Angie: i was diagnosed with tmj maybe 20 years or so ago. i wear a "dentist fitted" night guard every night since the tmj diagnosis. i am experiencing extremely severe headaches and also suffer from migraines but these severe headaches are totally different from a migraine. i have even used migraine medications but these have yet to come close to helping with these severe headaches. could the tmj issue be the culprit here??? these headaches are hurting in the jaws, temples, across the forehead, terribly behind the eyes and in the back of my head and neck. an mri recently showed nothing abnormal in the head or neck? i have even tried muscle relaxers and prednisone, no relief. i do not have health insurance but am willing to sell my house or at least my car to get some help{jk}. but seriously, what could be causing these headaches? who would be the best doctor to see? i have been to a neurologist, a dentist, natural healers, you name it, i've been there. can you he lp me with this before i go crazy? thank you and i painfully look forward to your reply.
Dr Shapira Response:
Dear Angie
I do not think there is a "Best Doctor" You did not say if your night guard improved your condition. If it does than consider a 24 hour orthotic. A night guard treats a 24/7 problem just at night.
The normal MRI is good news. I know patient's often want to find a problem on an MRI but ruling out serious organic disease is good news.
I normally spend an hour or two reviewing history before initiating treatment treatment and utilize numerous modalities to address specific portions of the problem.
A diagnostic neuromuscular orthotic is an excellent point to start treatment as it can often give miraculous results. I see long distance patients in my office, Ideally 4 days in a row. Come to town Sunday night and I will see you as a first patient Monday for exam and consultation, diagnostic work-up and delivery of an orthotic in the afternoon. I will then see you for adjustments over the next three days. If you are interested in pursuing treatment at my office I would like a lot more information prior to your visit.
Monday, April 11, 2011
Sunday, April 10, 2011
Gurnee Dental Office Utilizes Neuromuscular Dentistry to Treat TMJ, TMD, Chronic Headaches and Migraines
I have been practicing Neuromuscular Dentistry in Gurnee since 1984. My Partner, Dr Mark Amidei has an additional 20 years experience in Neuromuscular Dentistry. In addition to treating, eliminating and/or preventing headaches and migraines Neuromuscular Dentistry is excellent for treating TMJ disorders (TMD) and also for creating neck stability.
I frequently work with chiropracters and the combination of therapy can give phenomenal results.
Many people do not understand what Neuromuscular Dentistry is, so I am reprinting an article I wrote here that was originally published by the AES or American Equilibration Society and republished in the ICCMO Anthology and by Sleep and Health Journal. Additional information about Neuromucular Dentistry is available at our dental website at http://www.delanydentalcare.com/neuromuscular.html
NEUROMUSCULAR DENTISTRY (originally published in the American Equilibration Society magazine)
Ira L Shapira DDS, DABDSM, DAAPM, FICCMO
Neuromuscular Dentistry remains an enigma to many dentists who do not understand the purposes of the electrodes, the TENS, the computers and more. It has unfairly become a target of poor and misleading definitions by doctors who do not understand its basic principles.
There are several basic premises that underlie Neuromuscular Dentistry. The first premise is that the stomatognathic muscles are the primary determinate of the mandibles position during all jaw functions (when the teeth are not in occlusion) and that rest position is one of the most important positions in dentistry. Rest position is a maxillary to mandibular jaw relation where the teeth are not in occlusion but are prepared to occlude. In Neuromuscular Dentistry Rest is a position of bilaterally equal and low muscle tonicity from which the mandible moves into full occlusion with minimal muscle accommodation. Following closure from rest position the mandible should return to rest with similarly balanced low muscle tonicity. Rest position is determined not only by the mandible’s relation to the cranium but also by the position of the head relative to the body, the suprahyoid and infrahyoid muscles and the position of the hyoid bone. To fully understand the relation of jaw movement to head posture read the Quadrant Theorem of GUZAY (Available from the ADA Library). In essence it shows in engineering terms that after accounting for both rotation and translation of the mandible the actual axis of rotation of the mandible is at the odontoid process of the second vertebrae not at the mandible condylar head.
The second premise is that occlusion is important in neuromuscular dentistry as a resetting mechanism of the trigeminal nervous system’s control of the stomatognathic muscles. Myocentric occlusion is ideally a position in which the muscles move the mandible from a non-torqued rest position into full occlusion with minimal muscle accommodation and no interferences of occlusal contacts until full closure is attained thus eliminating all torque during closure. This means that there are no noxious contacts received by the periodontal ligaments or the muscular proprioceptors that must be avoided by the muscles (accommodation) but rather allow “free” entry into myocentric occlusion. The jaw muscles will return to rest position after closure with the muscles maintaining their healthy low tonicity. Relaxed healthy musculature is the gold standard of neuromuscular dentistry.
Swallowing is a primary activity when the jaw is closed into full occlusion. In order to swallow it is necessary to fixate the mandible and this happens as the teeth occlude. During chewing, speaking and other jaw functions the teeth do not actually occlude in normal function but are separated (during chewing by a bolus of food). Typically swallowing occurs approximately 2000 times a day and is momentary accounting for 6-10 minutes maximum time in occlusion over the course of the day and acts as a neuromuscular reset switch for trigeminally innervated muscles. During a healthy swallow the teeth will move freely without interference into full occlusion with bilateral equal contact and bilateral equal muscle activity and then return to rest position with low muscle tonicity. A deviate swallow as evidenced by scalloping of the tongue is a sign of a possible TMJ disorder and is also 80% predictive of sleep apnea (80% predictive in Dental study- 70% predictive ENT study)
Neuromuscular occlusion (myocentric) occurs when centric occlusion (maximum non-torqued intercuspation of teeth) is coincidental with a balanced muscle closure where the muscles will return to their relaxed state following closure. Myocentric is the ideal position for swallowing.
The dentist utilizing neuromuscular techniques does not determine a specific position of the condyles in the fossa. The position of the disk and condyle are determined primarily by the teeth (bite or orthotic during occlusal correction therapy) in occlusion (myocentric) and the application of muscle activity. Neuromuscular dentistry allows the patients healthy relaxed muscles to determine the joint relations with the teeth serving as a neuromuscular reset switch during closure. Neuromuscular dentistry rejects the notion that manipulation of the patient’s jaw by the intervention of the clinician muscles are more important in determining the relation of the components of the TM Joint than the muscles of the patient. Centric relation is not used as a reference position for mounting casts on an articulator. Centric Relation is considered a border movement of the mandible and as reported in orthopedic literature joints are rarely used in their border positions.
The HIP plane (defined by hamular notches, incisive papilla and the occipital condyles) and/or Campers plane is used to relate the maxilla to an articulator. When cosmetic considerations are involved photos are used to to incorporate this physiologic plane to soft tissues of the face. Ideally the occlusal plane (parallel to the HIP Plane) will bisect the odontoid process of the axis of the atlantoaxial joint the actual center of rotation for the mandible after accounting for translation and rotation according to the quadrant theorem.
This occlusal plane will be at a 90-degree angle to gravitational force when the head is in an upright position. A neuromuscular bite is used to mount the
mandibular casts according to data from EMG recordings and jaw tracings with TENS. The incorporation of the Curve of Spee based on Centro Masticale (CM) point which continues thru the mandibular condyle and the Curve of Wilson also based on CM point that is involved is stimulation of the autonomic nervous system via tongue reflexes when the lateral border of the tongue touches the lingual surfaces of the teeth. (Critical Reviews in Oral Biology & Medicine, Vol. 13, No. 5, 409-425 (2002)) This excellent article is available online at http://cro.sagepub.com/cgi/content/full/13/5/409
Neuromuscular dentistry considers many of the problems associated with TMD to be repetitive strain injuries. Movements become harmful when closure requires excessive accommodation and then the system fails at its weakest link. If the weakest link is muscle health we will see formation of tender sore muscles with eventual formation of taut bands and trigger points. If there is muscle overuse from clenching and/or grinding there will be post exercise pain secondary to anaerobic lactic acid build-up. If the weakest point is in the TM Joint then when repetitive strain occurs the muscle accommodation will lead to increased intra-articular pressure. This again will break down the joint at its weakest point. This may occur as a displaced disk or as wear of articular surfaces or many other conditions. It may come at the expense of the bone of the condyle leading to flattening or beaking of the condyle. Clenching and bruxism are two particularly well-known and harmful parafunctional habits that lead to varied repetitive strain injuries. There are many other parafunctions that can lead to problems. Some parafunctions are actually protective muscle accommodation such as the deviated or reversed swallow that protects the TM Joints and masticatory muscles at the expense of altered head, hyoid and spine position and consequent muscle problems.
The second type of problems would be described as I/O or Input/ output errors in computer lingo. The CNS is essentially a biological computer and is affected by input from afferent nerves from the body. Autonomic system function include the fight or flight response with concomitant release of adrenaline that alters the heart rate, blood pressure, muscle tone etc. This system effects the Hypothalamus pituitary complex with feedback to the adrenals and effects on ACTH and cortisol levels. During periods of acute stress these effects have a positive survival value but during chronic stress become a liability to the individual as described by Hans Selye in his book “The Stress of Life” and his discussion of the General Adaptation Syndrome. There are numerous biochemical changes that occur in the brain secondary to aberrant or nociceptive input into the brain these can be affected by correction of the neurological input, by using drugs to change the brain chemistry or a combination of these approaches. Ideally correction of the underlying cause of these biochemical changes is the preferred method of treatment.
The utilization of TENS or transcutaneous neural stimulation over the coronoid notch has been shown by Mitani and Fujii (1974 J. Dent Res.) to block the motor division of the trigeminal nerve and relax the musculature via anti-dromic impulses (hyperpolarisation) to both the alpha and gamma motor neurons without influence from proprioceptive and nocioceptive (tooth contacts) inputs The TENS is then use to create a balanced synchronize pulsing to find the trajectory of closure where a myocentric registration can be obtained. The muscles will return to their relaxed position following closure into myocentric.
The use of Computerized mandibular jaw tracking allows the dentist to measure and record resting jaw position relative to the cranium at a given head position. The location of myocentric occlusion is determined by the dentist with the aid of information from tracings recorded.
Electromyography or EMG is used to record relative values of resting muscle activity of masticatory muscles as well as muscles such as Sternocleidomastoid or Trapezius. While there are no absolute “normal values” of resting muscles the clinician uses his information to compare muscle activity within a given patient. Muscles should be approximately equal activity bilaterally. Thomas 1990 in Frontiers of Oral Physiology vol 7 pp162-170 demonstrated that Spectral analysis of the post TENS EMG may be utilized to evaluate muscle fatigue and differentiate between muscle atrophy or fatigue or relaxed muscle states. This was later confirmed by Frucht, Jonas and Kappert at Frieberg University in 1995 (Fortschr.Kieferorthop vol 56 pp 245-253)
Utilizing the two modalities together allows the clinician to evaluate the rest position of the jaw and simultaneously the health and functional activity of the muscles.
The EMG also allows tests to evaluate the functional capacity of the muscles and again compare the right and left sides for symmetry. The use of functional recordings (during clenching and closure into centric occlusion) allows the clinician to evaluate whether or not muscle function is satisfactory and functional. The use of EMG also allows evaluation and correction of first contact of closure position within microseconds bases on firing order of the masseter and temporalis muscles. The first point of contact on closure is vitally important and equilibration of orthotics and dentition must be finely adjusted until first contact is evenly dispersed on posterior dentition.
Neuromuscular dentistry is very concerned with the effects of mandibular position on the body as a whole and on the effects of the body on jaw and head position. The work of Sherrington and the righting reflex explains how ascending and descending disorders affect a patient. These phenomena have been best explained by Norman Thomas BDS, PhD. I will not attempt to explain this complicated topic in this agenda, which may be found in Anthology of ICCMO vol V pp159-170. It obviously must incorporate the Quadrant Theorem of Casey Guzay, the physiological aspects of the balance organ of the inner ear and the vestibular apparatus located in the brainstem as well as visual feedback. The control of sympathetic and parasympathetic systems by the cerebellum is quite intricate and also affected by head position.
Correction of the chewing cycle is an important part of occlusal finalization. It must be understood that the chewing cycle is different on the each side and that interferences can occur on both the opening and closing strokes of the chewing cycle. Interferences in chewing strokes are easiest to detect by study of the chewing strokes on computerized mandibular scans (MKG). Head position during chewing is not is normally in the upright head position but in the feeding position approximately a 30-degree anterior head flexion. Correction of the chewing cycle is at least as important as correction of right, left and protrusive excursions. Chewing is a healthy function of the craniomandibular apparatus where as excursive movements are actually exercises in parafunctional movements.
There is more commonality to treatment of TMJ disorders by neuromuscular and non-neuromuscular dentists than differences and complications caused by neural intensification in the reticular activating system, emotional aspects and the relation to the limbic system, connections to the sympathetic and parasympathetic nervous systems via the Sphenopalatine Ganglion and sympathetic chain, and chemical changes and cerebroplastic changes that occur during chronic pain leading to hyperalgesia and allodynia all can be discussed in greater detail and explained in relation to neuromuscular dentistry. The basics physiology including effects of Golgi tendon organs and muscle spindles on jaw muscles remain constant and must always be carefully considered during treatment.
Barney Jankelson’s famous quote, “if it is measured it is a fact otherwise it is an opinion “ rings as true today as when he first said it. Neuromuscular dentistry is about making accurate measurements and the use of those measurements to improve the doctor’s ability to make a differential diagnosis and tailor treatment to relieve pain and create stable restorative dentistry with healthy relaxed musculature.
I would like to make a disclaimer that this is my personal definition of Neuromuscular dentistry from 30 years of practice and to thank my mentors Barney Jankelson, Barry Cooper, Dayton Krajiec, Richard Coy, Harold Gelb, Peter Neff, Robert Jankelson and especially Jim Garry who first made me understand the connections between increased upper airway resistance and the common developmental aspects of sleep apnea and craniomandibular disorders. A special thank you for Dr Norman Thomas for his extraordinary help in understanding the complex physiology and anatomy underlying neuromuscular dentistry and in reviewing this paper prior to presentation.
My personal research in the 1980’s as a visiting assistant professor at Rush Medical School examined the jaw relations of patients with obstructive sleep apnea based on neuromuscular evaluations of jaw relations with a Myotronic's kinesiograph and a myomonitor to find neuromuscular rest position. These studies showed jaw relations in the male apnea patients that were strikingly similar to those found in female TMD patients. The National Heart Lung and Blood Institute considers sleep apnea to be a TMJ disorder. The NHLBI published a report, “Cardiovascular and Sleep Related Consequences of TMJ Disorders” in 2001 that can be found at
http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf
Dr Shapira returned to Rush as an assistant professor at the sleep center in the 1990’s where he treated a wide variety of obstructive apnea patients with commercial and customized intraoral sleep appliances. He was a founding and credentialed member of the Sleep Disorder Dental Society that has become the American Academy of Dental Sleep Medicine, He is a Diplomate of the American Board of Dental Sleep Medicine, on the board of the Illinois Sleep Society, a Diplomat of the American Academy of Pain Management, a Regent Fellow of the International College of Cranio-Manibular Orthopedics and a representative of that group to the TMD Alliance. He is a long time member of AES, AACFP, Academy of Sleep Medicine and the Chicago Dental Society. Dr Shapira teaches hands-on in-depth Dental Sleep Medicine courses to small groups at his Gurnee office. A family history of genetic cancer led Dr Shapira into research on stem cells an he also holds several patents (method and device) on the collection of stem cells during early minimally invasive removal of the uncalcified tooth bud of developing third molars. This procedure can be complete in minutes with greatly reduced morbidity compared to current surgical techniques used for removal of developed third molars. He hopes in the future that patients will routinely remove the tooth buds and collect and save the stem cells for anti-aging and regenerative medical uses.
For more information on headache diagnosis and treatment as related to neuromuscular dentistry, please read the entire I Hate Headaches Website
Neuromuscular Dentistry does have some illustrations that are reprinted at the Sleep and Health Journal site at:
http://www.sleepandhealth.com/neuromuscular-dentistry
I frequently work with chiropracters and the combination of therapy can give phenomenal results.
Many people do not understand what Neuromuscular Dentistry is, so I am reprinting an article I wrote here that was originally published by the AES or American Equilibration Society and republished in the ICCMO Anthology and by Sleep and Health Journal. Additional information about Neuromucular Dentistry is available at our dental website at http://www.delanydentalcare.com/neuromuscular.html
NEUROMUSCULAR DENTISTRY (originally published in the American Equilibration Society magazine)
Ira L Shapira DDS, DABDSM, DAAPM, FICCMO
Neuromuscular Dentistry remains an enigma to many dentists who do not understand the purposes of the electrodes, the TENS, the computers and more. It has unfairly become a target of poor and misleading definitions by doctors who do not understand its basic principles.
There are several basic premises that underlie Neuromuscular Dentistry. The first premise is that the stomatognathic muscles are the primary determinate of the mandibles position during all jaw functions (when the teeth are not in occlusion) and that rest position is one of the most important positions in dentistry. Rest position is a maxillary to mandibular jaw relation where the teeth are not in occlusion but are prepared to occlude. In Neuromuscular Dentistry Rest is a position of bilaterally equal and low muscle tonicity from which the mandible moves into full occlusion with minimal muscle accommodation. Following closure from rest position the mandible should return to rest with similarly balanced low muscle tonicity. Rest position is determined not only by the mandible’s relation to the cranium but also by the position of the head relative to the body, the suprahyoid and infrahyoid muscles and the position of the hyoid bone. To fully understand the relation of jaw movement to head posture read the Quadrant Theorem of GUZAY (Available from the ADA Library). In essence it shows in engineering terms that after accounting for both rotation and translation of the mandible the actual axis of rotation of the mandible is at the odontoid process of the second vertebrae not at the mandible condylar head.
The second premise is that occlusion is important in neuromuscular dentistry as a resetting mechanism of the trigeminal nervous system’s control of the stomatognathic muscles. Myocentric occlusion is ideally a position in which the muscles move the mandible from a non-torqued rest position into full occlusion with minimal muscle accommodation and no interferences of occlusal contacts until full closure is attained thus eliminating all torque during closure. This means that there are no noxious contacts received by the periodontal ligaments or the muscular proprioceptors that must be avoided by the muscles (accommodation) but rather allow “free” entry into myocentric occlusion. The jaw muscles will return to rest position after closure with the muscles maintaining their healthy low tonicity. Relaxed healthy musculature is the gold standard of neuromuscular dentistry.
Swallowing is a primary activity when the jaw is closed into full occlusion. In order to swallow it is necessary to fixate the mandible and this happens as the teeth occlude. During chewing, speaking and other jaw functions the teeth do not actually occlude in normal function but are separated (during chewing by a bolus of food). Typically swallowing occurs approximately 2000 times a day and is momentary accounting for 6-10 minutes maximum time in occlusion over the course of the day and acts as a neuromuscular reset switch for trigeminally innervated muscles. During a healthy swallow the teeth will move freely without interference into full occlusion with bilateral equal contact and bilateral equal muscle activity and then return to rest position with low muscle tonicity. A deviate swallow as evidenced by scalloping of the tongue is a sign of a possible TMJ disorder and is also 80% predictive of sleep apnea (80% predictive in Dental study- 70% predictive ENT study)
Neuromuscular occlusion (myocentric) occurs when centric occlusion (maximum non-torqued intercuspation of teeth) is coincidental with a balanced muscle closure where the muscles will return to their relaxed state following closure. Myocentric is the ideal position for swallowing.
The dentist utilizing neuromuscular techniques does not determine a specific position of the condyles in the fossa. The position of the disk and condyle are determined primarily by the teeth (bite or orthotic during occlusal correction therapy) in occlusion (myocentric) and the application of muscle activity. Neuromuscular dentistry allows the patients healthy relaxed muscles to determine the joint relations with the teeth serving as a neuromuscular reset switch during closure. Neuromuscular dentistry rejects the notion that manipulation of the patient’s jaw by the intervention of the clinician muscles are more important in determining the relation of the components of the TM Joint than the muscles of the patient. Centric relation is not used as a reference position for mounting casts on an articulator. Centric Relation is considered a border movement of the mandible and as reported in orthopedic literature joints are rarely used in their border positions.
The HIP plane (defined by hamular notches, incisive papilla and the occipital condyles) and/or Campers plane is used to relate the maxilla to an articulator. When cosmetic considerations are involved photos are used to to incorporate this physiologic plane to soft tissues of the face. Ideally the occlusal plane (parallel to the HIP Plane) will bisect the odontoid process of the axis of the atlantoaxial joint the actual center of rotation for the mandible after accounting for translation and rotation according to the quadrant theorem.
This occlusal plane will be at a 90-degree angle to gravitational force when the head is in an upright position. A neuromuscular bite is used to mount the
mandibular casts according to data from EMG recordings and jaw tracings with TENS. The incorporation of the Curve of Spee based on Centro Masticale (CM) point which continues thru the mandibular condyle and the Curve of Wilson also based on CM point that is involved is stimulation of the autonomic nervous system via tongue reflexes when the lateral border of the tongue touches the lingual surfaces of the teeth. (Critical Reviews in Oral Biology & Medicine, Vol. 13, No. 5, 409-425 (2002)) This excellent article is available online at http://cro.sagepub.com/cgi/content/full/13/5/409
Neuromuscular dentistry considers many of the problems associated with TMD to be repetitive strain injuries. Movements become harmful when closure requires excessive accommodation and then the system fails at its weakest link. If the weakest link is muscle health we will see formation of tender sore muscles with eventual formation of taut bands and trigger points. If there is muscle overuse from clenching and/or grinding there will be post exercise pain secondary to anaerobic lactic acid build-up. If the weakest point is in the TM Joint then when repetitive strain occurs the muscle accommodation will lead to increased intra-articular pressure. This again will break down the joint at its weakest point. This may occur as a displaced disk or as wear of articular surfaces or many other conditions. It may come at the expense of the bone of the condyle leading to flattening or beaking of the condyle. Clenching and bruxism are two particularly well-known and harmful parafunctional habits that lead to varied repetitive strain injuries. There are many other parafunctions that can lead to problems. Some parafunctions are actually protective muscle accommodation such as the deviated or reversed swallow that protects the TM Joints and masticatory muscles at the expense of altered head, hyoid and spine position and consequent muscle problems.
The second type of problems would be described as I/O or Input/ output errors in computer lingo. The CNS is essentially a biological computer and is affected by input from afferent nerves from the body. Autonomic system function include the fight or flight response with concomitant release of adrenaline that alters the heart rate, blood pressure, muscle tone etc. This system effects the Hypothalamus pituitary complex with feedback to the adrenals and effects on ACTH and cortisol levels. During periods of acute stress these effects have a positive survival value but during chronic stress become a liability to the individual as described by Hans Selye in his book “The Stress of Life” and his discussion of the General Adaptation Syndrome. There are numerous biochemical changes that occur in the brain secondary to aberrant or nociceptive input into the brain these can be affected by correction of the neurological input, by using drugs to change the brain chemistry or a combination of these approaches. Ideally correction of the underlying cause of these biochemical changes is the preferred method of treatment.
The utilization of TENS or transcutaneous neural stimulation over the coronoid notch has been shown by Mitani and Fujii (1974 J. Dent Res.) to block the motor division of the trigeminal nerve and relax the musculature via anti-dromic impulses (hyperpolarisation) to both the alpha and gamma motor neurons without influence from proprioceptive and nocioceptive (tooth contacts) inputs The TENS is then use to create a balanced synchronize pulsing to find the trajectory of closure where a myocentric registration can be obtained. The muscles will return to their relaxed position following closure into myocentric.
The use of Computerized mandibular jaw tracking allows the dentist to measure and record resting jaw position relative to the cranium at a given head position. The location of myocentric occlusion is determined by the dentist with the aid of information from tracings recorded.
Electromyography or EMG is used to record relative values of resting muscle activity of masticatory muscles as well as muscles such as Sternocleidomastoid or Trapezius. While there are no absolute “normal values” of resting muscles the clinician uses his information to compare muscle activity within a given patient. Muscles should be approximately equal activity bilaterally. Thomas 1990 in Frontiers of Oral Physiology vol 7 pp162-170 demonstrated that Spectral analysis of the post TENS EMG may be utilized to evaluate muscle fatigue and differentiate between muscle atrophy or fatigue or relaxed muscle states. This was later confirmed by Frucht, Jonas and Kappert at Frieberg University in 1995 (Fortschr.Kieferorthop vol 56 pp 245-253)
Utilizing the two modalities together allows the clinician to evaluate the rest position of the jaw and simultaneously the health and functional activity of the muscles.
The EMG also allows tests to evaluate the functional capacity of the muscles and again compare the right and left sides for symmetry. The use of functional recordings (during clenching and closure into centric occlusion) allows the clinician to evaluate whether or not muscle function is satisfactory and functional. The use of EMG also allows evaluation and correction of first contact of closure position within microseconds bases on firing order of the masseter and temporalis muscles. The first point of contact on closure is vitally important and equilibration of orthotics and dentition must be finely adjusted until first contact is evenly dispersed on posterior dentition.
Neuromuscular dentistry is very concerned with the effects of mandibular position on the body as a whole and on the effects of the body on jaw and head position. The work of Sherrington and the righting reflex explains how ascending and descending disorders affect a patient. These phenomena have been best explained by Norman Thomas BDS, PhD. I will not attempt to explain this complicated topic in this agenda, which may be found in Anthology of ICCMO vol V pp159-170. It obviously must incorporate the Quadrant Theorem of Casey Guzay, the physiological aspects of the balance organ of the inner ear and the vestibular apparatus located in the brainstem as well as visual feedback. The control of sympathetic and parasympathetic systems by the cerebellum is quite intricate and also affected by head position.
Correction of the chewing cycle is an important part of occlusal finalization. It must be understood that the chewing cycle is different on the each side and that interferences can occur on both the opening and closing strokes of the chewing cycle. Interferences in chewing strokes are easiest to detect by study of the chewing strokes on computerized mandibular scans (MKG). Head position during chewing is not is normally in the upright head position but in the feeding position approximately a 30-degree anterior head flexion. Correction of the chewing cycle is at least as important as correction of right, left and protrusive excursions. Chewing is a healthy function of the craniomandibular apparatus where as excursive movements are actually exercises in parafunctional movements.
There is more commonality to treatment of TMJ disorders by neuromuscular and non-neuromuscular dentists than differences and complications caused by neural intensification in the reticular activating system, emotional aspects and the relation to the limbic system, connections to the sympathetic and parasympathetic nervous systems via the Sphenopalatine Ganglion and sympathetic chain, and chemical changes and cerebroplastic changes that occur during chronic pain leading to hyperalgesia and allodynia all can be discussed in greater detail and explained in relation to neuromuscular dentistry. The basics physiology including effects of Golgi tendon organs and muscle spindles on jaw muscles remain constant and must always be carefully considered during treatment.
Barney Jankelson’s famous quote, “if it is measured it is a fact otherwise it is an opinion “ rings as true today as when he first said it. Neuromuscular dentistry is about making accurate measurements and the use of those measurements to improve the doctor’s ability to make a differential diagnosis and tailor treatment to relieve pain and create stable restorative dentistry with healthy relaxed musculature.
I would like to make a disclaimer that this is my personal definition of Neuromuscular dentistry from 30 years of practice and to thank my mentors Barney Jankelson, Barry Cooper, Dayton Krajiec, Richard Coy, Harold Gelb, Peter Neff, Robert Jankelson and especially Jim Garry who first made me understand the connections between increased upper airway resistance and the common developmental aspects of sleep apnea and craniomandibular disorders. A special thank you for Dr Norman Thomas for his extraordinary help in understanding the complex physiology and anatomy underlying neuromuscular dentistry and in reviewing this paper prior to presentation.
My personal research in the 1980’s as a visiting assistant professor at Rush Medical School examined the jaw relations of patients with obstructive sleep apnea based on neuromuscular evaluations of jaw relations with a Myotronic's kinesiograph and a myomonitor to find neuromuscular rest position. These studies showed jaw relations in the male apnea patients that were strikingly similar to those found in female TMD patients. The National Heart Lung and Blood Institute considers sleep apnea to be a TMJ disorder. The NHLBI published a report, “Cardiovascular and Sleep Related Consequences of TMJ Disorders” in 2001 that can be found at
http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf
Dr Shapira returned to Rush as an assistant professor at the sleep center in the 1990’s where he treated a wide variety of obstructive apnea patients with commercial and customized intraoral sleep appliances. He was a founding and credentialed member of the Sleep Disorder Dental Society that has become the American Academy of Dental Sleep Medicine, He is a Diplomate of the American Board of Dental Sleep Medicine, on the board of the Illinois Sleep Society, a Diplomat of the American Academy of Pain Management, a Regent Fellow of the International College of Cranio-Manibular Orthopedics and a representative of that group to the TMD Alliance. He is a long time member of AES, AACFP, Academy of Sleep Medicine and the Chicago Dental Society. Dr Shapira teaches hands-on in-depth Dental Sleep Medicine courses to small groups at his Gurnee office. A family history of genetic cancer led Dr Shapira into research on stem cells an he also holds several patents (method and device) on the collection of stem cells during early minimally invasive removal of the uncalcified tooth bud of developing third molars. This procedure can be complete in minutes with greatly reduced morbidity compared to current surgical techniques used for removal of developed third molars. He hopes in the future that patients will routinely remove the tooth buds and collect and save the stem cells for anti-aging and regenerative medical uses.
For more information on headache diagnosis and treatment as related to neuromuscular dentistry, please read the entire I Hate Headaches Website
Neuromuscular Dentistry does have some illustrations that are reprinted at the Sleep and Health Journal site at:
http://www.sleepandhealth.com/neuromuscular-dentistry
Quality of Life Destroyed By Chronic Daily Headache according to Cephalgia article. Neuromuscular Dentistry can improve Quality of Life
A total of 34 studies were reviewed in this paper. Chronic Daily Headache (CDH) and Chronic Daily Headache with Medication Overuse (MOH) consistently created a lower quality of life. The Cephagia Article "Quality of life impairment, disability and economic burden associated with chronic daily headache, focusing on chronic migraine with or without medication overuse: A systematic review." include 25 studies of patients and 9 studies of the general population.
I strongly recommend Neuromuscular Intervention as soon as possible when chronic headaches begin. These studies clarify the importance of utilizing a diagnostic neuromuscular orthotic early in the course of the problem. Almost every study done on headache treatment with a neuromuscular diagnostic orthotic shows at least a 50-80% improvement with NMD and frequently far superior results than medication.
Chronic Daily Headache frequently responds extremely well to Neuromuscular Dentistry but unfortunately a diagnostic orthotic is rarely offered to patients in pain centers and neurology offices. The biggest complaint about Neuromuscular Dentistry is that it can be expensive and time consuming when compared to writing a perscription. Long term savings and improvement in quality of life are essential considerations that must be taken into consideration. Insurance companies frquently are uncooperative using sneaky contract language to deny medically necessary treatment. One of the most common and unquetionably fraudulant techniques is to call all headaches and migraines treated by a dentist TMJ or TMD and then place an artificially low coverage maximum on that treatment. The article clearly states "Chronic Daily Headache was consistently associated with greater disability and productivity loss, more consultations, more or longer hospitalizations and higher direct costs than Episodic Headache, it is essential."
The principal conclusions of this review were"the findings of this review underline the detriment to Quality of Life and the disabling nature of CDH, and in particular CM and CDH with MOH, and negative impact on workplace productivity compared to other types of headache."
Reducing medication use and overuse is one of the real advantages of Neuromuscular Dental treatment of Chronic Migaine and Chronic Daily Headache. The side effects of massive drug use in headache and migraine often worsen the problem.
Prior to treating migraines, Tension -type headaches sinus headaches, and chronic daily headaches with dangerous medications it is logical to utilize a Dignostic Neuromuscular Orthotic, if relief is obtained the Medication Overuse is diminished. Medication Overuse Headaches are one of the worst headache types in destroying quality of Life.
The Neuromuscular Dental Institute (Institute for the Study of Neuromuscular Dentistry) is my answer to this disaster. Dr Barry Cooper, a leading Neuromuscular Dentistry Educator will teach his introduction to Neuromuscular Dentistry course to small groups of 4-6 dentists. We hope large numbers of these students will continue their Neuromuscular Dental Education at ICCMO (International College of CranioMandibular Orthopedics) meetings and at the Las Vegas Institue (LVI)
This wll be in addition to the current course I give on Sleep Apnea Treatment with oral appliance (Dental Sleep Medicine) as well as coverage of nerve blocks including the SPG block. The SPG or Sphenopalatine Ganglion Block can be incredibly effective in preventing and eliminating migraines. Ideally patients can learn to utilze and self administer SPG blocks to prevent or Amelliorate migraine headaches early in their course. It is simple, inexpensive and frequently incredibly effective.
The Alliance of TMD organizations (I am the ICCMO representative to the TMD Alliance) is working to prevent patients from being denied care that will mprove their overall quality of life and subsequently result in enormous long term savings in costs and expenses associates with chronic headaches and migraines.
The way TMJ, TMD and Neuromuscular Dentistry is dealt with by insurance companies is an example of Discrimination against women since the vast majority of patients with headaches, migraines and TM Joint disorders are female.
I will continue to treat patients at my Gurnee Dental practice, Delany Dental Care Ltd in our current locatin and in our new location that has a better layout for giving continuing educational courses to dentists, physicians and allied medical practitioners. Contact my office at 847-623-5530 for information on becoming a patient.
We do make special arrangements for long distance patients to make treatment requre less time and travel.
Ira L Shapira DDS, D,ABDSM, D, AAPM, FICCMO
Pub Med Abstract follows:
Cephalalgia. 2011 Apr 4. [Epub ahead of print]
Quality of life impairment, disability and economic burden associated with chronic daily headache, focusing on chronic migraine with or without medication overuse: A systematic review.
Lantéri-Minet M, Duru G, Mudge M, Cottrell S.
CHU de Nice - Hôpital Pasteur, France.
Abstract
Objective : To evaluate the evidence for quality of life (QoL) impairment, disability, healthcare resource use and economic burden associated with chronic daily headache (CDH), focusing on chronic migraine (CM) with or without medication overuse. Methods : A systematic review and qualitative synthesis of studies of patients/subjects with CDH that included CM, occurring on at least 15 days per month. Main findings: Thirty-four studies were included for review (25 studies of patients and nine of subjects from the general population). CDH and CDH with medication overuse headache (MOH) were consistently associated with a lower QoL compared to control or episodic headache (EH) and CDH without MOH. CDH was consistently associated with greater disability and productivity loss, more consultations, more or longer hospitalizations and higher direct costs than EH. Data were not amenable to statistical pooling. Principal conclusions : The findings of this review underline the detriment to QoL and the disabling nature of CDH, and in particular CM and CDH with MOH, and negative impact on workplace productivity compared to other types of headache.
PMID: 21464078 [PubMed - as supplied by publisher]
I strongly recommend Neuromuscular Intervention as soon as possible when chronic headaches begin. These studies clarify the importance of utilizing a diagnostic neuromuscular orthotic early in the course of the problem. Almost every study done on headache treatment with a neuromuscular diagnostic orthotic shows at least a 50-80% improvement with NMD and frequently far superior results than medication.
Chronic Daily Headache frequently responds extremely well to Neuromuscular Dentistry but unfortunately a diagnostic orthotic is rarely offered to patients in pain centers and neurology offices. The biggest complaint about Neuromuscular Dentistry is that it can be expensive and time consuming when compared to writing a perscription. Long term savings and improvement in quality of life are essential considerations that must be taken into consideration. Insurance companies frquently are uncooperative using sneaky contract language to deny medically necessary treatment. One of the most common and unquetionably fraudulant techniques is to call all headaches and migraines treated by a dentist TMJ or TMD and then place an artificially low coverage maximum on that treatment. The article clearly states "Chronic Daily Headache was consistently associated with greater disability and productivity loss, more consultations, more or longer hospitalizations and higher direct costs than Episodic Headache, it is essential."
The principal conclusions of this review were"the findings of this review underline the detriment to Quality of Life and the disabling nature of CDH, and in particular CM and CDH with MOH, and negative impact on workplace productivity compared to other types of headache."
Reducing medication use and overuse is one of the real advantages of Neuromuscular Dental treatment of Chronic Migaine and Chronic Daily Headache. The side effects of massive drug use in headache and migraine often worsen the problem.
Prior to treating migraines, Tension -type headaches sinus headaches, and chronic daily headaches with dangerous medications it is logical to utilize a Dignostic Neuromuscular Orthotic, if relief is obtained the Medication Overuse is diminished. Medication Overuse Headaches are one of the worst headache types in destroying quality of Life.
The Neuromuscular Dental Institute (Institute for the Study of Neuromuscular Dentistry) is my answer to this disaster. Dr Barry Cooper, a leading Neuromuscular Dentistry Educator will teach his introduction to Neuromuscular Dentistry course to small groups of 4-6 dentists. We hope large numbers of these students will continue their Neuromuscular Dental Education at ICCMO (International College of CranioMandibular Orthopedics) meetings and at the Las Vegas Institue (LVI)
This wll be in addition to the current course I give on Sleep Apnea Treatment with oral appliance (Dental Sleep Medicine) as well as coverage of nerve blocks including the SPG block. The SPG or Sphenopalatine Ganglion Block can be incredibly effective in preventing and eliminating migraines. Ideally patients can learn to utilze and self administer SPG blocks to prevent or Amelliorate migraine headaches early in their course. It is simple, inexpensive and frequently incredibly effective.
The Alliance of TMD organizations (I am the ICCMO representative to the TMD Alliance) is working to prevent patients from being denied care that will mprove their overall quality of life and subsequently result in enormous long term savings in costs and expenses associates with chronic headaches and migraines.
The way TMJ, TMD and Neuromuscular Dentistry is dealt with by insurance companies is an example of Discrimination against women since the vast majority of patients with headaches, migraines and TM Joint disorders are female.
I will continue to treat patients at my Gurnee Dental practice, Delany Dental Care Ltd in our current locatin and in our new location that has a better layout for giving continuing educational courses to dentists, physicians and allied medical practitioners. Contact my office at 847-623-5530 for information on becoming a patient.
We do make special arrangements for long distance patients to make treatment requre less time and travel.
Ira L Shapira DDS, D,ABDSM, D, AAPM, FICCMO
Pub Med Abstract follows:
Cephalalgia. 2011 Apr 4. [Epub ahead of print]
Quality of life impairment, disability and economic burden associated with chronic daily headache, focusing on chronic migraine with or without medication overuse: A systematic review.
Lantéri-Minet M, Duru G, Mudge M, Cottrell S.
CHU de Nice - Hôpital Pasteur, France.
Abstract
Objective : To evaluate the evidence for quality of life (QoL) impairment, disability, healthcare resource use and economic burden associated with chronic daily headache (CDH), focusing on chronic migraine (CM) with or without medication overuse. Methods : A systematic review and qualitative synthesis of studies of patients/subjects with CDH that included CM, occurring on at least 15 days per month. Main findings: Thirty-four studies were included for review (25 studies of patients and nine of subjects from the general population). CDH and CDH with medication overuse headache (MOH) were consistently associated with a lower QoL compared to control or episodic headache (EH) and CDH without MOH. CDH was consistently associated with greater disability and productivity loss, more consultations, more or longer hospitalizations and higher direct costs than EH. Data were not amenable to statistical pooling. Principal conclusions : The findings of this review underline the detriment to QoL and the disabling nature of CDH, and in particular CM and CDH with MOH, and negative impact on workplace productivity compared to other types of headache.
PMID: 21464078 [PubMed - as supplied by publisher]
Saturday, April 9, 2011
TMJ AND POSTURE: THE INTIMATE CONNECTION BETWEEN CHIROPRACTIC PROBLEMS AND TMJ DISORDERS (TMD) ARE CRITICAL.
PATIENTS LIVING WITH TMJ DISORDERS, CHIROPRACTIC DISORDERS, HEADACHES AND MIGRAINES are alll suffering from the same underlying disorders. It is well recognized that it is impossible to achieve long term successful treatment without addressing both the dental, TMJ and Trigeminal components in conjunction with with the Chiropractic aspects of care.
Atlas Orthoganal Chiropractic or NUCCA chiropractic focus on the first two vertebrae. Both are excellent techniques but I usually prefer working with A/O chiropracters as they take a more universal approach to care. Many NUCCA chiropracters think that they can correct everything even though research at the prestegious Las Vegas Institue has shown that NUCCA adjustments DO NOT HOLD when the Neuromuscular Dental Occlusion is not corrected. A/o Chiropracters tend to be mor inclusive in care.
Atlas Orthoganal Chiropactic focuses on the first two vertebrae, the Atlas and the Axis. According to the website http://www.atlasorthogonality.com/index.htm the website of the Roy W Sweat Foundation:
"Atlas Orthogonal (SCALE—Stereotactic Cervical ALignment methods) is a spinal healthcare program developed by Dr. Roy Sweat in the late 1960’s based on scientific and biomechanical procedures. Dr. Sweat is considered by many to be one of the world’s foremost authorities on the cervical spine. After years of extensive research he developed a non-invasive, precision instrument to restore structural integrity from cervical vertebral malposition. The percussion instrument achieves postural restoration without manipulation or surgery. This precision treatment reduces cervical spine misalignment and its related symptomatology."
I work with two excellent A/O Chiropracters Dr Mark Freund in Lindenhurst and Dr David Menner in Lake Villa. I have also worked with severl NUCCA Chiropracters.
The connection between the Trigeminovascular system, the masticatory apparatus and the TM Joints was best described by a series ofg patients called "The Quadrant Theorem of Guzay" that describes how the actual center of rotation of the mandible (lower jaw) after accounting for both rotation and translation is on the Odontoid Process of the Axis found within the confines of the Atlas. The head rests on the Atlas on two fcets and it was named for Atlas in Greek Mythology who held the world on his shoulders.
Yoy can consider A/o Chiropracters and NUCCA Chiropracters as a herois Atlas managing the balance of the head on the top of the cervical column.
The neuromuscular Dentist is the navigator who assures that the head stays balanced so Atlas Axis stability is retained. The two treatments are intimately connected.
There are many other important areas of treatment in the body but these TOP Blocks are most important for anyone with Headaches, Migraines, TMJ, TMD, Spinal Problems, Tension-Type Headaches, SUNCY, Chronic Daily Headaches and non-infectious Sinus Pain and Sinus Headaches.
Additional information on Neuromuscular Dentistry is available at: http://www.sleepandhealth.com/neuromuscular-dentistry and at Dr Shapira's Delany Dental Care Ltd website at: http://www.delanydentalcare.com/neuromuscular.html
Atlas Orthoganal Chiropractic or NUCCA chiropractic focus on the first two vertebrae. Both are excellent techniques but I usually prefer working with A/O chiropracters as they take a more universal approach to care. Many NUCCA chiropracters think that they can correct everything even though research at the prestegious Las Vegas Institue has shown that NUCCA adjustments DO NOT HOLD when the Neuromuscular Dental Occlusion is not corrected. A/o Chiropracters tend to be mor inclusive in care.
Atlas Orthoganal Chiropactic focuses on the first two vertebrae, the Atlas and the Axis. According to the website http://www.atlasorthogonality.com/index.htm the website of the Roy W Sweat Foundation:
"Atlas Orthogonal (SCALE—Stereotactic Cervical ALignment methods) is a spinal healthcare program developed by Dr. Roy Sweat in the late 1960’s based on scientific and biomechanical procedures. Dr. Sweat is considered by many to be one of the world’s foremost authorities on the cervical spine. After years of extensive research he developed a non-invasive, precision instrument to restore structural integrity from cervical vertebral malposition. The percussion instrument achieves postural restoration without manipulation or surgery. This precision treatment reduces cervical spine misalignment and its related symptomatology."
I work with two excellent A/O Chiropracters Dr Mark Freund in Lindenhurst and Dr David Menner in Lake Villa. I have also worked with severl NUCCA Chiropracters.
The connection between the Trigeminovascular system, the masticatory apparatus and the TM Joints was best described by a series ofg patients called "The Quadrant Theorem of Guzay" that describes how the actual center of rotation of the mandible (lower jaw) after accounting for both rotation and translation is on the Odontoid Process of the Axis found within the confines of the Atlas. The head rests on the Atlas on two fcets and it was named for Atlas in Greek Mythology who held the world on his shoulders.
Yoy can consider A/o Chiropracters and NUCCA Chiropracters as a herois Atlas managing the balance of the head on the top of the cervical column.
The neuromuscular Dentist is the navigator who assures that the head stays balanced so Atlas Axis stability is retained. The two treatments are intimately connected.
There are many other important areas of treatment in the body but these TOP Blocks are most important for anyone with Headaches, Migraines, TMJ, TMD, Spinal Problems, Tension-Type Headaches, SUNCY, Chronic Daily Headaches and non-infectious Sinus Pain and Sinus Headaches.
Additional information on Neuromuscular Dentistry is available at: http://www.sleepandhealth.com/neuromuscular-dentistry and at Dr Shapira's Delany Dental Care Ltd website at: http://www.delanydentalcare.com/neuromuscular.html
Friday, April 8, 2011
NEUROMUSCULAR DENTISTRY: HOW DOES NEUROMUSCULAR DENTISTRY HELP PATIENTS WITH MIGRAINES, HEADACHES AND TMJ DISORDERS
The real beauty of Neuromuscular Dentistry in the treatment and prevention of headaches and TMJ disorders is the simplicity of treatment.
The aim of treatment is to
1. Relax the jaw muscles to their physiologic healthiest state
2. Correct the occlusion so that muscle will return to their healthiest state after function by establishing a healthy neuromuscular path of closure to a stable occlusal position.
3. Remove problems that prevent achievement of a healthy neuromuscular occlusion.
Neuromuscular Dentistry enables us to target treatment to a specific area of healthy neuromuscular function.
Please explore this site and other blog entries for specifics on how this is accomplished.
The aim of treatment is to
1. Relax the jaw muscles to their physiologic healthiest state
2. Correct the occlusion so that muscle will return to their healthiest state after function by establishing a healthy neuromuscular path of closure to a stable occlusal position.
3. Remove problems that prevent achievement of a healthy neuromuscular occlusion.
Neuromuscular Dentistry enables us to target treatment to a specific area of healthy neuromuscular function.
Please explore this site and other blog entries for specifics on how this is accomplished.
Thursday, April 7, 2011
Can Dentists Prevent Migraines? The Answer Is Yes According To New Research Out Of Germany.
The Journal of Neuroscience (J Neurosci. 2011 Feb 9;31(6):1937-43) recently published an article titled "Trigeminal nociceptive transmission in migraineurs predicts migraine attacks"
I have long advocated that the majority of Migraines and Tension-Type headaches are actually input-output errors. Nociceptive information entering the Trigeminovascular system are the pathology that triggers migraines and other headaches.
This study looked at fMRI or functional MRI studies of the brain.
They found that predicting migraine by trigeminal nociceptive activity could predict migraines.
Whers does most nociceptive trigeminal input arise?
In the Jaw Muscles, Muscle Spindles, Golgi Tendon Organs and periodontal ligaments of the teeth.
Neuromuscular Dentistry is very effective in eliminating and preventing migraines and muscular tension-type headaches. The majority of "sinus headaches" are actually referred muscle pain. The reason for the success of Neuromuscular Dentistry is the ability to eliminate nociceptive input.
Input/output errors are often described in computer lingo as Garbage In / Garbage Out.
The neurofeedback loops from periodontal ligaments , muscles, muscle spindles etc send nociceptive input (ie Garbage in) into the trigeminovascular system.
Migraines and other headaches are the "Garbage Out " part of the equation.
The article states that:
"Remarkably, the distance to the next headache attack was predictable by the height of the signal intensities in the spinal nuclei. Migraine patients scanned during the acute spontaneous migraine attack showed significantly lower signal intensities in the trigeminal nuclei compared with controls, demonstrating activity levels similar to interictal patients. Additionally we found-for the first time using fMRI-that migraineurs showed a significant increase in activation of dorsal parts of the pons, previously coined "migraine generator." Unlike the dorsal pons activation usually linked to migraine attacks, the gradient-like activity following nociceptive stimulation in the spinal trigeminal neurons likely reflects a raise in susceptibility of the brain to generate the next attack, as these areas increase their activity long before headache starts. This oscillating behavior may be a key player in the generation of migraine headache, whereas attack-specific pons activations are most likely a secondary event."
Another article in Neurology. 2011 Jan 18;76(3):206-7 states "Photophobia is an abnormal sensitivity to light experienced by migraineurs during attacks. The pathophysiology of photophobia is poorly understood. Nevertheless, 2 facts appear to have a link with photophobia: visual cortex hyperexcitability on the one hand and interactions between visual pathway and trigeminal nociception on the other."
The photophobia or sensitivity to light during a migraine attack is also due, in part to trigeminal nociception (Garbage in. The nociceptive input from the teeth,jaws, periodontal ligaments are the "garbage in" and the migraines and photophobia are the Garbage out".
Experimental studies on rats "J Neurosci. 2010 Oct 27;30(43):14420-9.
Changes of meningeal excitability mediated by corticotrigeminal networks: a link for the endogenous modulation of migraine pain." confirm the effect of trigeminanl nociception on meningeal migraines. The Trigeminovascular system is always paramount in migraine. The Trigeminal nerve controls the blood flow to the anterior 2/3 of the meninges of the brain.
Primary Stabbing Headaches are also trigeminally innervated as reported in"
J Headache Pain. 2011 Jan 6. [Epub ahead of print]
Incidence and influence on referral of primary stabbing headache in an outpatient headache clinic." The article states that "Primary stabbing headache (PSH) is a pain, as brief, sharp, jabbing stabs, predominantly felt in the first division of trigeminal nerve." The trigeminal nerve you will remember is the Dentist's nerve.
PubMed Abstract below:
J Neurosci. 2011 Feb 9;31(6):1937-43.
Trigeminal nociceptive transmission in migraineurs predicts migraine attacks.
Stankewitz A, Aderjan D, Eippert F, May A.
Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany.
Abstract
Several lines of evidence suggest a major role of the trigeminovascular system in the pathogenesis of migraine. Using functional magnetic resonance imaging (fMRI), we compared brain responses during trigeminal pain processing in migraine patients with those of healthy control subjects. The main finding is that the activity of the spinal trigeminal nuclei in response to nociceptive stimulation showed a cycling behavior over the migraine interval. Although interictal (i.e., outside of attack) migraine patients revealed lower activations in the spinal trigeminal nuclei compared with controls, preictal (i.e., shortly before attack) patients showed activity similar to controls, which demonstrates that the trigeminal activation level increases over the pain-free migraine interval. Remarkably, the distance to the next headache attack was predictable by the height of the signal intensities in the spinal nuclei. Migraine patients scanned during the acute spontaneous migraine attack showed significantly lower signal intensities in the trigeminal nuclei compared with controls, demonstrating activity levels similar to interictal patients. Additionally we found-for the first time using fMRI-that migraineurs showed a significant increase in activation of dorsal parts of the pons, previously coined "migraine generator." Unlike the dorsal pons activation usually linked to migraine attacks, the gradient-like activity following nociceptive stimulation in the spinal trigeminal neurons likely reflects a raise in susceptibility of the brain to generate the next attack, as these areas increase their activity long before headache starts. This oscillating behavior may be a key player in the generation of migraine headache, whereas attack-specific pons activations are most likely a secondary event.
PMID: 21307231 [PubMed - indexed for MEDLINE]
Neurology. 2011 Jan 18;76(3):213-8. Epub 2010 Dec 9.
A PET study of photophobia during spontaneous migraine attacks.
Denuelle M, Boulloche N, Payoux P, Fabre N, Trotter Y, Géraud G.
Service de Neurologie et Explorations Fonctionnelles du Système Nerveux, CHU Rangueil, Toulouse, France. denuelle.m@chu-toulouse.fr
Comment in:
* Neurology. 2011 Jan 18;76(3):206-7.
Abstract
BACKGROUND: Photophobia is an abnormal sensitivity to light experienced by migraineurs during attacks. The pathophysiology of photophobia is poorly understood. Nevertheless, 2 facts appear to have a link with photophobia: visual cortex hyperexcitability on the one hand and interactions between visual pathway and trigeminal nociception on the other.
METHODS: We used H(2)(15)O PET to study photophobia induced by continuous luminous stimulation covering the whole visual field in 8 migraineurs during spontaneous migraine attacks, after headache relief by sumatriptan and during attack-free interval. The intensity of the luminous stimulation provoking photophobia with subsequent headache enhancement was specifically determined for each patient.
RESULTS: We found that low luminous stimulation (median of 240 Cd/m(2)) activated the visual cortex during migraine attacks and after headache relief but not during the attack-free interval. The visual cortex activation was statistically stronger during migraine headache than after pain relief.
CONCLUSION: These findings suggest that ictal photophobia is linked with a visual cortex hyperexcitability. The mechanism of this cortical hyperexcitability could not be explained only by trigeminal nociception because it persisted after headache relief. We hypothesize that modulation of cortical excitability during migraine attack could be under brainstem nuclei control.
PMID: 21148120 [PubMed - indexed for MEDLINE]
J Neurosci. 2010 Oct 27;30(43):14420-9.
Changes of meningeal excitability mediated by corticotrigeminal networks: a link for the endogenous modulation of migraine pain.
Noseda R, Constandil L, Bourgeais L, Chalus M, Villanueva L.
Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA.
Abstract
Alterations in cortical excitability are implicated in the pathophysiology of migraine. However, the relationship between cortical spreading depression (CSD) and headache has not been fully elucidated. We aimed to identify the corticofugal networks that directly influence meningeal nociception in the brainstem trigeminocervical complex (Sp5C) of the rat. Cortical areas projecting to the brainstem were first identified by retrograde tracing from Sp5C areas that receive direct meningeal inputs. Anterograde tracers were then injected into these cortical areas to determine the precise pattern of descending axonal terminal fields in the Sp5C. Descending cortical projections to brainstem areas innervated by the ophthalmic branch of the trigeminal nerve originate contralaterally from insular (Ins) and primary somatosensory (S1) cortices and terminate in laminae I-II and III-V of the Sp5C, respectively. In another set of experiments, electrophysiological recordings were simultaneously performed in Ins, S1 or primary visual cortex (V1), and Sp5C neurons. KCl was microinjected into such cortical areas to test the effects of CSD on meningeal nociception. CSD initiated in Ins and S1 induced facilitation and inhibition of meningeal-evoked responses, respectively. CSD triggered in V1 affects differently Ins and S1 cortices, enhancing or inhibiting meningeal-evoked responses of Sp5C, without affecting cutaneous-evoked nociceptive responses. Our data suggest that "top-down" influences from lateralized areas within Ins and S1 selectively affect interoceptive (meningeal) over exteroceptive (cutaneous) nociceptive inputs onto Sp5C. Such corticofugal influences could contribute to the development of migraine pain in terms of both topographic localization and pain tuning during an attack.
J Headache Pain. 2011 Jan 6. [Epub ahead of print]
Incidence and influence on referral of primary stabbing headache in an outpatient headache clinic.
Guerrero AL, Herrero S, Peñas ML, Cortijo E, Rojo E, Mulero P, Fernández R.
Neurology Department, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain, gueneurol@gmail.com.
Abstract
Primary stabbing headache (PSH) is a pain, as brief, sharp, jabbing stabs, predominantly felt in the first division of trigeminal nerve. Population studies have shown that PSH is a common headache. However, most people suffer attacks of low frequency or intensity and seldom seek for medical assistance. There are few clinic-based studies of PSH, and its real influence as a primary cause for referral to neurology outpatient offices is to be determined. We aim to investigate the burden of PSH as main complaint in an outpatient headache clinic. We reviewed all patients with PSH (ICHD-II criteria), attended in an outpatient headache clinic in a tertiary hospital during a 2.5-year period (January 2008-June 2010). We considered demographic and nosological characteristics and if PSH was main cause of submission. 36 patients (26 females, 10 males) out of 725 (5%) were diagnosed of PSH. Mean age at onset 34.1 ± 2.9 years (range 10-72). Mean time from onset to diagnosis 68.8 ± 18.3 months. Twenty-four patients fulfilled ICHD-II criteria for other headaches (14 migraine, 6 tension-type headache, 2 hemicrania continua, 1 primary cough headache and 1 primary exertional headache). 77.7% of patients were submitted from primary care. In 14 patients (39%), PSH was main reason for submission, its intensity or frequency in 5 (35.7%) and fear of malignancy in 9 (74.3%). Only two patients of those who associated other headaches were submitted due to PSH. In conclusion, PSH is not an uncommon diagnosis in an outpatient headache office. However, and according to our data, it is not usually the main cause of submission to a headache clinic.
PMID: 21210176 [PubMed - as supplied by publisher]
I have long advocated that the majority of Migraines and Tension-Type headaches are actually input-output errors. Nociceptive information entering the Trigeminovascular system are the pathology that triggers migraines and other headaches.
This study looked at fMRI or functional MRI studies of the brain.
They found that predicting migraine by trigeminal nociceptive activity could predict migraines.
Whers does most nociceptive trigeminal input arise?
In the Jaw Muscles, Muscle Spindles, Golgi Tendon Organs and periodontal ligaments of the teeth.
Neuromuscular Dentistry is very effective in eliminating and preventing migraines and muscular tension-type headaches. The majority of "sinus headaches" are actually referred muscle pain. The reason for the success of Neuromuscular Dentistry is the ability to eliminate nociceptive input.
Input/output errors are often described in computer lingo as Garbage In / Garbage Out.
The neurofeedback loops from periodontal ligaments , muscles, muscle spindles etc send nociceptive input (ie Garbage in) into the trigeminovascular system.
Migraines and other headaches are the "Garbage Out " part of the equation.
The article states that:
"Remarkably, the distance to the next headache attack was predictable by the height of the signal intensities in the spinal nuclei. Migraine patients scanned during the acute spontaneous migraine attack showed significantly lower signal intensities in the trigeminal nuclei compared with controls, demonstrating activity levels similar to interictal patients. Additionally we found-for the first time using fMRI-that migraineurs showed a significant increase in activation of dorsal parts of the pons, previously coined "migraine generator." Unlike the dorsal pons activation usually linked to migraine attacks, the gradient-like activity following nociceptive stimulation in the spinal trigeminal neurons likely reflects a raise in susceptibility of the brain to generate the next attack, as these areas increase their activity long before headache starts. This oscillating behavior may be a key player in the generation of migraine headache, whereas attack-specific pons activations are most likely a secondary event."
Another article in Neurology. 2011 Jan 18;76(3):206-7 states "Photophobia is an abnormal sensitivity to light experienced by migraineurs during attacks. The pathophysiology of photophobia is poorly understood. Nevertheless, 2 facts appear to have a link with photophobia: visual cortex hyperexcitability on the one hand and interactions between visual pathway and trigeminal nociception on the other."
The photophobia or sensitivity to light during a migraine attack is also due, in part to trigeminal nociception (Garbage in. The nociceptive input from the teeth,jaws, periodontal ligaments are the "garbage in" and the migraines and photophobia are the Garbage out".
Experimental studies on rats "J Neurosci. 2010 Oct 27;30(43):14420-9.
Changes of meningeal excitability mediated by corticotrigeminal networks: a link for the endogenous modulation of migraine pain." confirm the effect of trigeminanl nociception on meningeal migraines. The Trigeminovascular system is always paramount in migraine. The Trigeminal nerve controls the blood flow to the anterior 2/3 of the meninges of the brain.
Primary Stabbing Headaches are also trigeminally innervated as reported in"
J Headache Pain. 2011 Jan 6. [Epub ahead of print]
Incidence and influence on referral of primary stabbing headache in an outpatient headache clinic." The article states that "Primary stabbing headache (PSH) is a pain, as brief, sharp, jabbing stabs, predominantly felt in the first division of trigeminal nerve." The trigeminal nerve you will remember is the Dentist's nerve.
PubMed Abstract below:
J Neurosci. 2011 Feb 9;31(6):1937-43.
Trigeminal nociceptive transmission in migraineurs predicts migraine attacks.
Stankewitz A, Aderjan D, Eippert F, May A.
Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany.
Abstract
Several lines of evidence suggest a major role of the trigeminovascular system in the pathogenesis of migraine. Using functional magnetic resonance imaging (fMRI), we compared brain responses during trigeminal pain processing in migraine patients with those of healthy control subjects. The main finding is that the activity of the spinal trigeminal nuclei in response to nociceptive stimulation showed a cycling behavior over the migraine interval. Although interictal (i.e., outside of attack) migraine patients revealed lower activations in the spinal trigeminal nuclei compared with controls, preictal (i.e., shortly before attack) patients showed activity similar to controls, which demonstrates that the trigeminal activation level increases over the pain-free migraine interval. Remarkably, the distance to the next headache attack was predictable by the height of the signal intensities in the spinal nuclei. Migraine patients scanned during the acute spontaneous migraine attack showed significantly lower signal intensities in the trigeminal nuclei compared with controls, demonstrating activity levels similar to interictal patients. Additionally we found-for the first time using fMRI-that migraineurs showed a significant increase in activation of dorsal parts of the pons, previously coined "migraine generator." Unlike the dorsal pons activation usually linked to migraine attacks, the gradient-like activity following nociceptive stimulation in the spinal trigeminal neurons likely reflects a raise in susceptibility of the brain to generate the next attack, as these areas increase their activity long before headache starts. This oscillating behavior may be a key player in the generation of migraine headache, whereas attack-specific pons activations are most likely a secondary event.
PMID: 21307231 [PubMed - indexed for MEDLINE]
Neurology. 2011 Jan 18;76(3):213-8. Epub 2010 Dec 9.
A PET study of photophobia during spontaneous migraine attacks.
Denuelle M, Boulloche N, Payoux P, Fabre N, Trotter Y, Géraud G.
Service de Neurologie et Explorations Fonctionnelles du Système Nerveux, CHU Rangueil, Toulouse, France. denuelle.m@chu-toulouse.fr
Comment in:
* Neurology. 2011 Jan 18;76(3):206-7.
Abstract
BACKGROUND: Photophobia is an abnormal sensitivity to light experienced by migraineurs during attacks. The pathophysiology of photophobia is poorly understood. Nevertheless, 2 facts appear to have a link with photophobia: visual cortex hyperexcitability on the one hand and interactions between visual pathway and trigeminal nociception on the other.
METHODS: We used H(2)(15)O PET to study photophobia induced by continuous luminous stimulation covering the whole visual field in 8 migraineurs during spontaneous migraine attacks, after headache relief by sumatriptan and during attack-free interval. The intensity of the luminous stimulation provoking photophobia with subsequent headache enhancement was specifically determined for each patient.
RESULTS: We found that low luminous stimulation (median of 240 Cd/m(2)) activated the visual cortex during migraine attacks and after headache relief but not during the attack-free interval. The visual cortex activation was statistically stronger during migraine headache than after pain relief.
CONCLUSION: These findings suggest that ictal photophobia is linked with a visual cortex hyperexcitability. The mechanism of this cortical hyperexcitability could not be explained only by trigeminal nociception because it persisted after headache relief. We hypothesize that modulation of cortical excitability during migraine attack could be under brainstem nuclei control.
PMID: 21148120 [PubMed - indexed for MEDLINE]
J Neurosci. 2010 Oct 27;30(43):14420-9.
Changes of meningeal excitability mediated by corticotrigeminal networks: a link for the endogenous modulation of migraine pain.
Noseda R, Constandil L, Bourgeais L, Chalus M, Villanueva L.
Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA.
Abstract
Alterations in cortical excitability are implicated in the pathophysiology of migraine. However, the relationship between cortical spreading depression (CSD) and headache has not been fully elucidated. We aimed to identify the corticofugal networks that directly influence meningeal nociception in the brainstem trigeminocervical complex (Sp5C) of the rat. Cortical areas projecting to the brainstem were first identified by retrograde tracing from Sp5C areas that receive direct meningeal inputs. Anterograde tracers were then injected into these cortical areas to determine the precise pattern of descending axonal terminal fields in the Sp5C. Descending cortical projections to brainstem areas innervated by the ophthalmic branch of the trigeminal nerve originate contralaterally from insular (Ins) and primary somatosensory (S1) cortices and terminate in laminae I-II and III-V of the Sp5C, respectively. In another set of experiments, electrophysiological recordings were simultaneously performed in Ins, S1 or primary visual cortex (V1), and Sp5C neurons. KCl was microinjected into such cortical areas to test the effects of CSD on meningeal nociception. CSD initiated in Ins and S1 induced facilitation and inhibition of meningeal-evoked responses, respectively. CSD triggered in V1 affects differently Ins and S1 cortices, enhancing or inhibiting meningeal-evoked responses of Sp5C, without affecting cutaneous-evoked nociceptive responses. Our data suggest that "top-down" influences from lateralized areas within Ins and S1 selectively affect interoceptive (meningeal) over exteroceptive (cutaneous) nociceptive inputs onto Sp5C. Such corticofugal influences could contribute to the development of migraine pain in terms of both topographic localization and pain tuning during an attack.
J Headache Pain. 2011 Jan 6. [Epub ahead of print]
Incidence and influence on referral of primary stabbing headache in an outpatient headache clinic.
Guerrero AL, Herrero S, Peñas ML, Cortijo E, Rojo E, Mulero P, Fernández R.
Neurology Department, Hospital Clínico Universitario, Avda Ramón y Cajal 3, 47005, Valladolid, Spain, gueneurol@gmail.com.
Abstract
Primary stabbing headache (PSH) is a pain, as brief, sharp, jabbing stabs, predominantly felt in the first division of trigeminal nerve. Population studies have shown that PSH is a common headache. However, most people suffer attacks of low frequency or intensity and seldom seek for medical assistance. There are few clinic-based studies of PSH, and its real influence as a primary cause for referral to neurology outpatient offices is to be determined. We aim to investigate the burden of PSH as main complaint in an outpatient headache clinic. We reviewed all patients with PSH (ICHD-II criteria), attended in an outpatient headache clinic in a tertiary hospital during a 2.5-year period (January 2008-June 2010). We considered demographic and nosological characteristics and if PSH was main cause of submission. 36 patients (26 females, 10 males) out of 725 (5%) were diagnosed of PSH. Mean age at onset 34.1 ± 2.9 years (range 10-72). Mean time from onset to diagnosis 68.8 ± 18.3 months. Twenty-four patients fulfilled ICHD-II criteria for other headaches (14 migraine, 6 tension-type headache, 2 hemicrania continua, 1 primary cough headache and 1 primary exertional headache). 77.7% of patients were submitted from primary care. In 14 patients (39%), PSH was main reason for submission, its intensity or frequency in 5 (35.7%) and fear of malignancy in 9 (74.3%). Only two patients of those who associated other headaches were submitted due to PSH. In conclusion, PSH is not an uncommon diagnosis in an outpatient headache office. However, and according to our data, it is not usually the main cause of submission to a headache clinic.
PMID: 21210176 [PubMed - as supplied by publisher]
Sunday, April 3, 2011
HEADACHES AND MYOFASCIAL TRIGGER POINTS: HIGH POWER ULTRASOUND VS TRIGGER POINT INJECTIONS EQUIVILANT FOR TRAPEZIUS MUSCLE TPs
I have found that trigger point injections are extremely effective in reducing tension-type headaches and frequently can completely eliminate them when combined with a neuromuscular orthotic. This current study from the Archives of Physical Medicine and Rehabilitation shows high-power ultrasound as effective as trigger point injections in treating the Trapezius muscle.
The Trapezius muscle is a large easily treated muscle that can cause referred headache pain. Trigger point injections took less therapy sessions but there was equal effectiveness to both treatments. When treating headaches many of the muscles that cause tension-type headaches are not good candidates for high-power ultrasound. Treating headaches without medication usually requires elimination of muscle trigger points. Neuromuscular Dentistry uses Ultra-Low Frequency TENS to eliminate the underlying cause of Trigger Points and headaches. Trigger Point injections and and Spray and Stretch as described by Travell and Simons is extremely effective in eliminating and preventing re-occurence of trigger points that cause tension-type headaches.
This new study (see abstract below) shows that high-power ultrasound was as effective as trigger point injections when treating trapezius pain and reduction in motion. Treatment of headaches is usually much more effective with trigger point injections. Ultrasound is of little use in treating medial and lateral pterygoid muscles, TMJ oints, Temporalis Muscles, and supra and ifra hyoid muscles.
Tension-Type headaches and Myofascial trigger points are frequently triggers for Migraines.
The use of a diagnostic neuromuscular orthotic is a safe and effective method to evaluate patient's response to Neuromuscular Dentistry. I sometimes consider utilizing trigger point injections, spray and stretch techniques, SPG blocks and other treatment modalities as cheating. Neuromuscular dentistry is such a powerful tool but utilizing these other procedures can drastically enhance the therapeutic effect.
Arch Phys Med Rehabil. 2011 Apr;92(4):657-62.
Comparison of high-power pain threshold ultrasound therapy with local injection in the treatment of active myofascial trigger points of the upper trapezius muscle.
Unalan H, Majlesi J, Aydin FY, Palamar D.
Department of Physical Medicine and Rehabilitation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.
Abstract
Unalan H, Majlesi J, Aydin FY, Palamar D. Comparison of high-power pain threshold ultrasound therapy with local ınjection in the treatment of active myofascial trigger points of the upper trapezius muscle.
OBJECTIVE: To compare the effects of high-power pain threshold ultrasound (HPPTUS) therapy and local anesthetic injection on pain and active cervical lateral bending in patients with active myofascial trigger points (MTrPs) of the upper trapezius muscle.
DESIGN: Randomized single-blinded controlled trial.
SETTING: Physical medicine and rehabilitation department of university hospital.
PARTICIPANTS: Subjects (N=49) who had active MTrPs of the upper trapezius muscle.
INTERVENTIONS: HPPTUS or trigger point injection (TrP).
MAIN OUTCOME MEASURES: Visual analog scale, range of motion (ROM) of the cervical spine, and total length of treatments.
RESULTS: All patients in both groups improved significantly in terms of pain and ROM, but there was no statistically significant difference between groups. Mean numbers of therapy sessions were 1 and 1.5 in the local injection and HPPTUS groups, respectively.
CONCLUSIONS: We failed to show differences between the HPPTUS technique and TrP injection in the treatment of active MTrPs of the upper trapezius muscle. The HPPTUS technique can be used as an effective alternative to TrP injection in the treatment of myofascial pain syndrome.
Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
PMID: 21440713 [PubMed - in process]
The Trapezius muscle is a large easily treated muscle that can cause referred headache pain. Trigger point injections took less therapy sessions but there was equal effectiveness to both treatments. When treating headaches many of the muscles that cause tension-type headaches are not good candidates for high-power ultrasound. Treating headaches without medication usually requires elimination of muscle trigger points. Neuromuscular Dentistry uses Ultra-Low Frequency TENS to eliminate the underlying cause of Trigger Points and headaches. Trigger Point injections and and Spray and Stretch as described by Travell and Simons is extremely effective in eliminating and preventing re-occurence of trigger points that cause tension-type headaches.
This new study (see abstract below) shows that high-power ultrasound was as effective as trigger point injections when treating trapezius pain and reduction in motion. Treatment of headaches is usually much more effective with trigger point injections. Ultrasound is of little use in treating medial and lateral pterygoid muscles, TMJ oints, Temporalis Muscles, and supra and ifra hyoid muscles.
Tension-Type headaches and Myofascial trigger points are frequently triggers for Migraines.
The use of a diagnostic neuromuscular orthotic is a safe and effective method to evaluate patient's response to Neuromuscular Dentistry. I sometimes consider utilizing trigger point injections, spray and stretch techniques, SPG blocks and other treatment modalities as cheating. Neuromuscular dentistry is such a powerful tool but utilizing these other procedures can drastically enhance the therapeutic effect.
Arch Phys Med Rehabil. 2011 Apr;92(4):657-62.
Comparison of high-power pain threshold ultrasound therapy with local injection in the treatment of active myofascial trigger points of the upper trapezius muscle.
Unalan H, Majlesi J, Aydin FY, Palamar D.
Department of Physical Medicine and Rehabilitation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.
Abstract
Unalan H, Majlesi J, Aydin FY, Palamar D. Comparison of high-power pain threshold ultrasound therapy with local ınjection in the treatment of active myofascial trigger points of the upper trapezius muscle.
OBJECTIVE: To compare the effects of high-power pain threshold ultrasound (HPPTUS) therapy and local anesthetic injection on pain and active cervical lateral bending in patients with active myofascial trigger points (MTrPs) of the upper trapezius muscle.
DESIGN: Randomized single-blinded controlled trial.
SETTING: Physical medicine and rehabilitation department of university hospital.
PARTICIPANTS: Subjects (N=49) who had active MTrPs of the upper trapezius muscle.
INTERVENTIONS: HPPTUS or trigger point injection (TrP).
MAIN OUTCOME MEASURES: Visual analog scale, range of motion (ROM) of the cervical spine, and total length of treatments.
RESULTS: All patients in both groups improved significantly in terms of pain and ROM, but there was no statistically significant difference between groups. Mean numbers of therapy sessions were 1 and 1.5 in the local injection and HPPTUS groups, respectively.
CONCLUSIONS: We failed to show differences between the HPPTUS technique and TrP injection in the treatment of active MTrPs of the upper trapezius muscle. The HPPTUS technique can be used as an effective alternative to TrP injection in the treatment of myofascial pain syndrome.
Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
PMID: 21440713 [PubMed - in process]
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