Alexa: I'm just going to start by giving voice to what most people in the UK are probably complaining about right now, which is that it's too hot. No, thank you please desist. 

But perhaps an episode of the Singing Teachers Talk podcast can give us a little respite from the heat as this week, I am welcoming back Emer Tully, physiotherapist who specialises in hypermobility, TMJ, breathing mechanics, and vocal health 

Today we are focusing on the jaw. In this episode, we are unpacking why tension isn't always about the jaw specifically, some of the red flags and what we don't want to be ignoring in the jaw, what that clicking, crunching, cracking is all about, what considerations we might need to make when working with hypermobile singers, and the actual tasks that singing teachers like you and me can take straight into the studio to help. 

So to stop me from wondering why I still have a fringe even when temperatures are climbing towards that 38 degree mark, let's get into it. 

[00:01:00] Emer, welcome back to the podcast. How are you doing? You've got some real exciting life updates.  

Emer: I know. I think quite a lot's changed since we last spoke. Slightly different work setting, similar clientele. 

So I have set up a new space in South East London, so I am based in Blackheath now. I also work for a women's health clinic. I think last time we spoke a little bit about the connection of the voice and pelvic floor. So I work with a lot of pre-partum, post-partum, perimenopause, not always related to the voice, but I think that has really, um, helped me to kind of bridge that gap between hormonal changes and the way that it can affect someone's, biomechanics in a range of ways, to assist them with any changes in their voice. 

But a lot of work into pressure distribution and breathing mechanics. And of course, lots of jaw patients.  

Alexa: Yes, which is our topic for today. And [00:02:00] funnily enough, maybe my face knew it, but I woke up this morning and I was like, "Bloody hell." What was I doing in the night? My jaw felt so clenched.  

Emer: Oh let's chat it through.  

Alexa: So how is the jaw ideally designed to sit and move, and how do we know when it's functioning well?  

Emer: So the jaw is a mobile joint. It has to be to, accommodate all of the tasks that we need it for throughout the day. Obviously, the classic one is mastication, so being able to chew your food. It also needs to be able to move when we speak or sing, and it should be pain-free. It shouldn't be too audible either, so a lot of people will describe clicking, catching, or on the more extreme range, we can get, um, locking symptoms, and they would be suboptimal. We would ideally, not want you to be in pain when you're having to do any of those [00:03:00] tasks. 

But if you are maybe hypermobile, and we know that with hypermobility the joints can sometimes be a little bit more shallow and your proprioceptive capacity for joints can be a little bit impacted, and so that can really show up in the jaw. But of course, it's not isolated to just hypermobile people 

lots of individuals suffer with jaw issues, um, which for me I would say is often a symptom of something else going on. 

Hypermobility is a big spectrum. So we can have someone with isolated joint hypermobility in just one area, and then on the other end of the spectrum, we could have someone that has connective tissue laxity throughout the body, which can present in a variety of ways, but it could include chronic fatigue, it could be kind of fibromyalgia symptoms, significant joint [00:04:00] laxity, or changes to kind of gut tissue. 

There's a lot of connective tissue in the mouth, so jaw. We see changes in eyesight. Skin can be very stretchy. So huge range, and two people with hypermobility could come in and see me, and they both have completely different symptoms, so not a single crossover. So it's a really, really wide spectrum. 

There's a few things that we can look at. There's also a lot of great resources online for people to kind of complete to see if they fall under the hypermobile, kind of spectrum. 

But I think an important thing to note for those people is that if we take an area of stability away, you must always give their body somewhere else to create that stability from. So if you're asking them to kind of switch things off and relax, you need to tell that system where to find [00:05:00] control from. It kind of has to be a very transactional approach. 

Classic thing I also see is that their proprioceptive awareness is slightly impacted, which we mentioned this before, and, but that's just your body's ability to understand where it is in space. 

So if you say move your tongue in this position, move your jaw in this position they're gonna really struggle to understand what that means and apply it to their own anatomy. And those people can sometimes describe themselves as being more clumsy. They'll have chronic ankle injuries from going over. 

The classic thing I ask them is, " When you're walking down a road, are you looking at your feet the whole way or do you look forward at the horizon?" And they are always the people who are looking down at their toes, because just innately they do not know where their feet are in space and trust where they're stepping.  

Alexa: Is this why maybe movement [00:06:00] exercises where there's going to be other forms of stability in whatever direction can be useful for hypermobile people, whether that's rolling the shoulders or getting on a wobble board, I know we mentioned that last time, because there's still some stability as part of the task?  

Emer: Yeah. And it's giving them more biofeedback. You know, it's why standing on a wobble board can feel transformational, is because you've just suddenly given their central nervous system a little bit more communication to wake up that area. Whereas before, typically what happens is they end up kind of sinking into joints because the muscles and connective tissue aren't creating that same control and stability that the average person wouldn't even consciously know that they have, but it's the reason why that we're able to stand up, is those postural muscles are always working. 

Alexa: So when we're opening and closing our mouth, should it be a very [00:07:00] fluid up and down movement, no sort of skewing from side to side?  

Emer: Yeah. Ideally, it would be pretty neutral, so we don't wanna see any major deviation. Uh, you should have between 40 and 50 millimeters, so that would be our kind of benchmark that we're aiming for. 

Now when you're chewing, you need a combination of, you know, the opening motion as well as some deviation to be able to chew effectively. So we need to be able to combine those motions. But yes, when I ask someone to open and close, what I'm hoping to see is that they have a kind of easy opening without the jaw clicking, deviating and without the person being in pain. 

Alexa: If we notice that actually it's much smaller, I remember going through, like an unbiting stretch that I learnt through Chris Johnson's Evolve course, it just requires us to put our fingers on the chin, allow the jaw to drop and open, [00:08:00] and then slowly look to the ceiling. How do we basically get a little bit more motion or ability to open our mouths a little bit more?  

Emer: Yeah, I mean, probably a release. If the concern is more that the jaw feels really tight then absolutely doing stretches like that. I would start from their mid-back, doing a little bit of mid-back opening, position neck, and then absolutely you wanna be doing either a nice little release with, you know, a gua sha tool or your fingers. 

And then following up with movements such as that would be a perfect way of starting. 

Alexa: How do we know when the jaw is being overextended, particularly if we're singing and we're maybe wanting more volume and we're belting? How do we know when the jaw is open optimally and not sort of popping out?  

Emer: Hmm. I mean, sometimes people will be able to feel it. Some people y- and I watch people sing and sometimes it's a kind of technique option to be able to really [00:09:00] create a lot of space and open excessively. And if it feels comfortable and if you have control through that range and you've had a conversation with your singing teacher and that is kind of what you are purposefully aiming to do, then I don't see that there's any issues there. But it's like anything, you should have control throughout range. 

So if you're opening all the way and you're allowing your, jaw to open as much as it can and then you struggle to close it, or you feel like there's a pop or a click or a shift when it closes, that might be a sign that either you've just overextended, like you said, or you don't have the control in that range. 

And that's something that you can train.  

Alexa: So it's okay to actually allow the, what is it, the condyles to sort of slip out if you can then slip them back in?  

Emer: Yeah. And I mean we don't want them to be subluxing, and that can happen in some cases. If you're hypermobile, sometimes that joint can sublux. 

But it being able to move, absolutely the condyles shift anteriorly [00:10:00] as we open, and that's to be expected. That's n- a, a normal part of that, that range. There's such a big spectrum. So you'll be able to feel some movement when you open and close your mouth. But if it is, you know, accompanied with pain, a loud click or pop, or it's just kind of unilateral, just one side, then that might suggest that you're overdoing it. 

Alexa: When you are assessing somebody's jaw function and you note some abnormalities in their jaw movement, where else in the body would you be wanting to look at as a first port of call? 

Emer: First port of call would always be neck. You wouldn't wanna look at the jaw without assessing cervical range of motion. Followed by your thoracic spine, so really important that you have good rotation and general movement through your mid-back. If your mid-back is sat in a more flexed position or we're more protracted, what it means [00:11:00] is that it increases the load around the spine because your cranium, your skull, is positioned suboptimally on top of your spine. And so the muscles around that area have to work a little bit harder in order to stabilise it. And we see that a lot in the masseter, the temporalis, and the external neck flexors through the front of the neck. And so that can show up in your laryngeal muscles as well. 

But typically in, in that position, we get what's called a forward head posture. My jaw juts forward, and my tongue retracts back. And so we know that for singers, that's gonna be really s- unhelpful when you're trying to access your full range. 

But honestly, for, for an assessment of someone's jaw, I would look down as far as their feet. Yeah, I would, I would wanna look at the entire biomechanics to make sure that they are moving as well as they could be because [00:12:00] something might be, kind of an obvious link, but we often have these kind of secondary links that all tie in together, whether it's hip flexors, whether it's weakness into glutes, whether it's hyperextending knees. You know, there's, we wanna address the system as a, a whole so that that jaw joint has to do less.  

Alexa: From a physio perspective, speaking to singing teachers, would it therefore be a good idea for us to, if we see or hear the singer complaining about jaw, to look at a postural maladaptation, potential compensation as a first step rather than going straight to jaw activity? 

Emer: Yeah, I mean, I think that would be a really good place to start. 

I think if you don't have a qualification in the jaw, or you would struggle to assess if someone was hypermobile, it's probably not something that I would widely advise that people go in and assess [00:13:00] that joint or advise on treatment because for our stiff and tight patients who have been stressed, yeah, we can be just massaging those muscles. Go for it. 

If you're hypermobile, then actually some of that tension through the musculature can be a sign of instability somewhere, and we have to be really careful about the amount that we come in and release into what might already be a very mobile area. 

So we wanna really think about the full picture and in some ways, treating an ankle is a little bit easier. It's a bit more straightforward. When we're working with the jaw, there are so many components, and actually because jaw symptoms aren't always being caused by activities that they're doing in the day, you know, at nighttime if you're clenching your teeth as you already mentioned, you wake up, your jaw feels really tight, well, addressing why that is happening is also a really critical thing, and just coming in and [00:14:00] doing a massage into these masseter muscles every day might not be enough to address that root cause. 

So it's an okay place to start and definitely working on postural maladaptations, as you said, is always gonna be useful for a singer. But we wanna get a little bit deeper as to what else might be going on.  

Alexa: I sometimes feel like as teachers we do a lot of release. We want people to relax their shoulders or let go of abdominal tension, so we're wiggling or, as you say, we're doing some self massage and stretch, but I wonder how far that actually goes. 

Where does the idea of actually strengthening something happen?  

Emer: I mean, my opinion is that it should always be happening. You know, it's... and that's where I think you having a kind of singing teacher's hat on is able to look at kind of technique, and in those moments, asking the patient to relax is really important in order to improve the quality and sound of someone's [00:15:00] voice. 

For me, with my kind of MSK physio hat on, I want the person to be able to relax within your sessions, and they can't if they don't have a stable base, good control through their limbs. If their central nervous system is dysregulated, well, you know, how on earth are we gonna ask someone to relax in those instances? 

So, this is where I think that multidisciplinary team is a, is a really useful one because, you'll find that your clients are able to relax more once they've been given some good strengthening exercises and have a good routine to be doing. 

I'm talking about a, an MDT approach where possible, and I completely appreciate that that's not always the easiest thing to do. But the point I just made about having some stability, well, that could be the patient going away and going to Pilates classes. It could be them participating in a hobby that they really enjoy. It could be doing some exercises that I can give that are nice [00:16:00] and simple and just a good place to start. But not everyone is gonna require a full approach with five different clinicians in order to address a problem. 

For all singers, I think working on some form of strength and conditioning is really important. You know, if you're an athlete for your voice, well, you need to be considering some form of training, and gentle strengthening is a great option in order to give you that baseline support.  

Alexa: Could you show us a strengthening exercise that you might give to a singer? And also, what's your opinion on a singing teacher taking that and showing them, referring to the video or even self-guiding. 

Is that something that you would advise is okay?  

Emer: So I mean, one of the first things that I would have someone do is a release into their mid-back. So that could be things like cat cow, so [00:17:00] four-point kneeling, rounding through your spine, and then looking straight ahead without overextending into our neck, so I just have people do that with a neutral neck. 

They can then do some thread the needle, so a big reach through the gap and then up towards the sky. And I would do that on both sides, and that will help your mid-back get moving. And then if you retest and see how your jaw feels, automatically that should help to soften things. 

You know, if we do it here, Alexa, if you just round your shoulders forward and are- round your back in a really bad posture. But instantly when you do that, can you feel that your teeth touch? 

Alexa: Well, although to be fair, I, I always feel like my teeth are touching.  

Emer: Okay, fine. But for most it might exaggerate that. And when you sit up tall and tuck your chin in-  

Alexa: Oh, yeah, yeah. You do feel them come apart. 

Emer: Yeah. They should create much more space. So that's what we're aiming for. We're aiming for someone to be able to maintain a posture that [00:18:00] allows for opening. 

I mean, the other big thing that I will look at is tongue strength. Some really interesting research that's come out about one of the reasons why we might be clenching at night. And previously I would always signpost someone to look for reflux, because silent reflux can be a huge link as to why someone might be clenching. But actually there is some new ideas that if your tongue is not able to suction to the roof of your mouth, it's, you know, if you've heard of mewing, it's a very similar idea where we'd be a- we're able to keep that suction up at the top. 

If that's not happening at night, what happens is that your tongue is occluding your airways, and so the body's natural response is to try to arouse us, to make us wake up, and so we start to move our jaw. It's also to try to assist in getting more air in, because of course that would be the [00:19:00] body's main goal, is to ensure that we do wake up at the end of the night. 

So actually what I'll take a look is to see how someone's control is through the mainly the back of the tongue. So posterior tongue being able to lift and maintain that position. And that's been, that's made a huge impact for a lot of my patients where we've just struggled to work out why it is that they're clenching so much at night. 

This is why sadly it's one of those areas, unlike the ankle, where I end up having a good conversation about what someone's nighttime routine is, what they eat before bed, central nervous system dysregulation classically shows up in the jaw. And a, a, a typical thing which I think most people can relate to is that when you are stressed, jaw symptoms tend to feel worse. So there it's, you sadly can't just have that biomechanical hat on and only that because we need to think [00:20:00] about parafunctional lifestyle activities that you're doing, the ergonomics of your work, central nervous system regulation sleep hygiene, you know, the height of your pillow. All of these things can impact neck position. 

And then the other thing that we haven't spoken about, which you kind of just touched on, is breathing mechanics. I mentioned about upper respiratory airway stability. That's really important, but your diaphragm being able to move is, would be the other essential part of all of this and being able to breathe optimally. 

Alexa: When I was little, I used to have this habit of biting the side of my mouth, and so my whole face was sort of like contort to the other side. And my grandad would say, "When the wind changes, your face will stay like that." I wasn't really aware that I was doing it, so for other people who are listening or who might be working with singers who don't have that awareness that they've got a clenching [00:21:00] habit, how can we start to become aware of it during the day? 

Emer: It's a good question. I mean, s- it is a lot of just kind of conscious effort as to what you are doing. So sometimes the classic stuff where if you've got jaw pain, you'll Google, and it'll say, you know, stop chewing gum, don't bite your nails, don't chew the inside of your gums. And some people find that really easy. 

Other people, that takes a lot of untraining. And again, you know, I know this isn't always the easiest... Sometimes this is a bit annoying to keep mentioning the, an MDT. But if you do have more kind of psychological, emotional associations with that habit, then that's when I would, again, refer you off to someone that could address some of those things. 

But you know, if you're, if you are a fidgety person, which I totally am, you know, I work all day with my hands. I cannot keep them still, doing other small habits [00:22:00] when you think you are clenching can be really useful. So one thing that I give out a lot, and it ties into what we're talking about with the central nervous system, is tapping. 

Tapping around the chest around your neck really lightly is an instantly calming cue for your central nervous system. It starts to bring us into more of that parasympathetic rest and digest state. And either you can kind of, you know, if you're sat in the office, you can do it through your hands or forearms. You don't need to be kind of tapping your face, people wondering what on earth is going on. But something like that can be a useful thing or actually doing some jaw strengthening at a time where you think you would normally be chewing your mouth. I do a lot of like isometric holds where either someone is kind of pushing the jaw out to one side, but rather than allowing that motion to happen, we kind of block our jaw. 

 And [00:23:00] you're maybe working at kind of 50% of your maximum capacity, so it's just a very gentle hold on both sides. But particularly for someone that gets that big deviation, that can be really useful to try to retrain. Once I, I come in and I release that one side, and sometimes people still, it's better, but they'll still have a slight, a slight deviation out. It's because for years their joint has been shifting over to one side, so we need to retrain that opposite side, and that's where those can come in.  

Alexa: And is that something that we can advise in terms of that exercise you just mentioned, or is that like-  

Emer: Yeah, that's pretty, that's pretty gentle stuff, and because it's an isometric hold, you know, I wouldn't advise doing lots of big opening or doing lots of, like, big lateral shifts. 

If that joint is unhappy, that can exacerbate locking or catching symptoms. So really what they need is a bit of a release in the correct area. So let's [00:24:00] say that if I open my mouth and my jaw deviates to the right-hand side, and my left lateral glide was less, then I would know to work on the right-hand side, and I would come in... 

for me, I do a intraoral release into one of the muscles that attaches near the disc. But that could instead be some release into masseter, into temporalis around the forehead. And then I would do some strengthening. 

You know, it might not be that in-depth, but you could definitely come in and take a look and say, "Oh, you know, I can see that your jaw, when you open your mouth, is deviating to one side. Let me suggest that you do a gentle bit of massage on the side that it's deviating towards, and let's strengthen the opposite side." 

Alexa: If a singer was to say to us, "You know, my jaw feels completely fine, in every day I don't clench, I don't feel any pain, but as soon as I start singing, it all [00:25:00] comes in." What would your clinical brain be curious about? 

Emer: If I'm not seeing anything in terms of their biomechanics, then that's a technique issue, and that is something that either they, you know, don't have control elsewhere, they maybe don't have enough tongue strength or they're, maybe not overworking into their tongue, but definitely a tongue weakness would suggest that their jaw is doing a little bit too much. 

But if they're not, if they're not s- presenting anything to me and it's only in singing, I'm not the right person for that. 

But, you know, chances are that person would come in, and I'm sure I would find something biomechanically that I could work on that might explain why the jaw is doing too much, whether it's because of a postural change or a weakness. 

Alexa: Obviously, people are coming to you because they have an issue or they're feeling an issue, or they've been referred for some reason. 

 Is it possible that there's [00:26:00] anybody in the world who doesn't actually need physio help? Or is it something we all kinda need because it's just a product of our environment?  

Emer: Yeah. I mean, there's obviously a scale. Some people can really, really benefit from physio. And I mean, in today's current climate where we're all feeling the pinch, I totally understand why coming in to see physio isn't the top of your priority list. 

I mean, of course, I would say this, that I think physio has a lot of benefits. I work a lot with trying to optimise, someone's biomechanics so that they can live as pain-free and also future-proof themselves. And if you have all the money in the world, then of course that sounds great. But I completely understand why that wouldn't be the first thing for you to be thinking about. 

So instead, we know there's loads of evidence [00:27:00] around good forms of strengthening, that can be a great place to start. And then, you know, seeing physio as a backup when you're in, in pain is also, is also useful. 

The other big thing to, to mention is that when you come into physio, it can feel like quite a negative experience sometimes, where someone is assessing you and basically trying to work out all the things that maybe are wrong or suboptimal. But we now know that, like, a textbook posture is not always what we need. 

The point is, is that you are moving freely, that you have stability and that, you know, ideally I'd be thinking that I'm trying to improve someone's function even at a cellular level so that we're really thinking about the whole anatomy and not just kind of one joint that's in front of you. 

Alexa: I love going to a physio. I'm always [00:28:00] like, "Can you tell me what muscle you're feeling? What's it doing?" I'm really quite annoying as a patient.' 

Emer: No, I love that. Do you? I think it's important that we understand our anatomy, you know? And to, to have that autonomy over our own bodies and how we feel, you know. I really believe that when you leave a physiotherapy session, that I don't wanna tie my patients to me. I want them to have autonomy. I want them to be able to go away, and whenever they feel that pain again or they feel that restriction, they have the tools in their own toolbox to be able to address it. 

Alexa: There's a growing trend around aesthetics. I mean, just yesterday I had one of those plumping face masks on. It did fuck all. I need... I think I probably need to do it a few more times. But things like jaw-strengthening devices, facial sculpting, lymphatic drainage brushes, creams, various jawline-enhancing products. 

Is there any [00:29:00] genuine biomechanical basis behind these trends?  

Emer: I mean, there's kind of two camps here. One is to try to encourage more of a, an obvious jawline, and that's where we are training that muscle. Is that gonna help the joint? Is that gonna make you feel less tight? No. You are probably gonna feel a lot of tension around that area. In the same way that when you go to the gym, you're probably gonna feel tension in the muscles that you're working on. That's kind of the point of being there. But you will get some hypertrophy in that muscle, and that can give you the appearance of more, a more defined jawline. So that's one camp. 

And then some of the others that you've mentioned would be more about, like you said, lymphatic drainage or releasing tension through the muscles, which can really be useful. 

I do some form of lymphatic drainage every single day. I [00:30:00] use the pin and poke gua sha tool, which has a little jagged edge so we can get a little bit of blood flow as we're working through some of these areas. So if I've woken up and I think, "Wow, my jaw is tight," I have some method of releasing that before the day starts. 

And that can be really useful. There's lots of stuff online now about using them and in the right setting they are a great adjunct to what we need. I mean, some of the stuff that I see popping up is maybe not as appropriate for all singers. But yeah, some of them can be good. 

Alexa: I was seeing not recently, but a while back, those like sort of chewing toys that you could put in your mouth and just like work the masseters to pop.  

Emer: Yeah. As a singer, I would highly advise against using those. We use those muscles enough in everyday life, that [00:31:00] if you're not thinking of the aesthetics, I wouldn't say there's any other reason as to why we would want that joint to be working so consistently throughout the day. 

So if you care more about aesthetics than the biomechanics in that area and the technique, then you can make that decision that you'd want to use it. But I would say that the two don't go particularly well together if you are a professional voice user and wanna make sure that you're mobile in that area. 

Alexa: Maybe that's what we need now, a whole load of gua shas in our toolbox to hand out.  

Emer: Yeah. I know. I love mine. I, I use it a lot, and actually I will be posting a video on my Instagram about a TMJ release using it. 

So that will be there if people need it. 

Alexa: Can we just go back a bit to talking about hypermobility. So when it comes to doing movement with the jaw, I know you mentioned [00:32:00] about sometimes their jaw is, is just too released or too movable. So would we be doing the strengthening-y stuff more than, say, wiggles and-  

Emer: Yeah. So I would, I would start with strength, so wake up those muscles. So keeping it neutral, working through different ranges. 

I would do some tongue exercises, trying to keep the jaw completely still and just moving the tongue to strengthen the back of the tongue. I would then eventually start getting them to do some proprioceptive work into their jaw. So things like small circles with the bottom jaw, clockwise and anti-clockwise. Really small, but just being able to get that communication so they're able to control that area can be really helpful. 

I actually think the issue is more because it's such a mobile joint, the issue is that their jaw gets involved for other, you know, speaking breathing, tongue motions when it doesn't need to be, and that's why it [00:33:00] starts to, the joint starts to become a little bit angry over time, is because it's being overworked. 

So getting that isolation and to ensure that the jaw isn't moving quite as much, particularly into those lateral movements when it doesn't need to be.  

Alexa: I guess that's when we would do things like the jaw stop, whether we have like a bone prop or using the little finger between the teeth or a cork. 

Emer: And that's a great point actually that I haven't mentioned, is that if they're struggling with proprioception, have them put their hand on their chin so they can feel when their jaw is moving, or have a mirror in front, 'cause they're not gonna be able to feel what's happening. Instead, they need to be able to either visualise it or feel it through touch. 

Alexa: You do acupuncture work as well, don't you? How does that look from a jaw perspective?  

Emer: So there's a few things that we can use it for. I do something called medical acupuncture or dry needling, slightly different from, well, actually very different from traditional acupuncture. 

My goal is to come into [00:34:00] certain muscles that I know have increased tone or are hypertonic, and I wanna release those areas with the needles. It helps to calm down the central nervous system in that area. It also helps to modulate pain. And when we've got a very unhappy joint, actually sometimes me poking and prodding around here is just the last thing it needs. 

Similarly, through these muscles, I want to down-regulate some of that kind of nervous system overactivity. And actually, needles can be a great way of doing that. You know, it's intense, and, you know, having worked in theatre where you have people on stage, I make every effort to ensure that I don't leave a bruise, but of course, on your face, it's a very vascular area. I've had to be very, very careful with where we put things, especially for, leading performers and singers. 

But actually, it's a, it's such a great option. And for more [00:35:00] complex patients who aren't responding to other treatment options, needling can feel like magic.  

Alexa: What might that say about, in the studio room, having the singer kind of putting their fingers gently or with as much pressure as they feel is useful into the actual muscle that they feel is overacting as they do the activity. Is that proven or thought to be useful?  

Emer: As in to, to release that area?  

Alexa: Yeah. Let's say that the chewing muscles are just really clenching as they're singing in their higher range. If we're in the higher range and we sort of put a little bit of pressure into that muscle with our fingers as we're singing up there- is that a useful idea?  

Emer: Yeah. Like, proprioceptively trying to create a little bit more of a clear communication between that muscle in the hope of it starting to soften and relax can totally, be useful. So yeah, that, that can definitely [00:36:00] be a good option. 

Alexa: What symptoms or red flags around the jaw would you say we just should not be ignoring?  

Emer: So sudden onset of jaw pain, I would be a bit cautious around. If that's accompanied with a unilateral headache, so on one side. 

If they've got things like dizziness double vision, any other changes to eyesight, speaking, hearing. If their lymph nodes are enlarged, that can be quite a good one to come in and check. Lymph nodes raised or more scarily under the collarbone, I'd wanna, have them see their GP. Sudden hoarseness, as we know, should also be checked by a laryngologist. If it is unexplained and is not improving, then straight for a scope. 

Alexa: You know that clicking, crunchy sort of popping that [00:37:00] you've described, can you give us an idea of what that actually is and why that happens?  

Emer: Yeah. So when our jaw moves, the condyle should be hitting against something called the disc. 

And the disc is a very different type of structure to other anatomy in that area. Its whole job is a shock absorber. So it's the perfect substance in order to be able to tolerate the load of a bone bashing into it all the time. 

If that disc moves anteriorly, because it attaches to a muscle, so if that muscle is too tight, it pulls that disc forward, and so rather than it being the kind of block in the way, we then hit other more normal tissue. 

And like all our regular tissue, it is vascular. So if it has a blood supply, [00:38:00] it also means that it will be painful. So that's where we kind of start to see more jaw issues, is when that bone, the jaw bone, the condyle, starts hitting on what's called the retrodiscal tissue, which just means the tissue that sits behind the disc. 

Disc has moved forward, we hit a very vascular structure, it becomes painful, and we, and the click is the sound of the disc being shifted forwards. 

But actually, you know, we can work on that muscle that attaches to the disc to stop it from moving forward. So if we get in early enough and start to treat that area, we can reduce those symptoms. 

Because when someone starts to present with more locking, that's when it is a slightly harder process. Can take a little bit longer. 

But I should state they've done studies and clicking in the jaw is really common, and it's not something to be worried about. Yes, we can do something to improve it so that it doesn't return. But I don't want people to be at home kind of panicking that this is [00:39:00] something that is severely wrong. It's really not. 

Alexa: We also probably hear the phrase TMJ quite often. Can you explain a little bit about that?  

Emer: It is your temporomandibular joint. So it's just describing your jaw joint which, if you come to the tragus of your ear, and if you open and close, if you're just in front of it and then you open and close, you'll feel something move. 

That's your jaw That's your temporomandibular joint, where the temple of your cranium meets the mandible of your jaw.  

Alexa: So when people say, "I have TMJ", it's like we all have TMJ 'cause you've  

Emer: got the TMJ- Yeah, that makes no sense. I have TMJ pain is maybe what they mean. Or TMD, temporomandibular disorders. 

Alexa: And what tends to sort of cause that?  

Emer: That would be all the, clenching. It could be if they've got like a disc [00:40:00] derangement where it is moving. It can be postural. All those things that we mentioned before can cause pain and inflammation in that area. Yeah, that would be the classic ones. 

If you've had a direct impact on that area, that would be slightly different. You know, you can have subluxations or dislocations of that joint. You can get a fracture of your jaw. Yeah, either acute or more kind of chronic symptoms. 

I actually had somebody in the other day who was describing a lot of fullness in their ears. And I definitely do see this a fair bit in my TMJ patients. But actually because of the positioning of the eustachian tubes, you can often find that TMJ symptoms can present as a feeling of fullness in either one or both ears. 

So actually coming in and doing a little bit of release into that area can be really helpful for anyone with ear symptoms. 

Now, I should say this, [00:41:00] there is a lot of things that can cause a feeling of fullness or, reduced hearing in the ears, but it can be a good place to start if other treatment options have been unsuccessful and you think you might be clenching at night, that can be a really good thing to look into. 

And actually if anyone is uncertain if they're clenching at night, a really easy way that you can definitely do at home, and singing teachers can look at, is if someone has scalloping on the tongue. So when you stick your tongue out, for people that clench, you'll see these little what looks like teeth marks in, on the outside of the tongue. They'll also have cheek ridging. So when you rub your tongue on either side of the inside of your mouth, you'll basically feel a line where your two teeth, bottom and top teeth, meet. And that's because when you bite down, it creates quite an intense suction which just pulls the inside of your mouth and tongue [00:42:00] into that space, and so we create indentations, marking. 

Alexa: Wow. And is there anything that will exacerbate that feeling of fullness in the ears? Like, if we start singing, is that going to feel-  

Emer: Yeah, totally. You know, it can make you feel a little bit dizzy and lightheaded because you're just not getting the same input that you normally would. 

I have patients who have in-ears and, you know, it just makes it really, really tricky when performing when it just, something feels like there's, it's kind of blocking. 

And you also when you're ill and you just can't hear the sound of your own voice, it's really disconcerting, you know? It can really put you off. So, I've had a lot of, a lot of patients who've really struggled with that. 

Alexa: If there were three things singers could start doing today to look after their jaw health, what would they be? 

Emer: I think the first thing I would have most people do is some strengthening around their neck and tongue, if I'm allowed to include that in one point. So, you know, a forward head posture or that [00:43:00] translation, which is often because of a restriction through the top of the neck and a little bit of extra mobility through the mid part of the neck. But that automatically is gonna put your jaw in a position where it's more closed. So that'd be the first thing. Some deep neck stability and some postural awareness as well around that area. So particularly for your patients that like to lead with their chin when they're singing, that would be a really good one for them to be doing.  

So we're trying to translate the very top cervical levels. So C1 to 2. It is a small nod that comes from those levels. I would typically do it lying down on your back without utilising this big sternocleidomastoid muscle at the front. So they do a small nod, and they try to keep this switched off, and you should feel it a little bit deeper at the back of your throat, and that's called deep neck flexor exercises. 

 And then, yeah, a little bit of tongue as well. 

[00:44:00] Then I would also do something for central nervous system regulation. We need to factor in that stress component, trying to kind of calm down that system whether that is tapping, splashing cold water or cold showers bouncing or just, like hopping. You know, something that is going to take you out of fight or flight and into your parasympathetic or rest-and-digest state. Really useful for the jaw. 

And then the last thing would be for the people that think that they are clenching at night, trying to optimise sleeping habits. So making sure that you're not going to bed and you know, scrolling on your phone. There's a lot of things. You know, I see a lot of patients that come in who are hypermobile and also just quite sensitive systems. So anything that might cause your central nervous system to work throughout the night, that could be from the laundry detergent that you [00:45:00] use, it could be from mold in your home, it could be certain plants that you keep in your bedroom. 

So yeah, trying to make sure that your bedroom environment is conducive to really restful sleep. 

Alexa: Emer, it's always such a pleasure to have you on the podcast. You're so knowledgeable and so generous with sharing that information with us. Thank you so, so much.  

Emer: No, it's not a problem. Nice to be back and see you again.  

Alexa: Just remind us where people can book an appointment with you. 

Emer: Yeah, so I have got a room in Blackheath where I am situated, and either they can get me on Instagram Emer Tully or Corepoints Physio, and they can book in online via the link in my bio.  

Alexa: Great. Thanks, Emer, and good luck with the rest of the self-employed journey.  

Emer: Thank you so much.