Lec 9-11 MSK III Quiz 3: Lumbar Spine, Headaches, TMJ PDF
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Summary
These lecture notes cover lumbar spine diagnosis, headaches, and temporomandibular joint (TMJ) examination/treatment. Topics include pain mechanisms, headache types, TMJ anatomy, biomechanics, and treatment approaches. There are Rocabado's TMJ exercise program techniques and manual therapy.
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MSK III 117 Lec 9 - start of quiz 3 Diagnosis –review from lumbar spine hese categories have been defined by theICFbasedon impairments and by theTreatment T Based Classificationsystem based on which treatmentsare effective. Remember that we have decided this patient sho...
MSK III 117 Lec 9 - start of quiz 3 Diagnosis –review from lumbar spine hese categories have been defined by theICFbasedon impairments and by theTreatment T Based Classificationsystem based on which treatmentsare effective. Remember that we have decided this patient should NOT be referred for possible serious disease/injury. What is causing the Pain? A fter Red Flags have been ruled out, the PT is often trying to determine which is the dominant pain mechanism? PTs often jump to joints and muscles as dominant pain mechanisms. ○ However, great deal of evidence suggests more complexity. One approach (DeWitte, 2014, Manual Therapy) is to categorize dominant pain mechanism into the following: 1.Input:pain cause by input to the system a. Nociceptive pain:strains + sprains + inflammationof tissue cause firing of nociceptors. i. Achy, sharp; typical post traumatic pain, type of pain we spend the most time on b. Neurogenic pain:injury to anervesuch that the nerveitself becomes a source of pain. i. May include a nerve that is inflamed due to compression, ii. typically presenting withpins and needles. iii. more complex, team approach, more time 2. Processing a. Central sensitization:hypersensitivityto low levelstimuli. i. True physiological changes in the brain lead to increased pain perception. b. Cognitive affective mechanisms:perception of painrelated tothoughts and emotions i. often occurs simultaneously with central sensitization 3.Output:pain caused by ongoing output of the system a. Autonomic regional pain syndrome, e.g., CRPS i. not common but could happen after trauma/surgery b. Motor, e.g., compensatory movements that perpetuate pain .g. if you approach someone with a processing problem as though they were an input E problem, you might increase their pain. For example, if you treat someone whose primary problem isfear-avoidance (cognitive affective)as thoughthey were an input problem, you are unlikely to be successful in helping them. NOTE: Although much of our focus in this class is on input pain problems, in particular, on a model of biomechanics of articular dysfunction and muscle dysfunction. That is NOT because most patients have these kinds of problems but because those are areas requiring more time to learn the requisite skills. With clinical practice you will discover patterns that mix these dominant pain mechanisms and treat all parts of the patient appropriately. MSK III 118 HEADACHES Types (*All based on the 1988 HIS classification based on history and behavior of the headache) 1. Migraine | 2. Tension type | 3. Cervicogenic Migraines Tension Type Cervicogenic→ most common we’ll see as a PT Time 4-72 hours 30 minutes-7 days Episodes of varying duration→ no consistent answer intensity Moderate to severe Mild to moderate intensity Moderate to severe intensity Characteristics -Unilateral -Bilateral,pressing - Unilateral,not throbbing, starts in - nausea, vomiting tightening (no pulsations) theneckfromsustained or awkward -photo/phonophobia -no nausea or vomiting positions -Brought on by normal -no photo/phonophobia, or pain can go up into head -Aggravated by neck movements daily activities one but not the other p rovide education “Are headaches only there when - Not aggravated by routine for modulation your neck hurts?” activity -Related to blood flow -Etiology trigeminocervical nucleus - Occur within CNS disturbances in the CNS eurons located in the brainstem n -hereditary in nature, → can be seen on MRI that plays a crucial role in associated with triggered processing pain signals from the - No mechanical issue? → face, head, and neck PT will not help, usually points CN 5, 7, 9, 10 → cross at a nucleus medically managed - ST work affective HEADACHES –RED FLAGS Severe headache withsudden onset ○ Acute subarachnoid hemorrhage (aneurysm)/ hemorrhagicstroke Vomiting, seizures, “worse headache ever”, “thunderclap headaches” Carotid or vertebral artery dissection ○ Onset from headache to symptoms: vertebral artery dissection (bleed) → 14.5 hrs(slowbleed) internal carotid dissection → 4 days(extremely slowbleed) Sub-acuteandworsening headache ○ Intra-cranial tumor C hange in headache, new symptoms Progression of the headache and neurological symptoms MSK III 119 SCREENING TO RULE OUT SERIOUS HEADACHELocker 2006:Sn: 0.99;Sp: 0.34 Age > 50yo | Sudden onset | Any abnormality on neurological exam I f all predictors absent → headache from serious pathology can likely be ruled out (+) → hospital if they ask if its serious → educate, ask questions (MD) Cervicogenic Headache ✧ JOINT MOBILITY EXAMINATION CGH Usually presents with dysfunction inC0-C1 and C1-C2 Limitations in sagittal plane motion Cervical flexion rotation test (CFRT)(Ogince et al,2007) ○ Sn 90%, Sp 91%in diagnosing CGH ○ (+) test - If flexion-rotation test value is ≤32° (most restricted side) MUSCLE DYSFUNCTION IN CGH Muscle tightness: ○ upper trapezius, suboccipitals, levator scapulae, and pectoralis minor Impaired: ○ control on the craniocervical flexion test (CCFT) ○ performance of theDNF test Reduced strength + endurance of the cervical flexor and extensor muscles or the prophylactic (preventative) treatment of cervicogenic headache, there is evidence that both F neck exercise(low intensity endurance training)+spinal manipulationare effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation, and weaker evidence when compared to spinal mobilization (Bronfort et al 2004, Dunning et al 2016). Use the following general guidelines to help you make a clinical decision about the PRIMARY focus of your interventions. Remember: You must address inflammation + pain FIRST as necessary: Taping | Modalities | Soft tissue mobilization Education about rest, activity modification, posture, sleep MSK III 120 You MUST havemobilitybefore exercises focusing on strength Soft tissue mobilization Joint mobs—in particular,remember that thoracic mobilization/manipulationscan help cervical pain Establishmotor controlBEFOREfocusing purely onstrength Movement w/o compensations, normal motion, start small, with no resistance—AROM is ok Focus on strength as necessary Typically, endurancein the cervical spine. ○ But can usegravity or weightsas resistance Do not forget about the scapular and RTC muscles What about 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 patient’s ability to assume certain postures. IT DEPENDS → depends on the person and what they have been doing PRAGMATIC vsPRESCRIPTIVEDESIGNS FOR MANUAL THERAPY Roenz et al, 2018 – SR and MA (Prescriptive →meansyou do it exactly the same on every s ingle pt, every single day for standardization; good internal validity but not good external validity) S tudies using aprescriptive approach foundmanipulation> mobilizationat most time points for individuals withneck and low backpain. ○ Design type is not necessarily representative of clinical practice+ removes any clinical decision making →impacts the effectof either mobilization or manipulation. When clinicians had a choice in the manual therapy + segment targeted for treatment → no differenceb/w mobilization + manipulationfor neck or low back pain. When mobs is performed using pragmatic (real world) approaches it may be just as effective as manipulation. MSK III 121 Framework for Interventions for Improving Motor Control Efficient movement - satisfying task requirements viacoordinated progression of motor control. 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 necessaryfor task participation ○ restoring proximal controlshould remain a focus. Progression model ○ Mobility → proximal stability → weight shifting → stepping → complexity (e.g., dual tasks like walking while manipulating objects) Evaluate the patient’s movement based on task needs: ○ Do they have adequatejointmobility? ○ Do they demonstrateproximal stability? ○ Can theyweight shift+position limbsfunctionally? ○ Can theyprogress in gaitorperform dual tasks? ○ Interventions shouldtarget the missing componentscritical to achieving coordination and skilled movement. Mobility (both passive + active) ○ Definition:sufficient motor unit activityto initiatea contraction ANDavailable mobility(articular, soft tissue, neural, fascial,etc) for the movement in question. ○ Passive mobility is required prior to active mobility. ○ Thepre-requisites for attaining a posture or position. ○ e.g. 1. Talar mobility is necessary for neutral dorsiflexion and must be present for efficient stability in standing 2. Glenohumeral mobility is necessary for shoulder flexion to occur and therefore must be present for efficient reaching 3. Trunk mobility for a neutral sitting posture must be present for efficient static balance in sitting or standing MSK III 122 Stability ○ Definition: ability to maintain asteady positionin a weight bearingor anti-gravity posture; co- contraction around a joint or a body segment;static postural control.The ability to maintainone’s BOSover the COGstatically. ○ e.g., 1. Stability/co-contraction at the hip/pelvis girdle → efficient stance 2. Stability/co-contraction at the trunk → efficient static sitting or standing posture 3. the ability to actively stabilize the shoulder girdle complex → efficient function of the UE C ontrolled Mobility ○ Definition: ability tochange positions while maintainingstability proximally dynamic stability- when moving the body while maintainingstability maintaining balance and control during movement controlled mobility- ability to shift weight withina posture or between postures(controlled mobility involves the abilityto 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. ○ It begins to challenge balance reactions as it requires a shift of COG over the BOS. ○ e.g.: 1. Transitioning from STS 2. Weight shifting in quadruped or in half-kneeling or in standing Static-Dynamic(a transitional step between controlledmobility and skill): ○ Definition: ability to lift a previously weight bearingcomponent further challenging balance + equilibrium reactions from the controlled mobility level BOS + number of supporting joints ↓ as the individual lifts a previously weight bearing extremity ↑ challenge to dynamic stability ○ e.g.,: 1. Quadruped – lifting one upper extremity or one lower extremity (this happens in preparation for the skill or crawling) 2. Standing – lifting one lower extremity (this happens in preparation for stepping and walking) 3. Moving an upper extremity in space (this happens in preparation for using the UE to interact with or manipulate items in the environment) MSK III 123 Skill ○ Defintion:highly coordinated movementsthat allowfor interaction with the environment being able to manipulate items in the environment or being able to locomote (crawl, walk) movement of distal components over dynamically stable proximal components. Coordination, timing, sequencing occur at this level. ○ E.g.,: 1. Crawling 2. Walking 3. Picking up a glass and bringing it to one’s mouth 4. Writing, typing, etc LINICAL PREDICTION RULES →D ON'T HAVE TO KNOW C Identifying individuals likely to respond to mechanical cervical traction ge > 55 years old A + shoulder abduction test + ULTT A Symptom peripheralization with lower cervical (C4-C7) PA motion testing + Neck distraction test 4 variables +LR 11.7 Identifying individuals with cervical radiculopathy likely to respond to PT ge < 54 years old A Dominant arm not affected Looking down does not aggravate symptoms Multi-modal Rx for > 50% of visits (OMPT, traction, DNF strengthening) 3 variables +LR 3.2 4 variables +LR 8.3 Identifying individuals with neck pain likely to respond to thoracic spine thrust manipulation NOT VALIDATED 2010 ymptoms < 30 days S No symptoms distal to the shoulder Looking up does not worsen symptoms FABQPA < 12 Diminished upper thoracic kyphosis T3-T5 Cervical extension ROM < 30 3 variables +LR 5.5 MSK III 124 Individuals with neck pain likely to respond to cervical spine manipulation ymptoms < 38 days S Positive expectation manipulation helps Side-to-side differences of rotation 10 degrees of greater Pain with PA motion testing middle cervical spine 3 variables +LR 13.5 (39%-90%) Individuals with LBP likely to respond to thrust manipulation(know this doe) Pain < 16 days FABQW < 19 No pain distal to the knee Hypomobility of at least one segment with PA spring tests One hip > 35 degrees of IR Lec 10-4/3 - TEMPOROMANDIBULAR JOINT (TMJ) ✧TEMPORMANDIULAR DISORDER (TMD) Term for a collection of symptoms that affect thecranio-facial-mandibular complex (skull, face, brain, cervical region, jaw) ○ TMJ, orofacial muscles, teeth ○ Cervical spine, thoracic spine ○ Nervous system ○ other regions such as scapular region, rib cage, lumbar spine can also affect A collection of clinicalS&Sthat involve the TMJand associated supporting structures ○ Pain in + around the TMJ ○ Altered mandibular motions ○ +/- joint noises, clicking ○ Headaches | Dizziness | Ear aches ○ Tinnitus (ringing in the ears) / “fullness in the ear” PREVALENCE Estimated50-75%population suffer from one symptomof TMD at some point 17 million work days lost per 100 million full time workers in the US 3 – 5 times more prevalent infemales Most frequent15-40 yearsof age –MAYbe older oryounger MSK III 125 ETIOLOGY – causes 1. Macrotrauma→ whiplash injury, direct blow to thejaw, oriatrogenic dental procedure 1 2. Microtrauma→ no major traumatic event, more fromour own habits a. parafunctional clenching and bruxing (grinding teeth) b. must look at this from a psychosocial perspective 3. Degenerative osteoarthritis →not common 4. Systemic conditions→ autoimmune disease, RA, etc… 5. Mental health disorders PREDISPOSING FACTORS– which may require multidisciplinaryapproach to care Posture– typicallyforward head, increasedkyphosis Psychologicalstress – many patients havemyofascialpain syndrome and/or fibromyalgia Oralparafunctional habits ○ Chewing on pencils, pens ○ Bruxism ○ Sitting with the hand on the chin Malocclusion -misalignment of the teeth and jaws,resulting in an improper bite ○ Overbite or underbite ○ Not well supported with research ○ Expensive braces to correct this may or may not provide any long-term relief→ can possibly make pts worse Cervical movement dysfunction (caused from medical profession) → other examplesinclude losing sensation in fingers after 1 surgery MSK III 126 BONY ANATOMY Mandible ○ Condyle condylar head condylar neck ○ Angle ○ Ramus ○ Body ○ Coronoid process(similar to coronoid process on ulnar) M andibular fossa(temporal bone) - accepts condyleof the mandible Maxilla Zygomatic arch Sphenoid L ○ ateral pterygoid plate ○ Medial pterygoid plate ○ Greater wing T eeth ○ 32 teethin the adult pper right – U 1 Upper left – 16 Lower left – 17 Lower right – 32 MSK III 127 SUPPORTING CONNECTIVE TISSUE Articular disc-Disc Condyle Complex ○ 1. Posterior- most blood supply and innervation (still little) ○ 2. Intermediate – avascular/aneural ○ 3. Anterior Fibrous capsule (meaning there's a joint cavity) ○ v ery similar to a Synovial joint2 BUT more Fibrocartilage than hyaline cartilage (stronger) ○ Two joint cavities superior inferior Posterior region of the disc attaches to theretrodiscallaminae helps keep the condyle centered, prevents condyle from compressing retro/posterior tissues → cascade of events h elps stabilize and cushion disc movement. Collagen inferior retrodiscal lamina ○ F unction: Attaches the posterior disc to the posterior aspect of the mandibular condyle. ○ Role: Limits anterior movement of the disc and helps anchor it during jaw opening. E lastin superior retrodiscal lamina Function: Attaches the disc to the posterior glenoid fossa and the temporal bone. ○ ○ Role: Allows elastic recoil to reposition the disc posteriorly during jaw closing. highly vascularized, alot of pain fibers→ if rotated,extremely painful; probably where pain is coming from or at least part of it Anterior regionof the disc attaches to theLateralpterygoid muscle Disc attaches specifically to theTendon of thesuperiorheadof the lateral pterygoid muscle Temporal bone anterior to articular eminence 2 type of joint characterized by a fluid-filled cavity, allowing for a wide range of movement. It's the most common type of joint in the body, found in places like the knees, elbows, and hips. These joints are enclosed in a capsule and contain synovial fluid, which lubricates and nourishes the joint MSK III 128 Ligaments Temporomandibular ligament(aka lateral temporomandibular ligament; lateral ligament) ○ Limits rotationof the condyle during opening ○ Deeper fiberslimit posterior displacementof the condyle, thereby protecting the retrodiscal pad Collateral ligaments ○ Attach from the medial + lateral borders of the disc & insert onto the medial and lateral poles of the condyle ○ Function toresist excessive medial and lateral displacement of the disc→ keeping the disc centered Accessory ligaments -both havelimited function on kinematicsand instead suspend the mandible from the cranium(similar to coracoacromial ligament having no effect on GHJ) ○ Sphenomandibular ○ Stylomandibular MSK III 129 MUSCLES:(all innervated bymandibular nerve, branch of CN V – trigeminal nerve) (intrinsic TMJ muscles that directlycontrol) uperficialTMJ muscles S Masseter O rigin:inferior zygomatic bone and arch Insertion:ext. surface of the mandible b/w angle& coronoid process Action:bilaterallyelevates(close mouth) andprotrudesthe mandible; unilaterallyipsilaterallateral excursion emporalis T O rigin:temporal fossa Insertion:coronoidprocess and ramus of the mandible Action:bilaterallyelevatesandretrudes(only onethat does) the mandible; unilaterallyipsilaterallateral excursion eepTMJ muscles D Medial pterygoid O rigin:lateral pterygoid plate Insertion:internal surface of the mandible betweenthe angle and mandibular foramen (anterior to ramus) Action:bilaterallyelevatesandprotrudesthe mandible;unilaterally contralaterallateral excursion Lateral pterygoid (superiorhead) O rigin:greater wing (sphenoid) Insertion:medial capsule, TMJ, disc, and pterygoidfossa Action:bilaterallyeccentricallycontrols the discduring closing and protrudesthe mandible; unilaterallycontralaterallateral excursion Lateral pterygoid (inferiorhead) O rigin:lateral pterygoid plate Insertion:pterygoid fossa and neck of mandible Action:bilaterallyDEPRESSES(only one that does)andprotrudesthe mandible; unilaterallycontralateral lateral excursion SECONDARY MUSCLES OF MASTICATION MSK III 130 Infrahyoids – depressionindirectly(SOTS) Sternohyoid Omohyoid Thyrohyoid Sternothyroid Suprahyoids (depression – mandibularopening) (GMDS) Geniohyoid Mylohyoid Digastric Stylohyoid MSK III 131 BIOMECHANICS In general during rotational movement -mandibular condyle rolls relativeto the inferior surface of the disc translational movement- mandibular condyle + discslides together on the fossa. Depression:40-50mm Functional movement for eating is about18mm(lessthan an inch) Early phase→primarilyrotationonly ○ 35-50%of the entire movement pattern (inferior jointcavity) ○ Condyle rolls anteriorly → swinging the body of the mandible inferior + posterior ○ Rolling stretches the lateral ligament, which initiates the late phase of mouth opening Late phase → primarily involves translationof thecondyle and disc together in aforward and inferiordirection (superiorjoint cavity) ○ completes the other 50% or so most people have trouble opening their mouth Elevation Mechanics occur in the reverse order –translationfollowed by rotation MSK III 132 Protrusion / retrusion : 6-9mm(less than 1 cm) Condyle + disctranslate anteriorly without significant rotation Mandible slides slightlydownwardduring protrusion+upwardduringretrusion Extremelyimportant for full opening! Condyle + disc translate posteriorly without significant rotation Lateral excursion: 10mm each way (1/4 opening)(1cm) Side to side translation of the condyle + disc in the fossa Usually combined with other slight rotations and translations > 15mm is considered hypermobility if hypomobile → opposite side is what is restricting it (e.g. lateral excursion to the left → right side affected) NERVE SUPPLY Trigeminal nerve– cranial nerve V ○ Opthalamic ○ Maxillary ○ Mandibular: proprioceptive fibers TMJ Trigemino-cervical nucleus C1-C4 spinal nerves:Afferent pain fibers from C1-C4have projections through thespinal nucleusof the trigeminalnerve as it coordinates sensation from the ophthalmic, maxillary and mandibular portions. Consequently, suboccipital compression of C1-C4 nerves can present as TMD symptoms in the head and face. MSK III 133 EXAMINATION History – same template applies, with some specifics as below (LMNOQRST) 1. Trauma, dental work, pain w/ eating, speaking, bruxism, sounds, headaches, ear symptoms, cervical pain, lifestyle changes, etc 2. Does the pain change with TMJ motion? 3. Is there locking of the jaw, catching, or clicking? 4. Parafunctional activities, such as chewing pencils/pens, nails, gum 5. 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 inFHP swelling, ecchymosis, open wounds, bite on the inside of each c an’t escape FHP → everyone goes into the position at some point everyday length tension relationship issue → runs down the entire kinetic chain *overtime → mandible goes into subtle opening and posterior translation (push into tissues causing an inflammatory process) + temporalis masseter and medial pterygoid are going to want to clamp down and fire (lock down and go into chronic spasm can lead to an anterior disc placement over a very long time MSK III 134 Range of Motion AROM good reliabilityfor measuring opening, protrusion,and lateral excursion ○ Patient should be able to fit2-3 fingers(PIP joints)in the mouth PROM (osteokinematic)haspoor reliability, but isoften not performed PROM (arthrokinematic)also has poor reliability butne eds 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 aC-shaped or anS-shaped curve/deviationto movement? S-shaped(motor control issue) ○ during opening w/o pain → may indicate muscle imbalance, muscle incoordination, or an anterior disc displacement with reduction (ADDwR) ○ If pain or limited opening w/ S-shaped curve → may indicate involvement of the disc or capsule C-shaped(hypomobility issue) ○ during opening, mandibledeviates to one sidein themiddle of opening and returns to the centerat the end of opening and maybe caused by ADDwR ○ C-shaped to one side during openingwithout returningto the center at the end of the range is termeddeflection Indicative of asymmetry in the amount of anterior translation of the condyle 1.ADDwoR, with limited TMJ opening and deflection occurring to the side of the ADDwoR (ipsilateral) 2.Limited capsular mobility– limited TMJ opening with deflection to the ipsilateral side 3.Unilateral TMJ hypermobility– deflection occursaway from the hypermobile side (rare) MSK III 135 Joint/Capsular Mobility OA, AA, lower cervical, cervicothoracic junction TMJ ○ Intra-oral Inferior glide Anterior translation ○ Extra-oral: anterior translation Neurologic Light touch to three divisions of CN V – ophthalmic, maxillary, and mandibular Palpation Masseter, temporalis, medial and lateral pterygoids, suprahyoids, and infrahyoids Capsule, retrodiscal pad Accuracy of the TMJ Examination Is it a TMJ problem? ○ Restrictionof maximal mouthopening:+LR 8.7 Osteoarthrosis ○ Crepituswith auscultation = severe OA: +LR 4.8;ormild OA +LR 2.8 Anterior disc displacement/Internal derangement: ○ Deviationof mandible: +LR 2.5-3.6 ○ Clicking: Reciprocal clicking: +LR 15.2 ○ No deviation but with clicking: +LR 3 MSK III 136 TMJ DISORDERS Differential diagnosis Vascular:migraine or cluster headaches Intra-cranial disorder:weight loss, ataxia, weakness,fever, etc Neuropathies:trigeminal neuralgia Ear or sinus disorders ategorizing TMJ Disorders: all have pain in and around the TMJ, altered mandibular C mechanics/motions, +/- joint noises.(NO MALOCCLUSION) ✧ Osteoarthritis Crepitus | joint noises with movement | decreased opening with pain ✧ Capsulitis trauma or poor oral habits (inflammatory) Pain with palpation and movement | C shaped curve with opening with a deflection to the same side Pain thegreatest with closingis posterior capsulitis– MOST common ✧ Articular Disorders (Internal Derangement) Functional dislocation of the disc anteriorlywithreduction– ADDwR Noticeable openingclick, with a moresubtle closingclick ○ ○ Limited mouth opening with or without pain ○ Altered mandibular dynamics with an C or S shaped curve Functional dislocationwithout reduction– ADDwoR ○ L imitation of motion to rotation only app30mmopeningwith ipsilateral deflection and pain ○ Thislimitationof mouth opening, pain, and deflectionmay disappear as the condition becomes more chronic ☆ Cluster of 7 tests (NOT TESTED ON) J oint provocation test (mouth opening with pain) Deviation test (deflection to ipsilateral side during mouth opening) Laterotrusion test (limited lateral deviation to the contralateral side < 9mm) Joint mobility test (reduced anterior translation of the condyle assessed with palpation) Joint sound test (absent joint noise or crepitus is considered positive) Dental stick test (tongue depressor between back molars as the patient bites down with a positive test being pain elicited in the ipsilateral or contralateral joint) Isometric test (pain elicited with manual isometric resistance to contralateral lateral deviation Psychological ○ Up-regulation of central nervous system, trigeminal nucleus ○ Those with TMJ tend to be over-reactive to their environment ○ Anxiety, depression, anger, and fear all tend to increase with chronicity and may contribute to increased pain MSK III 137 PATHOMECHANICS EVER SEE CONDYLE IN FRONT OF DISC → N they are forever attached) Abnormal: disc anterior dislocated from the condyle; click = the condyle going back on top of disc / redislocating again (ADDwR; WITH REDUCTION = going on and back off disc) the longer it takes for click to happen → progressing to ADDwoR where it will eventually be dislocated all the way through (one this happens, they are never getting it back → going for pain modulation or surgical route) Internal Derangement Disc Dysfunction Stage I:disc slightly anterior displaced, inconsistentclick, mild or no pain;ADDwR Stage 2:disc anterior displaced reciprocal clicks,painful Stage 3:reciprocal clicks, now later during openingand earlier during closing,most painful stage Stage 4:click rare, no longer relocates, stays anterior,pain rare, limited motion;ADDwoR MSK III 138 Lec 11 - TMJ Treatment LAB EXERCISE N:Examination/Treatment of the TMJ Using the skull models: N ote 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 reatment: T MSK III 139 General Treatment Approach: SINSS– severity, irritability, nature, stage, andstability Address posture as needed, typicallyforward head. ○ Address rest position of TMJ and tongue Arthrokinematic mobility in TMJ + cervical spine: frequently the TMJ and the cervical spine will need mobilization Addresspredisposing factors:stress, oral parafunctionalhabits (e.g., chewing on pencils, bruxism, etc.) Recommended initial exercises by Rocabado Patient educationregarding soft foods, yawning, chewinggum, and other activities that would cause excessive TMJ motion/force Address need for dentist referral for occlusal appliance Massage and soft tissue mobilization to masticatory muscles and to neck Stretching: as needed, but typically ○ Scalenes, trapezius, pectoralis minor, levator scapulae Strengthening as needed, but typically ○ Cervico-thoracic stabilizers:shoulder shrugs, scapularretraction, serratus anterior “punch,” upright rows, horizontal rows ○ Cervical flexion (most common):progress from isometricto isotonic Palpation pt would be lying down extraorally:masseter, temporalis, medial pterygoid,hyoid bone, infrahyoids, suprahyoids intraorally: lateral pterygoid (medial to last molaron the top; “trying to come out her ear canal”) ○ gloves; don’t do if pt is sick; give pt hand signals one side at a time can't palpate lateral pterygoid but can palpate medial (underneath angle) gentle force → on pt face MSK III 140 Integrating Manual Therapy and Pain Neuroscience Education Adrian Louw, Emilio Puentedura, Stephen Schmidt, and Kory Zimney 2019 – OPTP PRINCIPLE 1:Effectiveness of Manual Therapy PRINCIPLE 2: Clinical Reasoning is a Cornerstone of Manual Therapy PRINCIPLE 3: Reshaping Beliefs and Attitudes about Pain PRINCIPLE 4: Nociception and Pain are not the Same Construct PRINCIPLE 5: Language Matters PRINCIPLE 6: Nerves are Sensitive for a Reason PRINCIPLE 7: The Brain has a Body Map PRINCIPLE 8: The Importance of Hands on Therapy PRINCIPLE 9: Trust is the Foundation of Therapeutic Alliance PRINCIPLE 10: The Importance of Assessing for Yellow Flags PRINCIPLE 11: Additional Treatments Complement Manual Therapy PRINCIPLE 12: Putting More Thought into Treatment Choices MSK III 141 Quiz 3 1) TMJ 2) Headaches 3) Review Cx
