W1 Extra Material Alexia Notes Flashcards
What is the incidence of TMD?
10-15% of the population
- 20-40 y/o
- Woman 4x more common
What are the 4 categories of classification of patients with orofacial pain?
- Primary headache/non-cervicogenic headache
- TMD
- Masticatory muscle disorder
- Cervicogenic headache
What are the contributing factors to TMD
- Microtrauma
- Malocclusion
- hypermobility
- Mouth breathing
- Nail biting
- Bruxism
- Stress, anxiety, anger, depression
Describe the anatomy of the TMJ
- 2 joint compartments: superior and inferior
- INFERIOR= roll and slide arthrokinematics
- SUPERIOR translation
- Disc sits on top of condyle, cartilaginous, moves with condyle, restrained by retrodisc laminae (ligament), superior head of lateral pterygoid attaches and gives it stability, lateral ligaments for lateral stability
During the opening of the mouth the first ___ mm comes from the inferior joint, then translation occurs for about ____mm
- 11
- 30-40
What muscles are involved with closing the mouth?
Temporalis
Masseter
Medial pterygoid
What muscles are involved with opening the mouth
Lateral Pterygoid, suprahyoids, infrahyoids
What muscles are involved with protrusion and retrusion
Protrusion= lat. pterygoid, med. pterygoid, masseter
retrusion= temporalis and masseter
What muscles are involved in lateral excursion?
Ipsilateral temporalis, contralateral pterygoids, masseter
What is arthralgia?
Blanket term for pain
What occurs in disc dislocation with reduction?
The disc rests anterior to condyle in a dislocated position
- when the mouth opens the disc is “reduced” and jumps back into place (click)
- As the patient closes the mouth before maximal closing the disc slips anteriorly again (click)
What occurs in disc dislocation without reduction?
The disc remains anteriorly dislocated throughout cycle of opening and closing
What is the key distinction between DDwR and DDwoR?
With DDwR, there is a click due to the reduction of the disc
- there is no click in DDwoR since the disc remains anteriorly dislocated
TMJ hypermobility means someone can open their mouth greater than:
50 mm
A patient may have an inflammatory condition if they test positive for what 2 tests?
Retrusive overpressure
Contralateral pain with force biting
If a patient has a positive ipsilateral forced biting test they may have what disorder?
Masticatory myofascial disorder
What is the difference between myofascial and periarticular pain?
Myofascial pain involves trigger points which refer pain
Periarticular pain does not refer
What 2 questions should we ask in the patient history to detect TMD?
- have you had pain or stiffness in the face, jaw, temple, in front of the ear, or in the ear in the past month?
- Have you ever had your jaw catch or lock so it would not open all the way?
____% of patient with TMD have forward head posture:
85%
How do the mechanics of FHP affect muscular length and strength ?
- Tight suboccipital muscles rotate cranium posteriorly, mandibular mechanics are affected, lengthened masseter and temporalis
What is the difference between overbite and overjet?
Overjet= horizontal issue where upper teeth protrude past the bottom teeth at an angle
Overbite= Vertical issue where upper front teeth overlap lower front teeth by >1/3
What do we look for in facial symmetry?
Corner eye to mouth, corner of mouth center of chin, alignment of center points
How do you palpate the later and posterior poles of the TMJ?
Lateral Pole= can feel right in front of the ear
Posterior Pole= feel inside ear
What muscles of the neck can refer to the face and jaw?
Traps/SCM
What is the test for functional opening of the jaw
3-knuckles test
What is the ratio of opening to lateral excursion that we should have available?
4:1
Why is measuring opening important?
It is the only measurement to discriminate between those with and without TMD
What is deflection VS Deviation?
- Deflection = Sign that the mandible is deviating towards the less mobile side because the side its deviating towards is not able to complete the rotation/translation it needs to –> the side that’s moving normally shows it shifts the whole mandible to the restricted side
- Deviation=
–>C-Curve= Hypomobility, internal derangement within the joint with reduction of the disc–> more like an anterior dislocation with reduction scenario
–> S-Curve= Result of muscle imbalance or momentary disc locking that corrects and then finishes in the neutral position
What side does the mandible deviate to with deflection?
Towards the less mobile side
For forced biting provocation test, what does it mean if symptoms are produced on the Ipsilateral side / Contralateral side
Ipsilateral side= Muscle/tendon irritation due to the activation of ipsilateral muscular origin
Contralateral side= Joint
What is likely the issue if the retrusive overpressure test is positive?
Retrodiscal structures
What is the functional ROM norms for the TMJ?
> 35 mm
What does the temporomandibular ligament restrict?
Downward and backward movement of the mandible
Muscle weakness and forward head posture can lead to:
Anterior open bite, lengthening of the lower part of the face, Increased mandibular angle
What is the basic examination for radiography of the TMJ?
Transcranial view
(Lateral oblique projection)
What is the best imaging device for imaging trauma , ankylosis, pain, cortical erosion of the condyle and developmental anomalies of the condyle?
Cone beam CT
MRI is the best imaging choice for:
Viewing soft tissues surrounding the TMJ and disc
What are the points of reference when viewing the TMJ?
Articular eminence, external auditory meatus, condyle
What type of imaging has been used for the diagnosis of dis displacement?
Ultrasound
What should the patient be educated about regarding TMD?
- Tongue position on the roof of the mouth with teeth 2-3 mm apart, soft foods, smaller bites, lips together breathing through nose with diaphragmatic breathing, stress reduction and sleep night guard, avoid activates that clench the jaw or compress the joint
What muscles should be activated/strengthened and which ones should be lengthened for TMJ interventions
Strengthened= DCF, cervical extensors, scapular retractors
Lengthened= suboccipital, Scalenes, SCM, Pecs
What should be done if a patient has joint inflammation?
Joint protection, ice, iontophoresis
What should be done if a patient has joint mobility issues with the TMJ?
Joint mobilizations, PROM/AROM
What should be done for disc or articular dysfunction?
Address impairments, DDwoR: educate about remodeling phase
What are the guidelines for soft tissue mobilization of the TMJ?
5-30 seconds at a time, masseter, pterygoids, temporalis; tolerable discomfort; pt may have rebound headache
Explain the Rocabado Exercises
6 exercises performed 6x each, 6x a day:
1. Nose breathing
2. Controlled opening
3. Mandibular rhythmic stabilization
4. Upper cervical distraction
5. Axial extension of cervical spine
6. Shoulder girdle retraction
What is the theory of condylar remodeling?
- Normalize forces between the disc and musculature
- While laterally deviating the contralateral side will gap and glide performing co-contraction to enhance stabilization
Why does cervical myelopathy occur?
the degenerative processes have acted upon the spinal canal and encroached on the spinal cord
What is DDD?
Degenerative disc disease
Decrease in disc height due to dehydration, nuclear herniation and annular protrusion
What view does a routine radiologic exam consist for the C-spine
- AP open mouth
- AP lower C-spine
- Lateral
- R oblique
- L oblique
What is the purpose of the AP open mouth view?
To look at the articulation of C1-C2
What is the most significant thing assessed in the lateral view?
3 vertebral parallel lines because they infer the anatomy is intact
What is best seen in the R and L oblique views
intervertebral foramina
What are indications for CT of the spine?
Acute trauma in adults, degenerative conditions, abnormal condition where MRI is contraindicated
For MRI, images are viewed in what planes
Axial and Sagittal
What is the purpose of MRI images for the spine?
To look at the spinal cord nerve roots and discs
At what segment is there a step off in the anterior vertebral body line?
C3-C4
What is Stable VS Unstable spinal injuries?
with examples
- Stable= no threat to spinal cord/nerve roots: compression fractures, disc herniations, unilateral facet dislocations
- Unstable= immediate or potential risk to spinal cord/nerve roots: fracture dislocations, bilateral facet dislocation
What is the purpose of the swimmers lateral view?
To take the shoulders out of the way to see the C7-T1 junction
What type of injuries are viewed in the lateral and extension stress views?
SprainsA
According to the Canadian C-Spine Rule what are the indications for a radiograph?
Patient is 65 years or older
Dangerous MOI
Paresthesia’s in extremities
How do you perform mobilizations with movement
- maintain sustained glide according to arthrokinematics rules while the patient performs the active physiological movement
What are the sets and reps for acute vs Chronic conditions with this manual therapy technique?
Acute= 3c 6 reps
Chronic 3x 10 reps
What is the purpose of mobilization with movement?
To correct improper mechanics that impede a joints movement
What is a muscle energy technique? (MET)
A direct joint manipulation provided by an isometric contraction from the patient
How to perform a MET?
Position the joint/muscle near the restrictive barrier as possible
- Patient performs isometric contraction in precise direction away from the barrier (submax)
- hold isometric for 3-5seconds, relax, and wait 3-5 seconds
- Move further into the barrier and repeat the cycle 3-5x return to normal range
What is the strain counterstain (positional release) technique?
Alleviate muscle tender points by placing the muscle on slack –> alleviates pain
How do you perform the positional release technique?
- Locate and palpate the tender point in the muscle
- Place patient in position of comfort in fully shortened position of the muscle (passive)
- Hold position for 60-90 seconds while palpating the tender point
- Return to neutral while palpating to keep point relaxed
- reassess and check for 70% reduction in tenderness
What is the presentation for Neck pain with radicular pain?
Pain or numbness/tingling radiating to distal UE or medial scapular border, UE dermatomal numbness, myotome weakness and or reflex deficits
What test cluster would determine the patient has neck pain with radicular pain?
- ULTT
- spurlings test
- Distraction test
- Ipsilateral cervical rotation <60 degrees
What are the parameters for mechanical cervical traction?
Max Pull: 10-20 pounds
Min Pull: 50% of max pull
On: off time = 30:10 or 60:20
Duration: 10-20 minutes
Angle of Harness: 15-30 degrees cervical flexion
What patients commonly fit into the neck pain with movement coordination impairments category?
trauma/Whiplash
What are the signs and symptoms of patients with movement coordination impairments?
- Aberrant movement during cervical ROM
- Positive CCFT and DCF endurance Test
- Trigger points
- Pain at mid and end range cervical motion
- Cervical segmental testing produces neck and referred pain,
- possible hypermobility at 1 or more levels
What are the global and deep core muscles of the neck?
Global= SCM, scalenes, levator scapulae, UT, erector spinae, rhomboids, mid/lower traps
Deep core muscle: Deep neck flexors ( rectus capitis anterior/lateralis, longus capitis and coli, suboccipital)
What are the signs and symptoms of patient with neck pain and mobility deficits?
- Loss of cervical active ROM
- Positive CRFT
- Positive cervical and thoracic segmental mobility tests
- Strength and endurance deficits in the upper neck muscles
- Absence of radiating pain or trauma
- Central or unilateral neck pain
- Negative neuro screen
How many weeks is the acute phase? What interventions are included for neck pain with mobility deficits?
6 weeks
- Thoracic/cervical manipulations
- Cervical mobilization
- Cervical ROM exercises
- Scapulothoracic and UE stretching and strengthening
What is included in the subacute phase of neck pain with mobility deficits?
6-12 weeks
- thoracic/cervical manipulations and or mobilizations
- Neck and shoulder girdle endurance exercises
Describe interventions for chronic phase of neck pain with mobility deficits
> 12 weeks
- Thoracic/cervical manipulations/mobilizations
- mixed exercises and scapulothoracic regions including neuromuscular exercises
- stretching
-strengthening
- endurance aerobic conditioning
- cognitive affect
- laser
-education
- intermittent traction
What is spondylosis ?
Its a blanket term including arthritis, arthrosis, spinal disc disease, and any stage of degenerative disc disease
Describe the phases of spondylosis
Asymptomatic
Dysfunctional=non specific pain, beginning of restrictions in ROM
Unstable= degeneration progressing, facet joint capsule laxity, uncontrolled arthrokinematics, facet syndrome, radiculopathy, “ catching
Stabilizing= degeneration continues into fibrosing of facets, disc degenerate, osteophytes, nerve root entrapment
How does a cervicogenic headache occur?
Possibly due to the interconnection between the trigeminal nerve and first cervical nerve root
- C1-C3 intermingle and converge with trigeminal afferents in the dorsal grey column
What is the diagnostic criteria for cervicogenic headache?
- Unilateral pain
- Pain in the neck triggered by movement or sustained postures
- Laying down alleviates symptoms
- reduced ROM
- Reduced deep neck cervical flexor strength
- Poor posture
What are the prognostic facts for WAD
- High neck pain intensity
- High self reported disability NDI
- High post traumatic stress symptoms
- Strong catastrophic beliefs
- Cold hyperalgesia
Why do trigger points develop?
- Acute overuse
- Direct trauma
- Persistent muscular contraction
- Prolonged immobility
-Systemic biomechanical imbalances
What is a trigger point?
Taut band located in a muscle
What are the clinical features of trigger points
Discrete bands of hardness, tenderness, referred pain, headache, radiculopathy symptoms
How do we diagnose a trigger point?
Spot tenderness within the taut band
-Referred pain
-reproduced pt’s pain when you press it
What is proximal crossed syndrome?
Due to habitual reasons regarding FHP
- Elevated shoulder girdle
- Winged Scapula causing an upper crossed posture
- Tight UT and Levator scap , tight pec major/minor, weak deep neck flexors, weak rhomboids, serratus anterior and LT
C-Spine Maximally closed position is…
Extension + side bend toward + rotate toward = closing restriciton
C-spine Maximally Open position is…
Flexion + side bend away + rotate away = opening restriction
What is a positive finding for the cervical flexion rotation test? CFRT
< 32 degrees of rotation or 10 degrees visual deficit to either side
What is the average time in subjects without neck pain when performing the DCF endurance test?
39 seconds
What are the special tests for craniocervical instability?
Modified sharp pursers
anterior shear test
Lateral/transverse shear test
alar ligament stress test
What is the normative data for the Neck Disability Index (NDI)?
4 points= no disability
5-14 points= mild disability
15-24 points = moderate disability
25-34 points= severe disability
35-50 points = complete disability
How can you differentiate between the causes of Dizziness? ( vestibular, vascular, cervicogenic)
Step 1= pt sits/stands, rotates head to one side, dizziness reproduced
Step 2=clinician holds pt’s head still while pt rotates their body fully
- If dizziness occurs in both steps = may be vascular or cervicogenic
-Dizziness in step 1 but not step 2 = vestibular problem
What is the most common serious adverse event for the neck ?
Craniocervical artery dissection (57% of SAE)
What are the 2 strongest risk factors for new onset neck pain?
Woman
History of prior neck pain
What age group has the highest incidence of neck pain?
woman in their 50’s
What are the signs and symptoms of a VBI? 3 N’s and 5 D’s
3 Ns = nausea, nystagmus, neuro symptoms
5 Ds= dizziness, drop attacks, diplopia, dysphagia, dysarthria
Proximal Vertebrobasilar artery=
Originate from aortic arch or common carotid artery: may be compressed by anterior scalene
Transverse Vertebrobasilar artery
Courses through transverse foramen C6 to transvers foramen of C2 : susceptible to osteophytes and subluxations
Suboccipital vertebrobasilar Artery
Sigmoid path
Runs from exit at C2 to foramen magnum ; cranio-cervical motion can affect vascular structure; broken down into different portions
1. Within transverse foramen of C2 (bends)–> between C2 and C1–> foramen magnum (bends again)—> between atlas and foramen magnum (upper portion); superficial, covered by traps, semispinalis capitis, rectus capitis
- Vulnerable to direct blunt trauma
