MMD Exam 2 Lecture Flashcards by Allie Hess

A patient is referred to physical therapy with subacute neck pain. The therapist suspects neck pain with movement coordination impairments secondary to whiplash-associated disorder (WAD). What is the MOST appropriate examination test to corroborate this diagnosis?
A. Spurling’s test.
B. Cervical mobility testing.
C. Cervical flexor muscle endurance testing.
D. Cervical flexion-rotation test

C. Cervical flexor muscle endurance testing

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During the patient interview, the therapist learns that the patient has rheumatoid arthritis. What special test is most appropriate to determine if the patient has upper cervical spine instability?
A. Spurling’s test.
B. Sharp Purser test.
C. Quadrant test.
D. Neck flexor muscle endurance test.

B. Sharp Purser test

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What elements from the patient interview make a diagnosis of cervical radiculopathy most likely?
A. Associated referred pain to the upper extremity.
B. Acute onset of unilateral neck pain.
C. Dermatomal paresthesia or numbness and myotomal muscle weakness.
D. History of headaches associated with neck movements.

C. Dermatomal paresthesia or numbness and myotomal muscle weakness

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What intervention is the BEST choice for reducing pain
and improving function in Neck Pain with Radiating Pain and a suspected acute cervical radiculopathy?
A. Transcutaneous electrical nerve stimulation (TENS).
B. Cryotherapy.
C. Thoracic manipulation.
D. Cervical mobilizing and stabilizing exercises.

D. Cervical mobilizing and stabilizing exercises

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A patient is referred to physical therapy with chronic neck pain. What is the MOST appropriate patient outcome tool for this diagnosis?
Choices:
A. Owestry Disability Index.
B. Neck Disability Index.
C. SPADI.
D. DASH.

B. Neck Disability Index

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What are the subgroups of neck pain classification?

Mobility deficits
Movement coordination deficits
Headache
Radiating pain

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According to the Canadian C-spine rule, what would be high risk factors that mandate radiography?

Age at least 65
Dangerous MOI
Paresthesia in extremities

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According to the Canadian C-spine rule, inability to rotate neck to what degree mandates radiography?

45 degrees

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What are the 5 D’s And 3 N’s of vertebral artery dysfunction?

Dizziness
Dysphagia (swallowing)
Dysarthria (speech)
Diplopia
Drop attacks
Ataxia
Nausea
Nystagmus
Numbness

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In increasing order of importance, CPG’s help clinicians with decision-making about:

Medical screening, neck pain categorization, condition stage/biopsychosocial factors, and interventions

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Differential diagnosis is when a PT determines the _______ of physical therapy and need for ____ by performing assessments and utilizing existing imaging studies to determine presence of serious pathology

appropriateness, referral

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There are numerous causes of neck/upper quarter pain yet, most do not have clearly defined diagnostic criteria.
Therefore, the 2 major jobs of the PT is to:

rule out serious medical pathology
identify impairments in an attempt to classify based on clinical characteristics and likely beneficial management strategies

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According to the Canadian C-spine rule, what low risk factors allow safe assessment of ROM?

Simple rear-end MVA
Sitting position in ER
Ambulatory at any time
Delayed onset of neck pain
Absence of midline c-spine tenderness

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Which conditions should we consider testing for cervical instability before performing interventions?

*Ligamentous instability (Sharp-Purser): post neck trauma, RA
Neurological (Distraction, Spurling’s): neck pain, headache, torticollis, other neuro signs
*Cervical myelopathy (Hoffman’s, reflexes, clonus)
Vertebral artery dysfunction (VAT if doing rotation manouvers)
1st rib mobility
Cervical muscle strength (DNF)
Cervical spine mobility

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Establish baseline for patient’s neck pain, function, and psychosocial matters by administering:

validated self reported outcome measures (neck disability index, patient specific functional scale, numeric pain rating scale, global rating scale)

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MCID for NDI

5-10 points (depending on condition/presence of radiculopathy)

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Which neck pain outcome measure asks the patient to rate the following on a scale of 0-5:
pain intensity
personal care (washing, dressing)
lifting
reading
headaches
concentration
work
driving
sleeping
recreation

NDI

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MCID for patient specific functional scale (PSFS)

2 points (average of activities)

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Which neck pain outcome measure asks the patient to describe 3 important activities their pain interferes with and rate it on a scale of 0-10?

PSFS

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MCID for numeric pain rating scale (NPRS)

2 points

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Which neck pain outcome measure asks the patient to rate their pain on a scale of 0-10?

NPRS

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MCID for global rating of change (GROC)

No change (-1, 0, 1)
Minimal change (+ 2 or 3)
Moderate change (+ 4 or 5) Significant change (+ 6 or 7)

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Which neck pain outcome measure asks the patient to rate their overall condition from the time they began treatment until now by checking a box?

GROC

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What are the 2 strong risk factors of new onset of neck pain? Moderate risk factors?

*Female sex, prior hx of neck pain
Older age, high job demands, smoking hx, low social support, prior hx of low back pain

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What are the common trajectories of clinical recovery of neck pain?

◦ Mild (45%) with rapid recovery ◦ Moderate (40%) with incomplete recovery ◦ Severe (15%) with no recovery

The following are expected findings within which classification of neck pain? Limited Cx ROM End-range pain (active & passive) Mobility restriction Pain with segmental provocation Strength and motor control deficits with acute/chronic cases

Mobility deficits

The following are expected findings within which classification of neck pain? + Cranial Cx flexion test + Neck flexor endurance test + Pressure algometry (pain sensitivity) + Strength and endurance deficits Mid-range pain, worse with end range TTP trigger points Sensorimotor impairment

Movement coordination impairments

The following are expected findings within which classification of neck pain? + Cx flexion-rotation test HA with segmental provocation Limited Cx ROM Restricted upper Cx segmental mobility Strength, endurance, and coordination deficits

Headache

The following are expected findings within which classification of neck pain? + Test cluster: ULTT, Spurling's, Distraction, limited Cx ROM UE sensory, strength, or reflex deficits

Radiating pain

Physical examination measures useful in classifying mobility deficits and the associated ICD categories of cervicalgia or pain in thoracic spine:

◦ Cervical active range of motion ◦ Cervical and thoracic segmental mobility

Physical examination measures useful in classifying neck pain with movement coordination impairments and the associated ICD categories of sprain and strain of cervical spine:

◦ Cranial cervical flexion test ◦ Deep neck flexor endurance test ◦ Deep cervical extensors

Physical examination measures useful in classifying headaches and the associated ICD categories of headaches or cervicocranial syndrome:

◦ Cervical active range of motion (upper>lower cervical ROM) ◦ Cervical segmental mobility ◦ Cranial cervical flexion test

Physical examination measures useful in classifying neck pain with radiating pain and the associated ICD categories of spondylosis with radiculopathy or cervical disc disorder with radiculopathy:

◦ Upper limb tension test ◦ Spurling’s test ◦ Distraction test

Combining cervical manual therapy (mobilization, manipulation with or without thrust) with ____ is more effective for reducing neck pain, headache, and disability than manipulation and mobilization alone

exercise

Research shows that most neck pain cases benefit from which manual treatment techniques?

Cervical DNF strengthening (100%) Cervical mobilization (98%) Thoracic mobilization (81%)

Examination and targeted flexibility exercises used for patients with neck symptoms are focused on which key muscles?

Scalenes Upper trapezius Levator scapulae Pectoralis major/minor

Coordination, strengthening, and endurance exercises used to reduce neck pain and headache are focused on which key muscles?

Deep neck flexors Deep cervical extensors

Whiplash associated disorder (WAD) falls into which category? What is a key intervention?

Movement coordination impairments Educate patient that early return to normal, non-provocative pre-accident activities is important; provide reassurance that prognosis is good and full recovery commonly occurs

Centralization is driven by change in ____ of symptoms with repeated movement (ex. chin tucks)

location

____ ______ is when the location of pain doesn't change but symptoms improve

Directional preference

Neck pain is the second most prominently treated (and worker's comp-ed) complaint by PTs behind ___, which is most prevalent

LBP

Indicators of poor short-term prognosis for neck pain

Older age >40 Concomitant LBP and HA

Indicators of poor long-term prognosis for neck pain

Older age >40 Concomitant LBP and HA Traumatic onset Duration of sxs >13 weeks Stable neck pain >2 weeks Previous episodes of neck pain

Consequences of forward head posture includes: ____ cervical extensors, suboccipitals, upper traps, levator scapulae ____ cervical flexors, rhomboids, middle and lower traps

tight, weak

Consequences of increased thoracic kyphosis includes: ____ thoracic extensors, middle and lower trapezius muscles, rhomboids, and posterior ligaments _____ anterior longitudinal ligament, upper abdominal, pectoralis, and anterior chest muscles _____ of discs anteriorly and fractures of vertebral bodies

weak, tight, compression

"Cross-syndrome" describes

forward head posture combined with thoracic kyphosis; weakness and tightness on opposite create a criss-cross

____ is the characteristic tilting of head to one side (congenital, acquired, or idiopathic)

Torticollis (cervical dystonia)

___ ____ _____ is an acute painful joint disorder, facet "locking" (stuck in Cx rotation and SB away from pain) MOA: unexpected/sudden movement, lying for long time period in prone with head rotated, synovial meniscoid blocks gliding movement, capsular/synovial inflammation (painful movement)

facet joint dysfunction source of symptoms typically involve disc and facet joint (~41% of cases)

the following are symptoms of ____ ____ ____: onset of sharp pain & protective deformity at same time (w/o trauma) unilateral, local mid-cervical pain most common at C2-3, C3-4, C4-5 AGG: neck movements or attempting to correct deformity EASE: rest, avoids aggravating movement

facet joint dysfunction

what are the signs of facet joint dysfunction acutely vs chronicly?

acute: deformity, locking chronic: pain and limited ROM, closing/opening restriction no neuro signs unless nerve root affected by hypertrophic joints

pain and LROM with EXT and SB/ROT to the painful side

closing dysfunction

pain and LROM with FLEX and SB/ROT away from painful side

opening dysfunction

the following are symptoms of ____ ____ ____: SB may be primary restriction typically associated with spondylosis neuro findings: none unless nerve root affected by hypertrophic joints not distinguishable from facet syndrome

uncovertebral joint dysfunction

the following describes ____ ____/____: acute pain arising from injured soft tissues of the neck acceleration-deceleration mechanism (MVAs) MOI complex: head/neck acceleration lag when struck (energy stored), then head/neck thrust forward (energy release)

cervical sprain/strain

the following are symptoms of ____ ____/____: non-radiating neck pain neck stiffness, fatigue, and worsening symptoms with cervical motion symptoms may extend into the trapezius/interscapular region HA common, originating in occiput region and radiating frontally increased irritability and sleep disturbances other: paresthesias, radiating arm pain, dysphagia, visual or auditory symptoms, dizziness

cervical sprain/strain

what are 5 signs of cervical sprain/strain?

deformity - protective posture decreased/painful ROM spasms - scalenes, SCM, paraspinal, trapezius, levator tenderness normal neuro signs - unless nerve compromised by guarding/spasm

describe the 4 classifications of WAD

WAD I: neck c/o; stiff/tender; no physical signs trauma WAD II: neck c/o; stiff/tender; (+) physical signs injury (point tender or pain w/ ROM) WAD III: neck c/o; stiff/tender; (+) neuro signs (reflexes or weakness) WAD IV: neck c/o; fracture or dislocation

the following are symptoms of ____ ____: Unilateral head pain begins in the occipital region and spreads to the ipsilateral temporal region or forehead (ram’s horn distribution) -may be bilateral (“unilaterality” on two sides) - may cross midline during severe or prolonged attacks Deep, pressing soreness in the head May develop a throbbing or pulsatile nature given the right aggravating factor May experience diffuse, vague ipsilateral arm pain

cervicogenic headache

structures innervated by __-__ nerves are potential pain generators for cervicogenic headache

C1-3: OA joints and ligaments Medial and lateral AA C2-3 facet joints Suboccipital, upper prevertebral, trapezius, and sternocleidomastoid muscles C2-3 intervertebral disc Spinal dura mater Vertebral artery

diagnostic cluster of CGH

palpably painful upper Cx joints restricted Cx ROM impaired muscle function on the cranio-cervical flexion test migraine features may be present (nausea, vomiting, photophobia) evidence of CGH: HA developed in relation to Cx disorder, HA improved with Cx disorder improvement, CROM improves HA/provocative movements worsens HA

common impairments seen with CGH

Joint dysfunctions in OA, AA or C2-3 facets Restricted cervical ROM (Cervical Flexion Lateral Rotation….same test as we’ll do for C1 on C2) Muscle tightness in the upper trapezius, levator scapulae, scalene, and suboccipital extensors Decreased strength in cervical flexor and/or extensor muscle groups Altered motor control of deep neck flexors (Craniocervical flexion test:CCFT) with activation of SCM

cervical spondylosis is aka ____ most commonly affects which levels of the Cx spine? radiographically associated with _____

arthritis, C5-6/C6-7, instability

what are the 3 symptom complexes associated with Cx spondylosis?

axial spine pain radicular pain (herniated disc, neuroforaminal stenosis, facet hypertrophy) myelopathy (central stenosis leading to cord compression)

the following are symptoms of ___ _____ Symptoms usually begin at age 30-50 years C/o neck pain, stiffness with loss of motion in one or more planes, and paraspinal muscle spasm. (+/-) Occipital headache (i.e. CGH) (+/-) Cervical radiculopathy symptoms: arm pain, weakness, clumsiness, paresthesia, or hypesthesia may be present (+/-) Pain in the trapezius, paraspinal, and interscapular areas Morning/immobility stiffness – eased with ~ 30 min movement DJD (facet symptoms) + DDD (disc symptoms)

cervical spondylosis

cloward's sign represents ______ ____

discogenic pain (C3-T1) referred to upper back

describe reliable referral patterns of discogenic neck pain

C2/3 - head C3/4 - head and upper neck C4/5 - neck, cap of shoulder, and upper back C5/6 - neck, shoulder, and upper back C6/7 - neck, shoulder, upper back, down arm

pathophysiology of Cx radiculopathy

nerve root disorder - mechanical compression (herniated disc, osteophytes, thickened soft tissue, foraminal stenosis, neoplasm) - chronic edema - DRG (chemical mediators, local response) - no definitive Dx criteria

the following are symptoms of ___ _______ Patient uncomfortable Neck and predominant sharp, radiating pain in the UE – dermatomal pattern Distal symptoms often worse than proximal (acute) Pain may refer into the shoulder, interscapular, or suboccipital regions N/T commonly noted in distal dermatome AGG: Neck motion; cough/valsalva maneuvers Weakness or inability to perform certain ADLs Pain often worse at night; sleep disturbances

cervical radiculopathy

the following are signs of ___ _______ Observations: - Lower cx roots (C7-8): may hold forearm for support - Upper cx roots (C5-6): may hold arm above head (to ease) Movement severely limited (EXT, ROT/SB to symptomatic side) (+) upper limb tension tests (ULTT1) Objective neuro findings with radiculopathy: - Diminished DTRs - Myotomal muscle weakness - Anesthesia in dermatomal pattern

cervical radiculopathy

diagnostic test cluster for Cx radiculopathy

+ spurlings + distraction + ULTT < 60 rotation to involved side

acute vs chronic Cx radiculopathy

acute: N/T symptoms worse distally, minimal Cx symptoms, moderately severe cloward referral chronic: distal symptoms not dominant, pain is deep/achy and hard to localize, rarely functionally limiting, *often referred to PT with primary shoulder, elbow or wrist diagnosis*

central vs lateral stenosis

central involves compression of spinal cord; sxs consistent with cervical spondylotic myelopathy (CSM), LMN and UMN signs lateral involves compression of nerve root canals or neuro foramina; sxs consistent with cervical radiculopathy, LMN signs depending on severity both: seen in pts over 50, (+,-) axial neck pain and/or stiffness due to IVD degeneration and facet joint arthritis

The following describes ___ ____ ____ Most common spinal cord disease affecting middle-aged and elderly patients Clinical presentation varies depending on severity of stenosis & portion of cord involved Gradual evolution of subtle symptoms for years Can progress rapidly (i.e. acute quadriparesis over hours) May result in significant and permanent disability Requires high degree of suspicion for diagnosis

cervical spondylotic myelopathy

The following are symptoms of _____ ____ _____ Variable with level and extent of involvement CC: weakness, clumsiness, balance difficulties, pain not typically present cord signs: weakness (UE>LE), decreased manual dexterity, ataxic broad gait, sensory changes, spasticity, urinary retention

cervical spondylotic myelopathy

The following are signs of _____ _____ _____ Extent of cord ± root involvement UMN lesion signs BELOW level: - Hyperreflexia, - Hoffmann’s sign, inverted radial reflex, clonus, Babinski’s sign, spasticity LMN lesion signs (coexisting radiculopathy) AT level: Lhermitte’s phenomenon (radiating lightning like sensation down the back with neck flexion) Decreased ROM, preferred position is flexion

cervical spondylotic myelopathy

syrinx are _____ cavities in the spinal cord which are often caused by Chiari malformation

longitudinal

the following are sxs of ______ Bilateral hand weakness/numbness Other extremity weakness/numbness Bowel/bladder problems Upper motor neuron signs Headaches Caused by: Chiari malformation, spinal trauma, tumors Anterior horn cells commonly affected & sensory pathways

syringomyelia

The following describes ____ ______ Osteochondrosis of the thoracic spine Abnormal cartilage with deficient bone growth under areas of abnormal growth plates causing wedge-shaped deformities and rigid kyphotic spinal deformity Schmorl’s nodes common: vertical herniation of nucleus into vertebral body Sharp angular deformity present with forward-bending Adolescents: 13-17 yrs Prevalence: males = females Misdiagnosed as “poor posture” Etiology: probable genetic defect Minimum of 3 levels involved, schmorl nodes anteriorly, end plate sclerosis, wedge deformity, loss of disc height

Scheuermann's disease (juvenile osteochondrosis/kyphosis)

The following are signs of ____ ____ Deformities: - Rigid thoracic or thoracolumbar kyphosis; does not correct in hyperextension (angles > 75 degrees usually require surgical intervention_ - Flexible lumbar hyperlordosis and cervical forward head posture - Limited ROM: Thoracic extension; Sharp kyphotic angulation noted in flexion - Tightness: Anterior shoulder musculature, hamstrings, and iliopsoas muscles - Neurologic signs can occur: due to severe kyphosis, dural cysts, or thoracic disc herniation

Scheuermann's disease (juvenile osteochondrosis/kyphosis)

Dowagers hump is related to what type of fracture?

compression causes: osteoporosis, trauma, tumors/radiation

intercostal neuralgia or myelopathy may be related to ___ ____ disease due to disc protrusion or trauma

thoracic disc

_____ _____ _____ symptoms: Thoracic or Lumbar presentation LMN – pain at level, decreased sensation at root level UMN signs and symptoms below level of lesion (variable; poss B) ▪ Postural (i.e. Rhomberg) and gait disturbance (i.e. wide-based) disturbances ▪ Leg parasthesias ▪ Pathologic reflexes: hyperreflexia, Babinski, clonus ▪ Spastic paraparesis

Thoracic compressive myelopathy

Painful joint disorder at the facet, costotransverse or costovertebral joint – “locking”

thoracic joint dysfunciton

the following are signs of ____ _____ ____: Deformity position: may assume postural position away from pain Limited ROM into restrictive barriers: - “closing restriction” – pain and LROM with EXT and SB into the restriction - “opening restriction” – pain and LROM with FLEX and SB away from the restriction Pain and/or stiffness with passive accessory or physiologic mobility testing No neuro signs Radicular nerve symptoms with advanced spondylosis/arthrosis affecting nerve

thoracic joint dysfunctions

symptoms of thoracic outlet syndrome

Neurological Symptoms (differentiate from nerve root or various B.P. entrapments) - neurogenic pain and referral (C8-T1) - motor weakness - paraesthesias - arm fatigue Vascular Symptoms – more of a whole hand/arm sxs prsentation - swelling in hand - arm fatigue - discoloration - deep, boring pain

Non-dermatomal paresthesia in one or both extremities with or without neck/head symptoms. Often mistaken for Thoracic Outlet Syndrome Occasionally diagnosed as bilateral CTS, or radiculopathy, spondylosis, malingering Woman more affected than men (3:1)

T4 syndrome - sympathetic referral

the following describes symptoms of ____ _____ ______ Unilateral pain over costovertebral joint or subscapular May refer pain into posterior shoulder AGG: ▪ Thoracic or shoulder movements into the joint restriction ▪ Deep breathing into restriction EASE: positions or motions away from joint restrictions

costovertebral joint dysfunciton

the following are symptoms of ____/_____ ______ Unilateral pain posteriorly over costotransverse joint, anteriorly over costochondral or chondrosternal joints, and anywhere along course of rib May complain of chest pain! May have Dx of “costochondritis” Hx of trauma / sports injury? Seatbelt? AGG: ▪ Thoracic or shoulder movements ▪ Deep breathing, coughing, sneezing

costochondral/chondrosternal dysfunction

rib movements: ____ (Inhalation) anterior ribs move up and posterior ribs move down ______ (Exhalation) posterior ribs move up and anterior ribs move down

Extension, Flexion

EXCESSIVE KYPHOSIS = emphasize movement of T/S into extension with _____. LOSS OF KYPHOSIS = emphasize movement of T/S into flexion with _____

inhalation, exhalation

EXCESSIVE KYPHOSIS = emphasize movement of T/S into extension with _____. LOSS OF KYPHOSIS = emphasize movement of T/S into flexion with _____

inhalation, exhalation

1st rib syndrome is typically thought of as an “elevated” 1st rib, with or without ____ tightness Sometimes residual sx following cervical radiculopathy perhaps due to decreased mobility Could be associated with trauma (skiing accident, fall on shoulder in sports)

scalene

the following are symptoms of __ ____ ______ upper pectoral pain/mammary pain mid to low scapular pain, dull ache can extend to axillary region dull, nagging ache/burn over upper trap occas. numb U/E, arm heavy but may need to consider TOS, low cervical radic with extremity pain / parasthesia overhead lifting, cervical motions usually aggravating activities

1st rib syndrome

the following are signs of __ ___ ______ restricted shoulder elevation at end range restricted cervical “closing” movement (esp SB) neural tension signs common palpatory tenderness and restricted mobility of 1st / 2nd ribs (+) Cervical Rotation Lateral Flexion (CRLF) test

1st rib syndrome

what are the 6 red flag conditions that may require medical referral?

spinal fracture cervical myelopathy neoplasm (cancer) upper cervical ligamentous instability vertebral artery insufficiency inflammatory or systemic disease

yellow flags are attitudes, beliefs, and behaviors indicating heightened _____-____ beliefs

fear-avoidance

red flags for headache

worst HA ever that wakes up pt or is present upon waking HA with documented elevated BP insidious/new onset(<6 months) HA with neurologic signs HA with consitutional signs or stiff neck blacking out with HA sudden severe HA with flue like sxs, muscle aches, jaw pain with eating, visual changes no previous history of migraines

referred pain patterns of MI

- common combination: midchest, neck, and jaw - larger area of chest, neck, jaw, and inside arms - lower center neck to both sides of upper neck; jaw from ear to ear - between shoulder blades

what are absolute contraindications for cervical manipulation?

athlerosclerosis, can lead to MI history of high cholesterol, taking statins or BP meds acute fracture acute soft tissue injury

risk factors associated with increased risk of internal carotid or vertebrobasilar artery pathology

prior hx of trauma to Cx spine/vessels hx of migraines HTN hypercholesterolemia, hyperlipidemia cardiac/vascular disease, TIA, CVA hx DM blood clotting disorders long term use of steroids hx of smoking recent infection immediately post partum trivial head/neck trauma absence of plausible mechanical explanation for sxs

triad symptoms of meningitis

sudden fever, severe HA, stiff neck

___ tumor is a malignant tumor in upper apices of lung often missed; presents as shoulder pain or cervical disc problem in men with smoking hx

pancoast

cervical myelopathy sxs

wide based spastic gait clumsy hands intrinsic muscle wasting of hands hyperreflexia + babinski, hoffmans, lhermitte (shooting pain with neck movement), clonus urinary retention followed by overflow incontinence

o Complaints vary – pain, dizziness, numbness, headaches, vertigo, visual, etc. o Severe limitation during neck AROM in all directions o Signs of cervical myelopathy o Abnormal Atlanto-dental interval (> 3.0 mm is considered abnormal)

upper cervical instability

sudden occlusal change in TMJ is generally caused by ___ ____ muscle holding condyle in a partially translated position

lateral pterygoid (due to ms spasm or TMJ arthralgia)

what are the muscles of mastication likely to become hypertonic?

temporalis, masseter, and medial pterygoid (closers) lateral pterygoid and digastric (openers)

what is the strongest muscle of mastication?

masseter

TMJ motion: upper joint _____ while the lower joint _____

translates, rotates

a condition associated with joint noises and blocked mouth opening without locking?

disk displacement with reduction

what are the thoughts behind the functional linkage of the cervical spine and TMJ?

Forward head posture Increased cranial rotation Reduced cervical lordosis Increased translation at TMJ Reduced condylar rotation Dysfunctional opening TMJ pain and degeneration

average DNF endurance time to be ___ seconds on subjects without neck pain and ___ seconds with neck pain.

38.95, 24