What is arthrokinematics?
Movement between joint surfaces.
What is osteokinematics?
Motion between two bones.
When grading accessory joint motion, what does a 0 mean?
Ankylosed
When grading accessory joint motion, what does a 3 mean?
Normal
When grading accessory joint motion, what does a 6 mean?
Unstable
In regards to arthrokinematics, what rule does the AO joint and TMJ follow?
Convex on concave
Mobilization is performed in what position?
Loose packed position
What position do you have the TMJ in to perform mobilizations?
Jaw slightly open
What is the closed packed position of the TMJ?
Maximal retrusion
What is the open packed position of the vertebra?
Midway between flexion and extension
What is the closed packed position of the vertebra?
Maximum extension
What is the capsular pattern of the TMJ?
Limited opening
What are normal end feels?
Soft, firm & hard
A boggy end feel is abnormal. What does it mean?
Edema or effusion
A firm end feel with decreased elasticity is an abnormal end feel. What does it mean?
Due to fibrosis of soft tissue
A rubbery end feel is an abnormal end feel. What does it mean?
Muscle spasm
A empty end feel is an abnormal end feel. What does it mean?
Pt. is guarding joint from pain.
A hypermobile end feel is an abnormal end feel. What does it mean?
End feel at a later time than opposite side.
What is muscle substitutions?
Stronger muscles compensate for the loss of motion or function of weak muscles
In upper crossed syndrome, which muscles are facilitated and which muscles are inhibited?
Facilitated: SCM/Pectoralis & Upper Trap/Levator Scapula
Inhibited: Deep cervical flexors & Lower Trap/Serratus Ant.
In lower crossed syndrome, which muscles are facilitated and which muscles are inhibited?
Facilitated: Rectus Femoris/iliopsoas & Thoraco-lumbar extensors
Inhibited: Abdominals & Gluteus Min/Med/Max
What does OPQRSTM stand for?
O: Onset
P: Palliative
Q: Quality of pain
R: Radiating symptoms
S: Severity
T: Time of day
Mechanism of injury
What does cramping, dull, or ache pain mean?
Muscle
What does dull ache pain mean?
Ligament or capsule
What does sharp, shooting pain mean?
Nerve root
What does burning, pressure like, stinging, or aching pain mean?
Sympathetic nerve
What does deep, nagging, and aching pain mean?
Bone
What does sharp, severe, intolerable pain mean?
Fracture
What does throbbing, diffuse pain mean?
Vasculature
What components make up history?
PMH, family history, social history, living history, occupational history, growth and development and functional status & activity level.
When a physical therapist does a systems review, what does that entail?
MSK, Neuromuscular, cardiopulmonary and integumentary.
What is included in a MSK system review?
ROM, MMT, Symmetry, Height and weight, and BMI
What is included in a Neuromuscular system review?
Coordinated mvmt and motor function
What is included in a cardiopulmonary system review?
BP, edema, HR, Respiratory rate
What is included in a integumentary system review?
Pliability, scar formation, skin integrity
What is involved in a COMPLETE PT MSK exam?
Pt. History
Observation
Palpation
ROM
Joint play
Motor/sensory/reflexes
Special tests
Imaging
Laboratory tests
A pt. comes into your clinic c/o R shoulder pain. The patient states that he has been having deep, aching pain (8/10) in his shoulder for about 2 weeks. The pt experiences the pain when he moves his arms past 90 degrees. The pain is constant and even wake
Pt. needs referral to a physician because constant pain and night pain are red flags for cancer.
What is an area of bone of fascia supplied by a single nerve root?
Sclerotome
The jaw jerk is what nerve level?
CN V
The biceps DTR is what nerve level?
C5-6
The brachioradialis DTR is what nerve level?
C5-6
The triceps DTR is what nerve level?
C7-8
The knee jerk is what nerve level
L3-4
The medial hamstring DTR is what nerve level?
L5-S1
the lateral hamstring DTR is what nerve level?
L4-5
The tibialis posterior DTR is what nerve level?
L4-5
The achilles tendon DTR is what nerve level?
S1-2
What are epaxial muscles?
Intrinsic muscles of the back
What are hypaxial muscles?
Muscles of the extremities
Where does CN I exit?
Cribriform plate
How do you test CN I?
Smell (Something familiar like coffee, vanilla, etc.)
Where does CN II exit?
Optic foramen
How do you test CN II
Snellen eye chart, color chart, peripheral fields, light reflex test (CN II & III)
Which nerve is responsible for the afferent limb of the pupillary reflex?
CN II (Optic nerve)
Which nerve is responsible for the efferent limb of the pupillary reflex?
CN III (Oculomotor nerve)
A patient suffers from homonymous hemianopsia. What is it and how do you test for it?
Homonymous hemianopsia - a eye disease caused by stroke where there is a loss in peripheral vision.
Confrontation eye test is a technique used to assess the eyes for peripheral vision.
A patient comes to your clinic c/o a curtain being drawn down their eye. What are you thinking?
Retinal detachment
Where does CN III exit?
Superior orbital fissure
How do you test CN III?
CN III, IV, & VI are tested together
Where does CN IV exit?
Superior orbital fissure
How do you test CN IV?
CN III, IV, & VI are tested together
Where does CN VI exit?
Superior orbital fissure
How do you test CN VI?
CN III, IV, & VI are tested together
What is strabismus?
Strabismus is a disorder in which the two eyes do not line up in the same direction, and therefore do not look at the same object at the same time.
A pt. comes to your clinic and during your evaluation, you suspect a lazy eye. What is a lazy eye and how do you test for it?
Lazy eye is another term for Amblyopia. Amblyopia is a degenerative eye condition that occurs in individuals with strabismus. To test for this you can perform the cover and uncover test for ocular deviation. The test involves having the patient focus on a
What is nystagmus?
involuntary eye movement.
Where does CN V exit?
Superior orbital fissure (V1), foramen rotundum (V2), and foramen ovale (V2)
How do you test CN V?
Sensory - Sensation over face (3 areas)
Motor - bite on tongue depressor, corneal reflex tests (CN V & VII), Jaw jerk
What nerve makes up the afferent portion of the corneal reflex?
ophthalmic branch (V1) of CN V
What nerve makes up the efferent portion of the corneal reflex?
CN VII (facial nerve)
Where does CN VII exit?
Internal auditory meatus
How do you test CN VII?
Motor: wrinkle forehead, smile, show teeth, blow kiss, close eyes
Sensory: Ant 2/3 of tongue: salt, sweet, sour, bitter
Where does CN VIII exit?
Internal auditory meatus
How do you test CN VIII?
Auditory: Rub fingers, weber, rinne.
Vestibular: Vestibulo-ocular reflex, past pointing, or calorics
What is the vestibulo-ocular reflex?
Reflex eye movement that stabilizes images on the retina during head movement by producing an eye movement in the direction opposite to head movement, and preserves the image on the center of the visual field.
Describe the weber test.
Can detect unilateral conductive hearing loss or unilateral sensorineural hearing loss. Place 256 hz vibrating tuning fork on top of head. If sound is heard more in affected ear = conductive. If sound is heard more in the normal ear = sensorineural
Describe the rinne test
Performed by placing a 512 hz tuning fork against the pt. mastoid bone and ask pt to tell you when sound is no longer heard, measure time. Place tuning fork by ear, pt should be able to hear sound. In normal ear, air conduction is better than bone. In con
What is the past pointing test?
Test for defective functioning of the vestibular nerve. Subject is asked to point at an object with eyes open and then closed first after rotation in a chair to the right 10 times, and then to left 10 times. Abnormality is indicated if the pt does not pas
Where does CN IX exit?
Jugular foramen
How do you test CN IX?
Motor: say AHH & gag reflex
Sensory: posterior 1/2 tongue
Where does CN X exit?
Jugular foramen
How do you test CN X?
Motor: Say ahhh
Sensory/motor: gag reflex
Where does CN XI exit?
Jugular foramen
How do you test CN XI?
Shrug shoulder & turn head against resistance
Where does CN XII exit?
Hypoglossal foramen
How do you test CN XII?
Stick out tongue
What type of posturing presents with a flexed UE and extended LE?
Decorticate posturing
What occurs neurologically during decorticate posturing?
First their is disinhibition of the red nucleus with facilitation of the rubrospinal tract. Next their is disruption of the lateral corticospinal tract which facilitates motor neurons in the lower spinal cord supplying flexor muscles of the lower extremit
What type of posturing presents as the head arched back, the arms extended by the sides, and the legs extended with teeth clenched?
Decerebrate posturing
What occurs neurologically during decerebrate posturing?
Brain stem damage, specifically damage below the level of the red nucleus.
How do you test for cerebellar dysfunction?
Coordination test... finger to nose or heel up opposite leg
What level of consciousness is being described?
Readily aroused, oriented and aware of surroundings.
Alertness
What level of consciousness is being described?
Memory is impaired, disoriented
Confusion
What level of consciousness is being described?
Sleeps when not stimulated, inattentive, responds to name
Lethargy
What level of consciousness is being described?
Responds to shaking or loud voice. Confused when aroused, talks in monosyllables, or mumbles.
Obtundity
What level of consciousness is being described?
Responds to painful stimulation, groans, reflex activity
Stupor
What level of consciousness is being described?
Does not respond to pain or other stimuli
Coma
What type of lesion is characterized by spastic paralysis or paresis, little or no muscle atrophy, hyperreflexive deep tendon reflexes in a non-segmental distribution, and the presence of pathological signs and reflexes
UMN lesion
What type of lesion is characterized by muscle atrophy and hypotonus, a diminished or absent deep tendon reflex (DTR) of the areas served by a spinal nerve root, or a peripheral nerve and an absence of pathological signs or reflexes
LMN lesion
A forward head posture will result in the TMJ being in what position?
posterior closed packed position
What type of joint is the TMJ?
Synovial joint w/ dense fibrous connective tissue (not hyaline)
What bones make up the TMJ?
Mandible, Maxilla, Zygomatic arch, and Temporal bone
Where is the TMJ intra-artcular disc the thinnest?
Centrally
Where does the TMJ intra-articular disc attach anteriorly?
Lateral pterygoid
Where does the TMJ intra-articular disc attach posteriorly?
Condyle
What moves the disc anterior when opening the mouth?
Lateral pterygoid
What makes up the ligamentous support of the TMJ?
lateral TMJ ligament
Stylomandibular ligament
Sphenomandibular ligament
What muscles depress the TMJ?
Lateral pterygoid, suprahyoid, and infrahyoid
What muscles elevate the TMJ?
Temporalis, Masseter, and Medial pterygoid
What muscles protrude the TMJ?
Masseter, lateral pterygoid, and medial pterygoid
What muscles perform retrusion of the TMJ?
Temporalis, masseter, and digastric
What muscle perform side to side movement of the TMJ?
Medial pterygoid, lateral pterygoid, masseter and temporalis
What muscle is the primary opener of the TMJ?
Lateral pterygoid
What muscles are the primary closer of the TMJ?
Masseter and temporalis muscle
What are the two joint motions of the TMJ and what occurs first?
Rotation (1st motion) & glide (2nd motion)
What does trismus mean?
Either reduced opening of the jaws caused by spasm or may refer to all causes of limited mouth opening.
What arthrokinematics are involved in mouth opening?
Anterior glide, lateral glide and inferior glide
What arthrokinematics are involved in mouth closing?
Posterior glide, medial glide, and superior glide
What arthrokinematics are involved in contralateral deviation?
Anterior, inferior and lateral glide of the mandibular head and disc
What arthrokinematics are involved in ipsilateral deviation?
Posterior, superior and medial glide of the mandibular head and disc
What arthrokinematics are involved in protrusion
Anterior, inferior and lateral glide of the mandibular head and disc
What arthrokinematics are involved in retrusion
Posterior, superior and medial glide of the mandibular head and disc
What is the functional ROM of opening?
40 mm
According to the convex-concave rule, which surface is convex, which surface is concave?
Mandible - convex
Temporalis - concave
What are the 3 common TMJ dysfunction categories?
DJD due to OA or RA, Myofascial pain, & internal joint derangement
Clinical presentation of TMJ dysfunction includes what?
Pain (w/ or w/o motion), muscle spasm, abnormal or limited jaw motion, headache, and tinnitus
What are risk factors for TMJ dysfunction?
Chewing on one side, clenching and grinding of teeth, gum chewing and nail biting
What are the three cardinal features of TMJ dysfunction?
Restricted jaw function
joint noise
orofacial pain
Referred pain from the TMJ may result in what?
Headache
Mandibular pain
What can cause reciprocal clicks?
Abnormally shaped disc, shortened jaw muscles, and/or improper bite.
What does early clicking indicate?
Small anterior displacement
What does late clicking indicate?
Disc is further displaced anteriorly
What is the most revealing and diagnostic movement for TMJ dysfunction?
Mouth opening
What is the knuckle test?
Two-three knuckle width of non-dominant hand. Used to asses ROM of mouth opening
What does a 'C-pattern' of motion indicate?
Hypomobility is due to internal derangement
What does an 'S-pattern' of motion indicate?
muscle imbalance
The jaw reflex involves what muscles?
Masseter and temporalis
What nerve does the jaw jerk test?
CN V
What special test can you use for TMJ?
TMJ compression and Chvostek test
What is the TMJ compression test?
Evaluates pain with compression of the retrodiscal tissue
-pt. sitting or supine
-Stabilize head w/ one hand and push mandible superiorly with other
-(+) is pain in TMJ
What is the Chvostek test?
Test of CN VII.
Tap parotid gland over masseter muscle.
If blood calcium is low the face will twitch
What modalities can be used to treat pain and inflammation?
heat, ice, biofeedback, US, e-stim, tens and massage
What is the primary glide for mobilization of the TMJ
inferior to gap joint, stretch capsule, and relocate anterior disc.
What must be normalized prior to any permanent dental procedure?
C-spine posture
What treatment can be performed during the acute stage of TMJ dysfunction?
6x6 exercise
Cork exercise
tongue positioning during mouth opening and closing