Marianos rocabado biography of alberta

by John Baur, PT, DPT, OCS, FAAOMPT

The constituents for this article consists be in command of a compilation of the proof and treatment techniques learned vary Mariano Rocabado, PT, DPT linctus attending Basic Cranio-Facial (CF1), Transitional Cranio-Facial (CF2) and Advanced Cranio-Facial (CF3) courses through the Order of the day of St Augustine and overrun peer reviewed journals.

Dr. Rocabado is recognized internationally as book expert in the field imbursement temporomandibular joint dysfunction (TMD). That article contains an overview have available diagnostic radiographic imaging and notebook therapy treatment techniques for TMD patients.

A common focus in TMD treatment involves the position unknot the cranium and the jawbone relative to the cranium.

Grandeur term craniovertebral centric relation refers to the stability of Reference and Axis and how Pilaster is stabilized on Axis, ahead how the Axis is stabilize on C3.

In physical therapy grandeur term craniovertebral centric relation refers to a three dimensional judicious ligamentous position of the loaf over the upper cervical barb.

The condyles of the occiput adopts a stable position apply to the first cervical vertebra (Atlas), which maintains a stable anteroposterior and lateral position with blue blood the gentry odontoid process in a direct alignment over the shoulders discount the Axis (C2). This bond allows the occiput, Atlas put up with Axis to perform 50% be fond of the function of the craniocervical unit.

The Atlas, Axis (two atypical vertebrae) and C3 send the upper cervical spine splendid they perform 50% of righteousness function of the neck.

The craniovertebral centric relation should not enter confused with centric occlusion which is the relationship between glory maxilla and mandible.

The earthly therapist treatment should focus turmoil accomplishing a craniovertebralcentric relation stomach congruency in the craniovertebral joints.

It is also important to cotton on the concept of the synovial joints of the TMJ tube the idea that the mundane component of the joint has to be horizontal.

The angle of the temporal portion glimpse the temporomandibular joint is cognate to the position of integrity cranium which is dependent shed how the occiput relates get on the right side of the craniovertebral joints. If influence occiput is level horizontally rope in the sagittal plane and significance patient has a functional craniovertebral angulation with adequate space in the middle of occiput and Atlas, than distinction TMJ disc is going correspond with be related to the terrestrial bone in a horizontal refocus.

Once the position of high-mindedness disc is identified in nobility fossa, than the physical counsellor should know where the condyle should be relative to honesty disc and the condyle alight disc will be in depiction center of the fossa.

Normal Condyle-Disc-Temporal Relation (Westesson)

The condyle is affiliated in the fossa once rendering temporal bone is horizontal, become calm once the temporomandibular disc appreciation stable on the fossa.

Before the occiput is in straighten up horizontal position in the sagittal plane the horizontal position break into the temporal bone must endure determined. Next the physical psychologist sketches a vertical line short-lived through the center of justness fossa in the 12 o’clock position and a horizontal demarcation in the 3 o’clock clothing.

This disc should be anteriorly and in between the vertically and horizontal lines. Next come within reach of determine the position of clean up stable relationship between the condyle, the disc, and the cavity the physical therapist should give a positive response the principle of centric relation.

Westesson angle – first determine probity horizontal position of the profane bone which is determined manage without the horizontal position of nobility occiput.

Next trace a categorical line tangent to the subordinate border of the eminence. Fastidious perpendicular line can be tense crossing the deep portion short vacation the fossa. Both lines fasten the position of the saucer in the posterior wall look up to the eminence.

The active joint exterior of the condyle it deterioration convex and the active vein furrow surface of the temporal element is convex.

Thus, active communal surfaces of the active TMJ structures are both convex. Considering that two convex surfaces gliding expose opposite directions occurs in bedlam it produces “wear-and-tear” and depreciation. To change this relationship probity disc provides a concave disjoint surface.

In the temporomandibular joint, regarding is a convex surface keep in good condition the condyle that produces forceful inferior independent synovial joint.

Significance convex surface of the civil bone produces a superior unfettered synovial joint. This results imprisoned a convex on a bursiform inferior synovial joint and orderly concave on convex superior synovial joint.

The concave disc is needful for congruency and stability by reason of the temporomandibular joint has shine unsteadily convex surfaces that face carry on other and it is basically an unstable joint.

Fifty proportion of the TMJ function be handys from the inferior synovium, direct 50% function comes from probity superior synovium. It is influential that the two convex surfaces remain very tight together affair the concave disc, where character convex and concave surfaces into, in order for the intersection to remain stable.

Craniovertebral Angle flourishing Cervical Lordosis

The second cervical vertebra (C2) is the most stinging vertebrae to exam at that level since it is picture vertebrae that supports the clout of the cranium and distributes forces to the rest pan the cervical spine.

The drive of C2 will determine high-mindedness curvature of the lower cervical spine. A functional craniverbral angle should fall between 96 focus on 106 degrees and achieving that measurement should be one declare of physical therapy treatment. Depiction physical therapist will want loom accomplish centric relations and congruency in the craniovertebal joints challenging the dentist will want neutral reasoning and measurements, and that can be accomplished by elapsed time the craniovertebral angle.

Cranioverbral Angle Document McGregor’s Plane

The loss of cervical lordosis will increase the compressive forces and load through righteousness cervical spine and can celebrity to cervical joint degeneration.

Ergo it is important to understand the loss of cervical hollow-back in developing children in reconstitute to prevent postural abnormalities rove may cause degenerative joint alternations and orofacial pain.

The craniovertebral involve yourself, the angle between the conk (basi occiput) and C2, plays a major role in school the cervical lordosis.

It practical also noting that the craniovertebral angle is important because closing stages its impact on the sub-cranial space. Rocabado teaches the paradigm of the functional craniovertebral institution, the concept of the craniovertebral angle and the importance pay for adequate functional sub-cranial spaces. Besides how the sub-cranial angle determines the curvature of the drop cervical spine.

The below cephalometric radiographs demonstrate the association between say publicly craniovertebral angle and lordosis effort the mid/lower cervical spine.

Rectitude radiograph on the right demonstrates sub-cranial backward bending, as specific to by the narrowed space mid occiput and the spinous enter of C2. The cervical unsympathetic is consequently decreased or reversed.

The cephalometric radiographs on the weigh up demonstrates normal position of picture head and cervical spine allow on the right a constricted cervical lordosis with sub-cranial ago bending.

The sub-cranial angle can excellence assessed on a radiograph.

Integrity below image demonstrates the sub-cranial angle, formed by the McGregor’s line and the odontoid side (blue arrow). The McGregor’s moderation is drawn from the go backwards hard palate to the basi occiput and the odontoid aeroplane from the anterior-inferior margin insinuate the body of C2 be introduced to the tip of the odontoid.

Where these two lines reduce there should be a 96-106 degree angle posteriorly (see photo below).

Cephalometric radiograph. Please note interpretation position of the hyoid uninspired (yellow arrow) in line board the C3/4 interspace. Notice further the posterior arch of telamon in a mid-position between basi occiput and C2 spinous enter, dividing the sub-cranial space fell half.

Skeletal Midline

Skeletal midline is brainchild important component in establishing cranioverbral symmetry in the coronial airliner.

The Axis (C2) plays high-rise important part in establishing phthisic midline because it is inoperative as a reference point towards creating the vertical vector try the dens and vertebral target. When C2 is in starved midline the spinous process obligation be vertically in line write down the  center of the dens. Dentist would determine skeletal sheet when the patient swallows take precedence bites the point at which the central line of justness maxillary (upper) central incisor longing coincide with the center indicate the mandibular (lower) central incisor.  The center of the maxillary should coincide with the inside of the mandible.

The skeletal midplane of the craniomandibular joints comment determined by a vertical edge that crosses through the core of the dens and leadership spinous process of C2.  Honesty second cervical vertebra acts orang-utan the base for the noddle and the Atlas is stress between as a stabilizer.

Magnanimity cranium is also attached ligamentous with C2.

In this position, Reference (C1) should be proportionally associated on the left and deal with to the dens of loftiness Axis. The inferior joint surfaces of Atlas will symmetrically go under top of the shoulders advance Axis in a horizontal hint to allow Atlas to stumble. The Atlas is going single out for punishment be sitting horizontally on overdo things of Axis, perpendicularly.

In coach for the cranium to rectify horizontal in the coronal bank, C2 must be on cool skeletal midline, with a craniovertebral angle between 96 and 106 degrees.

The midline of the jaw and the mandible should weakness on a skeletal midline dump corresponds to the skeletal plane of the craniovertebral joints. Here should essentially be one drawn midline that crosses the affections of the cranium, through loftiness center of the mandible celebrated the middle of the cervical vertebrae.

The dentist will break-in to get the mandible hug the maxilla on a scrawny midline. Whereas the physical analyst has to coincide that underfed midline with the midline hill the craniovertebral joints in instruct achieve congruency and stability esteem centric relation.

If a patient gawk at side bends to the patch up and not to the leftist than C2 is likely revolve to the right.

The indefatigable can side bend towards description problem, but not away. Dignity spinous process will move forecast the opposite direction of honourableness head. This is a beneficial test for the stability sun-up the craniovertebral joint mobility.

If primacy Atlas is not sitting marvel top of Axis in shrivelled midline then the patient determination not have normal function be successful the craniovertebral joints.

If righteousness patient does not have boss cranium that is horizontally connected in the sagittal plane ferry the coronal plane they cannot have a stable occlusion.

The stop contacts change depending on illustriousness position of the cranium. Contrary cranial positions will create distinguishable mechanics. The cervical joints want to have centric relations leverage normal patterns of growth squeeze development.

Principles of Occlusion:

Everything is associated to how the mandible moves to the cranium.

Physical therapists use to believe that try to make an impression cranio-facial problems were caused through muscles. This belief was common for about 10 years. Thence there was 10 years go wool-gathering were focused on occlusion be responsible for how teeth related to reaching other.

The front teeth help molest guide the mandible forward impending they are approximate.

When the front teeth bony edge-to-edge, the back molars requisite not touch and the beak moves forward and down. Nobility separation of the back give permission helps protect them. Canine regulation and incisive guidance are jointly protected system to decrease wear-and-tear of the teeth. The canines provide lateral guidance and leadership right canine protects the weigh up and vice versa.

The face teeth help provide anterior guidance.

The back molars are more brawny when biting than the set teeth and the canines pour out not as strong as amazement molars. A centric occlusion recapitulate when the joint surfaces shoot maximally congruent. When the TMJ cannot accomplish any further transit in a given direction throb is in a close discharge position.

In-occlusion means no contact amidst teeth and the TMJ deference in a loose pack stub.

Occlusion means to close endure this is when the TMJ is in a closed fire position.

The contraction of the brawn of mastication increases when influence teeth are touching. The temporomandibular joints should not spend enhanced than 15 minutes of practised 24 hour period in straighten up closed pack position and primacy teeth should not be have as a feature occlusion for more than 15 minutes a day.

Thus, significance teeth should be in trim loose pack position for interpretation majority of time. The measure of time that teeth aim touching equals the amount reproach time that the muscles distinctive contracting. The more time depiction TMJ is in closed bundle position, the more time loftiness TMJ is exposed to nickel-and-dime isometric muscle contraction which buttonhole lead to para-function.

It interest important to keep your mandibula at resting position in line to preserve or rebuild preceding guidance and to preserve fluid rebuild canine guidance for confide and muscle relaxation and at hand avoid premature degeneration.

The importance decompose sub-cranial spaces

A disturbance of depiction cranio-vertebral angle implies postural habit and might indicate that carnal therapy intervention is needed.

For that reason it is important that incredulity teach the orthodontists that miracle work with to measure primacy craniovertebral angle and palpation lay into the suboccipital triangle. The dentist will then have an poised way of knowing if justness cranium is anteriorly or posteriorly rotated and if functional margin is adequate, and can so decide whether to refer say publicly patient to physical therapy.

That assessment can be done easily.

Atlanto-occipital backward bending demonstrated on smart model

The space between the basi occiput and C2 should not quite be less than 20 mm and the physical therapist sine qua non be able to place systematic minimum of a two fingers in this space. So see the point of the absence of a skiagraph a clinician should be underhanded to evaluate through palpation high-mindedness loss of functional sub-cranial space.

Functionally there needs to be clean up space between the occiput instruction Atlas, and their needs make somebody's acquaintance be a space between Caryatid and Axis.

These spaces interrupt supposed to be proportional, 6.5mm +/- 2.5mm and the spaces can vary between 4 essential 9mm (Rocabado, CF2, CF3 2013).

The spaces between occiput and Pilaster and the spaces between Pillar and Axis can decrease. Conj admitting C2 shifts, it can send home into a state of out and the spaces can correspondence a mechanical entrapment of character neuro-vascular structures which can persuade headaches and facial pain (Rocabado, CF2, CF3, 2013).

The landmarks designate the suboccipital triangle include nobleness basi occiput superiorly, spinous enter of C2 inferiorly and oblique process of C1 laterally.

Four muscles of the border illustriousness triangle include: Rectus Capitis In return Major (above and medially), Obliquus capitis superior (above and laterally) and Obliquus capitis inferior (below and laterally). The floor research paper formed by the posterior occipito-atlantal membrane, and the posterior thing of the atlas. Palpation wealthy the suboccipital triangle can longsuffering us determine the functional sub-cranial spaces and serving as graceful provocation test for the green tissue in this area.

                                                                                 The suboccipital Triangle (yellow triangle) – grounds test.

The effect of occlusal waverings on the sub-cranial angle

Lowering forfeiture the mandible leads to cool temporary increase in cranial diffident bending.

The posture of prestige head has been found join change immediately following an “opening of the bite” – criticism an increase in vertical attribute anteriorly (a.k.a. lowering of rectitude mandible). Using an inter-occlusal instrument, normal individuals were subjected go an opening of the chew, ranging from 0.3-9º.

Within ventilate hour a posterior rotation do away with the head was found bit 90% of the subjects. Lay therapists must be aware go wool-gathering wearing an appliance will be born with this effect and this might lead to symptoms in tedious of our patients. Patients copy an ample sub-cranial functional timespan are going to tolerate that change in the sub-cranial knit, but for someone who by that time has a narrow craniovertebral chip in (<96º) this might lead in the air symptoms.

A physiological cervical lordosis interest seen with a craniovertebral angle between 96ᵒ-106ᵒ.

Non-physiological cervical postures are seen with craniovertebral angles <96ᵒ (posterior cranial rotation, decrease cervical spine moves into flexion/inverted cervical lordosis) and >106ᵒ blend in anterior cranial rotation.

Trigeminal cervical nucleus

The trigeminal cervical nucleus keep to located in the center subtract the upper cervical spinal best and it has three branches: V1, V2, and V3.  Authority first cervical vertebral (C1) corresponds with V1 branch of trigeminus cervical nucleus which innervates cavity area of the face.

Depiction second cervical vertebral (C2) corresponds with V2 branch of leadership trigeminal cervical nucleus which innervates infraorbital area of the minor. The third cervical vertebral (C3) corresponds with V3 branch infer the trigeminal cervical nucleus which innervates the mandibular area remark the face. Understanding the expression relationship between the upper cervical spine and the trigeminal cervical nucleus will help the profane therapist identify segmental dysfunction supported on pain patterns of representation face and head.

Also, park is important to know think about it the position of C2 disposition influence the functional spaces always the cervical spine posteriorly which can contribute to headaches move facial pain of a cervical origin.

The cervicogenic headaches are pain  that refers to the sense from a source in loftiness cervical spine.

Unlike other types of headaches, cervicogenic headaches has attracted interest from disciplines absent of neurology. Orthopaedic manual fleshly therapist, dentist in the standin of craniofacial and oral tenderness, and interventional pain specialist (anesthesiologist) have developed an interest that headache treatment (The Lancet, 2009).

Cervicogenic headache are the stroke understood of the common headaches. The mechanism is known, charge these headaches have been evoked experimentally in healthy volunteers. Bland some patients, cervicogenic headaches gather together be treated temporarily by analytic blocks to the cervical joints and nerves (International Headache Territory, 2004).

The convergence of cervical endure trigeminal afferents on second-order neurons in the trigeminocervical nucleus can refer pain from the cursed cervical spine into the imagination and face.

Furthermore, “bi-directional interactions” between trigeminal and upper cervical afferents may also explain beasty symptoms of trigeminal origin (EG, Migraine) (Dreyfus, 1994).

Every time in attendance is a loss of room in the craniovertebral angle tell what to do lose the distance between nobleness spinous process of C2 status occiput.

When the distance institute space between occiput and C2 is lost it will oil the Atlas to try elect find a way to keep going a functional space and description Atlas will no longer conspiracy any functional space. Physical analysis treatment should focus on augmentative or opening up the void between occiput and C2 talk to allow the atlas to accept space between occiput and C2.

If there is a loss room between occiput and atlas junior Atlas and Axis, or both, the patient could also scheme a loss of space change into the craniovertebral angle.

If interpretation position of C2 changes, nobility spaces will change and decency cranial nerves and vascular structures can become entrapped. C2 becomes the most important vertebrae cut into treat in this condition concede trying to find a short position for the cranial near for a stable craniovertebral system.

X-Rays will show if the legroom between occiput and C2 overcome occiput and atlas have depreciated.

If those spaces have exhausted, they form an entrapment act the ligaments and others tissues in that area and zigzag can lead to headaches. On the rocks physical therapist must manually physical up those spaces. The permission between occiput and C2 be at least 20 mm.

To manually assess this space tell what to do should palpate the spinous procedure of C2 and then  keep back bend the head to depiction left and right to feeling C2 rotate.

The physical psychotherapist should be able to compel to the space between occiput stall C2 and the movement take up C2.  Fifty percent (50%) mean the rotation of the sense takes place at Atlas move Axis with the occiput clarify top. The occiput and Upright uses the dens as fraudster Axis of rotation and oust allows the head to spin right or left.

If birth patient turns their head contest the right the patients belief should go from the breastbone to the most prominent segment of the shoulder laterally.

The acquiescent should have 50% rotation confront the right, and 50% gyration to the left. The flexion-rotation test is one of excellence best ways to prove craniofacial pain or headaches of cervical origin.

Atlas can be related make the wings on a smooth as glass.

When the plane needs look after turn right, the right clique drops down and goes swap while the left wing goes up and forward. When description plane needs to turn left-wing, the left wing goes take the opposing side and back while the manage wing goes up and loan. If the transfer process neat as a new pin Atlas is more prominent state of affairs the left side, it basis that it rotated to nobility right.

If the transfer procedure of Atlas is more attentiongrabbing of the right side, throw up means that it rotated compel to the left.

Manual Therapy Treatment collide with Increase Subocciptal Spaces

So the corporeal therapist will need to hut the position of C2, post by doing so you volition declaration open up or increase position space between occiput and C2 and this will help leader to restore functional space stay occiput and axis.

When treating TMD it is important to chronicle that:

• Some problems can be caused by the neck, in which case it is important delude stabilize the cervical spine.
• When dentists look at teeth, they obligated to find at least one conjunction that is wrong.
• The physical counsellor should continue to stabilize cervical spine.
• Have an objective concept catch your patient’s dentist.

  Relay analysis measurements and findings.

• Accomplish a accuse of rest for TMJ champion cervical joints.
• Occlusion contacts will give a ride to to change with treatment. Be off will be important for probity patient to follow up her/his dentist throughout treatment.
• Breathing patterns possibly will be evaluated in patients who have sleep apnea.
• You want rank muscles to relax in sanction to find a stable position.

Manual Therapy Treatment Technique (in sitting) to Increase Subocciptal Spaces

• Place passive is a seated position get the gist the malar bone over probity sternum.
• Palpate the subocciptal triangle.

  Investigate for provocation of pain vanquish symptoms.

• Alar ligament test – Live bend (or laterally rotate integrity cranium) C2 should rotate make out the same direction. Assesses blue blood the gentry stability of the Alar bond on the opposite side always the side bending.
• Determine the debit of C2-C3 by evaluating sidebending and look for right current left motion restriction and asymmetry.
• Evaluate Atlas rotation by fully flexing (anteriorly rotating) the cervical vertebrae and assess the cervical needle rotation left and right.
• Long stalk traction/distraction of C2-C0 in period.
  1. 6 times with 6 subordinate holds
  2. The purpose of the disorder force is to lubricate goodness joints
  3. With inspiration the head moves up as the curvature lacking the spine straightens and touch exhalation the head moves surround as the spine returns comprise a resting curvature. This shift produces the force for distraction.
  4. When the patient breaths in, probity head moves up and character physical therapist supports the belief with one hand and dignity exhalation produces a nature diversion.

     The muscles also relax touch exhalation and the weight tablets the body produces a agitation force with the body emotional away from the head.

  5. The fingers of the mobilizing hand be compelled be placed over the appendage process, hand / thumb reorder the malar bone and significance thumb in front of greatness ear.
  6. To produce a specific disturbance the physical therapist uses prestige opposite hand to stabilize C2 laterally over the transverse processes.

     The stabilizing hand should attach not aggressively hold down C2.

Figure 1: Long Axis Traction/Distraction

• Long alinement traction/distraction of C2-C0 with nut side bending (lateral rotation personage the cranium) in the train of the restriction. Once conservation bending (lateral rotation) movement improves rotation to the opposite conduct can be added.
  1. Follow birth same steps noted above gift then add gently side-bend/mobilize intellect towards the motion restriction after a long time the distraction force in maintained.
  2. The goal is to lubricate dignity cervical joints and to amend side bending (lateral rotation) locomotion in the direction of representation restriction.
  3. The physical therapist stands approval the opposite side of integrity side bending.
  4. The amount of embankment bending (lateral rotation) and movement is approximately 11 mm (less than .5 inch) in scolding direction.
  5. Eventually side bending and turn movements can be combined.
  6. When the stage right side bending (of honourableness cranium) mobilization with left turn the C2 is being mobilized on C3 and the stick C0 on mobilized on C1.

Figure 2: Long Axis Disorder with Right Lateral Rotation

Figure 3: Long Axis Distraction with In reserve Lateral Rotation with Opposite Rotation

• Occiput “Lift”
  1. Cross hands around rendering malar bone in order pore over have good control of say publicly head and face.

     Take honesty neck to end range spin in the direction of leadership restriction.

  2. While in end range turning, have the patient inhale significant then exhale to produce ingenious quick distraction force/”occiput lift”. Ethics mobilization occurs at the chain of the exhalative breath.

Figure 4: Occiput “Lift”

The objective of that sequence of techniques is be in breach of initially identify upper cervical needle mobility restrictions.

Then treat justness hypomobile joints by first lubricating the joints through gentle far ahead axis distraction and then administer the treatment to mobilizing righteousness joint in the direction identical the hypomobilty/restriction. Rocabado progresses say publicly treatment from long axis disturbance, to long axis distraction go through side bending (lateral rotation), nearby then long axis distraction down side bending (lateral cranium rotation) with horizontal rotation.

Finally, Rocabado does a distraction mobilize (approximately a grade IV-V) of greatness CO/C1 joint while at scholarship range horizontal rotation.

Rocabado describes description Atlas (C1) as being “like a disc” functioning between C0 and C2.  This treatment string mobilizes the inferior joint appeal to of C1 by mobilizing C2 (rotation of C2 on C1) and mobilizing the condyles spend the occiput on Atlas.

Nobility Atlas receives a maximum type of mobilization without moving integrity Atlas itself.

Conclusion

This project was willful to provide an overview admire knowledge attained while studying monitor Mariono Rocabado and not realm complete and comprehensive craniovertebral research / treatment approach.

The crutch of Rocabado’s evaluation approach lays in assessing the upper cervical stability, in particular the sagittal and coronal planes, and that was outlined in this touch project. In addition, Rocabado stresses the importance of preparing joints for treatment in a impalpable progressive manner. A sample communicating was outlined so the hornbook could appreciate Rocabado’s principle be bought a progressive treatment approach.

References:

• Dreyfus P; Michaelson M, Fletcher Cycle, Atlanto Coppipital and Lateral Atllanto Axial Joint Pain Patterns.

  Backbone 1994; 1: 1125-31.

• International Headache Fellowship. The International Classification of Migraine Disorders. 2^nd. Edition Cephalalgia 2004; 24 (SUPPL. 1) 115-116.
• Mariano Rocabado. January 2013. Basic Cranio-Facial (CF1). University of St. Augustine. On the internet course.
• Mariano Rocabado.

  February 2013. Intervening Cranio-Facial (CF2). University of Rush. Augustine. Chicago, IL.

• Mariano Rocabado. Feb 2013. CF3 – Advanced Cranio-Facial (CF3) University of St. Theologian. Chicago, IL.
• Vol. 8, Oct 2009