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Kinesiology Chapter 9 - Chapter 9 – The spinal column and...

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Unformatted text preview: Chapter 9 – The spinal column and thorax Chapter 9 – The spinal column and thorax Cervical Spine Cervical Spine Curves of the Spine: Normal Posture­plumb line 7 Cervical vertebrae and 8 discs C1­C2: Atypical joints: OA (occiput and atlas or atlanto­occipital joint) and the AA or atlanto­axial joint. C3­C7 are more similar in structure Lordosis is assisted by wedge shaped discs, like lumbar discs, which are larger anteriorly ANATOMY ANATOMY VERTEBRAL BODY FACET JOINTS NEURAL FORAMINA TRANSVERSE PROCESS SPINOUS PROCESS UNCINATE PROCESS O­A­A joints make up 40% of cervical flexion and O­A­A joints make up 40% of cervical flexion and 60% cervical rotation Atlas has concave masses that join with convex occipital condyles: Flexion and Extension; Concave and Convex Rule A­A or C1­C2: mostly Rotation No discs between O­A­A joints Stability in cervical spine especially within O­A­A complex is articulation and ligamentous DISC DISC NUCLEUS PULPOSUS ANNULUS FIBROSIS Discs: Contribute to 1/3 height of Discs: Contribute to 1/3 height of spine Viscoelastic material allowing it to sustain great loads when they are rapidly applied Vertebrae Vertebrae Compression strength increases from the Cervical to the Lumbar direction Bending moments occur in the vertebral bodies during movements Flexion causes tensile forces posteriorly and compressive forces anteriorly SPINAL CANAL AND NEURAL SPINAL CANAL AND NEURAL FORAMINA WHAT HAPPENS TO THE NEURAL FORAMINA, SPINAL CANAL AND ALSO TO THE SPINOUS PROCESSES WITH FLEXION? WHAT HAPPENS WITH EXTENSION? Range of Motion of Mid to Lower Range of Motion of Mid to Lower Cervical Spine: Rotation, Sidebending, Flexion and Extension Range of Motion to Upper Cervical Spine: lateral tilting and nodding During normal activities:Tying shoes Backing up a car Washing Angle of Facets or Zygoapophyseal Angle of Facets or Zygoapophyseal Joints What is the angle? Class example What motions will be limited with this angle? Combination movements: Combination movements: Retraction: what happens with upper cervical and lower cervical Protraction: what happens with upper cervical and lower cervical? SUBAXIAL SPINE SUBAXIAL SPINE Rotation of head one way causes SP to move in the same or opposite direction Direction of rotation based upon vertebral body or spinous process? Suboccipital spine Suboccipital spine Convex occipital condyles moving on concave atlas Lateral tilt to right will have right occipital condyle moving anterior and left occipital condyle moving posterior and vise versa Spinal Stability Spinal Stability OAA Complex: Transverse Ligament disruption from the following:RA and Down’s Syndrome Subaxial Cervical Spine Muscles and discs provide the most stability Supraspinous and interspinous and Ligaments that are important for attachment Ligaments that are important for attachment of the Dens from C2 to Anterior Arch of C1 Transverse Ligament Alar Ligaments Apical Ligaments Accessory Ligaments C3­C7:Spinous Process Transverse Process Lamina Facet joints Uncinate Process: arise from the lateral margins of the superior end plates of the vertebral body MYOTOMES AND DERMATOMES MYOTOMES AND DERMATOMES OF THE CERVICAL SPINE AND ASSOCIATED NERVE ROOTS WITH BRACHIAL PLEXUS STRETCHING STRETCHING UPPER TRAPEZIUS LEVATOR SCAPULAE SCALENES SCM PECTORALS PATHOLOGY PATHOLOGY CERVICAL SPRAIN AND STRAIN CERVICAL DDD/HNP/OA (PROBLEMS WITH PERIPHERAL NERVES AND VERTEBRAL ARTERY) CERVICAL STENOSIS CERVICAL RADICULOPATHY WHIPLASH OSTEOPOROSIS’ EFFECT ON CERVICAL SPINE CERVICAL FUSION: MID­LEVEL AND LOWER LEVEL, SURGICAL APPROACH TMJ TMJ Temporomandibular Joint TMJ is not the name of the disorder it is the name of the joint; the name of the disorder is Temporomandibular Dysfunction or Disorder Anatomy Review Osseous Muscular Articular Dentists and Physical Therapists Dentists and Physical Therapists Dentists starting to realize the craniocervical part of TMD Physical therapists can assist dentists with their patients because of our knowledge of the TMJ and concurrent effects with the cervical spine Basic Features Basic Features Compound synovial joint between the mandible and cranium Articulating surfaces are covered by avascular fibrocartilage which can withstand large amounts of compressive and shearing forces The active joint surface is from the superior part of the fossa to the anterior / inferior slope of the eminence all the way to the apex of the eminence Basic Features Basic Features The articular disc divides the TMJ into an upper and lower compartment Innervated by the mandibular division of the trigeminal nerve Basic Features Basic Features In the sagittal plane, The convex condyle does not articulate with the concave temporal or mandibular fossa but against the convex slope and apex Basic Features Basic Features In the Horizontal Plane, the direction of the temporal joint is in an oblique and sagittal direction This orientation causes the condyles to translate laterally as we open our mouths as the condyles slide forward Palpation of this movement Articular Disc Articular Disc Plays a central role in the stability of the TMJ by making up for the congruency problem between the two joint surfaces The disc is biconcave and oval in shape This orientation presents the disc to be thinner in the central portion and thicker in the peripheral portions; self seating capacity of the disc Excellent shock absorber Laterally and medially the disc is stabilized by collateral ligaments Articular Disc Articular Disc The superior disc surface contacts the middle one­third of the articular eminence The inferior disc surface articulates with the convex joint surfaces of the mandibular head The disc divides the joint into two compartments Rotation takes place in the inferior compartment Translation takes place in the superior compartment Muscles of mastication Muscles of mastication Temporalis: Muscle fibers in antero and postero inferior directions Origin: entire temporal fossa Insertion: coronoid process and anterior border of the ramus and some fibers to the skeletal orbit of the eye Function: Bilateral contraction closes the mandible Unilaterally deviates the mandible to same side Posterior fibers minimally retract the mandible from rest position All fibers retract mandible if it is fully protruded; helped by suprahyoid Guides biting motion Muscles of mastication Muscles of mastication Lateral pterygoid Prime mover of TMJ and guides disc both during eccentric and concentric contractions Two bellies: superior and inferior Origin: superior: sphenoid bone; inferior: lateral surface of lateral pterygoid plate Insertion: superior: condylar head and disc; inferior: neck of the condyle Function: two heads are antagonistic Inferior: mandibular depression as it pulls the condyle and disc forward and protrudes the mandible Superior: stabilizes the mandibular head and disc against the articular eminence as the mandible closes Assist in the deceleration of the posterior movement of the condyle during closing as well as stabilizing the anterior and medial joint capsule during closure preventing nipping of the capsule Muscles of mastication Muscles of mastication Medial pterygoid Similar to the masseter but smaller Origin: palatine bone and tuberosity of maxilla Insertion: medial surface of ramus and mandibular angle Function: elevates the mandible; if mandible is depressed, this muscle will limit protrusion; unilaterally deviates mandible toward opposite side; participates in chewing motion Decelerates the posterior movement of the condyle with closing Muscles of mastication Muscles of mastication Masseter: Origin: superficial and deep; superficial: anterior and inferior part of zygomatic arch and maxillary process; deep: deep side of zygomatic arch Insertion: superficial: angle and lateral ramus of mandible; deep: superior half of the ramus and lateral surface of coronoid process Function: initiates elevation of mandible adds force to closure Contributes to clenching and grinding Muscles of mastication Muscles of mastication Digastric: anterior and posterior bellies and a central tendinous portion connected to the hyoid bone via a fibrous loop Origin: anterior: digastric fossa of the mandible along the lower border lateral to the inner surface of the mandibular symphysis; posterior: mastoid notch medial to the mastoid process Insertion: anterior­intermediate tendon connects the anterior and posterior bellies, splints the stylohyoid muscle, and is attached to the hyoid bone by a fibrous bone by a fibrous ring which acts like a pulley forming an obtuse angle Function: if the hyoid bone is fixed by the action of the stylohyoid and infrahyoid muscles, the digastric muscle pulls the mandible back and down and functions during retrusive and opening movements of the mandible; during opening the digastric forms a force couple with the lateral pterygoid muscle Muscles of mastication Muscles of mastication Stylohyoid: fiber direction similar to that of the posterior belly of the digastric and also assists in jaw opening through its action on the hyoid bone Origin: styloid process of the temporal bone Insertion: hyoid bone Function: initiates jaw opening and draws hyoid up and back Muscles of mastication Muscles of mastication Geniohyoid: Mylohyoid: Function: determines the length of the floor of the mouth; pulls mandible back and down Function: forms the floor of the mouth; elevates the floor of the mouth when the hyoid is fixed Infrahyoid muscles: Includes: sternohyoid, thyrohyoid, omohyoid Function: depress the hyoid bone and stabilizes it for th action of the suprahyoid muscles Biomechanics of the TMJ Biomechanics of the TMJ Functional unit Cranio­cervical joint posteriorly Cranio­mandibular joint anteriorly TMJ problem, check the cervical spine and vice versa Biomechanics of the TMJ Biomechanics of the TMJ Complex synovial joint: moves in three planes 4:1:1 ratio between opening, lateral excursion, and protrusion For 40 mm if opening, there is 10 mm of lateral excursion and 10 mm of protrusion When we measure left lateral excursion, we are measuring the function of theright TMJ Biomechanics of the TMJ Biomechanics of the TMJ Joint surfaces and the articular disc Stability based upon on the shape and relationship of the joint surfaces TMJ is unstable The anterior slope of the temporal surface is convex and the condyle is convex: so convex on convex relationship: not stable Not a problem with rolling but a problem with sliding: grinding and instability Disc solves this problem by being biconcave and creates two compartments Biomechanics of the TMJ Biomechanics of the TMJ The 2 departments of the TMJ Disc­condylar (inferior) and disc­temporal/eminence (superior) joints Inferior department: rotation Superior department: translation Disc will follow the condyle as long as there is apposition of the two joint surfaces and there is no subluxation Centric relation: term that refers to the most congruent contact between disc/eminence and disc/condyle with the disc interposed TMJ Movements TMJ Movements Mandibular depression (opening) and elevation Osteokinematics: mandible moves back and down; center of rotation moves from behind and inferior to a position anterior and below the joint Arthrokinematics: ½ half of opening is rotational or roll­gliding of the condyle/disc in the inferior joint space; at the beginning of movement the condyle glides anteriorly and the disc posteriorly relative to each other; as the temporomandibular ligament tightens rotation will end and translation begins; condyle and disc will move together in translatory movement, down and forward on the articular eminence TMJ Movements TMJ Movements Elevation: reverse of depression Protrusion: Symmetrical anterior translation of both condyle/disc complexes on the articular eminence The motion occurs in superior joint space Lateral Excursion: The condyle and disc of the joint contralateral to the direction of movement are pulled forward, downward, and medially along the articular eminence The condyle of the ipsilateral side only minimal movement takes place, rotation around a vertical axis and a lateral shift; these motions take place in the upper joint space Left lateral excursion: left mid and posterior temporalis is active; inferior fibers of both lateral pterygoids are active; the right medial pterygoid is active; force couple of left lateral pterygoid and left temporalis Other biomechanical Other biomechanical considerations Closed position: Orthostatic position: teeth are slightly apart, normal freeway space, tongue placed on the palate Freeway space: separation between the central incisors; referred as interocclusal space Point of reference for mandibular movements Centric relation most stable position of the joint in which the condyles are in the unstrained position in the fossa in which the condyles are in a supero­anterior position in the fossa against the slope of the eminence Centric occlusion: teeth are in max intercuspation Other biomechanical Other biomechanical considerations The role of the tongue: Position of the tongue is important in that it can determine dentition an shape of maxillary bones Connects to the hyoid bone which affects muscle balance in the craniomandibular system Normal resting positon: tongue against the palate with the tip slightly behind the posterior side of the upper central incisors Functional role: swallowing; normal swallowing, teeth must be together; abnormal swallowing can disrupt the teeth Three forces: Anterior force: opposed by teeth and orbicularis oris Transverse force: opposed by teeth and buccinator Anterior­superior force:against the palate Other biomechanical Other biomechanical considerations Postural considerations: Movement or position of the head can challenge the normal rest positon Muscle hyperactivity: can lead to a deep overbite Forward head: the lowered mandible/tongue position facilitates eruption of the posterior teeth Loss of tongue position against the palate can lead to constriction of the maxilla and narrowing in of the upper teeth Respiratory difficulties: long face syndrome, leading to lowered mandible and tongue position and greater disruption of posterior teeth Postural and functional Postural and functional relationships Normal breathing: through the nose What happens with mouth breathing: Affects dentition and facial development Lowers the mandible Results in backward rotation of the cranium Stretches the infra­mandibular musculature Contact between the tongue and upper maxilla/teeth is lost and maxillary arch collapses Increased use of accessory respiratory muscles, such as scalenei and sternomastoid, decrease in diaphragmatic breathing Postural and functional Postural and functional relationships Mouth breathing leads to forward head posture which causes the following: Spondylosis Disc pathologies Facet joint pathologies Loss of cervical lordosis Narrow subcranial space Complaint of HA, itching scalp, sensations in the eye or fullness in the ear Assessment of the TMJ Assessment of the TMJ History: macro or microtrauma Macro: hit on the mandible via punch or fall Micro: bad oral habits; leaning forward to read or watch tv 6­12% of the population Women out number men 2:1 Mean age is 32 25­40% have clicking sounds Areas of pain Areas of pain Pain to the muscles of mastication Neurological cause: unilateral Pain reference from neck and shoulder muscles Tension HA in 50% of the patients Chronic pain with clenching Symptoms Symptoms Neurological pain is sharp Muscular pain is dull and aching Trigeminal pain: severe facial pain Pain usually low grade and intermittent but can become constant over time Painful restriction of range of motion Cold weather causes increased pain Salivation, rhinorrhea, lacrimation, photophobia, nausea, tinnitus and stuffiness Onset of symptoms Onset of symptoms 75% unknown cause History of tooth extractions History of clenching and grinding Orthodontic care Clicking, grating or locking Clicking, grating or locking Associated with disc displacement Associated with degenerative changes or disc perforation Disc derangement causing locking Precipitating factors Precipitating factors Lifestyle, occupations or habits can contribute Parafunctions: (nail biting, clenching, grinding) Smoke a pipe Playing a wind instrument or the violin Psychological factors Psychological factors Tension, fear, and certain personalities Depression Facial symmetry Facial symmetry Vertical dimension of the face Lower 1/3 is the most important for PT Vertical dimension of occlusion is controlled by dentist but may be altered by fillings, bridges, and implants Altered height of the lower 1/3 can result from biting, temporal HA, cervical muscle tightness/discomfort, increased muscle activitation Occlusion classes Occlusion classes Straight profile: neutral occlusion: class 1 type Retro­inclined profile: dorsal occlusion: class 2 type Antero­inclined profile: ventral occlusion: class 3 type Clapping of the teeth: Put finger on front of teeth and clap teeth lightly No bouncing or vibration in the upper anterior 6 teeth only neat clack Vibration means mandible hitting on the upper front teeth and bounding back No contact between lower/upper front teeth in maximum intercuspation, only between molars and premolars Observing parafunction Observing parafunction Biting nails: repeated sliding of the mandible in the same direction Increased action of masticatory muscles Negative effect of posterior neck muscles Increase subcranial sidebending Lip closure Lip closure Shortness of the upper lip Lead to increased activity of the muscles of mastication Normally: the upper lip should cover ¾ of the upper teeth Too short: mentalis muscle will have to raise the lower lip the distance needed to close the lips and cause muscle hypertrophy; this activates the masseter leading to clenching; posterior rotation of the head when trying to close the lips; interocclusal appliance makes this worse: how? Treatment: firm rubber to stretch the lip or stretches: can take 6 months Active movements Active movements Opening and closing: check deviations and measure vertical distance between upper and lower central incisors Lateral deviation: measure deviation of the mandible using the space between the lower central incisors as a reference and marking its terminal locations during lateral deviation Protrusion and retrusion: measure horizontal distance between upper and lower central incisors Basic concepts in TMD Basic concepts in TMD management Exercises for the rest position of the tongue: correct breathing in this position Exercises to control TMJ rotation: 1. rest position 2. chew in limited motion in front of mirror 3. this limits early translation and maintains optimal position of the disc Basic concepts in TMD Basic concepts in TMD management Mandibular rhythmic stabilization First in resting position Pressure in different directions Basic concepts in TMD Basic concepts in TMD management Upper cervical distraction: interlace fingers between C2­C7 and then forward bends the head Axial extension of the cervical spine: Retraction Exercises for shoulder girdle retraction: shoulders back and down; strengthen the low traps and rhomboids Patient Education Patient Education Explain structure and function of TMJ Explain causes Make patient aware of parafunctions Do not sleep on stomach Avoid biting off large pieces Refrain from habitual protrusion of the mandible Eat soft food If hypermobile: limit excessive movements like yawning Management of inflammation Management of inflammation Education, avoid excessive loading, stop parafunctional activities, soft diet, exercises such as correct tongue position and rest position, move mandible side to side with tongue in correct position, teach to breath and swallow in this position, nasal breathing promotes relaxation Management of hypermobility Management of hypermobility Do not open mouth wide Excessive mouth opening...
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