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Manual Functional Analysis Lecture 2
Mr. Abu Jad : A male aged 45-year old, smoker, he works a taxi driver, presented with the chief complaint of pain in the anterior of his right ear and in the zygoma. Medical history: He has CHD and takes Aspirin, Hypoprusre(Beta blocker, Metoprolol), and plavex( Clopidogrel). 3 months ago he went to Dentist with an acute pain in this region and the dentist extracted 18 & 48 but he mentioned that he had a severe pain during anesthesia. Now he suffers from a difficulty in mouth opening in the early morning and the pain in the same region.
Quiz 1
A female aged 55-year old, nonsmoker, presented with the chief complaint of a headache & pain in the posterior of her left ear and sometimes in the chin. Medical history: She has osteoarthritis in her knees joints and takes Indomethacin. 6 months ago she went to the hospital and the neurologist refers her to the dentist. Now she suffers from the pain in the same region.
Quiz 2
ManualFunctionalAnalysis
Muscle Palpation
Tissue-specific diagnosis
Arthrogenous and Myogenous disorders
Tissue-Specific Diagnosis
Anatomical structure which is responsible on patiant’s pains and
symptoms
Examination with tissue-specific stress
loading vector ?
Examination with tissue-specific stress
describes the direction of any load that is responsible for an area of tissue damage within the joint and provides a better understanding of malfunctions of the system. A determination of the specific loading vector is important if one is to follow an effective procedure for arriving at a diagnosis and treatment plan.
A nonphysiological load of a certain amount in a certain direction
loading vector
Specific loading vector Nonspecific loading vector
Specific treatment Coordination:
specific modification of muscle tone
(splints, physical therapy)
Nonspecific treatment :Nonspecific
muscle relaxation (stabilization, medication,
physical therapy, etc.)
Examination with tissue-specific stress
JointMuscles
Joint-play TechniquesDynamic Test
Muscles palpation
Tissue-Specific Diagnosis
SymptomsPain limitation of movement clicking
Passive movement Isometric contraction
Manual Functional Analysis
Influencers
OcclusionParafunctionDysfunction
Tissue-Specific Diagnosis
Functional Unit
Removable Structures limitation of movement StructuresMotor Structures
Lateral ligament Stylomandibular ligament
Sphenomandibular ligament
CondyleArticular disk
Bilaminar Zone
MusclesNerves
✤Patient History
✤ Initial Examinations✤ Extended Examinations
Manual Functional Analysis
Patient History
1- “What are the Complaints that Brought You to Me?”2- “Rank Your Problems in Order of Severity?” 3- “What Exactly Do You Expect from Me?"
Manual Functional Analysis
1. Initial Examinations
Active Movements
Isometric Contraction
Passive Movements
2. Extended Examinations
Manual Functional Analysis
Joint-play Techniques
Dynamic Tests
✤ Initial Examinations
Manual Functional Analysis
Active Movements
Active Jaw Opening
Active Movements
Laterotrusion Left / Right
Active Movements
Protrusion / Retrusion
Active Movements
Translation of the condyles during active jaw opening
Active Movements
Translation of the condyles during active protrusion
Active Movements
Sensitivity & Specificity
Sensitivity & Specificity
Isometric Contraction Vs Muscle Palpation
?
A comparison study (Thomas and Okeson 1987)
Isometric Contraction Muscle Palpatipon
Patient Group 27.1% 69.5%
Healthy Group 0% 27.6%
Sensitivity 73% 30.5%
Specificity 100% 72.4%
✤Reproducibility ✤Objectivity ✤Ability to test muscles that are inaccessible to palpation
Isometric Contraction Vs Muscle Palpation
The examiner's knowledge of the anatomy
Manual Functional Analysis
✤ Initial Examinations
Isometric Contraction
✤ No movement at the joints ✤ The effectiveness of muscle is maximal
Isometric contraction
Conditions of Isometric contraction
Pain Responce Power Development
Isometric contraction
Isometric contraction
2-Depressor muscles3-Mediotractors muscles4- posteriotractor muscles
1-Elevator muscles
Affected anatomical structuresTemporal muscleMasseter muscleMedial pterygoid muscle Lateral pterygoid muscle, superior head
Isometric contraction of the elevator (jaw- closing) muscles.The duration of the contraction should be between 20 and 80 seconds.According to EMG studies, correct positioning of cotton rolls between the second premolars and first molars results in maximal loading of the elevator muscles.
Isometric contraction of the elevator muscles
Isometric contraction of the elevator muscles
Monitoring contraction of the medial pterygoid muscles: Testing for
contraction of the medial pterygoid muscles. Following the contraction the patient is asked if, and exactly where, any pain was felt. The examiner must also ask if the pain is similar to that
reported in the patient history or if it is an unfamiliar pain was evoked only by the
examination.
Isometric contraction of the elevator muscles
Differential diagnosis
Arthrogenic Myogenic
Isometric contraction of the elevator muscles
Differential diagnosis
Painfull lesion at elevator muscles
painfull lesion at joint (Acute arthritis,Osteoarthritis, non inflammatory lesion)
Anterior disk displacement
Limitation the translation movement
without
Limitation the rotational movement
Isometric contraction of the elevator muscles
There is painful response
centric and eccentric position of the condyle in the fossa
Differential diagnosis
Anterior disk displacement
Isometric contraction of the elevator muscles
There is a painfull lesion at elevator muscles
MusclePalpa+onMassetermuscleTemopralmuscle
Differential diagnosis
Isometric contraction of the elevator muscles
Determine the mayofacial painful point
Isometric contraction ofthe depressor muscles
Differential diagnosis
Isometric contraction of the elevator muscles
Specific palpation is usually accomplished by laying the palpating finger parallel with the muscle fibers to be tested. The actual palpating movements then take place at right angles to the direction of the fibers. In this way even lesions in different layers of a muscle, such as the pars profunda and pars superficialis of the masseter, can be reliably differentiated (Goulet et al. 1998). A force of approximately 40 N/cm2 should be used during specific palpation. This procedure results in greater discrimination than do a number of quantitative methods for detecting painful areas (Wolfe et al. 1990).
Temopral muscle palpation
Palpation of the pars anterior of the temporal muscle
Palpation of the pars media and pars posterior of the temporal muscle
Isometric contraction of the elevator muscles
Palpation of the masseter muscle
Isometric contraction of the elevator muscles
Palpation of the masseter muscle
Palpation of the pars superficialis of the masseter muscle
Isometric contraction of the elevator muscles
Palpation of the masseter muscle
Palpation of the pars profunda of the masseter muscle
Isometric contraction of the elevator muscles
Isometric contraction
Affected anatomical structuresDigastric muscleMylohyoid muscle Ceniohyoid muscle Lateral pterygoid muscle, inferior head
3-Mediotractors muscles4- posteriotractor muscles
2-Depressor muscles1-Elevator muscles
Isometric contraction of the depressor muscles
Starting position of the mandible for isometric testing of the depressor muscles
Isometric contraction of the depressor muscles
Isometric contraction of the depressor muscles
Differential diagnosis
Painfull lesion at depressor muscles
painfull lesion at joint (Acute arthritis,Osteoarthritis, non inflammatory lesion)
Anterior disk displacement
Limitation the translation movement
without
Limitation the rotational movement
Differential diagnosis
Isometric contraction of the depressor muscles
There is a painfull lesion at depressor
muscles
Isometric contraction ofthe muscles
Isometric contraction
1-Elevator muscles2-Depressor muscles3-Mediotractors muscles4- posteriotractor muscles
Affected anatomical structures
lateral pterygoid muscle
Isometric contraction of mediotractors muscles
Isometric contraction of mediotractors muscles
Passive movements
1- Excitated pain myofacial pain of lateral
pterygoid muscle
2-No excitated pain myofacial pain of supra
hyoid muscles
Isometric contraction of the depressor muscles
Differential diagnosis
Supra hyoid muscles palpation at position of
the pain
Digastric muscle palpation
Isometric contraction of the depressor muscles
Digastric muscle palpation
Isometric contraction of the depressor muscles
Isometric contraction of the depressor muscles
Floor of the mouth muscle palpation
Affected anatomical structures- posterior belly of digastric muscle - pars posterior of the temporal muscle - Superior belly of the lateral pterygoid muscle
Isometric contraction
1-Elevator muscles
3- Mediotractors muscles4- posteriotractor muscles
2-Depressor muscles
Examination base points
✤ Excited pain
✤ development of the power
InnervationMuscles condision(Pain,Harmony,…)
Isometric contraction
There are no problems in the Nerves of the elevator muscles
There is no deficiency of power
Isometric contraction of the elevator muscles
Isometric contraction of thedepressor muscles
Differential diagnosis
or difficulties in active movements
There is deficiency of power There are problems in the
Nerves of the elevator muscles
Referral the patient to neurologist
Differential diagnosis
Isometric contraction of the elevator muscles
Mr. Abu Jad : A male aged 45-year old, smoker, he works a taxi driver, presented with the chief complaint of pain in the anterior of his right ear and in the zygoma. Medical history: He has CHD and takes Aspirin, Hypoprusre(Beta blocker, Metoprolol), and plavex( Clopidogrel). 3 months ago he went to Dentist with an acute pain in this region and the dentist extracted 18 & 48 but he mentioned that he had a severe pain during anesthesia. Now he suffers from a difficulty in mouth opening in the early morning and the pain in the same region.
Quiz 1
Isometric Contraction
Right Left
Pain Force Pain Force
Elevator ∅ ∅
Depressor + ∅
Lat. pterygoid + ∅
Right Lateral Pterygoid Muscle
A female aged 55-year old, nonsmoker, presented with the chief complaint of a headache & pain in the posterior of her left ear and sometimes in the chin. Medical history: She has osteoarthritis in her knees joints and takes Indomethacin. 6 months ago she went to the hospital and the neurologist refers her to the dentist. Now she suffers from the pain in the same region.
Quiz 2
Isometric Contraction
Right Left
Pain Force Pain Force
Elevator ∅ ∅
Depressor ∅ ∅
Lat. pterygoid ∅ ∅
Left sternocleidomastoid muscle