Head, Neck, and Jaw Course Materials

Acknowledgements and Disclaimers

Many thanks to past teachers, assistants, colleagues, and participants for their assistance in the development of this work and this manual. Teachers who have influenced these materials include Neal Powers, Emmett Hutchins, Liz Gaggini, Til Luchau, Nilce Silvera, Andy Goodwin, Michael Salveson, Art Riggs, and Jan Sultan, to name a few. Of course, also to be mentioned is the groundbreaking pioneer in this field, Dr. Ida P. Rolf, without whom, none of this would have been possible.

Special thanks to Linda White and Billie Shea, great teachers and practitioners here in Nevada, striving to better both the field of bodywork and the practitioners within it. And of course, many thanks to Eric Asay, the photographer and web site designer making this presentation possible.

Disclaimer: This course teaches soft-tissue myofascial technique for students and practitioners of manual therapy/massage therapy/bodywork. This is not a course in Rolf Structural Integration.

These methods do not constitute medical treatment and a physician should be consulted in advance about any conditions that are questionable or might contraindicate this work. While every attempt is made to insure the safety of the techniques taught, participants assume all risk for participation and subsequent application of the techniques learned.

It is recommended that students review anatomy before the class begins and use anatomical charts or books to aid in the understanding of this material.

Preface

In working with the body, the wonderful blessing to some and curse to others is that no amount of time, study, and practice will give you complete knowledge of the human body. It forever remains a mystery and presents an everlasting field of study and discovery, best undertaken with the eyes wide open rather than jaded with the blinders of arrogance. This continual learning process -- to look, to see, to strive to understand relationship within the body, is not a practice of gathering hard facts and insurmountable conclusions, rather it is a process of ongoing inquiry that allows us to tailor our touch, understand more, and most importantly, listen.

The most dangerous fool is fool who thinks he knows everything. As bodyworkers, it behooves us to know nothing for sure, to reach no conclusions. Rather we need to have only questions and see possibilities. This allows us to fully see and listen to our clients without skewed perspective, and this inevitably allows us to learn. This is not to say that study is a bad thing. On the contrary, practicing, studying, and garnering knowledge allows us to see more, to listen better, and to inquire further. It makes us better practitioners.

All life is relationship. The body exists within relationship, and form and function within the body is relationship. Thus, in learning about the body, we essentially learn about relationship and we inevitably come to the conclusion that no body part actually exists in isolation. Everything is connected in some form or fashion. From this point we can proceed to learning about the head, neck and jaw; pieces in a puzzle and parts of a greater relationship that should and must be evaluated and addressed if we are to address the client as a whole. The techniques given here are by no means the end all and be all, or as some sort of step by step method or protocol to treat head, neck, and jaw dysfunction. These are simply tools for evaluation and treatment within the greater framework of treatment of the body as a whole.

Regarding relationship, it can be said that our society commonly and wrongly treats the head and neck as separate from the rest of the body. Whether we’re speaking in terms of a psyche therapy that only aims to resolve dysfunction in the head, or our own sense of self being largely limited to our head and face, we often see the head as distinct and separate from the rest of the body. This feeling is often carried over into bodywork where a “full body” massage will touch on most everything available except the head.

Given our apparent disposition to “be” in our heads, much of our ‘tension’ lives there as well. Further, in a more clinical sense, the head and neck also has a profound effect on the rest of the body. Consider for instance the Atlanto-Occipital joint, where the spine meets the skull. Disorder here means disorder for the top of the spine and thus the entire spine and the entire body. Again, we are looking at and considering relationship, not only how the rest of the body affects the head, neck and jaw, but, just as importantly, how the head neck and jaw affect the rest of the body. So, without further ado...

I. Cervical Techniques

A. The Cervical Sleeve (Superficial Fascia)

Here we are first concerned with the top layer tissue. Our goal is to have separation between layers of fascia and muscles, so that all slide freely around and over each other. We start however, with the uppermost layer, called superficial fascia, or sub-cutaneous fascia. It is the fascia located directly underneath the skin, and when we pick up or move the skin, this layer of fascia also moves. Hence we focus our work on areas where the fascia and the skin seem “adhered” or “stuck” to the layer below it. Such adhesion is usually a clue that the area below (deeper to) the adhesion may also be problematic and may need further attention.

1. Differentiating Superficial Fascia of the Neck from the Layers Below

Here we use a soft fist to release the superficial fascia of the neck from the muscles, and fascial bags of those muscles, directly below.

Using a soft fist, engage the superficial fascia on the neck in a downward fashion (towards the table). As the stroke is applied, either slowly turn the client’s head in the opposite direction, or have the client actively turn her own head.

Notes: A classic technique of Dr. Ida P. Rolf

2. The Mother Cat

Using a gripping motion, gently grab the skin and superficial fascia and pull toward the midline posteriorly, as a cat would pick up a kitten. Hold, release, and repeat. Feel for separation of layers.

The superficial fascia here has connections into the nuchal ligament, running from the occiput down the posterior aspect of the cervical vertebrae. Loosening the fascia here will have a beneficial effect on the ligament.

This technique not only has the effect of loosening superficial fascia on the back of the neck, but has the neurological effect of soothing and relaxing the client.

Notes: Attributed to Dub Leigh by Moshe Feldenkrais

3. Neck and Anterior Shoulder Girdle Fascial Differentiation

Have the client rotate their heads. Look for restrictions where the neck intersects the shoulder girdle. This can be seen as a pulling on shoulder or pectoral superficial fascia as the head turns. Engage the superficial fascia at the restricted point while the client continues to turn his head and allow the restriction to soften and ease until it is no longer noticeable.

4. Neck and Trapezius Differentiation

Using a soft fist, engage the superficial fascia of the neck where it meets the trapezius. In a downward fashion, use the soft fist to push the superficial fascia of the trapezius towards the table as you slowly turn the clients head to the opposite side. You can also have the client actively perform the movement.

Notes: A classic technique of Dr. Ida P. Rolf

B. Separating the Muscles of the Neck

As we have unlocked the first layer of tissue, we will now begin to separate and free the muscles below. Bear in mind here that the posterior muscles of the neck begin in the thoracic spine and attach up onto the cranium, hence we must be mindful of treating the “whole” area, not just the cervical area. The muscles of the anterior neck attach at the ribcage, a so called “danger zone” in many massage circles. In freeing the neck and head, the anterior area is of paramount importance. Three rules apply here – a) If you are pressing on the anterior neck and you feel a pulse, move your fingers. b) The brachial plexus (innervating the arms) runs through the anterior neck (between the middle and anterior scalenes). Hence, good communication with your client is important. Before working in this area, inform your client that the brachial plexus is in this area and have the client warn you if you are working in this area and there is a overly “nervy” or “tingly” sensation in the area or their arm. If so, move your fingers. c) With palpation, be aware of what is the throat and what are the muscles near the throat. The throat itself is cartilaginous, while the muscles are not.

1. Separating and Freeing the Muscles of the Posterior Neck

Semispinalis Capitis, Splenius Capitis, Splenius Cervicis: these muscles all have their origin (fascial and otherwise) in the thoracics. Thus, to free them, we start working around the thoracic spine. Two positioning options exist here: either have the client in a seated position or the client prone with his head hanging from the table. The advantages of the latter are that the client will not need to dress or otherwise leave the table. However, extra care must be given here as the client will not be able to hold a prone position for an extended period of time. Also, make sure that the client’s head is sufficiently off of the table so that they are not compressing their throat on the table. It is very important to receive continual feedback from your client here.

Working from the T6 region up into the C7-C6 region, engage both superficial fascia and the muscles below with a soft fist or elbow. The client will slowly and continually rotate his head as you work. Try to first work with the top layer to ensure that the muscles below are free from the fascia above, and then concentrate on separating the individual muscles. As the client rotates his head, you should see movement around the thoracic spine all the way down to T5-T6. Where you do not see movement is where the work should be focused.

2. Separating Trapezius from the Neck

While trapezius is a muscle that both rotates, sidebends, and extends the neck and head, over-reliance on this muscle results in a loss of efficiency in body movement and a loss of range of motion. Freeing trapezius from the other neck muscles will restore this balance. Here, using the pads of our fingers, a knuckle, or even an elbow, we separate the antero-lateral border of the muscle from the muscles below (scalenes levator scapula, splenius capitis), slowly waiting for the fascia to release while we either rotate the client’s head to the opposite side (passive rotation) or allow the client to actively rotate the head.

3. Sternocleidomastoid (SCM) Lifting and Separating

SCM both flexes and rotates the head and neck. When it becomes shortened or adhered to the muscles and fascia around it, it has the tendency to pull the head forward, which results in strain on the muscles of the upper back and posterior neck.

Using a pincer movement with the fingers, gently grasp SCM between the thumb and side of the finger. Feel for restriction and wait for release as you pull the SCM away from the neck. Add active or passive rotation of the head.

If you have problems getting under SCM, have the client lift their head (flexing), activating the muscle and allowing you to find the borders.

C. Releasing the Muscles of the Neck

Here we are concerned with reducing the tonus (tightness) of the muscles of the neck. These techniques will also add length to shortened muscles and allow a greater range of motion. These techniques will focus on the attachment points of the neck muscles on the cranium, sternum, clavicles and ribs. By working with these attachment points we will persuade the golgi tendon organs (which have great control over muscle-tension), located in the tendons and musculo-tendinous junctions of each muscle, to release the muscle as a whole.

1. SCM Release

With the client’s head rotated you can either work from underneath the head or on top, using the pads of your fingers to pressure the attachment points of SCM on the cranium, just off of the mastoid process. Wait for release.

Similarly, work the attachment points of SCM on the sternum and clavicles (SCM attaches on both). Have the client raise her head for the attachments to “jump” into your fingers. Have the client relax their neck once you have found the attachments. While working the lower attachments, have the client slowly rotate their head to assist you.

2. Splenius Capitis, Semislinalis Capitis and Trapezius Release

These muscles are located directly posterior to SCM, starting with attachment points on the mastoid process and attaching all the way to the posterior midline of the neck and head. It is not important to know the names of these muscles, only how to release them.

In the same manner as we released the upper attachment of SCM, we will apply pressure with the fingertips, working from below pushing or moving the tissue in a direction off of the cranium and towards the neck. Before working, rotate the client’s head as necessary for your comfort, the client’s comfort, and to adequately pressure the attachments. Downward pressure on the client’s head can also be used to increase the pressure into your working fingers. Again, feel for restriction (hardness) and wait for release.

Note, we are working the attachment points directly on the cranium, but we are not yet fully engaging the sub occipitals which lie deep to and below the area we are working.

3. Sub Occipital Release/Occiput Wedge

Tension headaches, vision problems, lack of range of motion, and general restriction can often be caused by high tonus in the sub occipital group of muscles – small muscles that help us balance, align our vision, extend and rotate the head. In releasing these muscles, you also are releasing around the atlas and axis (C1, C2) ie: the top of the spine. Any effective spinal work requires work here as an aberration here (a twist, etc.) will be reflected into the spine.

With the client in supine, use fingers to wedge into the space between the atlas and the occiput (directly below the base of the occiput). Allow the weight of the head to apply the pressure and let your fingers sink into the sub occipital muscles, waiting for release. As you feel the muscles release, allow your fingers to move into the spaces that soften.

To facilitate this opening, have the client perform a “nodding” movement.

4. Scalenes Release

There are three scalene muscles per side – attaching commonly at the transverse processes (TP’s) of C2-C6 and inserting onto ribs one and two; anterior and medial (middle) scalenes insert into rib one, posterior scalene inserts into rib two. Shortened, restricted, or hardened scalenes will result in a loss of range of motion, a head-forward posture, and compression on the brachial plexus resulting in nerve irritation or thoracic inlet/outlet syndrome.

First assess the scalenes by passively side-bending the head and neck to both sides. Lack of movement in side-bending (neck fails to side-bend easily) may indicate that the scalenes are restricted.

Using a broad touch with the pads of the fingers, apply pressure at the insertions of the scalenes on the ribs. Wait for release and move the tissue headwards as the neck is passively extended and side-bent (to the opposite side).

Again, be careful of what you put your fingers on and stay in communication with the client. Be patient.

D. Additional Cervical Techniques

1. Vertebral Translation

Immobility of the cervical vertebrae can be common causes of pain and limited range of motion. This technique allows us to assess the relative mobility of individual vertebrae and the neck as a whole.

First, we are moving all of the cervical vertebrae by moving the head side to side in a “walk like an Egyptian” type of motion. Feel for cervical translation through each vertebra. Where you feel a lack of motion, gently sidebend the neck around the spots which appear stuck or immobile. Wait for release.

A second method is to translate each individual vertebra by pushing each vertebra into translation from the sides. Locate the vertebrae by feeling for the transverse processes. If a vertebra feels stuck or immobile, gently sidebend the neck around the immobile spot.

Another variation is to check translation with the neck in slight flexion and in slight extension. This will further challenge facet joint restriction.

Note: This is not an “adjustment” or a chiropractic technique. It is simply a method to “mobilize” cervical vertebrae.

2. First Rib release

The first rib can have a great affect on the neck and head, especially if it is stuck in a particular position. As noted above, the anterior and medial scalenes insert onto the first rib, thus mobility in the rib also affects the scalenes.

To first assess, we press down on the first rib bilaterally to test for mobility or “springy-ness”. Typically, a stuck side will be immobile and slightly raised (headwards). Apply pressure to the stuck side as you sidebend the head and neck towards that side. Wait for the restriction to soften and release.

3. Unwinding

Unwinding is a subtle technique whereby you are simply following the intrinsic movement of the head and neck. With the client relaxed (not assisting) start by holding the head and wait for subtle cues as to where you can move the head and neck (the path of least resistance). Continue to follow for several minutes.

4. Vertebral Unwinding

A more advanced technique is to unwind around a vertebra that is painful or immobile. In such a case, assess for tender points, restrictions or immobile vertebrae. While grasping the suspect vertebra with the thumb and fingers, use the other hand to unwind, grasping the head (occiput), following the subtle cues of the body.

II. Cranial Techniques

A. Head

1. Cranial Fascia

Superficial fascia on the cranium holds the same importance as superficial fascia in the rest of the body, and should be addressed before any deeper work takes place.

By engaging the fascia of the head and sliding it, we can assess where the fascia is held and we’ll focus our work there. Commonly, fascia on the occiput is both dense and restricted. Loosening the fascia here gives space to the nuchal ligament (originating at the occipital protuberance and running down the spine) and to the neck as a whole. To create a maximum amount of space at the sub occipitals, it is necessary to also release the occipital fascia. Other commonly restricted superficial facial points on the cranium include the area around the mastoid process and over temporalis. Again though, let your fingers assess and tell you where to work.

To release the fascia, apply pressure with the pads of the fingers, engaging only the superficial layer. Wait for release. Direction-wise, take the occiput fascia towards the neck. Take temporalis fascia towards the jaw. Take mastoid process fascia down toward the neck and toward the midline. It might help to imagine that you are “peeling an orange” as you work.

2. Temporalis

Temporalis is a chewing muscle located on the sides of the head. This muscle is much bigger in many other mammals, although it can be the source of much dysfunction in the jaw. One-side over tightness of temporalis can be the source of a TMJ (temporal mandibular joint) disorder or clicking on one side of the jaw. Typically, the side of the jaw that clicks is usually the side that is hyper-mobile (moves too much) and it is the other side that is restricted (hypo-mobile). In relieving this symptom, you will typically be focusing your work on the restricted side, starting with cranial fascia, then temporalis, then masseter and other chewing muscles.

To release temporalis, apply pressure broadly with the pads of the fingers, pushing the tissue down towards the TMJ. Temporalis is a thin muscle, so separation between it and the superficial fascia might not be readily apparent. To aid in your efforts, as you apply pressure to the tissue, have the client open her mouth, extending the muscle.

3. Vectors

Manipulating the bones of the cranium serves several functions. As any cranial sacral specialist, chiropractor, or osteopath knows, the head expands and contracts. The structures of the central nervous system (brain and spinal cord) are bathed in cerebrospinal fluid (CSF). The CSF is in constant motion, circulating under the influence of the craniosacral rhythm. This rhythm consists of flexion (active) and extension (passive). On flexion, there is a decrease in the anteroposterior dimensions of the skull (and body) accompanied by an increase in width. The opposite occurs on extension. In flexion, CSF flows into the brain and the cranium increases in width via the sutures of the skull. Many western doctors opine that the sutures (joints between the bones of the cranium) are fused and immobile. This is obviously false and the ability of these joints to open and close with flexion and extension are critical to good health. With this technique, taken from the osteopaths, you will be able to increase the ability of the sutures to open, thereby increasing the ability of the head to flex and extend, and the ability of CSF to flow. In doing so, you can have a very beneficial effect on headaches, both acute and future. The overall effect for the client will be a feeling of “lightness” in the head.

This technique is actually quite simple in that all you are doing is compressing the sutures. By compressing the joint, the body instinctively responds by resisting this force, resulting in an increase of space between/within the joints.

Using firm pressure and hands opposite to each other, press firmly together, as if you were compressing a basketball. Feel for connection and release across each vector. Move your hands while maintaining the compression, feeling for movement within the joint. Focus your work on the vector where there is less movement. Begin and end with the occipital vector, then the lateral vectors, then the diagonal vectors.

Notes: Thanks to Robert Schrei for the original firm-pressure osteopathic technique.

This technique is not a substitution for Cranial-Sacral training or practice, in which much more detail is involved.

B. Face and Jaw

1. Facial Fascia

As with everything here, we start on the face with the top layer – the superficial fascia. Feel for restrictions and ease them using the pads of the fingers, in a gentle yet firm way. Bring the fascia in such a direction that it enhances the face. Restrictions may often be found on the forehead where a wrinkle exists, on the cheekbones, and along the jaw line. Releasing these restrictions may aid in a youthful appearance.

2. Masseter

Masseter is a common culprit in bite and TMJ disorders. It is also often a place of extra tension, as clients will often clench in response to stress. Hence, releasing masseter can be a substantial release for the client in overall tension. Here we work from the outside, although it should be mentioned that masseter can also be accessed from inside the mouth. Using firm but gentle pressure with the pads of the fingertips, work masseter from it’s attachment of the zygomatic (cheekbone) down to the attachment on the mandible. Have the client open and close their mouth as you work. Focus on the side which is both denser and tighter.

3. Digastrics

The digastrics are muscles on the floor of the mouth (and under the chin). Here we are addressing them from under the chin. The fascia of the digastrics runs deep into the throat and continues into the fascia that runs beneath the sternum. For most clients with a “forward head” posture, the digastrics will be an area in need of attention.

To release the digastrics, apply broad and gentle pressure with the fingertips, working the tissue posteriorly. Pay attention to the fascia on the bony posterior edge of the mandible (jaw).

4. Medial Pterygoids

Medial Pterygoids are inside the mouth, however, you can access the lower attachments from the outside, under the jaw. From the palatine bone and maxilla, this bilateral muscle inserts into the lower back part of the inner surface of the mandible. This muscle is responsible for much of the side-to-side movement of the jaw. These muscles are often implicated in TMJ dysfunction.

Find the attachment point of the pterygoid under the lower and back aspect of the jaw. Hold and wait for release. Have the client open and close their mouths or protract their jaws to assist. This can be a very tender area.

5. Palate

The palate can be an important place to work for TMJ issues as well as migraines. Often migraine sufferers have palates that are smaller, imbalanced, with a large ridge in the center (running anterior to posterior). During a migraine attack, there will often be spots on the palate that are extremely sensitive. These are pressure points that a migraine sufferer can work themselves in order to lessen the intensity of the migraine.

Don’t be fooled into thinking the palate is a sensitive area of the body. You can typically use as much force here as you can muster. Still be aware of where you are working and do not put your fingers too far back on the palate, where the tissue becomes softer. To work here, your landmark is the ridge on the top. Feel for imbalances between the sides. Specifically, look for a side that is narrower (between the middle ridge and the gums). Focus your work here by moving tissue away from the midline ridge and towards the gums, encouraging width.

6. Maxilla Shear

Your upper teeth are imbedded in the maxilla, and for any jaw dysfunction, it is necessary to treat the upper area involved in the masticating process. This bone should have good side-to-side mobility. With a gentle grip, feel for lateral mobility (shear) in relation to the skull and gently encourage mobility to the side that feels restricted.