1.

01 Craniomandibular Joint and The Spine

Sir Krei || August 2021 PT 9 THERA EX
Transcribers: Bebelone, Bacalso, Bo, Co, Cobile, Cuadra, Go, Honoridez, Jalang,
Lim, Minoza, Pasion, Polvorosa, Veruasa, Villegas

OUTLINE - In simple cases posture problems, joint dysfunction or

muscles imbalances are sources of the problem =
therapeutic exercise
B. Spine: Management Guidelines
Legend:
Remember ● Pathology and Degeneration of the Disc
Lecturer Book
(Exams) ➢ Injury and Degeneration of the Disc
🖉 🗐 🕮 ➢ Disc Pathologies and Related Conditions
➢ Signs and Symptoms of Disc Lesions and Fluid
Stasis
Heading 1
A. Craniomandibular Joint / Temporomandibular Joint C. Injury and Degeneration of the Disc
● Structure: hinge and plane (ginglymoathrodial joint)
● Herniation - the displacement of discs material (nucleus
● Task: chewing , talking, yawning
pulposus) beyond the normal limits of the IV disc’s
● Degrees of Freedom: 2 space.

1. Motions
● Mandibular depression
● Protrusion
● Lateral Excursion

2. Signs and Symptoms

● Pain affected by movement:
➔ retrodiscal pad,
➔ ear
➔ muscle spasm / facial pain ● Protrusion - a.k.a Prolapse, displaced material is
➔ tension in the muscles continuous with the material of the disc. (Does not go
● Joint noise (clicking) out from the annulus fibrosus)
● Restrictions or limitations with jaw movement

3. Possible Causes of Pain

● Result of trauma
● Poor posture (head – forward; neck)
● Faulty movement patterns
● Poor oral hygiene
● Gum chewing (constant chewing)
● Heavy kissing
● Bruxism (grinding of teeth) ● Extrusion - extension of nuclear material beyond the
● Smoking confines of the posterior longitudinal ligament or above
● Inflammatory conditions and below the disc’s space.
● Open mouth breathing

4. Principles of Management and Interventions

● Problem:
➔ pain
➔ muscle spasm
➔ limitation of motion

NOTE: ● Sequestration - the material (annulus pulposus) is no

- Aggressive and irreversible treatments should be longer contained and has separated from the annulus.
avoided

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[PT 9 THERA EX] 1.01 Craniomandibular Joint and The Spine – Sir Krei
● Fatigue Breakdown and Traumatic Rupture
➢ Fatigue Breakdown
- Over time, the annulus breaks down as a result
of repeated overloading of the spine in flexion
with asymmetrical forward bending and
torsional stresses
➢ Traumatic Rupture
- Rupture of the annulus can occur as a one-time
event, or it can be superimposed on a disc
where there has been gradual breakdown of
the annular rings
- Due to degeneration
● Axial Overload
- a.k.a. compression
- results in end-plate or vertebral body fracture
before there is any damage to the annulus
fibrosus
- Scheuermann’s disease (common disease)
- Nucleus migrates either superior or
inferior through a cracked end-plate
- May occur due to a vertebral body
fracture.
- with compression fracture, flexion and axial
loading causes increased pain
● Age
- 30 - 45 years old are most susceptible to
symptomatic disc injuries
- People around this age are working which
causes repetitive stress on the spine/back.
● Degenerative Changes
- Any loss of integrity of the disc from infection,
herniation, or endplate defect becomes a
stimulus for degenerative changes in the disc.
- May be a result from an infection or disease,
and aging.
D. Signs and Symptoms of Disc lesions and Fluid Stasis
● Etiology of symptoms
○ Pain - pressure on the swollen disc or swollen
tissues on pain sensitive structures (e.g. nerves
and spinal cord)
○ Neurological signs and symptoms
- Type of Pain
- Myotomes and Dermatomes
○ Variability of symptoms - depends on the
degree and direction of the protrusion and
spinal level of the lesion. (Location of the
lesion).
- Lesions are usually posterolateral
○ Shifting symptoms - As protrusion occurs, it
may hit nearby structures or nerves which will
cause pain. This will result in the patient shifting
his body to the side of comfort.
- LAMS (Lateral-Away ; Medial-Same)
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- If location of protrusion is on the
lateral side, then the patient shifts his
body away for comfort
- If location protrusion is on the medial
side, then the patient shifts his body
on the same side as the protrusio for
comfort.
○ Inflammation
BOX 15.1 Summary of Common Impairments Related
to Disc Protrusions in the lumbar spine
● Pain, muscle-guarding
● Flexed posture and deviation away from
(usually) the symptomatic side
🗐 Flexed posture- posterolateral protrusion
● Neurological symptoms in dermatome and
possibly myotome of affected nerve roots
● Increased symptoms (peripheralization) with
sitting, prolonged flexed postures, transition
from sit to stand, coughing, straining
🗐 Peripheralization- pain radiates laterally away from
the center of the spine and/or down the extremity
following a dermatomal distribution.
Centralization- pain is localized.
● Limited nerve mobility, such as straight-leg
raising (usually between 30° and 60°)
● Peripheralization of symptoms with repeated
forward bending (spinal flexion) tests
BOX 15. 2 Summary of Common Impairments and
Activity Limitations Related to Facet Joint Pathology
(e.g. Spondylosis, Osteoarthritis, RA, Ankylosing
Spondylitis)
● Pain: When acute, there is pain and muscle
guarding with all motions; pain when subacute
and chronic is related to periods of immobility or
excessive activity.
● Impaired mobility: Usually hypomobility and
decreased joint play in affected joints; there may
be hypermobility or instability during early
stages.
● Impaired posture.
● Impaired spinal extension: Extension may
cause or increase neurological symptoms due to
foraminal stenosis; therefore, may be unable to
sustain or perform repetitive extension activities
without exacerbating symptoms.
● Any activity that requires flexibility or
prolonged repetition of trunk motions, such
as repetitive lifting and carrying of heavy
objects, may exacerbate symptoms in the
arthritic spine.
[PT 9 THERA EX] 1.01 Craniomandibular Joint and The Spine – Sir Krei
🗐 For pts. with RA, apply preventive interventions to
address further complications aside from muscle
guarding and pain interventions.
BOX 15.3 Summary of Common Impairments and Activity
Limitations Associated With Muscle and Soft Tissue
Injuries
Acute Stage
● Pain and muscle guarding
● Pain with contraction of the muscle or stretch on the
muscle
● Interference with ADLs (rolling over, turning, sitting, sit
to stand, standing, walking)
Subacute and Chronic Stages
● Impaired muscle performance
● Impaired mobility—may have contractures in muscle
and related connective tissue or may have adhesions
at site of tissue injury Impaired spinal control and
stabilization during functional activities
● Impaired postural awareness
● Limited IADLs, work, and recreational activities
(difficulty with repetitive or sustained postures, lifting,
pushing, pulling, reaching, and holding loads)
Principles of Management for the Spine
● 60% of acute back injuries resolve within 1 week and up
to 90% resolve within 6 weeks with a recurrence rate
less than 6%.
● Serious “red flag” conditions related to orthopedic
conditions should be referred to a physician for
management
● Psychological distress may interfere with patient’s
recovery
● Neurological symptoms should be explored in an
attempt to relate them to spinal cord, nerve root, spinal
nerve, plexus or peripheral nerve patterns
● Pain patterns should be explored to determine if they
relate to a known musculoskeletal pattern or signal a
medical condition
STAGES OF RECOVERY
Acute Inflammatory stage
● Constant pain, and there are signs of inflammation
● No position or movement completely relieves symptoms
● Anti-inflammatory medications is usually warranted
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Acute stage without signs of inflammation
● Symptoms are intermittent and related to mechanical
deformation
● There may be signs of nerve irritability when the nerve
root or spinal nerve is compressed or under tension
● Categorized into an extension bias (anterior affectation),
a flexion bias (posterolateral affectation) or non
weight-bearing bias (great compression on the nerve)
Subacute stage
● Certain movements and postures with some
instrumental ADLS (IADLs) still provoke symptoms
requiring repetitive movement of loads, so a basic
lifestyle cannot be fully resumed
Chronic stage
● Emphasis is placed on returning the patient on high-level
demand activities that require handling repetitive loads
on a sustained basis over a prolonged period of time
BOX 15.4 Impairment-Based Diagnostic Categories That
Direct Intervention
General: Stage of Recovery
● Acute with inflammation (0–4 weeks).
● Acute without inflammation (0–4 weeks): intermittent
symptoms with acute nerve root symptoms.
● Subacute (4–12 weeks).
● Chronic (>12 weeks).
● Chronic pain syndrome (>6 months).
Nonweight-Bearing Bias: Traction Approach
● Patient does not tolerate being upright for basic
ADLs and IADLs.
● Movement testing makes symptoms worse.
● Traction (or other nonweight-bearing procedures)
relieves symptoms.
Extension Bias: Extension Approach
● Patient usually presents with flexed posture—a
lateral shift may also be present.
● Extension tests decrease or centralize symptoms.
● Diagnosis may include intervertebral disc lesions,
impaired flexed posture, fluid stasis.
Flexion Bias: Flexion Approach
● Patient usually presents with flexed posture and is
more comfortable when flexed.
● Extension tests exacerbate or peripheralize
symptoms.
● Diagnoses may include spondylosis, stenosis,
extension load injuries, swollen facet joints.
Hypermobility/Functional Instability: Stabilization/
Immobilization Approach
● Patients present with hypermobile spinal
segment(s); poor spinal stability (segmental or
global).
● Diagnoses may include trauma, ligamentous laxity,
spondylolysis, or spondylolisthesis.
[PT 9 THERA EX] 1.01 Craniomandibular Joint and The Spine – Sir Krei

Hypomobility: Mobilization/Manipulation Approach

● Restricted mobility in one or more spinal segments. Basic stabilization: with arm
and leg motions (passive
Muscle and Soft Tissue Lesions: Exercise Approach support if needed, progress to
● Patient usually presents with guarded posture or active control).
increased muscle tension.
● Diagnoses may include strains, tears, contusions, or
overuse.

Postural Pain Syndrome: Exercise and Conditioning 6. Teach safe performance Roll, sit, stand, and walk with
Approach of basic ADLs; progress safe postures. Progress
● Patient presents with faulty posture; symptoms to IADLs. tolerance to sitting longer
increase with sustained position. than 30 minutes, standing
● Diagnoses may include postural strain, cervico-genic longer than 15 minutes, and
headache, thoracic outlet syndrome, poor physical walking > 1 mile
condition
● Movement, posture correction, and exercise
decrease symptoms BOX 15.7 Subacute Spinal Problems/Controlled Motion
Phase (p.458 Kisner 7th ed)

Impairments, Activity Limitations, and Participation

Restrictions
Management Guidelines ● Pain: only when excessive stress is placed on
vulnerable tissues
● Impaired posture/postural awareness
BOX 15.5 Acute Spinal Impairments/Protection Phase ● Impaired mobility
(p. 456 Kisner 7th ed) ● Impaired muscle performance: poor neuromuscular
control of stabilizing muscles; decreased muscle
Impairments, Activity Limitations, and Participation endurance and strength
Restrictions ● General deconditioning
● Pain and/or neurological symptoms ● Limited ability to perform IADLs for extended periods
● Inflammation of time
● Guarded posture (prefers flexion, extension, or ● Poor body mechanics
nonweight bearing)
● Limited ability to perform ADLs and IADLs Plan of Care Intervention

Plan of Care Intervention
1. Educate the patient Engage patient in all activities
to learn self-management.
Inform patient of anticipated
progress and precautions.
1. Educate the patient in Engage patient in all activities
self-management and emphasizing safe movement
how to decrease and postures.
episodes of pain. Home exercise program.
Ergonomic adaptation of work
or home environment

2. Decrease acute Modalities, massage, traction, 2. Progress awareness and Practice active spinal control
symptoms or mobilization/manipulation control of spinal in pain-free positions and with
as needed. Rest only for first alignment. all exercises and activities.
couple days if needed. Practice posture correction.

3. Teach awareness of neck Kinesthetic training: cervical
and pelvic position and and scapular motions, pelvic
movement. tilts, neutral spine
4. Demonstrate safe Practice positions and
postures. movement and experience
effect on spine. Help patient
find the functional spinal
position of comfort in supine,
sitting, standing.
5. Initiate neuromuscular Deep segmental muscle
activation and control of activation techniques:
stabilizing muscles. ■ Lumbar spine: drawing-in
maneuver, multifidus
contraction.
■ Cervical spine: gentle head
nods
3. Increase mobility in Joint mobilization/
restricted muscles/ manipulation,
joint/fascia/nerve. neuromobilization, muscle
inhibition, self-stretching.
4. Teach techniques to Progress stabilization
develop neuromuscular exercises; increase
control, strength, and repetitions (emphasize
endurance. muscle endurance).
Initiate
extremity-strengthening
exercises in conjunction with
spinal stabilization.
5. Develop cardiopulmonary Low to moderate intensity
endurance. aerobic exercises; emphasize
spinal bias.

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[PT 9 THERA EX] 1.01 Craniomandibular Joint and The Spine – Sir Krei

6. Teach techniques of Relaxation exercises and

stress relief/relaxation. postural stress relief

7. Teach safe body Practice stable spine lifting,

mechanics and functional pushing/pulling, and reaching
adaptations. practice activities specific to
desired outcome emphasizing
spinal control, endurance, and
timing

BOX 15.8 Chronic Spinal Problems/Return to Function

Phase (p. 460 Kisner 7th ed)

Impairments, Activity Limitations, and Participation

Restrictions
● Pain: only when excessive stress is placed on
vulnerable tissues in repetitive or sustained nature for
prolonged periods
● Poor neuromuscular control and endurance in
high-intensity or destabilized situations
● Flexibility and strength imbalances
● Generalized deconditioning
● Limited ability to perform high-intensity physical
demands for extended periods of time

Plan of Care Intervention

1. Emphasize spinal control Practice active spinal control

in high-intensity and in various transitional
repetitive activities. activities that challenge
balance.

2. Increase mobility in Joint

restricted muscles/ mobilization/manipulation,
joints/fascia/nerve. neuromobilization, muscle
inhibition, self-stretching.

3. Improve muscle Progress dynamic trunk and

performance; dynamic extremity resistance exercises
trunk and extremity emphasizing functional goals.
strength, coordination,
and endurance.

4. Increase Progress intensity of aerobic

cardiopulmonary exercises.
endurance.

5. Emphasize habitual use Motions and postures to

of techniques of stress relieve stress.
relief /relaxation and
posture correction.

6. Teach safe progression Apply any ergonomic changes

to high-level/ to work/home environment
high-intensity activities.

7. Teach healthy exercise Progressive practice using

habits for self- activity-specific training
maintenance. consistent with desired
functional outcome,
emphasizing spinal control,
endurance, balance, agility,
timing, and speed

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