Clinical Application of Neuromuscular Techniques The Upper Body Volume 1

1 2 The cranium 335 ,-- Alar process Perpendicular plate ---i\\ Crista galli --1H-1�fI' +--rI Ethmoidal air cells Slit for process of Anterior ethmoidal dura mater ---� groove Cribriform plate Posterior ethmoidal groove A Alae of crista galli »-If-=- Crista galli Orbital plate --t-l-r 1'</1ct-- Labyrinth Superior concha --��\"'C:::- -\\-\\- =--:rw'-l--- Superior concha Uncinate process Superior meatus Figure 12.9 Hand positions for contact with the greater wings of Middle concha -----t;,'; --- --' Uncinate process sphenoid. Reproduced with permission from Chaitow (2005). Perpendicular plate ---� '-- Middle concha supraorbital ridges or the orbital portions of the zygomae. B Then gradually increase thumb pressure on the greater wings, monitoring the status of the sphenoid, the occiput Figure 1 2. 1 0 Superior (A) and inferior (B) views of the ethmoid. and the sphenobasilar joint as you gently and fluidly intro­ Reproduced with permission from Chaitow (2005). duce decompression. • Shell-shaped air sinuses that form a honeycomb frame­ Milne suggests that it is possible to distinguish six levels of work to each side of the plate which is crowned by tissue separation from first contact to final completion. • A thin crest (crista gaUi) formed by the dragging attach­ 1. Skin, scalp and fascia ment of the falx cerebri 2. Slower muscular release (occipitofrontalis and tempo­ • Thin bony plate-like structures which form the medial ralis mainly) eye socket 3. Sutural separation ('akin to prising apart a magnet from • Additional projections and plates, one forming part of a piece of metal') the nasal septum, with the perpendicular plate being a 4. Dural release (like 'elastic bands reluctantly giving way') virtual continuation of the vomer (see below) 5. Freeing of the cerebrospinal fluid circulation ('the whole Articul ations head suddenly feels oceanic, tidal, expansive ... this is the domain of optimized cerebrospinal fluid') There are interdigitated sutures with the sphenoid and non­ 6. Finally energetic release ('a tactile sensation of chemical digitated sutures with the vomer, nasal bones, palatines, electrical fire unrolling and spreading outwards in waves maxillae and the frontal bone. under your fingers') Reci p roca l tension m e m brane rel ati onshi ps In this poetic language we can sense the nature of the debate between those who wish to understand what is happening • The falx cerebri attaches directly to the crista gaUL in orthopedic terms and those who embrace 'fluid/electric' • The inferior border connects with the nasal cartilage. and energetic concepts. There are no direct muscular attachments to the ethmoid. ETHMOID (FIG. 12.10) • A tissue paper-thin construction compnsmg a central horizontalplate (cribriform) which contains tiny openings for the passage of neural structures, surrounded by

336 CLINICAL APPLICATION OF NEUROMUSCULAR TECHNIQUES: THE UPPER BODY R a nge a nd d i rection of motion The traction of the falx on the crista galli pulls it superiorly and slightly anteriorly. Pulling of the falx must determine major aspects of the ethmoid's motion potential. The pre­ sumed axis of rotation suggests that the ethmoid rotates in an opposite direction to the supposed sphenoid rotational axis, as though they were geared together. Air passing through the shell-like ethmoid air cells is warmed before reaching the lungs and the alternation of pressures as air enters and leaves the ethmoid must influ­ ence minor degrees of motion between it and its neighbor­ ing structures. Because, in life, its tissue paper-like delicacy has a sponge-like consistency it is presumed that the struc­ ture acts as a local shock absorber. Other associati ons a nd i nfl uences Figure 1 2. 1 1 Treatment of the ethmoid using pincer contact. Reproduced with permission from Chaitow (1999). The 1st cranial (olfactory) nerve lies superior to the cribri­ form plate and from this derive numerous neural penetra­ tions of it, which innervate mucous membranes that provide us with olfactory sense. Dysfu ncti o na l p atterns • This method is thought to be more effective if this dual action coincides with what is perceived to be the flexion When sinus inflammation exists the ethmoid is likely to be stage of the cranial cycle. swollen and painful. Because of its role as a shock absorber it is potentially vulnerable to blows of a direct nature and to • Alternatively, the separation hold can be maintained soaking up stresses from any of its neighbors. until release (see Box 12.2) is noted. There is no direct way of contacting the ethmoid but it • The separation action (pulsed or constant) eases sutural can be easily influenced via contacts on the frontal bone or impaction which may exist between the ethmoid as it is the vomer. taken away from the frontal, nasal and maxillary bones into its presumed external rotation position (flexion Pa l pation exercises phase of the cycle). Nasal release technique (Fig. 72.7 7) VOMER [FIG. 12.1) • The patient's forehead (frontal bone) is gently cupped by • This is a plough-shaped sandwich of thin bony tissue the practitioner's caudad hand while standing to the side that houses a cartilaginous membrane, which forms the and facing the supine patient. nasal cartilage. • The practitioner's cephalad hand is crossed over the cau­ dad hand so that the index finger and thumb can gently • It separates and acts as a junction point between the eth­ grasp the superior aspects of the maxillae, inferior to the moid, maxillae, palatines and sphenoid. frontomaxillary suture. • The unused fingers of the previously cephalad and now Articu l ations caudad hand should be folded and resting on the dorsum of the other hand. • Superiorly, it articulates with the sphenoid as a tongue­ • A slow, rhythmical separation of the two contacts is intro­ and-groove joint of spectacular beauty. duced so that the hand on the forehead is applying gen­ tle pressure toward the floor, so pushing the falx cerebri • On the inferior aspect of the sphenoid the vomer also has away from the ethmoid and dragging on it, while the fin­ minor articulation contacts with the palatine bones at the ger and thumb of the now caudad hand are easing the rostrum. maxillae anteriorly. • The 'pumping' , repetitive separation and release applica­ • There is a direct, plain (not interdigitated) suture with the tions continue for at least 1 minute to achieve a local ethmoid at its anterosuperior aspect. The vomer is a vir­ effect, enhanced air and blood flow through the ethmoid tual continuation of the ethmoid's perpendicular plate. and release of the sutural restrictions. • The inferior aspect of the vomer articulates with the max­ illae and the paJatines. • There is a cartilaginous articulation with the nasal septum.

12 The cranium 337 There are no direct associations with the reciprocal tension Dysfu n ctiona l pattern s membranes and there are no direct muscular attachments. • In rare cases, the vomer can penetrate the palatine suture, R a n ge a n d d i rection of m oti o n producing an enlargement/swelling of the central por­ The vomer's range of motion i s identical t o the ethmoid and tion of the roof of the hard palate, a condition known as opposite to the sphenoid. torus palatinus. Other associ ati o n s a n d i nfl u ences • As with the ethmoid, inflammation of the vomer is prob­ • As with the ethmoid, this is a pliable shock-absorbing able in association with sinusitis. structure which conforms and deforms dependent upon • Direct trauma can cause deviation of the vomer and so the demands made on it by surrounding structures. interfere with normal nasal breathing. • The mucous membrane covering the vomer assists in warming air in nasal breathing. MANDIBLE (FIG. 12.12) • A body, which is the horizontal portion that meets with the body of the other side at the central jaw protuberance (the symphysis menti). Coronoid process ---, Head of mandible Figure 1 2. 1 2 Lateral (A) and medial (B) Temporalis ---+ aspects of the mandible showing muscular Alveolar part attachment sites. Reproduced with permission from Chaitow (2005). --:-'l Masseter Mental foramen --.- �-- Angle Mentalis ---� Depressor labii inferioris ---. \"-- Buccinator Mental protuberance ---,\\ Mental tubercle ---' '-- Platysma (part only) A Depressor anguli oris (part only) Temporalis ------�r- Lateral pterygoid Superior constrictor --.-, �-- Lingula Mandibular foramen r-�-\\-- Mylohyoid groove Sublingual fossa ---.\"l.: \"'':\" -' -+-- Medial pterygoid Genioglossus ---1. Submandibular fossa Geniohyoid --�;p- '-- Mylohyoid line B '-- Digastric anterior belly

338 C LI N I CAL APPLI CATION OF N EU RO M USCULAR TEC H N IQUES: THE U PPER BODY • Attached to the posterior aspect of the bodies are the • Digastric arises from two sites: the posterior belly from rami, the vertical portions of the mandible. the mastoid notch of the temporal bone and the anterior belly from the digastric fossa on the internal surface of • Each ramus forms two projections, the posterior of which the anterior aspect of the mandible. The two parts of the becomes the articular condyle, via a slender neck, for muscle link via a tendon that is attached to the hyoid its articulation with the temporal bone while the ante­ bone by a fibrous connection. Its actions are to depress rior forms the coronoid process to which attaches the the mandible, elevate the hyoid bone and assist in retrac­ temporalis. tion of the mandible. Articu lations • Platysma's anterior fibers interlace with the contralateral muscle, across the mid-line, below and behind the sym­ The only osseous articulation of the mandible is with the physis menti. Intermediate fibers attach to the lower bor­ temporal bone via the disc at the temporomandibular (TM) der of the mandibular body while the posterior fibers joint. It also articulates with its teeth, which articulate cross the mandible and the anterolateral part of the mas­ (occlude) with the upper teeth set in the maxillae. seter and attach to subcutaneous tissue and skin of the lower face. The actions of platysma involve reducing the There are no reciprocal tension membrane connections. concavity between the jaw and the side of the neck. Anteriorly, it may assist in depressing the mandible or Maj o r m uscu l a r attachments draw the lower lip and corners of the mouth inferiorly, especially when the jaw is already open wide. • Temporalis, which attaches to the temporal fossae, nm­ ning and converging medial to the zygomatic arch with • Mylohyoid arises from the inner surface of the mandible insertion on the coronoid process and the ramus of the and attaches to the hyoid bone. Its function is to depress mandible. The anterior/superior fibers occlude the teeth the mandible and to elevate the hyoid during swallowing. as the mandible is elevated while the posterior fibers assist in retraction of the jaw as well as lateral chewing • Geniohyoid attaches at the symphysis menti and runs to movements. the anterior surface of the hyoid bone, acting in much the same manner as mylohyoid. • Masseter attaches via its superficial fibers to the zygo­ matic process and arch while the deeper fibers arise from Mi no r mu scu l a r attachments (not described he re) the deeper surface of the zygomatic arch. Superficially, it inserts into the lateral ramus while the deeper fibers • Buccinator attach to the upper ramus and to the coronoid process. Its • Depressor angularis oris functions are to occlude the jaw during chewing, to assist • Orbicularis oris in lateral excursion, and (by means of fibers running in • Depressor labii inferioris different directions) to alternately retract and protrude • Hyoglossus the mandible during chewing. This is considered to be • Mentalis the most powerful muscle in the body. • Superior pharyngeal constrictor • Genioglossus • Lateral pterygoid attaches to the greater wing of the sphenoid (upper head) as well as to the lateral pterygoid Range and d i rection of m otion plate (lower head), both heads inserting via a tendon to the anterior aspect of the neck of the mandible; a portion Involuntary motion of the mandible relates to motion of the of the upper head may also attach to the joint capsule and temporal bones with which it articulates. This will be mod­ the articular disc of the temporomandibular joint. The ified by the degree of muscular contraction at their junction. various actions in which the muscle is involved include depression and protrusion of the mandible, and assis­ There is some disagreement as to the 'normal' active tance in contralateral excursion of the mandible, as well range of motion of the mandible that in various texts is con­ as offering stability to the temporomandibular joint when sidered to be between 42 and 52 mm (Rocobado 1985, Tally the mandible is closing. It is thought to stabilize the 1990). Skaggs (1997) reports: condyle when the teeth are clenched to prevent it from moving too far posteriorly (Gray's Anatomy 2005). Rocobado (1985) states maximum. mandibular opening to be 50 mm, thereby taking the periarticular connective tissue to • Medial pterygoid arises superficially from the tuberosity 112% stretch. He qualifies that the stretch of the periarticu­ of the maxiIla as well as from the palatine bone. A deeper lar connective tissue should not exceed 70-80%, thus mak­ origin is from the medial pterygoid plate and the palatine ing junctional mandibular range of motion approximately bone. Superficial and deeper fibers merge to attach to the 40 mm. Okeson 's recent (1996) guidelines cite normal min­ medial ramus of the mandible close to the angle. The ftmc­ imum interincisal distance and active ranges of motion to be tions of the muscle are to elevate and protrude the 36 to 44 mm and less in women. mandible (acting with the lateral pterygoid and the mas­ seter) and contralateral excursion of the mandible.

1 2 The cranium 339 Travers et al (2000) investigated the relationship of maxi­ A mum incisor and condylar movement using both straight­ line and curvilinear pathways of the central incisors. They report: 'Neither the straight-line distances nor curvilinear pathways of the incisors were correlated with those of the condyles.' They conclude that opening range (maximal inci­ sor opening) does not provide reliable information about the translation of the condyle and its use as a diagnostic indicator of condylar movement should be limited: '.. .healthy individuals may perform normal opening with highly vari­ able amounts of condylar translation ... [this] largely explained by variation in the amOlmt of mandibular rota tion'. There is more to the range of motion of the mandible than mecha nics, as Milne (1995) points out. The mandible is more open to psychoLogicaL input than any other bone in the head . . . unexpressed aggression, determi­ nation, orfear ofspeaking out, cause changes in mandibuLar motion that rangefrom subtLe to dramatic. For instance, in states of rage the mandibLe is so m uscuLarly tense that aLmost all movement is lost. Dysfuncti ona l patterns B Both physical and emotional injuries and stresses can result Figure 1 2. 1 3 Crowding fA) and decompression (8) stages of in dysfunctional temporomandibular joint behavior. The temporomandibular treatment. Reproduced with permission from effects are demonstrated in pain, clicking and variations on Chaitow (2005). the theme of restriction and abnormal opening and closing patterns (see Box 12.4, p. 359) . We believe that in almost all • The hands a re gently drawn cephalad so that traction is instances of TMJ dysfunction, soft tissue considerations applied to the skin and fascia of the cheeks, until all the should be prima ry. slack has been removed. The temporomandibular joints will in this way be overa pproximated/crowded. It is suggested that the soft tissues associated with the joint receive appropriate attention before joint corrections • This is held for not less than 1 minute and longer if it is are attempted and that this be combined with home self­ not uncomfortable for the patient. treatment and exercise strategies for rehabilitation, as well as with attention to underlying causes whether these lie in • The direction of traction is then reversed so that a dis­ habits (bruxism, gwn chewing, etc.) or emotional turmoil traction occurs as the skin and fascia a re taken to their and stress coping abilities. elastic limits and the underlying structures are eased away from the TM joints. This is held for at least one and Pa l pation exerci ses ideally several minutes. TMJ compression and decompression (Fig. 12. 1 3) • A sense of 'unwinding' may be noted as the tissues release, in which case the motion is followed without any CAUTION: Patients with anterior articular disc displace­ direction being superimposed. ment may find the compression techniques too uncom­ fortable but they may receive benefit and relief with the CAUTION: The fol lowing steps may not be appropriate decompression techniques. If the patient reports consid­ for patients with articular disc derangement. However, erable discomfort with compression, discontinue imme­ some may receive benefit and relief with these steps. To diately. avoid undue strain on the disc, proceed cautiously with regards to the degree of pressurelresistance as well as the • The patient is supine and the practitioner is seated at the head. • The palms of the practitioner's hands a re placed onto the sides of the patient's face so that they follow the con­ tours, the thenar eminences are placed over the TMJs and the fingers curve around the mandible. No lubricant is used at this stage.

340 C LI N I CA L A P P L I CATI O N O F N E U RO M U S C U LA R TECH N I QU E S : T H E U P P E R B O DY degree of force used (none) to obtain more range. If the patient reports considerabl e discomfort while applying these procedures, discontinue their use immediately. MET method 1 (Fig. 72.74) Figure 1 2. 1 4 M ET treatment of temporomand i b u l a r joint involving • If the mandible cannot open fully or adequately, recipro­ restricted opening. Reprod u ced with permission from Cha itow (2005). cal inhibition may be utilized. • The patient is seated close to and facing the treatment table. • The mouth is open to its comfortable limit and, following the isometric contraction (described below), it is gently opened further (by the patient and/or the practitioner) to its new barrier, before repeating. • The patient is asked to open the already open mouth fur­ ther, against resistance applied by the practitioner's or the patient's own hand (in self-treatment the patient places the elbow on the table, chin in hand and attempts to open the mouth against own resistance for 10 seconds or so), thus inhibiting the muscles which act to close the mouth. • This MET method has a relaxing effect on those muscles which may be shortened or tight and that are acting to restrict opening of the mandible. MET method 2 (Fig. 72. 75) Figure 1 2. 1 5 M ET treatment of temporo m a nd ibular joint i nvolving • Lewit (1992) suggests the following method for TMJ lateral deviation. Reproduced with permission from Cha itow (2005). problems, maintaining that laterolateral (lateral excursion) FRONTAL ( F I G . 1 2. 16) movements of the mandible are particularly important. • The patient sits with the head turned to one side (say • A central metopic suture which is usually fused but toward the left, in this example); the practitioner stands sometimes (rarely) interdigitated, on the inside of which behind the patient. lie the attachments for the bifurcated falx cerebri • The patient's head is stabilized against the practitioner's chest with the practitioner's right hand. • Bilateral concave domed bosses which house the frontal • The patient opens the mouth, allowing the chin to drop, lobes of the brain as well as air sinuses at the inferior and the practitioner cradles the mandible with the left medial corner hand, so that the fingers are curled under the jaw. • The mandible is drawn gently toward the practitioner's • Superciliary arches, a nasal spine and the medial aspects chest (pressing it into contralateral excursion) and, once of the eye socket the slack has been taken up, the patient offers a degree of resistance to it being taken further laterally. Articul ations • After a few seconds of gentle isometric contraction, the practitioner and patient slowly relax simultaneously and • With the parietals at the interdigitated coronal suture. the jaw will usually have an increased lateral excursion. • With the ethmoid at the ethmoidal notch. • This is repeated three times. • With the sphenoid at the greater and lesser wings. • This method should be performed so that the lateral pull is • With the zygomae via the interdigitated zygomatic process away from the side to which the jaw deviates on opening. at the dentate suture. Self-treatment exercise. Gelb (1977) suggests a retrusive exercise be used, as follows. • The patient curls the tongue upwards, placing the tip as far back on the roof of the mouth as possible. • While this is maintained in position, the patient slowly opens and closes the mouth (gently) to activate the suprahyoid, posterior temporalis and posterior digastric muscles (the retrusive group).

1 2 The cra n i u m 341 Supraorbilal notch ------i---1 - Frontal tuberosity Glabella ---\" �--\", Superciliary arch Remains of frontal �__+-- Zygomatic process (metopic) suture Supraorbital margin A Nasal spine ---\" Roofs of ethmoidal air cells ---, r---- Sulcus for sagittal sinus Zygomatic process --y-,�t -UilIW-�-IT Ethmoidal notch Fossa for lacrimal gland ---/ ---1(' Orbital plate Supraorbital foramen ---./ '-- Supraorbital foramen Frontal foramen ---\" '-- Frontal sinus B Frontal notch Nasal spine Frontal crest Figure 1 2. 1 6 Frontal (A) and infe rior ( B) aspects of the frontal bone. Reprod uced with perm ission from Chaitow (2005). • With the maxillae via the frontal process. Muscu l a r attachments (see Fi g . 12.27, p. 353) • With the temporals (not always). • With the lacrimal bones and the nasal bones. • Temporalis arises from the temporal fossa and its fibers converge to attach on the coronoid process and ramus of Reci p roca l ten s i o n m e m br a n e relations hi ps the mandible, medial to the zygomatic arch. The origin of temporalis crosses the coronal suture between the frontal The falx cerebri attaches strongly to the inner aspect of the and parietal bone as well as the suture between the tem­ mid-line of the frontal bone at a double crest formed by its poral bone and the parietal. bifurcated attachments, which creates a space that becomes the superior sagittal sinus. • Occipitofrontalis covers the entire dome of the skull from the superior nuchal line to the eyebrows, completely

342 C L I N I C A L A P P L I CATI O N O F N EU RO M U SC U LA R TECH N I Q U E S : T H E U P P E R B O DY enveloping the parietal suture. The muscle also spans the but clearly could not occur if the bones had fused, as hap­ lambdoidal and coronal sutures, attaching via direct or pens in most cases. indirect linkages with the frontal, temporal, parietal and occipital bones. Frontalis merges with the superficial fas­ Other associ ations a nd i nfl uences cia of the eyebrow area while some fibers are continuous with fibers of corrugator supercilii and orbicularis oculi Associations with problems of the eyes and sinuses are clear attaching to the zygomatic process of the frontal bone, from the geography of the region alone and congestion and with further linkage to the epicranial aponeurosis ante­ discomfort in this area can at times be related to frontal rior to the coronal suture. bone compression or lack of freedom of motion. The con­ • Corrugator supercilii lies medial to the eyebrow and nection with the falx cerebri offers other possible linkages, comprises a small pyramid-shaped structure lying deeper in particular to cranial circulation and drainage. than occipitofrontalis and orbicularis oculi. • Orbicularis oculi is a broad flat muscle which forms part Dysfunctiona l patterns of the eyelids, surrounds the eye and runs into the cheeks and temporal region. Parts are continuous with occip­ Apart from direct blows to the forehead, few problems itofrontalis. seem to arise as a direct result of frontal dysfunction. • Procerus is a slip of nasal muscle that is continuous with However, as with the parietals (see below), problems may the medial side of the frontal part of occipitofrontalis. arise as a result of the accommodation of the bone to influ­ ences on it, temporal, parietal, sphenoidal, or from the facial Ra nge a nd d i rection of m otion bones. During flexion the frontal bone is said to be: Pa l pation exerci s es . . . carried by the sphenoid wings and, heLd by the falx cere­ Hypothenar eminence application for frontal lift bri, and so rotates about an oblique axis through the squama (Fig. 72. 7 7) so that the glabella moves posterior, the ethmoid notch • The patient is supine and the practitioner sits at the head widens, the orbital plate's posterior border moves slightly inferior and lateral, the zygomatic processes move anterior of the table, elbows fully supported and fingers inter­ and lateral and the squama 'bend' and recede at the midline. laced so that the hypothenar eminences rest on the lateral (Brookes 1 981) angles of the frontal bones with the fingers covering the metopic suture. It is the combined effect of sphenoidal flexion and the back­ • As the patient exhales the interlaced hands exert light wards pull of the falx during the flexion phase of the cycle compressive force to take out slack (grams only) via the that is thought to produce the mid-line frontal bone flexion, hypothenar eminences (bringing them toward each other), which would be conceivable if a true suture were present utilizing a very slight contraction of the extensor muscles AB Figure 1 2. 1 7 Hand actions and d i rections of force (A) and contact positions (B) for decom pression treatment of fronta l bone. Reproduced with permission from Chaitow (2005).

1 2 The cranium 343 of the forearm (particularly extensor carpi radialis longus PARIETA L S. and brevis, extensor digitorum and extensor carpi ulnaris). • The simplest of cranial structures - two four-sided, curved, By uhlizing the forearm extensors in this way and avoid­ ing flexor contraction, the contacts on the frontal bone half-domes. avoid 'squeezing' it, while effectively increasing gentle compression. Articul ati ons • At the same time a slight upwards (slightly cephalad and See Figure 12.18. toward the ceiling) lift is introduced bilaterally to release the frontal bone from its articulations with the parietals, Reci p roca l tens i on m em brane relationshi p s sphenoid, ethmoid, maxillae and zygomae. The falx cerebri attaches strongly into a groove on each side • This lift is held during several cycles of inhalation and of the sagittal suture forming a space that is the superior exhalation, after which the frontal bone is allowed to set­ tle back into its resting position. Articulates with frontal bone --� �-- Superior temporal line �,.-. Inferior temporal line --�-- Parietal tuberosily a:---- Articulates with occipital bone Articulates with greater wing of Articulates with squamous '-- Articulates with mastoid A sphenoid bone ---' part oftemporal bone part of temporal bone Groove for superior sagittal sinus --,- '�\",r-- Frontal angle Articulates with opposite parietal bone --:-+ Occipital angle ---VI Groove for sigmoid sinus ---.,o>q �-- Sphenoidal angle Mastoid angle ---\" Groove for parietal branch Groove for frontal branch B of middle meningeat vessels of middle meningeal vessels Figure 1 2. 1 8 External (A) a n d i n ternal (B) su rfaces of the l eft pa rieta l bone. Reproduced with permission from Chaitow (2005).

344 C LI N I CA L A P P L I CATI O N OF N E U R O M U SC U LA R TE C H N I Q U E S : TH E U P P E R B O DY sagittal sinus. Any restriction of the sagittal suture's normal Pa l p ation exercises pliability (approximately 250 microns of rhythmic movement in normal subjects, 8-14 times per minute) (Lewandowski & Parietal lift (Fig. 12. 19) Drasby 1996) might therefore be expected to negatively • The patient is supine and the practitioner is seated at the influence the status of both the attaching reciprocal tension membrane (the falx) as well as drainage via this important head of the table. sinus. • The practitioner's fingers are placed so that the small fin­ Muscu l a r attachm ents gertip rests close to the asterion anterior to the lambdoidal suture. • Temporalis arises from the temporal fossa and its fibers • The other finger pads rest on the parietal bone just above converge to attach on the coronoid process and ramus of the temporoparietal suture so that the middle finger is the mandible, medial to the zygomatic arch. The origin of approximately one finger width above the helix of the temporalis crosses the coronal suture as well as that ear, on the parietal bone (not the temporal). between the temporal bone and the parietal. • The thumbs act as a fulcrum, bracing against each other or crossed above the sagittal suture without any direct contact. • Auricularis superior is a thin, fan-shaped muscle that arises • Gentle pressure is applied - approximately 1 0 grams - from the epicranial aponeurosis, converging to insert by medially with the finger pads to crowd the sagittal suture a flat tendon into the upper surface of the auricle. and to disengage their temporal articulation. • This pressure should be introduced by means of contrac­ • Occipitofrontalis does not attach directly to the parietals tion of the wrist flexors rather than by hand action. although its aponeurosis covers them. • The thumbs stabilize the hands as the pressure is main­ tained and a light but persistent lifting of the parietals R a nge a nd d i rection of m otion directly cephalad is introduced from the finger pads (while the medial compression is maintained) for between • Human studies indicate that approximately 250 microns 2 and 5 minutes, during which time a sensation might be of movement is available at the sagittal suture noted of the parietals 'spreading' and lifting superiorly. (Lewandowski & Drasby 1996). There is a greater degree • During this procedure the other restricting influence, of interdigitation on the posterior aspect of the sagittal apart from the temporal suture contact, is that offered by suture where motion potential is therefore greatest. the falx cerebri and sensitivity should be maintained to any resistance it is offering. • Osteopathic cranial concepts have the parietals flexing • Successful application of this parietal lift will enhance inferiorly (,flattening') at the sagittal suture. drainage via the superior sagittal sinus formed by the falx cerebri's attachments to the parietals. • A more pragmatic view is that the pliability of the suture • Contact with the temporals should be avoided during helps to absorb stresses imposed on the structure via this procedure. either internal or external forces (Chaitow 2005). TEMPOR A L S • Other models (Iiquid/electric, energetic, etc.) offer differ­ ent interpretations as to the motion potentials of these A complex arrangement of different bone formats. bones (Milne 1995). • A slim fan-shaped upper portion - the squama - with an Other a ssociations a nd i nfl uences internal bevel for articulation with the parietal. The connection with the falx cerebri is one of the most • A long projecting column - the zygomatic process - important links the parietals have with the inner circulation which reaches forward to articulate with the zygoma. and drainage of the cranium. • An anchorage point for the sternocleidomastoid - the The temporal bone articulation is a key area for evidence mastoid process. of cranial dysfunction and for treatment, usually by means of temporal contact. • A rock-like petrous portion, the apex of which links to the sphenoid via a ligament. Dysfu nctiona l patterns Articu lations See Figure 12.20. Dysfunctional patterns in the parietals are rare apart from when they receive direct blows or when the resilient sutures R eci p roca l tension m em bra ne relationshi ps lose their free articulation 'shock-absorbing' potential. The On the petrous portion of the bone, a groove is apparent bones that ar ticulate with the parietals are more likely to where the tentorium cerebelli attaches, forming the petrosal produce problems and, when they do, the parietals are sinus. obliged to accommodate to the resulting stresses.

1 2 The cra n i u m 345 � V --- c A Bo Figure 1 2. 1 9 Parietal lift tech n i q u e showing (A) h a n d positions, (B) fi nger contact sites, (C) contact sites avoiding sutu res a n d (D) d i rections of a pp l i ed light traction force. Reproduced with permission from Chaitow (2005). Muscular attachments muscle that will shorten under prolonged mechanical stress and therefore is capable of producing sustained, • Sternocleidomastoid arises from heads on the manubrium virtually permanent drag on the mastoid in an infe­ sternum and the clavicle and powerfully attaches to the rior/posterior direction. If such traction were combined mastoid process (clavicular fibers) as well as to the supe­ with a similar drag anteroinferiorly by sternocleidomas­ rior nuchal line (sternal fibers). This muscular influence toid, the temporal bone's ability to move freely would be allows enormous forces to be exerted onto one of the most severely compromised. vulnerable and important of the cranial bones. • Splenius capitis arises from the spinous processes of C7-T3 as well as the lower half of the ligamentum nuchae • Temporalis arises from the temporal fossae. The posterior and attaches to the mastoid process and the lateral aspect aspect of the origin of the muscle lies on the temporal of the superior nuchal line. Any sustained traction from bone. The inferior attachment is to the coronoid process. this would crowd the suture between the occiput and the temporal bone, reducing its potential for free motion. • Longissimus capitis arises from the transverse processes of Tl-5 and the articular processes of C4-7 attaching to the mastoid process. This is also a powerful postural

346 CLI N I CA L A P P L I CATI O N OF N E U R O M U S C U LAR TECH N I Q U E S : T H E U PP E R B O DY Squamous part ---�, Figure 1 2 .20 External (A) and i n ternal Zygomatic process --�- (B) aspects of the left tem pora l bone. Reprod uced with permission from Chaitow (2005). r--\"'\\ Groove for middle temporal artery bF<J.-.t6 Parietal notch f--f Squamomastoid suture Articular tubercle ---\" ---,\" Mastoid part Mandibular fossa ---\" Styloid process '-- Suprameatal triangle '-- Mastoid process Postglenoid tubercle Tympanosquamosal '-- Tympanic part (plate) (squamotympanic) fissure --./- Sheath of styloid process External acoustic meatus, anterior border ---' A Articulates with parietal bone ---� r--- Groove for parietal branch Arcuate eminence ---;.J� middle meningeal artery and accompanying veins Groove for frontal branch of middle meningeal artery and accompanying veins Sulcus for sigmoid sinus --3-.,1 \"'-- Sulcus for superior petrosal sinus Mastoid foramen --'-:4!c0.fti; \"-- Subarcuate fossa Aqueduct of the vestibule ---ol,;d'1I<r '-- Internal acoustic meatus Articulates with occipital bone --�- B Cochlear canaliculus '-- Styloid process Ra nge and d i rection of motion • The jugular vein passes through the jugular foramen, part of which is formed by the temporal bone's inferior The motion during flexion can be visualized as a flaring surface. outward of the squama (as it pivots at its beveled junction with the parietal) while the mastoid tip moves pos terome­ • The stylomastoid foramen allows passage of the 7th cra­ dially. These all return to neutral d uring the extension nial (facial) nerve. (internal rotation) phase of the cycle. • The mandibular fossa forms part of the temporo­ mandibular joint. Other associati ons a nd i nfl uences This is arguably the most complex (pOSSibly excluding the sphenoid) bone in the cranium, which is subject to a variety • The auditory canal passes through the temporal bone, of influences including thoracic and cervical stresses via while the internal auditory meatus carries the 7th and 8th sternocleidomastoid and longus capi tis, as well as from cranial nerves. dental influences via the temporomandibular joint and the temporalis muscle. The potential for direct negative • The trigeminal ganglion is in direct contact with the petrous portion.

1 2 The cra n i u m 347 AB Fig u re 1 2.21 H a n d positions (A) and d i rections of l i g h t force (B) i n a pplication of the b i tem pora l roll tec h n i q ue. Reproduced with permission from Chaitow (2005). influences on temporal mechanics, emerging from emotion­ • Following bitemporal rolling, synchronous rolling ally induced habits such as bruxism or upper chest breath­ should be performed (next exercise). ing patterns, is clear. Synchronous temporal rolling exercise Because of its di.rect l inkage with the tentoriwn cerebelli, • The hand hold and general positioning is as in the exer­ any dysfunctional pattern of a temporal bone automatically influences the other bones with which tentoriwn is connected, cise described above. the other temporal as well as the occiput and the sphenoid. • The deep flexors of the fingers are employed to exert gen­ Dysfunctiona l patterns tle pressure via the thumbs onto the mastoid p rocesses during the inhalation (external rota tion/ flexion) phase of A wide range of symptoms may be associated with tempo­ the cycle. ral dysfunction, often following trauma such as whiplash or • This takes the mastoids posterior and medial and encour­ a blow to the head. Among the commonest reported in ages normal flexion motion of the temporal bones. osteopathic literature are: • As exhalation (internal rotation/extension) occurs, the forearm muscles are released to prevent inhibition of a • loss of balance, vertigo return to neutral. • nausea • As this return to neutral occurs, a very slight (grams • chronic headaches only) pressure can be introduced via the thenar emi­ • hearing difficulties and recurrent ear infections in children nences resting on the mastoid portion of the temporal • tinnitus bone, taking this slightly medial and pos terior, encourag­ • optical difficulties ing a slight exaggeration of the extension phase. • persona li ty and emotional fluc tuations ('mood swings') • Repeating these motions will achieve an overall increase of • Bell's palsy the amplitude of both phases of the cranial motion cycle. • trigeminal neuralgia. • A gradual acceleration of the rate is possible which is thought to encourage greater cerebrospinal fluid Bitemporal rolling exercise (Fig. 12.2 1) fluctuation. • The practitioner sits at the head of the supine patient with • A slowing down of the rate is also possible, producing a relaxing effect. one hand cupped into the other, so that the head is cra­ • This synchronous rolling should always be used to com­ dled, thumbs on and parallel with the anterior surfaces of plete the treatment if alternate rolling has been used (see the mastoid processes, while the thenar eminences sup­ previous exercise). port the mastoid portion of the bone. The index fingers • Always complete contact with the temporals during the should cross each other (not shown in Fig. 12.21). neutral phase between the extremes of motion. • An alternating rocking motion is introduced (one side going into flexion as the other goes into extension) at the ZYG OMAE thumb contact by pivoting the middle joints of the index fingers against each other. • A central broad curved malar surface • The amount of pressure introduced at the mastoid • A concave corner making up most of the lateral and half should be in grams only and should initially maintain and enhance the current rhythm of cranial motion. of the inferior border of the orbit

348 C L I N I CAL A P P L I CATI O N OF N E U RO M U SC U LA R T E C H N I Q U E S : T H E U PP E R B O DY • An anteroinferior border articulating with the maxilla There are no direct reciprocal tension membrane rela­ • A superior process articulating superiorly with the tem­ tionships. poral portion of the frontal bone (via interdigitations) Muscu l a r attachm ents (see Fig. 1 2.22) and posteriorly with the great wing of sphenoid (not described here) • A posteromedial border articulating via interdigitations with the greater wing above and the orbital surface of the • Levator labii superioris maxilla below • Zygomaticus major • Zygomaticus minor Articul ations • Orbicularis oculi • Masseter See Figure 12.22. Supraorbital foramen --\"-'1 ----=,- -=-'--- - Anteroinferior angle of parietal bone Nasal bone ---., --'- Squamous part of temporal bone Orbital plate of ethmoid bone ---+_�; ---1 Greater wing of sphenoid bone Lacrimal bone --\"+-d.J ,.-.', Zygomatic bone Maxilla ---�_r ---; Ramus of mandible A ,-- Frontal process +Orbital surface ___________ Zygomaticofacial foramina --\"-� rA>\"-- Zygomaticus major Levator labii superioris ------..(. ::----- ��-- Masseter B '-- Zygomaticus minor �-- Zygomaticofacial foramina Articulation with maxilla Masseter c F i g u re 1 2 .22 A: Left zyg omatic bone and associated structu res. B: Lateral aspect show ing m uscu l a r attachments a nd a rticu lations. C: Medial aspect. Reproduced with permission from Cha itow (2005).

1 2 The cranium 349 Range a n d d i rection of m ot i o n Dysfu n cti o n a l pattern s The orbital border is said to 'roll antero-Iaterally, and the Sinus problems can often benefit from increased freedom of tuberosi ty rolls inferior' in the classic osteopathic descrip­ the zygomae. They should always receive attention after tion of flexion motion (Brookes 1981 ) . dental trauma, especially upper tooth extractions, as well as trauma to the face of any sort, as they are likely to have Other a ssoci ati o n s a n d i nfl u ences absorbed the effects of the forces involved. The zygomae offer protection to the temporal region and Habits such as supporting the face/ cheekbone on a hand the eye and are, as with the etlunoid and vomer, shock when writing (for example) should be discouraged as the absorbers which spread the shock of blows to the face. persistent pressure modifies the position of not just the Milne (1995) suggests that ' they act as speed reducers maxillae but all associa ted bones and s tructures. They between the markedly eccentric movements of the tempo­ should be assessed and treated in relation to problems rills and the relative inertia of the maxillae'. The zygomati­ involving the temporals, maxillae and sphenoid. cofacial and the zygomaticotemporal foramina offer passage to branches of the 5th cranial nerve (maxillary branch of MAXILLAE trigeminal). See Figure 1 2.23. Articulates with frontal bone Medial palpebral ligament Nasolacrimal groove -Frontal process ---___ 11+-1-.,.--. Orbicularis oculi Levator labii superioris __-_ --- Articulates with ethmoid alaeque nasi ---\\+ --\"..---- Orbital surface ,..-'�t--- Infraorbital groove Levator labii superioris ---\\,'i �;--+--- Zygomatic process. Infraorbital foramen ---+� with zygomatic bone Nasal notch ---1 o-t--�= Openings of alveolar canals {Nasalis --�1)-(_Anterior nasal spine ---1= Tuberosity transverse part alar part ---.' Depressor septi --/- Canine eminence --.-/ A Levator anguli oris Buccinator Articulates with frontal bone Nasolacrimal groove �.-- Ethmoidal crest -+-- Middle meatus Maxillary hiatus --+f-;:.t \"--;1 Conchal crest For perpendicular plate ---+ Inferior meatus of palatine bone --\\-.!v Greater palatine bone ---­ �����i\\�':i;:�;:�:; �---- Anterior nasal spine For perpendicular plate Palatine process of palatine bone ----' Incisive canal B Figu re 1 2.23 Latera l (A) and medial (8) aspects of the left maxi l l a showing a ttachments and a rticu l a tions. Reprod uced with permission from Chaitow (2005).

350 CLI N I CAL APPLICATI ON OF N EU R O M U SC U LAR TEC H N IQUES: T H E U PPER BODY Articu l ations Articu la ti o ns As described above, the maxillae articulate at nwnerolls • The conchal crest for articulation with the inferior nasal complex sutures, with each other and with the teeth they concha. house, as well as with the ethmoid and vomer, the pala tines and the zygomae, the inferior conchae and the nasal bones, • The ethmoidal crest for articulation with the middle the frontal bone and the mandible (by tooth contact) and nasal concha. sometimes with the sphenoid. • The maxillary surface has a roughened and irregular sur­ There are no direct reciprocal tension membrane rela­ face for articulation with the maxillae. tionships. • The anterior border has an articulation with the inferior Muscu l a r attachm ents (see Fig. 12.23) nasal concha. (not described here) • The posterior border is serrated for articulation with the • Medial pterygoid medial pterygoid plate of the sphenoid. • Masseter • Risorius • The superior border has an anterior orbital process (which • Orbicularis oculi articulates with the maxilla and the sphenoid concha) and • Levator labii sllperioris a sphenoidal process posteriorly (which articulates with • Nasalis the sphenoidal concha and the medial pterygoid plate, as • Depressor septi well as the vomer). • Levator anguli oris • Buccinator • The median palatine suture joins the two palatines. Range a n d d i rection of motion There are no direct reciprocal tension attachments. These follow the pala tines (which follow the pterygoid Muscu l a r attachm ents processes of the sphenoid) so that during the flexion phase of the cranial cycle 'the nasal crest moves inferior and pos­ The medial pterygoid is the only important muscular terior, the tuberosity moves lateral and slightly posterior, attachment. It attaches to the lateral pterygoid plate and the frontal process posterior border moves la teral and the palatine bones, running to the medial ramus and angle of alveolar arch widens posteriorly' (Brookes 1981) . the mandible. Other associ ati ons a n d i nfl uences R a n ge a nd d i rection of moti o n Because of the involvement of both the teeth and the air The palatines move, during flexion, to follow the p terygoid sinuses, the cause of pain in this region is not easy to diag­ processes of the sphenoid with the nasal crest moving infe­ nose. These connections (teeth and sinuses) as well as the rior and slightly posterior and the perpendicular part mov­ neural structures tha t pass through the bone plus its multi­ ing lateral and posterior. ple associations with other bones and its vulnerability to trauma make it one of the key areas for cranial therapeutic Other associations a nd i nfl u ences attention. These delicate shock-absorbing structures, with their multi­ Dysfu nctiona l patterns ple sutural articulations, spread force in many directions when any is exerted on them. They are capable of deforma­ Headaches, facial pain and sinus problems plus a host of tion and stress transmission and their imbalances and mouth and throat connections with emotion (especially deformities usually reflect what has happened to the struc­ 'unspoken' ones) mean that purely structural and largely tures with which they are articulating. mind-body problems meet here, j ust as they do in dysfunc­ tional breathing patterns. Great care needs to be exercised in any direct contact on the palatines (especially cephalad pressure) because of their PALATI NES extreme fragility and proximity to the sphenoid in particu­ lar, as well as to the nerves and b lood vessels which pass See Figure 1 2.24. through them. CAUTION: In a report on iatrogenic effects arising from inappropriately applied cranial treatment, Professor John McPartland (1996) presented nine i l l ustrative cases, two of which involved i ntraoral treatment. All cases seemed to involve excessive force being used, which strongly high­ lights the need for care, especially when working inside the mouth.

1 2 The cranium 3 5 1 Maxillary hiatus ---, Orbilal process ---, Sphenopalatine notch Sphenoidal process ---. ->r-- Frontal process Ethmoidal crest ---------___ 1.-- Nasolacrimal groove Perpendicular plale of palatine bone ---+ ,--# Conchal crest --�-.4Conchal crest --J-t.=� For opposite maxilla Rough area for medial pterygoid plate Pyramidal process ---/ A Greater palatine foramen Palatomaxillary suture �-- Orbital process Spenoidal process -----_;-:4 _./ �e-- Ethmoidal crest __-_ - ConchaI crest -t-- Maxillary process Pyramidal process --:t;-§,j(�. B Horizontal plate Fig u re 1 2.24 A : Medial aspect of left palatine bone a rticulating with the maxilla. B : M ajor features of the palati n e bone. Reproduced w i th permission from Chaitow (2005). NMT TREATMENT TECHNIQUES F O R Mimetic muscles are easily divided into four regions T HE CRAN I U M (Platzer 2004), those being the scalp (epicranial), orbital region and eyelids (circumorbital and palpebral), nose MUSCLES O F EXPRESSION (nasal) and mouth (buccolabial). These regions work together in endless combina tions to produce vast and often Mimetic muscles attach skin to skin, skin to underlying fas­ unconscious muscular movements that represent a physical cia or skin to bone and contribute to a wide variety of facial expression of the wide variety of emotions experienced in expressions. Youthful skin is highly elastic while aging skin daily life. These muscles, like those of postures tha t express does not recoil as well . Hence, wrinkles and folds of the skin general moods and feelings, are often used unconsciously commonly expressed by the contraction of these underlying by the person and frequently at chronic levels. muscles may remain etched on the aged face or on a younger face when the muscles are overused, such as a ver­ Gray's Anatomy (2005) offers another perspective, by divid­ tical furrow between the brows associated with eyestrain or ing the muscles of the head into craniofacial and mastica tory frowning. groups. Craniofacial muscles relate mainly to orbital margins, eyelids, nose, lips, checks, mouth, pinna, scalp and cervical

3 52 CLI N I CAL A P P L I CATI O N O F N E U RO M U S C U LA R T EC H N I QU ES : T H E U PP E R B O DY Frontalis -+-+-If::-'c. Palpebral also the insightful observations of Philip Latey (1996) who Procerus --\".'-:�H<¥riy ligament points out that during a lengthy osteopathic career he has sel­ dom seen anyone suffering from migraine headaches who has a normal range of facial expression. Levator labii Orbicularis oculi MIMETIC MUSCLES OF THE EPICRAN IUM superioris (palpebral alaeque nasi portion) The scalp itself is composed of five layers. The first three (skin, Levator labii subcutaneous tissue and epicranius with i ts aponeurosis) are superioris --J-. '-- Risorius best considered together as a single layer since they remain Orbicularis oris '-- Nasalis connected to each other when tom or surgically reflected. '-- Nasalis A Depressor angUli Mentalis The deeper subaponeurotic areolar tissue allows the inferioris (alar portion) scalp to glide readily on the deepest layer, the pericranium. Corrugator Epicranial muscles express surprise, astonishment, atten­ supercilii tion, horror and fright and are used when glancing upwards. When p ulling from below, the fron talis can draw >-- Orbicularis oculi the scalp forward as in worry, grief or profound sadness, especially in combination with other brow muscles. B OCCIPITOFR O N TALIS (FIG. 1 2.27) cD EF Attachments: Occipitalis portion: highest nuchal line of Effects of muscles on facial expression (from RouillEl) occipital and temporal bones to the cranial aponeurosis (galea aponeurotica) Fig u re 1 2.25 A: M uscles of expression. B: Orbita l m uscles of the Frontalis portion: cranial aponeurosis (galea aponeurotica) eye. C-F: Effects of m uscles on facial expression. Drawn a fter anterior to the coronal su ture to the skin and superficial Platzer (2004). fascia of the eyebrows, with fibers merging with pro­ cerus, corrugator supercilii and orbicularis oculi skin while the mastica tory group primarily move the TM joint. Gray's points out: 'Although the muscles can cause Innervation: Facial nerve (cranial nerve VII) movement of the facial skin that reflects emotions, because Muscle type: Not established they are grouped m�inJy arOlmd the orifices of the face, is Function: To elevate the eyebrows during expression, hence often argued that their primary function is to act as sphincters and dilators of the facial orifices and that the function of facial wrinkling the forehead expression has developed secondarily.' Gray's subdivides the Synergists: None muscles of facial expression into epicranial, circumorbital and Antagonists: Procerus, corrugator supercilii, orbicularis oculi palpebral, nasal and buccolabial groups. I n d i cati o n s fo r treatment While not all of these muscles are discussed in detail within this text, most are offered in the following overview of the • Deep aching occipital pain region. Those that are the most involved in head and facial • Intense deep pain in the orbit and eye pain are covered within this chapter. Orthodontic and cranial • Frontal headaches influences of the muscles of expression have yet to be fully • Frontal sinus pain established . Consider, for example, the influences which a tight, closed-lips smile of someone self-consciously covering TEMPOROPAR I ETALIS AND AURICULAR M USCLES the teeth could have on positioning of the anterior teeth and mandible. One has simply to produce that type of smile to feel Attachments: Epicranial aponeurosis to the an terior, supe- the potential effect on the mandible and on the teeth. Consider rior or posterior ear Innervation: Facial nerve Muscle type: Not established Function: To move the ear in various directions Synergists: Occipitofrontalis, indirectly Antagonists: None I n d ications for treatment • Tenderness anterior, superior and posterior to the attach­ ment of the ear

1 2 The cranium 3 53 B Figure 1 2.26 ARB : Distribution of relaxed skin tension l i nes of head a n d neck. Reproduced with permission from Gray's Anatomy (2005). Anterior auricular Superior auricular Fronlal belly of occipitofrontalis ---f'H+ Orbicularis oculi ---.J Procerus ---, OCcipital belly of occipitofrontalis Nasalis ---, Levator labii superioris alaeque nasi ---___ Levator labii superioris ---,=ft Zygomaticus minor ___..,. '-- Posterior auricular Zygomaticus major ---,�. Orbicularis oris --.-_ Depressor labii inferioris ---+ Mentalis --------/\".....1.-- +-+__,_ Depressor anguli oris -.J_____ Risorius ---' Buccinator ---' Platysma ---' Figure 1 2.27 Intense deep pain into the orbit and eye may be referred from occipita lis. Eye pathology should be considered, even when trigger poi nts a re fou nd to reproduce the pain com p l a i nt. Note that the modiolus, a fibromuscu l a r mass that is h i g h l y mobile a nd i m m ensely com plex, is noted but not clearly i l l ustrated here. Reproduced with permi ssion from Gray's Anatomy for Students (2005).

354 CLI N I CA L APPLICATI ON OF N E U R O M U SC U LAR TEC H N IQUES: THE U PPER BODY Special notes superficial fascia and to begin therapy of the muscles of the cranium. Brisk frictional scalp massage will create heat, The occipitofrontalis is a broad, thin, muscu lofibrous layer which may allow the external cOimective tissue to soften. Any tender areas found may be treated with combination that completely envelops the parietal suture. It additionally friction or static pressure. Special attention should be given to cranial suture lines, which may be more tender than other spans the lambdoidal and coronal fsrountutarle,st,eamttpaocrhainl, gpavni.a­ areas and may indicate a need for further cranial attention. direct or indirect linkages with the Light to moderate hair traction may now be applied at etal and occipital bones, with the potential to significantly palm-width intervals over the entire cranium, one handful at a time, if the hair is long enough to be grasped. The hair influence mobility and function of cranial structures. is gently lifted away from the scalp by the non-treating hand and the fingers of the treating hand slide into place Restrictions and tension in either the frontalis or occipitalis close to the scalp with segments of hair lying between the fingers. As the fingers close into flexion, they also wrap muscles will produce a ' tightening' of the scalp, which can be around the hair shafts so tha t they grasp the hair close to the scalp (Fig. 1 2.28) . The non-treating hand stabilizes the cra­ diagnostic. Lewit (1996) states: 'The scalp should move easily nium while the grasping hand gently pulls the hair away from the cranium until slack is taken out and tension pro­ in aU directions in relation to the skull. Examination of scalp duced . The hair traction is sustained for 30 seconds to 2 minutes. If brisk friction has been applied immedia tely mobility is warranted for patients with headache and/or before hair traction, the fascial tissues will usually quickly loosen and soften. When friction is not applied first, the vertigo.' Tension in the occipitofrontalis, or the epicranial release of the tissues is delayed a minute or two. �aponeurosis, can also be seen to The entire procedure may be repeated, although single minute degree of mobility that applications are often adequate. If craniosacral therapy is to pexoitsetns tbiaelltywienetnertfheereOwCCl iphi. tthale, be applied, the cranial techniques may precede or follow hair traction or frictional massage. parietal and frontal bones. locate and trea t tn. gger pom. ts m. Flat palpation is used to The auricularis muscles may sometimes be manually stretched by pulling the ear into various positions by grasp­ the occipitofrontalis. Trigger points from the frontalis belly of ing the ear cartilage at i ts attachment to the head and trac­ tioning it posteriorly, inferiorly and an teriorly. This this structure refer to the forehead while trigger points in the technique may also have effects on the posi tion of the tem­ poral plate and should not be applied without concern for occipital fibers refer to the back of the cranium and to the area the cranial system. The practitioner who is unfamiliar with cranial therapy but uses ear traction for these tissues should behind the eyes. Kellgren notes referral pa tterns of occipitalis Figure 1 2.28 The fingers wrap a round the h a i r shafts as they a re giving rise to earache (KeUgren 1938, Simons et aI 1999). gently p u l led a way from the cra n i u m w h i l e stretching and re leaSing the cra n i a l fascia. Temporoparietalis and auricular muscles lie superficial to the temporalis muscle and may be tender associated with trigger points in the underlying temporalis. While these muscles have significant use in most animals, they have very little obvious influence in most humans. However, Gray's Anatomy (2005) notes that a uditory stimuli evoke pat­ terned responses in these muscles. They may be irrita ted by ill-fitting glasses or by telephone headsets. The following techniques may be applied to assess the �epicranial tissues. Frictional or hair tract on techniqu�s should be avoided where hair loss is occurrmg, where hair transplants have been embedded or if segmenta l neurop�­ thy (shingles virus) is suspected, present or has occurred In the last 6 months. If the ha ir is missing completely, myofas­ ciaI release may be used as needed. If the hair is too short to grasp, the frictional applications may still be used. If the patient reports a current headache, the hair traction method may be applied and will sometimes relieve the headache. However, the frictional techniques usually prove too uncomfortable during active headache. Additionally, both techniques may be given to the patient for home care as they are easily self-applied . f NMT FOR EPICRANIUM The practi tioner is seated cephalad to the supine patient. A pillow or bolster is placed under the patient's knees and, in the case of an extreme forward head position, may also need to be placed under the head. Otherwise, the head rests on the table in neutral position. Rotation of the head will be necessary to reach the posterior aspect. Transverse friction and small, circular massage techniques may be applied to the entire cranial surface to soften the

1 2 The cra n i u m 3 5 5 end the treatment by p ulling the ear gently directly laterally Orbicularis oculi is divided into three parts: orbital, palpe­ and holding for 30-60 seconds. bral and lacrimal. The orbital portion of orbicu laris oculi encircles the eye and lies on the body orbit while the palpebral Manual treatment of occipitofrontalis. Direct manual portion lies directly on the upper and lower eyelids. The release of the fascial restrictions in occipitofron talis are rec­ short, small fibers of the lacrimal portion cross the lacrimal ommended. Tension in the scalp interferes with cranial sac and attach to the lacrimal crest. Its trigger points may motion, just as gross restriction in the thoracolumbar fascia refer to the nose or create 'jumpy prin t' when reading. can drag on the sacrum . As a sphincter muscle, orbicularis oculi is responSible for The methods which will achieve release of such struc­ closing the eye voluntarily or reflexively, as in blinking. I t tures can involve NMT, massage methods, myofascial release also aids i n reducing the amount o f light entering the eye and and positional release approaches. If NMT is employed, as hence is involved w ith squinting. Levator palpebrae superi­ outlined above, this can be assisted by an isometric contrac­ oris antagonizes eye closure by elevating the upper eyelid. tion of the muscle prior to NMT. A strongly held frown, for 7-10 seconds, will reduce hypertonicity and allow easier Corrugator supercilii\" blends with the frontalis muscle and manual applications to the soft tissues. the orbicularis oculi and radiates into the skin of the eye­ brows. It draws the brows toward the mid-line. I. POSITIO N A L RELEASE METHOD FOR These tvvo muscles are responsible for bunching the brows , OCCIPITOFRONTA L I S to shield the eye from intense light or when eyestrain pro­ duces a similar 'squinting' movement. They create vertical • With the pads of two or three fingers the practitioner furrows between the brows that, over time, may become applies light compression, less than half an ounce, onto the deeply entrenched lines. Additionally, orbicularis oculi pro­ skin overlying those parts of the muscle tha t appear most duces radia ting lateral lines commonly called 'crov,r's feet' tightly adherent to the skull, identified by light to-and-fro and expresses worry or concern while corrugator supercilii gliding assessments of skin on the underlying fascia. is called the muscle of pathetic pain and also produces the expression associated with thinking hard. • The point of initial contact is the starting, 'neutral' point. • From this contact, assess the rela tive freedom of move­ It N MT FOR PA LPEBRA L REGION ment of the skin on underlying fascia in two opposite The eye region contains the most delicate tissues of the face, directions, say moving laterally one way, then back to which are treated w ith the most gentle touch. Ex treme care neutral and then in the opposite direction. must be exercised to avoid stretching the skin of the eye • Decide which direction of movement is 'easiest' and region. Spray and stretch techniques are not recommended glide the skin on the fascia toward that direction. near the eyes while injections into the eye region may result • Next, from this first posi tion of ease, assess the relative in ecchymosis, 'a black eye' (Simons et al 1999). freedom of glide in another pair of directions, say mov­ ing anteriorly and posteriorly. Flat palpa tion is used to press fingertip portions of the • Which of these offers least resistance? orbicularis oculi against the underlying bony orbit (Fig. 12.29). • Ease the tissues toward the direction, so achieving a com­ bination of two positions of ease. • From this second position of ease assess whether light rotational motion is easier in a clockwise or a counter­ clockwise direction. Take the tissues toward this and hold them there for 20-30 seconds. • After this allow the tissues to return to the starting position and reevaluate freedom of skin glide motion; it should have improved markedly compared with the commencing assessment . • Repeat this approach wherever there appears to be a degree of restriction in free motion of the skin of the scalp over the underlying fascia. MIMETIC MUSCLES OF THE CIRCUMORBITA L Figure 1 2.29 Any tech n iques a pplied to the eye reg ion should be A N D PALPEBR A L REGION g entle and carefu lly placed as the connective tissue of this reg ion is extre mely del icate. Orbicularis oculi and corrugator supercilii comprise the mimetic muscles of the eye region (palpebral fissure). These two muscles are important not only for facial expression but also in ocular reflexes. Like all mimetic muscles, they are innervated by the facial nerve.

3 5 6 C L I N I CA L A P P L I CATI O N O F N E U R O M U S C U LA R TECH N I Q U E S : TH E U P P E R B O DY Levator labii superioris alaeque nasi attaches the skin of the upper lip and nasal wing to the infraorbital margin.vVhen it contracts, it enlarges the nostrils and elevates the nasal wing, producing transverse folds in the skin on each side of the nose and a look of displeasure and discontent, espe­ cially noted when sniffing an unpleasant odor. Fig u re 1 2.30 Compression a n d precise myofascia l release may 1 N MT F OR NASAL REGION soften deep vertical furrows between the brows. Procerus is easily grasped between the fingers and thumb at Gentle static pressure or an extremely gentle transverse the bridge of the nose. Since this is an action people often per­ movement may help assess the tmderJying muscle.However, form when experiencing a headache or eyestrain, its associa­ frictional movements, gliding techniques or skin rolling, tion with those patterns of dyshmction may be implied. which is usually effective in locating trigger points, may also be too aggressive for this delicate tissue. Use of 'skin Flat palpation and light friction may be used along the drag' palpation (as described in Chapter 6, p. 1 20) is, how­ sides of the nose and spreading slightly laterally onto the ever, gentle, safe and effective in localizing underlying trig­ cheeks to treat the remaining nasal muscles. The two index ger pOint activity. fingers, very lightly placed, may provide precise myofascial release but the practitioner is reminded that the facial tis­ The corrugator supercilii is easily picked up near the sues are very delicate and anything other than exception­ mid-line between the brows and compressed between the ally light pressure is contraindicated. Strong tension of the thumb and side of the index finger (Fig. 1 2.30) . It can also be tissues is also not recommended. rolled gently between the palpating digits. This compres­ sion and rolling technique is applied at thumb-width inter­ Trigger point locations and patterns of referral in this vals the width of the brow and may also include fibers of region have not yet been established but we suggest that the procerus, frontalis and orbicularis oculi as well as corru­ these muscles be assessed when nose, lips and eye problems gator supercilii. are encotmtered or facial pain or sensations are experienced near or into these tissues. Wrinkled skin may suggest tmder­ MIMETIC MUSCLES OF THE NASAL REGION lying muscular tensions, possibly involving chronic overuse. Procerus arises from the facial aponeurosis over the lower MIMETIC MUSCLES OF THE BUCCOLABIAL nasal bone and nasal cartilage and attaches into the skin of REGION the forehead between the eyebrows. It reduces glare from excess light and produces transverse wrinkles at the bridge The movements of the lips are derived from a complex of the nose. Expressions associated with procerus include three-dimensional system that postures the lips and con­ menacing looks, frowns and deep concentration. trols the shape of the orifice. Structure of the lips and their limits of motion are comprehensively discussed in Gray's Nasalis consists of a transverse (compressor naris) por­ Anatomy (2005), as are details of the muscles listed below. tion which attaches the maxilla to the bridge of the nose and an alar (dilator naris) portion which attaches the maxilla to • Elevators, retractors and evertors of the upper lip: levator labii the skin on the nasal wing. The transverse portion com­ superioris alaeque nasi, levator labii superioris, zygo­ presses the nasal aperture while the alar portion widens it, maticus major and minor, levator anguli oris and risorius reducing the size of the nostril and producing a look of desiring, demanding and sensuousness. • Depressors, retractors and evertors of the lower lip: depressor labii inferioris, depressor anguli oris and mentalis Depressor septi attaches the mobile portion of.the nasal sep­ tum to the maxilla above the central incisor tooth.It depresses • Compound sphincter: orbicularis oris, incisivus superior the septum during constriction and movement of the nostrils. and inferior • Buccinator The muscles of the buccolabial region function in eating, drinking and speech as well as emotional expression. A multitude of expressions, including reserve, laughing, cry­ ing, satisfaction, pleasure, self-confidence, sadness, perse­ verance, seriousness, doubt, indecision, disdain, irony and a variety of other feelings, are displayed in the lower face by the action and combined actions of these muscles. The movements as well as individual expressions are covered in detail in both Gray's Anatomy (2005) and Color Atlas/Text of Human Anatomy, Vol l , Locomotor System (Platzer 2004).

Levator tabii superioris alaeque nasi ---, 1 2 The cranium 3 57 Levator labii superioris ---. ,-- Levator anguli oris Zygomaticus minor _+,.l\\-.'i�< I-f-- Buccinator Zygomaticus major --v-\\�:=' Risorius --� Platysma --l\\-_'., Depressor anguli oris --\"- Depressor labii inferioris J_____ '-- Orbicularis oris Mentalis Figure 1 2 .31 Oral group of facial muscles. Reprod uced with permission from Gray's Anatomy for Students (2005). A number of muscles of the buccolabial region converge Figure 12.32 A g loved i nd ex finger com presses the b ucco l a b i a l into the modiolus just lateral to the buccal angle of the mouth. m uscles against the external t h u m b at s m a l l i nterva ls a ro u n d t h e The modiolus can be palpated in an intraoral examination entire mouth. and is usually felt as a dense, mobile fibromuscular mass that may or may not be tender. This fan-shaped radiation of The b uccolabial muscles may also be treated from an muscular fibers allows the three-dimensional mobility of the external perspective by pressing them against the underly­ modiolus to integrate facial activities of the lips and oral fis­ ing maxilla, mandible or teeth and flat palpation can be sure, cheeks and jaws, such as chewing, drinking, sucking, used to assess and trea t them, If the teeth or gums are obvi­ swallowing and modulations of various vocal tones. ously unhealthy or are tender or painful, pressure against them should be avoided and referral to a dental health prac­ I NMT FOR BUCCOLABIAL REGION titioner strongly encouraged. Infections of the teeth have been noted to be associated with TM joint pain and dys­ An intraoral examination including the labial area will function (Simons et aI 1999). address the muscles in this region. The practitioner should wear protective gloves - see precautions for intraoral exam­ ination on p. 371 . Additionally, some of the attachments of buccolabial muscles can be treated when applying the mas­ seter's external examination by continuing medially along the inferior surface of the zygomatic arch to near the nasal region, The index finger of the gloved treatment hand is placed inside the mouth and the thumb is placed on the outside (facial) surface. The tissue is compressed between the two digits as the internal finger is slid against the external thumb while manipulating the tissue held between them (Fig. 1 2.32). The treating digits progress at thumb-width intervals around the mouth until all the tissues have been examined. Tender spots or trigger points may be treated with static pressure; alternatively, spray and stretch tech­ niques, as described by Simons et al (1999), may be used with precautions as noted in their text.

358 CLI N I CAL APPLI CATI O N OF N E U R O M USCU LAR TECH N I Q U ES : THE U PPER BODY MUSCLES OF MASTICATION zone was lost with the following results. 'Regardless of occlusal conditions, the weight distribution was changed The action of fracturing food, blending i t with saliva and during clenching . . . The weight distribution was shifted preparing it for swallowing is a complex process collec­ anteriorly during clenching regardless of the condition of tively called mastication. Compressional forces are placed the occlusal supporting zone.' Addi tionally, they noted upon the food by the tooth surfaces due to the applied loads that weight distribution shifted more laterally to the of the muscles that cross the temporomandibular (TM) joint. opposite side of the lost occlusal supporting zone during The process of mastication is a complex, coordinated inter­ clenching when the occlusal supporting zone was lost action of numerous muscles and glands and is tremen­ more unilaterally than bilaterally. 'From the present find­ dously dependent upon the integrity of the TM join t and ings, it is suggested that the body posture may be teeth, and the health of the associated myofascial tissues. affected and changed to an tmusual position causing Trigger points wi thin these tissues, intrajoint dysfunctions neck or shoulder pain, especially when the occlusal sup­ or dental factors that inhibit normal occlusion of the teeth porting zone is lost both unilaterally and bilaterally.' (such as the inability to chew on a particular side which, in • Fink et al (2003) examined the relationship between the turn, overloads the contralateral side) are only a few of the craniomandibular system, the craniocervical system and many conditions that interrupt and affect the synchronized the sacropelvic region. Twenty people were screened for action of eating. Since these muscles are also responsible for healthy dentition and TMJ, functional upper cervical ver­ many of the activities needed for speaking, the dysfunc­ tebrae, normally mobile SIJ, normal Patrick's test for tions associated with TM joint and tongue movements can adductors. Occlusal interference was provoked (Gerger have a far-reaching impact on our daily lives. resiliency test) by placing a 0.9-mm piece of tin foil in the area of the premolars on the left side. The participants The suprahyoid muscles form the floor of the mouth and were then measured three times within 1 hour for cervical are involved in opening the mouth and deviating the hypomobility, SIJ hypomobility and adductor tightness. mandible la terally. These muscles are discussed and The following results were recorded at the first examina­ addressed with the intraoral treahnent approach following tion (pre-placement), second examination (three times external palpation. The muscles of the soft palate and within 1 hour after placement) and third examination tongue are also included in the intraoral approach. (5 minutes after removal of interference). The muscles that directly cross the TM joint include tempo­ Cervical region O/e l C 1 /2 C2/3 ralis, massetel� lateral pterygoid and medial pterygoid. These LR LR LR muscles most powerfully move the mandible while others influence its quality of movement directly (as in digastric) First exam ination 0 0 00 00 or indirectly (as in those which position the head in space). Second examination 11 0 29 5 Th ird examination 0 0 0 00 Recent research has demonstrated the far-reaching influ­ ences that the stoma tognathic system (all of the structures Sljoint LR LR involved in speech and in receiving, mastica ting and swal­ lowing food and in speech) in general, and the occlusal sur­ LR 00 00 faces of the teeth (premolar and molar) in particular, have 14 1 15 1 on the body as a whole. A number of studies that are partic­ First exami nation 00 00 00 ularly worthy of consideration are detailed below. Second examination 1 6 2 R • Yoshino et al (2003a) explored head position during clenching and with loss (unilaterally and bilaterally) of Third exam ination 00 1 6.3 (3. 1 ) the occlusal supporting zone (splint). 'The results were as 1 6.4 (2.3) follows: . . . Regardless of the occlusal conditions, the Adductors by Patrick's test (cm) 1 6.4 (2.9) head position was changed by clenching . . . The occlusal L condi tions did not a ffect the changed distance of the head position . . . The head position was changed forward First exami nation 1 6.3 (3.8) and down by clenching regardless of the condition of the Second examination 1 8.4 (3.8) occlusal supporting zone.' The head position changed Th ird exam ination 1 6.4 (2.9) more la terally to the side opposite the lost of occlusal supporting zone during clenching when the occlusal Results showed that occlusal interfertmce produced significant supporting zone was lost unilaterally ra ther than bila ter­ ally. 'Based on this study, it is suggested that unilateral cervical hypomobility, Sf! hypomobility and loss of adductor loss of the occlusal supporting zone may cause the neck range of motion within 1 hour of placement and this was muscles to become inharmonious and thus affect body reversed within 5 minutes after the removal of thefoil. Fink et posture.' al concluded: '. . . it seems to be sensible to include an investi­ • Yochino et al (2003b) then investigated changes in weight gation of the cervical spine and lumbar and pelvic regions in distribution at the feet when the occlusal supporting the examination of CMD patitmts . . . and also to investigate the craniomandibular system in neck and back pain patitmts.'

1 2 The cranium 359 The significance of thls study points to the far-reaching (and myofascial therapy, cranial manipula tion and / or acupunc­ often hldden) influences that simple procedures, such as ture, may significantly influence neurological activity via filling a tooth or placing a crown, might have on the pos­ sensorimotor integration between the brainstem, subcortical tural, proprioceptive and both local and distant aspects of and cortical centers, the cervical region, proprioception and the musculoskeletal system. The astute practi tioner must body posture. question the patient on all aspects of health history, includ­ ing dental work, which might have impacted the body and Modulating (via treahnent) occlusion-related propriocep­ necessitated an adaptive or compensatory process. A clearer tive afferents may be considered to be a way of enhancing health picture will help shape the trea hnent room choices, postural function, balance control, oculogyric stabiliza tion including professional referral. and sporting performance (Gangloff et al 2000). Other con­ nections include the configuration of the plantar arch NECK PAI N AND TMD (Valentino et a1 2002) as well as physical speed, back strength (Ishijima et al 1998) and biceps brachli function (Ferrario A strong association has been identified between neck pain et al 2001). and temporomand ibular symptomatology (Ciancaglini et al 1999). Sensory information from the cervical spine converges In assessing the muscles associated with primary move­ with trigeminal afferents withln the spinal tract of the trigem­ ment of the mandible, an external palpation and an intrao­ inal nucleus, while fibers arriving in the subnucleus caudalis ral treahnent of the muscles can be used . While most of the descend to C2-3 and even C6 (Xiong & Matsushlta 2000). external palpation is intended as assessment (with some benefit of treatment), the external palpation of temporalis is Restricted spinal segments in the cervical region (espe­ primary rather than secondary since it lies almost entirely cially at the CO-C3 levels), as well as tender points in the ex terior to the oral cavity. Only its tendon a ttachment to the sternocleidomastoid and upper trapezius muscles, have coronoid process is palpable from inside the mouth. been found to be significantly more common in patients Conversely, the internal applications to the remainder of with TMD symptoms than in controls (De Laa t et aI 1998). these four muscles, as well as the floor of the mouth and the tongue, are considered their primary trea tment. A l though a It has been proposed (Yin et a1 2006) that therapies target­ general discussion is included with the extraoral examina­ ing the masticatory system, including occlusal splints, mas­ tion below, specific anatomy details will be found with the ticatory muscle work, lifestyle intervention of oral habits, intraoral protocols. Box 1 2 .4 Temporomandibular jOint structure. function and dysfunction The temporomandibular (TM) joi nt, located bi laterally just anterior to • a viscous synovial fl uid (synovia) which provides a l i quid environ­ the tragus of each ear, is a compound (hinge-sl iding) synovial joint, ment with a small pH range, lubrication, reduction of erosion and whose fibrocartilaginous su rfaces and interposed articular d isc a l low which is concerned with maintenance of living cel ls in the articu­ for a tremendous variety of movements in response to the demands lar ca rtilages, disc or men iscus. of eating, speaking and facial expression. The multiple movements of the mandible include protraction, retraction, lateral rotation and A d isc may extend across a synovial joint, d ividing it structura lly and excu rsion, a degree of circu mduction, depression and elevation. functionally into two synovial cavities i n series, with the advantage These motions a re often in combination with each other, with each of combined ranges for the two joints. muscle possessing components to allow a triplanar force in parasag itta l, coronal and horizontal pla nes (Gray's Anatomy2005) as The function of the d isc is u ncerta in and may include shock well as coord inated with the contralateral TM joint. absorption, improvement of fit between surfaces, facilitation of combined movements (slide and rotation occurring in different Synovial a rticulations, l i ke that of the temporomandibular joi nt. compartments), checking of translation at joi nts (such as the kneel. are noted by Gray's Anatomy (2005) to have: deployment of weight over larger surfaces, protection of articular margins, facilitation of rol l ing movements and spread of lubrication. • a fibrous capsule, usually having intrinsic ligamentous thicken­ ings (often by internal or external accessory ligaments) Discs a re connected peripherally to fibrous capsules, usua l ly by vascularized connective tissue (vessels and afferent and motor • osseous surfaces which are covered by articu lar cartilage (hya l i ne (sympathetic) nerves). or fibroca rtilage) and are not in continu ity with each other The term 'meniscus' should be reserved for incomplete discs. • synovial membra nes, which cover all non-articular surfaces Discs may be complete or perforated. including non-articular osseous surfaces, tendons and ligaments Where men isci are usual, complete discs may occur or may be partly or wholly within the fibrous ca psule slightly perforated. The articular d isc of the TM joint, composed of dense non­ • synovial membrane which usually covers and projects outwardly vascular fibrous tissue (Gray's Anatomy 2005, Simons et al 1 999), is together with any tendon that attaches into the joint and issues bound tightly to the condyle, its inferior concave surface fitting the from it condyle l i ke a cap while its concavoconvex upper su rface corresponds to the mandibular fossa and glides against the articular • an articular d isc or meniscus (composed of fibrocartilage with the tubercle. The joint surfaces as well as the interposed disc are fibrous element usually predominant) which may occur between designed to remodel in response to stress, changing its shape to articu lar su rfaces where congru ity (conformity of the bones to each other) is low box continues

3 60 CLI N I CA L A P PLI CAT I O N O F N EU R O M U SC U LA R T EC H N I QU ES : T H E U P P E R B O DY Articular accommodate forces imposed, such as oral mechanics, head eminence posi tioning or from postural or structural compensations. Lateral nIA,·vnrll(1 J Capsule Lower lamina The d isc is firmly attached at the medial and lateral condylar (non-elastic) poles by strong bands and is attached anteriorly to the joint capsule, as well as to fibers of the upper head of lateral pterygoid. The upper Figu re 1 2_33 The temporo mand ib u la r intraa rticu lar d isc. head of lateral pterygoid a lso attaches to the condyle and pulls the Rep roduced with perm ission from Gray's Anatomy (2005). disc and condyle forward as a unit during opening of the mouth (Ca i ll iet 1 992, Simons et al 1 999). Posteriorly is the fibrovascular bilaminar zone where the thick fibers separate into two layers, the inferior one made of non-elastic fibrous tissue attaching to the back of condyle while the upper fibroelastic layer attaches to the posterior margin of the fossa. The area between the two layers is loose connective tissue that is highly vascularized and richly supplied with nerve endings. This region appears to primarily provide a firm attachment rather than intraarticu lar support. The in terposed d isc is a deformable pad that is thicker anteriorly (pes) and posteriorly (pars posterior) and thinner in the center (pars gracilis). Increasing its load thickens its annu lus (see below) (Gray's Anatomy 2005). Its job remains controversia l and is generally thought to be to stabil ize the TM joint while allowing considerable movement of roll, spin and glide of the condylar head (often performed with fu ll loading) while red ucing the possibil ity of trauma. Gray's Anatamy (2005) suggests otherwise, pointing out that one must consider that: The addition ofa slippery disc doubles the number of virtually friction free sliding surfaces suggesting that its function is to destabilize the condyle (certainly not to stabilize it) in the same way that stepping on a banana skin destabilizes the foot. All otherjoints are most heavily loaded when their articulation surfaces are closely fitted together. Upper joint cavity Lateral pterygoid muscle AB Capsule Fibrocartilage on articular surface _'-- Lowerjoint cavity Articular tubercle Hinge movement at lower joint Figu re 1 2.34 AHB : Opening range and motion of the mandibular condyle a nd d isc. Reproduced with perm ission from Gray's Anatomy far Studen ts (2005). box con tinues

1 2 The cranium 361 creating a large area of contact, and braced to prevent further influencing the body a n d its healing process while interfacing with movemen t. However the condyle of the mandible is most heavily each other. Understa nding the roles the other tea m members play loaded when it is required to move, sliding backward during the buc­ will assist in a wel l-formulated overall plan to remove the causes as cal phase of the powerstrake ofa mastica tory cycle on the opposite wel l as some of the results of long-term dysfunction. Much of what side of thejaw. is seen in the jaw may be the result of structural, habitual, postural, nutritional, hormonal or emotional stresses rather than the localized As the condyle hinges into place, in preparation for translation TM joint syndromes so often described. likewise, reduction of against the articular tubercle, it engages the central (thinner) occlusal interferences, splint therapy and reduction of infection portion of the disc, 'thereby \"squeezing out\" material to form a might remove considerable stress, not only from the TM joint but thickened zone, the annulus of Osborn, which surrounds the thin also from the cervical reg ion. The combined efforts in the areas of area - a recess for the mandibular condyle' (Gray's Anatomy 1 999). dental, musculoskeletal (especia l ly postural) and emotional wellbeing The lateral pterygoid engages the disc and the condyle to slide down may offer substa ntial and often im med iate pain rel ief while recovery the articular tubercle (by virtue of its incline) until the posterior and restoration to fu nctional stability progress. fibroelastic elements are stretched to their limit. The condylar head may further hi nge and glide aga inst the inferior su rface of the disc Delany ( 1 997) notes: to articulate with its most anterior parts. During closure movements, the condylar head is seated in the central recess as it glides back up TMD is characterized by many symptoms that could arise from other the incline and rests in the mandibular fossa. ailments, and it therefore has a reputation as an elusive, baffling candi­ tion. These symptoms include headache, toothache, burning or tingling Gray's Anatomy ( 1 999) points out that: sensations in the face, tenderness and swelling on the sides of the face, clicking or popping of thejaw when opening or closing the mouth, The elastic tissues mayact to withdraw tissues and thus preven t reduced range ofmotion of the mandible, earpain without infection, entrapment between the articular surfaces during mouth closure. hearing changes, dizziness, sinus-type responses, overt pain behaviors and postures, as well as major losses in self-esteem and social support • In pratrusion the teeth are parallel to the occlusal plane but caused by decreases in normal social and occupational activities. variably separated, the lower carried forwards by both lateral pterygoids. Otorh inolaryngologist James Costen ( 1 934, Kalamir et al 2007a) first associated ear and sinus pain with temporomandibular dysfunction • In retraction the mandible is returned to the pOSition of rest (teeth (TMD) and since that ti me, controversy has erupted regarding slightly apart). diagnostic criteria. Although historically TMD has been thought to be primarily based on mechanical dysfunction (such as disc • In rotatory movements ofmastication (in occlusal plane but derangement, malocclusion, deformity or bruxism) and has been clearly not in occlusion), one head with its disc glides forwards, primarily addressed by the dental profession, a more integrated rotating around a vertical axis immediately behind the opposite biopsychological model has now emerged (Kalamir et al 2007a). head, then glides backwards ratating in the opposite direction, as the opposite head comes forward in turn. This alternation swings Kalamir et al (2007a) explain: the mandible from side to side. The difficulty i n predicting both the likelihood ofdeveloping TMD, as Ideal ly, the temporomandibular joint, enhanced by its design, should well as its potential chronicity. stems in part from the poor success function normally as numerous daily demands a re imposed upon it. experienced by researchers in achieving a consensus of definition. Conditions that improve the chances for heal thy joint function There have been many attempts to simplify the diagnostic criteria include the following. comprising TMD, al/ of which have met with differing degrees of failure, but virtually unanimous agreement that its diagnosis is • The d isc stays firmly attached to the condyle and rests on it in an complex and controversial [emphasis added]. As with other such ideal position to load and transport the mandible in a variety of conditions, researchers have tried to agree on the presence ofseveral d irections. qualifying major signs or symptoms ... Unfortunately. a review of the literature gives widely differing inclusive criteria. • The disc deforms during these motions and reforms after term ina­ tion of motion (Cail liet 1 992). In their comprehensive d iscussion, based on considerable literature review, Ka lamir et al consider causes of parafunctional activity, such • The internal joint surfaces are well nourished and l ubricated by as clenching and grinding of the teeth. In an approach that suggests healthy synovia. that such activity '... could represent physiologically normal activity rather than a subconscious stress/a nxiety response during dreaming', • The muscu lature overlying the joint is free of contractures, tris­ they imply function for a behavior that is otherwise accepted as mus, trigger points and myofascial pain and a l lows ful l ra nge of dysfu nctional. For example, 'It has been suggested that nocturnal motion in all directions. bruxism may be a physiolog ica l attempt at increasing respiratory oxygenation, since protrusion of the jaw widens the pharyngeal • The musculature whose trigger point target zones include the space and rhythmica l jaw movements cou ld be construed as temporoma ndibular joint or any of the TM joint muscles is free of influencing the airwaY: trigger points. Although a clear diagnostic criterion does not yet exist, a • The person's posture reflects sym metrical balance and coronal diagnosis of TM joint dysfunction (TMD) is commonly g iven. The alignment with head and pelvis in neutral position when standing signs and symptoms might include one or more of the fol lowing or seated. biomechan ically faulted internal derangements of the disc. These may be due to gross trauma, such as that incurred in • No significant traumas have been suffered by the joint or by the acceleration-deceleration injuries, or to strain imposed on the joint cervical region. by faulty muscles, occl usal interferences, damaging oral habits or postu ra l positioning. • Occlusion is harmonious. box continues Rea l-l ife situations seldom offer all of the above simultaneously. More often, various combinations to the contrary are observed and, in some cases, what the patient presents is contrary to all of the above and with nutritional, emotiona l and structural stresses imposed as wel l. The causes and effects of temporomandibular joint dysfunctions often requ i re the efforts of a team of clinicians, each

362 CLI N I CA L APPLICATI ON OF N E U R O M U SCULAR TECH N IQUES: T H E U PPER BODY Anterior displacement with reduction Ca i l l iet ( 1 992) comments: The disc may be torn from the underlying condyle, which may a llow it When there have been repeated dislocations with ar without reduc­ to dislocate anteriorly ( Gray'sAnatomy 2005), possibly being pul led tion, the cartilage of the glenoid and the condyle undergo damage forward by the lateral pterygoid fibers (Cailliet 1 992). When this and degeneration with resultant degenerative arthritis. In the pres­ occurs, the condylar head will need to overcome the thick posterior ence of degenerative arthritic changes, there is a persistent crepita­ rim, producing a 'click' as it seats itself onto the disc (often with tion, pain, joint range-of-motion limitation, and concurrent spasm of pain). If a reduction has occurred (condylar position recaptured). the the muscles of mastication. In systemic inflammatory arthritis condyle may translate (if not otherwise prohibited) and the jaw will (rheumatoid, psoriatic, ankylosing, gouty, etc.), the TMJ frequently open. When the disc is not reducible, the range of motion will becomes involved. In these etiologicalconditions there is painful abruptly end as the condylar head encounters the posterior aspect of crepitation, limited opening, protrusion, and lateral and rotatoryjaw the anteriorly displaced disc. Range of motion is usually significantly movement, and concurrent masticatory muscle spasm with muscle lessened with a non-reducible anterior displacement. pain and tenderness. Cailliet ( 1 992) comments: 'In the presence of a click, indicating TM joint pain and associated factors the possibil ity of a disc impi ngement syndrome, there are factors Sign ificant research from many fields of health care has led to more that influence the prognosis and even the preferred treatment. Pai n comprehensive eval uation of TMD. The following summarizes some or no pain with the click is a prognostic factor with the presence of of the evidence that current research has uncovered. pain being more ominous: Forward head posture often accompanies TM joint pain and this Ca i l l iet states that the response to conservative treatment is should be a primary focus in rehabilitation of TM joint dysfu nction. more favorable if the history of clicking is brief, if the cl ick occurs early in the opening phase of jaw motion and if the click is reduced Forward head posture and its related myofascial dysfunctions, by repositioning the mandible (with orthosis). especially when little including the evol ution of nests and chains of trigger points, distance is req u i red. The prognosis is less favorable if more than 3-5 emphasize the important role these alarm mechanisms play in mm of repositioning is needed to abolish the click. alerting the body (and the practitioner) to emerg ing problems, when stra in, overuse, misuse or abuse of a tissue is occu rring. Ca i l l iet notes: Examining for forward head posture (anterior head position) is The earlier the placement of the orthosis fram which the patient noted by Simons et al ( 1 999) to be 'the single most useful postural receives relief. the better is the long-range prognosis. If clicking is not parameter' regarding head and neck pain. They note that a forward painful, treatment is deferred unless the clicking is considered unac­ head position : ceptable to the patient. The implication is that clicking, per se, is usu­ • occurs with rounded shoulders ally reasonably innocuous. However, there is a prevalent opinion that • results in suboccipital, posterior cervica l , upper trapezius and clicking forebodes ultimate degeneration of the disc and/or the carti­ lage of thejoint. splenius ca pitis shortening to a ll ow the eyes to gaze forward • most often presents with a loss of cervical lordosis (flattening of The click (as well as crepitation) produced during translation of the mandible may wel l be the first indication of a prog ressive TM joint cervical curve) problem. Often the patient issues no complaint until pain is • overloads SCM and splenius cervicis experienced or until 'Suddenly one day I noticed I could not open my • places extra stra i n on the occipitoatlantal joint (places it i n mouth to bite a sandwich'. extension) When the disc is anteriorly displaced, the posterior bilaminar • increases the change of compression pathologies zone (if still attached) is stretched and positioned to lie directly above the condylar head. Damage to the fibers, irritation to the Figure 1 2.35 'Forwa rd head' ca uses sign ifican t postura l neurovascu lar tissues and resu ltant excitation of the overlying conseq uences. muscles are some of the perils that may result the moment the disc displaces. Recapture of the disc (if possible) by orthotic intervention box continues may reduce pressure on the elastic fibers by repositioning the condylar head forward and onto the disc in ideal position. By reducing pressure on the neurovascu lar tissues by both removal of the condylar head's presence as well as reduction of muscular tension and its often resultant intrajoint pressure, a q uieting of the muscu lature may result, due to the effects of Hilton's law. H i l ton's law The nerve supplying ajoint supplies also the muscles that move the joint and the skin covering the articular insertion of those muscles. Anterior displacement without reduction A closed lock is a more serious condition. The process is similar to a displaced disc with reduction, except the d isc is unable to reposition over the condyle and, instead, impacts the condyle against the posterior aspect of the disc and is unable to translate further. This condition results in li mitation of opening, often to 25 mm or less. This condition is a locked displacement without reduction and is a difficu lt one to correct with conservative measures. '

1 2 The cra n i u m 363 • places the supra- and infrahyoids on stretch and places down­ problem they have often become very serious pain and/or dysfunction ward tension on the mandible, hyoid bone and tongue cases. These patients require the practitioner to have the broadest possible knowledge or at least the understanding of many disciplines • induces reflexive contraction of the mandibular elevators to so that proper referrals can be made. counteract downward traction of the mandible (which then) Til ley ( 1 997) maintains that whatever the mode of treatment, active • results in increased intraarticular pressure in the TM joints, which and thorough self-care is important. could g ive rise to the development of cl icking, especially i n a pos­ teriorly thinned disc (see also crossed syndrome patterns in The fol lowing shou ld be considered : Chapter 5). • avoid gum and other sticky, chewy foods Kalamir et al (2007b) concluded from a literature review that • avoid apples and thick sandwiches requiring excessive opening 'Manual therapy has also been shown to be more cost effective and • improve nutrition through a better diet and supplementation less prone to side effects than dental treatment: Some of the • exercise: stretching (especially cervical and shoulders), strength­ following points to why this might be so. ening, endurance McLean (2005) recorded su rface EMG data from the dominant • avoid long-term use ofanalgesics, which can result in rebound side on 18 healthy subjects, including the fol lowing muscles: levator scapulae, upper trapezius, supraspinatus, posterior deltoid, masseter, headaches rhomboid major, cervical erector spinae and sternocleidomastoid. • learn to use self-applied acupressure or neuromuscular techniques Compared to forward head posture, corrected sitting posture • learn relaxation techniques produced a significant reduction in muscle activity: • avoid activities that aggravate the condition (lifting, sweeping, Corrected posture in standing required more muscle activity than driving) habitual or forward head posture in the majority ofcervicobrachial • evaluate work station for possible postural irriton ts - keyboard too andjaw muscles, suggesting that a graduated approach to postural correction exercises might be required in order to train the muscles to high, cradling phone with shoulder appropriately withstand the requirements of the task. A surprising • keep headache diary finding was that muscle activity levels and postural changes had the • elimination diet to identify and cut out offending substances largest impact on the masseter muscle, which demonstrated • avoid caffeine activation levels in the order of20% maximum voluntary electrical • evaluate sleep pasture - on back with cervical pillow and pillow octivation. under knees or on side with pillow between legs Evcik & Aksoy (2004) investigated the relationship between • moist heat or cold compresses for temporal and cervical area temporomandibular joint dysfu nction and head posture, using MRI, • herbal therapy might be considered x-ray and physical measurements. They reported : 'This study supports • continue to be active in family and church activities. that poor posture causes m uscle imbalance and pain which are highly correlated with developing temporomandibular dysfu nction While it is outside the scope of this text to d iscuss the dental factors syndrome: that may be involved in TM joint dysfunctions, it is recommended that the cli nician thoroughly u nderstands the dental diagnosis and Tsai et al (2002) investigated masticatory muscle activity and jaw treatment plan as well as the case h istory, i ncluding history of head position as the subject was placed under the stress of mental and neck pa in, sign ifica nt fa l ls, direct traumas, motor vehicle arithmetic. They mon itored EMG activities of the right masseter, accidents, habits such as nail biting and gum chewing, pertinent right posterior temporalis and suprahyoid m uscles and used a dental history, indications of habitual mouth breathing, stressfu l life kinesiograph to observe the jaw position. They reported 'a significant situations, signs of hormonal changes (such as menopause or thyroid increase in EMG activity of all three muscles during mental imbalance), known and suspected food al lergies, use of over-the­ a rithmetic compared with baseline; different patterns of increased counter and prescription medications and expected fam i ly (or other) EMG activity were noticed in the three muscles under a continuous support or resistance. Often a tra i l of clues is uncovered when stress condition. Under stress, the incidence of tooth contact at q uestions are asked regarding what induces and what seems to intercuspal position was a lso i ncreased'. relieve the pa in. Modifications i n both physical and emotional environments may be needed and may be synergistic with each other. Travers et al (2000) investigated the relationship of i ncisor opening and condylar translation, questioning the degree to which opening Examination of the soft tissues of the neck and cranium may range of motion is diagnostically relevant. They concluded that: reveal trigger points, postural tension, reduced ra nge of motion and hypertonic myofascia. Release of the soft tissue elements, (7) maximum incisor opening does not provide reliable information restoration of active range of motion to the cervical spine, shoulders about condylar translation and its use as a diagnostic indicator of and TM joints as well as steps toward assessing and enhancing condylar movement should be limited, (2) healthy individuals may whole-body postural bala nce are warranted from the onset of TM perform normal opening with highly variable amounts ofcondylar joint therapy. The dental orthosis (spli nt) or occl usion may need more translation, (3) the straight-line distances of the incisor and condyles frequent assessment if changes in pelvic, spinal or cranial provide adequate information about the length of the curvilinear positioning alter the position of the mandible a nd, therefore, the pathway, ond (4) variation in maximum incisor opening is largely teeth or appliances. explained by variation in the amount of mandibular rotation. Assessment of associated structures Larry Tilley DMD ( 1 997) notes: The following assessments performed before and after appl ications of therapy will g ive basic information as to possible involved tissues Even after finding a knowledgeable dentist we must remember that as well as assisting in assessment of response to treatment. same patients are very 'straightforward' and respond to the most basic treatment. Others, however, require the most comprehensive, Elimination of trigger points in TM joint muscles and associated holistic and multidisciplinary approach. By the time many of these cervical muscles, postural repositioning of head and neck and long-suffering patients have been diagnosed as having a TMD rebalance of the agonist and antagonist muscles of the TM joint may a lter measurements, movement and tension in musculature of the box continues

364 C L I N I C A L A P PLI CA T I O N OF N E U R O M U S C U L A R TE C H N I Q U E S : T H E U PP E R B O DY Fi g u re 1 2 .36 Move m e n t of t h e TM joints may be b i l a tera l ly Fi g u re 1 2 .38 A m i n i m a l two-knuckle or m a x i m a l t h ree-knuckle assessed for sy m m etry d u ri n g o pe n i ng a n d closing of the m o u t h . o p e n i n g range of motion i s an easy assessment the patient can perform o n h e rself. Figu re 1 2 .37 G e n t l e co m p ress i o n o f t h e TM j o i nt. This step instance), w h ich either d i rectly or i n d i rectly displace the head is o m i tted i f a nterior d isc displace m e n t i s present. a n teriorly. The additional stress placed upon the mand i b u l a r elevators and t h e occlusal a l ignment i n response t o t h e forward TM joint. Charting of dietary, overuse and abuse hab its as well as patterns and frequency of pain may offer i nsight as to areas of head is ill ustrated and discussed by Cail l i et ( 1 992) and is l i kely necessary modification. Education, counse l i n g , l i festyle a n d nutritional changes, exercise and stretching coupled w i t h myofascial to be a pplicable to chronic shortness of the suprahyoids due to modalities w i l l supplement the effo rts of the dental team (Ca i l l iet mouth breathing. Whole-body posture and steps toward sym metrical bala nce should be one concern when developing a 1 992). Assessment and correction of forward head posture is of treatment plan. primary i m portance as noted by Simons et al ( 1 999): 'Anterior head This text offers t reatment options for the cervical region that positio n i n g with reflex elevator muscle activity also ca uses increased should be i ncluded with the myofascia l elements of intraarticu lar pressure in the TMJs and can precipitate m i l d i nternal temporom andibu l a r joint dysfunction. The practitioner should dera ngements i n joi nts with compromised d iscs: They a lso note that inclu de the upper trapezius, SCM, posterior cervical lamina glid ing, mandibular position i n g, such as occurs in forward head position, can suboccipital reg ion, supra- a n d infrahyoids a nd, if ind icated, a nterior activate tempora lis and/or its tri gger points. deep cervical muscles due to their postural influences as well as associated trigger point referral patterns. Trigger points from as far Forward head position may be associated with habitual mouth away as the soleus have been noted to refer into the breath ing or other breathing dysfu nctions (overactive scalen es, for temporoma ndibular region (Trave l l Et Simons 1 992). Assessment of TM joint • The practition er's palpating fi ngers ca n be placed over the bilateral temporomandibular joints to assess local te nderness in response to mild or moderate pressure on the joint capsule (Fig. 1 2.36). • The angle of the mandibl e may be pressed gently toward the top of the head to assess for intrajoint tendern ess. This step may be omitted if anterior displacement of the d isc is present as it may produce extreme discomfort within the joint (Fig. 1 2.37). • The condylar heads may be external ly pal pated during translation in a l l directions and compa red for symmetry of movement. • A sim ple m i l l i meter ruler, dental gauge or Therabite® ra nge of motion sca l e can compare pretreatment and posttreatment open­ ing ranges to each other as well as to normal ranges. The a d u lt in cisal ope n i n g may measure 50-60 mm (Gray's Anatomy 2005) with m i n imal normal opening being 36-44 mm (Simons et a l 1 999) a n d with 5- 1 0 mm of range a llowed i n protrusion a n d lat­ era l displacement i n each d i rection, with much i n d ividual variation ( Gray's Anatomy 2005). Although a less than idea l range of motion might not be conclusively d i a g nostic of TMD, aim toward movement within this ra nge is suggested. box continues

1 2 The cranium 3 65 Box 1 2.4 (conti nued) • The patient is seated in front of a m i rror with lips retracted so that the two toothpicks protrude from between the lips. • A simpler, self-appl ied assessment of two (m inimum) and three (maximum) knuckles (Simons et a 1 1 999) placed vertica l ly • The patient very slowly opens and closes the mouth and in doing between the upper and lower incisors is a test read ily usable by so concentrates on maintaining the tips of the toothpicks in line, the patient to assess the need for self-appl ied or practitioner­ one with the other. applied neuromuscular therapy (Fig. 1 2.38). • Repetition of this 5- 10 times several times daily helps 'retrain' • An opening range greater than three knuckles (over 60 mm) may dysfunctiona l muscle patterns. indicate l igamentous laxity and is a ca utionary sign when apply­ ing intraoral work. Excessive opening may result in an open d islo­ Several of the myofascial treatments offered in this section ca n be cation that is painful and frig htening and can usually be avoided appl ied by the patient at home, including masseter, temporalis, with special care. lateral pterygoid, tongue and floor of the mouth. Applications to the soft palate structures are best performed by a trai ned clinician due • As the mandible is depressed during open ing of the mouth, the to the delicacy of the palatine bones, vomer and hamulus and practitioner may observe the lower central incisor path to note possible (probable in seated position) stimulation of the gag reflexes. deviations or unusual movements d uring tracking. Such devia­ tions may be the result of trigger points or shortened fibers The complexity and controversy surrounding TMD can be within the muscu lature (deviation will usua l ly be toward the side overwhelming to an individual as well as for the practitioner. A of shortening), internal derangement of the d isc or other interna l comprehensive knowledge base must be constantly assessed and pathologies. potentia l ly regularly revised in order for clinical treatment to be successful. Kalamir et al (2007a) understand this and concl ude: • A hard end-feel to open ing, especially when the range is sign ifi­ cantly reduced, may indicate anterior displacement without The current paradigm for chronic pain management emphasises a reduction or onset or presence of degenerative arthritis. biopsychosocial approach to potient care for comprehensive recovery. Purely mechanistic models of intervention are giving way to both • Referral to a dental specia list for eva luation (or for a second multimodal and multidisciplinary strategies. In tegrated treatment opinion) ca n be of sign ificant value and a necessary part of the models of this nature arestill in theirinfancy for TMD. However, there course of treatment when soft tissue appl ications are successfully used due to their ability to significantly alter the position of the is an emerging trend of cooperation between differen t health disci­ head and mandible and therefore the occlusion of the teeth. plines, such as psychotherapy. dentistry. chiropractic, osteopathy. physiotherapy. massage and acupuncture. Viable, conservative treat­ Rehabi litation self-treatment method ment protocols based on all the available evidence need to be CO(1- • The patient gently wedges a wooden toothpick between the mid­ structed, in order to overcome the historical limitations suffered by dle upper central incisors and another between the lower central individual health professions. incisors. Fig u re 1 2.39 Su perficial lym ph pathways of the head a n d neck region. �\\ \\\\\\\\ d�r\\\\�. 1 + \\ \\ EXTERNAL PALPAT I ON AND TREATMENT O F Since this joint is a bilateral joint (the mandible spans the CRANIOMANDIBULAR MUSCLES cranium) dysfunctions affecting one side also affect the contralateral side. When techniques that release the hyper­ The therapist is seated cephalad to the supine patient's tonic, shortened muscles and/or assist in toning any inhib­ head. The ipsilateral hand is used throughout the external ited (weakened or lax) muscles are applied to both sides, a palpation. Each procedure is performed to both sides.

366 C LI N I CA L APPLICATIO N OF N EU RO M U SC U LA R TECH N I QUES: THE U PPER BODY This necrotizing a rteritis condition is characterized by ,-- Temporalis infla mmation of medium- and smal l-sized blood vessels and is often in itia l ly manifested with fever, a norexia, weight loss, Figure 1 2.40 The tempora l is fibers a re vertica l ly oriented a n teriorly headache, fatigue and myalgia, and prog resses to head pain over and h orizo nta l ly oriented posteriorly, with va rying diagonal fibers in the tempora l artery or over the face, cranium a nd jaws. between. Referred pattern of trigger points i ncludes i nto the teeth. Examination may reveal tender, painfu l nodules in scalp tissues Drawn after Simons et al (1 999). and the tender temporal artery may be devoid of pulse. Infi ltration of polymorphonuclear leu kocytes and eosinophils within the wa l l s of the involved arteries may result in thrombosis and segmental fibrinoid necrosis (Ca i l l iet 1 992). Rene Cailliet says: This condition may be accompanied by ocular motorpalsy with blindness from an optic neuropathy, occurring rapidly and usually irreversibly. Loss of vision is the most feared sequela of this condition, especially in patien ts not diagnosed and appropriately treated. Vision can be lost in the other eye within a week of the initial affliction. Gradual blindness rather than abrupt visual loss is rare. Ka ppler Et Ramey ( 1 997) report: This ... is usuallyseen in patien ts over age 50. The artery is swollen and tender. The associated headache is severe, throbbing, or stabbing and is localized overone temple. The pain is worse when the patient stoops or lies flat. The pain decreases when pressure is applied over the common carotid artery. Visual disturbances may develop secondary to ischemic optic neuropathy. The diagnosis is confirmed by biopsy. Early treatment is critica l. When the patient presents with the a bove symptoms, friction of the temporal area shou ld be avoided until diagnosis rules out temporal arteritis. If it has been d iag nosed, trea tment of this a rea is avoided until the attending physician recommends that it is safe to perform it. balanced state can be achieved which allows more normal friction is applied while pressing with enough pressure to joint function. However, if techniques are applied unilater­ feel the vertical fibers or to produce a mid-range discomfort ally, imbalance of the musculature is probable with pre­ level. The fibers are examined their entire length to the dictably undesirable consequences. upper edge of the temporal fossa. Taut fibers are assessed for central and attachment trigger points and are treated with Although the treatment procedures (as described below) static pressure. could conceivably be performed by applying the entire rou­ tine (first on one side and then the other), it is suggested The fingers are moved posteriorly a fingertip wid th and that only one or two steps be performed before those same placed once again on the tendon just above the zygomatic steps are repeated on the contralateral side, prior to contin­ arch. The examination now addresses the next group of fibers uing with the protocol. In this way, the practitioner can in a similar manner. This process is continued throughout the immediately compare the two sides while mainta ining a temporal fossa. Since the muscle is shaped somewhat like a more even balance of the muscula ture. fan, the middle fibers lie on a diagonal while the most poste­ rior fibers are oriented anteroposteriorly over the ear. I NMT F OR TEMPORALIS The portion of the tendon which lies above the zygomatic CAUTION: The fol lowing treatments should NOT be arch can be assessed by using transverse friction while the performed if temporal arteritis is suspected. See Box 12.5 mouth is either open or closed. An open mouth treatment stretches the tendon and requires less pressure than when regarding temporal arteritis. the mouth is closed. The tendon may also be pressed as the The practitioner uses the first two fingers to apply trans­ patient actively and slowly shortens and lengthens the tis­ verse friction to the entire temporal fossa, a small portion at sues under pressure. a time. The fingers begin cephalad to the zygomatic arch and on the most anterior aspect of the rather large.tendon of terri­ With the mouth still open, the practitioner locates the poralis (Fig. 12.40) . The fingers are then moved cephalad to coronoid process wh.ich is the first bone encountered (besides address the most anterior fibers of temporalis. Transverse teeth) when moving the finger from the corner of the mouth

1 2 The cranium 367 ! Figure 1 2 .41 The pati ent's mouth m ust be open wide a n d the Fig u re 1 2.42 Lig h t friction appl ied to the i nferior su rface of the treating fi nger p recisely placed to avoid the pa rotid d u ct w h i l e accessing the small portion of tempora lis tendon available a t the zygomatic arch w here masseter attaches. coronoid process. CAUTION: If there is evidence of inflammation or infec­ toward the top of the ear. The mouth is opened as far as pos­ tion in the parotid (salivary) gland or the teeth, referral to sible which will lower the coronoid process to below the zygomatic arch (unless depression of the mandible is a dentist or physician is suggested before applying any restricted) and make the temporalis tendon available to pal­ techniques to the face or internal musculature. If redness, pation. Caution must be exercised along the anterior aspect of the coronoid process to avoid compressing the parotid edema, heat, extreme tenderness or other signs of infec­ duct against the anterior aspect of the bony surface. The duct may be palpated on most people by using a light tion are present, the procedure i s delayed until a diagno­ cranial!caudal friction approximately mid-way along the sis reveals the extent of the condition. Salivary gland anterior aspect of the coronoid process. Once located, the palpating finger is placed cephalad to the duct and avoids stones commonly occur within the glands and should be contact with it during treatment. ruled out as a source of pain and infection. Applications The palpating finger needs to be placed so that it is com­ pletely anterior to masseter and does not press through of heat are contraindicated when edema or infections are masseter fibers as this could be wrongly interpreted as tem­ poralis tenderness. Additionally, the practitioner 's index present (or suspected). finger rests below the zygomatic arch with its lateral edge touching the inferior surface of the arch and the palpa ting The practitioner lightly lubrica tes the external face from the finger pad 'hooked' onto the anterior surface of the coro­ zygomatic arch to the lower angle of the mandible. The noid process. The fingernail faces toward the ceiling when thumb pad is placed on the most anterior fibers of masseter the finger is properly placed on the supine patient's face just under the zygomatic arch. This muscular edge is easily (Fig. 12.41). When the tendon attachment is located, it is palpated as the patient clenches the teeth but the muscle often found to be exquisitely tender and pressure may need should be treated with the jaw relaxed and the teeth very to be reduced significantly. Static pressure may be used or, if slightly apart, lips together. not too tender, light friction may be applied. The thumb glides caudally 6-8 times and then is moved It NMT FOR MASSETER posteriorly onto the next segment of masseter fibers. The gliding techniques are repeated in segments until the entire The masseter attachments to the zygomatic arch and the masseter muscle has been treated. Since the parotid gland anterior portion of the attachment a t the lateral surface of the covers the posterior half of the masseter, care is taken to lower angle of the mandible can be assessed with due cau­ avoid excess pressure over the gland as well as the TM joint tion applied to the parotid gland on the lateral face and to itself. Though skin care specialists usually advise people to the 1M joint itself j ust anterior to the auditory meatus. The glide superiorly on facial tissues, in this particular protocol mandible is supported on the contralateral side by the palm which addresses craniomandibular dysfunctions, an excep­ of the practitioner 's non-treating hand whenever any pres­ tion is made and caudal glides are used to avoid pressing sure is applied to avoid lateral displacement of the mandible the mandible superiorly into the temporal fossa and against during the procedure. One side is addressed at a time. the articular disc or i ts posterior fibers. The practitioner places the pad or tip of the index finger onto the face just lateral to the nose and presses onto the inferior aspect of the zygomatic arch or onto the maxilla and applies static pressure or friction (Fig. 12.42) . The finger is moved one fingertip width laterally and the frictional tech­ niques or s tatic pressure are again applied. The first two or three finger placements may assess levator labii superioris,

368 C LI N I CA L APPLICATI O N OF N EU RO M USCU LAR TECH N IQUES: T H E UPPER B O DY F i g u re 1 2.43 Pressure on t h e parotid gland is avoided when friction is appl ied to the lower attachment of masseter. Figu re 1 2.45 '5' bend myofascial rel ease of masseter m uscle. Figure 1 2.44 Appro priate placement of t h e t h u mb, so that the tip up to 3 minutes during which a sense of release or leads the glide, is important to avoid mechanical damage to the 'unwinding' may be noted. thumb joi nts. • Inunediately following this, the thenar eminences are placed onto the tissues overlying the masseters with the levator anguli oris, nasalis, zygomaticus or orbicularis oris, fingers resting on the face, following its contours. A slightly depending upon finger placement. The masseter will fill the increased degree of pressure should be applied, up to 4 remainder of the inlerior surface of the zygomatic arch to ounces (112 grams), as the wrists gently move into and out j ust anterior to the TM joint. Avoid frictioning the TM joint. of extension so that a slow repetitive stroking/kneading effect, in an inferior/posterior direction, is adtieved along The attachment of masseter on the lower lateral surface of the long axis of the muscle. A light lubricant may be used. the mandible can be assessed using flat palpation against the • Goodheart (Walther 1988) recommends application of a bony surface deep to it. Taut bands found in the anterior half 'scissor-like' manipulation across the muscle by the of the muscle may be 'strummed' with snapping palpation or thumbs (or fingers) which form an '5' bend - one thumb the practitioner may reassess them with the intraoral tech­ pushing superiorly across the fibers while the other niques offered later. Friction is not used on the posterior half p ushes inferiorly (Fig. 1 2.45). The fibers that lie between of the masseter due to the overlying parotid gland (Fig. 12.43). the thumbs are thereby effectively stretched and held for some 10-15 seconds. A series of such stretches, starting �. MASSAGE/MYOFASCIAL STRETCH TREATMENT close to the ramus of the jaw and finishing at the zygo­ matic arch, can be applied. The buccinator muscle is also , OF MASSETER effectively being treated at the same time. • A very gentle myofascial release approach is achieved by It POSITIONAL RELEASE FOR MASSETER sitting at the head of the supine patient and placing the pads of the three middle fingers onto the tissues j ust infe­ 5cariati (1991) describes a counterstrain method for treating rior to the zygomatic process. The contact should be 'skin tenderness in the masseter muscle. on skin' with no perceptible pressure. The amount of force applied in an inferior/posterior direction should be . • The patient is supine and the operator sits at the head of minimal, barely a half ounce (14 grams). This is held for the table.

1 2 The cranium 369 Fig u re 1 2.46 A small portion of l a teral pterygoid may be i nfl u enced Figure 1 2.47 Medial pterygo id's l ower attachment may b e accessed externa l ly by pressing through the masseter with the patient's externa l ly when the head is rotated ipsi l a te ra l ly. mouth half open. condyle toward the fossa and also to avoid pressing onto • One finger monitors the tender point in the masseter the styloid process. Friction should not be applied to the muscle, below the zygomatic process. facial artery and vein as they course around the inferior aspect of the mandible approximately 1 inch (2.5 cm) ante­ • The patient is asked to relax the jaw and w i th the free rior to the angle of the mandible. hand the operator eases the jaw toward the affected side until the tender point is no longer painful. STYLOHYOID (see FIG. 1 2.62) • This is held for 90 seconds before a return is allowed to Attachments: Posterior surface of the styloid process to the neutral and the point repalpated. body of the hyoid bone at the junction of the greater horn (just above omohyoid) It NMT FOR LAT ERAL PT ERYG OID Innervation: Facial nerve With the patient's mouth open as far as possible without Muscle type: Not established inducing pain, the practitioner locates the coronoid process. Function: Elevates the hyoid bone and p ulls it posteriorly, The index finger is placed just posterior to the coronoid process while remaining anterior to the mandibular condyle. which may indirectly influence opening of the mouth As the patient closes the mouth slowly, the overlying tissues when the hyoid bone is stabilized by the infrahyoid will soften and an indentation will be felt at the location of muscles the mandibular notch. The mouth is open approximately Synergists: Suprahyoid muscles, especially digastric half way (Fig. 12.46). Antagonists: To elevation of hyoid bone: infrahyoid muscles To posterior positioning: geniohyoid The index finger presses into the indentation (through the To opening of mouth: mandibular elevators masseter muscle) and onto the lateral pterygoid muscle belly. Static pressure is applied to one side at a time while the I n d ications fo r treatm ent mandible is supported on the opposite side of the face. This step most likely encounters the upper head of lateral ptery­ • Tenderness at styloid process goid and the posterior portion of the lower head (Simons et • Swallowing difficulties aI 1999). Note that in pressing through masseter to reach lat­ • Posterior positioning of the hyoid bone eral pterygoid, masseter tenderness may be mistaken for lat­ • Diagnosis of Eagle's syndrome - see below eral pterygoid tenderness. The overlying masseter may need to be treated intraorally to reduce i ts involvement. Specia l notes � NMT FOR MEDIAL PT ERY G OID The stylohyoid muscle arises via a tendon from the posterior surface of the styloid process and attaches onto the hyoid With the patient's mouth closed, two fingers are placed onto bone, having been perforated by the tendon that joins the two the (external) interior aspect of the lower angle of the bellies of the digastric muscle. Its action is to elevate the hyoid mandible, where the medial p terygoid muscle attaches (Fig. 12.47). Ipsilateral head rotation usually allows more room for the fingers to slide into place. Friction or static pressure is used on the medial aspect of the lower angle of the mandible while care is taken not to press the mandibular

370 C LI N I CA L A P P LI CATI O N O F N E U R O M USCU LA R TECH N I Q U E S : THE U P P E R B O DY Box 1 2.6 Notes Oft the ea.r. '<..> .' o' r' • The ear serves two major purposes: hearing and maintenance I n formation that the brain integrates to mai ntain orthostatic of equilibrium. posture derives from the fol lowing sources: • The temporal bone houses most of the structures of the ear, • retinal which suggests that temporal bone dysfu nction may con­ • otolithic (vestibular) tribute to vertigo or hearing problems. • plantar exteroceptive • proprioceptive sou rces in the 1 2 oculomotor muscles • This fu rther suggests that imbalances i n the m uscles attaching • paraspinal muscles to the temporal bone might a lso be implicated i n heari ng dys­ • muscles of the legs and feet. function or vertigo, notably: 1 . sternocleidomastoid which arises as two heads on the Loss of bala nce may therefore resu lt from fai l u re of sensory manubrium sternum a nd the clavicle and powerfu l ly information, including that from the vestibular mechanisms in attaches to the mastoid process (clavicu lar fibers) as well t h e ea rs, or fa u lty i ntegration o f information received b y the as to the superior nuchal line (sternal fibers) bra i n. 2. tempora l is which a rises from the temporal fossae. The pos­ terior aspect of the origin of the m uscle lies on the tempo­ Labyri nthine test ra l bone itself, while the i nferior attach ment is to the • The patient is standing with eyes closed. coronoid process of the mandible • The patient is asked to hold the head in various positions, 3 . longissi mus capitis, which a rises from the transverse processes of T1 -5 and the a rticu lar processes of C4-7, flexed or extended with rotation i n one d i rection or the other. attaches to the mastoid process • Changes of d i rection of swaying are i nterpreted as the result 4. splenius capitis arises from the spinous processes of C7-T3 as well as the lower half of the ligamentum nuchae and of labyrinth i mbala nce. attaches to the mastoid process and the lateral aspect of • The patient sways i n the d i rection of the affected labyrinth. the superior nuchal line. Rehabilitation choices • The Eustach ian tube con nects the nasopharynx and the middle Sta n d i ng and walking with eyes closed, with the floor covered i n ear and is designed to equalize middle ear and atmospheric th ick foam to reduce normal sti m u lation of receptors in the foot, pressure. retrains the vestibu lar a nd somatosensory systems. • Kappler Et Ramey ( 1 997) state: 'Eustach ian tube dysfu nction is Retra ining of vestibular mechanisms may also i nvolve use of the most co mmon cause of otitis media and benefits from ... hammocks and gym balls. treatment to the cra n i u m, medial pterygoid and cervical fas­ cias: The authors of this text suggest that treatment of the deposition which may, in turn, cause pressure or irritation tensor palatini a lso be i ncluded in th is list. (See NMT for soft to surrounding structures, including the carotid artery. palate, p. 382). Regardless of its etiology, the abnormal elongation of the styloid process resulting in facial pain is termed Eagle's • Travel l Et Simons ( 1 983) report that ear pa i n can result from syndrome (Stedman's Medical Dictionary 1998) or stylalgia. trigger points in the latera l or medial pterygoids, sternocleido­ Panoramic a nd frontal radiographs may confirm calcifica­ mastoid (clavicu lar) or masseter (deep). tion of the styloid ligament or intraoral palpation of the process near the tonsillar fossa may reveal elongation of the • Tensor palatini opens the entrance to the auditory tube to process i tself (Grossmann & Paiano 1998). equal ize air pressure d u ring swa l lowing (Drake et al 2005, Leonhardt 1 986) and hypertonicity of this muscle has im por­ Symptoms may include recurrent throat pain, dysphagia, ta nt clinical mea n i ng as the auditory tube, when open, may pharyngeal foreign body sensation, referred otalgia and provide a n easy passageway for ororespiratory tract infections neck pain (Beder et al 2005, Fini et al 2000). Grossmann & to reach the middle ear (Clemente 1 987). See further Paiano (1998) concur and note: 'In patients with mild symp­ discussion with the text of this chapter. toms, it is often possible to control it with conservative ther­ apy. However, severe cases should be treated surgically.' bone, drawing it backwards and elonga ting the floor of the mouth, thus influencing speech, chewing and swallowing. Simons et al (1999) cite trigger points in posterior digas- tric and s tylohyoid as a factor in Eagle's syndrome. Stylohyoid muscle fibers lie in close relationship to digastric, which sometimes also attaches to the stylOid The patient with this syndrome complains of pain in the process (partially or wholly) (Gray's Anatomy 2005). The angle of the jaw on the side of involvement, and also may fibers of stylohyoid and the posterior fibers of digastric are have symptoms of dizziness and visual blurring with difficult to distinguish by palpation alone (Simons et al 'decreased' vision on the same side . . . Active TrPs in these 1999). The digastric trigger point target zone includes the muscles can result in sustained elevation of the hyoid. The tenderness at the styloid process and calcification of the sty­ area of the stylohyoid muscle, whose pain pattern is not yet loid ligament can represent enthesitis and subsequent calci­ clearly established but is presumed to be similar (Simons fica tion due to the sustained tension caused by TrP taut et al 1999). Additionally, this referral pattern includes the bands. The dizziness and blurred vision can be caused by superior portion of the sternocleidomastoid muscles and associated TrPs in the adjacent sternocleidomastoid muscle. contrib utes to the expression 'pseudosternocleidomastoid pain' used by some practitioners. Myofascial and ligamentous tension on the styloid process may result in elongation of the process due to calcium

1 2 The cranium 3 7 1 Protrusion: medial and lateral pterygoid Retraction: temporalis (posterior fibers), masseter (middle and deep fibers), digastric, g eniohyoid Elevation: temporalis, masseter, medial pterygoid, lateral pteryg o i d Depression: lateral pterygoids, digastric, geniohyoid, mylohyoid, gravity Loteral translation: medial and lateral pterygoid Maintains position ofrest: temporal is Fig u re 1 2.48 Three m uscles a n d two liga m ents attach to t h e frag i l e Defensive reactions by the immune system agai nst norma l ly styloid process. D igastric a ttaches to the a nterior su rface of the i noffensive substances often produce a l lergic responses. As with m astoid p rocess j ust posterior t o the styloid p rocess. most a l l ergic and sensitivity reactions, great variations exist in the degree of severity displayed, ranging from no apparent Examination of the hyoid bone would also be warranted due reaction to m i ld or severe skin eru ptions, respi ratory to simultaneous tension that would be placed on it through compl ications and, rarely, death. the digastric central tendon attachment by fascial loop. Since u n iversal precautions were initiated in the late 1 980s to ,� EXTER N A L PALPATION AND TR EATM E N T O F prevent com m u nication of diseases, such as H IV and hepatitis, exposure to latex products (which provide barriers to these and , STYLOID AND MASTOID PR OCE SSE S other viruses) has increased sig nifica ntly, especia l ly for healthcare providers. Latex, derived from the m i l ky sap of the rubber tree The head is rota ted slightly contralaterally and a small and other plants from the Euphorbiaces fa m ily, is used in the amount of lubrication is applied to the styloid process. The production of medical suppl ies (including gloves), paints, index finger is placed just under the earlobe and posterior ad hesives, bal loons and n u merous other common products. It has to the mandible with the pad of the finger placed directly on only been recognized within the last 1 5 years as a cause of the styloid process and with the tip of the finger pointing serious allergic reactions. toward the patient's feet (Fig. 12.48). The styloid process can be very fragile and only light pressure is used on this struc­ Latex is com posed of proteins, lipids, nucleotides and ture as the finger slides caudally along the anterior surface cofactors. The protein element is thought to be the cause of of the styloid process or at least the palpable musculoliga­ allergic response, w h i le the powders, which are often used to mentous ex tension of it. As the finger glides caudally, the coat the gloves to make them easier to get on a nd off, provide end of the s tyloid process (or its ligamentous continuance) the protein with additional airborne capabi lities. I ncreased is apparent as the osseous-like firmness yields to a much exposure to latex is apparently associated with increased softer tissue. It is important to end the stroke abruptly since sensitivity and onset of a l lergic reaction often a ppears insidiously. continued motion would encounter the carotid artery, which Althoug h the exact connection is not fu lly understood, those is not advised. This process will treat the styloglossus, sty­ people who are a l lergic to avocado, banana, kiwi and chestnut lopharyngeus and stylohyoid muscles and the s tylohyoid are often also latex sensitive. and stylomandibular ligaments. These tissues may be sur­ prisingly tender; however, several repetitious gliding strokes Allergic responses may i nclude hives, dermatitis, a l l erg ic will usually result in a rapid response. conju nctivitis, swel ling or burning around the mouth or airway fol lowing dental procedures or after blowing up a balloon, genital The index finger is moved posteriorly and onto the mas­ burning after exposure to latex condoms, coug h ing, wheezing, toid process. With light lubrication, gliding strokes are shortness of breath and occupational asthma with latex exposure. applied to the upper 2 inches (5 em) of the SCM muscle 8-10 Extreme cases may result in anaphylactic shock that may prove times. The head is rotated further contralaterally and pas­ fatal. sively angled toward the ipsilateral shoulder to further relax the SCM. The SCM is displaced posteriorly (if needed) Avoida nce of exposure is certai n ly recommended for those and an index finger placed onto the anterior aspect of the people who a re a l ready latex sensitive and may also be the best mastoid process. Static pressure or mild friction is applied course of action to avoid future development of sensitivity. Additional ly, the National I nstitute for Occupational Safety a nd Health (N IOSH) has published a 1 997 alert titled Preventing allergic reactions to natural rubber latex in the workplace (N IOSH publication #97-1 35) which may be obtained online (www.cdc.gov/niosh/latexa lt.html) or by ca l l i ng (800) 356-4674. At the time of publ ication of this text, nu merous websites a re available, including some which l ist l atex-free a l ternative barriers, and may be found with a website search for the topic 'latex allergies'.

3 7 2 C L I N ICAL APPLICATION O F NEU ROMUSCULAR TEC H NIQUES : THE UPPE R BODY to the digastric attachment at the digastric notch of the adjustments to avoid strain and gain the best access to the mastoid process. Friction may be used if the area is not too muscle. tender. The treating finger remains posterior to the styloid process and pressure on the styloid process is avoided due TEMPORAl I S to its fragility. Attachments: Temporal fossa and deep surface of the tem­ INTRAORAL PALPATI ON AND TREATMENT O F poral fascia which covers it to the medial, apex, anterior CRANI OMAND I B U LAR M U SCLES and posterior borders of the coronoid process and to the anterior border of the ramus of the mandible Prior to the intraoral examination, it is recommended that the practitioner takes a full case history, including dental, Innervation: Temporal nerves from mandibular branch of medical, traumas or chronic conditions especially related to trigeminal (cranial nerve V) the oral cavity, face, jaw, cranium or neck. Allergies to latex should be noted and exposure avoided by using non-latex Muscle type: Not established barriers. All precautions should be taken to prevent latex Function: Elevation and retraction of the mandible, lateral overexposure for both patient and practitioner, while also providing adequate barriers to direct intraoral contact. The excursion fingernail of the index finger (or other treating finger) should Synergists: For elevation: contralateral temporalis and bilat­ be weU trimmed. eral masseters, medial pterygoids, lateral pterygoids Protective gloves are always worn when examining the (upper head) intraoral cavity. Unpowdered gloves are recommended since For retraction: deep head of masseter allergy or sensitivity to the powder may not be known prior Antagonists: To elevation: suprahyoids, infrahyoids (stabi­ to its use. The used gloves are properly disposed of imme­ lize hyoid bone), lateral pterygoid (lower head) diately after treatment. The practitioner who chooses to use To retraction: lateral pterygoids latex gloves (see Box 1 2.9) should keep in mind that oil dis­ solves latex. The hands and any surfaces the gloves touch, I n d ications for treatment including the patient's face, should be oil free. • Lateral headache Before beginning intraoral work, the practitioner should • Maxillary toothache or tooth sensitivity note any removable partial dentures, orthodontic appliances or any other structures that might tear the glove. In the case Spec ia l notes of orthodontic appliances, wax may be applied over sharp surfaces to avoid tearing the barrier. This fan-shaped structure covers a large part of the side of the skull. It passes deep to the zygomatic arch with anterior A glance inside the mouth might also reveal bony excre­ fibers coursing vertically, posterior fibers orienting horizon­ tions (mandibular or pala tine torus), fleshy growths or tally and the intermediate fibers varying obliquely. discolorations of the gums or internal cheek. Reference to a dentist or oral specialist is recommended regarding any AU fibers contribute to the major function of closing the suspicious tissue if diagnosis has not previously been mandible with the posterior fibers involved in retrusion made. Whereas tori are usually of concern only if they inter­ and lateral deviation of the mandible toward the same side fere with dentures, partials or speech, suspicious intraoral while the anterior fibers are largely involved in elevation tissues should be checked, especially if the patient does (closure) and positioning of the anterior middle incisors. not frequent the dental office. Additionally, wearing pat­ Temporalis is responsible for postural positioning and bal­ terns noted on the occlusal surfaces of the teeth might ancing the jaw. Masseter, on the other hand, is involved offer clues that the patient is bruxing, inappropriately trans­ primarily with chewing, clenching and strong closure of la ting the teeth on each other or otherwise abusing the the jaws. dentition. The two temporalis muscles are directly connected to the INTRAORAL NMT AP PLICATI ONS temporal bones (fossa and squama), the parietals (squama), the greater wings of the sphenoid and the posterolateral The patient is supine throughout the intraoral examination aspects of the frontal bones, crossing the coronal sutures, the and treatment. The practitioner stands at the level of the sphenosquamous sutures and the temporoparietal sutures. It patient's shoulder for most of the steps and may reposition is hard to imagine muscles with greater direct mechanical freely to avoid straining the wrist. While most of these steps influence on cranial function than these thick and powerful are performed ipsilaterally, some of the muscles are best structures. treated by reaching across the body to the contralateral side and are noted as such in the text. The practitioner should Upledger & Vredevoogd (1983) point out that when the experience all the techniques as non-straining and should teeth are tightly clenched, contraction of the temporalis reposition the hands, switch hands or otherwise make draws the parietal bone down. Because of the architecture of the squamous suture between the temporal bone (inter­ nal bevel) and the parietal bone (external bevel), a degree of sliding is possible between them.

1 2 The cranium 373 Prolonged crowding of this suture (resulting from dental \\�� . malocclusion, anger, tension, bruxism, trauma, etc.) can V 'l II lI lead to ischemic changes as well as pain locally and at a ( ---- )---- distance. � --- Subsequent influences migh t involve the sagittal sinus and possibly CSF resorption. Upledger & Vredevoogd Figure 1 2.49 The mandible is shifted toward the side being treated (1983) report that such a scenario can lead to mild to mod­ to a l l o w more room fo r the fi nger to reach the i nterna l aspect of the erate cerebral ischemia that is reversible. coronoid process and the tem pora l i s tendon attach ment. Trigger points from the temporalis muscle refer to the Masseter side and front of the head, eyebrows, behind the eye and upper teeth, as well as the TM joint. Temporalis lies in the reference zone of several cervical muscles, including trapez­ ius and sternocleidomastoid, and its trigger points may be satellites of trigger points in these muscles (Simons et al 1999) (see Fig. 12.40). CAUTION: A differential diagnosis with polymyalgia rheumatica is necessary if widespread pain is a feature (PR usually occurs in the over-50s and its pain distribution is usually greater than trigger point influences on the facelhead. A blood test confinns PR). Temporal arteritis should also be ruled out, especially if particularly severe head pain is localized over the temporal artery or wide­ spread over the cranium, face or j aws, as sometimes sudden unilateral blindness will result (see Box 12.5). Temporal arteritis shares many of the symptoms of polymyalgia rheumatica (Stedman's Medical Dictionary 1998). f N MT FOR I N TRAORAL TEMPORALIS TEND O N The practitioner treats the ipsilateral temporalis. The patient is asked to open the mouth as far as possible without induc­ ing pain and to shift the mandible toward the side being treated to allow sufficient room for the treating finger to rest between the coronoid process and the teeth. The pad of the index finger touches the inside cheek surface and the finger glides posteriorly until it runs into the coronoid process, a bony surface embedded in the cheek. The index finger slides onto the inside surface of the coronoid process and uses static pressure or gentle friction to examine the anterior, superior, interior and posterior aspects of the coronoid process (or what can be reached of them) where the temporalis tendon attaches (Fig. 12.49). The tendon is very hard and will feel like a continuation of the coronoid process. It is often very tender so light pressure is applied and increased only if appropriate to do so. MASSETER (FIG. 12.50) Fig u re 1 2.50 Masseter a n d other masticatory m uscles may refer d i rectly i nto the teeth, creating pa i n or sensitivity. D rawn a fter Attachments: Three heads arise from the zygomatic process Simons et al (1 999). of the maxilla as well as from the inferior aspect of the zygomatic arch inserting onto inferior, central and upper Synergists: For elevation: bilateral temporalis and medial aspects of the lateral ramus of the mandible pterygoid, contralateral masseter. Superior head of lat­ eral p terygoid remains controversial (Simons et a1 1999) Innervation: Masseteric nerve from mandibular branch of trigeminal (cranial nerve V) Antagonists: Suprahyoids and the inferior head of lateral p terygoid Muscle type: Not established Function: Elevates mandible; some influence in retraction, protraction and lateral deviation (Gray's Anatomy 2005)

374 CLI N I CA L A P P LICATION O F N EU R O M U SCU LAR TEC H N IQUES: THE U PPER BODY I n d i cati o n s for treatment also cause unilateral tinnitus or bilateral tinnitus if both sides are involved. Emotional problems that lead to exces­ • Pain in areas indica ted in Figure 12.50 sive jaw clenching can cause major problems in the muscle, • Restricted opening of the mouth which may also be involved in malocclusion. Similarly, the • Tinnitus, unilateral unless both masseters are involved pain and dysfunctions associated with this and other TM • Bruxism joint muscles may contribute to emotional stress. • Repetitive habits, such as gum chewing, nail biting or In subjects presenting with la tent MTrPs in the masseter clenching the teeth muscle, Blanco et al (2006) suggest that postisometric relax­ ation technique is more effective than the strain/ counter­ Spec i a l n otes strain technique in improving active mouth opening. This technique can be easily incorporated in the stretch portion Masseter comprises three layers stacked onto each other. of the steps described below, provided that the articular The deeper stratum of masseter, whose fibers lie vertically, disc is not at risk. is not as large as the more d iagonally oriented superficial portion. Its geographical position can result in disturbance Masseter is involved primarily with chewing, clenching of the temporal bone and TM joint and its sharing of con­ and strong closure of the jaws. Temporalis, on the other siderable nociceptive neurons (Simons et a1 1999) w ith the hand, is responsible for postural positioning and balancing joint may explain i ts high tendency to be involved when TM the jaw. Advice should be given regarding irritant activity joint pain is present. including mouth breathing, chewing gum, bruxing, clench­ ing and grinding the teeth as well as possible dental Marked restriction in opening range is often associated involvement. with trigger points in the muscle. Deep triggers here can Box 1 2. 1 0 Tinnitus: the TMD and trigger point connection Tinnitus Ti nnitus involves a perception of sound without an actual external 60 acoustic sti m u l us. I t is considered a symptom and not the d isease/cond ition itself. The sound is usually high pitched but can be 50 of a ny pitch or type, continuous or i n termi ttent. Tinnitus is relatively common with a pproximately one in five people reporting they are � 40 occasionally affected. Around one i n 200 people have tinn itus so badly that it affects the abil ity to lead a normal life. �.� 30 There are many different disorders that can produce such symptoms, ' 20 including dysfunction affecting the temporomandibular joint. 10 £-�':; TMD and tinnitus In a study involving 1002 chronic tinn itus sufferers, earlier research o concluded that temporomandibular joint dysfunction is a likely causal feature i n those tinnitus patients where no other cause can Disrupts sleep be ascertained (Vernon et a l 1 992). Figure 1 2.51 I ncidence of tinnitu s i n temporomandibular (TMD) Parker Et Chole ( 1 995) who have focused their attention a nd grou p com pa red with two control g ro ups. Reprod u ced with research on the l i n k between tinnitus and TMD state: 'Our research perm ission from Parker Et Chole ( 1 995). verifies the relationshi p between TM D and tinn itus, ota lgia, and vertigo. The cause of the symptoms of tinn itus and vertigo in temporalis) in 34 consecutive tinnitus patients, and, coupled with a patients with TMD is unknown. The otalgia may possibly be patient questionnaire, came to the fol lowing conclusions. explained by the proximity of the temporomandibularjoint and the structures of the ear: They found trigger points to be present i n 24 patients (70.59%) in at least one muscle (usually trapezius, deep masseter, infraspinatus What is also clear, they maintain, is that: 'There is l ittle or no l i n k and sternocleidomastoid). Among them, 1 3 patients reported tinnitus between tinnitus and high blood pressure, which can be relegated to modulation at least once, this represented by tinnitus increasing in the role of a \"popular u rban myth\": n i ne patients, decreasing i n two patients, and by a variable response (increase a nd/or decrease) in two patients. They concluded: 'Trigger Pa rker Et Chole point out that hypertension was not found to be poi nts a re surprisingly common i n tinnitus patients and evoke a high more frequent i n the TM D group. This finding was i n agreement with rate of tinnitus modulation when pressured. Thus, their presence in that of Weiss ( 1 972) who found no relation between systolic or tinnitus patients should be more investigated as a possible etiologic diastolic pressure and tinnitus i n a sample of 6672 adults. Chatellier factor, especia l ly when they induce tinnitus mod u lation: et a l ( 1 9B2) found no correlation between blood pressure levels and tinnitus in 1 771 u ntreated hypertensive patients. Trigger points and tinnitus Sanchez Et Bezerra (2003) assessed n i n e m uscles (i nfraspinatus, levator sca pulae, trapezius, splenius capitis, scalenus 'medius, sternocleidomastoid, digastric, deep masseter and anterior

12 The cranium 375 NMT FOR I N TRAORAL MASSETER above is best applied first, to release muscular restrictions so as to better determine if restriction of range of motion is due The outside su rface of the face is supported with the dor­ to myofascial or osseous (in this case disc) tissue. sum of the external hand. The gloved index finger of the intraoral hand is placed inside the mouth and j ust inferior There is often a profound change in the tension of mas­ to the zygomatic arch with the pad of the finger facing seter when a thorough (not aggressive) treatment has been toward the cheek. Gliding strokes are applied from the applied. The patient will usually note an appreciable differ­ zygomatic arch to the lower edge of the mandible while ence when comparing the side that has been treated with compressing the masseter and buccinator muscles against the other. Both sides are always treated to avoid unbalanc­ the dorsum of the external hand. The strokes are repeated ing the mandible. 8-10 times in strips until the entire masseter has been treated . The external hand's index finger is not allowed to LATERAL PTERYG OID touch the face since it will treat the opposite side intraorally. Attachments: Upper head arises from the infratemporal crest With the finger still in place, the patient is asked to clench and lateral surface of the greater wing of sphenoid to the teeth to contract the masseter 's deep portion and then to insert onto the pterygoid fovea (on neck of mandible) relax the jaw. It may be necessary to have the patient shift and to the articular disc and capsule; lower head arises the mandible toward the side being treated to allow room from lateral surface of lateral pterygoid plate to attach to for the treatment finger. the neck of the mandible Static pincer compression which ma tches the tension Innervation: La teral p terygoid nerve from mandibular found in the tissues is applied at finger-width intervals branch of trigeminal (cranial nerve V) beginning just caudal to the zygomatic arch and working down the muscle as far as possible, one fingertip at a time Muscle type: Not established (Fig. 12.52) . Pressure may be applied against an external fin­ Function: Moves the condyle and disc complex as a unit; ger of the opposite hand (except the index 'treating' finger) or between the external thumb and internal finger of the active during opening and closure of the jaw, protrusion same hand. While most tissues respond to compression of the mandible and contralateral deviation within 8-12 seconds, masseter may release quickly or may Synergists: Opening: suprahyoid muscles require a longer compression of 15-20 seconds or more. Closure: masseter, temporalis, medial pterygoid Protrusion: superficial masseter, anterior temporalis, Stretch of the muscle is achieved by a sustained but not medial p terygoid forceful forward and downward pull, taking out all available Contralateral deviation: ipsilateral medial pterygoid, con­ slack and then holding to allow a 'creeping' release to evolve. tralateral masseter and contralateral temporalis Care must be taken to avoid the use of force when opening Antagonists: To opening: masseter, temporalis, medial the mouth as the articular disc might be dysfunctional and pterygoid could be damaged with force. Manual treatment as listed To closure: suprahyoids To protrusion: portions of temporalis, deep masseter To deviation: contralateral medial and lateral p terygoids and ipsilateral masseter and temporalis I I n d i cations fo r treatment \\ • Pain or clicking in TM joint • Occlusal disharmony, premature contact ---­ • Maxillary sinus pain, excessive secretion or s inusitis • Tinnitus Figure 1 2.52 Compression is appl ied to the masseter in fi nger- • Bruxism width i nterva ls down t h e muscl e's belly a n d a lso along t h e inferior • Repetitive habits, such as gum chewing, nail biting or su rface of the zygomatic a rch. clenching the teeth • Lateral deviation patterns when opening or closing the jaw Specia l notes The mandibular attachments of the upper (superior) head of lateral pterygoid (SLP) and the lower head (ILP) remain controversial although there is full agreement on their cra­ nial attachment to the pterygoid plate and sphenoid bone

3 7 6 CLI N I CA L A P P L I CATI O N O F N EU R O M USCULA R T E CH N I Q U E S : T H E U PP E R B O DY Infratemporal crest Upper head of lateral pterygoid ;--- Articular disc Lower head Capsule lateral pterygoid ---.� '-- Sphenomandibular ligament -..1. --- ---- Deep head Superficial head medial pterygoid --------..�. �. .... medial pterygoid F i g u re 1 2 .53 The superficia l fibers of medial pterygoid may be treated w h e n the l a teral pterygoid procedure is being performed, and may be at least part of the source of freque n t tenderness i n t h is region. Reprodu ced with permissio n from Gray's Anatomy for Students (2005). (Gray's Anatomy 2005, Simons et al 1999) . There is general • Simons et al (1999) report a review by Klineberg (1991) of agreement that both heads attach to the neck of the condyle s tudies examining the attachments. The results imply but disagreement as to the amount of attachment of the that, 'The traction that is applied by the superior ptery­ upper head to the disc and condyle. This portion of the con­ goid (superior division) during mouth closure affects the troversy becomes clearer when we consider cadaver studies condyle and disk complex as a Lmit and does not affect that have found a wide variation regarding lateral p tery­ the disk selectively'. goid (LP) attachments. Once such study was reported by Naidoo (1 996), which describes 65% of specimens having • Abe et al (1997) report: 'The lateral p terygoid muscle the upper head attached to the capsule, meniscus and condyle, 27.5% attaching solely to the condyle and the fibers attach to the articular disk at the inner point of the remaining 7.5% having other types of attachment to the medial pole. Based on this finding, we can say that the meniscus, confirming that 'lateral pterygoid has a variable muscle fibers can both draw the articular disk anteriorly attachment to the meniscus'. and balance it by supporting it posteriorly. That is to say, the lateral pterygoid muscle has two actions: to elevate Kertesz et al (2003) draw attention to the fact that the lat­ the articular disk anteriorly and to support the articular eral pterygoid muscle is different from that reported in pre­ disk.' They further describe that the sphenomandibular vious literature with significant variations in arrangement ligament is continual with the articular disc tissue medi­ and insertion. They point to an important finding that has ally, suggesting that these fibers draw the disc posteri­ clinical relevance. 'The degree of muscle insertion into the orly during closure, thus enabling the articular disc to disc capsule complex was not a predictor of anteromedial move smoothly. disc displacement.' • G ray's Anatomy (2005) points out that contralateral excur­ sion (as when grinding food) may (arguably) be the most The actions of the lateral pterygoid are also confusing important function of this muscle. In regards to pulling when one compares various articles and texts; particularly on the articular disk, G ray's states: ' . . . electromyography if older texts are involved. Given the wide variations of studies have proven that the upper head is inactive during anatomy, this is not surprising. Here are a few of opinions. jaw opening and most active when the jaws are clenched .

1 2 The cranium 377 An explanation for the surprising activity is as follows in this regipn. . . . Considering the lack of validity and reli­ (Osborn 1995). Most of the power of a clenching force is ability associated with the palpation of the lateral ptery­ due to contractions of masseter and temporalis. The asso­ goid area, this diagnostic procedure should be discarded.' ciated backward pull of temporalis is greater than the • Stelzeruniiller et al (2006) using MRI evidence counter associated forward pull of (superficial) masseter, and so and 'reliably confirmed the palpation of the lateral ptery­ their combined jaw closing action potentially pulls the goid muscle, which was controlled by two imaging pro­ condyle backward. This is prevented by the simultane­ cedures. All three of the procedures confirmed palpation. ous contraction of the upper head of lateral pterygoid.' The difficulty in reliably identifying the muscle seems to • Simons et al (1999) report that reciprocal activity of the be due to the fact that the medial pterygoid muscle must two heads as antagonists during vertical and horizontal be passed before palpating the lateral pterygoid muscle.' mandibular movements may be indica ted but la ter state: • The authors of this text suggest that in clinical practice it 'Since it is now generally agreed that there is not always is doubtful that the practitioner will know which muscle a separate attachment of the superior division to the disc, tissue is being palpated. If medial pterygoid fibers are it is now thought that both divisions of the muscle affect present, they will likely be treated by this process and, the condyle and disc complex as a unit. Any tendency to even in those people, a portion of lateral pterygoid might reciprocal activity [of the two heads to each other] would be reached, depending upon the muscle's arrangement most likely reflect mechanical advantage by one or the and perhaps influenced by the size of the practitioner 's other division because of the difference in angulation of finger. What we have found clinically is that this region is their fibers.' tender in most people (which is diagnostic of something) and that treatment of this region offers relief for many in The authors of this text suggest that the lateral pterygoids the treatment of TMJ dysfunction. We suggest that the (collectively) are involved in all movements of the mandible treatment of this 'lateral pterygoid region' remain a viable except retraction; the degree to which it is involved in each part of the protocol even though one may not know pre­ action very likely depends upon the particular architecture cisely which fibers of which muscles are benefiting. of the muscle in that individual. Even the name of the muscle can be confusing since there Under considerable debate regarding manual techniques are various terms to i dentify the two heads of the lateral is the controversy as to whether the lateral pterygoid can pterygoid or to distinguish lateral and medial pterygoid, even be palpated. Opinions are diverse, despite cadaver which are sometimes called the external and internal ptery­ and MRI evidence. goids, respectively (particularly in older texts). In this text, the terms found in Gray's Anatomy (2005) have been used, that • Stratmann et al (2000) studied 53 fresh and unfixed cadav­ being lateral and medial pterygoid muscles and, regarding ers to determine if the lateral pterygoid was palpable by lateral pterygoid, the two portions being called upper and first palpating and rendering an opinion, then palpating lower heads, except where quoted from other texts. a second time and observing through the dissected infratemporal fossa to see whether the examiner's finger TMJ dysfunction often involves lateral pterygoid, which, did or did not touch the inferior head of the LP muscle. due to its attachmen t sites, may also influence more wide­ They note tha t in 86 of 106 dissected specimens, a super­ spread cranial dysfunction, most notably of the sphenoid. ficial portion of the medial pterygoid muscle was found Travell & Simons (1983) state: 'The external (lateral) ptery­ superficial to the rLP muscle and, in the 20 remain.ing goid muscle is frequently the key to understanding and specimens with an absent superficial fascicle, the finger managing TMJ dysfunction syndrome and related cran­ was able to reach the ILP muscle in 10 specimens. They iomandibular disorders.' concluded: 'It is recommended that the rLP muscle pal­ pation technique should no longer be considered as a Upledger & Vredevoogd ( 1 983) report that, 'It [lateral standard clinical procedure because it is nearly impossi­ pterygoid] is a frequent cause of recurrent craniosacral and ble to palpate the ILP muscle anatomically and because temporomandibular joint problems'. Along with other key the risk of false-positive findings (by palpation of the muscles of the region, assessment and (if needed) therapeu­ medial pterygoid muscle) is high.' See Figure 12.53 for a tic attention to the lateral pterygoid is an absolute prerequi­ view of the superficial fibers of medial pterygoid as illus­ site of craniosacral therapy. trated in Gray's Anatomy (2005). Referred trigger point pain from this muscle focuses into • Turp & Minagi (2001 ) also question the evidence that it is the TMJ area and the maxilla. Because dysfunction of the actually lateral pterygoid that is being palpated when the upper head of lateral pterygoid may directly impact TM finger is in the position described in the intraoral treat­ joint disc status (leading to clicking and possible condylar ment below. They cite four studies that show 'the lateral and/ or disc displacement) it is important to treat associated pterygoid muscle is practically inaccessible for intraoral trigger points in this muscle as well as those in other mus­ palpation due to topographical and anatomical reasons. cles which include this area in their target zone of referral. Other anatomical structures, such as the superficial head of the medial pterygoid muscle, may be palpated instead Intraoral palpation requires great sensitivity as this region is often extremely tender. The intraoral technique described

3 7 8 CLI N I C A L A P PLICAT I O N O F N E U R O M U SCU LAR T E C H N I Q U E S : T H E U P P E R B O DY \\ \\ Figu re 1 2. 54 A portion of lateral pterygoid may be treated i n te rn a l ly w i t h the i ndex finger o r smallest digit (shown here) if the index fi nger is too l a rge. The mandible is sh ifted i psi latera l l y to create more roo m . Trigger point referred pattern d ra w n after Simons et al ( 1 999). Figure 1 2. 5 5 Finger position for intraora l access to lateral pterygoid. the lower head may possibly be influenced from an external perspective (Simons et aI 1999), discussed on p, 369. below most likely reaches only the anterior ·aspect of the lower head and likely the superficial fibers of medial ptery­ It NMT FOR I NTRAORAL LATERAL PTERYG OID goid when they are present. The posterior aspect of the upper head of lateral pterygoid and the posterior portion of The practitioner will reach across the face to trea t the con­ tralateral side. The patient's mouth is open and the jaw deviated toward the side being evaluated to allow room for the treating finger to be placed between the maxilla and coronoid process, The finger nail rests against the cheek while the finger pad rests against the maxilla. A gloved index finger (pad facing medially) is slid on the maxilla above the gingival margin as far posteriorly as possi­ ble. Pressure is applied medially (toward the lateral pterygoid plate). If the tissue is not tender, the finger is moved slightly caudally and again pressed toward the mid-line, The finger may sometimes be moved another fingertip caudally and sometimes may be slid 'under ' the muscle(s) slightly to reach a small portion of the caudal aspect. At each location, mild pressure is used until the tissue tenderness is evaluated and pressure is increased only if appropriate to do so (Fig. 12.55). If the treating finger continues medially, the medial pterygoid would be encountered, as would the sharp ptery­ goid hamulus. Pressure on the hamulus is to be avoided during this and all other intraoral palpation as the delicate overlying tissues may be damaged by ind iscriminate or excessive pressure.

1 2 The cranium 379 ---\"(-�\\p�-=;o�-I�\\\\V I :' i) Figure 1 2.56 The fi nger is pl aced medial to the teeth to access / medial pterygoid w h i le lateral pterygoid is reached with the fi nger placed lateral to the teeth. It is important to note that when the finger is placed cor­ --./- \\ ,\\ rectly with the pad facing the maxilla, the lateral pterygoid region is being treated; however, if the finger is turned so that --- the pad faces the cheek and presses against the coronoid process, the temporalis tendon is addressed. It is important to F i g u re 1 2.57 Pal pation of mid-belly of medial pterygoid. Trigger differentiate and localize the tenderness the patient reports. point referred pattern d rawn after Simons et al (1999). MEDIAL PTERYG OID I n d ications fo r treatment Attachments: The palatine bone and the medial surface of • Pain in TM joint, especially if increased by chewing, the lateral pterygoid plate of the sphenoid bone to the clenching the teeth or opening of mou th pterygoid tuberosity on the posteroinferior part of the medial surface of the mandibular ramus and angle; a • Sore throat smaller head sometimes arises from the maxillary tuberos­ • Painful swallowing ity and palatine bone (Gray's Anatomy 2005) (la teral • Restricted range of mandibular opening pterygoid plate, according to Platzer 2004) to attach with the deeper head, which allows it to course superficial to Speci a l notes the lateral pterygoid Medial pterygoid's position on the medial aspect of the Innervation: Medial pterygoid branch of the mandibular mandible mirrors the position of the masseter, which lies division of trigeminal (cranial nerve V) lateral to it and they form a mandibular sling for powerful elevation of the mandible. A hypertonic medial pterygoid Muscle type: Not established can interfere with sphenoid function, with the maxilla and Function: Elevates mandible; some influence in protraction, with normal motion of the palatines. It is commonly involved in TM joint problems. contralateral deviation and rotation about a vertical axis (Gray's Anatomy 2005) Observation of opening and closing of the mouth will Synergists: For elevation: bilateral temporalis and masseter, usually demonstrate contrala teral deviation when medial contralateral medial pterygoid For protrusion of mandible: lateral pterygoid For contralateral deviation: same side lateral pterygoid Antagonists: To elevation: digastric and lateral pterygoid To contralateral deviation: contralateral medial and lateral p terygoids

380 CLI N ICA L APPLICATI O N O F N EU RO M USCULA R TECH N I QUES: T H E U P P E R BODY Fig u re 1 2.58 B i l a tera l compression of medial pterygoid m u scl es. patients. They conclude with emphasis that the tensor veli Reproduced with permission from La u g h l i n (2002). palatini muscle and the pterygoid hamulus should be kept intact when performing veloplasty and that it should be pterygoid is hypertonic (usually in association with the lat­ kept in mind that the medial pterygoid muscle is not only a eral p terygoid). Trigger points in this muscle involve swal­ masticatory, but also a 'Eustachian tube muscle'. lowing difficulties, sore throat and restriction in ability to fully open the jaw, as well as TM joint pain. It N MT FOR I NTRAORAL MED IAL PTERYG OID The course of the superficial fibers (when present) may These steps are best done on the same side on which the interfere with palpa tion of lateral p terygoid. Trus detail has practitioner is standing. The gag reflex is easily activated in produced considerable controversy, particularly in the field this region and may be temporarily inh.ibited by having the of dentistry, the main points of which are discussed below person exhale or inhale fully and hold the breath. Trus can with lateral pterygoid. be further inhibited by the patient forcing the tip of the tongue laterally and posteriorly, which is away from the When medial pterygoid contracts, this increases the force palpated side, as strongly as possible during the palpation. of tensor veli palatini on the distal part of the auditory tube (see below); relaxation of medial pterygoid decreases it. The index finger of the treating hand is placed between the Hence, medial pterygoid moderates the opening pressure of upper and lower molars, medial to the teeth, and moved pos­ the auditory tube. Leuwer et al (2002) suggest: 'The influence teriorly until it contacts the most anterior edge of the medial of the medial pterygoid muscle on the opening pressure of pterygoid muscle, wruch is posterior and medial to the last the auditory tube may have an impact on the d iagnosis and molar. Static pressure or short gliding strokes may be applied therapy in patients with pa tent auditory tube as well as the onto the belly of the medial pterygoid (Fig. 12.56) . Extreme middle ear pathology in patients with cleft palate.' tenderness is likely if there is an active trigger in the muscle so pressure should be mild until tenderness is assessed. The auditory (Eustacruan) tube's function is complex, including taking care of ventilation, drainage, and protection The finger may be carefully slid up to the medial ptery­ of middle ear. Therefore, the tension applied by both tensor goid's attachment on the medial pterygoid plate and the veli palatini and medial pterygoid may influence the mouth palatine bone as long as the hamulus is avoided due to its of the auditory tube, and thereby have some bearing on the sharp tip and the overlying delicate tissues. Pressure on the development of chronic middle ear pathology. Sehhati­ palatine bones is also to be avoided . The palatoglossus and Chafai-Leuwer et al (2006), in their d iscussion of pathophys­ palatopharyngeus muscles may be treated at the same time. iology of the E ustachian tube in cleft palate, suggest that integrity of the pterygoid hamulus and of the tensor veli The treating finger glides caudally as far as possible wrule attempting to reach the inferior attachment on the inside sur­ palatini muscle impact the condition of persistent chronic face of the ramus of the mandible (Fig. 12.57). If gliding down the medial pterygoid causes too much discomfort or a gag middle ear d isease and that the medial pterygoid also play reflex is provoked, the lower angle may be reached by glid­ an important role in Eustachian tube function in non-cleft ing the index finger along the inside surface of the mandible until the internal surface of the lower angle is reached. Static pressure or gentle friction may be applied if appropriate. MUSCULATURE OF THE SOFT PALATE (FIGS 1 2. 5 9 , 12.60) The soft palate is a mobile muscular flap that hangs down from the hard pa late with its posterior border free and, when elevated, closes the passageway between the nasopharynx and the oropharynx, thereby preventing food from entering the nasal cavity. The uvula hangs from the posterior border and, when relaxed, rests on the root of the tongue. The ele­ vated uvula aids the tensor and levator veli palatini muscles in sealing off the nasopharynx. Nearby are the palatine ton­ sils and the sharp hamulus, around wruch the tensor veli palatini turns to radiate horizontally into the palatine aponeurosis. The palatine musculature includes levator and tensor veli palatini, palatoglossus, palatopharyngeus and musculus uvula. Innervation to the soft palate musculature includes the trigeminal, glossopharyngeal and the cranial part of the

1 2 The cranium 3 8 1 accessory nerve via the pharyngeal plexus (Gray's Anatomy aponeurosis. This muscle, in conjunction with tensor veli 2005) . These muscles are involved in swallowing and speech. palatini and musculus uvulae, pulls the soft palate upward Palatoglossus is discussed with the tongue and palatopha­ and backward. It 'has little or no effect on the pharyngo­ ryngeus is considered with degluti tion later in this section. tympanic tube, although it might allow passive opening' (Gray's Anatomy 2005). Levator veli palatini is a cylindrical muscle which courses from the petrous portion of the temporal bone, the carotid Tensor veli palatini is a thin, triangular muscle that sheath and the inferior aspect of the cartilaginous part of the attaches to the root of the pterygoid process, the spine of the auditory tube to blend into the soft palate and palatine sphenoid bone and the membranous wall of the pharyngo­ tympanic (auditory) tube. It wraps arow1d the hamulus Levatorveli palatini (LVP) (which appears to act as a pulley) before attaching to the Tensor veli palatini (LVP) palatine aponeurosis, which it elevates during swallowing Upward and backward when bilaterally contracting or, with unilateral contraction, pull of LVP pulls the soft palate to one side. Its primary role, however, appears to be to open the entrance to the auditory tube (Abe :;\"IP-- Horizontal pull from TVP et al 2004) to equalize air pressure during swallowing or yawning (Gray's Anatomy 2005). Hypertonicity of this mus­ Pterygoid hamulus cle has important clinical meaning as the auditory tube, .-I�- Upward pull of PG when open, may provide an easy passageway for ororespi­ ratory tract infections to reach the middle ear (Clemente _-- Palatoglossus (PG) 1987). Contraction and relaxation of medial pterygoid may --- Palatopharyngeus (PPG) considerably influence this muscle's action on the auditory Elevation of pharynx by PPG tube opening (Leuwer et al 2002). 'f--fiHtI Entrance into the larynx Ear infection in young children, and its relationship with tensor veli palatini hypertonicity and trigger points, is an Fig u re 1 2.59 The soft pa l a te m uscles from a n a n terior view. D ra w n area deserving of clinical research. Since these infections after Leonhardt ( 1 986). readily (and most often) occur in young children who are in a chronic sucking stage (thumbs, fingers, pacifiers, toys, nipple of the bottle or breast), the association of the tensor veE palatini seems obvious and deserves consideration. Kappler & Ramey (1997), however, suggest that 'Eustachian tube dysfunction is the most common cause of otitis media' and that this can be the result of fixation of the temporal bone (see discussion of temporal bone earlier in this chapter as well as previous discussion of auditory tube with medial pterygoi d ) . Tongue Lateral �-- Medial pterygoid plate F i g u re 1 2.60 The soft pa la te pterygoid plate .-- Muscular part of tensor veli palatini m uscles from a posterior view. Reproduced with permission from '-- Cartilaginous part of pharyngotympanic tube Gray's Anatomy for Students (2005). --I--I Levator veli palatini .i-- Superior constrictor of pharynx ,.:;..- Musculus uvulae from underside of aponeurosis Palatine tonsil .,;.-:.'\\\" Palatopharyngeus

382 C LI N I CA L A P P L I CATI O N O F N E U RO M U SCU LAR TECH N I Q U E S : T H E U P P E R B O DY F i g u re 1 2.61 The soft palate m uscu lature is carefu l ly addressed to and have the primary task of changing the shape of the avoid the palatine bones, the sharp h a mulus and the gag reflex main body of the tongue (Leonhardt 1986). The tongue mechanisms. muscles are inen rvated by the hypoglossal nerve (cranial nerve XlI). The paired uvulae muscles a ttach the uv ula to the hard palate and soft palate. They radiate into the uvular mucosa, Extrinsic muscles of the tongue include the following. elevating and retracting to seal off the nasopharynx. The uvula may contain trigger points that induce hiccups (Simons • Hyoglossus attaches the side of the tongue to the hyoid et al 1999, Travell 1977). bone below by vertical fibers that serve to depress the tongue (as in saying aahh). I N MT FOR SOFT PALATE (FIG. 12.61) • Genioglossus courses from the geniotubercle (cephalad The patient tilts the head into extension and breathes through from geniohyoid) fanning posteriorly and upwardly to the mouth slowly or holds the breath on full inhalation or attach to the hyoid bone, blend with the middle pharyn­ exhalation to inhibit the gag reflex. A confident but not geal constrictor, attach to the hyoglossal membrane and aggressive pressure is used to avoid a tickling sensation, the whole length of the ventral surface of the tongue which might cause gagging. Tapping on the temples for from root to apex and intermingle with intrinsic lingual about 10 seconds immediately prior to touching the muscle muscles. It tractions the tongue forward to protrude its may also suppress gagging. tip from the mouth. The index finger of the practitioner's treating hand is • Styloglossus anchors the tongue to the styloid process placed just lateral to the mid-line of the hard palate and near its tip and to the styloid end of the stylomandibular glides posteriorly on the hard palate until it reaches the soft ligament. Its fibers divide into a longitudinal portion, palate. No pressure is placed on the pala tine bones or the which merges with the inferior longitudinal muscle, and vomer. The finger is hooked into a 'e' shape as it sinks into an oblique portion, which overlaps and crosses hyoglos­ the soft palate posterior to the pala tine bone and sweeps out sus to decussate with it. It draws the tongue posteriorly to the lateral one-third of the soft palate. A back and forth and upwardly. medial/lateral movement of the finger or static pressure is applied into the lateral third of the soft palate w hile press­ • Chondroglossus ascends from the hyoid bone to merge ing through the superficial tissues of the soft palate and with the intrinsic musculature between the hyoglossus onto the palatini muscles. and genioglossus and assists the hyoglossus in depress­ ing the tongue. MUSCLES OF TH E TON G UE ( F IG. 12.62) • Palatoglossus extends from the soft pala te to the side of Extrinsic tongue muscles arise from outside the tongue to the tongue and the dorsal surface and in termingles with act upon it, while intrinsic muscles arise wholly within it the transverse lingual muscle. It elevates the root of the tongue while approximating the pala toglossal arch, thus closing the oral cavity from the oropharynx. Intrinsic muscles of the tongue include the following. • Superior longitudinal bilaterally extends from submucous tissue near the epiglottis and from the median lingual septum to the lingual margins and apex of the tongue. It shortens the tongue and turns the tip and sides upward to make the dorsum concave. • Inferior longitudinal extends from the lingual root and the hyoid bone to the tip of the tongue, blending with sty­ loglossus. It shortens the tongue and turns the tip and sides downward to make the dorsum convex. • Transverse lingual ex tends from the median fibrous sep­ tum to the submucous fibrous tissue at the tongue's lin­ gual margin. It narrows and elongates the tongue. • Vertical Lingual ex tends from the dorsal to the ventral aspects in the borders of the anterior tongue. It makes the tongue flatter and wider. The tongue muscles can act alone or in pairs and in endless combination. They provide the tongue with precise move­ ments and tremendous mobility, which impacts not only the acts of chewing and swallowing but also speech. Though trigger point location and referral patterns are not yet

1 2 The cra n i u m 383 Pterygoid hamulus --'*0'-. �-- Tensor veli palatini �-- Levator veli palatini Buccinator --:=,-1 __-_ - Rectus capitis Superior constrictor ---'t lateralis i1\"F�IiiI ��'..Pterygoma n dibular rapl1e -----------=-\" -#'''--.- .--.-= .'.: --- -'-'- /�-'+-- Superior oblique Styloglossus '+I-\"7'rfIFi:�S Stylohyoid ligament Stylopharyngeus --:\"-.Wft _1IfT'i-- Transverse process of atlas !(,tI,!--=¥ lnferior oblique Genioglossus --.;-:t+' Hyoglossus ,W--rfH�. Anterior intertransverse �--- Vertebral artery Geniohyoid ---' Thyrohyoid membrane ---1la«:= --- Transverse process of axis --- Middle constrictor --- Stylohyoid Inferior constrictor ----- -------Cricothyroid- --.-'\" .:. :-:- �wt1tt'11fh - Figure 1 2.62 M uscles of the styloid process, tongue and soft pa late. Reproduced with perm ission from Gray's Anatomy (2005). established for these muscles, one author aD) has observed f N M T F OR M U SCLES O F TH E TON G U E trigger points in several of these muscles, most notably the most caudal, most posterior lateral aspect of the tongue, in These muscles are most easily addressed b y reaching across regard to chronic sore throat and the immediate relief of the the body to the opposite side of the tongue. The practi­ condition with application of static pressure and gliding tioner's gloved index finger is placed on the lateral surface strokes as described below. of the tongue as far posteriorly as possible. The finger curls into a 'C' shape as it is slid forward the full length of the Myofascial tissues are known to produce trigger points tongue. The curling action of the finger sinks it into the side and trigger points are known to produce pa tterns of referral of the tongue and penetrates the musculature more effec­ as well as dysfW1ctions in coordinated movement of tively than does sliding a straight finger (Fig. 12.63). the muscles in which they are housed. It seems reasonable to assume that the tongue muscles might also contain trig­ The gliding, curling movement is repeated 6-8 times. The ger points and that they might produce pain in surrounding finger is moved caudally at fingertip widths and the process tissues, as well as being involved in dysfunctional repeated as far caudally as possible. Special attention responses which interfere with swallowing or with normal should be given to the most caudal, most posterolateral speech patterns. The tongue should be examined and, if aspect of the tongue, where the long gliding strokes previ­ necessary, treated, in these conditions as well as in those ously applied may become shorter and more precisely involving voice dysfunction, elevated hyoid bone or sore applied or static pressure may be used. throa t .

3 84 CLI N I CA L A P P L I CATI O N O F N E U RO M U S C U LA R TEC H N I Q U E S : T H E U PP E R B O DY Figu re 1 2.63 The treating fi nger is c u rled as it is d ragged forward SUPRAHYOID M U SCLES - THE F LOOR O F to penetrate the tong ue m uscles. THE MOUTH / The suprahyoid group form the floor of the mouth and I serve to position the hyoid bone and, when the hyoid bone is fixed by the infrahyoids, depress the mandible. The stylo­ \\ hyoid has been discussed previously with palpation of the external cranial muscles (p. 371). The remaining suprahy­ --- oids, which include digastric, mylohyoid and geniohyoid, are presented here and should be addressed with the treat­ Figure 1 2.64 Tongue m uscles may be gently stretched by p u l l i n g ment of the anterior neck, temporomandibular joint and the t h e to n g u e forw a rd. muscles of the tongue. They are innervated by the trigemi­ nal and hypoglossal nerves. The tongue may also be gently pulled forward and the muscles stretched by grasping it firmly through a clean • Geniohyoid extends from the hyoid bone to the symphysis cloth (Fig. 12.64). This stretch can be held for 30-60 seconds menti on the inner surface of the mid-portion of the and the direction of tension changed by pulling the tongue mandible where it serves to elevate the hyoid bone and to one side or the other. draw it forward and to depress the mandible when the hyoid is fixed. Since these muscles are readily treated by the patient, self-care can be applied at home when indicated. Tongue • Mylohyoid extends from the whole length of the mylohy­ stretching, as described, may usefully be combined with oid line of the inner mandible to the front of the body of spray and stretch methods (applied to the anterior neck) as the hyoid bone. Its anterior and middle fibers decussate described by Simons et al (1999) for the suprahyoids. in a fibrous raphe, which extends through the mid-line from the hyoid bone to the symphysis menti, allowing this muscle to form the floor of the mouth. It elevates the floor of the mouth as well as the hyoid bone and depresses the mandible when the hyoid is fixed. • Digastric has two bellies joined by a central tendon. The posterior belly arises from the mastoid notch of the tem­ poral bone while the anterior belly attaches to the digas­ tric fossa of the mandible (near symphysis). They are joined together by a common tendon that passes through a fibrous sling that is attached to the hyoid bone and is sometimes lined by a synovial sheath. The tendon perfo­ rates stylohyoid. The fibers of stylohyoid and the poste­ rior fibers of digastric are difficult to distinguish by palpation alone (Simons et al 1999). Digastric depresses the mandible (secondary to lateral pterygoid), elevates the hyoid bone and, together with geniohyoid, can assist retraction of the mandible. When digastric is hypertonic it places a load onto the contralateral temporalis and masseter which attempt to balance the deviation which a taut digastric may produce. The suprahyoid muscles usually function as a paired team in the movements described. Since the position of the hyoid bone is important to the maintenance of a clear air passage­ way, of consistent dimension, as well as a food passageway, its freedom of movement is critical in swallowing, normal breathing patterns and speech. When habitual mouth breathing is noted, these muscles, as well as any tendency to a forward head position, should be addressed, along with the causes of the mouth breathing (allergies, deviated sep­ tum, sinus infections, etc.). The upper abdominal area as well as the diaphragm should be evaluated (and treated if necessary) as well as the intercostals (see respiratory sec­ tion, p. 570).