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A Clinical View  Module 1  By Todd Henkelmann, PT, MS, CCTT UPMC Centers for Rehab Services.

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Presentation on theme: "A Clinical View  Module 1  By Todd Henkelmann, PT, MS, CCTT UPMC Centers for Rehab Services."— Presentation transcript:

1 A Clinical View  Module 1  By Todd Henkelmann, PT, MS, CCTT UPMC Centers for Rehab Services

2   Today’s lecture and demonstrations will be primarily about the basics. Plan to pair up at times!  [Suggest to bring with you: vinyl/non-latex disposable gloves, small tape measure]  What questions would you like answered?  If you delve deeper into the problem of TMD, you’ll discover a very complex and controversial disorder and perhaps the best way to approach it is K.I.S.S.  A good place to start is the AAOP – aaop.org Introductory Remarks 3/8/14T. Henkelmann, PT, MS, CCTT2

3   “I’ve got TMJ” – Yes, you have two, one on each side…  TMJ Disorder = TMD  Orofacial Pain = OFP  American Academy of Orofacial Pain  Craniofacial Pain = CFP  American Academy of Craniofacial Pain  Craniomandibular Disorder = CMD  European Academy of Craniomandibular Disorders What’s in a Name? 3/8/14T. Henkelmann, PT, MS, CCTT3

4   This is our role as physical therapists; why you can successfully work in conjunction with dentists and oral surgeons, have a successful niche practice  We need to not let 3 rd party private payers prevent treatment of this devastating condition  Medicare & Medicaid cover it’s treatment  The TMJ Association – www.tmj.org, Terrie Cowley, Presidentwww.tmj.org Conservative treatment of TMD 3/8/14T. Henkelmann, PT, MS, CCTT4

5  3/8/14T. Henkelmann, PT, MS, CCTT5 Functional Anatomy Stomatognathic system Bony structures  Temporal bone: mandibular fossa, external auditory meatus, articular eminence (a.k.a. tubercle), mastoid & styloid processes  Mandible: condyle (head of the mandible), neck, coronoid process, ramus, angle, and body  Zygoma, teeth  Hyoid bone  Upper cervical spine

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7  3/8/14T. Henkelmann, PT, MS, CCTT7 Joint Classification: TMJ  A synovial, condylar joint of 2 types:  Ginglymus (hinge) – 0 to 25mm (+/- 2-3) for rotation  Arthrodial (gliding) - 25-50mm for translation  As a synovial joint, it has a joint capsule and synovial fluid. The bony surfaces are covered by fibrocartilage (not hyaline cartilage…too soft). Fibrocartilage remodels – why it can heal.

8  3/8/14T. Henkelmann, PT, MS, CCTT8 Joint Capsule and Ligaments  Thin, synovial joint capsule, stabilized by the following ligaments:  Medial: sphenomandibular lig. – suspends mandible during wide opening, stylomandibular lig. – acts as a stop to extreme opening  Lateral: Lateral (temporomandibular) lig. – prevents excessive A-P and lateral movements  TMJ is stabilized primarily by ligaments and convex on concave relationships above & below by the bi- concave articular disc

9  3/8/14T. Henkelmann, PT, MS, CCTT9 The Disc (Meniscus)  Fibrocartilagenous structure – areas of collagen fibers, loose connective tissue, blood vessels, and nerve fibers  Function of disc is to act as shock absorber, improve congruency, and enhance joint stability during movement

10   Attached to capsule, poles of the condyle via collateral ligs., and superior belly of lateral pterygoid muscle. It divides the joint into 2 distinct cavities  Posterior attachment (also called ‘retrodiscal tissue’) has a superior (elastic) and inferior (vascular & neural) stratum that serve to keep disc from moving too far anteriorly 3/8/14T. Henkelmann, PT, MS, CCTT10

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12  Cervical spine  Forward head posture:  Loss of cervical lordosis  Backward bent OA  Effects orientation of TMJ  Leads to early DDD and DJD  Can cause neural impingement! 3/8/14 T. Henkelmann, PT, MS, CCTT 12

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14  Neurology  Trigeminal nerve (CN V) is the principle nerve supplying the structures of the TMJ  Ophthalmic branch (V1) – sensory to upper face, eye, nose, frontal sinuses, dura  Maxillary branch (V2) – sensory to cheek, upper lip, lower sinuses, maxillary teeth, dura  Mandibular branch (V3) – sensory to lower face, mandibular teeth, chin & jaw (but not angle of jaw =C2 & C3); motor to muscles of mastication 3/8/14T. Henkelmann, PT, MS, CCTT14

15  Location of C2-C3 dermatomes 3/8/14T. Henkelmann, PT, MS, CCTT15

16  Trigeminocervical nucleus 3/8/14T. Henkelmann, PT, MS, CCTT16

17   Time for everyone to stand up and stretch back! 3/8/14T. Henkelmann, PT, MS, CCTT17

18  1.History 2.Cervical screen 3.Posture 4.Active TMJ ROM 5.Strength – cervical, mandible 6.Specific TMJ tests – palpation & loading 7.Special tests: sensory exam, jaw jerk, facial nerve 8.Muscle palpation 9.Outcome measure Overview of TMD Evaluation 3/8/14T. Henkelmann, PT, MS, CCTT18

19   When did it start, what were you doing?  Gradual or sudden onset  What tests have been done?  Panorex x-ray, CT scan, MRI – provide “clues”  Have you suffered a blow to the jaw?  Volleyball, soccer ball, fist, MVA  Do you have a click/pop now or in past?  Was there period of prolonged immobilization?  Mouth wired shut? Could cause capsular restriction 1. History 3/8/14T. Henkelmann, PT, MS, CCTT19

20   What makes the pain worse?  What makes the pain better?  “What do you do to get any relief?”  “What can’t you do because of this problem?”  Have you worn braces and for how long?  Ask about parafunctional habits  Start the education process here 3/8/14T. Henkelmann, PT, MS, CCTT20

21  Parafunctional Habits  Clenching teeth (daytime) – teeth touching at rest?  Bruxing at night  Chewing gum, fingernails, ice  Habitually chewing hard-to-chew items  Hand rest on jaw  Holding phone with shoulder against head  Tongue thrusting  High stress level – we all have stress, ask if worse in the past 6 months  Prone sleep position 3/8/14T. Henkelmann, PT, MS, CCTT21

22   Take AROM – Rot, SB, Flex, Ext  Alar & transverse ligament tests – See next slide  Spurling’s test  Cervical compression & distraction tests  I do not do anything else, unless there is a reason to  If the patient has radicular symptoms, then you need to recognize that you’re dealing with 2 different problems – not part of TMD per se 2. Cervical Screen 3/8/14T. Henkelmann, PT, MS, CCTT22

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24   First thing: just observe head, neck & face at rest  Look for overt asymmetry or swollen area  Before you say anything about posture, look at head/neck posture from the side  Minimal, moderate, severe forward head?  Are they missing teeth? Does bite come together evenly?  Malocclusion vs. unilateral joint effusion vs. unilateral muscle spasm 3. Posture 3/8/14T. Henkelmann, PT, MS, CCTT24

25   Mandible depression: 0mm to 40-60mm (adult)  Measure R incisors, unless unavailable  Side glide (aka, lateral excursion): 0mm to 8mm (I don’t usually measure)  Protrusion: 0mm to 6-9mm (I don’t usually measure)  Retrusion (aka, retraction): Not measured  Watch for deviation or deflection with depression & protrusion – can confirm or deny disc displacement 4. AROM of TMJ 3/8/14T. Henkelmann, PT, MS, CCTT25

26  3/8/14T. Henkelmann, PT, MS, CCTT26 TMJ Muscle Actions  Depression (opening): Lateral Pterygoid – inferior belly, Anterior Digastric, and gravity  Elevation (closing): Temporalis, Masseter, Medial Pterygoid  Lateral Excursion: To Right : R Lat. Pterygoid, L med. Pterygoid, to Left: L Lat. Pterygoid, R med. Pterygoid  Protrusion: Lat. Pterygoids – inferior belly, acting bilaterally, Med. Pterygoids – indirect

27   Manual muscle tests of:  Cervical SB, Rot, Flex, Ext  Mandible SB, Depression, & elevation  Note: It is not common to see weakness, in my experience. Roughly 90% of all orofacial pain patients I see don’t test (+) for weakness. Don’t know that MMT is the best way to test strength in this population 5. Strength Testing 3/8/14T. Henkelmann, PT, MS, CCTT27

28   Force biting test  Lateral condyle palpation test  Teeth together, mouth opened  Retrussive overpressure test  External auditory meatus test 6. Specific TMJ tests 3/8/14T. Henkelmann, PT, MS, CCTT28

29   Sensory testing - I consider this crucial, yet doctors and many therapists don’t take the time…  Test V1, V2, V3, & C2  Pain sensation, light touch sensation  Slightly diminished can be caused by mm. spasm, greater involvement in V2, V3 may mean a tumor  Jaw Jerk reflex  Indicative of upper motor neuron condition, but is not diagnostic  Facial nerve screen – go through all facial mov’ts. 7. Special Tests 3/8/14T. Henkelmann, PT, MS, CCTT29

30   Internally: masseter, medial & lateral pterygoids  Externally: temporalis, digastric, sternocleidomastoid (SCM), suboccipitals, upper trapezius  Others for consideration: zygomaticus, buccinator, tensor veli palatini, frontalis 8. Muscle Palpation 3/8/14T. Henkelmann, PT, MS, CCTT30

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35   TMD Disability Index Questionnaire (TDI)  Similar to Oswestry or Neck Disability Index  Used by Joshua Cleland, et al in research studies (see bibliography)  Published by a chiropractor and has not undergone validation studies  Scoring method is on last page of handout  It’s not perfect, but it’s all I have to recommend at this time  For Medicare: I am also using AMPAC 4 Outcome Measures 3/8/14T. Henkelmann, PT, MS, CCTT35

36   Stand up and stretch backward  Relax your jaw – were your teeth touching?  How’s your posture? Are you setting a good example for your patients? Take a Break 3/8/14T. Henkelmann, PT, MS, CCTT36

37  3/8/14T. Henkelmann, PT, MS, CCTT37


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