Cervical/Neck Retraction

When I do the excercise below my tinnitus goes away 80% when my head is pulled in the back position. Someone else please try it.

McKenzie Method: Cervical/Neck Retraction

 

When I do this, my T goes 50% louder

 

Mine gets louder......

 

Louder, too.
But change of loudness by movement might be interesting....

 

Interesting, I am reviewing the paper that this exercise may have originated from, among others right now, in preparation for my next video.
https://www.ncbi.nlm.nih.gov/pubmed/17956785
This posture was NOT intended to be a test for whether you would get better. Actually, this particular study was for Meniere's disease, which includes tinnitus.

This stretch is part of a bigger therapy program that was mainly CBT at first and continuing home physical therapy. It was SLOW to work, but it had lasting results:

Intensity of symptoms assessed using a visual-analog scale in 24 patients with Meniere's disease at baseline (C0) and at the six half-year follow-ups (C1–C6) after coordinated treatment of temporomandibular and cervical spine disorders. The reduction in intensity of Meniere's disease symptoms from the coordinated treatment was in most cases not significant at the first 6-month follow- up (C1), except for pain in neck and shoulders. All symptoms were significantly reduced at the 1-year follow-up (C2); vertigo, dizziness, tinnitus, pain in face and jaws, pain in neck and shoulders.
At the 3-year follow-up (C6), the intensity of all symptoms was reduced with high significance​

 

@Dr. Jay Hobbs

What is your opinion of information in this video? Of all the explanations of the mandibular junction in association with the neck, this video does make a lot of sense.

Some somatic tinnitus does relate to hearing and there's detailed articles about the neck and jaw connection to hearing. Some problems/conditions are related to age factors within neck and jaw - possible injury factors. So a standard treatment will not fit all.

The Mandibular (lower jaw) Cervical (neck)...

 

@Greg Sacramento , I think Dr. Tamura's IMPLICATIONS are entirely accurate about the interdependence of the jaw and upper cervical spine, and I think it is a well-constructed concept of where the pivot point of rotation of the mandible. I am not so sure about the reasoning behind the cause and effect between the two.

I would argue that the more likely connection is more neurological. Here are a couple studies demonstrating the neurological relationship. ( https://www.ncbi.nlm.nih.gov/pubmed/8949854?dopt=Abstract , https://www.ncbi.nlm.nih.gov/pubmed/15140167?dopt=Abstract )
Of course, having a neurological relationship does NOT detract from Dr. Tamura's hypothesis.

The point we should all leave with is the same. TMJ and upper cervical are powerfully interconnected and must be considered as a unit, one influencing the other.

This is a good lesson for me. Thank you Greg.

 

@Dr. Jay Hobbs I also think there's has be a neurological connection. Both articles that you provide express that in simple logical terms.

I posted some stuff from a study with brain scans a while back that said that the right thalamus and left cuneus parts of the brain are responsible for tinnitus. A neuro, who can't see me as a patient has been very nice to call me twice.

He believe that the right thalamus and left cuneus are the control centers for severe subjective tinnitus. Additional information:

https://www.ncbi.nlm.nih.gov/pubmed/28174532

He also said with or without hearing loss that somatic neck-jaw tinnitus must be directed by physical therapy.

Dr. Hobbs A question - Do you think that those with somatic tinnitus and have a loss of normal lordosis should focus with exercises there first as long as soft tissues are within normal limits. I'm thinking that it could also help with TMJ.

Also how do feel about the short term use of a collar when there is loss of normal lordosis? I know we have talked about this, but not in mention to loss of normal lordosis.

 

Hi there, I have exactly the same ... You may be hearing your blood flow, and the change in volume is because your artery is less compressed when your head is in the "back" position. If this is indeed because of the arterial compression, your tinnitus should also be louder when you pull your head backwards (looking up). In that case, the best cure is to do as much stretching as you can, and it will eventually go away.

 

@reeax Thanks for your comment. My tinnitus becomes louder when I bend my neck forward. I have osteoporosis, joint hypertrophy and spondylosis and now loss of normal lordosis. So I get muscle soreness when I pull my neck forward. I have bad posture, always lifted improperly and I still tend to bend my neck forward.

Stretching still should be done, but I'm wondering if I should start with loss of normal lordosis exercises. Then maybe a cervical soft collar after exercises. So many different opinions for my situation.

 

So, as the study states, I do believe these areas likely represent "neuroimaging markers" of tinnitus, but I have come to believe that these and similar imaging and EEG markers are picking up on the signals of perception and associated suffering, as much or more than the CAUSE.

I think it is fine to address the lordosis WHILE also doing the other neck exercises.

 

I am looking into the use of cervical collars for broader use. I am trying to get in touch with the author. For now:

​

A cervical collar will likely REDUCE the lordosis, as will many of the cervical exercises. That's okay for the short term, and I believe the 2 would a good balance, since we have seen benefit from both, at least for neck and head symptoms in general.

 

My TMJ and neck therapist frequently discuss my case and adapt the therapy to influence the facial pain, T and headaches. So far the major headaches are mostly gone, facial pain on the right side is most of the days gone but T and TMJ is still very bad on the left side.

 

@Codaz , What has been involved with your TMJ therapy?

 

It's funny, I am also pretty confident that I got this somatic tinnitus (100% reactive to body posture) because of the heavy lifting & 0% stretching. It was when I lifted the most (5-6x a week) that this started, back and neck muscles became very tense and compressed everything (spine, nerves, arteries ..) and finally LEARNED to stay permanently contracted, without going back to the "relaxed" state. Of course, I have some high-level loss in that ear (this is why I can hear the blood flow, because the brain has tuned up high frequencies). I often use a soft cervical collar when working on a computer (I am a software engineer, so do that a lot ..), it is great to help you keep a good posture, and prevent putting strain on the neck.

 

TMJ is in my area a specialism that is only practiced by a hand full of therapists. Not only is the official requirement for craniomandibular therapists a university degree, but also not a lot of general physiotherapists choose to do it. In short: knees and elbows are more popular under therapists.

I have a team of 4. 1 senior jaw therapist who already is working with jaws since the 90's and 2 juniors who are doing their masters education right now. The fourth is working on my neck with various manual therapy techniques.

It all depends on how much pressure the jaw therapist uses on your cheeks. With their thumb (with gloves on) they go inside the mouth and the other four fingers are placed right under your ear (lower jawbone) or on the position before the ear on the cheekbone and the interconnecting junction that connects these two bones.

I'm asked to bite a little bit on their hand and then the muscles are massaged with various pressure. Last week I was almost crying of pain. The thumb which is inside the mouth reaches as far as possible behind the teeth in order to give the necessary back pressure from inside the mouth. So the cheek is hold very firmly between the thumb and other four fingers only seperated by the skin.

Other movements indicate total movement of the hand of the therapist while still pinching the cheek from the in and outside as described in circular clockwise and counterclockwise movement for the masseter muscles.

I definately feel pain and tension from the back of my jaw via the masseter muscle flowing up right to my nose.

In order to work on the temporalis muscles the four fingers are moved to these position while the thumb still stays in the mouth. Or the therapist sits behind my head on a stool and massages the outer muscle attachment, as these produce the most pain and headaches.

Each therapist uses their own tricks to set pressure on the muscles. Some also work on the splenius capitis muscles but they have set their priorities now to the sternocleomastoides as time is limited per therapy session. Sternocleomastoide muscles are tensioned while you nod and have an indirect influence on tinnitus level, since they basically put tension on your face while nodding.

I started measuring nodding level with a pressure meter with my fourth therapist, which works on my neck. Nodding goes in various degrees of head tilt. If you tilt your head too far (chin is on your chest) tinnitus is increased a lot. For now I'm only allowed to tilt my head with very small movements forward, very little degrees forward. Practicing this 10 times and hold in that nodding position for 10 seconds before release into original position. I am only allowed to practice while laying on my bed with a rolled up towel under my neck for support.

Every four weeks progression is consulted and adjustments are made. So far the major headaches on the top of my head are mostly gone.



I did over 70 sessions now combining the 4 therapists. Tinnitus has changed a lot but is not gone as the problem is multi staged. It also involves facial pain / headaches / eye pain / nausea / fatigue and other problems that we try to counter. The problem with chronic muscle pain is that tension builds up over time again and is related also to stress. So eventually I have to visit the therapists again after some weeks or matters get only worse. More pain, more tinnitus and so on.

So far it's the only thing that helps apart from the bite occlusional splint / NTI-TSS splint.

However, while therapy is a recurring event in my life the effect diminishes over time. The first year I had bigger steps in lowering T than the second. The third year I had again some big results but the fourth year so far the left ear is gone much worse and I still don't have any clue why such a setback happened.

Other option is the anesthesiologist and general pain team in the hospital which I'm hoping to visit later this year or in 2018. It all depends on getting a referral letter which is quite troublesome. Opinions differ on whether more specialists could be of any help apart from psychological councelling which is less invasive in their opinion. I have to convince MD's in order to try new stuff since the isn't any treatment indication in multi disciplinary fields. In short: jaw surgeons don't know anything about facial pain and facial pain specialists are unaware of neck physiotherapy needs. I have to connect the dots myself in order to get relief.

 

@Codaz , That is super that you have such a qualified support team to help you. I'm glad you have had some good results, and I'm sorry to learn of your regression. 4 years is a long time. Most people don't stick to something that long.
Thanks for your thorough explanation of what you are doing.

 

Well I am sometimes quite proud to have achieved such results with this team and sometimes I'm really down and in tears of the (facial)pain that is still going on. Four years seems long but there is no other option. Quitting therapy for someone of just 30 years of age is a no go. What else would I do for the next 40-50 years?
In other bad news I filled a survey at my therapists office which describes other patients with 10+ years of these complaints

 

I am reading through quite a few articles and a book by one of the best researchers and practitioners now on TMJ Diagnosis, Prognosis, and Treatment. I always thought I was quite good at this, but I found that I had much to learn. Here's a couple good articles that relate to Temporomandibular Disorder (TMD) and tinnitus.
> https://www.ncbi.nlm.nih.gov/pubmed/17873977

This one was specifically about Meniere's, demonstrating that people who stuck with the recommendations relatively well for 3 years noted uniquely good improvement, even though 6 months showed tinnitus improvement, but not statistically significant.
> https://www.ncbi.nlm.nih.gov/pubmed/12555932

• Results in VAS change for Tinnitus: Estimating from the graph:
  • C0 (Baseline): 8.7
  • C1: (6 months): 7.2 (-1.5) = 18%
  • C2: (1 yrear): 4.3 (-4.4) = 51%
  • C6: (3 years): 2.0 (-6.7) = 77%

​

Having been at it for FOUR year, that may or may not be encouraging to you, but I do want to encourage you. I think you are doing some great things, but I also believe there is something missing. I don't know what it is, but I do believe you will find it. I am fairly certain that you can at least reach the point of greatest improvement that you had reached before.

I think one difficult balance it to continually strive for improvement while being content where you are, at least content enough to habituate.

May God bless your efforts.

 

@Dr. Jay Hobbs From going thru all of Pub Med and other study articles on somatic tinnitus treatments here are some that have the highest success rates. However, I still don't know what exercises are best for individual pre existing cervical spine conditions.

Temporary relief
Breathing exercises - heat and cold - TENS

Moderate term relief
Physical therapy with muscles trapezius, levator, scapulax and sternocledomastoid - other muscles to a lesser degree

stretch suboccipital muscles

occipital neuralgia as in damage to nerves would be eqidural nerve block and radiofrequency to C2 - C4.

Longer term
injections to C1 and C2.

cranial therapy for head and neck

mouth guard or splits

exercises for loss of normal lordosis with after use of neck brace

 

From my experience, I don't now that I would look hard for that particular answer. I believe that the same treatments are appropriate for short-term and chronic or complicated C-spine conditions. The difference will be that the chronic or complicated ones will usually be more resistant, resulting in slower recovery and limited recovery, necessitating more patience, persistence, and maintenance.

Now that I consider your wording, were you asking about "exercises" specifically, like strengthening exercises? In that case, I rarely give strengthening exercises. I give range of motion exercises and occasionally add a small resistance to those.

 

@Dr. Jay Hobbs I would like to thank you for your time, kindness, caring and concern with those with somatic tinnitus. Not many professionals would come to this board and try to assist others.

"Recovery for chronic and complicated ones will usually be more resistant, resulting in slower and limited recovery ..." Understood, as age related factors such as disc space narrowing, joint hypertrophy, spondylosis and arthritis add to the equation.

Somatic tinnitus is complicated and many professional articles also state limited results, and more often for older ones. They also state that long treatment periods are often needed for older people with chronic and complicated conditions.

I think that you are right in saying that range of motion has value. It also may be safer than strengthening exercises for middle age and older ones where conditions are not subjectable or understood. Having x rays of the neck is important as you know.

When cervical spine or other diseases are present, especially for older people, there's challenges, but I don't consider it an end game. I think that some of the treatments that I mentioned in above post can ready help younger ones without disease. TMJ treatment can be very helpful to those that have that alone or with connection to the cervical spine element.

Thanks for your assistance and honestly.

 

I wouldn't recommend this. It made it worse then better, much like clenching the jaw and relaxing does... But with a little more practice, gave me a huge high pitch spike in my left ear (most of my T is in the right ear).

Ugh.

 

I had headgear and premolar extractions done when I was a young teen. I'm fairly certain that it had a negative affect on my cervical alignment (among other things). It wasn't my decision to make, but it really messed my jaw up. I spoke with a number of orthognathic surgeons later on in life and they all agreed that it was poorly done orthodontic treatment.

 

Thanks so much for the encouraging words. There is very little known and for sure no ENT ever suggested the link to TMJ diagnosis. What is missing is the daily routine. In simple words: not being shut down for two days in a row after some days of work or activity. Balancing my energy and pain is something I need to find a good psychologist for and unfortunately that didn't work out yet.

Today I saw my gnathologist again and he made a T-Scan. This is a scan to determine occlusional force and possible where problems occur in the mouth that give overuse of jaw muscles and thus tinnitus. Since my muscles are overused and therefore painful and tense it is necessary that clenching and grinding stops and also that the occlusional force is lowered so muscles can rest. Turns out only a couple of molars are used when my upper and lower jaw are fully closed. That's why the pressure is on these teeth and not on the rest. But: even on a perfectly fine occlusion there can be problems so I'm a bit skeptical.

The t-scan is a device that is stuck into your mouth and pressure is measured while you bite. It's a computerized occlusional analysis device, connected via USB to a pc. Quite expensive as these devices are 11.000 euro. About 150 dentists in the Netherlands have such a device.



It gives the following results (not mine). After the results the gnathologist decided some teeth have to be adjusted in order to spread the maximum load while biting over more support points. In two months I have a follow up procedure to see what can be done. As you can see in this image load is spread over about 10 teeth. In my situation this is much lower. Some teeth do not even touch each other. What makes me skeptical is that I had this already for my entire life. I understand the fact that jaw muscles are one of the strongest in your body and force needs to be evenly spread otherwise it can give problems. But what I don't understand is that in combination with bite splint use which prevents touching your teeth, force spread should be even, since with the NTI-TSS bite splint force is located at the front teeth.



Pubmed paper about T-scan and tinnitus from 2016:

https://www.ncbi.nlm.nih.gov/pubmed/27372169

So to speak there is a lot of tech stuff coming into the dentist / TMJ practice and patients have to pay the bill. If it works or is just hocus pocus is not yet clear to me. The t-scan was already available in 1984 but not yet reliable until 2006.

 

@Codaz The information that you provide is interesting.

I've been reading the writings of Cynthia Peterson PT. After reading her detailed informative 269 page book, I'm still unsure about one thing, that being the use of a mouth guard either hard or soft. For some people that will help considerably, but for others maybe not. For me, it doesn't help.

What does help, is placing a folded tissue on traumatized side with half hanging out of mouth to relax jaw. I don't place pressure on the tissue, but the tissue does find a way to quickly resolve my disorder. However it's not lasting. Maybe with more continued use it would help.

 

Well, I haven't seen any research (haven't specifically looked) on how critical correcting occlusion is. The best research I have seen included (but didn't question) grinding off high spots on the teeth ("recurring active shining bruxing facets were dulled") for improving occlusion. Apparently the "best" approach for improving occlusion is a bit questionable among the professionals: http://www.nature.com/bdj/journal/v191/n7/full/4801185a.html

That tool is super cool. I want one of those.
So, this is what the rest of us use to check occlusion:


...paper that you bite down on that leaves marks on the teeth where the teeth come together.

 

Interesting Greg, I don't know the answer, but it makes me think that a self-equalizing splint may be helpful. I have a sample of this device, but have no experience with it yet.
https://www.dentaldepot.com/category/AQUALIZER_TMJ_STOP_MIGRANE_HEADACHES

 

I have asked this and there was no significant difference between hard and soft bite splints, according no my jaw surgeon. My gnathologist wasn't really keen on this and made the NTI-TSS bite splint which only separates the front teeth and is claimed to reduce biting force by 70%. Not sure if that is just marketing. What I do know is that in the first weeks of wearing that new one there was indeed improvement, but that is now diminished.
I suggest if you can try both. My TMJ therapist is now advising to switch them randomly. So day one the normal bite splint, day two the NTI-TSS, and day 3 no bite splint at all to see what that gives. Going to start with that soon.

For all TMJ patients: see a specialized physiotherapist every couple of weeks. It's the only thing that is guarenteed to help. It's the best bang for buck you can get as they actively put tension on your face, jaw and muscles.
You simply cannot do this yourself, no matter what all books and Youtube movies tell you. Simply because you are too close and cannot make the movements a third party hand can do.

And no: don't expect results after 10 therapy sessions. You probably need half a year or more to see any results. That's why most of the research papers see no significant effect. Because there is no longitudinal effect measured of chronic facial pain. Most research papers only question a couple of months (because of research costs?).
This pain behavior is unpredictable and foremost not an A-B relation. So you would assume that high stress = high pain. My gnathologist explained that the pain system does not work like that. There is no direct relationship he said. Although tension builds up over time and you need a rest period afterwards. I would like to ask @Dr. Jay Hobbs if he agrees on that as I am no MD. There is so much more to learn on how the pain system works so I can improve my work / rest balance in order to avoid buildup of trouble.

Thanks for this paper. Well I have to believe my Gnathologist on his blue eyes if he said the occlusion can be improved. Occlusion paper which leaves colored residue on where the teeth touch is an older method. The ACTA (Academic school for dentists in Amsterdam) wasn't convinced that the T-scan would work, probably because of the high cost involved in getting such a machine and yearly service agreement.

Oh and the self equalizing splint (it looks like a one size fits all on that link) isn't probably what you want. The splint I have is made by puting a type of paste into your mouth that is turning into a hard piece after 10 minutes. After that a lab constructs a bite splint out of that mold.
Next step in developing this mold is a 3D scan of your mouth so exact measurements can be made.

Newer treatments such as the DIR-bite splint claim to treat malocclusion and thus the necessary correction of jaw and bite. This functional prosthetic is claimed to be different than all others as it is precisely measured via computer imaging.



http://www.dir-system.de/en/dentists/the-dir-bite-splint

The problem is, the system is only used by dentists in Germany so far. So I don't have access to it.

 

I would say that there is a tendency toward that relationship, but certainly, I would agree, the perception of pain is NOT easily predicted from physical findings nor life experiences (incl. stress) in any individual.

They have several sizes...just another tool in the tool bag.