Here's a short video describing this functional screening. (If you want to see it full screen, click the little box with arrows in it on the lower right.)
Let me know if you have any questions about it.
Here's an overview for those of you interested in learning about the head – its geography and organization. This is the architectural underpinning that the jaw, neck and facial musculature rests on.
The Head and its Appendage, the Jaw
Given the many bones and muscles we tackle as beginning massage students, it’s understandable that we approach the head as a single unit. Once we have a closer look, however, we see that the head is composed of three anatomical areas: the neuro-cranium, the viscero-cranium, and the mandible.
The neuro-cranium is simply the round ball that holds the brain. It has a dense “base,” which is a nest for the brain with many openings for nerves and blood vessels, and a thin “vault,” which caps the brain and distributes the force of any bumps or blows. If you imagine wearing a cap, the edge of the cap would outline the place where the base and the dome meet.
The viscero-cranium is the bony scaffolding of the face, from nose to mouth and ear to ear. Structurally, the face hangs from a set of sutures just at the bridge of the nose and behind the eyes, and it includes most of our sinuses and special senses. Like the bones of the vault, the bones in the face are designed to disperse most impact forces superficially, rather than into the nerve- and vessel-rich area of the sinuses and cranial base.
The mandible is the lower jaw: a dense bone that hangs from the cranial base, like the chin strap of an old motorcycle helmet. Connected to the rest of the head by the temporo-mandibular joints (TMJ), the jaw is highly mobile and performs a variety of functions. So, looking at someone face-to-face we can see all three aspects of the head: the neuro-cranium at the forehead, the viscero-cranium from the eyes to the upper teeth, and the lower jaw at the chin. This perspective becomes very useful when assessing the alignment of each aspect in relation to each other and the neck.
Since we’re accustomed to considering the face as a whole, we don’t tend to think of the jaw as an highly mobile appendage of the head. However, just as the arms and legs are appendages that can either support or drag on the torso, the mandible can rest in balance…or not, which strains the head and upper neck. This heavy bone and related myofasciae form a functional unit which plays an important role in our overall balance.
If you've just finished our article on Intraoral work and Pain, and want more, here are further resources you can check out:
Sources and Further Reading:
Barral, Jean-Pierre, Visceral Manipulation: Thorax, Eastland Press, Seattle, WA, 1991.
Biel, Andrew, Trail Guide for the Body, 2nd Edition, Books of Discovery, Boulder, CO, 2001.
Chaitow, Leon & Walker DeLany, Judith, Clinical Application of Neuromuscular Techniques, Volume 1 The Upper Body, Churchill Livingstone, London,UK, 2000.
Liem, Torsten, Cranial Osteopathy – Principles and Practice, 2nd edition, Elsevier, London, UK, 2004.
Milne, Hugh, Heart of Listening, Volume 2, North Atlantic Books, Berkeley, CA, 1995.
Myers, Thomas, Anatomy Trains: Myofascial Meridians, 2nd Edition, Elsevier, London, UK, 2009.
St. John, Paul & Langnes, Dawn, Trigger Points – TMJ (poster), self-published, 1991.
Werner, Ruth, A Massage Therapist’s Guide to Pathology, 2nd Edition, Lippincott Williams & Wilkins, Philadelpia, PA, 2002.
For those reading the article in the AMTA magazine, who want a little more information about musculature, here's a quick review of the four muscles of mastication: masseter, temporalis and the pterygoids.
The Inner and Outer Slings of the Jaw
Two of the muscles that suspend the jaw are well-known to most massage practitioners—the masseter and temporalis. The masseter spans from the cheek bone (zygomatic arch) to the angle of the mandible. It is a dense, multilayered muscle with a reputation—the strongest muscle in the body for its size. It closes, clenches, bites, and grinds; with it, we can “hold our tongue” by closing our mouth or “mull things over” ruminating til we’re ready to speak.
The temporalis forms a fan of fibers on either side of the head. The belly crosses the TMJ just in front of the ear, and dives beneath the cheekbone to attach to the coronoid process of the mandible (the thin flange at the upper, anterior aspect of the ramus). This is the muscle that we instinctively rub at the temples when we get a headache. If we look closely at its shape, we can see how the anterior (and more vertical) fibers assist the masseter in closing the jaw, while the posterior (more horizontal) fibers draw the mandible back, setting the bone in the joint. The temporalis can “rein in” the mouth—anatomically in full closure of the TMJ, or metaphorically in inhibition of self-expression. Together, the masseter and temporalis create the “set of the jaw” and everything that that implies, from anger and aggression to tenderness and vulnerability (think of the quivering chin at the brink of tears).
Less known to practitioners and clients alike is an inner sling created by the pterygoid muscles. (The “p” is silent, as in pterydactyl. Both words derive from the root word ‘wing’—in this case, the wing of the sphenoid bone deep in the skull). There are two muscles—the medial and lateral pterygoid—each with a distinct path and function.
The medial pterygoid is the larger and more accessible of the two. It lies on the medial aspect of the mandible, anchoring on the angle and rising toward the roof of the mouth. (In this illustration, you’re looking at the right medial pterygoid ‘through’ the inside of the mouth.) Think of its relationship with the masseter this way: if you were to make a “v” with your index and middle finger, then imagine the jaw bone resting between them where they meet, one finger could be the masseter and the other the medial pterygoid. Along with closing the jaw, the medial pterygoid works with the masseter to create grinding, that side-to-side, round-and-round movement that horses and cows do so well.
The lateral pterygoid is tucked away behind the upper jaw, making it a little tricky to get to but well worth the effort. To imagine its location, let’s first get oriented to the TMJ: bring both hands up to your cheeks, Macaulay Culkin-style (with your index finger pad at the hole of each ear). If you slowly open your mouth, the condyle of the TMJ will rise up just beneath your middle finger. That condyle is one attachment of the lateral pterygoid; the other is at the top of the roof of the mouth, covered over by the soft palate (pterygoid plate of the sphenoid).
The lateral pterygoid is a relatively small muscle, with two bellies (one inferior, one superior), and because of its structure, it plays a key role in TMJ function. The most unusual anatomical feature of the TMJ is its highly mobile articular disc. The upper surface of the joint (the temporal fossa) is curved like a spoon, and the disc rides that curve from front to back and can even move forward out of the fossa if needed (as in taking an extra large anaconda-style bite). How does the disc do it? The superior belly of the lateral pterygoid reaches into the joint and attaches to the disc, drawing it forward when we open the jaw and allowing it to ease back when we close the jaw. If the lateral pterygoid becomes chronically shortened or immobile, the disc can’t move properly, and mouths open with strain, pain, pops or limitation.
Notoriously tight and tender, the lateral pterygoid is often the key to releasing the jaw fully, but working on it can be challenging. In 15 years of practice, I have yet to meet a client for whom this work isn’t intense (i.e., painful)—and remarkably effective. Once clients feel the ease of movement and decreased tension that’s possible, they are “on board” and often come back requesting for more of that specific treatment. And, although these muscles can be initially confusing to find in one’s own mouth, it can be very useful to teach clients to massage them as part of their home care.
I just realized yesterday that I've sustained my first iPhone overuse injury—by playing solitaire, which I'd been doing for a couple of months. The ulnar side of my right wrist has been sore and a little swollen for the last couple of weeks, and I was nursing it along until I realized what had caused the problem. Bad biomechanics AND just too much repetition! So now it's cold turkey for the solitaire for awhile…
We have a nice group of people signing up for ACOM this year in its new format. We're going to go more hi-tech this year: I'm going to video demos and explanations of key content and post them to this site. There's going to be a new blog (ACOM content) going up. I just have to figure out how to place it on the home page, then I'll password-protect it and go from there. Lauren and I have already figured out how to place video files in a blog for downloading.
I've just come from teaching an Anatomy Trains course in Chicago with a group of movement practitioners. This is my second time this year adapting my teaching to work with a group of professionals with a divergent view of the body – and it's absolutely fascinating! As a manual practitioner, there is so much about the fascial anatomy of the body that fascinates me, and I forget the box I'm living in until I'm asked to step outside it.
Working with a group of Pilates instructors, athletic trainers and yoga teachers is a wonderful challenge. I have to rethink my assumptions about why the body has the shape it does. They have focus and insight into muscle strength (or weakness, as the case may be), and see length and shortness in the body as reflective of muscle tone. I get to introduce them to the fascial bed — which also creates shortness (or allows for length) in the body. And together we get to explore the idea of lasting change in the body.
I get to talk with a movement professional who believes that any and all structural change that a body requires can be accomplished through movement alone. Needless to say, as a manual practitioner, I can't quite accept that — even while I see the huge advantages and overlapping of our realms. I believe that much of the lengthening that I can achieve with my hands can be accomplished through directed movement. And still, there are structures (the fascial septa, the viscera, the nerves, fascial membranes, etc.) that are best accessed with our hands… And, people move in habitual ways — with ease in some cases and with forgetfulness in others. Once we have an area that is restricted, it often goes off our radar; our kinesthetic map is effected. It's difficult to move what we are no longer feeling. So just as it takes a skilled manual practitioner to open tissues that have become restrictive, I believe a skilled movement educator can help us recover our map and highlight the ways our movement patterns can be improved.
And there is a lot to be said about the efficiency of manual therapy as a precursor to skilled movement education. If I can help my clients can freedom of movement and better alignment (from fascial restriction), then they will be better position, literally, to take full advantage of whichever physical activity they choose.
Being out of my box for a bit helps me gain perspective on what it is I offer clients and how I can best advocate for their health. Because whether it's yoga or Pilates or walking or free running, barefoot running, stairs or swimming, moving our bodies everyday is a fundamental part of well-being.
I was invited to do a brief demonstration of myofascial work on the neck as part of a workshop this past Saturday. The workshop was co-led by Diana Thompson, one of the local/national massage luminaries, and Richard Adler of Adler Giersch, a PI attorney; it was about both the treatment of whiplash and the legal/insurance implications of accident cases. I was lucky enough to have Lauren as my model.
Technique was also demonstrated by Taya Countryman (Structural Release Therapy); Arik Gohl (Ligament Release Therapy); and Diane Kincaid (MLD). It was good company to be in. I saw some old friends, including Carolyn Brady of Oak Harbor. We used to be study groups together in the mid-80's! Time flies.
Meanwhile, we're finalizing the calendar and pricing for the new ACOM, starting December 2010. More about that soon.
Susan Rosen and I just finished up the 5th round of ACOM (Advanced Certification in Orthopedic Massage) classes at the Port Townsend School of Massage. We've had a good run—five nice groups of people in five years. Next time (late fall 2010) we're going to try something different: separating Susan and me in most of the classes, so that each of us can have extended periods of working with the students in our somewhat overlapping areas of concentration (Susan's more weighted towards the orthopedic/treatment realm; I'm more in the structural balancing realm). Blending the two, each day in each class, has worked well, but I think we can do better in this slightly different format. We'll see!
I also have some ideas about going a bit more high-tech in this next round. I would like to try making casual videos of each technique demonstration, and uploading them to an online drop box so that students can download them. This summer, I'm going to be exploring the technology.
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