AAMT Conference

Gold Coast, May 2006

NEUROSTRUCTURAL INTEGRATION TECHNIQUE

IMPACT OF TMJ ON BODY FUNCTION

Presented by Ron Phelan

NST Practitioner and Instructor
Remedial Massage Therapist

Assessment and treatment guide

for soft tissue therapists:
the NST approach

Copyright Ron Phelan 2006

Table of contents

Introduction

Workshop outcomes

Overview of TMJ
- Physical
- Neurological
- Hormonal

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3
4
4

Muscle testing

NST approach to treatment

- Assessment
- Muscle testing for the TMJ
a) Latissimus Dorsi
b) Iliopsoas
- Treatment
- Post treatment assessment
- Stabilisation
- Referral

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5

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9
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10

References

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TMJ prone procedure diagram

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TMJ supine procedure diagram

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Neurostructural Integration Technique Copyright 2006

International Institute for Applied Health Services Germany
International Centre for the Neurostructural Integration Technique Pty Ltd

Introduction
I M PA C T O F A D YS F U N C T I O N A L T E M P O R O
MANDIBULAR JOINT (TMJ) UPON BODY
FUNCTION
Presented by Ron Phelan, Remedial Therapist, Bowen (NST) Instructor/Practitioner
Temporomandibular Joint (TMJ) disorder is referred to as the hidden imposter because
it mimics the symptoms of many other musculoskeletal problems. Dysfunction of the TMJ
typically affects around 30 percent of the population, with symptoms such as neck pain,
back pain, headaches, migraines, clicking jaw and bruxism being the most common
problems. The TMJ has many functions, involved in chewing, swallowing and talking. To
gain a fuller understanding of the implications of TMJ disorder, its relationship within the
context of a broader system, the Stomatognathic system (SGS) must be considered. The
SGS consists of the cranial, spinal and pelvic structures and is considered a closed loop
feedback network. Hence imbalances in the TMJ locally are reflected not only locally but
also to the pelvis via the dura mater. The imbalances can also be distributed: mechanically
(causing distortions in the cranial area, spinal and pelvic regions resulting in irregular
muscular tensions anywhere in the body), hormonally (by affecting the regulation of the
pituitary gland), and neurologically (through pressure on cranial nerves). In most cases,
TMJ disorder can be effectively treated using NST technique in isolation or in conjunction
with other supportive modalities. These techniques involve a comprehensive assessment
protocol to isolate the source of the problem, followed by NST treatment.

Workshop outcomes:
Understanding of TMJ relationship to the body
Assess the impact of dysfunctional TMJ
Diagnostic protocol for fault isolation
Observe/experience the effect of a NST move.

Neurostructural Integration Technique Copyright 2006

International Institute for Applied Health Services Germany
International Centre for the Neurostructural Integration Technique Pty Ltd

Overview of TMJ
Overview of the TMJ: (An edited and updated version taken from the newsletter,
The straight news) -reproduced with the kind permission of Brendan Stack D.D.S., M.S
There are a number of factors that make the TMJ unique in the whole body, as it has two
joints in one. The two joints, one in front of each ear, are connected by the jawbone.
One joint may influence the function of the other joint. Because they are connected by
the jawbone, this means that you cannot move one joint without moving the other. The
two temporomandibular joints can differ from one side to the other in size, shape, and
function. It is frequently possible to have a problem in one joint but have the symptoms
expressed in the other joint. You could also have pain that starts on one side of the head
and migrates to the other side simply because of the relationship of these joints.
The second factor making this joint unique is that another structure dictates its function.
The other structure is the teeth. The teeth are passive members of the upper and lower
jaws, but they have a specific way they must fit together and interrelate. As far as the brain
is concerned, tooth position has priority over joint position. This means that the TMJ is
forced by the muscles to move so that the teeth will fit together properly. This can
potentially cause misalignment within one or both joint capsules. If that happens, the
muscles are put in a compromising situation, causing them to spasm and resulting in pain.
Many of the problems experienced are a result of muscle spasm, but the cause is not a
muscle problem. The muscles are simply caught between two positions: the tooth position
and the jaw position.
The third factor making this joint unique is that it has an articular disc located between the
condular head of the mandible and the glenoid fossa of the mandible. The disc has a
muscle attached to the front of it that pulls the disc forward as the condyle moves forward
in the glenoid fossa. The disc is also attached in the back by elastic connective tissue that
is much like a rubber band, and pulls the disk back as the condyle moves backward in the
glenoid fossa. In other words, this attachment can stretch and recoil as the jaw opens and
closes. Since the disc is a separate structure and may move independently from the
condyle, it can be displaced and damaged causing many problems.
This disorder is called an internal derangement of the TM joint. Internal derangement
of the TM joint can cause a distressing syndrome of pain, limited jaw movement, clicking,
popping and crepitus in the joint.
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This derangement may be caused by genetic pathological changes in the joint or acquired
pathological changes as a result of trauma. Often, internal derangement of the TMJ is
preceded by myofascial pain dysfunction that can involve severe spasms of the muscles of
the head, neck, shoulder and/or back. A wide range of local symptoms may occur, such
as headache, muscle pain, ear pain, dizziness, stiffness and ringing in the ears. Distally,
because of the connection via the dura mater, the effects of the misalignment can be
observed in pelvic and sacral area as well as causing unresolved sacral, coccyx, lumbar and
thoracic problems.
Neurologically, local effects of TMJ disorder can be experienced by entrapment of the
Vagus, Hypoglossal and Trigeminal nerves. Distally due to muscular imbalances between
the cranium and pelvic region, spinal nerves may become compromised and the individual
may experience many seemingly unrelated symptoms such as digestive, respiratory, urinary
and bowel disorders, etc.
Respiration involves flexion/expansion of the sacral-iliac joint. This movement is likewise
mimicked at the sphenobasilar junction in the cranium. At the centre of the sphenoid bone
lies the Sella Turcica or Turkish Saddle, this houses the pituitary gland. The pituitary
gland requires consistent rhythmical motion at that joint to regulate the glands function.
Irregular movement can cause variations in hormonal output, thus effecting growth,
pancreas function, fertility and more.

Muscle Testing
Reference: NST Update and Expansion Manual 2001, by Michael J. Nixon-Livy
Manual muscle testing was originally developed to evaluate muscle function for the
assessment of insurance claims by Kendall, Kendall and Wadsworth in the late 1940s and
early 1950s. It was a specific diagnostic technique in the broader developing field of
kinesiology, which basically refers to the study of motion of the human body, and
subsequent movement of related muscles, joints and limbs.
The tests were designed to isolate a single muscle or group of muscles, in the most
contracted state, to determine if a manually applied force from the tester could be resisted.

Neurostructural Integration Technique Copyright 2006

International Institute for Applied Health Services Germany
International Centre for the Neurostructural Integration Technique Pty Ltd

The test itself is not intended as an absolute measure of strength (which relates to muscle
size), but rather a dynamic test of the muscles neurological integrity, or ability to lock.
Therefore, a strong muscle will quickly and firmly resist an increasing test pressure, while a
weak muscle will be slow to respond, feel indecisive and mushy, or may even give way
altogether. This is called unlocking.
Generally speaking a strong muscle (locking) will reflect a positive state, while a weak
muscle (unlocking) will reflect a negative state, of the subject being tested.
Muscle testing has evolved and developed over the decades to the extent, that these days it
is used as a very accurate diagnostic methodology for evaluating not only for neurological
integrity of the muscles, but emotional states, nutritional imbalance, allergies, postural
disorders, physiological dysfunction and more.

NST approach to TMJ treatment

1)
2)
3)
4)

Assessment
Treatment
Stabilisation
Referral

Assessment
TMJ integrity can be assessed by: Symptomatic Headaches, neck pain, balance problems,
recurring back pain, tinnitus, etc
Observation Clicking and/or joint deviation on opening and closing the jaw.
Palpation - Temporalis, Lateral Pterygoid, Masseter, Sternocleidomastoid, Trapezius TMJs
Muscle testing typically Latissimus Dorsi and Iliopsoas.

Muscle Testing for the TMJ

TMJ integrity is quite easily and simply tested using appropriate muscle. Typically
latissimus dorsi or Iliopsoas muscle tests provide concise testing results for both pre and
post test assessments.
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Latissimus Dorsi: Shoulder

Because of the connections of latissimus dorsi to the iliac crest, thoracic, lumbar and
sacrum, this muscle gives good proprioceptive feedback to any imbalances in the cranial
area due to the dural attachments.
Actions:

Extension, adduction (prime mover)

Internal rotation, horizontal extension (assistant mover)

Typically the muscle is tested with the client holding the slightly extended and internally
rotated arm thus bringing the back of their hand to their hip area.
a) The therapist tests the arm in a resisted test so as to ascertain the neural locking
ability of the shoulder. The neural integrity is noted.
b) The client is asked to swallow and open their mouth. Whilst their mouth is open,
the test (a) is then repeated. The neural integrity is then compared against that
measured in (a).
c) No difference in strength means that the TMJ complex is sound.
d) A difference in strength means the TMJ complex is compromised.

Iliopsoas: Hip
Actions:

Flexion (prime mover)

Abduction, external Rotation (Assistant mover)

Due to the relationship of iliopsoas and the pelvic girdle, its attachments to the last
thoracic and Lumbar transverse processes, (fascial and dural), any imbalance between the
TMJ and pelvic girdle is quickly and accurately assessed using this muscle.
Typically the muscle is tested with the client in supine position, hip flexed, externally
rotated and slightly abducted.

Neurostructural Integration Technique Copyright 2006

International Institute for Applied Health Services Germany
International Centre for the Neurostructural Integration Technique Pty Ltd

a) The therapist tests the leg in a resisted test so as to ascertain the neural locking
ability of the hip. The neural integrity is noted.
b) The client is asked to swallow and open their mouth. Whilst their mouth is open,
the test (a) is then repeated. The neural integrity is then compared against that
measured in (a).
c) No difference in strength means that the TMJ complex is sound.
d) A difference in strength means the TMJ complex is compromised.

Treatment
Recipient Prone

(Refer to diagram on page 11)

1. Place hand over the recipients sacrum and stabilize body. Recipient inhales
and then slowly exhales. Once exhalation is complete apply a moderate
downward pressure to the Sacral area (as instructed) and release. Repeat the
above sequence another two times.
2. Without delay place fingers deep on the medial margin of the hamstring
muscle group and immediately distal to the Ischial Tuberosity, firmly roll
over the head of the Hamstring muscle group in a lateral direction.
(abc) Using thumbs make three posterior movements along the Iliotibial tract
commencing at the distal aspect and finishing on the belly of the Tensor
Fasciae Late muscle.
Immediately repeat this sequence on the right side of the body,
alternating fingers and thumbs as instructed.

Recipient Supine

(Refer to diagram on page 12)

3. Using the left thumb make a rolling movement over the Levator Scapulae
muscle in a superior/oblique direction and release the thumb.
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International Centre for the Neurostructural Integration Technique Pty Ltd

Immediately repeat this sequence on the right side of the body using the right
thumb.
4. Standing at the head of the recipient, place the middle finger of the left hand
on the lateral margin of the upper Trapezius muscle in line level with spinal
vertebrae C4, and roll over the upper Trapezius muscle in a medial direction.
Immediately repeat this movement on the right side of the neck.
5. Without delay place the left thumb on the medial border of the left
Sternocleidomastoid muscle slightly superior to its sternal origin and roll over
the muscle in a lateral direction.
(abc) Repeat this action three more times, moving superiorly onto the
Mastoid process, and making a final lateral move over the insertion of the
muscle.
Immediately repeat this sequence on the right side of the neck using the
right thumb.
6. Without delay using the thumb and index finger wiggle the Hyoid bone as
instructed.
7. Place index and middle fingers bilaterally over the TMJ. Ask recipient to
swallow and then open mouth wide an then close.
8. Ask recipient to partially open their mouth, inset their index finger and gently
bite on it until the remainder of the procedure is completed.
9. Place the left thumb on the Condular head of the Mandible. Draw the skin
superiorly over the TMJ and then move inferiorly crossing the joint. Without
removing thumb draw the skin anteriorly over the lateral ligament and then
move posteriorly crossing the joint, and then release the thumb.
Immediately repeat this sequence on the right side of the Mandible.
10. Without delay place the left thumb on the anterior margin of the Masseter
muscle on top of the Coronoid process. Roll across the Masseter muscle into
the depression (created by the open position of the jaw) and apply digital
pressure to the Lateral Pterygoid muscle for five seconds. Release thumb.
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Neurostructural Integration Technique Copyright 2006

International Institute for Applied Health Services Germany
International Centre for the Neurostructural Integration Technique Pty Ltd

Immediately repeat this sequence on the right side of the face.

Ask recipient to remove finger from mouth and ensure they are warm and
comfortable whilst leaving them rest for 2-5 minutes.

Post treatment Assessment

Typically after having completed the treatment procedure, the recipient can be tested once
again using either Latissimus Dorsi or Psoas testing protocols.
A positive response will be indicated by the test being strong with both positions of the
mouth, (open and shut) holding a similar strength in either Latissimus Dorsi or Psoas
tests.
Under certain situations, the adjustment may not hold, this weakness indicates that there
may in fact be another structural weakness, such as degeneration of the disk or wear of any
of the components within the TMJ/Cranial system. In this case stabilization of the joint is
imperative. Other situations, upon becoming weight bearing, the weakness will return,
indicating the need for additional pelvic/sacral re-alignment to create the required pelvic
stability.

Stabilisation
Further stabilization therapy may be included at this point by way of the TMJ appliance.
The appliance allows gapping between the condular head of the mandible and the
temporal fossa. This allows relaxing of the muscles locally and in the neck region, relieves
the pressure on the TMJ, thus allowing the disk to regenerate and finally reduces the effect
of bruxing and grinding.
For further information regarding this appliance, refer to the TMJ Appliance handout.

Neurostructural Integration Technique Copyright 2006

International Institute for Applied Health Services Germany
International Centre for the Neurostructural Integration Technique Pty Ltd

Referral
A small number of clients will require additional work to help relieve the symptoms of
TMJ disorder. In these cases, referral to an experienced TMJ orthodontist will be the only
solution to the problem. In these cases the structure underlying the TMJ/cranial system is
typically worn to such an extent that adjustment and stabilization techniques as outlined
are unable to correct the situation.
Emotional conditions can also be the root cause of the TMJ disorder and as such, referral
to the appropriate health practitioner should also be considered.
References:
The straight news (newsletter) Spring 2004, Brendan Stack. DDS. MS. Self published
The TMJ Appliance (brochure) Myofunctional Research Co. Self published
Applied Kinesiology; A synopsis. Vol 1+2. David S Walther. Systems DC, Pueblo,
Colorado 1988.
Head and face pain, edition 1 Rene Cailliet, MD. Published by F.A. Davis
The Heart of Listening - Hugh Milne - Volume 2, A Visionary Approach to Craniosacral
Work, North Atlantic Books.
NST Introductory course workshop manual Michael J. Nixon-Livy. Self published.
NST Basic course workshop manual Michael J. Nixon-Livy. Self published.
NST Update and Expansion course notes Michael J.Nixon-Livy. Self published.

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International Centre for the Neurostructural Integration Technique Pty Ltd

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Neurostructural Integration Technique Copyright 2006

International Institute for Applied Health Services Germany
International Centre for the Neurostructural Integration Technique Pty Ltd

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Neurostructural Integration Technique Copyright 2006

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International Centre for the Neurostructural Integration Technique Pty Ltd

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