Download Cervical Muscle Energy - Lab

Edward Via Virginia College of Osteopathic
Medicine
Block 7 - 2013
Stuart F. Williams D.O.
Additional Slides from David G Harden DO,FAAFP
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Define TMJ (Temporomandibular Dysfunction)
Describe the role of the temporal bone in TMJ
Define approaches to treatment of TMJ in Osteopathy in the Cranial
field
Define Counterstrain Points associated with TMJ
MUSCLES
Lateral Pterygoid Muscle
Medial Pterygoid Muscle
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Tony, an otherwise healthy 22-year old
male presents with left sided ear pain of
4 weeks’ duration after biting into an
apple & feeling his jaw ‘pop’
Seen at the ER that night, as his jaw hurt
immediately
Told he had ‘TGM’ or something & was
treated symptomatically
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PMHx – none
PSHx – none
All – penicillin
Meds – none
Social – single, no children, lives in
graduate dorm, binge ETOH &
tobacco use; won’t admit nor deny
marijuana use, but denies anything
“heavier”
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Depression (opening of the mouth from rest)
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Elevation (closing of the mouth to rest)
Protrusion (carrying the mandible forwards from rest)
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head anteriorly, disc posteriorly
Retraction (carrying the mandible back to rest)
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Head and articular disc move anteriorly
Head posteriorly, disc anteriorly
Small amount of lateral movement (side-to-side movement from the rest
position) bc of pterygoids
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Smooth, normal motion is a
blending:
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Muscular contraction on
mandible
Ligamentous tension
Contraction, or lack thereof,
by lateral pterygoid
Gravitational and structural
forces acting on cranium and
mandible
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TMJ is a synovial joint, formed by
the mandibular condyle in the
fossa in the temporal bone
Different from other synovial joints
in that it:
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Formed from membrane (vs.
endochrondron and therefore has no
hyaline cartilage)
Lined by fibrous tissue
Joint cavity is divided into 2 by an
intra-articular disc
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This division by the disc means that
there are actually two joints on each
side:
– One between the ramus of the
mandible and the articular disc
– Another between the disc and the
temporal bone fossa
During low-load opening activities
(talking, gentle chewing) the motion is
confined to the first
During high opening activities
(Eating/Yawning )the motion involves
the second joint – this is usually when
/ where dysfunction occurs
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The stylomandibular ligament – purpose
of the ligament is unknown
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Stylohyoid ligament provides attachment
to the superior fibers of the middle
pharyngeal constrictor and is closely
related to the oral pharynx
Lateral ligament helps strengthen the
capsule
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Upper Head originates on the Greater Wing
of the Sphenoid
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Lower Head of lateral pterygoid originates
on the Lateral pterygoid plate
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Upper head attaches to disc
Lower head attaches to mandible
Together, they coordinate opening & closing
of the mandible with the articular disc
Also helps with protrusion and lateral
deviation
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Temporalis – anterior fibers elevate,
posterior retract
Medial Pterygoid – elevates the mandible
& helps with lateral & protrusive
movements
Digastric – depresses the mandible
Mylohyoid – depresses mandible when
hyoid fixed
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Masseter – elevates the mandible
3 points of attachment:
– Superficial part from zygomatic process of the
maxilla & from the anterior 2/3 of lower
border of the zygomatic arch
– Middle part from the deep surface of the
anterior 2/3 of the zygomatic arch & from the
lower border of the posterior one-third of the
arch
– Deep part arises from the deep surface of the
zygomatic arch
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Really, really involved…more than
we’ll go into depth here without
more anatomy
Note approximation of arterial and
nervous supply in area of TMJ
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Pain & clicking with mandibular
motion
Tenderness to palpation over TM
joint
Lateral pterygoid draws disc and
mandible anteriorly with opening
 when tight, prevents posterior
motion of both
Anteriorly displaced mandible – ↓
closing
Posteriorly displaced mandible –
↓opening
•
Smooth, normal motion is a
blending:
Muscular contraction on
mandible
– Ligamentous tension
– Contraction, or lack thereof,
by lateral pterygoid
– Gravitational and structural
forces acting on cranium and
mandible
–
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Jaw Opening - 40-50 mm
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Side to Side (lateral motion) - 8 mm
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Gravity alone can cause 15mm of depression
Due to pterygoids
Protrusion - 6-8mm
Retrusion- 3mm
Hot bilateral masseter & medial
pterygoid TPs with severe
hypertonicity.
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20% population
3:1 (female : male)
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Etiologies:
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Malocclusion (tooth loss, improper alignment of dentures)
 Trauma
 Psychological / Emotional
 Neuromuscular
 “Poor Health”
 Internal Derangement
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Pillow too high
Children: mm spasm after recent orthodontia
Bruxism – grinding their teeth
Dental malocclusion
Jaw clenching
Excessive gum chewing
Trauma
Lyme Disease
JRA (other Connective Tissue Disease)
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Juvenile Rheumatoid arthritis
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If > 3-4 days duration
Unilateral
Otoscopy & pneumo-otoscopy wnl
Up to 48% can have TMJ dysfunction!
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TMJ tenderness on palpation
Restricted MOTION of jaw
Unilateral “clicking”
Aggravated by chewing or biting
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Ear Pain Etiologies (Preauricular referred pain secondary to TMJ)
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Nerve irritation
Muscle spasm
DJD (older pt)
Other: jaw, ear, facial pain, H.A., masicatory muscle pain, fatigue,
“tightness.”
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Traumatic
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Whiplash
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Bruxism (clenching
or grinding teeth)
http://peninsulaclarion.com/images/111801/knockout.jpg
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Cervical dysfunction
 Scoliosis
 Short leg
http://www.whiplashandtmj.com/logo.jpg
Cranial dysfunction
http://www3.telus.net/hotdigitaldog/plumb%20bob.jpg
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Total body structural exam
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Postural imbalance perpetuates problem
Higher incidence in dysautonomia
Evaluation of the cranial mechanism vital
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Myofascial trigger points & muscle imbalance
• Masseter, pterygoids, temporalis, digastric
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Skeletal arthrodial dysfunction
• Sphenobasilar compression
• Temporal bone restrictions
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Ligamentous dysfunction
• Sphenomandibular ligaments
• Stylomandibular ligaments
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Anteriorly displaced mandible – can’t
close well.
Posteriorly displaced mandible – can’t
open well.
Monitor pt’s TMJ with flats of fingers over
TMJ just anterior to the tragus while patient
opens & closes jaw.
Observe the mental area of the mandible
for deviation while you simultaneously
palpate the TMJs.
Similar in concept to open/closed facets…
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Anteriorly displaced mandible – can’t close
well.
Posteriorly displaced mandible – can’t
open well.
Monitor pt’s TMJ with flats of fingers over
TMJ just anterior to the tragus while patient
opens & closes jaw.
Observe the mental area of the mandible
for deviation while you simultaneously
palpate the TMJs.
Similar in concept to open/closed facets…
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Anteriorly displaced mandible – can’t close well. (more common)
Posteriorly displaced mandible – can’t open well.
Common TMJ problem:
anterior gliding motion of mandible is restricted
Ex: L TMJ restriction
R side works normally
causes deviation of
chin to L(restricted side)
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Multifaceted and multidisciplinary
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Proper DX may require Imaging
Manual Treatment-OMT
Medications
 Anti-inflammatory and antispasmodic
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Dental appliance or orthodontia
Psychosocial
Manipulative Treatment
in TMJ Disorders
Somatic dysfunction:
Skeletal – Arthrodial - Myofascial
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Can be either direct or indirect
Clues as to which to use:
Acute
 Chronic
 Cause of injury/problem
 Pt tolerance
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Left TMJ Dysfunction
Jaw Deviation to L
Muscle Energy
Restricted Jaw/Mouth Opening
“Close mouth.”
Two fingers under chin.
“Open mouth against my fingers.”
Hold 3-5 seconds.
Repeat 3-5 times.
Reevaluate motion of mandible to
see if technique effective.
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50 YOF c/o debilitating headaches(h.a.), neck pain, and R arm and hand
pain. HA prompted spinal taps and a dx of aseptic meningitis. HA are
described as “everywhere,” and “nasty” all the time. Recent cervical
MRI revealed mild to moderate central stenosis & moderate L foraminal
stenosis from a herniated disc at C5-6. Patient has seen multiple times
by several other physicians with minimal relief. She says, “Dr. _____,
you are my last hope.”
PMH: SLE with significant arthritis & synovitis.
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General: Anxious appearing female c/o h.a. of “13” on a 10
scale.
Neuro:
Alert & Oriented X 3.
 CN 2-12 grossly intact.
 Funduscopic benign
 DTRs +2 in UE & LE except +1 brachioradialis
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HENT: Normocephalic, TMs clear & mobile, Pharyx with minimal
ant pillar injection, no exudate. No enlarged ant or post
nodes.
Multiple TPs found in the trapezius (rarely palpated)
Other TPs found:
Levator scapulae (h.a.)
Right teres minor (shoulder pain)
Right subscapularis (shoulder pain)
Bilateral supraspinatus (shoulder pain)
LAC 5 (neck pain)
RPC3 (neck)
LPC1 (neck)
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Multiple TPs were tx & relieved!
On d/c, pt stated pain was 0/10! No h.a.!
Will f/u patient for reassessment of cervical pain secondary to
DJD & SLE.
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Patient referred from dentist with “closed and locked” jaw.
Unable to open mouth > 10mm (normal is 40mm).
No deviation of mandible noted.
Severe local muscle pain at end range esp in masseter region.
C/O pain in R TMJ, ear, and supraorbital.
Began 2 days after a dental procedure where she had to hold her mouth
open for an extended period of time.
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Neuro:
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Oriented X 3
CN 2-12 grossly intact
DTRs + 2
Eyes: PERRLA, Funduscopic benign
HENT: TMs clear & mobile. Pharynx noninjected. Neck supple
withour adenopathy
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Upper cervical, sphenobasilar & occipitomastoid areas
unremarkable.
Hot bilateral masseter & medial pterygoid TPs with severe
hypertonicity.
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Counterstrain to bilateral TPs.
On reevaluation, both bellies of masseter and medial pterygoid
were soft and much less tender.
Patient could open mouth to 40mm without difficulty.
Placed on soft diet for 3 days.
F/U: Patient continued to improve and was able to open mouth
without difficulty.
TP
Location
Tx
Masseter
Superficial and deep fibers of the masseter
muscle.
Press posterior toward anterior border of
ascending ramus of mandible.
Push slightly open jaw towards the TP
from opposite side
Medial pterygoid
Posterior surface of ascending ramus of
mandible approximately 2 cm above the
angle of the mandible (press anteriorly).
Pull with fingers of opposite hand
slightly open jaw laterally away from
the TP, deviating mandible to the
opposite side.
Lateral pterygoid
1 cm anterior to neck of the condyle (press
medial and sl posterior).
Lower edge of greater wing of sphenoid
(press medial).
With open jaw, use fingers of opposite
hand to pull jaw laterally away from
TP, deviating mandible to the opposite
side.
Temporalis
anywhere in the fan-shaped fibers of the
muscle (press medially
With opposite hand push relaxed jaw
toward the TP.
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Stand opposite the TMJ to be treated
Gloved caudad thumb is placed inside
patient’s mouth on surface of last molar
tooth
Cephalad thumb & index fingers stabilize
greater wings of the sphenoid
Slight pressure on gloved thumb moving
mandible in a caudal direction
Balance and hold until release is felt
Stabilize temporal bone while the gloved hand applies gentle caudal
& anterior traction on the mandible
Hold until a release is felt
Stabilize temporal bone with a
five-fingered hold
Middle finger in external auditory
meatus
Index finger & thumb grasp
zygomatic arch
Ring and little fingers on the
mastoid process
Ext Rotation with Flexion
Thumb down & out
Ring up & in
Int Rotation with
Extension
Index up & in
5th down & out
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Short Leg Syndrome:
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Can be a factor in TMJ
dysfunction.
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Tony’s jaw still hurts, but he can now close it
more easily and with less pain. You also notice
less deviation.
You instruct him to apply heat for 15-20 mins,
3x/day (you expect him to do this once daily,
maybe), and continue prn pain meds
He’ll follow up in 2 weeks & avoid any further
bar bets…oh yeah, and he says you’re “Pretty
cool – for a doc.”