Friday 5! 5 Tips to Use with TMD Patients | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Friday 5! 5 Tips to Use with TMD Patients

Thanks to a reader who found me through Craig Libenson for asking a question that lead me to write this blog post. Here are 5 things I make sure to focus on for TMD patients.

The question specifically was other than light tissue work around the TMJ, how do you lock in the improvements?

1) Education
  • locking the improvements with any manual technique has to be done with education
  • letting the patient know the effects of your treatments are transient
  • avoiding hard, crunchy, chewy foods for a few weeks similar to avoidance of hard ADLs after spraining an ankle
  • education of the head/neck posture influencing mandible position, and possibly contributing to neck pain/headaches which leads to point...
2) Every TMD patient is a cervical patient
  • I look at every TMD patient as 90% cervical, 10% TMJ and only tweaks in the educational pieces are needed
  • get a symptom baseline, start with postural correction and see if there are any changes
  • ask them if different head positions change their bite or occlusion
  • here is a vid I made explaining how I go about this with a patient interaction

3) STM to the mandible elevators

  • the pattern of greatest resistance that seems to offer the best relief and decrease tone is light and slow stroking of the mandible elevators (temporalis and masseter) in a proximal to distal direction
  • start very lightly and stroke slowly to reduce tone
  • use reciprocal inhibition of the mandible depressors to assist with this
  • teach the same reciprocal inhibition techniques to keep the tone reduced throughout the day - make sure to keep them in neutral, it's easy to protract the head and retract the mandible doing this!

4) Light TMJ mobilizations
  • patients who have dysfunctional clenching, capsular or movement dysfunction or small subluxations often benefit from light TMJ distractions along with lateral greater than medial glides
  • too often providers just focus on restoring mandible depression, but you cannot forget about lateral excursion
  • mastication is a circular motion, we do not eat like pac man, so we need to restore medial and lateral glides to improve mandible lateral excursion, which assists with eating
  • this is a small joint so you can get grade 3 or 4 oscillations very easily, Rocabado says "Finesse" - sounds a lot better with a Chilean accent!

5) Lock it in!
  • cervical retractions to restore craniomandibular position
  • education on bringing the food to you while sitting mostly upright as opposed to bringing your head to the food often helps
  • lingual re-education, tongue at the rest position (like saying "nnnnnn" or clucking), clucking - snapping the tongue off of the palate just behind the two upper middle incisors and leave it there
    • tongue in rest position should reflexively decrease mandible elevator tone
  • scapular retractions (90% down, 10% back to inhibit upper traps by firing lower traps
  • diaphragmatic breathing should be looked at as well if the above are not locking in improvements
  • occasionally a patient may also need to be cued on repeated mandible protrusion, but not to end range, just a few millimeters to counter the inferior posterior pull of a forward head
Those are some of my top tips for TMD in an nutshell. I hope everyone has a wonderful weekend! You stay classy!

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