Learning with laughter

If you have a TM Joint problem this is a step by step protocol to manage your symptoms

February 25th, 2013

Please refer to newsletter index to find this blog : November 09th, 2011 “Do you know why poor posture can affect the jaw?’

1.First stand with your back against the wall to do Rocabado exercises below.

Standing Position: Distribute your weight evenly through both feet between your big toe, smallest toe and the heel. (Think about having your ears over shoulders, over hips, over knees, over ankles, chest lifted and arms relaxed at your side). If your head does not touch the wall place a small towel roll behind your head.

Breathing – What is good breathing? The cornerstone of managing TMD is to practice deep diaphragmatic breathing frequently. Practice TTTT… tongue on palate, teeth apart, lips together, shoulders ‘high beaming’ everyone and stand on the balls of your feet. I have a naughty rhyme to remember this “Tongue, teeth, tits and toes lips together breathing slow!” NOTE: The tongue tip should always be up on the palate even when standing and sitting. Say the letter “n” to know if your tongue is in the right place

Action: EXHALE first and Inhale pushing down through feet, feel the lengthening of your spine, zipping up the abdominals and “Roll tongue as far back on roof of mouth”

Reason: This helps stretch the deep frontal line of fascia. The deep front line plays a major role in unlocking your overall ability to move properly. The diaphragm is a large component of the deep front line and should not be overlooked.  On the internet is a picture from Tom Meyers Anatomy Trains -Deep frontal line. Note the tongue is connected by one piece of fascia to top of your toes.

Deep Frontal Line from Tom Meyers Anatomy Trains -Cadaver view


2. Alternate Nostril Breathing  See my March 26th, 2010 blog on “Sabers approach to TMD”

(Note: 50-70% patients visiting specialists are habitual over breathers. Normal rate of breathing is 1–12 breaths a minute)

Rocabado 6 x 6 Exercise Program
The activities are as follows:
1) Rest position of the tongue (tip should be on roof of mouth)
a) Make a clucking sound with the tongue x 6
b) Find normal resting position = holding one third of tongue gently against the roof of the mouth just behind the front teeth
c) Diaphragmatically breathe through nose while tongue is in resting position x 6 breaths
2) Control TMJ Rotation on Opening – tongue on roof of mouth and open x 6 rep
3) Mandibular Rhythmic Stabilization – apply light resistance to opening, closing, and lateral deviation with the jaw in a resting position holding for 6 seconds (this is key when a patient has instability as this assists with visualization/neuromuscular reeducation)
4) Stabilized Head Flexion = upper cervical flexion (nodding) – facilitate upper cervical flexion as most of these patients have forward head posture resulting in upper cervical extension deviation. Nod head x 15 degrees back and forth 6 x reps.
5) Lower Cervical Retraction – chin tuck x 6 second hold
6) Shoulder Girdle Retraction – pull shoulders back and down – hold x 6 seconds

When the TMJ is restricted joint mobilization can be performed in various directions to improve joint play at the temporomandibular joint.

Strengthening/Stabilization Instructions from Health South Outpatient Division Clinical Education Department

1) Isometric Contraction with Jaw in Neutral – Open your jaw to neutral. Place your two thumbs under your mandible (chin) and both your index fingers so that they are touching your bottom teeth. You will then gradually apply resistance to your lower teeth in the directions of lateral deviation, protrusion / retrusion or opening / closing while maintaining the position of your mandible.

2) Isometric Contraction of Supra/Infra-hyoid Muscles – Bring your head forward slightly forward about 15 degrees. With two fingers against your head, bring your head forward into your fingers so that your fingers resist upper cervical flexion. Don’t allow your head to move past 15 degrees.

3) Isometric Cervical Flexion in Forward Trunk Flexion – Sit forward in a chair with your forehead supported by your forearm which is on a table. In this position, bring your head forward about 15 degrees by flexing into your forearm while maintaining your jaw in the resting position.

4) Resisted Lateral Deviation Out of Neutral – From a neutral posture, laterally deviate your jaw away from the involved side until your top and bottom canine teeth match. In this position, use 1-2 fingers to provide resistance for bringing your jaw back to a neutral position. “This helps to stabilize the articular disc on the condylar head by strengthening its lateral ligament attachments”

Stretching/Mobility: Instructions from Health South Outpatient Division Clinical Education Department

1) Functional Jaw Opening – In front of a mirror open and close your mouth to a comfortable distance while attempting to prevent your jaw from deviating out of a neutral position. In order to help with feedback, you can also palpate the condylar head of your TMJ joint and tongue with your index fingers.

“Controlled opening facilitates joint mobility, good circulation to the condylar head, cartilage conditioning, relaxation of the pterygoid muscles, and neuromuscular control of a hypermobile joint”

2) Controlled-ROM Lateral Deviation – In front of a mirror, with your jaw in a resting position, laterally deviate your jaw until the canine tooth on the lower jaw matches the canine tooth of the upper jaw. In order to help with feedback you can also palpate the condylar head with one index finger and the upper canine tooth with another index finger to cue movement limitations.

“Controlled lateral deviation causes distraction of the joint capsule, which can help attain ROM, improve joint mobility and circulation, and control muscular spasm”
3) Lateral Deviation + Functional Opening – In front of a mirror, with jaw in a resting position, laterally deviate your jaw followed by opening of your mouth. This movement causes distraction of the joint capsule.
4) Protrusion ROM – In front of a mirror, with jaw in a resting position, perform protrusion of your mandible by bringing it forward followed by retrusion back to a resting position.

5) Self-stretch into Opening – Open your mouth in midline and provide a mild overpressure to the top and bottom teeth at end-range. “Prolonged stretching may also be recommended to increase opening ROM”

6) Self-distraction Mobilizations – From a sitting and resting position, rotate your head slightly to the opposite side of the involved joint. Palpate the mandibular condyle with 1 finger while the other thumb and fingers from the uninvolved side are placed on the mandible towards the involved side. Distraction is provided by sidebending your wrist inwards (ulnar deviation).


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