TMJ and thoracic

vertebra

Body Transverse Processes Spinal Process Costal facets Pedicles Laminae Articular facets Costal demifacets: each body has 2 pair (superior and inferior) for articulation with the rib heads T10-T12 only have 1 pair

more conserv tx

Diaphragmatic breathing reduce over-activity of the scalene muscles and accessory respiratory muscles Aerobic exercise pec stretch

cervical spine screening

Differentiate between lower cervical spine and upper thoracic spine Screen cervical spine with AROM, overpressure, accessory mobility testing

patient ed

a central component of TMD management individ education: reduction of parafuncctional habits biopsychosocial factors pain science education normal daily function (yawning, modifiction may be required) stress mangaement

otological ear pain

inner ear infection (otitis media) fever, redness, warmth, mallaise external ear infection (otitis external) rapid onset, itching, discharge, pain/tenderness of ear, jaw pain, hearing loss ruptured tympanic membrane barotrauma, fullness, tinnitus, hearing loss vertigo, 90% heal spontaneously

special questions

jaw fatigue food type clicking popping locking inability to finish meals HA dizzy earache fullness tinnitus (over sens of trigeminal) toothache eye pain orthodonic tx emotional stress parafunctional habits? (gum chewing, clenching, leaning on hand)

outcome measures

jaw pain and dysfunction questionnaire (cutpoint between 5-12 to distinguish TMD from controls) tampa sclae of kinesiophobia TMD (good reliability and validity, functional complaints are more related to patietns fear of movement than the pain with the activity) oral health impact progile (reliable and valid to measure impact on quality of life)

trigeminal neuralgia

preevelence .3% M:F = 2:3 characteristics unilateral stabbing/burning/superficial severe (10/10) freq episodic duration <1 sec to 2 min commonly V2 or V3 autonomic and or sensory deficits triggers (mechanical stimuli, normally subthreshold stimuli cold wind)

cervical spine involvement

present across all patient with TMD upper cervical spine and or head pain?? accessry movement restrictions multiple levels may be involved unilateral or bilateral confirmed thorugh manual therapy and symptom reduction (high error rate with diagnostic imaging) found to be more prevalent in worse cases of TMD greater TMD sx reported in patients with worse spine pain chronicity of spine pain = greater likelihood of developing TMD arugment for screening and tx both in either condition?

splinting

primary purpose is to protect teeth secondary to decrease bruxism, reduce TMD symptoms fabricatd by dentist may show trend toward reducing symtpoms not supported during multimodal therapy

TMJ OA

proposed mechanisms: direct trauma hypoxia/reperfusion neurogenic inflammation women > men occurs more freq in discomandibular space OA does not equal pain may begin as early as 20 yrs anterior glide lost first spin lost after

red flag

psych status CAD upper c spine instability cardiac dysfunx CN dysfunction infections weight loss/gain

passive accessory motion testing

80% agreement on accessory glides anterior posterior lateral medial distraction/inferior compression for pain, crepitus etc. 93% agreement reliability slight-fair (K = .19-.47

respiration 3

Caliper Action (R11 & R12) Move laterally to increase the lateral diameter

diabetic thoracic radic

Case report: 64 year old male, Type 2 diabetes, with chest wall and abdominal pain 3 months following video-assisted thoracoscopic surgery. Pain, sensory loss, abdominal and thoracic muscle weakness Pain and sensory loss usually resolve within 1 year Distinguished from intercostal neuralgia based on clinical and EMG findings

surgical management

arthrocentesis arthroscopy arthroplasty total joint reconstruction

subjective

ask about splits/corrective eqquipment

odontogenic

associated with a specific tooth dull throbbing and sharp with specific aggs may radiate into ear and cause HA aggs: chewing cold hot release of bite want to screen for freq of dental care

arhtrogenic pattern

associated with joint line pain, arthritis or arthosis arthralgia, hyper mob and joint pain with movement joint line tenderness crepitus )palpable or audible to pt or clinician) positive joint compression test accessory movement irregularitites confirmed thorugh joint techniques / pt education for hypermobile joints

DDWR pattern

associated with joint noises and blocked opening may resolve spontaneously opening and or reciprocal noise not associated with severe locking of joint +joint compression test unilateral confirmed through response to joint interventions poor clinical differential of direction of displacement

DDNR pattern

associted with blocked opening and possible hx of DDWR may have hx of opening and or reciprocal noise locking does not permit functional range pos joint compression test unilateral confirmed through response to joint interventions poor clinical differential ton of direction of displacement

intraarticular disc

attachment? medial and lateral mandicular condyles joint capsule lateral pterygoid retrodicsal tissue whats special about the retrodiscal tissue? highly vascularized and neural fibroelastic tissue limits forward disc motion what directions can the disc displace? ANY

thoracic outlet syndrome

Peet 1956 'thoracic outlet syndrome' compression of the neurovascular structures in the interscalene triangle (Hooper et al 2010, Ferrante et al 2016) There is controversy over the definition, the incidence, the pathoanatomical contributions, diagnosis and treatment of TOS. Currently the medical literature recognizes 5 entities as TOS

GI

Peptic ulcer - posterior wall of the stomach or duodenum Boring pain from the epigastric area to the middle of the thoracic spine Pain either triggered or relieved by eating Risk factor: prolonged use of NSAIDs Flank: lateral region of the trunk between the rib cage and iliac crest Renal Colic: flank pain accompanied by lower abdominal pain that spreads into the labia in women and into the testicles in men Duodenal ulcer: pain relieved by eating Gastric ulcer: pain increased with eating, black tarry-colored stools IBU: use greater than 3 months at doses > 1600 mg/day Symptom relief with antacids Cholecystitis - inflamed gall bladder Pain in the upper right quadrant and right infrascapular region Pain often accompanied by a moderate fever, nausea, and vomiting Symptoms occur 1-2 hours after ingesting a heavy meal pain increased with eating fatty foods Murphy sign: palpating the right subcostal region and asking the patient to take a deep breath + if pain with inhalation (Godges et al 2005, Goodman & Snyder 2007) Pancreatitis - Acute inflammation of the pancreas Pain around the thoracolumbar junction Pyelonephritis (kidney, renal pain, kidney infection) Pain referred to the costovertebral angle or flank area Fever, nausea, vomiting, renal colic History of UTI or current UTI = risk of kidney infection

AROM

Performed with the patient in a seated position Determine the ROM present in each direction Behavior of the symptoms at rest, during, and immediately following the movement FW, BW, Side-bending, rotation in cardinal planes Passive overpressure at end ranges Symptom response End-feel Looking for any movement impairments/restrictions/pain Combined movement (ext, lat flex, rot toward) Looking to reproduce symptoms if cardinal planes did not They are also positions similar to functional movement Example: right handed tennis player reports middle thoracic pain while reaching for an overhead shot Thoracic extension with right rotation and right side-bending The patient may need to perform repeated movements or sustained movements Keep in mind you may be trying to provoke their symptoms OR Trying to alleviate symptoms Overpressure, is that all they have? Or do they have more with overpressure Push in...then ossilate a couple of times ***

assessing for centralization

Peripheralizes: a neurological sign or paresthesia is produced the patient's paresthesia or pain moves distal to the thoracic spine The pain can radiate into the upper or lower extremity The pain can wrap around the rib cage to the anterior aspect Interpretation: spread of pain may be due to central sensitization Centralizes: A neurological sign is improved Paresthesia or pain is relieved or moves from the periphery toward the thoracic spine Again, when looking at ROM, we're looking at the amount of movement, the quality of the movement and determining the effect of each movement on the symptoms. Depending on the patient presentation, we may need to assess for centralization. Symptoms may stay status quo: the symptoms may increase or decrease in intensity, but do not centralize or peripheralize Allodynia caused by central sensitization (nonnoxious fibers) Hyperalgesia caused by central sensi (noxious fibers) Stimulating different fibers

prone rib mobilization

Prone Rib Mobilization PT stands at head of table, patient in prone PT uses cross-handed technique Stabilize the opposite side of the t-spine With mobilizing hand, contact shaft of the rib just lateral to transverse process with hypothenar eminence Apply graded mobilization to the rib Common impairments in the thoracic spine or rib cage include limited joint mobility of the thoracic vertebral joints and ribs; impaired posture, soft tissue mobility restrictions, impairments in muscle strength, endurance and motor control

comparable sign

"A comparable joint or neural sign refers to a combination of pain, stiffness and/or spasm which the examiner finds in examination and considers to be comparable with the patient's symptoms." Maitland, 1991 Abnormal: range, resistance and/or spasm Be in the anatomical area of the patient complaint Must reproduce the persons symptoms Produce abnormal pain Want to find the most comparable sign

conditions diagnoses

...

incidence epi

1. Arterial TOS: <1% of cases 2. Venous TOS: 3 to 5% of cases 3. Traumatic neurovascular TOS 4. True Neurogenic TOS: 90% of all cases (objective findings) 5. Disputed Neurogenic (a condition without the same objective findings) 20-50 year olds, 3-4x F>M, dominant arm Due to the controversy over the definition of TOS, the incidence is hard to track and it varies between specialties (ie surgeons and neurologists). Many dispute the existence of disputed neurogenic altogether TOS can occur in teenagers or the pediatric population, but rarely

thoracic vert fx

1. Traumatic Injury 2. Compression fracture (ie. Osteoporotic fracture) High incidence of fractures in thoraco lumbar junction (Reid 1996) Burst Fracture: Middle column injury Thoracolumbar junction, neurological injury Fracture-Dislocation: Involves all 3 columns Neurological injury, associated intra-abdominal injury T-L junction: secondary to a change in stiffness between the upper more flexible segment and a lower segment that is inflexible in rotation. Not usually associated with any neurological deficit Burst: fragments into spinal canal Flexion-Distraction: Posterior column or all 3 Lap belt Extension: Compresses posterior column. Stable Treatment Surgical intervention Degree of cord compromise Instability Rigid Bracing (limit kyphotic postures)

guidelines for imaging: trauma

100% sens 39% spec

epidemiology

30% percived dysfxn 44-49% clinical dysfunction 4.6% day long pain typical age 20-50 majority female

fx case

33 year old female with mid thoracic pain for 10 days Sudden pain when transferring a patient (8/10) Pain worse with UE movement, not relieved by rest or meds Exquisite tenderness at T9

fx

73 year old F Complaint: middle thoracic spine pain Deep ache, can be sharp with movement Onset: 2 days ago after she bent down to pick up a laundry basket Aggravating: sitting, standing, walking Eases: laying down Denies radiating pain No neurological complaints PMHx: smoked 1 pack per day, quit 10 years ago Chronic shortness of breath, hypertension, postmenopausal Oswestry Disability Index: 52% -IM pain -deep ache -8/10 NPRS

extension rib

Accompanying motion of the rib at the costotransverse joint in inferior glide Posterior rotation of the rib head

flexion

Anterior rotation of the rib Anterior aspect of rib travels inferiorly Costotransverse joint: Superior glide with anterior roll

patient presentation

Arterial TOS Pain, numbness in non-radicular distribution Coolness to touch Pale discoloration All worsen with cold ambient temperatures Presentation will very with every patient depending on the location of the neurovascular tension/compression within the thoracic outlet. Mild pain and sensory changes to limb and/or life threatening complications. Present with multiple unilateral or bilateral signs and symptoms if both neurogenic and vascular components.

patient presentation 2

Awake at night with paresthesia in the upper limb 'release phenomenon' Release of tension and/or compression of the perineural blood supply to the brachial plexus Signals a return of normal sensation Prognostic indicator of a favorable outcome Symptoms through day with prolonged postures that increase tension or compression Sitting with rounded shoulders and FHP Working with elevated arms

respiration 2

Bucket handle action (R7-10) Ribs 7-10 mainly increase in lateral or transverse dimension Ribs move upwards, backwards, and medially to increase infrasternal angle

precautions for t-spine manip

C/T junction: VBI screen Post menopausal women and osteoporosis Long term steroids and asthma People dependent on manipulations Recent fracture TB or recent infection Malignancy or inflammatory arthritis or active inflammatory disease

intercostal neuralgia

Caused by an intercostal neuroma secondary to a prior thoracotomy, radical mastectomy, or fractured rib Can also be idiopathic (Flynn p. 118) Burning pain and paresthesia in the thorax or abdomen Usually follows the path of the affected nerve Focal tenderness over the affected intercostal area Case report of a 50 y/o male with esophageal carcinoma, otherwise healthy, was referred for treatment for post thoracotomy pain after gastroesophagectomy. One moth after surgery, the patient began complaining of sharp, continuous, incisional pain, worse with deep inhalation, radiating from his right side of the middle of his anterior torso around his lower ribs (Byas-Smith 2006)

bony abnormalities

Cervical rib Type I: a complete cervical rib that articulates with the first rib or manubrium Type II: incomplete cervical rib with a free end expanded to form a bulbous tip Type III: an incomplete rib that is continued by a fibrous band Type IV: a rib that appears as a short bar of bone a few mm beyond the C7 transverse process Elongated C7 transverse process, abnormal 1st rib or clavicle can create compression. Maybe a tumor, callus or fracture of the 1st rib. Risk for TOS when there is malunion of a clavicular fracture, fragmentation or retrosternal dislocation

joint impairments

Clavicle Elevate, retract and spin backwards during upper extremity elevation Acromiocalvicular Joint (ACJ) Allows movement of the scapula Sternoclavicular Joint (SCJ) History of subluxation Any changes or dysfunctions to movement can compromise the thoracic outlet space and load the nerve tissue

TOS diagnosis

Cluster Testing: for symptomatic individuals who do not have any positive radiological findings 1. A history of aggravation of symptoms with the arm in the elevated position 2. History of paresthesia in the segments C8-T1 3. Tenderness over the brachial plexus supraclavicularly 4. A positive "handsup" test (ROOS test) Considered + for TOS if 3 of 4 criteria were met Testing each of the Upper Limb Neural Provocation Positions A sensitive test for irritation of the neural tissue Cervical roots, brachial plexus, peripheral nerves *Good screen for sensitization of the neural tissue in the cervical spine, brachial plexus and upper limb, but is not specific for one area

examination

Communicating to the patient during the examination in their language If they feel pain Where Intensity Is this the same pain that you get when you ... (functional movement)?

conservative tx

Complex patients, individualized approach to symptoms Review of 13 studies between 1983 and 2001 good or very good results in 76-100% of disputed neurogenic TOS patient at short-term follow up (within 1 month) Found 59-88% good or very good results after at least 1 year (Vanti et al 2007) Poor outcome due to: Obesity Worker's compensation Double crush (involving carpal or cubital tunnels) (Novak et al 1995) No real consensus on optimal treatment for TOS

pathoanatomy review

Components of the thoracic outlet 1. Interscalene triangle Anterior: Anterior scalene Posterior: middle scalene Inferior: 1st rib What is so important about the thoracic outlet? The neurovascular supply to the shoulder and upper extremity travels through the thoracic outlet: brachial plexus, subclavian arteries and veins 2. costoclavicualr space Anterior: Middle 1/3 of clavicle Inferior: 1st rib Posterior: anterior scalene insertion Superior: clavicle 3. subcoracoid space Superior: coracoid process Anterior: Pectoralis minor Posterior: Ribs 2-4 Thoraco-coraco-pectoral space or retropectoralis minor = space located beneath the pectoralis minor tendon

thoracic verte fx osteop

Compression Fractures More common, Anterior column Osteoporosis 2 million broken bones per year 1 in 2 women, 1 in 4 men will break a bone due to osteoporosis 20% of seniors die in first year after fracture 2 categories: traumatic injury such as blunt trauma or injury or osteoporotic fracture

compression fx

Compression fracture of T10 Hyperflexion of lower thoracic spine

soft tissue abnormalities

Congenital abnormality of the scalene muscles Hypertrophy of the anterior scalene Brachial plexus passing through the anterior scalene muscle Broad middle scalene (excessively anterior) Tight fibrous bands within the thoracic outlet space (stiffen the space)

thoracic spine

Consists of 12 vertebra Gradually become larger and more dense as they descend Second least mobile portion of the spinal regions Due to the rib cage Lower intervertebral disc height least mobile = pelvic girdle

interventions - stable injuries

Control pain (ice, heat, NSAIDS) Avoid compressive loads for about 12 weeks Physical therapy Walking, postural training, extension biased exercises, stretching Manual Therapy Joint mobilization above or below the segment initially Treat the joint (hypomobile) (Manual Therapy 2006)

cardiovasuclar

Dissecting thoracic aneurysm Pain felt in the chest - can radiate to the back (if the descending aorta is involved) Sudden onset Unrelenting Not relieved by positional change Requires emergent care What might some of your questions be during your subjective examination if you're speculative of CV referral? Myocardial Ischemia Anterior chest pain/heaviness Occasional nausea Sometimes pain radiating to the back Immediate medical attention (Goodman & Snyder 2007) Exertional or variant myocardial ischemia Stable angina Pain is related to exertion and relieved with rest Unstable angina Occurs at random, not related to activity Usually a progression of stable angina Risk factor for pending myocardial infarction Pericarditis Substernal, anterior chest pain May radiate like angina CPR to rule out coronary artery disease in primary care (Bosner et al 2010) 1. Age/sex (female >/= 65; male >/= 55) 2. Known clinical vascular disease coronary artery occlusive vascular cerebrovascular diseases 3. Pain worse during exercise 4. Pain not reproducible by palpation 5. Patient assumes pain is of cardiac origin Sensitivity: .98 if 2 were met Sensitivity: .87 and Specificity of .80 if 3 were met (+ likelihood ratio of 4.52) Subject older than 35 years old and reported anterior chest wall pain were included. Evaluate risk factors, BMI, BP, HR

inspection/observation

Does posture matter? (Greigel-Morris et al 1992) Assess the association of postural abnormality and a history of pain 88 asymptomatic subjects aged 20-50 Visually assessed for FHP, rounding of the shoulders and degree of thoracic kyphosis using a plumb line No relationship was found between pain frequency and severity and the severity of postural abnormalities Chi-square analysis showed a significant increase in pain (interscapular pain) in subjects with the most severe postural abnormalities *Postural abnormalities in isolation may have uncertain relevance to the patient's symptoms, but their presence alerts us to areas of potential movement dysfunction. Increased kyphosis: suggest extension restriction Decreased kyphosis or flatness: suggest flexion restriction

facet joint

Facet joint resting position: midway between flexion and extension Closed Pack Position: extension

rules of 3s

Geelhoed et al 2006: Transverse Processes in the thoracic spine are anatomically located a the level of the most prominent point of the spinous process of the vertebra 1 level above. With maybe some variability at T11&T12 SP is one level below transverse process

tx

Hyperkyphosis: >40 degrees Postural habits, slouching Affects muscle efficiency Exercise group: 5 weeks of stretching and strengthening Manual therapy group: 15 sessions massage, mob, muscle energy, myofascial release Grade IV, T4-T9 Digital dynamometer to test muscle strength Significant increase in strength and posture in both groups

slipping rib syndrome

Hypermobility of the anterior ends of the false rib costal cartilages Often leads to slipping of the affected rib under the superior adjacent rib That slipping/movement can lead to Irritation of the intercostal nerve Strain of the intercostal muscles Sprain on the lower costal cartilage General inflammation on the affected area (Turcious 2012) Differential DX: Cholecystitis, Esophagitis, Gastric Ulcer, Herpes Zoster, Pleuritic chest Pain (Turcious 2012) Traumatic or insidious onset Intermittent, sharp stabbing pain followed by dull, achy sensation for hours or days Slipping or popping sensations are common Aggravating activities: bending, coughing, deep breathing, lifting, reaching, rising from a chair, stretching, turning in bed Relatively uncommon, often misdiagnosed Adults > children (Turcios 2012) More common at 8, 9, 10 M=F Hypermobility due to disruption of the interchondular fibrous attachments of the anterior connection of the ribs, which allows the costal cartilage tips to subluxate and impinge the intercostal nerves

surgical management arterial

Indication Potential for upper limb ischemia Goals Decompression of structures compressing the subclavian artery Arterial reconstruction Thrombolytic therapy or balloon thrombolectomy Distal bypass grafting

surgical management neurogenic

Indication Weakness Wasting of hand intrinsic muscles Nerve conduction velocity less than 60m/second Those who fail conservative therapy and continue to experience significant pain Goal Relieve the mechanical load on structures in the thoracic outlet Normal: 85m/second Procedures 1st rib resection Cervical rib resection Anterior and middle scalenectomy Remove fibrous bands Remove callus (from a previous clavicular fracture

diagnostic imaging

Individuals with acute thoracic spine pain at risk of osteoporotic fracture should have plain radiographs to assess for the presence of a fracture (Australian Acute Musculosketal Pain Guidelines Group 2003) MRI or bone scan in cases where cancer or infection are suspected High sensitivity in detecting these conditions If trauma Plain radiographs are not sensitive enough to diagnose osteoporosis, just ruling out a fracture

anklylosing spondylitis

Inflammatory condition that can affect the thoracic spine and rib joints Diagnostic Criteria proposed with predictor variables 1. Stiffness > 30 minutes 2. Improvement in back pain with exercise but not with rest 3. Waking up from back pain during the second half of the night only 4. Alternating buttock pain 2/4 = Sen .70, Sp .81 3/4 = Sen .33, Sp .94 Can affect the discovertebral, zygapophyseal, costovertebral and costotransverse joints, and paravertrbral ligamentous structures of the thoracic spine (Khan 1994, Chapter 5). Rare to have only thoracic spine pain, usually scaro-ileitis. Physical Exam Findings: Limited chest expansion (< 2.5 cm) Sacroilitis Morning pain/stiffness Peripheral joint involvement M>F (3:1), 15-40 years old HLA-B27 positive Chest expansion measured at 4th intercostal space for men and below the chest in women

lateral flexion of ribs

Ipsilateral approximation Contralateral separation

clinical anatomy

Key landmarks used in the examination of the thoracic spine and rib cage 1. Spinous Process 2. Transverse Process 3. Rib angle Costovertebral joint = rib dysfxn

tx techniques

Lack of high quality clinical trials for interventions on thoracic spine pain Schiller 2001: manipulation vs placebo US Manipulation group with significant reduction in pain after 6 treatments and at 1 month follow up Kelley & Whitney 2006: immediate relief of right lower chest wall pain following a non thrust manipulation of the middle thoracic spine in an adolescent athlete Fruth 2006: Patient with right upper thoracic pain that was resolved after 7 physical therapy visits Non-thrust manipulation of the ribs Trigger point treatment Therapeutic exercise Case report: Patient had a 4 month history of pain, limited trunk and shoulder AROM. Found costovertebral and costotransverse joint hypomobility and pain at ribs 3-6 Was able to resume preinjury activities. Treating pain, stiffness, weakness, instability, incoordination Think about impairments found during the examination Treatments grow out of the test movements Select an appropriate test and ASSESS the effects (Maitland text) Common impairments: Limited joint mobility of the thoracic vertebral joints and ribs, impaired posture, soft tissue mobility restrictions involving shortened and hypertonic muscles and impairments tin muscle strength, endurance, and motor control particularly of the scapular stabilizing muscles. (OCS review) Pain Dominant I and II grade mobilization techniques Reduce/eliminate pain Stiffness Dominant III and IV grade mobilization techniques Produce pain during treatment to increase range Looking to increase range of movement Joint Mobilization Decreases spinal excitability (Courtney 2009) Enhances descending pain modulation (Courtney 2016) Targeting motion impairments may not be necessary for a positive outcome in treating patient's with thoracic spine pain May consider treating above or below the painful segment Egan, Burns, Flynn, Ojha, The Thoracic Spine and Rib Cage: Physical Therapy Patient Management Utilizing Current Evidence, 3rd Edition, 2011 Manual therapy modulates pain (Courtney 2009 & 2016) Less emphasis on biomechanical reasons for change in pain post treatment Continue to use and recommend using palpatory and examination and mobility testing to direct OMPT techniques Use test-retest model Previously painful functional movements are improved and less painful Target above or below the painful segment Go in the opposite or pain-free direction

infection

Less than 0.01% Causes of t-spine infection Osteomyelitis Diskitis Epidural infection Sign of infection Fever, pain and malaise (Deyo & Diehl 1988) The probability of infection as the cause of back pain in the primary care setting is less than 0.01%. 1:100,000 to 1:250,000 persons in US Osteomyelitis = Secondary to a lung infection Someone might be more susceptible to bone infection if their immune system is compromised such as long term steroid use from treating RA, IDDM, organ transplant patients, AIDS, malnutrition, CA Diskitis: inflammation of the disk, often present with osteomyelitis Osteomyelitis and diskitis are rare but most common in lumbar, than cervical, then thoracic spine Infection does usually originate in the vertebra or disk space, but spreads via the blood stream maybe due to UTI, pneumonia, following surgery, or IV drug use.

subj/obj exam

Location of symptoms Amplitude of present symptoms When do the symptoms occur What makes them better/worse Examine the cervical spine Examine shoulders, elbows, wrists Neurological exam

ribs

Long, elastic, curved bones 12 pairs of ribs True: 1-6 Cartilage attaches directly to sternum False: 7-10 Floating: 11, 12

brachial plexus

Lower brachial plexus is more common Upper is more head face and jaw pain

hypermob: dislocation

MOI : trauma, latrogenic, insidious contrib factors: female, unstable dentition, genetic hypermobility clinical signs: unable to close mouth, may palpate condyle anterior to glenoid fossa, masseter muscle spasm, preauricular indentation reduction techniques typically 2 weeks post reduction ROM

grade V

Manipulation Risks are low in the thoracic spine No data on the thoracic spine, but complications of lumbar spine manipulation are rare (Bronfort 1999) Contraindications Osteoporosis Seated longitudinal traction/distraction

sleeping position

Many TOS patient's have difficulty sleeping Sleeping with arms abduction, overhead Because of release phenomenon Use Cyriax's release test before going to bed Patient to sleep longer into the night without waking Possible to sleep through the night after 1-2 weeks of consistent use (Hooper et al 2010) If the symptoms are position dependent (patient can't avoid the provocative position) Pin the sleeve of the pajama arm to the pajama leg Sleep on the uninvolved side, put pillow under involved arm Avoid laying prone Try pillows under each arm when supine Postural correction (head and shoulder position) Orthopedic Manual Physical Therapy HEP for shoulder girdle and trunk as appropriate Patient instruction 1. Good posture 2. Do not carry heavy objects on affected side 3. Modify sleeping habits 4. Modify occupations habits 5. Bra modifications 6. Avoid rapid breathing 7. Avoid emotional stress 8. Adequate rest with recreational activities 9. Adjust seat-belt if needed 10. Avoid overhead work 11. Rest arm on armrest or pillow 12. If acute episode: shrug shoulders 13. In public: roll shoulders, put hand in coat pocket Describes a protocol of treatment that was established at Amsterdam Memorial Hospital, Amsterdam, New York 88% were satisfied with their treatment (119 patients) (Lingren 1997 paper) using conservative treatment

more more more

Mechanical cervical traction with hot pack and exercise x3 weeks reduced numbness more than hot pack and exercise alone (Taskaynatan et al 2007) NSAIDS for pain and inflammation (Parziale et al 2000) Botulinum toxin injection into anterior and middle scalene muscles Temporary relief of pain and spasm as a result of neurovascular compression 64% of subjects had a minimum of 50% decrease in pain, numbness, and fatigue for at least 1 month (Jordan et al)

CV/CT joint disloaction

Most common CV dislocation occurs at Ribs 1,11,12, CT more likely to be injured/sprained. (Christensen E 1980) More likely to fracture than dislocate rib due to ligamentous stability. Common in contact sports: Wrestling, hockey, football, baseball Injury to CC in 58% wrestling chest injuries (Gregory 2002) Signs and Symptoms "Lump-like deformity" "Popping" sensation with torso rotation Typically unilateral, Can present Bilaterally. Painful swelling over anterior chest wall. Swelling may become more prominent with shoulder abduction. Radiograph may be negative CT scan may reveal bone fragment or Subluxation (Mudgal 1998) Management Rest, Ice, NSAIDs Avoid aggravating activities Mobilization (above/below) Manipulation (Reduction) Should only be performed in the absence of fracture or additional underlying pathology (Greenman 2011) Surgery Debridement of any boney fragment and imbrication of stretched capsuloligamentous structures (Mudgal 1998)

neural technique

Nee et al 2012 Reduce mechanosensitivity, resolve symptoms, restore function Precautions: highly irritable condition Contraindicated: Recently repaired nerve Malignancy involving a nerve or its surrounding tissue Active neurologic or inflammatory condition

neuro presentation

Neurogenic Pain Paresthesia Numbness and/or weakness(grip strength) Will not be in a dermatomal/myotomal pattern Could be in a myotomal patternif involves the cervical or upper t-spine nerve root

physical exam

Neurological - if needed Functional Movement! Observe the patient Active physiological movements Passive physiological intervertebral movements Passive accessory intervertebral movements Special tests

outcome measures

No specific outcome measures for thoracic spine and rib cage pain Neck Disability Index for patients with pain above the level of T4 Oswestry Disability Index for pain below T4 Patient Specific Functional Scale Reliable, responsive and valid with knee pain, neck pain and low back pain 3-5 functional activities related to their ability to perform it and they grade them on 0-10 (zero can't do it, ten is perfect) Accepted by insurance (Pengal et al 2004, Westaway et al 1998, Chatman et al 1997)

biomechanics thoracic spine flexion

Occurs in sagittal plane During exhalation phase of respiration Slight anterior translation Inferior articular facets of the superior vertebra glide upward and forward on the inferior partner (Lee 1993)

lateral flexion

Occurs in the frontal plane During RIGHT lateral flexion Inferior facets of the superior vertebra slide superioanteromedially Costovertebral joint: movement posterior and inferior on the R and anterosuperior on the L

thoracic extension

Occurs in the sagittal plane Posterior translation Inferior facets of the superior joint partner glide posteriorly and inferiorly

what is abnormal in TMD

PPT of temporalis masseter TMJ traps and lateral epicondyle mechanical cutaneous pain and temporal summation (dorsum of digits) heat pain thresholds, tolerances, temporal summation (forearm) change in fxn down at the hands how has the CNS been effected?

costovertebral/costotransverse joint sprain

Pain in the posterior thorax - May radiate to anterior chest wall, along the rib Usually unilateral symptoms Pain with deep breathing, coughing/sneezing, laughing Increase pain with flexion, rotation, and ipsilateral lateral flexion Palpable pain costotransverse joint and rib angle Feel increased muscle spasm/tension Sudden joint force, maybe torsional or compressive, spontaneous movement Bend, twist, pull; sudden heavy lifting Repetitive movement/work, long periods of sitting CV/CT joint mobilization, avoid aggravating activity as needed (Fruth 2006) Addressing active trigger points, maybe middle traps, rhomboids, serratus posterior

modified cyriax release test

Passive shoulder elevation held for up to 3 minutes + test: paresthesia normal sensation return of numbness

ROOS or EAST test

Patient abducts arms to 90 degrees and externally rotated with elbows bent to 90 degrees Patient then opens and closes hands slowly for 3 minutes + if symptoms are reproduced or there is early fatigue (dropping of arms) Testing for vascular insufficiency on the symptomatic side Elevated arm stress, hands up Findings are common in the normal population As the clavicle descends to rest on the upper surface of the first rib, the costoclavicular space closed and the brachial plexus was compressed NOT A VERY GOOD TEST have because its on the boards Reliability: 1.0 Sen: 52-84 Spec: 30-100 +LR: 1.2-5.2 -LR: .4-.53

conservative tx TOS

Patient education Lessen anxiety Activity modifications Postures or activities that increase symptoms Overhead activities Avoid lifting heavy objects with affected extremity Correct muscle imbalances, weaknesses what muscles would be weak? Restore normal joint mobility ACJ, SCJ, GHJ 1st rib Decreased TOS symptoms by restoring mobility with OMPT Self mobilization for HEP (Hooper et al 2010)

HEP 1st rib

Patient in sitting Cervical spine retraction, side bent away and rotated towards the treatment side Thin sheet over the 1st rib Pulls sheet toward opposite hip Emphasize scalene stretch Rotating head to opposite side = emphasizes rib mob

1st rib cervical rotation lateral flexion

Patient in sitting Cervical spine rotated passively and maximally away from the side being tested Gently side bent as far as possible (ear toward the chest) + = when the side bending movement is limited or blocked Suggesting an elevated 1st rib Transverse process of T1 contacts, closed by the superiorly subluxed rib (Lindgren et al 1989)

cervical rotation lateral flexion test

Patient in sitting Rotate cervical spine passively and maximally Away from the side being tested Then, gently side-bend the head as far as possible (moving ear toward chest) + test is when the side-bending movement is limited or blocked Suggests elevated first rib Cervical side bending is limited due to transverse process of T1 contacting and being blocked by the elevated 1st rib Excellent interrater reliability (k=1.0) Sen: 100 Reliability: .42-1.0 (Hooper et al 2010)

chest wall ROM ribs 2-12

Patient lays supine PT stands at the side of the patient and assesses the ribs in groups Upper ribs (2-5) Middle ribs (6-10) Lower ribs (11-12) Upper and middle groups Feel for bucket handle and pump handle motions Place finger tips on the lateral aspect of the ribs Feel for pump handle Place fingers on anterior aspect of the ribs Lower ribs Caliper motion Palpate lateral aspects while the patient fully inspires and expires (Bookhout 1996)

cyriax release test

Patient seated or standing PT stands behind pt and grasps under forearms Passively elevates pt shoulder girdle Hold up to 3 minutes Reliability: .92 Spec: 77-97 Goal of the test Fully unload neurovascular structures in the thoracic outlet As the load on the brachial plexus in released, symptoms begin and gradually increase As nerve functional normalizes, the paresthesias decreased and eventually disappear Symptoms can rapidly decrease but take 3-4 hours to resolve Should remain in position as long as tolerated to unload the thoracic outlet Symptoms may not decrease during first few sessions, but repeating the technique over time can cause the symptoms to gradually resolve more quickly preferably until the symptoms are appreciably resolved

rib

Patient: 23 year old F with c/o right anterior chest wall pain I/M, sharp pain, 6/10 Aggravating: worse with deep inspiration, rowing, push-ups and pressure Ease: rest, ice, IBU Onset: 6 weeks ago, collegiate rowing PMHx: unremarkable

pulmonary

Pneumonia Recently have the flu Fever Productive cough Shaking chills Shortness of breath (climbing stairs) Crackling, bubbling, rumbling sounds with inhalation chest x-ray Do you have any pain on taking a deep breath? Pleurisy or Pneumothorax Sharp stabbing pain on inhalation Auscultate Pulmonary Embolism Recent surgery or immobility PHMx Cancer Smoker Pleurisy: 2 inflamed surfaces rubbing on each other. Sounds like walking on snow or cracking leather Substernal chest pain

examm

Posture Forward head posture Increased thoracic kyphosis Position of scapulae Visual inspection of the limbs Cyanosis, edema (venous) Paleness (vascular) Feel patient's hands Increase tension loading of the brachial plexus Supraclavicular Pressure - brachial plexus Patient seated with arms at the side Place fingers on upper trap and thumbs on anterior scalene (near 1st rib) Squeeze for 30 seconds + test = reproduction of pain or paresthesia Sp: 85-98% Feel for pulse of subclavian artery Move hands just posterior to the pulse

post op PT

Precaution Avoid overhead activities and lifting for 2-4 weeks Address impairments Postural abnormalities Cervical ROM Shoulder ROM Thoracic spine mobility Neural mobilization (Hooper et al 2010)

taping

Proprioceptive feedback on positions to avoid Postural taping in population with osteoporotic vertebral fracture induced in immediate reduction in thoracic kyphosis But...it did not influence trunk muscle EMG activity or balance (Greig et al 2007)

integumentary

Psoriasis Rash on extensor surfaces (elbow) Psoriatic arthritis Herpes zoster/shingles Rash in dermatomal distribution on thorax Herpes virus remains in the body after a primary chicken pox infection Harbors in the nerve root ganglia Reactivated by immunosuppression (disease or stress) The reactivated virus migrates to the skin causing the rash Pain 2-3 days before the rash, lasts from a few weeks to a few months after the lesions have healed Shingles/herpes zoster Rash in dermatomal distribution on thorax Pain 2-3 days before the rash Treatment: Acyclovir 7-10 days (Snow 2006) 800 mg NSAIDS for pain Post herpatic neuralgia Shingles: herpes virus remains in the body after a primary chicken pox infection Harbors in the nerve root ganglia Reactivated by immunosuppression (disease or stress) The reactivated virus migrates to the skin causing the rash and pain in a dermatomal Herpes zoster/shingles Risk factors: Age, underlying neoplasm, immunocompromised patients, surgery 10-20% of the US population Treatment: Acyclovir 7-10 days 800 mg IBU for pain Capsaicin, lidocaine and nerve blocks (Opstelten et al 2003) Herpes zoster = reactivated chicken pox virus Post herpetic neuralgia (Godfrey et al 2006) Pain and hyperesthesia that persist for over a month after the rash of acute herpes zoster has cleared Frequency increases with age: 30-50 years old: 4% >80 years old: 34% Pain resolves spontaneously in 50% of patients within 3 months, 78% in 1 year and 98% in 5 years Treatment: TENS helpful in some cases Lancinating, steady burning or ache along a thoracic dermatomal pattern; allodynia

respiration

Pump Handle action (R1-6) Increases the anterior and posterior diameter of the ribs With inspiration they are pulled up and forwards Manubrium/sternum moves upward and forward

imaging

Radiographs: to rule out a cervical rib, long transverse process of C7 or sequelae of a prior clavicle fracture (Accessory ribs are found in 0.5% of population) (Atasoy Hand Clin 2004) C-spine radiographs useful to rule out spondylolysis, osteophytes, etc Chest radiographs: rule out Pancoast tumor EMGs may show abnormal results in some neurologic cases of TOS (Foley, Toxins 2012) DDx: C8 or T1 radiculopathy, median or ulnar nerve mononeuropathy, advanced CTS

herpes zoster/shingles

Rash - dermatomal distribution ***Pain 2-3 days before the rash Herpes virus remains in the body after primary chicken pox infection Harbors in the nerve root ganglia Reactivated by immunosuppression (disease or stress)

purposes of physical exam

Reproduce the comparable sign! Establish a benchmark for reassessment Looking for R1, P1 (or R2, P2) using PROM Feel how the patient moves "Tell me the moment the pain starts" Confirm, reject and modify clinical hypotheses Identify appropriate treatment techniques Look at how our patient moves

exam thoracic slump

Reproduction of the comparable sign Entrapment, tension (T6 spinal canal is narrow) Inflamed Swollen nerve root Others: Upper Limb Neural Provocation Testing Thoracic Outlet Syndrome Testing Ribs * Confirm/reject hypotheses

atypical and typical ribs

Ribs 3-9: Typical - share common structure Ribs 1, 2, 10, 11, 12: Atypical

segmental mobility

Ribs palpated for tenderness and symmetry 1. costochondral junction (supine) 2. Rib angle PA springing with hypothenar eminence 3. Intercostal spaces 4. Costotransverse joint *Rib cage dysfunction frequently presents with tenderness at the rib angle Document mobility and presence of pain

rotation

Right rotation Right inferior articular facet of the superior vertebra glide inferiomedially Coupling with rotation in the thoracic spine is variable Right lateral flexion with right rotation Posterior rotation of the right rib and anterior rotation of the left rib

rib stress fx

Rowing Modify form: decrease scapular protraction as oar enters the water Modify equipment: shorter oar, diminished level arm (less stress on serratus anterior) Gregory 2002

conditions causing thoracic pain

Rule out a serious patholocal or visceral cause of thoracic pain that requires a medical referral.

post op PT guidelines

S/P release, need early aggressive mobilization inflammation management (ice, NSAIDs, soft diet, possibly splinting) other surgeries post op guidelines 1-2 post op = active controlled opening and lateral excursion, no translation, isometrics 1 week = gentle stretching, manually guided lateral excursion and protrusion 3 weeks = movement awareness exercises 1 month = add manual resistance check with surgeon on particular guidelines

PPIVM

Selected based on active test results FEEL the movement Looking for R1-R2, P1, P2 Looking for onset of pain: "I'm going to perform this movement again and I want you to tell me the moment the pain starts." Flexion, extension, lateral flexion, rotation

points to consider

Several structures as potential sources of pain Muscle, joints, ligaments, disc, nerve, etc Remember the influence on the upper/mid-thoracic spine on scapulothoracic and shoulder regions Trapezius: O: all T spine spinous processes, external occipital protuberance, ligamentum nuchae and spinous process of C7 I: Importance: assist with force coupling to allow for normal scapular upward rotation and posterior tipping during elevation of the humerus. Iliocosalthoracis O: I: I: iliocostalis lumborum O: I: I: serratus anterior O: I: I: Pectoralis major O: I: I: Anterior scalenes O: I: I:

ULNPT IIb

Shoulder girdle depression 10 degrees G/H ABD in coronal plane Elbow extension GH IR Wrist and finger flexion + ulnar deviation GH ABD

ULNPT IIa

Shoulder girdle depression 10 degrees GH ABD in coronal plane Elbow extension GH ER Wrist & finger extension GH ABD

chest wall ROM 1st rib

Sit at head of table with patient supine Palpate just inferior to sternoclavicular joint Instruct patient to take a deep breath and exhale completely Monitor symmetry of motion L vs R Ask for presence of pain (Bookhout 1996)

neoplasm

Spinal metastases Secondary to a primary breast, lung, or colon cancer, testicular (Ozaki et al 2002) Historical findings predicting cancer: 1. Age over 50 (Sen .77, Sp .71, +LR 2.7, -LR .32) 2. History of CA (Sen .31, Sp .98, +LR 15.5) 3. Unexplained weight loss (Sen .15, Sp .94, +LR 2.5) 4. Failure of conservative therapy (Sen .31, Sp .90, +LR 2.6) Primary thoracic spine tumors - not common Testicular cancer - metastasizes in the lungs Screening for lung cancer: Moyer on behalf of U.S. Preventive Services Task Force: A low dose CT annually for asymptomatic adults aged 55-80 who have a 30 pack-year smoking hx and currently smoke or have quit smoking within the past 15 years Truly constant pain Pain does not change regardless of position Night pain May have weight loss *Unable to changes patient's pain on physical exam Referral back to physician May get better but not going to last (Godges et al 2005, Goodman & Snyder 2007) Area of pain: interscapular pain, "girdle-type" pain, stabbing intercostal pain (secondary to intercostal nerve involvement), anterior chest pain Neurological deficit (Chapter 5) Their ROM may improve and decreased pain even though it is non musculoskeletal pain due to central analgesic effect BUT it will only be temporary

anterior thorax

Sternoclavicular joint Manubrio-sternal joint Costochondral joint Costosternal joint **Potential sources of pain (Gregory 2002)

ribs

Subjective Breathing patterns Aggravating/easing factors Pain pattern Body chart Mechanism of injury Objective Palpation Feel the tissue Ask about pain PAIVM/PPIVM Costovertebral/Costotransverse joints Active motion Deep breathing Symmetry Chest expansion

facet joint

Superior Articular Facets Slightly convex 60 degrees from horizontal plane 20 degrees from frontal plane Inferior Articular Facets Slightly concave Face anteriorly, slightly inferiorly and medially to match the superior facets of the level below

neurogenic TOS

Symptoms reported: 1. Paresthesia in upper limb (98%) 2. Neck pain (88%) 3. Trapezius pain (92%) 4. Shoulder and/or arm pain (88%) 5. Supraclavicular pain (76%) 6. Chest pain (72%) 7. Occipital headache (76%) 8. Paresthesia in all 5 fingers (58%) 9. Paresthesia in 4-5th fingers (26%) 10. Paresthesia in 1st, 2nd, 3rd fingers (14%)

mobilization

T-spine mobilization increases lower trap strength Liebler et al. 2001 found that after performing PA Grade IV mobs on T6-T12 for 30 seconds each, improved lower trap strength A joint must have normal mobility for its muscles to work efficiently

transitional zones

T1-T3 T11 & T12 More prone to problems Thoracic vertebrae are distinct b/c they have facets on the body and the transverse processes for articulation with the ribs

relationship to HA

TMD common in migranes and TTH TMD and bruxism increase risk for migrane and TTH TMD may lead to chronifications of migranes migraines and frequent HAs increase risk of developing TMD

palpation

TMJ (at rest and with movement) temporalis lateral medial ptery suboccip sternocleidomastoid upper trapexius lymph nodes

RA

TMJ sx in up to 65% bileratla or unilateal pain limited MMO? anterior open bite 2/2 condylar resorption pain at rest, with opening, with palpation and with chewing TMJ hyperalgesia in RA associated with systemic inflamm

PAIVMs

The patient is in prone, skin exposed Assessing for tenderness and tissue reactivity Posterior to anterior spring testing with hypothenar eminence to spinous process (Central PA) Feeling for R1-R2 Presence of pain Unilateral PA springing with tips of the thumbs Transverse mobility Looking to reproduce the comparable sign passively Establish a benchmark for reassessment Feeling for R1 Confirm, reject, modify your hypotheses Further localizing the site of the disorder Identifying treatment techniques Pain modulation by downregulating, affects locally and globally Cant do mobilizations NEAR the affected area and will still get the pain modulation effect Doesn't matter if its above or below

manual scalene stretch

The patient is positioned supine with the chin retracted and the cervical spine laterally flexed away and rotated towards the treatment side. The clinician uses the (R) radial hand at the second MCP to direct the mobilization force in a caudal and contralateral direction (towards the opposite hip). The (L) hand is used to maintain a chin tuck. Lindgren 1997 Isometrics of the anterior/middle/posterior scalene muscles 5 sec x5-6 reps Mobilization of he 1st rib by isometrics of scalene muscles 10 times a day in all 3 directions Symptoms resolved within a few days Shoulder girdle exercises to open up the chest

sympathetic nervous system

Thoracic sympathetic ganglia correspond to the T1-T9 segments which lie against the anterior heads of the ribs, just lateral to the vertebral bodies The sympathetic chain ganglia, which innervate the arm, lie in close proximity to the thoracic costovertebral and zygapophyseal joints 12 thoracic spinals nerves that exit below its intervertebral disk. They divide into anterior and posterior primary rami. The cutaneous branches of the anterior and posterior thoracic rami spinal nerve form each thoracic dermatome. The thoracic dermatomes run in a circumferential pattern just inferior to the corresponding thoracic vertebrae from posterior midline to anterior midline.

surgical managmenet venous

Thrombolytic therapy to dissolve an acute thrombosis Most effective within 1 week of symptom onset Still effective up to 1 month post symptom onset Resolve any external compression

neural prov test

To perform - MUST BE SYSTEMATIC! Patient positioning in neutral Clarify resting symptoms Instruct pt, "Please indicate any change in symptoms." Add 1 component at a time Hold each component into resistance and add next component Positive test is reproduction of patient's* symptoms.

slipping tx

Treatment based on severity of symptoms 1. Minor - conservative, ice/heat, avoid aggravating activities, gentle joint mobilization, therapeutic exercise 2. moderate - local anesthesia intercostal blockade (Robb 2013) 3. Severe - Resection to anterior end of rib and costocartilage (Turcios 2012) Clicking rib, displaced ribs, interchondral subluxation, nerve nipping, painful rib syndrome, rib tip syndrome, slipping rib cartilage syndrome, traumatic intercostal neuritis, and 12th rib syndrome. 20 year old female collegiate swimmer Warming up, gently swinging her arms Mild pain left lower rib cage Swam 2 races with mild discomfort 3 days later Trouble sleeping Moderate diffuse pain, left lower rib cage 4 months: activity modification, chiro, US, e-stim, ice/heat, NSAIDs 6 months postinjury: Diagnosed with: left lower rib cage pain and somatic dysfunction Referred to PT Over the 9 months: Images Radiographs (several times), bone scans 6 months post injury 9 months: thoracic surgeon Hooking maneuver Surgery: resection of abnormal cartilaginous attachment of rib 11 to 10 20 weeks later: return to competitive swimming PT 10 sessions: manual therapy (STM, myofascial release, AP mob T9-L2) stretches, strengthening activities After surgery: restricted activity x weeks Abdominal training helped

rib fx

Type Traumatic: result of fall of MVA Pathological: due to metastatic lesion, myeloma or severe osteoporosis Symptoms Severe pain on inspiration associated with hypoventilation Examination Palpable or visible defect, tenderness long rib angle, ecchymosis (Sueki 2010) Management Rest from aggravating activity 4-6 weeks (healthy population) Gentle mobilization of upper and lower CV/CT Light cardiovascular & sport specific training with reduced intensity 8 weeks return to sport (pending satisfactory progress) Exercise induced non-traumatic fractures Strengthening of serratus anterior may prevent re-occurrence Mobilization of any residual hypomobility (CV/CT)

upper vs lower plexus

Upper plexus (C5, C6, C7) Anterior neck from clavicle to mandible, ear, mastoid, side of face Spread into upper chest Periscapular region Across trapezius ridge Down the outer arm Radial nerve distribution toward dorsum of thumb and index finger Lower plexus (C8, T1) Symptoms on ulnar side of arm and hand Anterior shoulder and axillary region Release phenomenon = when lay down don't have the pull or compression through the thoracic outlet space SO they find more parathesias at night because blood and action potentials are firing like crazy bc not firing as much

venous presentation

Venous Excruciating deep pain in the chest, shoulder and entire upper extremity Feeling of heaviness - especially after activity Cyanotic discoloration Distended collateral veins Maybe accompanied by edematous increased in volume of the extremity

osteop tx

Vertebroplasty: inject cement into vertebra Kyphoplasty: balloon inflated Double blind placebo controlled trials No significant difference between vertebroplasty vs sham procedure Pain, function, disability, quality of life, perceived improvement 1 and 6 month follow ups (Buchbinder et al 2009 & Kallmes et al 2009) However, population on both studies was chronic 12 months post fracture Still argument that vertebroplasty is affective in the acute patient (Gangi & Clark 2010, Muller et al 2010) 20 patients with osteoporotic compression fracture (btw 3 month to 2 years) 50 years of age or older 1. Control group 2. Multimodal PT, 1x/week x10 weeks Education Postural taping Manual therapy Soft tissue massage Non-thrust PA t-spine ROM exercises Back extensor strengthening (Bennell et al 2010) Results: Decreased pain Improved physical functioning Improvements in physical impairments

thoracic subj and objective exam

What you hear from the patient Very important to listen Area of the symptoms Behavior of the symptoms Intensity Onset Past history Establish rapport with patient Special Questions Location of the symptoms Pain, weakness, numbness, stiffness, instability What is the main reason you're here? Can you point to the area of your pain? Does the area spread? Direction Confirm by touching/palpating Clear the rest of the body Deep or superficial? Paresthesia, anesthesia, autonomic symptoms Occurrence of symptoms IM, constant (clarify!) 24 Hour pattern Aggravating/Easing factors Looking for irritability Onset of symptoms Sudden, gradual Better, worse, same Previous treatments Have they had this pain before? More or less frequent How long does it last Unique questions for the thoracic spine: Do you any pain or problems with breathing or deep breathing? Have you been coughing a lot recently? Any heaviness or tiredness in your arms or legs? Do you have pain after eating a heavy meal? General Health Medications Social Life Images, testing What did their referring provider say about it? What do you think is going on? Do you think you are going to get better? Is there anything I didn't ask you about that is important? *Recap Work, marital status, exercise, recreational activities

expanded DC/TMD

adhesions: no hx of clicking + loss of jaw motion limited ROM deviation to ipsilateral limited contra deviation ankylosis: progressive & severe loss of ROM radiographic evidence of fibrous or bony ankylosis

quantitative sensry tetsing

allodynia statis mechianical detection vibration detection pressure pain thresholds (PPT)

arthroplasty

anesthesia open joint technique reduce ankylosis restore joint structure improve ROM allow for symmetrical mandib growth

total joint reconstruction

anesthesia open full joint space mandib and fossa components reduce pain improve motion good response generally for QOL screws can pop out because skull is not that strong of a bone

arthroscopy

anethesia 1 large portal clean remodel release reduce pain increase mouth opening better pain and MMO than arthrocentesis more expensive than arthrocentesis higher comp risk/rates

other causes of hypomobility

ankylosing spondylitis trismus post-radiation therapy post-op / post-immob congenital hyperplasia post traumatic ankylosis

occlusion / intercuspation

central incisors in firm approx, black molars together mandibular resting position - 1.5 to 5 mm freeway space between top and bottom teeth frenula may be better reference

diff diagnosis

cervical spine dysfunction msucle pain referral trigem neuralgia sinus pain neoplasm parotid gland vacular otological odontogenic pain teeth PAIVMs first confirm findings with PPIVMS if really irritatble will do a PAIVM because less provoting (usually not always) PAVIMS expectations? occiput to T5 thoracic is mid cervical thorughout thoracic spine

occlusion types

class I: normal class II: retrognathic mandible (short) class III: prognathic mandible (long) not found to be associated with TMD in adolescents

PT vs surgery

compared medical management rehab scope and arthroplasty in 106 patients with closed lock (disc displacement) surgical groups go same rehab post as rehab group no statistical difference at 3, 6, 12, 24, or 60 mo between groups only 2 in conservative group ended up getting surgery conclusion: medical management and rehab initially always

osteo/arthrokinematics

convex on concave opposite glide and roll

slipping rib syndrome hook maneuver

diagnosis of exclusion

subjective screening for TMD

do you have pain in your temple, face, jaw, or jaw joint once a week or more? do you have pain once a week or more when you open your mouth or chew? does your jaw lock or become stuck once a week or more? >/1 positive = 81% sens, 79% spec -LR = .24 +LR = 3.8 3 positive = 99% specific +LR = 21

multimodal

effective for TMD across the board

psych questioning

follow up to PHQ2 have you ever thought of harming yourself? do you have a plan in place to hurt yourself

observation : posture

forward head: reduced retrodiscal space higher incidence in TMJ OA greater in TMD questionable correlation to internal derangements? reduced PPT but wider MMO addressing posture more effective than nothing unclear association

sinus pain

frontal HA facial ear or tooth pain changes with head positiion TMJ tenderness +/- positive imaging MRI CT or labs conirmed via temporal connection to onset/resolution of sinus symptoms -post nasal drainage -upleasant taste

patient ed - food consumption

harder, drier foods requires and increased number of chew cycles and longer times in the mouth before swallowing trial period of diet modification to reduce symptoms (weeks to months) once symtptoms are controlled, harder foods can be tested for provocation and reintroduced when appropriate

complications

higher risk and more severe consequenes of more invasive surgery 1-5% infection rate depending on surgery damage to ear 2/2 misplaced scope facial nerve damage transient V3 sx vs damage maxillary artery damage symp/parasymp injury/sx prothesis malpositioning dislocations recurrent ankylosis

manual therapy: 3 reviews

implication: expect to see more referrals to PT

open bite

inability to touch teeth together anterior or posterior associated with higher prev of TMD any type of occlusion deformity not related to any type of TMD

why psych screening?

linked to higher likelihood of developing TMD depression higher in TMD pop than general pop and is a risk factor for TMD development QOL is adversely affected worse with more symptoms and increasing age subjective perception of symptoms > clinical signs on QOL depression and pain associated disability linked to increased impact on QOL severe TMD linked to suicidal ideation

arhtrocentesis

local anethesia 2 ports often combined with manip clears joint of inflamm cells and degen by products/waste of inflamm reduce pain/inc MMO used when nonsurgical is ineffective

dry needling

masseter: immediate improvements in PPT and MMO masseter/temp: immediate and 1 wk improvements in pain, PPT, MMO and disability external lateral ptery: reduced pain and improved motion all directions

if you don't have any teeth?

more compression on the TMJ use frenulum as midline of the jaw because teeth might be shifted

exercise

motor control, controlled MO improves deviation during opening neck flexors stabilization & relaxation stretching/relaxation/isometrics therabite self mob postural exercise

active/passive motion testing

mouth opening (deflection vs curce, max vs pain free, MMO reliability 95%) lateral deviation protrusion retrusion caudal, anterior, medial condyle motions if there is no anterior translation on the L, then will shift to the L S curve = motor control or trying to recapture a disc if deflect towards L

screening for referral or contributing factors

neuro (CN, balance, UMN signs) cardiac (HTN, worse on exertion) infection (fever, rash, mallasie, taste changes) neoplasm (weight changes, no imrpovement over 1 mo) ear/tooth (loss of hearing/fullness, sensitivity to food temp) cervical spine (ROM/OP, PAIVMs)

guidelines for imaging: insidious loss of mouth opening (<30mm opening)

no improvement in 1 mo? - recommend imaging

mob with movement

only ever examined as part of multimodal nice as HEP

disc displacement and reduction

open mouth - if click present protrude close in protruded position

observation

posture resting jaw position prominence of musculature facial symmetry swelling ecchymosis occlusion / intercuspation

strength

quan bite force reliability low to moderate isometrics: pain / abnormalities clenching on cotton roll (GAP TMJ) increase pain = muscular / capsulitis? decrease pain = intraarticular eating parameters how long til you need a break deep neck flexor endurance = reduced in TM D

measuring jaw movement

ruler specialized disposable devices therabite, orastretch trimeasure boley guage caliper

tongue blade test for mandibular fx

sens/spec 87/81% 95/67% 95/68%

ULNPT I

shoulder girdle depression (maintained) 110° GH abduction forearm supination with wrist/ finger extension G/H external rotation elbow extension

function of TMJ

speech and expression mastication

TMJ muscles

temporalis, temporomandicular ligament, lateral pterygoid, masseter, medial pterygoid

ULNPT III

wrist/ finger extension forearm pronation full elbow flexion shoulder girdle depression GH external rotation Shoulder abduction

symptom provoking functional activities

yawn max vs pain free mouth opeing biting/clenching prolonged opening leaning on hand some can't be tested: pain with prolonged eating