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NEUROSTRUCTURAL INTEGRATION TECHNIQUE®
IMPACT OF TMJ ON BODY FUNCTION
Presented by Ron Phelan
NST Practitioner and Instructor
Remedial Massage Therapist
Assessment and treatment guide
for soft tissue therapists:
the NST® approach
Copyright © Ron Phelan 2015
Table of contents
Introduction
2
Workshop outcomes
2
Overview of TMJ
- Physical
- Neurological
- Hormonal
3
3
4
4
Muscle testing
4
NST approach to treatment
- Assessment
- Muscle testing for the TMJ
a) Latissimus Dorsi
b) Iliopsoas
c) “Omura” ring test
- Treatment
Post treatment assessment
- Stabilisation
- Referral
5
5
7
8
8
9
Other considerations
9
References
9
TMJ procedure diagram
6
-
10
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Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd
Introduction
IMPACT OF A DYSFUNCTIONAL TEMPORO
MANDIBULAR JOINT (TMJ) UPON BODY
FUNCTION
Presented by Ron Phelan, Remedial Therapist, Bowen (NST) Instructor/Practitioner
Temporomandibular Joint (TMJ) disorder is referred to as the “hidden imposter” because it
mimics the symptoms of many other musculoskeletal problems. Dysfunction of the TMJ
typically affects around 30 percent of the population, with symptoms such as neck pain, back
pain, headaches, migraines, clicking jaw and bruxism being the most common problems. The
TMJ has many functions, involved in chewing, swallowing and talking. To gain a fuller
understanding of the implications of TMJ disorder, its relationship within the context of a
broader system, the Stomatognathic system (SGS) must be considered. The SGS consists of
the cranial, spinal and pelvic structures and is considered a closed loop feedback network.
Hence imbalances in the TMJ locally are reflected not only locally but also to the pelvis via the
dura mater. The imbalances can also be distributed: mechanically (causing distortions in the
cranial area, spinal and pelvic regions resulting in irregular muscular tensions anywhere in the
body), hormonally (by affecting the regulation of the pituitary gland), and neurologically
(through pressure on cranial nerves). In most cases, TMJ disorder can be effectively treated
using NST technique in isolation or in conjunction with other supportive modalities. These
techniques involve a comprehensive assessment protocol to isolate the source of the problem,
followed by NST treatment.
Workshop outcomes:
Understanding of TMJ relationship to the body
Assess the impact of dysfunctional TMJ
Diagnostic protocol for fault isolation
Observe/experience the effect of an NST move.
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Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd
Overview of TMJ
Overview of the TMJ: (An edited and updated version taken from the newsletter,
“The straight news”) -reproduced with the kind permission of Brendan Stack D.D.S., M.S
There are a number of factors that make the TMJ unique in the whole body, as it has two
joints in one. The two joints, one in front of each ear and are connected by the jawbone.
One joint may influence the function of the other joint. Because they are connected, by the
jawbone this means that you cannot move one joint without moving the other. The two
temporomandibular joints can differ from one side to the other in size, shape, and function.
It is frequently possible to have a problem in one joint but have the symptoms expressed in
the other joint. You could also have pain that starts on one side of the head and migrates to
the other side simply because of the relationship of these joints.
The second factor making this joint unique is that another structure dictates its function. The
other structure is the teeth. The teeth are passive members of the upper and lower jaws, but
they have a specific way they must fit together and interrelate. As far as the brain is
concerned, tooth position has priority over joint position. This means that the TMJ is forced
by the muscles to move so that the teeth will fit together properly. This can potentially cause
misalignment within one or both joint capsules. If that happens, the muscles are put in a
compromising situation, causing them to spasm and resulting in pain. Many of the problems
experienced are a result of muscle spasm, but the cause is not a muscle problem. The muscles
are simply caught between two positions: the tooth position and the jaw position.
The third factor making this joint unique is that it has an articular disc located between the
condular head of the mandible and the glenoid fossa of the mandible. The disc has a muscle
attached to the front of it that pulls the disc forward as the condyle moves forward in the
glenoid fossa. The disc is also attached in the back by elastic connective tissue that is much
like a rubber band, and pulls the disk back as the condyle moves backward in the glenoid
fossa. In other words, this attachment can stretch and recoil as the jaw opens and closes.
Since the disc is a separate structure and may move independently from the condyle, it can be
displaced and damaged causing many problems.
This disorder is called an “internal derangement” of the TM joint. Internal derangement of
the TM joint can cause a distressing syndrome of pain, limited jaw movement, clicking,
popping and crepitus in the joint.
This derangement may be caused by genetic pathological changes in the joint or acquired
pathological changes as a result of trauma. Often, internal derangement of the TMJ is
preceded by myofascial pain dysfunction that can involve severe spasms of the muscles of the
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Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd
head, neck, shoulder and/or back. A wide range of local symptoms may occur, such as
headache, muscle pain, ear pain, dizziness, stiffness and ringing in the ears. Distally, because of
the connection via the dura mater, the effects of the misalignment can be observed in pelvic
and sacral area as well as causing unresolved sacral, coccyx, lumbar and thoracic problems.
Neurologically, local effects of TMJ disorder can be experienced by entrapment of the Vagus,
Hypoglossal and Trigeminal nerves. Distally due to muscular imbalances between the cranium
and pelvic region, spinal nerves may become compromised and the individual may experience
many seemingly unrelated symptoms such as digestive, respiratory, urinary and bowel
disorders, etc.
Respiration involves flexion/expansion of the sacral-iliac joint. This movement is likewise
mimicked at the sphenobasilar junction in the cranium. At the centre of the sphenoid bone
lies the “Sella Turcica”, or “Turkish Saddle”. This houses the pituitary gland. The pituitary
gland requires consistent rhythmical motion at that joint to regulate the glands function.
Irregular movement can cause variations in hormonal output, thus affecting growth, pancreas
function, fertility and more.
Muscle Testing
Reference: NST Update and Expansion Manual – 2001, by Michael J. Nixon-Livy
Manual muscle testing was originally developed to evaluate muscle function for the assessment
of insurance claims by Kendall, Kendall and Wadsworth in the late 1940’s and early 1950’s. It
was a specific diagnostic technique in the broader developing field of kinesiology, which
basically refers to the study of motion of the human body, and subsequent movement of
related muscles, joints and limbs.
The tests were designed to isolate a single muscle or group of muscles, in the most contracted
state, to determine if a manually applied force from the tester could be resisted.
The test itself is not intended as an absolute measure of strength (which relates to muscle
size), but rather a dynamic test of the muscles neurological integrity, or ability to lock.
Therefore, a strong muscle will quickly and firmly resist an increasing test pressure, while a
weak muscle will be slow to respond, feel indecisive and mushy, or may even give way
altogether. This is called unlocking.
Generally speaking a strong muscle (locking) will reflect a positive state, while a weak muscle
(unlocking) will reflect a negative state, of the subject being tested.
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Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd
Muscle testing has evolved and developed over the decades to the extent, that these days it is
used as a very accurate diagnostic methodology for evaluating not only for neurological
integrity of the muscles, but emotional states, nutritional imbalance, allergies, postural
disorders, physiological dysfunction and more.
NST approach to TMJ treatment
1)
2)
3)
4)
Assessment
Treatment
Stabilisation
Referral
Assessment
TMJ integrity can be assessed by: Symptomatic – Headaches, neck pain, balance problems,
recurring back pain, tinnitus, etc
Observation – Clicking and/or joint deviation on opening and closing the jaw.
Palpation - Temporalis, Lateral Pterygoid, Masseter, Sternocleidomastoid, Trapezius TMJ’s
Muscle testing – typically Latissimus Dorsi, Iliopsoas and “Omura” ring test.
Muscle Testing for the TMJ
TMJ integrity is quite easily and simply tested using appropriate muscle. Typically latissimus
dorsi or Iliopsoas muscle tests provide concise testing results for both pre and post test
assessments.
Latissimus Dorsi: Shoulder
Because of the connections of latissimus dorsi to the iliac crest, thoracic, lumbar and sacrum,
this muscle gives good proprioceptive feedback to any imbalances in the cranial area due to
the dural attachments.
Actions:
Extension, adduction (prime mover)
Internal rotation, horizontal extension (assistant mover)
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Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd
Typically the muscle is tested with the client holding the slightly extended and internally
rotated arm thus bringing the back of their hand to their hip area. Switch point - Spleen 1.
Iliopsoas: Hip
Actions:
Flexion (prime mover)
Abduction, external Rotation (Assistant mover)
Due to the relationship of iliopsoas and the pelvic girdle, its attachments to the last thoracic
and Lumbar transverse processes, (fascial and dural), any imbalance between the TMJ and
pelvic girdle is quickly and accurately assessed using this muscle.
Typically the muscle is tested with the client in supine position, hip flexed, externally rotated
and slightly abducted. Switch point - Kidney 1.
Forearm flexor : “Omura” ring test
The Omura ring muscle test, developed by Dr Yoshiaki Omura from Japan in the 1970's,
found that finger muscles were more appropriate than large muscles in determining functional
relationships in the body. The test uses the flexors of the thumb (flexor pollicus longus and
brevis) in conjunction with the flexors of the hand and fingers (flexor digitorum). Switch
point – Pericardium 6.
Actions : flexion of the fingers and hand.
Typically the client will hold the thumb and one of the other fingers together and the therapist
would apply a force to try and separate these. Typically the ring finger provides an accurate
test result, however other fingers may be required to facilitate the test procedure.
a) The therapist tests the muscle in a resisted test so as to ascertain the neural locking
ability of the hip. Neural integrity is noted. Retest with switch point held and muscle
should unlock. If muscle does not unlock, then recipient most likely dehydrated.
b) The client is asked to swallow and open their mouth. Whilst their mouth is open,
the test (a) is then repeated. The neural integrity is then compared against that
measured in (a).
c) No difference in strength means that the TMJ complex is potentially sound.
d) A difference in strength means the TMJ complex is most likely compromised.
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Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd
Treatment
Recipient Supine
(Refer to diagram on page 10)
1 Perform the muscle test as discussed on pages 5 and 6, noting the results.
2 Place your fingers over both TMJ’s and observe any deviations/clicking or other
sounds during the opening and closing phases.
3 Using the left thumb make a rolling movement over the Levator Scapulae muscle
in a superior/oblique direction and release the thumb.
Immediately repeat this sequence on the right side of the body using the right
thumb.
4 Standing at the head of the recipient, place the middle finger of the left hand on
the lateral margin of the upper Trapezius muscle in line level with spinal
vertebrae C4, and roll over the upper Trapezius muscle in a medial direction.
Immediately repeat this movement on the right side of the neck.
5 Without delay place the left thumb on the medial border of the left
Sternocleidomastoid muscle slightly superior to its sternal origin and roll over the
muscle in a lateral direction.
(abc) Repeat this action three more times, moving superiorly onto the Mastoid
process, and making a final lateral move over the insertion of the muscle.
Immediately repeat this sequence on the right side of the neck using the right
thumb.
6 Without delay using the thumb and index finger wiggle the Hyoid bone as
instructed.
7 Place index and middle fingers bilaterally over the TMJ. Ask recipient to swallow
and then open mouth wide an then close.
8 Ask recipient to partially open their mouth, inset their index finger and gently
bite on it until the remainder of the procedure is completed.
9 Place the left thumb on the Condular head of the Mandible. Draw the skin
superiorly over the TMJ and then move inferiorly crossing the joint. Without
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Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd
removing thumb draw the skin anteriorly over the lateral ligament and then
move posteriorly crossing the joint, and then release the thumb.
Immediately repeat this sequence on the right side of the Mandible.
10 Without delay place the left thumb on the anterior margin of the Masseter
muscle on top of the Coronoid process. Roll across the Masseter muscle into the
depression (created by the open position of the jaw) and apply digital pressure to
the Lateral Pterygoid muscle for five seconds. Release thumb.
Immediately repeat this sequence on the right side of the face.
Ask recipient to remove finger from mouth and ensure they are warm and
comfortable whilst leaving them rest for 2-5 minutes.
Post treatment Assessment
Typically after having completed the treatment procedure, the recipient can be tested once
again using either Latissimus Dorsi, Psoas or “Omura” ring testing protocols.
A positive response will be indicated by the test being strong with both positions of the
mouth, (open and shut) holding a similar strength in either Latissimus Dorsi or Psoas tests.
Under certain situations, the adjustment may not hold, this weakness indicates that there may
in fact be another structural weakness, such as degeneration of the disk or wear of any of the
components within the TMJ/Cranial system. In this case stabilization of the joint is
imperative. Other situations, upon becoming weight bearing, the weakness will return,
indicating the need for additional pelvic/sacral re-alignment to create the required pelvic
stability.
Stabilisation
Further stabilization therapy may be included at this point by way of the TMJ supportive
appliance.
The appliance allows gapping between the condular head of the mandible and the temporal
fossa. This allows relaxing of the muscles locally and in the neck region, relieves the pressure
on the TMJ, thus allowing the disk to regenerate and finally reduces the effect of bruxing and
grinding.
8
Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd
Referral
A small number of clients will require additional work to help relieve the symptoms of TMJ
disorder. In these cases, referral to an experienced TMJ orthodontist will be the only solution
to the problem.
As such, the structure underlying the TMJ/cranial system is typically worn to such an extent
that adjustment and stabilization techniques as outlined are unable to correct the situation.
Typically the orthodontist will insert a number of different types of splints to stablise the TMJ
complex.
Pivot Appliance - increases the “freeway space” by increasing the vertical dimension only.
Indications for Pivotal Appliance; no “superior” joint space, unilateral closed lock and bilateral
closed lock.
Repositional Appliance - moves the jaw in an anterior/posterior direction.
Indications for Repositioning appliance; adequate “superior” joint space, myofascial pain,
unilateral and bilateral clicks, unilateral and bilateral internal locks, unilateral and bilateral joint
surgery and after manipulation of the joint.
Other considerations
Emotional conditions can also be the root cause of the TMJ disorder and as such, referral to
the appropriate health practitioner should also be considered.
References:
The straight news (newsletter) – Spring 2004, Brendan Stack. DDS. MS. Self published
Brendan Stack course notes – 2008 Brendan Stack. DDS. MS. Self published
The TMJ Appliance (brochure) – Myofunctional Research Co. Self published
Applied Kinesiology; A synopsis. Vol 1+2. David S Walther. Systems DC, Pueblo, Colorado
1988.
Head and face pain, edition 1 – Rene Cailliet, MD. Published by F.A. Davis
The Heart of Listening - Hugh Milne - Volume 2, A Visionary Approach to Craniosacral
Work, North Atlantic Books.
NST Introductory course workshop manual – Michael J. Nixon-Livy. Self published.
NST Basic course workshop manual – Michael J. Nixon-Livy. Self published.
NST Update and Expansion course notes – Michael J.Nixon-Livy. Self published.
For more information regarding the NST® approach, refer to the NST website:
at www.nsthealth.com or contact Ron at [email protected]. 0419380443
9
Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd
10
Neurostructural Integration Technique Copyright © 2006
International Institute for Applied Health Services – Germany
International Centre for the Neurostructural Integration Technique Pty Ltd