Osteopathic treatment protocol in patients with temporomandibular disorders (TMD).

Each patient will receive the 10 techniques that I describe below in each of the 2 sessions that the patient attends. Each session will last approximately 30 minutes. The second session will take place one week after the first session. One of the examiners will monitor adherence to the intervention using a checklist. ARM 1 1. Brief Name: Flexion-Extension Stretching 2. Why: the intervention reduces pain, increases PPT (pressure pain threshold) in masseters and temporalis muscles, and stimulates the central nervous system. 3. Materials: - 4. Procedures: The patient is in supine position with his cervical spine in neutral position. The therapist applies an anterior posterior upper cervical movilization on the 3 upper cervical segment (C0-C3). The movilization will be applied at a rate of 1 oscillation per 2s (0.5Hz). The caudal hand takes the occipital bone. The thumb and the index must touch the transverse atlas process. The other hand is placed over the frontal bone. This hand must push the occipital in the flexion way, while the other keep the atlas still. 5. Who will deliver the intervention: Every technique (both experimental and control) will be applied by a Physical Terapist (with more than 10-year expertise), C.O. (Certificado en Osteopatia with 4-year expertise). The professional has trained in the techniques during the period of development of project (starting in early 2020). Video records of the techniques being applied will be sent to the EOM (Escuela de Osteopatia de Madrid) Director for revision. 6. How: The treatment will be applied individually. This will be the same in every technique. 7. Where: The interventions will take place in an Osteopathic Center in Córdoba City, Argentina. This will be the same in every technique. 8. When and How Much: Both groups (experimental and control) will receive 2 sessions of the protocols. Session 2 will take place one week after Session 1. This will be the same in every technique. 9. Tailoring: - This will be the same in every technique. 10. Modifications: This technique was modified. Hand contact was changed to be as described by the EOM. 11. How Well: Planned: Techniques will be assessed by the Director or any PhD Osteophath from EOM. This will be the same in every technique. 12. Actual: - This will be the same in every technique. ARM 2: 1. Brief Name: Suboccipital inhibition 2. Why: This technique increases the PPT (Pressure Pain Threshold) over the TrPs (Trigger Points) in the temporalis and masseter muscles. 3. Materials: - 4. Procedures: Patient is in supine position. The hands of the therapist are behind the head of the subject with the palms facing upwards and the finger flexed with the finger pads positioned on the posterior arch of the atlas. A force is applied on the atlas in the direction of the ceiling, with a slight traction in a cranial direction for 2 minutes. ARM 3: 1. Brief Name: Bilateral OAA (Occipital Atlas Axis). 2. Why: the application of an atlantoaxial joint thrust manipulation results in an increase in active mouth opening and PPT over a trigeminal nerve distribution area. 3. Materials: - 4. Procedures: the patient is supine and the head is rotated to one side. With the middle and the ring finger of one hand, the therapist contacts the mastoid process. With the palm of the other hand, the therapist contacts the patient's jaw line and cheek. A slight traction is cranially introduced with both hands. When joint tension is perceived by the therapist, a high-velocity low-amplitude thrust is performed in the direction of traction with a gentle rotary force. If no popping sound is heard on the first manipulation attempt, the therapist repositions the patient and performs a second manipulation. A maximum of 2 thrust attempts are performed on each patient. The manipulation is performed bilaterally in all patients in the experimental group. ARM 4: 1. Brief Name: Muscle Energy Technique (MET). 2. Why: To produce an increase in range of motion in temporomandibular joint. 3. Materials: -. 4. Procedures: patient is in supine position and the therapist is seated with the cranial hand stabilizing the head contacting the frontal bone. The caudal hand contacts the chin of the patient. The therapist puts the TMJ in the maximun open passive range and asks to make an isometric contraction for 3 seconds and rest 3 seconds. This is repeated in 3 cycles of 3 contractions of 3 seconds. Between each cycle the therapist must win a new range barrier. ARM 5: 1. Brief Name: TMJ (Temporomandibular Joint) Movilization. 2. Why: To increase the limited range of motion. Contributes to the immediate improvement of postural control in TMD patients. 3. Materials: Latex gloves. 4. Procedures: The technique is performed with the patient in supine position. The osteopath stands at the other side of the patient. He holds the patient's head by the frontal bone and, with the other hand, mobilizes the mandible with his thumb contacting the 2nd and 3rd molars. The traction is made in a low range, for a minute. There are five repetitions. Between each mobilization the patient must open his mouth 10 times with the tongue contacting the incisive papilla. The side to be treated will be previously determined by the Diagnostic Criteria for Temoporomandibular Disorders (DC/TMD). ARM 6: 1. Brief Name: Intra-oral Myofascial therapies (IMT). 2. Why: IMT alone or with the addition of self-care may be of some benefit in the management of chronic TMD over the short-medium term. 3. Materials: Latex Gloves. 4. Procedures: a) Intra-oral temporalis release. The therapist is positioned homolateral to the side being treated. A gloved index contact of the caudal hand is placed onto the coronoid process of the mandible, applying light posterior and caudal pressure within pain tolerance of the patient. The cephalad index and middle fingers apply superior pressure longitudinally along the fibres of the temporalis muscle moving gradually anteriorly to posteriorly. The patient is asked to incrementally open their mouth to its maximum range. b) Intra-oral medial and lateral pterygoid (origin) technique. The practitioner is seated either homolateral or contralateral to the side being treated. A gloved index finger is inserted along the lateral wall of the pharynx, posterior to the last molar. Posterior and cephalad pressure is applied into the pharyngeal tissues overlying the pterygoid origins arising from the lateral pterygoid plate of the sphenoid. Contact is maintained for 5 seconds. ARM 7: 1.Brief Name: Hyoid Bone functional technique. 2. Why: This technique was developed by Richard, from EOM. It reduces anterior neck fascia tension. 3: Materials: -. 4. Procedure: The patient rests in supine position and the therapist is seated next to the shoulder. 1st stage: Functional Phase: the mandibular hand makes a bilateral compression in the upside direction of 5grs in the temporomandibular joint and leaves the mandibula balanced with the temporal bones. Then, the hyoid hand balances the hyoid bone where there is less tension in 3 dimensions (upside down, front an back side and left-right side). Structural Phase: it reverses the order of the parameters while the patient breathes widely until the tissues get relaxed. ARM 8: 1. Brief Name: Tongue technique. 2. Why: It reduces opening mouth pain. 3. Materials: Latex Gloves. Gauze. 4. Procedure: 1st technique: The tongue is held with one hand using a piece of gauze (in order not to release the hold), while the patient is in supine position. The other hand with the palm open has to be placed behind the head of the patient, in an area that includes the cervical and occipital surface. The tongue must be gently pulled out, until the tension generated is perceived in the occipital–cervical area. This position has to be maintained until tension in the muscular tissue of the tongue and the posterior cervical and occipital tract is reduced, and a sensation of looseness and lightness is perceived. For the 2nd technique, with the patient always in supine position, the tongue is held with one hand as previously described, whereas the other hand gently grasps the hyoid bone. In this position, the therapist waits until the suprahyoid tissue and the tongue reach a balanced tension, resulting in a perception of looseness and lightness. ARM 9: 1. Brief Name: Myofascial Technique. 2. Why: It produces improvements for pain symptoms. 3. Materials: -. 4. Procedure: Temporalis muscle: localize the central area of the muscle. The patient rests in supine position with their head turned toward the healthy side. The inferior hand makes index fascial creeping contact over the muscle, while the other hand stabilizes the head. The therapist must deep-massage the muscle until the pain is reduced and the tissues get relaxed. Masseter muscle: localize the mandibular angle. Same position for the patient and therapist. 10. Modifications: The therapist must localize the trigger points and apply the technique in that area. ARM 10: 1. Brief Name: Maxillopharynx Fascia Technique. 2. Why: It relaxes fascial tissue. 3. Materials: -. 4. Procedures: Patient is in supine position. One hand is placed over the sternum, clavicle and the thorax superior part. The other hand contacts the lateral side of the patient's head with flex fingers in the horizontal branch of the mandible, contacting the fascia. 1st time: Fascial Test: the therapist must create tension in the fascial fibers with alternating flexing of the fingers. 2nd time: the thoracic hand follows the costal respiration, pushing the thorax to an exhale position during the patient's deep exhale until the therapist feels the repercussion in the mandibular fingers. This must be repeated until the tension is reduced.