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MSK 2 > 1i - TMJ PT > Flashcards

1i - TMJ PT Flashcards

1
Q

what are previous consultations you want to know about in the pt hx and why

A

dentist
oral surgeon
orthodontist
ENT

tell you if had a recent oral screen
- good tooth and gum health

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2
Q

what are previous treatments you want to know about in the pt hx

A

meds
mouth guards

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3
Q

why do you want to know the date of onset in the pt hx

A

what stage of tissue healing are you in

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4
Q

what is the most common MOI

A

unknown
- just gets worse over time and don’t know why

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5
Q

what are the 3 main types of MOI

A

unknown
macro-trauma
micro-trauma

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6
Q

what are examples of macro-trauma for a possible MOI

A

physical impact on TMJ
recent major dental work
- prolonged opening, force by dentist
MVA, falls, etc.

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7
Q

what are examples of micro-trauma

A

parafunctional habits
- non functional uses of jaw

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8
Q

what could the time of day of the pain tell you

A

pain in morning = grinding at night

pain at end of day = maybe from what doing in work

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9
Q

what are questions to ask when trying to suss out provocation vs alleviation

A

position
activities - eating, talking, yawn
time of day
sleeping

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10
Q

how could sleeping be a provocative activity

A

stomach sleeping position
-> asymmetrical translation of mandible -> pillow and pressure ipsilaterally results in medial ipsilateral translation and a lateral contralateral translation

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11
Q

what are common locations for pain (5)

A

jaw
ear
face
neck
temple

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12
Q

what are other sx besides pain to ask about in the pt hx

A

HAs - temporal & occipital
tinnitus
stuffiness
dizziness
facial fatigue
locking/catching/clicking

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13
Q

what is a validated scale that is helpful for its dx properties

A

Jaw Functional Limitation Scale

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14
Q

how are scores interpreted from the jaw functional limitation scale

A

higher score = more severe limitation

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15
Q

what are components of the anatomy screen

A

dental screen
cranial anatomy (CNs)
secondary TMJ ms
AO, cervical facet (C2-3) joints
suboccipitals, SCM, scap ms

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16
Q

why is a dental screen included

A

look at teeth, gums, tongue
- if caused by tooth pain -> refer out

could have secondary ms guarding that causes pain but still have to treat tooth first

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17
Q

why is the SCM part of the anatomy screen

A

postural component
also SCM has referral pattern into jaw

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18
Q

why is a CN screen included in the anatomy screen

A

CN V innervates the area

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19
Q

what is an important part of your observations

A

cervical/head and thoracic posture
- forward head posture and rounded shoulders

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20
Q

why do we care about if someone is resting their head on their hand

A

asymmetrical compression on one side while leveraging the other
- creates stretching of capsule

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21
Q

what observations can help with our CN screen

A

facial asymmetries
- speaking
- smiling
- blinking

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22
Q

what should you look for during your pt exam

A

parafunctional habits
- biting lip
- chew nails
- gum

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23
Q

what do you look for when having them open and close their mouth

A

opening
- any limitations

closing
- bite symmetry
- occlusion b/w maxillary and mandibular teeth
- how does it feel when teeth touching

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24
Q

how does forward head posture impact the TMJ

A

posterior rotation of cranium on AO joint
- upper cpsine ext, lower flex

stretch infrahyoid ms -> inferior force on hyoid -> stretch suprahyoid ms -> MANDIBLE PULLED INTO RETRUSION AND DEPRESSION

altered resting position of condyle

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25
Q

why is the altered resting position of the condyle from forward head posture significant

A

excessive disc compression
- disc might be more at articular eminence than fossa

chronic lateral pterygoid spasm to counter the position

more effort to maintain closed position bc of stretched ms
- ms overuse to pull jaw back

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26
Q

what does the evidence say about the relationship of head/neck posture (like forward head posture) and TMD

A

while makes sense, poor evidence
- enough to support using cervical and postural interventions

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27
Q

what are the 2 main opening and closing abnormalities

A

c-curve or deflection
s-curve or deviation

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28
Q

what is c-curve or deflection abnormality and what is it likely caused by

A

gradually jaw moves to one side throughout range
- unilateral hypo (dec ipsi) or hypermobility (inc contra)

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29
Q

what are reasons for hypo or hypermobility seen in a c-cerve or deflection

A

hypo:
- capsular
- ms spasm
- OA
- disc displacement w/o reduction (closed lock)

hyper:
- EDS
- dislocation

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30
Q

what is an s-curve or deviation abnormality and why might this be pain-free or painful

A

deviate to one side and then comeback to midline

painfree
- ms imbalance
- ms incoordination

painful
- disc displacement w reduction (joint sound)

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31
Q

what is the range of motion for opening/depression to be WFL

A

38mm

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32
Q

how is range of motion of opening/depression measured

A

use therabite lined up from edge of mandibular center incisor to edge of maxillary center incisor

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33
Q

what is the smallest detectable change in ROM of opening/depression

A

5mm

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34
Q

what are the norms of females and males for opening/depression ROM

A

females = 45-50mm
males = 40-45

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35
Q

when taking a ROM measurement of opening/depression, why might you take it twice

A

take it 1st just as sitting on table

then take it again after correcting posture
- can get several more mm after taking it again

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36
Q

what are 5 things that can impact the ROM measured of opening/depression

A

ms disorder
ADDWOR - ant disc displacement w/o reduction
capsular adhesions
OA
fear of movement

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37
Q

how is lateral deviation measured

A

therabite from line b/w mandibular center incisors to line b/w maxillary center incisors

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38
Q

what is the norm for lateral deviation ROM

A

1/4 of depression ROM
or 8-10mm

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39
Q

what is the norm for protrusion ROM

A

6-9mm

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40
Q

what is the norm for retrusion ROM

A

3-4mm

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41
Q

how is protrusion and retrusion measured

A

therabite measures distance b/w mandibular and maxillary incisors

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42
Q

what are 3 things that can impact lateral deviation, protrusion, and retrusion ROM

A

ADDWOR (ant disc displacement w/o reduction)
capsular involvement
ms incoordination

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43
Q

what ms is intra-oral palpation reliable for

A

TMJ
masseter
temporalis

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44
Q

how can the TMJ be palpated extra-orally

A

lateral - ant to ear
post - thru ear

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45
Q

what ms can be palpated extra-orally

A

temporalis
masseter
suprahyoids
infrahyoids
medial pterygoids
- med aspect of mandib angle

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46
Q

what else should be palpated besides TMJ joint, and primary and secondary TMJ ms

A

cervical and scap ms
facet assessment

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47
Q

what ms can be palpated intraorally and where

A

outside max teeth to coronoid process
- masseter
- temporalis tendon (expose w inc opening)
- lateral pterygoid

inside max teeth back and inferior
- medial pterygoid

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48
Q

how can medial and lateral glides be palpated

A

extraorally:
- stabilize contra temporal bone
- mobilize ipsilateral mandible medially
- we like this one better, easier to stabilize and feel**

intraorally:
- thumb on medial or lateral aspect of mandibular posterior molar

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49
Q

how is most joint mobility assessed

A

intraorally

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50
Q

what is a consideration if trying to assess an anterior glide

A

need to be opened ~20-26mm

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51
Q

what is the significance of assessing antero-caudal translation

A

mimics TMJ mvmt w full opening

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52
Q

what are 2 considerations to set up of how you conduct resisted testing

A

apply broad contact w hand to disperse force

start w mouth open a little bit so less provocative and not compressive

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53
Q

what are the resisted movements you test

A

depression
elevation
lateral deviation
protrusion

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54
Q

what ms are assessed w resisted depression (3)

A

lateral pterygoids
suprahyoids
infrahyois

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55
Q

what ms are assessed w resisted elevation (3)

A

temporalis
masseter
medial pterygoid

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56
Q

what ms are assessed w resisted lateral deviation (4)

A

ipsilateral:
- temporalis
- masseter

contralateral:
- medial and lateral pterygoids

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57
Q

what ms are assessed with resisted protrusion testing (3)

A

masseter (deep fibers)
temporalis
suprahyoids (digastric)

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58
Q

what is the separation-clench test used for

A

to distinguish b/w joint arthralgias and ms disorders

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59
Q

what is the procedure of the separation-clench test

A

biting on tongue depressors placed b/w back molars
- acts as joint spacer

  1. bilateral placed depressors
  2. unilateral placed depressor
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60
Q

reproduction of pain w bilaterally placed depressors w the separation-clench test indicates what

A

ms or tendon disorder/pain source

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61
Q

ipsilateral reproduction of pain w unilateral placed depressor w the separation-clench test indicates what

A

muscular or tendon disorder/pain source

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62
Q

contralateral reproduction of pain w unilateral placed depressor w the separation-clench test indicates what

A

there is joint compression on the contralateral side to testing

possible joint arthralgia, capsulitis/synovitis, disc, etc.

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63
Q

what are (+) separation-clench test results

A

reproduction of pain

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64
Q

what is cervical dysfunction

A

dysfunction in anatomical, functional relationships b/w cspine and TMJ & their pathophysiological connections

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65
Q

what are s/sx of cervical dysfunction (4)

A

posture
changes in or pain w ROM
changes in cerv joint mobility
- w possible segmental referral
pain w palpation
- w possible referral to face/jaw

66
Q

what are peripheral and cranial neuralgias

A

nerve tissue damage or irritation
- burning, tingling, shooting pains, hyperalgesia, etc. in a C2 and C3 dermatomes

67
Q

what is trigeminal neuralgia and how does it present

A

severe paroxysmal facial pain (~2min) d/t nerve entrapment

facial and TMJ sensation input
ms of mastication motor & proprioception input

68
Q

what are red flags (7)

A

tooth-related pain
primary & secondary HAs
recent fevers or infections
- ear or sinus
pain w eye mvmt, change in vision
hx of cancer
psych disorders
recent trauma (broken jaw?)

69
Q

what do we think if someone has pain w eye mvmt and changes in vision

A

optic neuritis

70
Q

why are psych disorders considered a red flag

A

TMJ might be location of stress
- if not getting intervention for stress, doesn’t matter what you do

71
Q

what are secondary headaches caused by

A

systemic
related to:
- cspine
- teeth
- sinus and ear infections
- TMD

72
Q

what are red flags that are an immediate referral

A

CNS signs
- change in gait/balance
- sudden onset severe HA
- sudden onset paresis/paralysis
- slurred speech (new)
- hx of CVA
- altered mental status

sx and hx of cardiac path
5Ds and 3Ns

73
Q

why are sx and hx of cardiac path a red flag immediate referral (3)

A

referral to orofacial area
angina manifest as neck pain
HTN can cause severe, systemic HAs

74
Q

what are intra-articular TMJ dysfunctions

A

internal disc displacements
- ant (w or w/o reduction)
- post
joint arthralgias
- hypermobility
- hypomobility

75
Q

what are extra-articular TMJ dysfunctions

A

ms disorders
- ms spasms
- tendinopathy
- myofascial pain syndrome

76
Q

what is anterior disc displacement w reduction

A

disc ant to condylar head at rest
with opening, reduction of disc with closing, dislocation of disc

77
Q

what are causes of anterior disc displacement w reduction

A

macrotrauma - damage to or laxity of retrodiscal tissue ligaments
- progression of hypermobility
- lateral pterygoid spasm

microtrauma - repetitive excessive force on disc
- disc thinning or perforations

78
Q

what are secondary problems that can be caused by anterior disc displacement w reduction

A

secondary retrodiscal tissue, joint, and/or ms pain (guarding)

79
Q

how is opening ROM impacted in anterior disc displacement w reduction

A

normal opening ROM
- secondary ms spasm, guarding, or capsulitis can change the amt of opening and the opening opattern

80
Q

describe what happens during opening with an anterior disc displacement w reduction

A

reduction of disc - “click”
- can be painful as disc reduces over posterior aspect of disc which is vascularize and innervated
- disc can heisitate and pop bc thicker posterior aspect to get over

S-curve /deviation to affected side

ant translation w condyle

81
Q

describe what happens during closing with an anterior disc displacement w reduction

A

dislocation of disc w “click”
- at rest disc anterior to condyle

82
Q

what is the significance of reciprocal joint sounds often heard w anterior disc displacement w reduction

A

don’t use for dx, use for part of exam

83
Q

how should anterior disc displacement w reduction be treated (3)

A

joint mob
proprioception
STM

84
Q

what is anterior disc displacement without reduction

A

permanently ant dislocated disc
- no reduction, will always stay in front of condyle

85
Q

at are causes of anterior disc displacement without reduction

A

ruptured and maximally stretched ligaments and/or dec elasticity of retrodiscal fibers
-> hx of reciprocal joint noise (progression of ADDWR)

86
Q

what is a common sx of anterior disc displacement without reduction and why

A

TMJ and/or ear pain
- retrodiscal inflammation, inc joint compression and friction, capsulitis/synovitis, ms spasms

(extra pressure on the synovial membrane and fibrocartilage w every bite bc disc not there anymore)

87
Q

how is opening affected by anterior disc displacement without reduction

A

limited opening (<20-30mm)
- closed lock
- c-curve / deflection to affected/limited side bc disc is in way (and prevents ant translation of condyle and the other side keeps going)

88
Q

what movements are impacted by anterior disc displacement without reduction

A

opening
lateral deviation (to unaffected)
protrusion w deviation to affected

89
Q

how is anterior disc displacement without reduction treated (3)

A

joint mobs
STM
proprioception to dec joint compression

90
Q

what is a posterior disc displacement

A

disc is posterior to condyle
- condyle pops off anterior part of disc

91
Q

what type of disc displacement is less common than the other

A

posterior disc displacement is rare

92
Q

what are causes of posterior disc displacement

A

excessive opening beyond normal physiological ROM (opening beyond range over and over again) -> general hypermobility

yawning

prolonged mouth opening
- dental work

93
Q

what motion does a posterior disc displacement affect and how

A

closing

“open lock”
- unable to close mouth d/t posterior disc displacement blocking condylar movement

94
Q

why is pain a common sx of posterior disc displacement

A

if disc permanently dislocated, biting thru lateral pterygoid

95
Q

what are treatment interventions for posterior disc displacement (4)

A

motor control/proprioception to avoid end range (work in mid-range)

altered eating
- cut things up to avoid end range

manual therapy

postural exercises

96
Q

when is hypermobility considered a red flag and what does this indicate and what should you do

A

excessive AROM
- opening >40-50mm d/t excessive condylar anterior translation

subluxation or dislocation

send to ED

97
Q

what are 7 common s/sx of hypermobility

A

excessive AROM
TMJ/capsule TTP but no crepitus
painful ms guarding
may be asymptomatic
joint sound at end range open
deflection contra in end open
hyper accessory jt motion

98
Q

why might someone w hypermobility be asymptomatic

A

body may have accommodated it and stretched joint capsule

99
Q

what can hypermobility lead to

A

disc displacement bc of altered joint mechanics

100
Q

what are interventions for general hypermobility (3)

A

stability program
- ms activation
- body awareness
- joint proprioception

avoid end range

manual therapy

101
Q

what are 2 reasons for hypomobility

A

arthritis
capsulitis/synovitis

102
Q

what are 2 arthritis can can cause hypomobility at TMJ

A

OA
RA

103
Q

what are 5 s/sx of OA in TMJ

A

limited opening AROM
pain w closing
pain w TMJ palpation
crepitus thru entire ROM
radiographic evidence

104
Q

why is crepitus seen in OA

A

degeneration of articular cartilage d/t chemical changes

105
Q

what is seen in radiographs of OA in TMJ

A

osteophyte formation
subchondral bone changes

106
Q

what are 3 interventions for arthritis and resulting hypomobility

A

joint mobs
- grade 1 and 2 to calm down
postural strengthening
- give joint support
joint protection strategies

107
Q

is it important to differentiate capsulitis from synovitis

A

not really
treat the same

108
Q

what are 2 causes of capsulitis and synovitis

A

macrotrauma or microtrauma
tears or lengthening
–> altered disc movement

109
Q

how does a capsular pattern manifest in s/sx for capsulitis

A

limited opening <25mm
C-curve/deflection to affected
dec unaffected lateral excursion

110
Q

what is a movement that is limited in both capsulitis and synovitis and why

A

protrusion on affected side
- deflection bc of lack of anterior translation d/t tight capsule or synovial membrane

111
Q

where/when is pain seen in capsulitis and synovitis (5)

A

biting
at rest
end range accessory motion
ROM testing
palpation of lat capsule & TMJ
- esp posterior

112
Q

what are 3 interventions for capsulitis and synovitis

A

joint mobilizations
proprioception
- optimize joint mechancis
postural exercises

113
Q

what is often the result of chronic capsulitis and how is this often treated

A

capsular fibrosis
- adhesion formation

hard to treat conservatively

114
Q

what direct injuries lead to ms disorders at the TMJ (3)

A

traumatic blows to mandible
overstretching w dentistry
- ms spasms (esp temp, mass)
overuse w parafunctional habit
- ms strain
- tendinopathy

115
Q

what indirect injuries can lead to ms disorders at the TMJ (2)

A

ms guarding
- stress (manifests here)
- dental path, TMD conditions, cspine disorders
central sensitization
- trigger points
- hypersensitivity
- up-regulation of pain

116
Q

what is the risk of ms guarding if prolonged

A

contracture

117
Q

what are common sx (other than pain) of ms disorders (3)

A

no joint sounds

inconsistent mandibular control
- deviation or deflection

altered dental occlusion w mouth closed/at rest

118
Q

how is pain reproduced with ms disorders

A

palpation of ms
- referred pain patterns
ipsilateral pain w activation
ipsilateral pain w end range
- stop themselves before that point -> dec ROM

119
Q

what are the 3 ms most often affected by ms disorders

A

masseter
temporalis
lateral pterygoid

120
Q

how is the masseter and/or temporalis impacted by a ms disorder (3)

A

pain w palpation (trigger points)
pain w stretching at end range opening
pain w activation when clenching

121
Q

how can a masseter and/or temporalis ms disorder impact ROM

A

opening may be limited <40mm

122
Q

how is the lateral pterygoid impacted by a ms disorder (2)

A

lateral facial pain
- esp in periauricular area (ear)
pain w:
- protrusion
- opening
- contralateral lateral deviation

123
Q

what are interventions for ms disorders and why (6)

A

STM
postural exercises
- dec extra strain on ms
motor control
- trigger points
ms relaxation
isometrics (relax!)
pt ed to dec parafunctionals
- don’t want to add insult to injury

124
Q

what is myofascial pain syndrome

A

very common form of TMD
pain originates from myofascial structures
- often chronic w presence of trigger points (central sensitization)

125
Q

what are 4 common areas of referral for myofascial pain syndrome

A

temporalis
masseter
lateral pterygoid
medial pterygoid

126
Q

what is the temporalis referral pattern for myofascial pain syndrome (4)

A

maxillary teeth
TMJ
retro-orbital area/temple
around eyebrow

127
Q

what is the masseter referral pattern for myofascial pain syndrome (3)

A

maxillary and mandibular teeth
ear (may cause tinnitus)
sinuses

128
Q

what is the lateral pterygoid referral pattern for myofascial pain syndrome (1)

A

sinuses/cheek bone

129
Q

what is the medial pterygoid referral pattern for myofascial pain syndrome (1)

A

ear or lateral TMJ

130
Q

what are sx of myofascial pain syndrome (5)

A

facial, ear, jaw, tooth pain
HAs
dizziness
limited opening ROM
swallowing difficulties

131
Q

what are interventions for myofascial pain syndrome (4)

A

STM
ms relaxation
motor control exercises
postural exercises

132
Q

why is it crucial to treat both sides/TMJs

A

right and left function together but act independently
- TMJ mvmt requires bilateral action, so have to function together
- influence each other
- abnormal function on one side interferes w function of other

133
Q

what is one function that each TMJ does asymmetrically

A

mastication

134
Q

what are the 4 main goals of manual therapy

A

pain control
dec ms tension/guarding
improving joint mobility
inc proprioception to area

135
Q

what are 4 manual therapy interventions

A

STM, manual release
joint mobs
PROM
stretching

136
Q

what manual therapy intervention did the evidence say helped to improve opening and clenching

A

intra-oral temporalis, medial and lateral pterygoid releases

137
Q

what does the literature say about cspine treatment with TMD

A

greater improvements w cspine treatment

no improvement in opening w adding cervical manips

138
Q

according to the evidence, who did trigger point releases help specifically

A

HA patients

139
Q

what are the 4 main goals of ther-ex

A

reduce ms tension
pain control
inc ROM
inc motor control/strength

140
Q

why is the goal with ther-ex to work on motor control instead of strengthening

A

ms are probably already pretty strong
- more ab working on motor control, activation and fear of activation

141
Q

what are the 2 main ther-ex interventions

A

TMJ isometrics
postural exercises

142
Q

what is a consideration of TMJ isometrics and how do you progress them

A

careful, the ms may be in spasm or overused

gradually inc hold times

143
Q

what are 3 types of postural exercises

A

scap retraction (rows, ER)
pec stretching
cervical mobility/strength
- chin tucks

144
Q

what are the 3 main goals of NM re-ed

A

relaxation
joint proprioception
ms activation/coordination

145
Q

what are 3 types of NM re-ed interventions

A

relaxation techniques
ms coordination
joint proprioception

146
Q

what are 2 relaxation techniques

A

breathing exercises
contract-RELAX

147
Q

what are ms coordination exercises

A

opening/closing patterns
“touch and bite”
- have them open/do different motions/deviation and bite same spot on finger each time

148
Q

what are joint proprioception exercises

A

resting position
-> open-packed position, teeth slightly parted and tongue against hard palate
- have them maintain this position with breathing or other exercises

controlled opening/closing
- manually guided
- mirror

isometrics and stabilization
- start in neutral and progress to different ROMs

149
Q

what is the most commonly used PT exercise plan

A

Rocabado 6x6

150
Q

how does Rocabado 6x6 target its exercises

A

tope 3 are TMJ
- resting position
- controlled opening
- rhythmic stabilizations

other 3 are cervical and posture
- OA flex/mobs
- chin tuck
- scap retraction

151
Q

what modality actually has good evidence backing it

A

dry needling

152
Q

what are the 4 main goals of modalities

A

pain control
promote ms relaxation
inc blood flow
dec inflammation

153
Q

what modality do most people w TMD prefer

A

heat

154
Q

why is TENS not a great modality to use w the TMJ

A

so much sensory input already for this area

155
Q

what ms has successful EBP for dry needling and what are the outcomes

A

lateral pterygoid

dec in pain w mastication
inc in ROM for opening, L/R lateral deviation, and protrusion

156
Q

what are 7 important pt education points

A

can’t fix disc or ligaments
minimize painful movements
- ie end range
eating soft foods/avoid hard, chewy foods
- chew on uninvolved side
change sleeping habits
relaxation techniques
body awareness and posture
pain science

157
Q

what about body awareness and posture should you educate the pt on (3)

A

work set up/ergonomics
stopping parafunctional habits
proper TMJ resting position

158
Q

what about pain science should you educate the pt on (3)

A

central sensitization w chronic pain
prognosis
general exercise/aerobic plan
- aerobic is one of the best things for pain bc help w upregulation of pain and settle it in

159
Q

what are other types of treatment for TMDs besides PT (5)

A

pharmacologic
acupuncture
occlusion splint therapy/mouth guards
surgery
psychosocial

160
Q

what are pharmacologic treatment options for TMDs (5)

A

ms relaxants
NSAIDs
trigger point injection
intra-articular corticosteroid or local anesthetic injections
botox

161
Q

what surgeries can be done for TMDs (3)

A

arthroscopic to release adhesions
repositioning of disc
total joint replacements
- last resort, poor outcomes

162
Q

what are psychosocial treatment options for TMDs (3)

A

stress management
behavioral modification
addressing depression/anxiety

MSK 2 (20 decks)

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