Cranofacial pain

Question 1

what was TMJ orginally believed to be???

Answer 1

Costen, an otolaryngologist (1934)
Believed the TMJ was a common source of facial pain, headaches, ringing of the ears, as well as other Sx.
Initially believed these Sx were due to dental malalignments
Therefore only dentists could treat this
Costen took a musculoskeletal problem, which can be corrected by exercises, and postural reeducation into a dental problem
Sound like something a physical therapist performs on a daily basis
As a footnote, dentists have performed the majority of the res1950’s, Costen’s theory was doubted and focus for craniofacial pain turned towards muscles and the intraarticular disc
Currently, believe craniofacial pain is multifactorial in origin
Frequently referred from the cervical spine

Question 2

what some other common names for TMJ!!!

Answer 2

Alternative names for craniofacial pain:
TMJ disease 
Temporomandibular disorders (TMD)
Temporomandibular pain and dysfunction syndrome (TMPDS)
Craniofacial pain
Orofacial pain
Sound more like PT problems?

Question 3

stats on TMJ dysfunction

Answer 3

40% of $80 billion spent annually on the treatment of chronic pain is due to craniomandibular pain
Pain in the temporomandibular region affects 10% of the population > 18 y.o.
Women > Men 2:1

Question 4

what is the normal spacing between c1 and c2??

Answer 4

6.5 mm

Question 5

what is the number one reason for cervical headaches

Answer 5

loss of mobility or function at the Co-C2 junction causes overloading c3 - c7

Question 6

how much space should be between the C0-C2 what is the rough measurement of this space!!! What do you result if you don’t have this much space??

Answer 6

Normally, there should be 6.5 +/- 2.5mm of space between the posterior arch of atlas and the occiput, as well as between the spinous process of atlas and axis
A decreased subcranial angle = subcranial extension
Palpation of the spaces- 2 fingers should fit between c0-c2

Question 7

what causes an increased in the C0-C2 angle what action besides extension obviously

Answer 7

Opening the mouth: causes a temporary increase in subcranial backbending
See the relationship

Question 8

Tell me about the importance of the craniovertebral angle

Answer 8

Importance of craniovertebral stability and suboccipital triangule normality
Rectus capitus posterior major and minor get tight due to parafunction
Atlas becomes static due to tightness
Atlas ends up following occiput
Results in static atlas syndrome

Question 9

where can the greater occiptal nerve get entrapped at??? Importance of the sub occiptal triangle

Answer 9

Greater occipital nerve comes out at the facet joint of C1-C2
Nerve can get entraped at the joint or muscular level
Can get entraped at:
1. facet of C1-C2
2. Inferior oblique muscle
3. Semispinalis capitus muscle
4. Upper trapezius muscle

Question 10

what is the importance of the subocciptial triangle

Answer 10

Note: 50% of cervical rotation occurs at the subcranial joint
Ex: “Everytime I drive in reverse and turn my head, I get sharp pain in my head.”
Red Flag

Question 11

space greater than how much can cause problems at the subocciptal triangle

Answer 11

Space < 4mm between C1-C2 can cause Sx

This is a repetitive mechanism; typically not traumatic

Question 12

Posterior Ponticle

Answer 12

A small bridge of bone resulting from complete ossification of the atlantoccipital membrane, reaching the posterior notch of C1.
Increases risk of posterior circulation
Cerebral ischemia – Vertebral artery passes through the notch

Question 13

what are some ST of the Craniocervical joint to test for before performing any interventions. What conditions typically cause instability at the C1-C2 joint??

Answer 13

Alar ligament – DS or RA typically are people who get a + sign for these tests DS = down syndromeAlar ligament
Sharps/Pushers – transverse ligament test
Vertebral artery test

Question 14

things to check out when examining a patient with C0-C2 instability!!!

Answer 14

C0-C2 space
Is it normal, or do we potentially have a static atlas
Also palpate the suboccipital triangle, spinous process, and transverse process of C1-C3
Look at posture
Forward head/round shoulder posture? Or decreased lordosis?
Increased thoracic kyphosis
Surrounding musulature- upper trapezius, SCM

Question 15

how to perform the distraction with cervical extension added to it.

Answer 15

Mobility assessment
Suboccipital release
Specific distraction with cranial flexion
Add axial extension
Manual stretching of surrounding musculature