OROFACIAL MYOFUNCTIONAL THERAPY IN THE WORK OF A Speech Pathologist

Age restrictions for the use of myocorrection

Gymnastics for the correction of disorders of the dentoalveolar system is used when working with children aged 4-8 years, during the period of primary occlusion. If developmental anomalies are mild, then 2-3 months of training is sufficient. A positive effect can be achieved during the period of teeth change at the age of 9-12 years. During this period, the jaw is not yet fully formed and can be corrected. In later periods, the effect of therapy is minimal and requires a very long period of use (more than a year), so myofunctional exercises are not prescribed.

Non-childish problem in children

Most teenagers need braces due to uneven teeth.
If this defect does not cause anxiety and worry in adolescents, then as they grow older they will have cause for concern. The reason for crooked teeth lies in the lack of dental space. Many young patients require tooth extraction to solve this problem. How to avoid an unpleasant procedure? It is necessary to achieve expansion of the dental space by stimulating jaw growth (jaw expansion).

Indications and contraindications for the use of myofunctional therapy

Myofunctional correction is prescribed if:

• abnormal bite of the first degree;
• dysfunction of the circular muscles of the tongue and mouth;
• uneven placement of crowns;
• disorders of the temporomandibular joint;
• hypotonicity of the facial muscles.

Contraindications when the use is not justified by the achieved effect include:

• poor jaw mobility;
• hypertrophy of the facial muscles;
• third degree abnormal bite;
• visible restrictions of mobility in the temporomandibular joints;
• abnormal jaw growth due to previous diseases.

Facial orthotropy

Orthotropy

– a new concept in orthodontics. This is a treatment technology that directs (corrects) the growth of facial bones and corrects the oral cavity. The procedures do not require surgery.

The growth of a person's jaw is determined genetically. But this process is influenced by a number of insurmountable factors. For example, the environmental environment, which often causes allergic reactions in children. Which, in turn, make breathing difficult and cause the habit of breathing through the mouth. There are many obstacles to the correct formation of the child’s skeleton (including the bones of the facial part of the skull): incorrect posture, position of the tongue in the oral cavity, etc.

Orthotropy pays special attention to correction and directed growth of the face, realizing the full potential of proper growth. Orthotropic practice has many challenges. The main ones include:

• increase in jaw size;
• straightening teeth naturally;
• ENT treatment support.

The first signs of disorders of the dental system

The need to use myofunctional correction arises if the following conditions are recorded:

• breathing occurs primarily through the mouth;
• swallowing requires strong tension of the jaw muscles;
• speech defects appear;
• baby sucks thumb;
• the child has no gaps between primary teeth;
• An uncontrollable state of biting nails or pencil occurs.

Any of these conditions indicates the need for myofunctional correction to timely block disorders of the dentofacial system.

Orthodontics vs Orthotropy

Any deformation of the skull bones, distortion of shape, dysfunction will be reflected in the bite. If this influence is not taken into account, and the root causes of crooked teeth and malocclusions are not identified and eliminated, the problems cannot be solved.

Any problem with teeth is not based on a dental cause. At least the jaw. The close interconnections in the human body do not allow us to consider the face or teeth as autonomous parts. Therefore, the practice of orthotropy is an indispensable tool for the orthodontist.

Orthotropy is thoughtful and meaningful orthodontics. Holistic – from general to specific. First, the skeletal part is put in order, and then the problem teeth are corrected. At the same time, failures in vital functions are eliminated. Such as:

• breath;
• chewing and swallowing;
• speech;
• dream.

The main causes of violations

Experts note that disorders of facial and masticatory muscles arise due to disruptions in the functioning of the body. The development of these disorders is facilitated by:

• prolonged feeding on soft and pureed food, drinking from a bottle with a nipple leads to disruption of the development of swallowing function;
• the lack of solid food provokes slower growth of the jaws and incorrect formation of the position of the teeth, which causes malocclusion;
• Excessive use of pacifiers or thumb sucking contributes to deformation of the jaw bones;
• poor posture affects myodynamic balance;
• genetic predisposition;
• incorrect articulation contributes to speech disorders;
• Frequent colds provoke the development of mouth breathing and weakening of nasal breathing.

Moneybox of knowledge

Exercises to normalize nasal breathing

Exercise 1. Air massage of the nasal mucosa. Feet to the sides, mouth tightly closed, slowly inhale air alternately through the right and left nostrils, alternately pressing the opposite nostril with your fingers.

Exercise 2. “Start the car” Long pronouncement of the sound “D-D-D” (30 sec)

Exercise 3. “The ball burst.” Puff out your cheeks and slowly squeeze out air through pursed lips.

Exercise 4. With your lips open, place your little fingers on the corners of your mouth in this position and try to close your lips.

Speech therapy massage is one of the methods of correctional and pedagogical influence used in the correction of severe speech disorders. This is an unconventional and effective method of correcting sound pronunciation, because Speech therapy massage helps to normalize the pronunciation side of speech, improves the condition of the voice, speech breathing, and normalizes the emotional state of a person suffering from speech disorders.

Consultation with an osteopath in Zelenograd.

An osteopath gets to know the problem that concerns you. And then, with the help of osteopathic techniques, he finds out the possibility of solving the problem. The most commonly used technique is Craniosacral Therapy.

Great idea for a breathing machine.

The effect of using myofunctional therapy

To achieve a therapeutic effect, it is necessary not only to follow all recommendations for performing the selected exercises, but also to correctly determine the degree of anomaly in the development of the defect. With timely and correct prescription of myofunctional exercises, the following occurs:

• restoration of the performance of the maxillofacial muscles;
• normalization of the tone of facial and chewing muscles;
• elimination of speech defects;
• improved posture;
• restoration of the process of swallowing and breathing;
• formation of chewing skills;
• correct tongue placement.

It is worth remembering that various anomalies require special exercises, which should be prescribed by a specialist after conducting a comprehensive examination of the patient and identifying all possible pathologies and disorders.

Basic rules of myofunctional therapy

Myofunctional exercises must be performed following the basic rules of physical therapy:

• muscle tension occurs smoothly and slowly;
• tension should alternate with relaxation;
• it is necessary to correctly select the load to limit overvoltage;
• the exercise is performed several times until you feel slightly tired;
• classes must be conducted regularly;
• The duration of the exercises and the speed of their execution should gradually increase.

By observing these provisions, it is possible to rebuild the work of muscles and correct the development of the skeleton towards anatomical balance. The effect is achieved thanks to:

• normalization of functional characteristics;
• biological stimulation of muscle development and bone growth;
• beneficial effect on trophic processes;
• formation of a compensating mechanism.

The main set of myofunctional exercises

Various methods and sets of exercises have been developed to eliminate developmental disorders of the dentofacial system. The main ones include exercises for the following anomalies:

• Deep bite. The exercises are based on moving the lower jaw forward.
• Open bite. The classes are aimed at training the muscles that are responsible for raising the lower jaw.
• Underdevelopment of the orbicularis oris muscle. These exercises are necessary for the development of mouth breathing and disruption of the contours of the mouth opening. Successful training helps prevent the development of relapse of the inclination of the upper incisors.
• Mesial bite. The exercises are aimed at developing the correct position of the jaws.
• Oblique bite. The lessons are based on moving the lower jaw to the side, as well as correcting the closure of teeth.
• Underdevelopment of the tongue muscles. In this case, therapy is carried out depending on the degree of development of the anomaly and includes correction of lip closure, exercises after cutting the frenulum of the tongue, development of the muscles of the front part of the tongue (infantile swallowing), exercises for the middle and back part of the tongue.
• Impaired development of the muscles that protrude the lower jaw. These exercises are aimed at correcting the bite and forming a lip closure.

Myofascial pain syndromes localized in the back

O. V. Vorobyova, Doctor of Medical Sciences, Professor of the State Budgetary Educational Institution of Higher Professional Education First Moscow State Medical University named after. I. M. Sechenova Ministry of Health of the Russian Federation, Moscow

At an outpatient clinic, patients with back pain make up from 30% to 50% of patients, depending on the doctor’s specialization. The etiology and mechanisms of formation of back pain are extremely variable.

There are at least four most significant factors leading to pain:

structural changes in cartilage tissue (pathology of intervertebral discs, degenerative arthritis);

chronic muscle dysfunction (tension, spasm);

damage to the nerve fiber primarily due to compression (disc herniation, osteophyte, spinal canal stenosis);

psychological factors contributing to the complex components of psychosocial dysfunction.

In most patients, pain is caused by a combination of several factors that are the source of primary pain and/or support the persistence of pain. Musculo-ligamentous disorders almost obligately accompany back pain, and sometimes are the root cause of pain. They often remain unrecognized, which is due to the low awareness of medical specialists. The pathology of the musculo-ligamentous apparatus of the back is most clearly reflected by myofascial pain syndrome (MPS), characterized by muscle dysfunction and the formation of local painful compactions in the affected muscles. Approximately a quarter of all unilateral back pain syndromes are caused exclusively by MFS. How to diagnose myofascial pain?

Diagnosis of myofascial pain is based on anamnestic characteristics of pain and clinical examination. It is important to determine the type, intensity, duration and location of pain, as well as the factors influencing the intensity of pain. What facts should be clarified in the anamnestic? Particular attention should be paid to the facts of possible muscle injury. For acute pain, it is important to determine what movement caused the pain and test the muscles involved in that movement. With the gradual development of pain, it is important to examine chronically overworked muscles that are subject to microtrauma.

What examination should the clinician perform? Clinical examination necessarily includes assessment of passive and active movements and muscle tone. MFS is characterized by an asymmetric restriction of the motor pattern. An integral part of the diagnosis of MFS is muscle palpation and identification of trigger points (TP). When examining the effector muscle, extremely sensitive “nodules” called trigger points are palpated within the spasmodic muscle cords. Most researchers recognize palpation as the main method for diagnosing MFS; with sufficient knowledge of this technique, it is possible to identify 85–90% of TT. TTs localized superficially or in the area of ​​localized spasm are most easily detected. To more accurately identify the localization and activity of TP, it is advisable to first relax the spasmodic, painful muscles. For this purpose, the post-isometric relaxation technique or, in the absence of special skills, passive mechanical relaxation can be used.

Depending on the location and volume of the muscle, various palpation techniques can be used (direct pressure on the TT with fingers, superficial palpation, pinch palpation). For superficially located small muscles, gentle palpation is performed with the fingertips. Easily accessible muscles (eg, sternocleidomastoid, upper trapezius, hip adductor, and others) are grasped between the thumb and fingers and the muscle fibers are passed between the fingers (pinch palpation). Finally, deep palpation is used for deep-lying muscles (gluteal, piriformis and others). It is necessary to wait 2–5 seconds after finger pressure on the TT and evaluate the reproducibility of the referred pain. The effectiveness of the method increases when using topographic maps of the favorite location of TP in muscles. Associated dermatomal sensitization and trophic swelling can be assessed using skin plucking. Additional research methods (electromyography, algometry, thermography, ultrasound techniques) play a supporting role in the diagnosis of MFS, since they have low sensitivity and specificity. How to clinically evaluate a trigger point? On palpation, the trigger point is felt as a clearly limited area of ​​sharp pain. The CT size on average varies between 2 and 10 mm. Usually it is detected along one cord as the most painful point. When palpating the active TT, pain is observed under the examiner’s finger and in the usual pain zone (zone of referred pain).

The intensity of the pain often reaches such an extent that the pain leads to a rejection reaction (jumping symptom). Active trigger points can also cause non-painful phenomena. The most common vegetative symptoms are: local vasospasm, local hyperhidrosis, pilomotor activity. Paresthesias may be equivalent to pain phenomena in the reflected zone. It is generally accepted to distinguish active and latent myofascial TP. In the active form, there is constant pain, decreased muscle elasticity, and the development of referred pain in response to direct pressure on the TT. The intensity of pain and the length of the pain zone depend mainly on the degree of excitability of the TT. Latent TT demonstrates the same clinical characteristics as active points, but is significantly less pronounced. In addition, in the latent form, the pain is induced rather than constant. The induced pain is usually localized to the area of ​​the affected muscle and the referred area. Some researchers believe that latent TTs may be associated with the genesis of muscle spasm. Potentially, they can reorganize into an active state. In addition, TTs can be classified into primary and secondary. Primary are called TPs, which are formed as a result of acute or chronic overload of the muscle concerned and whose activity is not related to the activity of other muscles. Secondary or satellite TTs are the result of mechanical stress and/or neurogenic inflammation due to the activity of primary TTs. In the absence of supporting factors, TTs may spontaneously disappear if the muscle remains at rest for several days. On the contrary, negative factors, and most importantly, the persistence of the influence of the original pathogenic factor, contribute to the formation of secondary triggers and an increase in the area of ​​pain. Thus, the main clinical markers of MFS, summarizing the clinical picture, are: local or regional pain, limiting range of motion; palpation determination of hypertonicity in the affected muscle with areas of increased sensitivity within the “tight” cord (trigger point); reproducibility of pain when trigger points are stimulated; reduction of pain when stretching the affected muscle.

What factors contribute to the formation of MFS in the back? The formation of the MFS is based on both the characteristics of the muscular system bearing the postural load and specific load factors. The actual anatomical features of the back muscles, namely the absence of long tendons with close interaction between the muscles, paraspinal ligaments and fascia, make these muscles especially vulnerable to the formation of MFS. In addition, the muscles of the back and neck are among the least trained, which limits their functional reserve. Loading factors vary somewhat at different levels of the spinal column.

1. Cervical level. Myofascial pain syndromes are the most common cause of pain in the neck, shoulder, and headaches. This is the reason why neck pain occurs in 30–85% of people. Chronic strain of the neck muscles is most often a consequence of: anti-physiological postures associated with work organization disorders (improper sitting at a school desk, when working with a computer monitor, etc.); neck position during sleep (pillow features); postural adaptation of the neck in the presence of primary pain in adjacent regions (shoulders, temporomandibular joint, etc.). Acute injury to the musculo-ligamentous system of the neck is most often associated with an acceleration/deceleration type injury (extensor mechanism of injury). Most whiplash injuries occur in transportation accidents, but they can occur in other situations, such as diving.

2. Lumbar level. Instability of the motion segment most often leads to overload of the trunk muscles. A decrease in the elasticity of the disc fibers and dehydration of its matrix is ​​the cause of the most common functional disorder in the motion segment - hypermobility of the intervertebral disc. At an early stage, this is compensated by contraction of the trunk muscles. However, the functional reserve of the muscle is limited and depends on the training of the muscles. Muscle tissue can be injured during single or recurrent episodes of biomechanical overload. Modern working conditions expose the back muscles to additional overload associated with muscle imbalance. For example, with a sedentary lifestyle, the human body is subjected to static loads most of the time, at this time dynamic muscles are constantly inhibited and gradually become flabby, while at the same time postural muscles contract and gradually lose elasticity. Chronic muscle imbalance is characteristic of modern urbanization. Also, various postural disorders, such as scoliosis and other skeletal asymmetries, can contribute to muscle overstrain.

3. Pelvic level. MFS affecting the pelvic floor muscles occur almost exclusively in women [1]. This is primarily due to the anatomy of the female body and the structural changes that the female body experiences during reproductive life. During puberty after menarche, the girl's pelvis expands, the gluteal muscles increase in volume, and the hips rotate inward, leading to a lateral displacement of the patella. Constant internal rotation of the hips can negatively impact the pelvic diaphragm, which increases a woman's risk of developing pelvic floor spasms in the future. Pregnancy or weight gain increases this risk. Normally, the kneecap extends beyond the second toe, which helps maintain stable balance when standing. In many women, due to lateral deviation of the patella, the mobility of the joint decreases, which leads to a flattening of the arch of the foot. These structural changes in the lower extremities lead to disruption of the physiological maintenance of balance when standing and to excessive stress on the pelvic floor muscles. Ligaments in women are more extensible than in men, which is a necessary condition for maintaining joint stability and ensuring the process of physiological childbirth, but at the same time, this ability is a predisposing factor in the formation of fascial and ligament dysfunction in women. A fall on the buttocks can lead to limited mobility of the sacrum and the appearance of pelvic pain due to tension in the ligamentous apparatus of the pelvic floor muscles. In humans, the lower half of the body has more mass than the upper. Insufficiently developed muscles and muscle hypotonia can aggravate lumbar lordosis and increase the forward tilt of the pelvis. Increased lumbar lordosis is also observed during pregnancy. The reduction of estrogen during menopause is the main factor in the disruption of the physiological curves of the spine in old age. Changing the natural curves of the spine creates additional stress on the muscular frame, especially on the pelvic floor muscles. How to diagnose secondary muscle pain? Regardless of the primary source of pain and its pathogenetic characteristics, the muscles of the trunk are involved in the pathological process, becoming secondary sources of pain. Secondary pain occurs in the skeletal muscles outside the spinal motion segment due to a reflex increase in muscle tone. The physiological basis for muscle tension that follows any pain lies in the immobilization of the affected area of ​​the body, the creation of a muscle corset. However, the muscle spasm itself leads to increased stimulation of the muscle's nociceptors. An increase in the flow of nociceptive impulses increases the activity of motor neurons in the anterior horns and contributes to increased muscle spasm. A reflex tonic muscle tension is formed. An additional factor in the development of painful muscle spasms is the antalgic posture. Transferring weight to one leg leads to curvature of the torso and asymmetrical position of the pelvis with the subsequent development of pain in the sacro-lumbar joints and the muscles that provide movement in these joints. The nature of secondary muscle pain is dull, aching, and pulling. Their intensity can vary widely. From a diagnostic point of view, it is important that pain is provoked by movements and is significantly intensified in positions in which the muscles surrounding the spinal column are stretched. Pain can also intensify when maintaining the same position for a long time (driving a car, sleeping in an uncomfortable position, long flight, etc.). There are no symptoms of loss.

With lumbar musculoskeletal pain, pseudo-Lasegue syndrome can be observed. If, when performing the Lasegue test, pain occurs only locally in the lower back, or hip, or under the knee, or in the lower leg, this is due to a stretch of spasmodic muscles (paravertebral or posterior thigh muscles) (“short” pain). On palpation, the paravertebral muscles are compacted, tense, and painful. Secondary muscle pain can become chronic and persist on its own even after the original cause has been eliminated. How to treat myofascial pain? Treatment of MFS requires multipronged approaches. Standard treatment includes: drug therapy with drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants; impact on TT, including physiotherapy; therapy aimed at restoring the normal functioning of muscle tissue: reducing muscle strain, strengthening the muscle frame, changing lifestyle. The main short-term task is to destroy trigger points, which leads to pain reduction. But the impact on TT should not be carried out in isolation. The long-term goal is to relax the muscles, restore the balance between postural and dynamic muscles, and neutralize predisposing factors, which reduces the risk of recurrence of pain. Warming the muscle can help it relax; for this, applications of “warming” ointments, gels, as well as hot wet wraps of the affected muscle, and wet warm compresses can be used. If you have certain skills, TT can be mechanically destroyed by injection of anesthetics (novocaine, lidocaine), which shortens the period of pain associated with the procedure. TT injections can provide excellent results. Less commonly used is “dry needling” without the use of an anesthetic. Specialized centers use muscle stretching exercises and gentle muscle relaxation techniques, such as post-isometric relaxation. In addition, traditional relaxation massage can be effective. The duration of therapy is significantly reduced with rapid and effective pain relief for the patient. Pain relief with NSAIDs is generally accepted for MFS - Nise, Diklak, Brufen SR, Movalis, etc. The prescription of NSAIDs is mandatory for any severity of pain - from mild (NSAID monotherapy) to severe (in combination with other drugs). Applications to painful areas of gels and ointments containing NSAIDs or their general dosage forms (tablets, suppositories, injection forms) can be used. The combination of NSAIDs and muscle relaxants in the treatment of MFS has become almost standard, making it possible to reduce treatment time. In addition, the simultaneous use of muscle relaxants and NSAIDs allows you to reduce the dose of the latter and, therefore, avoid the development of side effects of therapy. While taking muscle relaxants, post-isometric muscle relaxation, massage, and physical therapy are facilitated. It has been proven that the use of muscle relaxants makes it possible to rid the muscle not only of active, but also of latent TP, i.e., it improves the long-term prognosis, reducing the recurrence of MFS. Randomized controlled trials demonstrate the superiority of this class of drugs over placebo.

A study conducted by the Cochrane Physicians Society, which included over thirty controlled trials, also confirmed the usefulness of the use of benzodiazepine and antispastic muscle relaxants [2]. Domestic researchers prefer non-benzodiazepine central muscle relaxants. Usually tizanidine, tolperisone, and baclofen are used. These drugs have fewer side effects than benzodiazepines. Tizanidine (Sirdalud) is a prominent representative of central muscle relaxants. The drug is registered for the treatment of painful muscle spasm caused by musculoskeletal diseases and spasticity. The combination of tizanidine with NSAIDs demonstrates a more pronounced effect on pain reduction compared to NSAID monotherapy in patients with back pain [3, 4]. In addition to reducing pain, tizanidine reduces the need for NSAIDs and tranquilizers in patients, thereby reducing potential side effects from treatment. Placebo-controlled studies have shown the actual analgesic effect of tizanidine, as well as its effect on muscle tension and reduction of active trigger points [5]. Therapeutic tactics completely depend on the severity of the pain syndrome, its duration and the number of muscles affected by the MFS. In acute MFS, Sirdalud can be used in monotherapy. The recommended daily dose of Sirdalud is 6 mg per day in 2 or 3 divided doses. For severe MFS, combination treatment is used, combining pharmacological and non-pharmacological methods. Adding Sirdalud to a comprehensive treatment regimen allows you to reduce the duration of taking NSAIDs and avoid taking tranquilizers. Since the mild sedative effect of Sirdalud allows you to cope with mild anxiety without prescribing psychotropic therapy. Adjuvant treatments (antidepressants, anxiolytics, hypnotics): There are no high-quality randomized controlled trials on the use of these agents in patients with MFS. But numerous studies show the effectiveness of these drugs for treating chronic pain. It should be noted that chronic pain is often associated with depression, and effective treatment of depression can significantly reduce pain. The presence of comorbid syndromes requires mandatory targeted therapeutic efforts. A necessary component of treatment is the patient's physical activity. It is necessary to recommend that the patient return to normal daily activities. Physical therapy has a positive effect. Avoiding postural tension, daily physical therapy, mastering autogenic training with the ability to relax muscles is an effective defense against muscle pain. It is necessary to encourage the patient to make a positive change in life style (avoidance of anti-physiological poses, rational equipment of the workplace, stopping smoking, weight control, physical therapy, annual massage courses, mastering autogenic training with the ability to relax muscles).

Literature Vorobyova O.V. Painful spasm of the pelvic floor muscles as a cause of chronic pelvic pain in women // Farmateka. 2011, no. 5 (218): 51–55. Van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM Cochrane Back Review Group. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the cochrane collaboration // Spine. 2003, Sep 1; 28 (17): 1978–1992. Berry H., Hutchinson DR Tizanidine and ibuprofen in acute low-back pain: results of a double-blind multicentre study in general practice // J Int Med Res. 1988; 16:83–91. Pareek A., Chandurkar N., Chandanwale AS et al. Aceclofenac–tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone // Eur Spine J. 2009; 18 (12): 1836–1842. Lepisto P. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration // J Int Med Res. 1981; 9 (6): 501–505.

The article was published in the journal The Attending Physician

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