Evidence Based Assessment and Treatment for TMJ, Cervical Spine - - PowerPoint PPT Presentation

Evidence‐Based Assessment and Treatment for TMJ, Cervical Spine Dysfunction, and Headaches

• Dr. David J. Denton, PT, DPT, CIDN, CVT

1

Learning Objectives

• Utilize your client’s functionality through relief of neck and jaw

pain through manual based intervention for immediate relief.

• Examine clinical practice and review differential diagnosis, cervical

spine, balance system, and jaw physiology/anatomy, and symptomatic connection.

• Establish the best practices in assessment and re‐assessment

strategies for relieving pain, underlying conditions, and manual based lab techniques.

• Demonstrate different treatments, exercise prescription, and

documentation for TMD patients.

• Participate in interactive hands‐on labs for assessing the

involvement of the cervical spine (cervicogenic vertigo, cervicogenic headache), affected balance, and TMD treatment approaches.

• Implement effective , evidence based interventions for all

involvement at the upper cervical spine resolving dizziness, restoring the balance system, resolving headaches, and relief of TMD pain. 2

Cour Course se Outline Outline

• 8:00 Connection of Cervical Spine, Headaches, and TMD
• 8:30 Upper Cervical Spine, Headaches, and Upper Cervical Nerves
• 9:00 First Rib, Thoracic Outlet, and Radicular Symptoms
• 9:15 Upper Cervical Palpation Lab
• 10:00 BREAK
• 10:15 Describe causation of balance disorders and define vestibular rehab.
• 10:30 Enhance knowledge base of sensory and motor control roles.
• 10:45 Postural Control Lab
• 11:30 Upper Quarter Screen/Special Tests and Clearing Exam with Lab
• 12:00 Lunch
• 1:00Cervicogenic Dizziness and Vestibular Hypofunction
• 1:30 CGH Treatment theories and Exercise prescription.
• 2:00Vestibular Rehabilitation, Cervicogenic Vertigo and Hypofunction Lab
• 2:45 Break
• 3:00 Biomechanics and Pathology of TMD
• 3:30 TMD Evaluation (Videos and Lab) and Treatments
• 4:15 Comments, Course Evaluation, and Closure

3

Connection of Cervical Spine, Headaches, and TMD

• What does the evidence say?
• TMD ‐ commonly associated with conditions of the

head and neck region.

• Cervical spine disorders (including Cervicogenic

Dizziness)and Headache.

• Presence of neck pain was shown to be associated with

TMD 70% of the time. (Silveira, 2015)

4

Cervical Connections

• Most of the studies agree that symptoms from the

cervical spine can be referred to the stomatognathic (teeth, jaws, tissue) region through the trigeminocervical nucleus.

• Presence of signs and symptoms in the cervical region
• f patients suffering with TMD and that the presence of

tender points in the cervical area of these patients co‐ exist.

• Muscle tenderness in the cervical spine and jaw was

shown to be associated with increased levels of jaw and neck disability (Silveira, 2015).

5

Whole Body Connection?

• The body as a whole operates on the principle of
• compensation. Disturbances in the upper quarter like

increased muscle tension leads to compensatory changes within the muscle tension in the spinal region.

• Review of the literature showed that pain in the upper

quarter and masticatory motor system may be caused by cervical spine disorders (generally by dysfunction of muscular origin) and vice versa (Dragon, 2014).

6

Cervical Spine and Headaches

• Types of Headaches:
• Primary headaches include those of vascular origin

(cluster and migraine headaches) as well as those of muscular origin (tension‐type headaches).

• Secondary headaches result from another source

including inflammation or head and neck injuries (Cervicogenic)

7

Upper Cervical Spine and Headache Connection

• Criteria for Neck Pain and Headache:
• Unilateral pain with a facet ‘lock’ irradiating from the

back of the head

• Evidence of cervical dysfunction presenting during

manual examination

• May occur with trigger point palpation in the head or

neck

• Aggravated by sustained neck positions
• Normal imaging (Page, 2011)

8

Upper Cervical Spine and Headache Connection

• Trigeminal Pathway:
• It is suggested that CGH is a “final common pathway” for

pain generating disorders of the neck.

• Proposed pathophysiology theory: CGH results from a

convergence of sensory input from the upper cervical spine into the trigeminal spinal nucleus, including input from:

• Upper cervical facets
• Upper cervical muscles
• C2‐3 intervertebral disc
• Vertebral and internal carotid arteries
• Dura mater of the upper spinal cord
• Posterior cranial fossa (Bogduk, 2014).

9

Headache Statistics

• Approximately 47% of the global population suffers

from a headache.

• 15‐20 percent of those headaches are
• Epidemiological researchers suggest a higher

prevalence of headache in adults with neck pain.

• Females seem more predisposed to CGHs affecting 4

times as many women as men. (Page, 2011).

10

Red‐flags Associated with Headache

• Headaches that are getting worse over time
• Sudden onset of severe headache
• Headaches associated with high fever, stiff neck, or rash
• Onset of headache after head injury
• Problems with vision or profound dizziness

11

Pathophysiology of Cervical Spine and Headache Screening

• Nearly 50% of CGH patients as well as asymptomatic

subjects had bulging cervical discs.

• The most important clinical finding to diagnose CGH is

impairment of C1‐C2 (atlanto‐axial) motion.

• CGHs can occur in patients with lower cervical dysfunction,

particularly after trauma.

• Preadolescent (10‐13 year old) children with neck pain and

headache have dysfunction of the lower cervical spine.

• Cervical osteoarthritis, common in many older patients may

be associated with headache and cervical muscle

• Diagnosis of CGH should be made by carefully examining the

etiology of the headaches, not just the symptoms.

12

Trigeminocervical Nucleus

13

TCN Trigeminal Nerve TCN – Trigeminocervical Nucleus C1‐3 – Spinal Nerve Roots of C1 to C3 C1 C2 C3

Diagnostic Criteria

14

Major criteria

• I. Symptoms and signs of neck involvement
• a) Precipitation of comparable symptoms by:
• 1) neck movement and/or sustained,

awkward head positioning, and/or

• 2) external pressure over the upper cervical
• r occipital region
• b) Restriction of range of motion in the neck
• c) Ipsilateral neck, shoulder or arm pain
• II. Confirmatory evidence by diagnostic anaesthetic block
• III. Unilaterality of the head pain, without sideshift

Head pain characteristics

• IV. Moderate‐severe, non‐throbbing pain, usually starting

in the neck

• Episodes of varying duration, or fuctuating, continuous

pain

Migraine vs. CGH

15

Migraine CGH

Gender ratio 1.69 female/male 0.71 female/male Age at onset 18 years 33 years Headache onset Anterior head Posterior head/neck Pain area 50% unilateral Predominately unilateral Nausea Frequent Infrequent Photo/phonophobia Very frequent Infrequent T robbing pain Frequent Infrequent Pain increases when bending forward Very frequent Infrequent Migraine medication Usually helpful Not helpful Sustained/awkward neck position provokes pain Rare Universal

TMJ and CGH Connection

• Temporomandibular Disorders (TMDs) and

headache are closely related pathologies; prevalence of headache in the dysfunctional population varies between 48% and 77%, while in the general population the prevalence of headache is around 45% (Paolo, 2017).

16

TMJ and CGH Connection

• According to several studies, there is a strong

correlation between headache and other dysfunctional symptoms, such as joint noise, pain during mandibular movement, pain in the temporomandibular area, depression, anxiety, and poor sleep quality (Paolo, 2017).

17

Trigeminocervical Nucleus

18

Occipital Nerves and HA/Dizziness

• Occipital Neuralgia (C2 neuralgia), is a medical condition

characterized by chronic pain in the upper neck, back of the head and behind the eyes. These areas of the head correspond to two nerves located in the back of the neck at the base of the skull.

• Greater and Lesser Occipital nerves.
• Symptoms of the condition:
• chronic headache, tenderness and pain at the base of the skull, in
• ne or both sides, aching, burning, and throbbing pain that

typically starts at the base of the head and radiates upwards into the scalp, pain behind the eye, sensitivity to light and tenderness throughout the scalp.

• Causes of Occipital Neuralgia:
• compression to either the greater or lesser occipital nerves as they

penetrate the muscles high up in the neck just under the skull lateral to C2.

• Secondary to whiplash, or poor posture and head position that

develops gradually over time. 19

Auriculotemporal Nerve

• The superficial temporal branches run with the

superficial temporal arteries.

• Branches innervate the skin over the temple and

anastomose with the facial and also the zygomaticotemporal nerves.

• Branches to the external auditory meatus, which are

typically two in number, run between the cartilaginous and bony ear canals and innervate the skin of the meatus, but also provide innervation to the tympanic membrane.

20

Greater Auricular Nerve

• The great auricular nerve (or greater auricular nerve)
• riginates from the cervical plexus, composed of branches of

spinal nerves C2 and C3.

• It provides sensory innervation for the skin over parotid

gland and mastoid process, and both surfaces of the outer ear.

• It can be damaged by the neck surgery, tumor,and

prolonged pressure on the neck.

• Can be an etiology of parietal pain and headaches.

21

Current Perspectives on Orofacial Pain

• Innervation of trigeminal system (head, face, masticatory

musculature, temporomandibular joint and associated structures).

• Temporomandibular disorders (TMD) are the most prevalent
• rofacial pain conditions for which patients seek treatment.
• Temporomandibular disorders include a number of clinical

problems that involve the masticatory musculature, the temporomandibular joint (TMJ) or both.

• Trigeminal neuropathic pain conditions can arise from injury

secondary to dental procedures, infection, neoplasias, or disease or dysfunction of the cervical spine (Reyes, 2015).

22

The First Rib and Pain Referral

• First Rib ‐ most superior of the twelve ribs.
• Atypical rib and anatomical landmark.
• It is one of the borders of the superior thoracic aperture
• Innervation
• Innervated by the first intercostal nerve.
• The intercostal nerves are distributed chiefly to the

thoracic pleura and abdominal peritoneum and differ from the anterior rami of the other spinal nerves in that each pursues an independent course without plexus formation.

23

24

The First Rib and Pain Referral

• So Many Attachments!!
• Anterior scalene muscle: scalene tubercle
• Middle scalene muscle: between groove for the

subclavian artery and transverse tubercle

• Intercostal muscles: from the outer border
• Subclavius muscle: arises from the distal shaft and first

costal cartilage

• First digitation of the serratus anterior muscle
• Parietal pleura: from the inner border
• Costoclavicular ligament: anterior to the groove for

the subclavian vein

25

How to Palpate the First Rib

• The first rib is often noted as the most difficult rib to
• palpate. To palpate the first rib, find the superior border
• f the upper trapezius muscle and then drop off it

anteriorly and direct your palpatory pressure inferiorly against the first rib. Asking a patient to take in a deep breath will elevate the first rib up against your palpating fingers and make palpation easier

• https://youtu.be/zwDO_VXOItM
• https://youtu.be/PrDZD1erucI

26

First Rib Pathology

• Thoracic Outlet Syndrome ‐ compression of the

neurovascular structures as they exit through the thoracic outlet (cervicothoracobrachial region)

• The thoracic outlet is marked by the anterior

scalene muscle anteriorly, the middle scalene posteriorly, and the first rib inferiorly.

• The term ‘TOS’ does not specify the structure being

compressed.

27

First Rib Pathology

• TOS affects approximately 8% of the population and is

3‐4 times as frequent In woman as in men between the age of 20 and 50 years.

• Signs and symptoms of thoracic outlet syndrome vary

from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain (referred to the shoulder blade/chest and around shoulder) and sensory changes to limb threatening complications in severe cases

28

First Rib Pathology

• Pancoast Tumor ‐ refers to a relatively uncommon

situation where a primary bronchogenic carcinoma arises in the lung apex at the superior pulmonary sulcus and invades the surrounding soft tissues.

• The most common symptoms at presentation are

chest and/or shoulder pain, with arm pain being also common. Weight loss is frequently present

29

TOS Exercises

• https://youtu.be/lnaxIFP2_yA
• https://youtu.be/q0r5XfZ‐NXc
• https://youtu.be/MpojqL‐B5pc
• https://youtu.be/wz6KRl3YtqU
• https://youtu.be/YQMpmJbpfgY

30

TOS Exercises

• Literature synopsis of first rib mobilization:
• While literature investigating manual therapy in the

treatment of thoracic outlet syndrome is very limited, results show a manual depression of the 1st rib to be an easy, effective option in conservative management

• f thoracic outlet symptoms.

31

Causa Causation ion of

• f Balance

Balance Di Disor sorder ers and and Vestibular ibular Rehabilit habilitation ion De Defined ned

• Function
• Statistics
• Etiology
• Gait Assessment
• Balance Testing

32

Function of the Vestibular System

• The vestibular system functions:
• Detects motion of the head and maintains stability of images on

the fovea of the retina

• Vestibular‐ocular reflex
• postural control during head motion (cervical), ‐Minor 1998
• Vestibulo‐spinal reflex
• The system is made up of 3 components:
• Peripheral sensory apparatus (Picture next Slide)
• Motion sensors that send info to the CNS (Vestibular nucleus complex

and cerebellum)

• Information on head velocity and linear acceleration
• Central processor
• The CNS
• Processes signals to estimate head and body orientation in space
• A mechanism for motor output
• Info is sent to ocular muscles and the spinal cord in 3 reflexes:
• Vestibulo‐ocular reflex (VOR)
• Vestibulocollic reflex (VCR)
• Vestibulospinal reflex (VSR)

33

• Hain

34

Function of the Vestibular System

• VOR – generates eye movements
• Enables clear vision while the head is in motion.
• Stabilizes images on the retina
• Elicits eye movement by stimulating the vestibular system

(Nystagmus)

• Nystagmus is rhythmic back and forth beating (VOR generates

slow phase to keep eye focused)

• When eye reaches max range; a Saccade (quick phase) in

generated in Opposite direction to new target

• VCR – acts on the neck musculature to stabilize the head
• Reflex initiated by vestibular system. “Righting reflex”
• VSR – generates compensatory body movement to maintain head and

postural stability

• Fall prevention and balance strategies
• The performance of all 3 reflexes is monitored by the CNS and re‐

adjusted accordingly by the cerebellum. – (Hain, T)

• LAB – VOR Activity

35

Function of the Vestibular System

• Statistics
• Population based study in US reported that 24‐30% of older

people >age 72 have dizziness (Iwasaki/Klaus)

• Falls are the leading cause of hospital admission and accidental

death in elderly population (Iwasaki)

• Vertigo and unsteadiness causes a fear of falling.
• This is a predictor for those who will suffer one or more

subsequent falls.

• Vestibular rehab significantly decreases the risk of falls in the

elderly (Macias)

• Age related decline of the vestibular system correlates with age

related decrease in the number of vestibular hair cells and neurons (Iwasaki)

• Mitochondrial anti‐ox (alpha lipoic acid and co Q10) may

reduce age dependent hair cell loss in study (Iwasaki 2015)

36

Sensory and Motor Control Roles

• Postural Control
• Vestibulopathy,
• Nystagmus Assessment
• Involuntary movement of the

eye

• Balance Components
• VOR – reflex where activation
• f Vestibular system causes

eye movement

• Bilateral vs. Central Loss

37

Po Postural Con Control

• Postural control is the ability to control the body position

in space. –Huang 2006

• Normal CNS involvement keeps the body in vertical

postural alignment

• Patients with affected vestibular function will lean, tilt, or

shift toward the weaker side.

• Patients will correct this with compensation strategies.
• Patients immediately experience hypermetria (movement of

a body part beyond its goal) after a vestibular hit

• Ataxic with severe postural instability
• Increased amplitude of both reactive and anticipatory

postural responses

38

Postur ural al Con Control

• Boundaries = Limits of stability.
• Ankle strategy allows ~4 degrees backward and ~8 degrees

forward on stable surface.

• In vestibulopathy, responsive reactions are larger

movements than are needed

• Theory for vestibular hypermetria:
• Reduced cerebellar inhibition of the spinal motor system
• Loss of vestibular input reduces the inhibitory mechanism of

Purkinje cells (in cerebellum)

• Poor reactive synapses from the somatosensory system to the

vestibular nucleus after loss of vestibular drive –Hurak 2009 39

Po Postural Con Control

• Changes with age related to sensory systems include:
• Reduced joint position sense
• Reduced visual function
• Decreased vestibular function
• In elderly Shumway‐Cook reported a 40% reduction in lower body

muscle strength compared to young and healthy pt

• Altered muscle response organization
• More frequent co‐activations of antagonist muscles
• Elderly exhibited a decreased ability to react to external

perturbations

• Difficulty in sensory re‐weighting
• Lastly “stance of elderly people is reported to be less stable with

absent or altered proprioceptive, vestibular and visual information.” (Peterka) 40

Postur ural al Con Control

• Normally, proprioceptive

information regarding sensory data is congruent.

• Eyes, ears and feet all

contribute proportionally to body position in space and movement.

• Sensory situations that are

not congruent are:

• Uneven or an altered

surface

• Modification or absence
• f vision

41

Po Postural Con Control

• Postural Tests per Clinical Preference/Practice for goals and

return of Postural Control Tracking

• Sensory Organization Test (SOT) – objectively identifies

abnormalities in varying three sensory systems

• Modified Clinical Test of Sensory Interaction (mCTSIB) –

derivative of SOT to provide objective evidence of sensory dysfunction

• Dynamic Visual Acuity (DVA) – changes in visual acuity at head

velocities (visited again in formal Eval Section) Highly reliable for Vestbular hypofunction

• 10‐15 feet away from eye chart
• Stability Evaluation Test (SET) – balance control measures of

postural sway velocity on available test conditions (per clinic)

• Others you may wish to employ after independent study or

clinical opinion:

• Motor Control Test, Adaptation Test, Limits of Stability, Gaze

Stabilization test, Unilateral Stance, Sit to Stand 42

Po Postural Contro rol

• 6 conditions of Postural

Control

• During more challenged

environments, the CNS relies more on the vestibular system for fall prevention

• Elderly studies on

proprioception

• Results in elderly showed

a decline in amplitude of motor feedback.

LAB – Rehab Tx

43

Cer Cervical al Scr Screen een and and Special Special Te Tests

• Vertebral Artery Test
• Cervical sidebend and rotation in slight extension
• Chin on Hand testing to mimic Dix Hallpike positioning for

clearance (picture 1)

• Arms extended test watching for drooping of one arm,

parasthesia, dizziness or nystagmus (picture 2 and 3)

• Red Flags: diaphoresis, dysphasia, dysarthria, drop attacks,

diplopia, high pain

44

Special Special Te Tests

45

Special Special Te Tests

• Cervical Instability
• Sharp Purser – assessment
• f transverse ligament.
• 1. Forward flex head and

support with hand or elbow, opposite hand on SP of C2.

• 2. Soft end feel, clunk or

reduction of symptoms with shear

• 3.Positive test and ER call.
• The test without head

flexion is also an effective headache SNAG 46

Special Special Te Tests

• Ligamentous Stability
• Cranial Axis Lift
• Transverse Ligament

Assessment

• 1. Supine
• 2. Support occiput with

fingers on posterior arch of atlas

• 3. gently lift axis and atlas

while preventing upper cervical flexion

• 4. Negative test = hard end

feel

• 5. Excessive motion or soft

end feel = positive test

• Monitor for parasthesia and

nystagmus 47

Special Special Te Tests

• Ligamentous Stability
• Atlas – Axis Shear Test for

Transverse Ligament

• One hand on C1 and one

hand on C2

• Arms parallel to table
• Press hands toward each
• ther in a shear motion
• Hard/Firm end feel is

negative

• Soft end feel = positive

48

Special Special Te Tests

• Ligamentous Stability
• Alar Ligament
• Find C2 Spinous process
• Passively sidebend the upper

cervical spine

• Passively rotate the upper

cervical spine

• Hard end feel = negative
• Soft end feel or increased

pain/spasm = positive test

49

Special Special Te Tests

• Ligamentous Stability
• Tectoral Membrane
• 3 positions:
• Gentle long axis traction in

neutral

• Add upper cervical spine

flexion with traction

• Keep position and block

axis

• An empty or soft end

feel/lag = positive test

50

Upper Upper Quart Quarter Scr Screen een

• Manual Muscle Testing
• Cervical Spine
• ROM
• Compression
• Distraction
• Sensation
• Dull
• Sharp
• Light Touch
• Deep Tendon Reflex
• Normal
• Brisk
• Absent
• Diminished
• Coordination
• Finger to Nose
• Heel Shin
• Rapid Alternation
• Finger Opposition

51

Scr Screening eening Lab Lab

• Vertebral Artery
• Transverse Ligament
• Alar Ligament
• Tectoral Membrane
• UE Screen/ROM/MMT/Neuro

52

Ce Cervic icog

• genic

ic Dizziness zziness

• Cervicogenic dizziness may be a result of whiplash injury,
• ther forms of cervical spine dysfunction, or spasms in the

cervical muscles. Wrisley, 2000

• The diagnosis of cervicogenic dizziness is characterized by

dizziness and dysequilibrium that is associated with neck pain in patients with cervical pathology

• Cervicogenic dizziness is most often associated with

flexion‐extension injuries and has been reported in patients with severe cervical arthritis, herniated cervical disks, and head trauma. In these patients, complaints of ataxia, unsteadiness of gait, or postural imbalance associated with neck pain, limited neck range of motion,

• r headache predominate, Wrisley 2000

53

Cervic icogenic ic Dizziness Dizziness

• Pathophysiology
• With strong connections between the cervical receptors and

balance function, it is believed that injury or pathology of the neck may be associated with a sense of dizziness or disequilibrium, (Wrisley 2000)

• Current theory is that cervicogenic dizziness results from

abnormal input into the vestibular nuclei from the proprioceptors of the upper cervical region. (Wrisley 2000)

• The interconnections between the cervical proprioceptors and

the vestibular nuclei may contribute to a cyclic pattern, where the cervical muscle spasms contribute to dizziness; and dizziness contributes to muscle spasm, although the causal relationship is unclear. (Wrisley 2000)

54

Cervic icogenic ic Dizziness Dizziness

• Cervicogenic dizziness is a diagnosis of exclusion
• (ie, the diagnosis is usually based on the elimination of the other

competing diagnoses, such as vestibular or central nervous system pathologies), (Wrisley 2000)

• The neck torsion nystagmus test, or head‐fixed, body‐turned

maneuver is considered by some to identify cervicogenic dizziness.

• Test requires the head of the patient to be stabilized while the

body is rotated underneath.

• Theoretically, the neck proprioceptors are stimulated while the

inner ear structures remain at their resting. Nystagmus is elicited in a positive test.

• Determine if the patient with a chief complaint of dizziness or

vertigo has neck pain, either at rest, with active neck movement, or with palpation of the neck musculature.

• This step is important because, by definition, a diagnosis of

cervicogenic dizziness is excluded in a patient without neck pain. (Wrisley 2000) 55

Cervic icogenic ic Dizziness Dizziness

• Manual therapy is recommended treatment for cervicogenic

dizziness directed at decreasing muscle spasms and trigger points of pain in the cervical musculature.

• Treatment for cervicogenic dizziness:
• Manual therapy to decrease the irritation on the cervical

proprioceptors from muscle spasms and trigger points

• Exercises with graded exposure to sensory inputs to improve the

patient's use of vestibular and proprioceptive inputs for balance.

• Eye exercises to improve the function of the vestibular‐ocular

reflex.

• Evidence shows the use of manual therapy/mobilization for

cervicogenic dizziness showed improvement in postural stability, ROM, muscle tenderness and neck pain. Therefore manual therapy combined with vestibular rehab yielded good treatment outcomes (Lystad)

56

Vestibular ibular Hypofunction Hypofunction

• Defined as postural instability, visual blurring with head

movement and subjective complaints of dizziness

• Results: Based on Strong evidence of benefit over harm
• Clinicians should offer vestibular rehab to uni and bilateral

vestibular hypofunction with impairments and limitations related to deficit

• Clinicians should NOT include voluntary saccadic or smooth

pursuit eye movements in isolation (without head movement)

• Should be perscribed 3 x per day for gaze stability as at least
• ne component of HEP
• Based on expert opinion ‐ acute or subacute unilateral

hypofunction may need 1 x per week for 3 sessions then HEP

• Chronic unilateral 1x per week 4‐6 visits, Bilateral 1 x for 8‐12 V
• Evidence derived: APTA Neurology section Clinical Practice

Guidelines 57

Theories, Theories, In Interv rven entio tions, and and Ex Exer ercise cise Pre Prescription

Vestibular Rehabilitation Therapy

58

Section Section Obj Objecti ctives es

• 1. Understand the role and effectiveness of Vestibular

Rehabilitation Therapy (VRT) on Unilateral/Bilateral Peripheral Vestibular Hypofunction.

• 2. Review indications for VRT regarding Peripheral Vestibular

Hypofunction including enhanced gaze stability, enhanced postural stability, improved vertigo, and improved ADL’s.

• 3. Understand and apply interventions of adaptation,

substitution, and habituation.

• 4. Demonstration of progressive treatments of VRT to alleviate

the primary and secondary problems caused by vestibular disorders.

• 5. Demonstration and understanding of causation and manual

treatment for cervical caused dizziness.

• 6. Reference of outcomes and considerations for various

conditions

59

60

61

Ce Cervic icog

• genic

ic Dizziness zziness

• Possible result of cervical spine dysfunction including:
• Whiplash injury
• HNP
• Forms of cervical spine dysfunction (Trauma/OA)
• Spasms in the cervical muscles. (Wrisley, 2000)
• Diagnosis
• Characterized by dizziness and dysequilibrium
• Associated with neck pain in patients with cervical pathology
• True spinning vertigo is rarely associated with this syndrome
• Presentation and Symptoms
• Complaints of ataxia/unsteadiness
• Headache
• Postural imbalance associated with neck pain
• Limited neck range of motion (Wrisley 2000)

62

Cer Cervic icog

• genic

enic Dizziness Dizziness

• Pathophysiology
• Strong connections between the cervical receptors and

balance function

• Injury or pathology of the neck ‐ associated with a sense of

dizziness or disequilibrium, (Wrisley 2000)

• Current theory
• Abnormal input into the vestibular nuclei from the

proprioceptors of the upper cervical region. (Wrisley 2000)

• Cyclic pattern
• Cervical muscle spasms contribute to dizziness
• Dizziness contributes to muscle spasm, although the causal

relationship is unclear. (Wrisley 2000)

63

Vestibul ibular ar Hypof Hypofunction unction

• Bilateral Vestibular Hypofunction
• Reduction or loss of vestibular function
• Difficulty walking in the dark or on uneven surfaces

(Balance)

• Decrease in the patient’s ability to see clearly during

head movements.

• Ototoxicity, meningitis, sequential vestibular neuritis,

progressive disorders, autoimmune disorders, and

• neurofibromatosis. (usually idiopathic)
• Oscillopsia ‐ Another problem for patients with

bilateral vestibular loss is the visual blurring that

• ccurs during head movements. Almost 70% of all

patients with BVH complain of oscillopsia even after a course of gaze stabilization exercises.

64

Vestibul ibular ar Hypof Hypofunction unction

• Unilateral Vestibular Hypofunction (UVH)
• A condition in which one of the peripheral vestibular

receptors or the vestibular portion of cranial nerve VIII (vestibulocochlear) is not functioning properly.

• Oscillopsia during gaze activity or head movement
• Postural Instability and Deconditioning
• Causes: neuritis, labyrinthitis, perilymphatic fistula, and

acoustic neuroma

65

Vestibular ibular Rehab habilit litation ion Ther Therap apy (VR (VRT) & Cer Cervic icog

• genic

enic Di Dizzine zziness: ss:

Theories, Theories, In Interven entio tions, ns, and and Ex Exer ercise cise Prescrip escriptio tion

• Adaptation
• Substitution
• Habituation
• Balance Retraining
• Cervicogenic

Dizziness

• Manual Therapy
• Treatments

66

Traditio aditional nal Re Rehab vs.

• vs. VR

VRT

• Therapeutic Exercise
• Isometric Exercise
• Isotonics
• Resistive
• Vestibular Rehab
• Exercise based program

to reduce vertigo and dizziness, gaze instability and imbalance with falls.

• Can use Apps, programs

and Metronome to set and document speed

• Adaptation
• Substitution
• Habituation

67

VR VRT Trea eatmen tment Theori Theories es and and Ex Exer ercise cise Pre Prescription

• Recovery
• Healing and rehabilitaon opportunies → plascity of the CNS
• The brain is able to recalibrate (use other senses)
• Compensation from incorrect signals sent to the vestibular

system

• VRT improved vestibular function, reduced dizziness, improved

mobility, postural stability, and gaze stability with head movement (Tee)

• BPPV
• Evidence shows CRT and incorporated VRT is effective as a

preventative measure and recovery (Hillier 2016)

• Two stages
• Acute Compensation (Adaptation and Substitution)
• Brain recognizes signal are incorrect and shuts them off with a

cerebellar clamp

• Chronic Compensation (Habituation)
• Brain is getting signal bilaterally and begins to “make sense” of

it all. 68

Adap Adaptation tion

• Indication: Gaze Instability category, lack of coordination of

head and eye movements

• Goal: Reduce error and restore VOR and VSR
• ↓ Renal slip/blur or “error signals” through demands
• Step 1 in recovery of symptoms during static positioning

accomplished through the cerebellar clamp

• Adaptation is the mechanism of recovery during the acute

stage of compensation

• Capability of the vestibular system to facilitate indefinite changes

in the neuronal response to a stimulus via plasticity.

• Performance of head movements while keeping a target (X1)

(or 2 targets X2) in focus (Dye)

• Eyes must be focused on a word or letter to effectively induce

retinal slip 69

Sub Substitutio titution

• Indication: Dysfunctional and non‐recovering vestibular system
• r to strengthen drive compensation for the partially

functioning vestibular system. (all types of vestibular loss)

• Goals: Strengthen the remaining sensory systems (oculomotor,

somatosensory) or drive improvement into the other systems.

• The substitution of alternative strategies to replace the lost or

compromised function

• Internal substitution
• Most likely central pre programming the pt vision
• To compensate for vestibular loss.
• External substitution
• Assistive devices, home modifications, lifestyle changes
• Promotes the vestibular system removing visual cueing and

changing somatosensory input (proprioceptive balance exercises) Creath 2002

70

Habi Habitua tuation ion

• Indication: Motion provoking category
• Goal: Rebalance tonic activity with the vestibular nuclei and reduce

responsiveness to repetitive stimuli

• Ability of brain to tune out a continuous repetitive tone (Dye)
• Desensitization ‐ the more you feel your symptoms, the more likely

the symptoms are to be suppressed.

• One movement may improve (horizontal), but doesn't transfer

to another (vertical).

• Not appropriate for bilateral vestibular loss (Initially) *
• At the beginning phase, sitting symptoms will resolve while standing

symptoms will persist due to the continued cerebellar clamp

• Balance signals turned off where the cerebellum reduces firing

through the brainstem

• Near the end of the acute stage of compensation, the cerebellar clamp

will release allowing balance information from the vestibular system to transmit to the brain.

• Study of postural re‐arrangement (Alessandrini)

71

Habitua Habituation ion

• Chronic Stage of Compensation
• Brain will receive bilateral signals and decode/re‐learn info
• Correct any discrepancy between the two ears
• The more signals the brain receives, the more it understands and

interpret what the balance organs are relaying

• Normal ADL movements will assist in compensation phase
• Habituation and Gaze Stabilization exercises in 6 weeks improved

DHI and MSQ outcome scores (Clendaniel)

• Habituation through repetition of recovery to specific

movements.

• Begin to allow pts to encounter movements that caused symptoms

to maximize compensation

• Barriers to recovery: use of meds outside post acute phase.
• They result in turning off signals and keep the brain clamp

engaged 72

Sub Substitution titution Ex Exer ercises cises

• Seated Treatment
• 1. Hold 2 cards or targets
• Keep visible when holding

them straight

• 2. Turn head and eyes to one

target

• 3. Turn eyes to opposite

target then move head to the same direction

• Repeat on the other side
• 4. Manipulate speed, target

distance, surface and background

73

Sub Substitution titution Ex Exer ercises cises

• Exercise Advancement
• 1. Unstable surface
• 2. Vertical plane
• 3. Single leg in seated

(swiss ball)

• 4. Walking
• Backward, Sideways or

Tandem

• 5. Obstacles

74

Sub Substitutio titution Ex Exer ercises cises

• Eyes Open/Establish

“Neutral”

• 1. Laser on bullseye target
• 2. Close Eyes – rotate entire

body/head away from target

• 3. With eyes closed look back

to where you feel target “neutral”

• 4. Open eyes and test

accuracy

• 5. Repeat Bilaterally
• Progression to standing
• Progression to unstable

(foam) 75

Adap Adaptation tion Ex Exer ercises cises

• X1 and X2 Viewing – VOR exercises to improve gain and accuracy
• X1 – Head movements in phase with a target. Held Target during

movement

• Card with lettering held at arm length, eyes focused on the letters
• Move head side to side 30 degrees. Vertically or Horizontally
• Move your head as fast as you can as long as the letter stays in

focus

• X2 – Head movement out of phase with target. Target and

head both are moving opposite of each other

• Card held with lettering at arm length, eyes focused on letters
• Keep in focus, move as fast as possible 1‐5 minutes.
• Vertical and horizontal.
• Slower and smaller amplitude than x1 viewing ex.
• Should not be performed until x1 viewing is mastered.

76

Adap Adaptation tion Ex Exer ercises cises

77

Adap Adaptation tion Ex Exer ercises cises

• X1 Viewing with Wall Targets
• Stand in view distance from target at wall (2‐3 ft)
• Eyes remain focused on target (side to side/vertical)
• Various Targets, pictures, distorted/busy patterned

backgrounds

• Advancement Progression (per response and tolerance)
• Seated
• Standing
• Solid
• Foam
• Tandem
• Step forward/step back
• Step up/step down

78

Adap Adaptation tion Ex Exer ercises cises

79

Adap Adaptation tion Ex Exer ercises cises

• Advanced X1 and X2
• Head piece resistance band/wall station
• Promotion of cervical and postural

stabilization

• Movement of head against resistance

up/down, side to side and side bending while performing X1 and X2 activity

• Advancement in surface and positioning:
• Solid Surface
• Foam Surface
• Swiss ball
• Tandem
• Walking
• Stepping
• Step ups/Down
• Held Targets
• Multiple Wall targets

80

Con Conver ergence nce and and Di Divergence ence

• 2 Spatula each with a written

letter or Number

• Hold each at arm length apart
• Bring objects to and from patient

(one at a time)

• Stagger objects and bring to and

from patient

• Busy background patterning
• Search for 3D image in the picture
• Same advancement protocol

applies from adaptation section

• Sitting
• Standing
• Stepping
• Surface
• Walking

81

Habitua Habituation ion Ex Exer ercises cises

• Effective for Visual Vertigo
• Oscillopsia, Motion sickness (sea sickness/car sickness)
• Challenge Balance While focusing on noxious visual target
• Use of Biofeedback – Body Stability
• Laser or forehead flashlight
• Do not let light/laser move while doing sts, walking, heel toe,

squats

• Standing activity Functional Tasks
• Pointing and UE motions at target for location during movement
• Progression:
• Stable
• Unstable / Wobble‐board
• One leg
• Multiple patterns/speed
• Wii /ski/soccer/snowboard/tightrope/squat/lunge/leg ext
• Eyes Closed
• ADL Simulation
• Obstacles
• Carrying

82

Habitua Habituation ion Ex Exer ercises cises

83

Habitua Habituation ion Ex Exer ercises cises

• Target Tracking During Movement
• Standing ball toss and catch
• Walking toss and catch
• Pivot toss and catch
• Trampoline toss and catch
• Pickup and toss from ground
• Stool rotation while focused on

target

• Stool roll forward and back while

focused on target

• Pinhole Glasses with Environment

Advancement/Hardening

• Peds – Hippotherapy or zoom ball

(Astronaut program) 84

Ca Cawthorne wthorne and and Cook Cooksey sey Ex Exer ercises cises

• Vestibular Therapy Exercise Theory
• Eye exercises designed to gradually retrain the eye and body

musculature

• Uses vision and proprioceptive signals to compensate for

loss.

• Patients are encouraged to move into positions that provoke

symptoms.

• Exercises include:
• Adaptation Exercises to improve VOR (gain)
• Habituation Exercises (repeated head and visual movement)
• Balance and Gait Exercises (static and dynamic)

85

Ce Cervic icog

• genic

ic Ve Vertigo Trea eatmen tment

• 1. Stabilization
• 2. Postural Awareness/Coping
• Ergonomic Modification
• Forward Head
• In pain phase, relief techniques (whole body turning)
• 3. Flexibility and Stretching
• 4. Manual Therapy
• Manual Cervical Flexion in flexion
• SNAGS
• Ischemic Compression to trigger Points
• UE Dry needling https://www.youtube.com/watch?v=‐thao1ElN7Q
• Suboccipital release (OA release/OA rocking with distraction)
• Instrument assisted soft tissue mobilization
• 5. Joint mobilization/SNAGS
• 6. Modalities

86

Ce Cervic icog

• genic

ic Ve Vertigo Trea eatmen tment

• Stabilization Exercises
• Chin Tucks and Cervical Retraction
• Planks and Superman’s
• Arm movement in prone (head off of plinth)
• Swiss Ball WITY
• Chin Tuck with Ball on wall (advance with X1 Viewing)
• Depression of swiss ball into table
• Ball on wall CCW and CW
• Sick Scapula (closed chain IR/ER with protraction/retraction
• n door)
• Cervical Side bending into ball
• Swiss ball pushups

87

Ce Cervic icog

• genic

ic Ve Vertigo Trea eatmen tment

• Cervical SNAG (picture 1 top left)
• Brace forehead with one hand
• Mobilize C1/C2 with opposite Hand
• Extend Neck
• Extension SNAG (picture 2 top right)
• Thumbs at articular pillars
• Glide into Facet Plane
• Patient actively Extends neck (painless)
• Work down into various levels
• Rotation SNAG (picture 3 bottom left)
• Thumb on thumb on unilateral articular pillar (unilateral if motion is

restricted)

• Glide into active patient rotation
• Block joint into pain free zone
• Work down into various levels
• Thoracic Spine mobilization (picture 4 bottom right)
• PA grade IV or V manipulation (prone)
• Today’s demonstration of “fall back technique”
• Supine active Foam Roller

88

Ce Cervic icog

• genic

ic Ve Vertigo Trea eatmen tment

89

Lab Lab Tim Time!! !!

• Use Examples
• Think Clinic Equipment
• Innovation
• Application
• Safety

90

Anatomy and Biomechanics of the Temporomandibular Joint

• Background
• 50‐75% of individuals have experienced or will

experience a TMD problem

• 33% have >1 persistent problem
• F>M 2:1
• Cook, 2007

91

Anatomy and Biomechanics of the Temporomandibular Joint

92

Anatomy and Biomechanics of the Temporomandibular Joint

• Disc Anatomy
• Displacement is Anterior and Lateral
• Bioconcave, A&P Innervated
• Retrodiscal Area
• Highly innervated, has synovial fluid
• Prone to inflammation
• Does not tolerate tensile forces or constant load (Cook,

2007)

93

Anatomy and Biomechanics of the Temporomandibular Joint

• Ligaments
• Lateral guide opening
• Medial disc has lateral pterygoid attachments
• Sphenomandibular and Stylomandibular
• Suspend mandible
• Muscles – see next slide

94

Anatomy and Biomechanics of the Temporomandibular Joint

95

Anatomy and Biomechanics of the Temporomandibular Joint

96

Anatomy and Biomechanics of the Temporomandibular Joint

• Biomechanics
• Movements: open, close, protrusion, retraction,

lateral deviation

• If rotating – condyle rolls with inferior portion of disc
• If translating – condyle and disc move together

97

Anatomy and Biomechanics of the Temporomandibular Joint

• Jaw Opening
• First phase posterior roll – mandible moves inf/post
• Late Phase transitions from rotation to ant/inf

translation

• Muscles involved: Lateral Pterygoid and Suprahyoid

98

Jaw Opening and Curves

C-Curve

• This occurs secondary to

hypomobility due to an internal derangement.

• The mandible deviates to

the involved side during the mid-range of motion before the jaw returns back to the center.

• In the example below, a

C-curve is noted to the Right with the dysfunctional TMJ being

• n the Right.

S-Curve

• Occurs secondary to

hypermobility due to poor neuromuscular control of the muscles of mastication.

• Structures causing the

dysfunction can include the masseter, temporalis, disc, and lateral ligaments.

99

Anatomy and Biomechanics of the Temporomandibular Joint

• Biomechanics
• Jaw Closing
• Posterior/Sup translation then Anterior rotation
• Muscles Masseter
• Medial Pterygoid
• Temporalis

100

Anatomy and Biomechanics of the Temporomandibular Joint

• Biomechanics
• Retraction – posterior translation, aides in closing
• Muscles: temporalis and suprahyoid
• Protrusion – Anterior translation, aides in max
• pening
• Muscles: Lateral Pterygoid (Primary), Medial

Pterygoid, Masseter

101

Anatomy and Biomechanics of the Temporomandibular Joint

• Lateral deviation – side to side translation
• Ipsilateral side of deviation serves as pivot
• Contralateral rotates anterior and medial
• Muscles: Med Pterygoid (CL), Lat Pterygoid (CL),

Masseter (IL), Temporalis (IL)

102

TMJ ROM Values

• Opening – 50mm
• Protrusion – 3‐6mm
• Retraction – 3‐4 mm
• Lateral Deviation – 11mm
• (Magee, 2006)
• Palpation: Physiopedia
• https://youtu.be/wtOTI5Yt28w

103

Definitions and Pathology in Temporomandibular Dysfunction

• Disc Displacement with Reduction
• Clicking – first sign of TM dysfunction, the farther

into opening that the click occurs = the worse the problem

• Reciprocal Clicking
• Opening ‐ condyle moves beneath the disc, snaps and falls

back into normal concave seat

• Closing – occurs at end of closing. Condyle slides posterior

and disc is displaced anterior 104

Definitions and Pathology in Temporomandibular Dysfunction

• Disc Displacement without Reduction
• Disc remains displaced during all motion
• Initially a “closed lock”
• https://youtu.be/mB468Jh9aAY (Physiopedia)

105

Evaluation of TMD

• Locked Jaw and Clicking Patterns
• Closed Lock
• Caused by disc
• Disc Dislocation with Reduction and opening limited
• Open Lock
• 2 clicks with opening (dislocation posterior then

slides off anterior disc)

• 2 clicks with closing

106

Evaluation of TMD

• Special Tests
• OA = AM stiffness
• Deep neck flexor imbalance = Mouth breather
• Bruxism = adhesions and clenching click
• Vertebral Artery test
• Trismus – tonic contraction of masticatory muscles
• Tongue Thrust
• Tongue pushed forward against teeth
• Ask patient to swallow with neutral posture
• Normal – hyoid bone moves up/down
• Abnormal – Hyoid ONLY moves upward as well as

suboccipital contraction 107

Manual Treatment Techniques and Relaxation Activities

From: (Cleland, 2006)

• Intra‐oral Manual Therapy ‐
• Cervical Spine mobilizations
• Cervical Soft tissue work
• TMJ mobilizations
• Rocobado exercises
• Ionto with Dex

108

Manual Treatment Techniques and Relaxation Activities

• Videos:
• https://youtu.be/9og0M0hCMbY

(www.sleepandtmjtherapy.com)

• https://youtu.be/RhO1fEXKAjQ (Freedom Physical

Therapy)

109

Manual Treatment Techniques and Relaxation Activities

• Isometric Jaw Exercises
• Functional Jaw Opening
• Controlled ROM Lateral deviation
• Self distraction mobilizations
• Dynamic cervical stabilization
• Scapular Stabilization
• 6x6 Exercises (Rocobado)

110

Dry Needling to Cervical Spine, Jaw, and Lateral Pterygoid

111

Dry Needling to Cervical Spine, Jaw, and Lateral Pterygoid

112

Dry Needling to Cervical Spine, Jaw, and Lateral Pterygoid

113

Dry Needling to Cervical Spine, Jaw, and Lateral Pterygoid

114

IASTM and Cupping to Upper Cervical and TMJ Tissue

115

IASTM and Cupping to Upper Cervical and TMJ Tissue

116

Roles of Cervical Spine, Radicular Symptoms, and Posture on TMD

117

Roles of Cervical Spine, Radicular Symptoms, and Posture on TMD (Travell)

118

The The Upper Upper Cer Cervic ical al Eval alua uation/T

• n/Tool
• ols/Out

s/Outcomes

• mes
• 1. Perform Screen to Rule Out:
• Artery involvement
• Cervical Instability
• Ligament Instability
• Upper Quarter Clearing Exam
• 2. Once Clear:
• Move on to the Objective Exam

119

The The Upper Upper Cer Cervic ical al Eval alua uation/T

• n/Tool
• ols/Out

s/Outcomes

• mes
• Objective Examination
• 1. Palpation
• 2. ROM
• 3. MMT
• 4. Neural Tension Tests
• 5. Special Tests
• LAB and Cases

120