





MS issues



cervical dx



not cover TMD




joints








































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






Hypermobility





2009 13427-433

























History








bull Arthrogenous

bull Myogenous





bull Ankylosis









bull Headache


Myogeneous





Artrhogeneous













Diagnosis





MS issues



cervical dx



not cover TMD




joints








































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip
























History








bull Arthrogenous

bull Myogenous





bull Ankylosis









bull Headache


Myogeneous





Artrhogeneous













Diagnosis





MS issues



cervical dx



not cover TMD




joints








































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip










bull Arthrogenous

bull Myogenous





bull Ankylosis









bull Headache


Myogeneous





Artrhogeneous













Diagnosis





MS issues



cervical dx



not cover TMD




joints








































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip













Diagnosis





MS issues



cervical dx



not cover TMD




joints








































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip































B Does NOT require


a) Sonograph

b) EMG


2 Radiographs






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






Computed Tomography











MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip







MRI














































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip







































Management of TMDs


ndash Decrease pain










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip










bull Medications
























Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip















Ear Symptoms


ndash tensor typani





















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






















side












Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip







Subjective















bull Temporalis

bull Masseter






TEMPORALIS


MasseterMasseter


Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






Medial Pterygoid

Medial Pterygoid

Temporalis Tendon








basically feasible
















bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip











bull No Chew Diet




Modalities

Intraoral Massage


Self Help

Modalities


bull Iontophoresis


LLLT



ESTIM

bull Rich-mar Unit

bull Pre Mod IF



bull 2x2 dual lead

bull 2 leads 1R 1B
























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip



























condylar head


I


















Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






Trismus Treatment





















Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip







Joint Palpation














Joint Pain Map

















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip
















LAB


Bite Test






Hypermobility









DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip










DEFLECTION
















a b

c





range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip








range of motion




































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip
































Stage 1


Stage 2


Stage 3




bull Trauma





ndash Sustained


DDWR- STAGE I




DDWRbull Subjective





DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






DDWR










DDWoR WLO- STAGE II






DDWoR WLO- STAGE II

bull Objective-














bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip











bull Subjective-




















Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip







Pain







ndash Arthralgia

ndash Muscle pain








Manual Techniques




































Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






























Home Program

bull Handouts























Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






Rocabado 6 x 6

























101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip
















101

C2-7V

65

65

5


Rocabado


OF AGE

ADULTPEDIATRIC

Rocabado


Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






Metal Mayhem







vice versa






Key Points














By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip

















By





Mobilization


And Joint mobility


musculature



Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






Soft tissue massage









PTOT RESPONSIBILTY










3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip














3 Quick Screens




























much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






















much extension























Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip









Trapezius


Levator

Anterior scalene







Chin Nod



Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip







Stabilize C2










as tolerated











PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip







PRONE CHIN NOD



Thumb is up

Start position

Finish Position




EXERCISE

Thumb is pointing

back

Start Position

Finish Position






Palms

facing out

Lower only to

shoulder height

Theraband should

be behind head



Alternate View





Lower Trapezius

Mid Trapezius



Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip







Serratus Anterior











YAMUNA BODY ROLLING


Ergonomics








wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip












wwwlumobodytechcom



wwwvarideskcom










Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip














Dr Stanley Paris





ndash Bite guard

ndash Night guard




































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






































ndash Increase pain






















PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip













PTDDS








DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip










DPT CSCS CMTPT


414-352-2082 work414-352-5279 fax










anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip












anxiety















Location ________________________________________________________________










Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip













Other symptoms _______________________________________________________________

______________________________________________________________________________









Pain No ___ Yes ___ 1 2 3 1 2 3





D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip









D Pain Map





























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






























_____________________________________________________________________________________




______________________________________________________________________________



ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip







ROCABADO 6 X 6

















program are
























Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip





















Stabilize C2


















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






















1 to 2 x a day








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip








In general avoid


Repetitive chewing

Forceful bites



Gum

Jaw breakers

Popcorn

Caramel

Steak

Pizza

Bagels

Chips

Nuts

Ice

Beef jerky


French bread

Hard cereal

Lettuce




Sleeping on stomach

ldquoBigrdquo yawns

Singing

Yelling

Nail biting


Biting lip






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