Thoracic Spine Manipulations :), Gudda \ illes 6final ct8, TMJD: Temporomandibular Joint Dysfunction

30.What is the Biomechanical function of ligament?

Allows movement and prevents accessive movement

TMJD: *5 types of treatment?*

-modalities, massage, relaxation techniques -splints -facial muscle relaxation and tongue control -exercises to cervical area and TMJ -manipulation

TMJD: *3 cardinal signs?*

-pain in TMJ region that is worse with movement -joint noise during movement -restrictions with jaw movement

14.What is the name of the test that evaluates isometric endurance of the hip and back extensor muscles?

Biering-Sorenson Test

compressive fracture

Centralized pinpoint pain

AAA risk factors

1. Smoking 2. Male 3. Caucasian 4. CAD/PAD 5. FmHx 6. Marfan's (other genetics) (rare AAA)

8.What pressure stops blood circulation?

>80mm Hg

3.The cervical facets don't allow much movement in all directions; therefore the cervical spine is not the most movable portion of the vertebral column. True or False?

? False

when using a cane, maintain

2 points of support on the ground at all times

Cervical spine and upper quadrant screen:

Cervical spine and upper quadrant screen: Assess cervical and shoulder A/PROM, muscle length including deep cervical flexors, myotomes, dermatomes and reflexes.

Vertebral compression fracture

Osteoporosis (type I: postmenopausal woman; type II: elderly man or woman)

Indications for Treatment: Tmj

Pain Clicking, crepitus or popping Decreased ROM in mouth opening Locking of the jaw with mouth opening Difficulty with functional activities of the TMJ: chewing, talking, yawning

17.What is how much weight you can lift?

Power

TMJ ROM test

ROM: AROM: Range of motion can be measured from top tooth edge to bottom tooth edge marking on a tongue depressor and measuring the distance in millimeters.18 · Opening and closing of mouth Normal opening = 35-50 mm3 Functional opening = 25-35 mm or at least two knuckles between teeth3 · Protrusion of mandible Normal = 5 mm3 · Lateral deviation of mandible Normal = 8-10 mm3 · Note asymmetrical movements, snapping, clicking, popping or jumps. Mechanical derangements account for the common clinical signs of clicking and locking.10 · Record deviations: lateral movements with return to midline · Record deflections: lateral movements without return to midline PROM: Apply overpressure at the end range of AROM to assess end feel

22.What type of activity is done with fast-twitch muscle fibers?

Sprints or Burpees

2.The cervical spine must balance the weight of the head atop a relatively thin and long lever, making it quite vulnerable to traumatic forces

T True

32.The faster you apply the load the more _________?

TStiff

PRONE Bilateral Hypothenar/Transverse Push T6/T7 flexion restriction

Vectors: I-S, slight P-A -wider "shark fin" in mid thoracic spine -Wide fencer stance -"Shark fin" down -jugular notch behind contact point -for extension restrictions, vector is: P-A and jugular notch is over contact point, "Shark fin" is up

PRONE Unilateral Hypothenar/Transverse Push T5/T6 left rotation restriction

Vectors: P-A -stand on opposite side of rotation -use hand of the side that you are standing on (stand on right side, use right hand with DCP) -stand facing *cephalad* or caudad (as long as you know where you need to contact) -jugular notch behind contact point

SITTING Hypothenar Transverse Pull T6/T7 right rotation and right lateral flexion restriction

Vectors: Rotatory Pull -Start patient in right lateral flection and right rotation. -Doc pulls patient into right rotation with right hand across chest -Hypothenar contact on the high side of the left T6 TP

PRONE Unilateral Hypothenar/Spinous Push T3/T4 right rotation and right lateral flexion restriction

Vectors: S-I, L-M, P-A -coupled motion -SCP ipsilateral toSP -"diagonally down" (45 degree angle) -mid-line hand contacts, outer hand reinforces -use hand of the same side that you are standing on (right side, right hand for DCP) -facing caudad

TMJD: *articulating surfaces of the joint?*

condyle on mandible and fossa on temporal bone

Muscles of TMJ depression

• *Lateral pterygoid* • *Supra hyoid* • *Infra hyoid*

capsulitis/synovitis s/s jaw

inflammation of the joint capsule

synovitis and tmj

inflammation of the synovial membrane that results in swelling and pain of the affected joint

TMJD: *type and shape of joint?*

synovial hinge

TMJD: *4 causes of?*

*developmental abnormalities:* misalignment/malocclusion or bones different sizes *diseases:* OA/RA *macro trauma:* hit in the face/jaw *dysfunctions:* bruxism (grinding the teeth), forward head posture, sinus problems resulting in mouth breathing, whiplash injury

Using a cane

- flex elbow 30 degrees and hold handle - tip of cane should be 15 cm lateral to the base of the fifth toe Cane On Affected Leg

Prognosis tmj

1. Active exercises and joint mobilizations, either alone or in combination, may be helpful for mouth opening in patients with acute disk displacement, acute arthritis, or acute or chronic myofascial pain.14 2. Postural training may be used as an adjunct to other treatment techniques as it's effectiveness alone is not known.14 3. The inclusion of relaxation techniques, biofeedback, EMG training, proprioception education may be more effective than placebo or occlusal splints in decreasing pain and mouth opening in patients with acute or chronic myofascial pain.14 4. A combination of active exercises, manual therapy, postural training, and relaxation training may decrease pain and increase mouth opening in patients with acute disk displacement, acute arthritis, or acute myofascial pain. It is not known, however, if combination therapy is more effective than providing a single treatment intervention.14

TMJD: *where pain is felt and how it is described?*

1. referred to head, neck, jaw or ear 2. general facial pain, greater occipital nerve irritation secondary to tension in cervical muscles

4.What is the rotation of C1-C2 in degrees?

40 degrees

ROM: TMJ Opening

40mm (25mm rotation, 15mm glide)

5.At what angle are the cervical facets oriented at?

45 degree to the horizontal plane

Low back pain; 50 year old white male smoker

AAA

Somatic Dysfunction

An impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and related vascular, lymphatic, and neural elements.

Lower Crossed Syndrome: Lengthened Muscles

Anterior tibialis Posterior tibialis Gluteus maximus Gluteus medius Transverse abdominis Internal obliques

Falls in the elderly

Are primarily due to decreased mobility and sense of balance

18.What type of muscle contraction shortens the muscle

Concentric

11._________ training is the most effective strategy by which to improve neuromuscular and cardiorespiratory functions as well as functional capacity in the elderly?

Concurrent

TMJ syndrome

Contraindications / Precautions for Treatment: Post-operative patients may have surgeon specific precautions regarding physical therapy progression. Contact the surgeon, as appropriate, to clarify case-specific precautions.

Dynamic loading7:

Dynamic loading7: · Load contralateral TMJ - bite on cotton roll. · Compression of bilateral TMJ - Grasp the mandible bilaterally and tip the mandible down and back to compress the joints. · Distraction of bilateral TMJ - Grasp the mandible bilaterally, distract both joints at the same time. · A positive finding to dynamic loading is pain.

19.What type of muscle contraction elongates the muscle?

Eccentric

33.What is elasticity?

Elasticity is a property of a body that deforms under load and returns to its original position when the load is removed.

21.What type of activity is done with slow-twitch muscle fibers?

Endurance Exercises (Long distance running)

10.In the research article about therapeutic alliances, were all spinal levels the treated with the same acceleration amplitude paramenters. True or False?

False

23.True or False: A cane should be used on the same side as the injury?

False

Functional Activities:

Functional Activities: Assess chewing, swallowing, coughing, and talking. Either have patient demonstrate task or ask for patient's subjective report. Include changes the patient has made to their own diet to accommodate for their pain and dysfunction.

Goals tmj

Goals Short term (2-4 wks) and long term (6-8 wks) goals may include but are not limited to: Reduce or independently self manage pain symptoms or joint noises Normal ROM and sequence of jaw movements Maximize strength and normalize motor control of muscles of mastication, cervical spine and periscapular region Maximize flexibility in related muscles as indicated Maximize postural correction in sitting and/or standing Correct ergonomic set-up of workstations at home and/or at work Independence with home exercise program Independence with relaxation techniques

Lower cross syndrome with posterior pelvic tilt

Heel lifts needed Hypolordosis ASIS is anterior to pubic symphysis Lengthened/inhibited - psoas, quadriceps, erector spinae Hypertonic/facilitated muscles - hamstrings, gluteals, abdominals

20.What type of muscle contraction is where the muscle is held at a constant length?

Isometric

15.What kind of test is the Biering-Sorenson Test?

Isometric Strength test

27.What is the study of motion without the consideration of forces?

Kinematics

6.In coupled motion, left lateral flexion of the cervical spine is paired with ___________?

Left rotation of the cervical spine

LUMBAR SPINE

Low back; The part of the spine comprised of five vertebral bodies (L1-L5) that extend from the lower thoracic spine (chest) to the sacrum (bottom of the spine).

13.Which region of the spine can negatively influence trunk muscle strength, balance, and endurance, the military readiness of active-duty military personnel with LBP is potentially compromised

Lumbar or Low Back Pain

lumbar spine strain

MCC lower back pain dull, diffuse, may radiate to hips pain worse with bending and better with rest

28.What things make up a force?

Magnitude, Direction and Point of Application

AAA symptoms

Most common in geriatric males, testing back pain, symptoms of hypovolemic shock, possible pulsating mass

34.In a case of Mobilization vs manipulation, what newtons law are you using?

Newtons 2nd law

Tx TMJ dysfunction

Non-surgical treatments such as counseling, pharmacotherapy and occlusal splint therapy continue to be the most effective way of managing over 80% of patients. 12 Treatment strategies may include but are not limited to: · Modalities for pain control: Heat, ice, electrical stimulation, TENS, ultrasound, phonophoresis · A/AA/PROM · Stretching: active, assisted and passive stretching, can use tongue depressors or cork as needed. Refer to physical therapy texts for specific techniques. · Joint mobilization or manipulation: Restore normal joint mechanics of the TMJ, cervical and/or thoracic spine as appropriate. Refer to appropriate texts for treatment techniques.9,19, 21 · Soft tissue mobilization, myofascial release and deep friction massage · Muscle energy techniques · Neuromuscular facilitation: hold-relax, contract-relax, alternating isometrics. For specific exercises refer to physical therapy references e.g. Hertling and Kessler's Management of Common Musculoskeletal Disorders.19 · Relaxation techniques: learning to relax masticatory muscles and maintain this relaxed state during the day; learning stress management and coping skills4 · Biofeedback and EMG training to promote muscle control and relaxation 4 · Therapeutic exercises: Including Rocobado 6 x 6 isometrics program.22 Cervical stability exercises. Frequency & Duration: The frequency and duration of follow up treatment sessions will be individualized based on the specific impairments and functional limitations with which the patient presents during the initial evaluation. On average, the frequency may range from 1-2 times per week for 4-6 weeks.

24.Which part of the Intervertebral Disc takes more load in a healthy disc?

Nucleus pulposus

spinal stenosis symptoms

Numbness, weakness, burning sensations, tingling, pins and needles in the shoulders or legs, depending on the area of the spine affected

Observation:

Observation: · Opening and closing of mouth: Inspect that the teeth normally close symmetrically and that the jaw is normally centered. · Alignment of teeth: Take note of a cross bite, under or over bite. Identify any missing teeth.17 · Symmetry of facial structures (eyes, nose, mouth): Note of any facial deformity which can range from very subtle to severe and readily visible deformation.10 Examine both soft tissue and bony contours between left and right halves.17 Pay special attention to muscular paralysis, such as ptosis of the eyelid or drooping of the mouth, which may be associated with Bells Palsy.17 Also determine whether the upper and lower lip frenulums are properly aligned.17 · Posture: Note the presence of forward head posture, rounded shoulders and scapular protraction.18 Also be aware of scoliosis or cervical torticollis, which affect the length tension relationships of the muscles attaching to both sides of the mandible causing an uneven pull to one side.18 · Breathing pattern: Assess if diaphragmatic breathing occurs or if there is an accessory pattern to breathing. · Tongue: Examine for presence of bite marks, scalloping (tongue resting between teeth) resulting from tongue not properly resting on the hard palate or from tongue being excessively wide. A dry or white appearance of the tongue is an abnormality and may indicate bacterial infections, dysfunction of salivary glands or adverse reaction to medications.17

Assessment

Often patients with TMJ dysfunction present with pain, forward head posture, protracted shoulders, mouth and accessory muscle breathing patterns, abnormal resting position of the tongue and mandible, and abnormal swallowing mechanism. Patients with these clinical signs will benefit from skilled physical therapy intervention to correct these upper quarter muscle imbalances and to restore the normal biomechanics and motor control of the TMJ.19

Palpation:tmj

Palpation: · TMJ: Palpate the TMJ bilaterally while the patient opens and closes the mouth several times.18 Assess for joint integrity and structural deviations. The mandibular condyles on both sides should move smoothly and equally.18 If the examiner feels one side rotate before the other or shift laterally while the mandible is moving, this may indicate TMJ dysfunction.18 · Muscles of mastication: Palpate and compare bilaterally, assess for pain and/or muscle spasm o Some of the muscle to be palpated can include: lateral pterygoid (intraorally), insertion of temporalis (intraorally), medial pterygoid (externally), masseter (externally) 12 o It is recommended that the masseter, anterior temporalis and TMJs be palpated to ensure that it intensifies or reproduces the patient's pain in order to determine the primary source of pain.4 These areas can be palpated by having the patient clench the jaw and palpating the muscle over its origin and muscle belly.18Areas of tenderness, trigger points and patterns of pain referrals should be noted.12 Joint sounds and their location during opening, closing and lateral excursion may be palpated or detected with a stethoscope placed over the preauricular area.12

31.What is viscoelasticity?

Property of materials that behave differently depending on how fast the load is applied, both solid and fluid content

TMJ dysfunction

S/S - joint noise (clicking, popping), joint locking, limited flexibility of jaw, lateral deviation of mandible during depression or elevation, decreased strength/endurnace of mastication muscles, tinnitus, headaches, forward head posture, and pain with movement of mandible Must look at C-spine too Dysfunctions fall into 3 categories: -DJD, such as OA or RA in TMJ -Myofascial pain - MC form of TMJ dysfunction, which is discomfort or pain in muscles controlling jaw function, as well as neck and shoulder muscles. -Internal derangement of joint, meaning a dislocated jaw, displaced articular disc, or injury to condyle. Loss of function -joint mob -flexibility -patient ed -night splints may be prescribed by the dentist to maintain -resting jaw position -educate patient regarding resting position of tongue on hard palate -it is critical to normalize the C spin posture before the patient receives any permanent dental procedures and/or appliances.onal mobility may result from increased activity in muscles of mastication d/t stress and anxiety. Causes: trauma, congenital, abnormal function. x-ray, MRI if necessary PT goals: -postural re-ed -modalities -biofeedback to minimize effects of stress -joint mob -flexibility -patient ed -night splints may be prescribed by the dentist to maintain -resting jaw position -educate patient regarding resting position of tongue on hard palate -it is critical to normalize the C spin posture before the patient receives any permanent dental procedures and/or appliances.

Lower cross syndrome with anterior pelvic tilt

Sole lifts needed Hyperlordosis ASIS is anterior to pubic symphysis Lengthened/inhibited muscles - hamstrings, gluteals, abdominals Hypertonic/facilitated muscles - psoas, quadriceps, erector spinae

16.What is how fast you can lift an object and it involves speed?

Strength

lumbar strain

Symptoms achy dull worst with activity

pain

The main complaint may include orofacial pain, joint noises, restricted mouth opening or a combination of these.12 It is helpful to evaluate pain in terms of onset, nature, intensity, site, duration and aggravating and relieving factors. Also consider how the pain relates to features such as joint noise and restricted mandibular movement.12 Determine which movements cause pain, including opening or closing of mouth, eating, yawning, biting, chewing, swallowing, speaking, or shouting. The patient may also present with headaches and cervical pain. Pain may also be present in the distribution of one of the three branches of the trigeminal nerve (CN V).11 Pain is generally located with the masseter muscle, preauricular area, and anterior temporalis muscle regions. The pain is usually an ache, pressure, or a dull pain which may include a background burning sensation. There may also be episodes of sharp pain and throbbing pain. This pain can be intensified by stress, clenching and eating. Pain may be relieved by relaxing, applying heat to the painful area or taking over the counter analgesics.4

STANDING Long-Axis Distraction T7/T8 extension restriction

Vectors: I-S, A-P *in book usually used for flexion restrictions*p.226 -interace fingers across patients chest -contact: sternal angle on T7 -modified fencers stance -have patient relax and look up for extension (patient would tuck chin for flexion restriction)

PRONE Unilateral Hypothenar/Spinous Push T8/T9 right rotation and left lateral flexion restriction

Vectors: I-S, L-M, P-A -coupled motion (same sided coupling) -SCP ipsilateral to the SP -"diagonally up" -mid-line hand contacts, outer hand reinforces -facing cephalad

26.How do Alar and Transverse ligaments behave?

They behave differently depending on how fast you apply the load.

Falls in the elderly

Top cause of accidental death in those >65 years Fall prevention a top priority of geronolist Hip fracture causes most deaths and problems

1.Greater than 50% pain relief following Cox Technique Flexion-Distraction chiropractic distraction spinal manipulation was seen in 81% of postsurgical patients receiving a mean of 11 visits over a 49-day period of active care.

True

12.Performing strength prior to endurance exercise may optimize both neuromuscular and cardiovascular gains. True or False?

True

7.In the research article, acceleration amplitudes varied significantly across spinal regions with relatively little differences in acceleration latencies. True or False?

True

AAA Dx

U/S: test of choice, 100% sensitive CT: only use in hemodynamically stable pts for surgery prep Ab xray: not so great

PRONE Unilateral Hypothenar/Spinous Push T7/T8 flexion restriction

Vectors: I-S, P-A -jugular notch behind contact point -fingers horizontal to spine -outside hand contacts first -SCP is under the SP (on top of SP hurts) -Vector for extension restriction is P-A, jugular notch over contact, SCP ipsilateral to SP

Symptoms of AAA

Usu asymptomatic sense of fullness pulsatile mass on abdominal exam if pain-->found in hypogastrium, lower back ("throbbing")

PRONE Bilateral Hypothenar/Transverse Push (crossed bilateral) T6/T7 left rotation restriction

Vectors: *Caudal hand is I-S *Cephalad hand is S-I *P-A -Stand on opposite side of rotation -toggle stance -caudal hand goes down first -caudal hand on superior segment -cephalad hand on inferior segment -tork skin counterclockwise

PRONE Bilateral Hypothenar/Transverse Push (crossed bilateral) T6/T7 left lateral flexion restriction

Vectors: *caudal hand is I-S *cephalad hand is S-I *P-A -stand on opposite side of rotation -contact both TP's on each side of same segment -toggle stance -caudal hand goes down first

PRONE Hypothenar Spinus Crossed Thenar/Transverse Push T4/T5 right rotation restriction

Vectors: *Spinus Push with cephalad hand: L-M, P-A, slight I to S (hand is more parelle) *Transverse Push with caudad hand: P-A -stand on the same side of the rotation -square stance or modified fencer stance -outer hand (Cephalad hand) hypothenar *or thumb* contact on T4 SP, mid-line hand (caudad hand) thenar contact on T4 TP -tork skin

SUPINE Thoracic Opposite-Side Thenar/Transverse drop T7/T8 extension restriction

Vectors: A-P, -tissue pull (I-S for lower T spine; S-I for upper T-spine)

SUPINE Thoracic Pump-Handle T7/T8 flexion restriction

Vectors: A-P, I-S tissue pull -contact on T7 TPs -contact upper lower

25.What is a property of an Intervertebral Disc?

Viscoelastic

Mandibular Gait

___Mark bottom tooth w/pencil if there is overlap of top teeth. ___Measure maxi opening by asking pt to open mouth as wide as possible & measure from the bottom of the top tooth to the top of the bottom tooth (or pencil mark on the bottom tooth) ___Line up top & bottom teeth for appropriate reference point & mark tooth if necessary & have patient deviate to right & measure from center of top teeth to reference point on bottom tooth ___Repeat by deviating & measuring to the left ___Ask patient to protract the jaw & observes for symmetry ___Patient's findings: ranges, pain, clicks, deviations

AAA

abdominal aortic aneurysm

Hip OA

anterior groin pain symptom

TMJD: *what is between those two surfaces?*

articulating disc

TMJD: *internal pterygoid muscle actions?*

bi-protrudes mandible uni-deviates mandible to opposite side

TMJD: *external pterygoid muscle actions?*

bi-protrudes mandible uni-deviates mandible to same side

compressive fracture

bone is crushed

report findings

by reporting results to others, they can replicate the experiment if desired

Lower crossed syndrome

characterized by an anterior tilt to the pelvis(arched lower back)

functional activities of the TMJ?

chewing talking yawning

Report of findings protocol -

clear explanation of: Diagnosis & proposed treatment, including explanation of manipulation & scheduleDiscuss risks, side effects & do nothing optionPrognosis/expected recovery timeQuestions & sign consent

TMJD: *masseter muscle actions?*

elevates mandible

TMJD: *temporalis muscle actions?*

elevates mandible retracts mandible

M/c problem in the elderly

falls

Jaw clicking is an indication for what treatments?

lateral pterygoid

inferior head of lateral pterygoid origin

lateral surface of lateral pterygoid plate

TMJD: *what is the strongest mouth closing muscle?*

masseter

spinal stenosis

narrowing of the spinal canal with compression of nerve roots

Muscles of TMJ

open mouth: external pterygoids closing mouth: masseter, temporalis and internal pterygoids

superior head of lateral pterygoid

stabilizes the articular disk during clenching (power stroke)

anklyosing spondylitis

stiffness that start SI joints bilat

Muscles of TMJ elevation

temporalis, masseter, medial pterygoid

9.What kind of loads can ligaments take?

tensile loads

80 year old female tmd pain

think vascular tmd

29.What is the Biomechanical function of tendon?

transmission of force from muscle to bone

Compressive fractures occur in: - vertebral bodies - calcaneus - clavicle - metacarpals

vertebral bodies - calcaneus - clavicle - metacarpals