Lumbar Spine: Pain Mechanisms

• Lecture 9 is the start of quiz 3 and constitutes a review from the lumbar spine

Diagnosis

• Categories are based on the ICF impairments and the Treatment Based Classification system, which is based on effective treatments
• Patients should not be referred for possible serious disease/injury

Causes of Pain

• After ruling out red flags, determine the dominant pain mechanism

Common dominant pain mechanisms

• Joints and muscles
• However, a great deal of evidence suggests more complexity

Categorizing Dominant Pain Mechanism

• One approach is to categorize it as input, processing, or output

Input

• Pain caused by input to the system

Nociceptive Pain

• Strains + sprains + inflammation of tissue cause firing of nociceptors
• Achy, sharp pain is a typical post-traumatic pain

Neurogenic Pain

• Injury to a nerve causes the nerve to become a pain source
• May include a nerve inflamed due to compression
• Typically presents with pins and needles
• More complex cases require a team approach and more time

Processing

• How the body processes painful stimuli

Central Sensitization

• Hypersensitivity to low-level stimuli
• True physiological changes in the brain lead to increased pain perception

Cognitive Affective Mechanisms

• Perception of pain related to thoughts and emotions
• Often occurs simultaneously with central sensitization

Output

• Pain caused by ongoing output of the system

Autonomic Regional Pain Syndrome

• Regional pain syndrome (e.g., CRPS)
• Not common but can happen after trauma/surgery

Motor Output

• Motor pain is caused by compensatory movements that perpetuate pain

Clinical Note

• Approaching a processing problem as an input problem can increase pain
• Treating fear avoidance (cognitive affective) as an input problem is unlikely to be successful
• The class primarily focuses on input pain problems, specifically biomechanics of articular and muscle dysfunction
• This is because these problems require more time to learn the requisite skills
• Clinical practice reveals patterns that mix dominant pain mechanisms requiring comprehensive patient treatment

Headaches

• Types are based on the 1988 HIS classification, based on headache history and behavior

Headache Types

• Migraine
• Tension Type
• Cervicogenic

Migraines

• Time: 4-72 hours
• Intensity: Moderate to severe
• Characteristics:
  • Unilateral
  • Nausea and vomiting
  • Photo/phonophobia
  • Brought on by normal daily activities
    • Provide education for modulation
  • Related to blood flow disturbances in the CNS
    • Can be seen on MRI
  • Not a mechanical issue; Physical therapy will not help; usually medically managed

Tension Type

• Time: 30 minutes to 7 days
• Intensity: Mild to moderate
• Characteristics:
  • Bilateral, pressing and tightening (no pulsations)
  • No nausea or vomiting
  • No photo/phonophobia, or one but not the other
  • Not aggravated by routine activity
  • Occurs within the CNS
  • Hereditary, associated with triggered points
  • Stress work affective

Cervicogenic

• Intensity: Moderate to severe
• Time: Varying duration and no consistent answer
• Characteristics:
  • Unilateral, not throbbing, starts in the neck from sustained or awkward positions
    • Pain also radiates up into the head
  • Aggravated by neck movements
    • Are headaches only there when your neck hurts?
  • Etiology trigeminocervical nucleus
    • Neurons located in the brainstem that process pain signals from the face, head, and neck
    • Cranial nerves 5, 7, 9, and 10 cross at the nucleus

Headaches - Red Flags

• Severe headache with sudden onset

Acute subarachnoid hemorrhage (aneurysm) / hemorrhagic stroke

• Vomiting and seizures
• Experiencing "the worst headache ever", or "thunderclap headaches"

Carotid or vertebral artery dissection

• Onset from headache to symptoms
  • Vertebral artery dissection (bleed) takes 14.5 hours (considered a slow bleed)
  • Internal carotid dissection can take up to 4 days (extremely slow bleed)

Intra-cranial tumor

• Sub-acute and worsening headache
• Change in headache
• New symptoms
• Progression of the headache and neurological symptoms

Screening to Rule Out Serious Headache

• Serious if age > 50 years old, sudden onset, or any abnormality on neurological exam
• Headache from serious pathology can likely be ruled out if all predictors are absent
• if they ask if its serious → educate, ask questions (MD)

Cervicogenic Headache

• Includes joint mobility examination of the CGH

Joint Mobility Examination CGH

• Usually presents with dysfunction in C0-C1 and C1-C2 spinal segments
• Limitations in sagittal plane motion

Cervical Flexion-Rotation Test (CFRT)

• Sn 90%, Sp 91% in diagnosing CGH
• (+) test - If flexion-rotation test value is ≤ 32° in the most restricted side

Muscle Dysfunction in CGH

• Muscle tightness in the upper trapezius, suboccipitals, levator scapulae, and pectoralis minor
• Impaired control on the craniocervical flexion test (CCFT)
• Impaired performance of the DNF test
• Reduced strength and endurance of the cervical flexor and extensor muscles

Cervicogenic Headache Treatment

• Neck exercise (low intensity endurance training) + spinal manipulation are effective in the short and long term
• Spinal manipulation is effective in the short term compared to massage or placebo spinal manipulation
• Weaker evidence when compared to spinal mobilization

General Guidelines

• You must address inflammation + pain FIRST as necessary
• Modalities to use are taping, soft tissue mobilization
• Education about rest, activity modification, posture, and sleep are also important

Manual Therapy

• Mobility MUST come before exercises focusing on strength
  • Use soft tissue mobilization
  • Joint mobs, in particular, remember that thoracic mobilization/manipulations can help cervical pain

Motor Control

• You need to establish motor control BEFORE focusing purely on strength
  • Movement w/o compensations, normal motion, start small, with no resistance-AROM is ok
• Then focus on strength as necessary
  • Typically, endurance in the cervical spine.
    • But can use gravity or weights as resistance
  • Do not forget about the scapular and RTC muscles

Postural Training

• Posture relies on mobility, motor control, and strength (primarily endurance)
• It is OK to begin postural training early, but understand that lack of mobility will limit the the patient's ability to assume certain postures.
• IT DEPENDS → depends on the person and what they have been doing

Designs for manual therapy

• Pragmatic vs Prescriptive

Pragmatic

• Real world

Prescriptive

• Do it exactly the same on every single patient every single day for standardization
• Good internal validity but not good external validity

Manual therapy studies

• Studies using a prescriptive approach demonstrate that manipulation > mobilization generally for individuals with neck and low back pain
• Clinical decision-making is removed, impacting either mobilization or manipulation's potential impact
• No difference between mobilization + manipulation for neck or low back pain when clinicians chose the manual therapy and target segment
• Mobs as effective as manipulation when performed with pragmatic ("real-world") approaches

Motor Control

• Framework for Interventions for Improving Motor Control
  • Efficient movement satisfies task requirements via coordinated progression of motor control

Motor Control Principles

• Mobility MUST come before controlled mobility
  • If joint doesn't move (due to stiffness or weakness) - skilled movement can't occur
• Proximal stability generally before distal mobility (e.g., trunk control is needed before efficient arm or hand use)
  • Exceptions exist-- some pts may perform distal tasks (e.g., feeding) using compensation before achieving full proximal stability
• Compensations (e.g., straps, devices) -- when necessary for task participation; restoring proximal control should remain a focus.

Progression Model

• Mobility → proximal stability → weight shifting → stepping → complexity (e.g., dual tasks like walking while manipulating objects)
• Evaluate patient's movement based on task needs:
  • Adequate joint mobility
  • Demonstrate proximal stability
  • Can they weight shift + position limbs functionally
  • Can they progress in gait or perform dual tasks
• Interventions should target the missing components critical to achieving coordination and skilled movement.

Mobility

• Both passive + active
  • Definition: Sufficient motor unit activity to initiate a contraction AND available mobility (articular, soft tissue, neural, fascial, etc) for the movement in question.
  • Passive mobility is required prior to active mobility
  • The pre-requisites for attaining a posture or position
    • Talar mobility is necessary for neutral dorsiflexion and must be present for efficient stability in standing
    • Glenohumeral mobility is necessary for shoulder flexion to occur and therefore must be present for efficient reaching
    • Trunk mobility for a neutral sitting posture must be present for efficient static balance in sitting or standing

Stability

• Ability to maintain a steady position in a weight bearing or anti-gravity posture
• Co-contraction around a joint or a body segment
• Static postural control - The ability to maintain one's BOS over the COG statically like: - Stability/co-contraction at the hip/pelvis girdle which equals efficient stance. - Stability/co-contraction at the trunk which equals efficient static sitting or standing posture. - Ability to actively stabilize the shoulder girdle complex which equals efficient function of the UE

Controlled Mobility

• Definition: ability to change positions while maintaining stability proximally - dynamic stability - when moving the body while maintaining stability, while maintaining balance and control during movement - controlled mobility - ability to shift weight within a posture or between postures which involves the ability to move efficiently and smoothly within a joint's range of motion - can mean either the ability to stabilize proximally while moving distally or movement of proximal joints over fixed distal components
• Begins to challenge balance reactions as it requires a shift of COG over the BOS.
  • Examples:
    • Transitioning from STS
    • Weight shifting in quadruped or in half-kneeling or in standing.

Static-Dynamic

• Static-Dynamic is a transitional step between controlled mobility and skill
  • Definition: ability to lift a previously weight bearing component further challenging balance + equilibrium reactions from the controlled mobility level; BOS + number of supporting joints decrease, as the individual lifts a previously weight bearing extremity, challenge to dynamic stability increases

Skill

• Definition: highly coordinated movements that allow for interaction with the environment.

Examination

• Includes history and physical exam

History

• The same template applies, with some specifics as below (LMNOQRST)
• Trauma, dental work, pain w/ eating, speaking, bruxism, sounds, headaches, ear symptoms, cervical pain, lifestyle changes, etc
• Does the pain change with TMJ motion?
• Is there locking of the jaw, catching, or clicking?
• Parafunctional activities, such as chewing pencils/pens, nails, gum
• Psychological considerations, such as anxiety and/or depression (consider CBT)

Observation

• Facial asymmetries, appearance of maxilla and mandible, upper cervical spine position, muscle atrophy/hypertrophy, tongue assessment
• posture → head weights 12 pounds in neutral, 45 in FHP swelling, ecchymosis, open wounds, bite on the inside of each

Range of Motion

• AROM good reliability for measuring opening, protrusion, and lateral excursion
  • Patient should be able to fit 2-3 fingers (PIP joints) in the mouth.
• PROM (osteokinematic) has poor reliability, but is often not performed.
• PROM (arthrokinematic) also has poor reliability but needs to be performed
• Does the jaw open and close in a straight line?
• Is there a space anterior to the ear with opening indicating that the condyle is translating anteriorly

Opening/Closing patterns

• Is there a C-shaped or an S-shaped curve/deviation to movement?
  • S-shaped is usually a motor control issue
    • During opening w/o pain the issue may indicate muscle imbalance, muscle incoordination, or an anterior disc displacement with reduction (ADDwR)
    • If pain or limited opening w/ an S-shaped curve → may indicate involvement of the disc or capsule
  • C-shaped pattern are indicates hypomobility
    • During opening, mandible deviates to one side in the middle of opening and returns to the center at the end of opening and may be caused by ADDwR
    • C-shaped to one side during opening without returning to the center at the end of the range is termed deflection

Indicate Asymmetry

• Can indicate asymmetry in the amount of anterior translation of the condyle
  • ADDwoR, with limited TMJ opening and deflection occurring to the side of the ADDwoR (ipsilateral)
  • Limited capsular mobility – limited TMJ opening with deflection to the ipsilateral side
  • Unilateral TMJ hypermobility – deflection occurs away from the hypermobile side (rare)

Joint/Capsular Mobility

• OA, AA, lower cervical, cervicothoracic junction are assessed
• TMJ can be assessed intra-oral
  • Testing: Inferior glide, Anterior translation

Extra-oral Examination

• Anterior translation is assessed

Neurologic Examination

• Light touch to three divisions of CN V – ophthalmic, maxillary, and mandibular are tested

Palpation

• Masseter, temporalis, medial and lateral pterygoids, suprahyoids, and infrahyoids are palpated around the TMJ
• Capsule, retrodiscal pad palapted around the TMJ

TMJ Examination Accuracy

• Focus of the exam is if it is a TMJ problem
  • Restriction of maximal mouth opening is strong evidence
• Osteoarthrosis can also be diagnosed
  • Crepitus with auscultation = severe Osteoarthritis; or can indicate mild Osteoarthritis
• Anterior disc displacement/Internal derangement is an associated symptom
• Deviation of mandible

Muscles

• Superificial and Depp TMJ muscles

Superificial TMJ muscles

• Masseter
• Temporalis

Deep TMJ muscles

• Medial pterygoid
• Lateral pterygoid

TMJ Disorders

• All have pain in and around the TMJ, altered mandibular mechanics/motions, +/- joint noises

TMJ Disorder Classifications

• No Malocclusion
• Osteoarthritis presents with crepitus
• Capsulitis is the same as trauma
• Articular disorders are internal derangements

Intrahyoids

• Depression indirectly (SOTS)
• Sternohyoid
• Omohyoid
• Thyrohyoid
• Sternothyroid

Suprahypoids

• Depression – mandibular opening (GMDS)
• Geniohyoid
• Mylohyoid
• Digastric
• Stylohyoid

TMJ Biomechancis

• In general biomechanics during rotations and movememnts

Normal: opening to closing

• Can't see condyle when opening or closing disc

Opening: depression

• 40-50mm total movement

Opening: early phase

• Primarily rotation About 35-50% of the entire movement pattern Condyle rolls anteriorly → swinging the body of the mandible inferior + posterior Rolling stretches the lateral ligament, which initiates the late phase of mouth opening

Opening: late phase

• Primarily involves translation of the condyle and disc together in a forward and inferior direction
• Completes the other 50%
• Involves the slide along the articular eminence

Closing: elevation

• Mechanics are in the reverse order and this is translation followed by rotation

TMJ Treatment

• Lab Exercise N: Examination/Treatment of the TMJ
• Using the skull models:
• Note the origin and insertion of the masseter, temporalis, medial and lateral pterygoid, and the resultant line of pull for each.
• Move the jaw and conceptualize which muscles generate movement for opening, lateral excursion, and protrusion.
• Open + close the jaw and attempt to approximate the early phase rotation and late phase translation at the TMJ Practice an inferior glide and an anterior glide on the skull model using the appropriate hand (fingers/thumb) placement - Assisted mandibular opening - Self-mobilization to C2 - Extension self-mobilization to upper thoracic in sitting--may also use foam roll in supine - Upper thoracic postural stabilizers - scapular retraction ("row") - Focus on lower traps, serratus anterior, upper thoracic spinal extensors while maintaining cervical neutral to flexion Cranio-cervical flexion in supine - Focus on using longus colli and capitis NOT SCM

General TMJ Treatment Approach

• SINSS is important to recognize
• Severity, irritability, nature, stage, and stability
• Address posture as needed, typically forward head, and address the rest position of TMJ and tongue
• Arthrokinematic mobility in TMJ + cervical spine: frequently the TMJ and the cervical spine will need mobilization
• Address predisposing factors: stress, oral parafunctional habits (e.g., chewing on pencils, bruxism, etc.)
• Recommend initial exercises by Rocabado and patient education regarding soft foods, yawning, chewing gum, and other activities that would cause excessive TMJ motion/force

Clinical Tips

Address need for dentist referral for occlusal appliance, massage and soft tissue mobilization to masticatory muscles and to neck, stretching is needed, and so is Cervico-thoracic stabilizers Also utilize Scalenes, trapezius, pectoralis minor, levator scapulae

• Stabilizers: shoulder shrugs, scapular retraction, serratus anterior "punch," upright rows, horizontal rows

Additional Clinical Tips

• Cervical flexion is most common: progress from isometric to isotonic Palpation pt should be lying down, in extraorally: masseter, temporalis, medial pterygoid, hyoid bone, infrahyoids, suprahyoids
• intraorally: lateral pterygoid (medial to last molar on the top; “trying to come out her ear canal"), ensure there are gloves and do not do this procedure when a player is sick
• one side at a time
• can't palpate lateral pterygoid but can palpate medial (underneath angle) ensure there is gentle force and on pt face (do not be close)

Quiz 3 Covers

1.) TMJ 2.) Headaches 3.) Review Cx