NPTE : TMJ + Spine (joints , actions , ranges , etc)

TMJ Musculature : Depression

(opening) bilatateral lateral pterygoids (inferior head) suprahyoids (submandib ms)

TMJ Hypermobility

(popping) disc (typically anteriorly displaced) NOT STUCK = moves too much = pain and degeneration of disk. Classic scenario: - opening pop of the disk and - closing pop of the disk as it snaps in and out of place on the condyle.

ARTHROKINEMATICs of TMJ : Depression vs. Elevation 2 main principals where does each occur when does each occur describe each TMJ motion

1) Rotation = lower joint space mandibular condyles rolls on inferior surface of disc = first < 50% of opening 2) Translation = upper joint space condyle AND disc slide together = added to rotation during last 50+% for full opening. TMJ elevation (closing) = reverse order. TMJ protrusion and retrusion = all translation of condyle-disc complex. TMJ lateral deviation = mostly translation of condyle-disc complex + some multiplane rotation (mostly horizontal plane)

Typical Spinal Segment : - how many joints - name the joints + what type are they

2 vertebrae 2 facet joints (synovial) 1 intervertebral (cartilaginous) 3 total

Facet Joint Orientation at AA - describe their orientation and how this impacts movement

20° from transverse plane = ROTATION

How many IVDs

23 none between: 9 fused vertebrae + Occipital - C1 + C1 - C2

how many spinal nerve how are they named

31 pairs C1-C7 = comes out above vertebrae C8 T1-S5 = comes out below vertebrae

Anatomy of the Spine how many vertebrae (including fused) what are the regions (+ how many vertebrae in each) how many spinal nerves

33 vertebrae (9 fused) Cervical = 7 Thoracic = 12 Lumbar = 5 Sacral = 5 (fused) Coccyx = 4 (fused)

ROM C-Spine Lateral Flexion primarily occurs at what levels also coupled with what motion + type of coupling

40-45° occurs at all levels C2-T4/5 Type II couple (same direction) with rotation

ROM C-Spine Flexion primarily occurs at what levels

45-60° max motion occurs at C4-5 & C5-6.

ROM C-Spine Extension primarily occurs at what levels

50-65° max motion occurs at C4-5 & C5-6.

ROM C-Spine Rotation where does this occur at what levels also coupled with what motion + type of coupling

70-80° TOTAL (each direction) 35-40 from AA BEFORE rest = Type I coupling (opposite directions) 35-40 from lower c-spine = Type 2 coupling (same directions)

Spinal Segment = made of up _________ Arthrokinematics of Spinal Segment Motion

= 2 vertebrae, disk, & facet joints "Top moving on Bottom" motion Facets glide/slide (arthrokinematics) Flexion anterior-superior slide (top moving) = open pack position. Extension posterior-inferior slide (top moving) = closed pack position Rotation & Sidebending = also top-on-bottom

TMJ Hypomobility (+ misalignment) - what is hypomobile? - what does it result in?

= anteriorly displaced disk (= stuck) - limited ROM (blocked by the disk) + - pain (loading on improper area of the disk)

When a spinal segment is in extension - where is the tension (stretch) in the anulous fibrosis (AF) and which direction is the nucleus pulposous (NP) pushed (due to compression) What about when a segment is in Flexion?

AF = tension is Anterior NP = pushed Anterior flexion = opposite

What determines the AMOUNT of movement between two vertebrae vs. The Direction of Movement (ie in what plane)

Amount of movement = Intervertebral Jt. vs. Direction of movement in each plane = Facet Jts

intra-articular disc of the TMJ : attachments

Anterior - bone - joint capsule - tendon of lateral pterygoid muscle (superior head) Posterior = bilaminar retrodiscal tissue

Only spinal ligament to prevent EXTENSION where does it run from/to describe its shape from c-spine --> L-spine

Anterior Longitudinal Ligament C1 - sacrum narrow (c-spine) --> wide (L-spine)

Major Ligaments of the Spine what do they prevent NARROW vs. BROAD

Anterior Longitudinal Ligament C1 - sacrum; = tightens w/ extension = narrow (c-spine) -> Wide (L-spine) Posterior Longitudinal Ligament C2 - sacrum = tightens w/ flexion = Wide (c-spine) - Narrow (L-spine) Ligamentum Flavum C2 - sacrum = lamina to lamina = tightens w/ flexion Interspinous Ligament - tightens w/ flexion; weaker •Supraspinous Ligament C7 - sacrum (= Ligamentum Nuchae in C-spine) - tightens w/ flexion; weaker

Describe the Progression of C-spine Rotation

Approx 50% of the total rotation occurs at the AA BEFORE any rotation occurs in the rest of the cervical region.

What is unique about the two joints of the TMJ compared to other synovial joints?

Articular Surfaces are covered in fibrocartilage rather than hyaline cartilage

Suboccipital Region : lower joint name the joint(s) articulating surfaces (3) arthrokinematics motions (inc ranges) why is it unique

Atlanto-Axial Joint (AA) 3 synovial joints - 1 pivot joint - 2 facet joints NO DISK. Motion: Rotation = 35-40° but NOT coupled + Flexion/Extension is minimal (10-15°) + Lateral Flexion is even less rotation atlas (C1) on stationary axis (C2) Ex: Left rotation = atlas turns CC on axis. IMPORTANT: Approximately 50% of the total rotation of the entire cervical region occurs at the AA before rotation occurs in the rest of the cervical region.

Which joint has the max rotation of c-spine What is the ROM

Atlanto-axial (AA) Joint 35-40°

Limits Anterior Translation of the Intraarticular disc of the TMJ parts?

Bilaminar Retrodiscal Tissues Superior Lamina = elastin rich - attaches to the temporal bone Inferior Lamina = collagen rich - attaches to the neck of the mandibular condyle

Facet Joint orientation : lower c-spine what segments describe orientation what motion does this favor?

C2 on C3 - C7 on T1 (6 segments) = 45° from transverse (and frontal) ... transitions to ~30° at lower end (towards frontal) = favors rotation + lateral flexion

Lower Cervical Spine Motions (ROM) : Flexion/ Extension describe the motions at what segments does the most movement occur?

C2-T1 F = 45-60 E = 50 -65 max motion occurs at C4-5 & C5-6. = these 2 segments are often the first to show signs of disk and joint degeneration.

Lower Cervical Spine Motions (ROM) : Flexion / Extension at what segments does the most movement occur?

C2-T1 max motion occurs at C4-5 & C5-6. = these 2 segments are often the first to show signs of disk and joint degeneration.

C-Spine Segments that are often first to show disc + joint degeneration Why?

C4-5 & C5-6. because this is where max flexion + extension of c-spine occurs

TMJ Musculature : Lateral Deviation

Contralateral Pterygoids + Ipsilateral - temporalis - masseter

T- Spine : Unique Synovial Articulations (2) what are they classification of joints are they mobile , well innervated?

Costovertebral Joints Costotransverse joints plane, synovial joints mobile and well innervated

Muscles of the Spine/Trunk: Function to stabilize trunk & pelvis (control postures) and move the trunk/spine. (TABLE)

External Oblique = SCM for Action (ie Ipsi flexion + sidebend but opposite rotation)

The PROPORTION of movement in a given plane

Facet Jts

Overall AROM at C-spine: - what motions - ranges

Flexion 45-60° Extension 50-65° Lateral Flex 40-45° Rotation 70-80° each (35-40 from AA prior to rest occuring)

Upper TMJ Joint type of joint articulation between

Gliding Joint - superior disc surface + - articular eminence

Lower TMJ joint type of joint articulation between

Hinge Joint - mandibular condyle (covered in fibrocartilage + dense fibrous CT) + - inferior disc surface.

Weighbearing surface of the TMJ Intraarticular Disc compare this potion of the disc to the rest of the disc

Intermediate : between condyle and temporal bone - thinnest portion - NOT innervated

What determines the AMOUNT of movement between two vertebrae

Intervertebral Jt.

Lumbar Region : Facet joint Orientation - overall orientation - superior vs. inferior vertebrae for a given section differentiate between 2 regions

L1-4 = Sagittal Plane (close to) at each segment - upper facet = faces laterally vs. - lower face = faces medially L5-S1 = near the Frontal Plane - facet surface of L5 faces anterior - facet surface of S1 faces posterior = resists anterior movement of L5 on S1 due to normally occurring anterior shear forces (Just like T-Spine)

Facet Joint Orientation at OA - describe their orientation and how this impacts movement

O = convex on A = concave CVX on CC = roll = opposite to slide

Summary : Type I vs. Type II motion in the C-spine - name the 3 segments and their respective motions

OA = Type I AA - neither (rotation only) C2-3 thru C7-T1 = Type II

Suboccipital Joint Motions : upper joint name the joint articulating surfaces arthrokinematics motions (inc ranges) why is it unique

Occipito-Atlantal Joint (OA): 2 x occipital condyles (convex) + 2 x articular surfaces of atlas (CC) NO DISK Motion - Flexion/Extension ~15°of each (nodding of head) + small amounts of - Lateral Flexion & Rotation (Type I motion)

TMJ Musculature : Protrusion paired with what other motion

Paired with Depression bilateral primarily lateral pterygoids + - masseters - medial pterygoids

TMJ Musculature : Retrusion paired with what other motion

Paired with Elevation bilateral temporalis + suprahyoids

Motions of Thoracic Spine : Flexion / Extension compare upper vs. lower

Possible throughout thoracic spine extremely limited in upper T-Spine = ROM increases caudally More Flexion available overall

Posterior Attachments of Disc of TMJ

Posterior = bilaminar retrodiscal tissue

Scoliosis : Changes in Rib Position

Posterior Rib Hump - Same side as rotation and thus opposite to side of lateral flexion (be represents lower T-spine = type I coupling) thus anterior hump = same side as lateral flexion Contralateral to Lateral Flexion - Ribs elevate - Thoracic cage enlarged - Intercostal spaces widen vs. Ipsilateral to Lateral Flexion - Ribs depress - Thoracic cage shrinks - Intercostal spaces narrow

Motions : Lumbar Spine primary motion(s) coupling?? explain what happens to facet joints on each side

Primarily : Flexion & Extension (due to facet orientation) + Lateral flexion + rotation = limited due to orientation of facets. Type I Coupling ( Lateral Flexion and Rotation ) = OPPOSITE DIRECTION Ex. R. lateral flexion = L. rotation (some) Lateral flexion (pictured) = Closing of ipsilateral facet + opening of contralateral facet vs. Rotation (pictured) = opening of ipsilateral facet + closing of contralateral facet Therefore, a person with a hypomobile lumbar facet joint on the RIGHT will be limited in right rotation and left lateral flexion (at that vertebral segment) Q: How does this effect the entire lumbar spine?

Motion of Sacrum on Ilium: how does this affect pelvic inlet/outlet changes during pregnancy?

Primary motion of SI Flexion (nutation) (nod) - anterior tip of sacrum moves anteriorly + inferiorly - coccyx moves posteriorly vs. Extension (counternutation) - anterior tip of sacrum moves posteriorly + superiorly - coccyx moves anteriorly. How do Nutation & Counternutation affect size of the Pelvic Inlet & Pelvic Outlet ?? pregnancy - softening of ligaments = increased joint mobility + decreased stability of SI joints = likelihood of joint dysfunction and pain.

Protrusion vs. Retrusion average motions Paired with what other motions

Protrustion = <8 mm = depression Retrusion = <5 mm = elevation

Type I Motion Coupling what motions same or opposite directions where does it occur

Rotation + sidebending occur together BUT opposite directions Where : - O/A (not A/A - does rotation only) - mid & lower T-spine - all of L spine.

Coupling of Motion Which motions are coupled together Type I vs. Type II

Rotation and Lateral Flexion (Sidebending) at most but not all regions of the spine. All assume NEUTRAL starting position Type I Motion Coupling Pattern: - Rotation + sidebending occur together BUT opposite directions Where do this occur - O/A (not A/A - does rotation only) - mid & lower T-spine - all of L spine. Type II Motion Coupling Pattern: Rotation and sidebending together + in same direction Where does this occur - lower C-spine - upper T-spine

Counternutation

SI "Extension" 1. SI moving on stable Pelvis 2. Posterior Pelvic tilt (stable sacrum)

Nutation what is it 2 possible ways for it to occur

SI "Flexion" 1. SI moving on stable Pelvis 2. Posterior Pelvic tilt (stable sacrum)

Any Spinal Curvature in the Frontal Plane =

Scoliosis

Spondylolisthesis what is it what structures support / protect against this?

Slippage of L5 on S1 - damage spinal nerves / cauda equina limited by facet orientation (frontal plane) - L5 = anterior vs. - S1 = posterior = BLOCKS L5 from slipping anteriorly

Sub regions of the Cervical Spine (2) define (inc how many segments in each)

Suboccipital (upper C-spine) = occipital bone, C1, & C2 (2 spinal segments) Lower Cervical Spine bottom of C2 - Top of T1 (6 spinal segments)

Muscles attached to TMJ Disc

Superior head of lateral pterygoid note : eccentric action during closing of mouth to manage disc position

Facet Joint Orientation in the T-spine - break it down by region - how does this impact motion

T 1 - T 10 = Frontal Plane vs. T 10 - 12 = quick transition to Sagittal = favors flexion & extension

Type II Motion Coupling what is it where does it occur

Type II Motion Coupling Pattern: Rotation and sidebending together + in same direction Where does this occur - lower C-spine - upper T-spine

Scoliousis Class Example Upper thoracic vs. Lower thoracic / Upper Lumbar - which side is the lateral flexion - what happens to the ribs on each side - which direction is the rotation

Upper Thoracic = L Lateral Flexion ribs on R side - elevated - IC spaces more open ribs on L side - depressed - IC compressed / shrink Rotation to the Right Posterior Rib Hump = RIGHT (vs. rib flattening on Left) VS. Lower Thoracic / Upper Lumbar = R Lateral Flexion LEFT ROTATION Posterior Rib Hump on LEFT

Are SI joints strong/stable why or why not

VERY STABLE Extremely strong ligaments reinforce the joint on all sides.

Intervertebral Foramen Space Issues: describe structures in relation to IV foramen / spinal nerve how does flexion / extension affect space affect of disc height?

anterior = disk posterior = facet joint posteromedial = ligamentum flavum degeneration or dehydration of disc = narrows IV space flexion = increases size extension = decreases size

Intradiscal pressures in Lumbar Region what is the baseline describe trends = what causes you to go above or below baseline

compression due to body weight & m contraction standing = 100% leaning forward = increases forces supine = lowest side design programs to prevent lumbar disk NP herniation or limit any additional damage. In order for the nucleus pulposus to escape the annulus fibrosis, the annulus must be weakened or torn.

Motions available at T-spine what are they describe each in terms of rostral --> caudal

flex/ext = INCREASES caudally very limited in upper t-spine lateral flexion = INCREASES caudally limited due to rib cage rotation = DECREASES caudally limited due to ribs + facet orientation

A person with a hypomobile lumbar facet joint on the RIGHT will be limited in _____________ Explain

limited in: - right rotation + - left lateral flexion (at that vertebral segment) bc TYPE I Coupled

OSTEOKINEMATICS: TMJ movements available (5) - distances of each in mm

mandibular movements Depression (opening): 35-50 mm -requires protrusion Elevation (closing) - requires retrusion Protrusion (chin forward): <8 mm Retrusion (chin backward; aka: Retraction): <5 mm Lateral Deviation (lateral jaw excursion) 10-15mm

How does the intra-articular disk of the TMJ move

moves WITH the condyle most of the time

Bilaminar Retrodiscal Tissues of TMJ location + function superior vs. inferior - attachments - composition

posterior anchor to limit anterior translation of the disc Superior Lamina = elastin rich - attaches to the temporal bone Inferior Lamina = collagen rich - attaches to the neck of the mandibular condyle

ex. Lower c-spine rotation to the right - describe in terms of facet joints

right facet = closes left facet = opens

TMJ Joint Capsule attachments is it vascularized / innervated? compare its tightness A-P vs. M-L - why is this important

superiorly = temporal bone inferiorly = neck of mandibular condyle. Highly vascularized + innervated Loose (lax) A-P - easier opening + closing Tighter Med-Lat = for lateral stability with chewing

Anterior Attachment of Disc of TMJ

tendon of lateral pterygoid muscle (superior head)

Protraction of the Head (Forward Head) compare position of upper c-spine vs. mid to lower c-spine what is the overall outcome of this?

upper C-spine = extension vs. Mid & Lower C-spine = flexion increases stress on : - levator scapulae - semispinalis capitis + shortens SCMs