Evidence for Early and Regular Physical Therapy and Exercise in Parkinson’s Disease

by Tyler Tice, PT, DPT, MS, ATC


Over the last few decades, the treatment options for Parkinson’s disease (PD) has significantly improved, resulting in effectively prolonged period of time people with PD live with disability. Due to this, the role of effective physical therapy (PT) and rehabilitative management for people with PD has greatly increased. PD affects dopamine within the brain, resulting in the presence of motor symptoms such as tremors and bradykinesia (slow movement) and non-motor symptoms such as changes in mood and changes in sense of smell. Diagnosis of PD is usually made after the classical motor signs of bradykinesia, rigidity, tremor, and postural instability (balance issues) emerge. Currently, there is no neuroprotective treatment for PD available so medical treatment is focused on treating the symptoms. As PD is projected to continue affecting higher numbers of our population as well as younger individuals, there is a need for effective non-pharmacological treatment early in the course of the disease. This review investigates the effects of a variety of modes of exercise and PT in the treatment of PD.

Aerobic Training:

Moderate to high intensity aerobic training may be the most beneficial in managing motor symptoms, improving physical function, and reducing disability in persons with PD. Studies where treadmill training was completed demonstrated better results regarding improvements in walking, most likely due to the intensity in which it could be completed, however, cycling is a viable option for persons with PD where walking may not be a safe option when initially beginning aerobic exercise. Additional research needs to be completed regarding the effect of aerobic exercise on non-motor symptoms, however existing research is promising as one study showed an improvement in executive function (higher level thinking needed to plan and carry out tasks), attention, and memory after one month of treadmill training.

Resistance Training:

Moderate to high intensity resistance exercise focused on movement speed or muscle power production may be beneficial in reducing disease severity, improving physical function, and reducing disability. One study demonstrated an improvement in cognition in addition to strength and mobility after the 2-year course of the study, suggesting long-term motor and non-motor benefit of participating in resistance exercise. Multiple studies also demonstrated benefit of resistance exercise when specific functional limitations such as climbing stairs or standing from a chair were targeted. Additional research is still needed to investigate the benefit of resistance exercise, especially in relation to their effects on non-motor symptoms.

Balance Training:

For persons with mild to moderate PD, balance training has demonstrated a significant ability to reduce fall rates. Additionally, studies that were clinic-based rather than home-based provided a greater level of supervision and intensive training, resulting in greater reductions in fall rates. Balance training also improved non-motor symptoms such as reductions in pain, depression, and apathy. However, it is important to note that in patients with severe PD appeared to have an increase in falls rate following participation in balance training. What causes this increase is unknown but may be attributed to increased gait-related mobility without an improvement in postural control or increased exposure conditions that challenge the individual’s balance without having the skills to manage these challenges.

Gait Training:

Gait training is effective in improving various aspects of walking in persons with PD. Treadmill training and moderate intensity overground walking have been shown to improve gait speed, walking capacity, and step/stride length. This is important as gait is not primarily impacted by current pharmacological treatments for PD. Providing cueing while ambulating has also been shown to improve various aspects such as giving auditory cues for gait speed or auditory and visual cues for freezing of gait. Dual-tasking such as walking and talking or walking and carrying an object is an aspect of ambulation that can be difficult for persons with PD. Practicing dual-tasking in a safe and controlled environment is effective in improving walking under dual-tasking conditions.

Physical Therapy:

Despite the evidence that supports early and regular exercise intervention in persons with PD, the utilization of PT services in the US is remarkably low. There are many factors that may contribute to this such as insurance coverage and other medical provider knowledge on the benefit of exercise and PT in persons with PD. Typically, to justify the need for PT to insurance companies, the patients must demonstrate functional improvement in order to continue with PT, however, policy and guideline changes have been implemented to improve access to PT for persons with PD. By initiating PT earlier in the disease process, more preventative measures can be taken, which ultimately will positively impact the quality of life of the individual.

Secondary Prevention Model:

Once initially diagnosed with PD, patients consult with a PT with expertise in PD. The PT performs what is referenced as a clinical battery of tests to establish a baseline level of function that can be tracked throughout the disease course. In the first few visits, the PT will prescribe an exercise program that is tailored to the individual and give them the tools to be success in consistently completing the program. A critical element of this approach is regular follow-up visits. Just as regular visits to the neurologist are necessary for reassessment of PD symptoms so appropriate adjustments to medication can be made, regular follow-up visits to a PT allow for reassessment of functional status and necessary adjustments to their exercise program to address changes in symptom presentation. There has also been an increase in community-based exercise programs, which further expands access to physical activity. These exercise programs can vary in intensity, however regular follow-up visits to PT can allow PTs to assist in finding programs that appropriately challenge their patient.

Take Home Message:

Regular exercise is highly beneficial for persons with PD. The advantage of beginning PT early in disease progression is that it can help mitigate the extent to which the motor and non-motor symptoms impact daily life. Additionally, if there were to be a change in function, receiving PT treatment can directly help with being able to successfully complete functional tasks such as climbing stairs to promote safe independence of persons with PD.

Article Reference:

Ellis, T. D., Colón-Semenza, C., DeAngelis, T. R., Thomas, C. A., Hilaire, M. S., Earhart, G. M., & Dibble, L. E. (2021). Evidence for Early and Regular Physical Therapy and Exercise in Parkinson’s Disease. Seminars in neurology41(2), 189–205. https://doi.org/10.1055/s-0041-1725133

Restoring physical function after knee replacement: a cross sectional comparison of progressive strengthening vs. standard physical therapy

by Tyler Tice, PT, DPT, MS, ATC


Over 700,000 total knee arthroplasty (TKA) surgeries are performed each year in the US with this number expected to increase to over 3 million by 2030. A TKA is typically performed to reduce knee pain as well as self-reported physical function ability. However, even when considered full recovered 12 months after surgery, patients’ physical function when formally measured by performance-based measures and quadriceps strength are rarely improved compared to pre-surgery function. As shown in previous research, post-op protocols that include strengthening and functional exercises that are progressed based on clinical milestones promotes better outcomes compared to protocols that lack these interventions. However, there is no current research that compares patients who completed a progressive strengthening post-op protocol to healthy age-matched peers, which makes it difficult to determine whether these protocols are effective in fully restoring physical function. As younger, more active populations begin to undergo TKA surgeries, it’ll be imperative to know whether these progressive strengthening interventions are effective in restoring the level of physical function required to return to physically demanding occupations and recreational activities.


This study investigated at 205 participants who underwent a unilateral primary TKA for knee osteoarthritis (OA). Additionally, 88 participants were recruited to serve as the healthy age-matched control group. Exclusion criteria for both groups can be found in the original article. Participants who underwent a TKA were randomized into one of three groups: progressive strengthening rehabilitation, progressive strengthening rehabilitation plus neuromuscular electrical stimulation for the quadriceps, or standard of care. All participants received inpatient rehabilitation in the hospital, followed by home and outpatient PT. Participants in the progressive strengthening rehabilitation groups completed at least 12 outpatient PT visits at the University of Delaware Physical Therapy clinic. Treatment focused on addressing the physical impairments after TKA as well as progressive strengthening exercises that targeted muscle groups in the lower extremity. Participants in the standard of care group attended other physical therapy clinics in the community and completed an average of 23 outpatient PT sessions with no set guidelines for clinicians to follow. Treatment primarily consisted of range of motion (ROM) exercises, stationary cycling, and various straight-leg exercises.

Outcome measures:

The Knee Outcome Survey – Activity of Daily Living (KOS-ADL), active knee ROM, maximal voluntary isometric contraction (MVIC) of the quadriceps, the Timed Up and Go (TUG), stair climbing time (SCT), and 6-minute walk (6MW) test were measured 12 months following surgery as well as in the control group to compare between groups.


There was a significant between-group effect for all clinical variables.
A higher proportion of participants in the progressive strengthening group achieved the lower bound cut-off for knee extension ROM, quadriceps strength, and SCT compared to the standard of care group.
Participants in the progressive strengthening group were 2-4 times more likely to achieve performance above the lower bound of the of the confidence interval of the control group for knee extension angle, performance on SCT, and quadriceps strength.
The percentage of participants in the progressive strengthening group that achieved the lower bound cutoff in at least one of the seven variables analyzed was greater compared to the standard of care group (67% vs. 47.5%).


Similar to previous research, participants who underwent a TKA demonstrated worse self-reported scores, greater physical impairments, and lower performance-based outcomes compared to the control group. However, a greater proportion of patients in the progressive strengthening protocol achieved what could be considered normal clinical and functional scores when evaluating the outcomes individually. This suggests that patients who follow a progressive strengthening protocol post-TKA may improve their likelihood of achieving normal age-matched outcomes. Also, a greater proportion of participants in the progressive strengthening group achieved the lower bound cut-off for quadriceps strength, knee extension angle, and SCT, suggesting progressive exercises may be more effective in optimizing outcomes after TKA.

It’s important to note that all participants still had substantial impairments 12 months after surgery compared to the control group. Failing to restore function by 12 months after surgery may overall impact the patient’s ability to achieve normal function as progress measured by outcome measures typically plateaus around 12 months post-surgery. There are many factors that may contribute to this such as pre-operative function, lack of consensus between providers regarding rehabilitation protocol and surgical procedure. Regardless, this highlights the importance of including the inherent limitations of the surgical procedure and post-op rehabilitation at restoring normal function for patients with end-stage OA when educating patients.

Take Home Messages:

TKA is a surgery that is becoming increasingly more common as time goes on and research has consistently showed that after surgery, it is difficult for patients to achieve pre-surgery function that can be comparable to age-matched peers without knee pathology. As more active patients begin to undergo this surgery, it’ll be important that they are able to achieve pre-surgery function to enable them to participate in recreational activity or more physically demanding occupations. While this study showed that overall, all participants demonstrated worse functional outcomes compared to the control group, participants in the progressive strengthening group demonstrated better functional outcomes compared to the standard of care group. This suggests that the inclusion of these exercises may be beneficial to the functional recovery of TKA patients. There are still many other factors that may be contributing to why TKA patients have difficulty recovering to their pre-surgery function, which emphasizes the role of patient education in the recovery process to set realistic expectations for these patients while also enabling them to recover to their greatest ability.

Article Reference:

Pozzi, F., White, D. K., Snyder-Mackler, L., & Zeni, J. A. (2020). Restoring physical function after knee replacement: a cross sectional comparison of progressive strengthening vs standard physical therapy. Physiotherapy theory and practice36(1), 122–133. https://doi.org/10.1080/09593985.2018.1479475

Manual Therapy vs Therapeutic Exercise in Non-Specific Chronic Neck Pain

Reviewed by Mark Boyland PT, DPT, CSCS

This study sought to explore the effect times of manual therapy alone vs therapeutic exercise alone as well as to break down and compare the effects of these two interventions in the short and mid term.

The authors compared visual analog scale, pressure pain threshold, cervical disability through the Neck Disability Index Outcomes.  These values were assessed at evaluation, week 1, week 4, and week 12.

The participants were split into 1 of 3 intervention groups; Manual Therapy, Therapeutic Exercise, or Sham.  At the end of the trial the study was able to analyze date across 67 participants, 22 in the Manual Therapy Group, 23 in the Therapeutic Exercise Group, and 20 in the Sham treatment group. Demographic date was relatively similar between groups, however there were more female participants than males. 

The interventions were listed for each group.  The manual therapy group included frequency of interventions, grading of mobilizations/manipulations, speed of mobilization, duration of mobilization, and sets of mobilizations.  The therapeutic exercise group include progressions of exercises from week 1 and 2 and the exercises after week 2.  Exercise descriptions included patient position with equipment required, and duration/frequency of exercises.  The authors also provided a description for how the sham treatment was provided.  It is noted that the sham treatment group did receive either manual therapy or therapeutic exercise interventions only after completion of the study.  The study was conducted by researchers from the University of Seville, Seville, Spain and potential mistranslations may be present when reviewing the applied interventions.

The intervention groups had significant improvements in VAS at weeks 1,4, and 12.  Both intervention groups had significant changes for the NDI at weeks 1 and 4.  However, the manual therapy group was able to maintain these improvements into week 12 with no statistical difference and the therapeutic exercise group had a poorer score relative to the 4 week evaluation however the 12 week score was still lower than the patient’s initial score.  The pain pressure threshold was only reduced in the manual therapy group at 4 weeks, however at 12 weeks both intervention groups showed improvements.  The control group demonstrated no significant changes throughout the study.

In regards to selection of these interventions as stand alone treatments, therapeutic exercise may improve function more quickly whereas manual therapy may improve pain more quickly, both interventions can have similar results in the mid term.  The authors note that a larger sample size may refute their findings and that treatment of chronic non specific neck pain should include multiple interventions not limited to only manual therapy and therapeutic exercise but could also include patient education and pain science education.   The authors also note that there is no method that guarantees patients complete their home exercises.

For patients:  Physical therapy for non specific chronic neck pain can be treated with hands on and an exercise approach and there can be significant changes made within just 4 weeks that can last up to twelve weeks but there is some work on your part that has to be done as well in the short, mid, and long-term

Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomized clinical trial

Article Review: by Kira Zarzuela, SPT, Tyler Tice, PT, DPT, OCS


Patellar tendinopathy (PT) is a common chronic tendon injury that not only effects a high percentage of the athletic population, but also a number of people that participate in physically demanding work. Currently, there is no known direct cause of PT, making it difficult to determine first-line treatment as not all people respond the same way to the same treatments. Eccentric exercise therapy (EET) is one line of treatment that has strong evidence supporting its effectiveness for PT, however, EET can be pain-provoking. Additionally, the onset of pain with this mode of treatment makes its use debatable during the competitive season for athletes as they are less likely to adhere to treatment. Recent research proposes the utilization of progressive tendon-loading exercises (PTLE) within the limits of “acceptable” pain, however, there is no current comparison between EET and PTLE. This study compares the effectiveness of PTLE with EET in patients with PT.


This study looked at 76 recreational, competitive, and professional athletes with clinically diagnoses and ultrasound-confirmed PT that were randomly assigned to receive either EET (control group) or PTLE (intervention group) for 24 weeks. Most participants (82%) had previously underwent treatment for PT but failed to recover fully. PTLE consisted of 4 stages: 1. daily isometric exercises, 2. isometric and isotonic exercises, 3. plyometric loading and running exercises, and 4. sport-specific exercises. Progression through these stages was determined by individual progression criteria based on pain provocation during a single-leg squat. EET consisted of 2 stages: eccentric exercises performed 2x/day for 12 weeks followed by sport-specific exercises for 12 weeks if the participant was compliant to stage 1. Both groups received exercises targeting risk factors for PT such as flexibility exercises and hip strengthening exercises.

Outcome measures:

The primary outcome was the VISA-P questionnaire. Secondary outcomes were return to sport rate, subjective patient satisfaction, and exercise adherence.


The improvement in VISA-P score was significantly better for PTLE than for EET after 24 weeks (28 points vs. 18 points).
There was a trend towards a higher return to sports rate in the PTLE group (43% vs. 27%).
The percentage of patients with an excellent satisfaction was significantly higher in the PTLE group (38%) than in the EET group (10%).
There was no significant difference between subjective patient satisfaction and exercise adherence between the PTLE and EET groups after 24 weeks.


This study demonstrated improved performance in the PTLE group compared to the EET group that was both important and clinically relevant. Additionally, as this study included participants who had received prior treatment for PT but did not improve, the findings of this study also indicate that PTLE is still beneficial to this population. Other findings from the PTLE group are that there was a higher return to sports rate compared to the EET group and participants in the PTLE group reported that the exercises were significantly less painful to perform. However, it should be noted that in the PTLE group, less than half of the patients returned to sports at a preinjury level after performing PTLE for 24 weeks. This indicates the need for further improvements on the PTLE program. Both groups demonstrated improvements in pain, function, and ability to play sports, suggesting the importance of exercise therapy in general as a form of conservative management for patients with PT.

Take Home Messages:

Patellar tendinopathy is a chronic condition that affects a large number of people, however there is constant research being conducted to investigate what forms of conservative treatment are the best to trial prior to more invasive procedures. At the time this study was conducted, eccentric exercise training, or training done where the muscle is loaded during the phase where its length is increasing, had strong evidence supporting the effectiveness in PT. The difficult part regarding EET is that it is pain-provoking and its beneficial use during a competitive season for an athlete was uncertain. Another challenge of PT is that one treatment doesn’t work for all patients diagnosed with PT, resulting in several patients having gone through an unsuccessful bout of physical therapy, which only adds to the frustration surrounding the rehabilitation process. This study demonstrated that progressive tendon loading not only worked the same, if not better, than EET and was less pain-provoking, but also was successful in participants who had gone through unsuccessful bouts of treatment for their PT. For clinicians, this means that utilization of progressive tendon loading should be trialed in patients with longer-standing PT or previously failed bouts of treatment. For patients, this means progressive tendon loading is worth trialing, regardless of chronicity or history of treatment, as a form of treatment for PT.

Article Reference:

Breda, S. J., Oei, E., Zwerver, J., Visser, E., Waarsing, E., Krestin, G. P., & de Vos, R. J. (2021). Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British journal of sports medicine55(9), 501–509. https://doi.org/10.1136/bjsports-2020-103403

Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy

Article Review: by Kira Zarzuela, SPT, Tyler Tice, PT, DPT, OCS


Eccentric exercise is the most commonly prescribed exercise for the treatment of tendinopathy, however, is often too painful to complete. In the competitive season, athletes are less likely to adhere to an eccentric loading program due to increased pain and experiencing either no benefit or worse outcomes, however they may be more compliant with pain reduction strategies that enable ongoing sports participation. Few interventions reduce patellar tendinopathy (PT) pain in the short term. Isotonic exercise has been shown to be as effective as eccentric loading in PT, however there is little to no current research demonstrating this form of exercise’s effect on pain. Isometric exercise has been shown to reduce pressure pain thresholds in normal populations but has not been studied in PT. This study compared the effect of a short bout of isometric and isotonic quadriceps loading on PT pain, maximum contraction strength of the quadriceps, and the neurophysiology of the two exercises.   


This study looked at six male volleyball players with PT pain. Three players had unilateral pain and the other three had bilateral pain. Immediate and 45-minute effects following a bout of isometric and isotonic muscle contractions were compared. Complete inclusion and exclusion criteria can be found in the original article. Below are the loading protocols utilized in the study.

Outcome measures:

PT pain during the single leg decline squat (SLDS), quadriceps strength on maximal voluntary isometric contraction (MVIC), and measures of corticospinal excitability and inhibition.


Isometric contractions reduced pain with SLDS from 7.0­­±2.04 to 0.17±0.41 and isotonic contractions reduced pain with SLDS from 6.33±2.80 to 3.75±3.28.
Isometric contractions released cortical inhibition from 27.53%±8.30 to 54.95%±5.47, but isotonic contractions had no significant effect on inhibition.
Condition by time analysis showed pain reduction was sustained by 45 minutes post-isometric but not isotonic condition.
The mean reduction in pain scores post-isometric was 6.8/10 compared to 2.6/10 post-isotonic
MVIC increased significantly following the isometric condition by 18.7%±7.8, and was significantly higher than baseline and isotonic condition, and at 45 minutes post-intervention.


Isometric exercise immediately reduced patellar tendon pain with the effect sustained for 45 minutes while isotonic exercise had a smaller magnitude immediate effect on patellar tendon pain that was not sustained. There were also no non-responders to isometric exercise regardless of pain severity or length of time of symptoms while there was variable pain reduction experienced following isotonic exercise that was no sustained. Individuals with PT have higher amounts of cortical muscle inhibition for their quadriceps and heavy isometric exercise reduced this inhibition, which may be a factor in the mechanism of pain reduction. The clinic implication of this is isometric exercise may be an important option for clinicians to offer in tendons that are difficult to load without aggravating symptoms. This study had multiple limitations, one of which was the small sample size that was comprised of men, which makes it difficult to determine if the results are generalizable to all patellar tendon pain. Another limitation of the study was participants were diagnosed with patellar tendinopathy so it is difficult to determine if the same effects would be observed in other cases of anterior knee pain. This study also lacked a control group, or group where no intervention was performed, which would further qualify observed results of the study.

Take Home Message:

One of the most well-known interventions for tendinopathy in the world of physical therapy is to eccentrically load the tendon to an individual’s pain tolerance, however what interventions are you left with when the patient is unable to participate because of high levels of pain? The findings from this study give clinicians an alternative intervention for their patients that have more painful tendons by reducing the patient’s pain in the short-term, which would then allow them to tolerate other interventions that may have previously been too painful. As stated in the article, the use of isometric exercise for pain reduction in patellar tendinopathy is a great option for in-season athletes who may not want to stop participating because of their pain but would still benefit from short-term pain reduction. This study had a handful of limitations, such as a small sample size, however this shouldn’t deter clinicians from utilizing isometric exercise as a tool for pain management for PT pain.

Article Reference:

Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British journal of sports medicine49(19), 1277–1283. https://doi.org/10.1136/bjsports-2014-094386

Mariano Rocabado’s Approach to Tempormandibular Joint Evaluation and Treatment

by John Baur, PT, DPT, OCS, FAAOMPT

The material for this article consists of a compilation of the evaluation and treatment techniques learned from Mariano Rocabado, PT, DPT while attending Basic Cranio-Facial (CF1), Intermediate Cranio-Facial (CF2) and Advanced Cranio-Facial (CF3) courses through the University of St Augustine and from peer reviewed journals.  Dr. Rocabado is recognized internationally as an expert in the field of temporomandibular joint dysfunction (TMD).  This article contains an overview of diagnostic radiographic imaging and manual therapy treatment techniques for TMD patients.

A common focus in TMD treatment involves the position of the cranium and the mandible relative to the cranium.  The term craniovertebral centric relation refers to the stability of Atlas and Axis and how Atlas is stabilized on Axis, and how the Axis is stabilized on C3.

In physical therapy the term craniovertebral centric relation refers to a three dimensional articular ligamentous position of the cranium over the upper cervical spine.  The condyles of the occiput adopts a stable position over the first cervical vertebra (Atlas), which maintains a stable anteroposterior and lateral position with the odontoid process in a horizontal alignment over the shoulders of the Axis (C2).  This relationship allows the occiput, Atlas and Axis to perform 50% of the function of the craniocervical unit.  The Atlas, Axis (two atypical vertebrae) and C3 form the upper cervical spine and they perform 50% of the function of the neck.

The craniovertebral centric relation should not be confused with centric occlusion which is the relationship between the maxilla and mandible.  The physical therapist treatment should focus on accomplishing a craniovertebral centric relation and congruency in the craniovertebral joints.

It is also important to understand the concept of the synovial joints of the TMJ and the idea that the temporal component of the joint has to be horizontal.  The position of the temporal portion of the temporomandibular joint is related to the position of the cranium which is dependent on how the occiput relates to the craniovertebral joints.  If the occiput is level horizontally in the sagittal plane and the patient has a functional craniovertebral angulation with adequate space between occiput and Atlas, than the TMJ disc is going to be related to the temporal bone in a horizontal position. Once the position of the disc is identified in the fossa, than the physical therapist should know where the condyle should be relative to the disc and the condyle and disc will be in the center of the fossa.

Normal Condyle-Disc-Temporal Relation (Westesson)

The condyle is related in the fossa once the temporal bone is horizontal, and once the temporomandibular disc is stable on the fossa.  Once the occiput is in a horizontal position in the sagittal plane the horizontal position of the temporal bone must be determined.  Next the physical therapist sketches a vertical line passing through the center of the fossa in the 12 o’clock position and a horizontal line in the 3 o’clock position.  This disc should be anteriorly and in between the vertical and horizontal lines.  Next to determine the position of a stable relationship between the condyle, the disc, and the fossa the physical therapist should understand the principle of centric relation.

Westesson angle – first determine the horizontal position of the temporal bone which is determined by the horizontal position of the occiput.  Next trace a horizontal line tangent to the inferior border of the eminence.  A perpendicular line can be drawn crossing the deep portion of the fossa.  Both lines determine the position of the disc in the posterior wall of the eminence.

The active joint surface of the condyle it is convex and the active joint surface of the temporal component is convex.  Thus, active joint surfaces of the active TMJ structures are both convex.  When two convex surfaces gliding in opposite directions occurs in joint it produces “wear-and-tear” and degeneration.  To change this relationship the disc provides a concave joint surface.

In the temporomandibular joint, there is a convex surface of the condyle that produces an inferior independent synovial joint. The convex surface of the temporal bone produces a superior independent synovial joint.  This results in a convex on a concave inferior synovial joint and a concave on convex superior synovial joint.

The concave disc is needed for congruency and stability since the temporomandibular joint has two convex surfaces that face each other and it is inherently an unstable joint.  Fifty percent of the TMJ function comes from the inferior synovium, and 50% function comes from the superior synovium.  It is important that the two convex surfaces remain very tight together with the concave disc, where the convex and concave surfaces meet, in order for the joint to remain stable.

Craniovertebral Angle and Cervical Lordosis

The second cervical vertebra (C2) is the most important vertebrae to exam at this level since it is the vertebrae that supports the weight of the cranium and distributes forces to the rest of the cervical spine.  The position of C2 will determine the curvature of the lower cervical spine.  A functional craniverbral angle should fall between 96 and 106 degrees and achieving this measurement should be one aim of physical therapy treatment.  The physical therapist will want to accomplish centric relations and congruency in the craniovertebal joints and the dentist will want objective reasoning and measurements, and this can be accomplished by measuring the craniovertebral angle.

Cranioverbral Angle / McGregor’s Plane

The loss of cervical lordosis will increase the compressive forces and load through the cervical spine and can lead to cervical joint degeneration.  So it is important to recognize the loss of cervical lordosis in developing children in order to prevent postural abnormalities that may cause degenerative joint changes and orofacial pain.

The craniovertebral angle, the angle between the cranium (basi occiput) and C2, plays a major role in establishing the cervical lordosis. It is also noting that the craniovertebral angle is important because of its impact on the sub-cranial space.  Rocabado teaches the concept of the functional craniovertebral unit, the concept of the craniovertebral angle and the importance of adequate functional sub-cranial spaces. Also how the sub-cranial angle determines the curvature of the lower cervical spine.

The below cephalometric radiographs demonstrate the association between the craniovertebral angle and lordosis in the mid/lower cervical spine. The radiograph on the right demonstrates sub-cranial backward bending, as seen by the narrowed space between occiput and the spinous process of C2. The cervical lordosis is consequently decreased or reversed.

The cephalometric radiographs on the left demonstrates normal position of the head and cervical spine and on the right a flattened cervical lordosis with sub-cranial backward bending.

The sub-cranial angle can be assessed on a radiograph. The below image demonstrates the sub-cranial angle, formed by the McGregor’s line and the odontoid plane (blue arrow). The McGregor’s line is drawn from the posterior hard palate to the basi occiput and the odontoid plane from the anterior-inferior margin of the body of C2 to the tip of the odontoid. Where these two lines intersect there should be a 96-106 degree angle posteriorly (see radiograph below).

Cephalometric radiograph. Please note the position of the hyoid bone (yellow arrow) in line with the C3/4 interspace. Notice also the posterior arch of atlas in a mid-position between basi occiput and C2 spinous process, dividing the sub-cranial space in half.

Skeletal Midline

Skeletal midline is an important component in establishing cranioverbral symmetry in the coronial plane.  The Axis (C2) plays an important part in establishing skeletal midline because it is used as a reference point for creating the vertical vector through the dens and vertebral body.  When C2 is in skeletal midline the spinous process should be vertically in line with the  center of the dens.  Dentist would determine skeletal midline when the patient swallows and bites the point at which the central line of the maxillary (upper) central incisor will coincide with the center of the mandibular (lower) central incisor.  The center of the maxilla should coincide with the center of the mandible.

The skeletal midline of the craniomandibular joints is determined by a vertical line that crosses through the middle of the dens and the spinous process of C2.  The second cervical vertebra acts as the base for the cranium and the Atlas is in between as a stabilizer.  The cranium is also attached ligamentous with C2.

In this position, Atlas (C1) should be proportionally related on the left and right to the dens of the Axis.  The inferior joint surfaces of Atlas will symmetrically on top of the shoulders of Axis in a horizontal position to allow Atlas to rotate.  The Atlas is going to be sitting horizontally on top of Axis, perpendicularly.  In order for the cranium to be horizontal in the coronal plane, C2 must be on a skeletal midline, with a craniovertebral angle between 96 and 106 degrees.

The midline of the maxilla and the mandible should be on a skeletal midline that corresponds to the skeletal midline of the craniovertebral joints.  There should essentially be one skeletal midline that crosses the center of the cranium, through the center of the mandible and the middle of the cervical vertebrae.  The dentist will try to get the mandible to the maxilla on a skeletal midline.  Whereas the physical therapist has to coincide that skeletal midline with the midline of the craniovertebral joints in order achieve congruency and stability in centric relation.

If a patient can side bends to the right and not to the left than C2 is likely rotated to the right. The patient can side bend towards the problem, but not away.  The spinous process will move in the opposite direction of the head.  This is a good test for the stability of the craniovertebral joint mobility.

If the Atlas is not sitting on top of Axis in skeletal midline then the patient will not have normal function of the craniovertebral joints.  If the patient does not have a cranium that is horizontally related in the sagittal plane or the coronal plane they cannot have a stable occlusion.

The occlusive contacts change depending on the position of the cranium.  Different cranial positions will create different mechanics.  The cervical joints need to have centric relations for normal patterns of growth and development.

Principles of Occlusion:

Everything is relative to how the mandible moves to the cranium.  Physical therapists use to believe that all cranio-facial problems were caused by muscles. This belief was accepted for about 10 years. Then there was 10 years that were focused on occlusion or how teeth related to each other.

The front teeth help to guide the mandible forward until they are approximate.  When the front teeth are edge-to-edge, the back molars should not touch and the mandible moves forward and down.  The separation of the back teeth helps protect them.  Canine guidance and incisive guidance are mutually protected system to decrease wear-and-tear of the teeth.  The canines provide lateral guidance and the right canine protects the left and vice versa. The front teeth help provide anterior guidance.

The back molars are more powerful when biting than the front teeth and the canines are not as strong as back molars.  A centric occlusion is when the joint surfaces are maximally congruent.  When the TMJ cannot accomplish any further movement in a given direction it is in a close pack position.

In-occlusion means no contact between teeth and the TMJ is in a loose pack position.  Occlusion means to close and this is when the TMJ is in a closed pack position.

The contraction of the muscles of mastication increases when the teeth are touching.  The temporomandibular joints should not spend more than 15 minutes of a 24 hour period in a closed pack position and the teeth should not be in occlusion for more than 15 minutes a day.  Thus, the teeth should be in a loose pack position for the majority of time.  The amount of time that teeth are touching equals the amount of time that the muscles are contracting.  The more time the TMJ is in closed pack position, the more time the TMJ is exposed to an isometric muscle contraction which can lead to para-function.  It is important to keep your mandible at resting position in order to preserve or rebuild anterior guidance and to preserve or rebuild canine guidance for protection and muscle relaxation and to avoid premature degeneration.

The importance of sub-cranial spaces

A disturbance of the cranio-vertebral angle implies postural aberration and might indicate that physical therapy intervention is needed. Therefore it is important that we teach the orthodontists that we work with to measure the craniovertebral angle and palpation of the suboccipital triangle. The dentist will then have an objective way of knowing if the cranium is anteriorly or posteriorly rotated and if functional space is adequate, and can then decide whether to refer the patient to physical therapy. This assessment can be done easily.

Atlanto-occipital backward bending demonstrated on a model

The space between the basi occiput and C2 should not be less than 20 mm and the physical therapist should be able to place a minimum of a two fingers in this space.  So in the absence of a radiograph a clinician should be able to evaluate through palpation the loss of functional sub-cranial space.

Functionally there needs to be a space between the occiput and Atlas, and their needs to be a space between Atlas and Axis.  These spaces are supposed to be proportional, 6.5mm +/- 2.5mm and the spaces can vary between 4 and 9mm (Rocabado, CF2, CF3 2013).

The spaces between occiput and Atlas and the spaces between Atlas and Axis can decrease.  If C2 shifts, it can go into a state of immobilization and the spaces can cause a mechanical entrapment of the neuro-vascular structures which can cause headaches and facial pain (Rocabado, CF2, CF3, 2013).

The landmarks of the suboccipital triangle include the basi occiput superiorly, spinous process of C2 inferiorly and transverse process of C1 laterally.  Three muscles of the border the triangle include: Rectus Capitis Posterior Major (above and medially), Obliquus capitis superior (above and laterally) and Obliquus capitis inferior (below and laterally).  The floor is formed by the posterior occipito-atlantal membrane, and the posterior arch of the atlas.  Palpation in the suboccipital triangle can help us determine the functional sub-cranial spaces and serving as a provocation test for the soft tissue in this area.

                                                                                 The suboccipital Triangle (yellow triangle) – provocation test.

The effect of occlusal changes on the sub-cranial angle

Lowering of the mandible leads to a temporary increase in cranial backward bending. The posture of the head has been found to change immediately following an “opening of the bite” – with an increase in vertical dimension anteriorly (a.k.a. lowering of the mandible).  Using an inter-occlusal appliance, normal individuals were subjected to an opening of the bite, ranging from 0.3-9º. Within one hour a posterior rotation of the head was found in 90% of the subjects.  Physical therapists must be aware that wearing an appliance will have this effect and this may lead to symptoms in some of our patients. Patients with an ample sub-cranial functional space are going to tolerate this change in the sub-cranial angle, but for someone who already has a narrow craniovertebral angle (<96º) this might lead to symptoms.

A physiological cervical lordosis is seen with a craniovertebral angle between 96ᵒ-106ᵒ.  Non-physiological cervical postures are seen with craniovertebral angles <96ᵒ (posterior cranial rotation, lower cervical spine moves into flexion/inverted cervical lordosis) and >106ᵒ result in anterior cranial rotation.

Trigeminal cervical nucleus

The trigeminal cervical nucleus is located in the center of the upper cervical spinal cord and it has three branches: V1, V2, and V3.  The first cervical vertebral (C1) corresponds with V1 branch of trigeminal cervical nucleus which innervates supraorbital area of the face.  The second cervical vertebral (C2) corresponds with V2 branch of the trigeminal cervical nucleus which innervates infraorbital area of the face.  The third cervical vertebral (C3) corresponds with V3 branch of the trigeminal cervical nucleus which innervates the mandibular area of the face.  Understanding the anatomical relationship between the upper cervical spine and the trigeminal cervical nucleus will help the physical therapist identify segmental dysfunction based on pain patterns of the face and head.  Also, it is important to know that the position of C2 will influence the functional spaces of the cervical spine posteriorly which can contribute to headaches and facial pain of a cervical origin.

The cervicogenic headaches are pain  that refers to the head from a source in the cervical spine.  Unlike other types of headaches, cervicogenic headaches has attracted interest from disciplines outside of neurology.  Orthopaedic manual physical therapist, dentist in the area of craniofacial and oral pain, and interventional pain specialist (anesthesiologist) have developed an interest this headache treatment (The Lancet, 2009).  Cervicogenic headache are the best understood of the common headaches.  The mechanism is known, and these headaches have been induced experimentally in healthy volunteers.  In some patients, cervicogenic headaches can be treated temporarily by diagnostic blocks to the cervical joints and nerves (International Headache Society, 2004).

The convergence of cervical and trigeminal afferents on second-order neurons in the trigeminocervical nucleus may refer pain from the upper cervical spine into the head and face.  Furthermore, “bi-directional interactions” between trigeminal and upper cervical afferents may also explain neck symptoms of trigeminal origin (EG, Migraine) (Dreyfus, 1994).

Every time there is a loss of space in the craniovertebral angle you lose the distance between the spinous process of C2 and occiput. When the distance or space between occiput and C2 is lost it will cause the Atlas to try to find a way to maintain a functional space and the Atlas will no longer have any functional space.  Physical therapy treatment should focus on increasing or opening up the space between occiput and C2 to allow the atlas to have space between occiput and C2.

If there is a loss space between occiput and atlas or Atlas and Axis, or both, the patient could also have a loss of space in the craniovertebral angle.  If the position of C2 changes, the spaces will change and the cranial nerves and vascular structures can become entrapped.  C2 becomes the most important vertebrae to treat in this condition of trying to find a horizontal position for the cranial and for a stable craniovertebral system.

X-Rays will show if the space between occiput and C2 or occiput and atlas have decreased.  If those spaces have decreased, they form an entrapment for the ligaments and others tissues in that area and that can lead to headaches.  A physical therapist must manually open up those spaces.  The space between occiput and C2 should be at least 20 mm.

To manually assess this space you should palpate the spinous process of C2 and then  side bend the head to the left and right to feel C2 rotate. The physical therapist should be able to feel the space between occiput and C2 and the movement of C2.  Fifty percent (50%) of the rotation of the head takes place at Atlas and Axis with the occiput on top.  The occiput and Atlas uses the dens as an Axis of rotation and it allows the head to rotate right or left.  If the patient turns their head to the right the patients head should go from the sternum to the most prominent portion of the shoulder laterally.

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

Atlas can be related to the wings on a plane. When the plane needs to turn right, the right wing drops down and goes back while the left wing goes up and forward. When the plane needs to turn left, the left wing goes down and back while the right wing goes up and forward.   If the transfer process of Atlas is more prominent on the left side, it means that it rotated to the right. If the transfer process of Atlas is more prominent of the right side, it means that it rotated to the left.

Manual Therapy Treatment to Increase Subocciptal Spaces

So the physical therapist will need to change the position of C2, and by doing so you will open up or increase the space between occiput and C2 and this will help atlas to restore functional space with occiput and axis.

When treating TMD it is important to note that:

  • Some problems can be caused by the neck, in which case it is important to stabilize the cervical spine.
  • When dentists look at teeth, they should find at least one contact that is wrong.
  • The physical therapist should continue to stabilize cervical spine.
  • Have an objective concept with your patient’s dentist. Relay evaluation measurements and findings.
  • Accomplish a state of rest for TMJ and cervical joints.
  • Occlusion contacts will continue to change with treatment. It will be important for the patient to follow up her/his dentist throughout treatment.
  • Breathing patterns may be evaluated in patients who have sleep apnea.
  • You want the muscles to relax in order to find a stable position.

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

  • Place patient is a seated position with the malar bone over the sternum.
  • Palpate the subocciptal triangle. Assess for provocation of pain or symptoms.
  • Alar ligament test – Side bend (or laterally rotate the cranium) C2 should rotate in the same direction. Assesses the stability of the Alar ligament on the opposite side of the side bending.
  • Determine the position of C2-C3 by evaluating sidebending and look for right and left motion restriction and asymmetry.
  • Evaluate Atlas rotation by fully flexing (anteriorly rotating) the cervical spine and assess the cervical spine rotation left and right.
  • Long axis traction/distraction of C2-C0 in sitting.
    1. 6 times with 6 second holds
    2. The purpose of the distraction force is to lubricate the joints
    3. With inspiration the head moves up as the curvature of the spine straightens and with exhalation the head moves down as the spine returns to a resting curvature. This movement produces the force for distraction.
    4. When the patient breaths in, the head moves up and the physical therapist supports the head with one hand and the exhalation produces a nature distraction. The muscles also relax with exhalation and the weight of the body produces a distraction force with the body moving away from the head.
    5. The fingers of the mobilizing hand should be placed over the mastoid process, hand / thumb over the malar bone and the thumb in front of the ear.
    6. To produce a specific distraction the physical therapist uses the opposite hand to stabilize C2 laterally over the transverse processes. The stabilizing hand should be not aggressively hold down C2.

Figure 1: Long Axis Traction/Distraction

  • Long axis traction/distraction of C2-C0 with cranium side bending (lateral rotation of the cranium) in the direction of the restriction. Once side bending (lateral rotation) movement improves rotation to the opposite direction can be added.
    1. Follow the same steps noted above and then add gently side-bend/mobilize head towards the motion restriction while the distraction force in maintained.
    2. The goal is to lubricate the cervical joints and to improve side bending (lateral rotation) mobility in the direction of the restriction.
    3. The physical therapist stands on the opposite side of the side bending.
    4. The amount of side bending (lateral rotation) and rotation is approximately 11 mm (less than .5 inch) in each direction.
    5. Eventually side bending and rotation movements can be combined.
    6. When performing right side bending (of the cranium) mobilization with left rotation the C2 is being mobilized on C3 and the right C0 on mobilized on C1.

Figure 2: Long Axis Distraction with Right Lateral Rotation


Figure 3: Long Axis Distraction with Right Lateral Rotation with Opposite Rotation

  • Occiput “Lift”
    1. Cross hands around the malar bone in order to have good control of the head and face. Take the neck to end range rotation in the direction of the restriction.
    2. While in end range rotation, have the patient inhale and then exhale to produce a quick distraction force/”occiput lift”. The mobilization occurs at the end of the exhalative breath.

Figure 4: Occiput “Lift”

The objective of this sequence of techniques is to initially identify upper cervical spine mobility restrictions.  Then treat the hypomobile joints by first lubricating the joints through gentle long axis distraction and then progress the treatment to mobilizing the joint in the direction of the hypomobilty/restriction.  Rocabado progresses the treatment from long axis distraction, to long axis distraction with side bending (lateral rotation), and then long axis distraction with side bending (lateral cranium rotation) with horizontal rotation.  Finally, Rocabado does a distraction mobilize (approximately a grade IV-V) of the CO/C1 joint while at end range horizontal rotation.

Rocabado describes the Atlas (C1) as being “like a disc” functioning between C0 and C2.  This treatment sequence mobilizes the inferior joint surface of C1 by mobilizing C2 (rotation of C2 on C1) and mobilizing the condyles of the occiput on Atlas.  The Atlas receives a maximum amount of mobilization without moving the Atlas itself.


This project was intended to provide an overview of knowledge attained while studying with Mariono Rocabado and not his complete and comprehensive craniovertebral evaluation / treatment approach.  The foundation of Rocabado’s evaluation approach lays in assessing the upper cervical stability, in particular the sagittal and coronal planes, and this was outlined in this capstone project.  In addition, Rocabado stresses the importance of preparing joints for treatment in a gradual progressive manner.  A sample treatment was outlined so the reader could appreciate Rocabado’s principle of a progressive treatment approach.


  • Dreyfus P; Michaelson M, Fletcher D, Atlanto Coppipital and Lateral Atllanto Axial Joint Pain Patterns. Spine 1994; 1: 1125-31.
  • International Headache Society. The International Classification of Headache Disorders. 2nd. Edition Cephalalgia 2004; 24 (SUPPL. 1) 115-116.
  • Mariano Rocabado. January 2013. Basic Cranio-Facial (CF1). University of St. Augustine. Online course.
  • Mariano Rocabado. February 2013. Intermediate Cranio-Facial (CF2). University of St. Augustine. Chicago, IL.
  • Mariano Rocabado. February 2013. CF3 – Advanced Cranio-Facial (CF3) University of St. Augustine. Chicago, IL.
  • thelancet.com/neurology Vol. 8, October 2009