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160 Cards in this Set

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define a trigger point.
area of hypersensitivity in a muscle; this muscle sends sensory pain information to the spinal cord where it then refers pain to some location. the area from which the pain arises is the trigger point
the area that the trigger point refers pain to is called______?
reference zone
how far back does the idea that trigger points are associated with some internal pathology?
back several millennia; the origin of TP is from Germany and Scandanavian countries
Who and when spent 50 years researching and documenting pain patterns?
Janet Travell, MD; 1940s
who worked with the internist in co-authoring a book on trigger points? name the book.
David G Simon, MD; Myofascial Pain and Dysfunction: The Trigger Point Manual
If you were to biopsy an acute trigger point, what would you see?
normal muscle
If you were to biopsy a chronic trigger point, what would you see?
muscle atrophy with fatty infiltration, increased number of nuclei per muscle fiber, fibrosis, serous exudates and abnormal mucopolysaccharide deposits
Name the 3 types of trigger points.
Active TP, Latent TP, and Tenderpoint
what is the difference in the 3 types of trigger points?
Active TP: hurts without touching it or when moving the involved muscle; Latent: hurts with digital stimulation; Tenderpoint: located at trigger point and tender to deep palpation, normal people are not tender to deep palpation
how does one acquire a TP?
same way you get somatic dysfunction or possibly a manifestation of somatic dysfunction
What maintains the TP?
MNMPCO: Mechanical Stress, Nutritional Inadequacies, Metabolic & Endo deficits; Psychological factors; Chronic infection or Infestation; Other factors
List the mechanical stresses that maintain TP.
poor posture, repetitive movements, short leg, short first long second toe (aka Morton's Foot); constriction of muscles, abuse of muscles, immobility, small hemipelvis, short upper arms
List the nutritional inadequacies that maintain TP.
lack of B1,B6,B12, folic acid, vitC, Mg2+, Fe, Ca, K+
What metabolic or endo deficits can maintain a TP?
hypothyroidism, hypoglycemia, gout
What psychological factors can maintain TPs?
Stoic personality (workaholic), hopelessness, depression
What chronic infections can maintain TPs?
Viral Dz, Bacterial Infections: UTIs, Sinusitis, Dental Infections
What chronic infestations can maintain TPs?
Diphyllobothrium latum (fish tapeworm); Giardia lamblia "Bever Fever"; Entamoeba histolytica
Name some other factors that can maintain TPs?
allergic rhinitis, impaired sleep, and nerve entrapments
what are the steps in diagnosing a trigger Point?
1. get pt to identify painful area; 2. use the reference charts to find out what muscles could contain TP that could produce that pain; 3) search each muscle for TP
Trapezius, SCM(sternal), temporalis, and semispinalis capitis are the possible muscles involved in what type of pain?
Temporal Headache
SCM (clavicular and sternal), frontalis, and zygomaticus major are possible muscles involved in what type of pain?
Frontal Headache
What are the steps in treating a TP?
1)do something to the TP (OMT,Physical Modalities, Injections; 2)stretch the muscle containing the TP, 3)recheck the TP
What are some physical modalities shown to help relieve a TP?
apply cold then stretch; U/S, Electrical Muscle Stim; Magnetic Therapy, Energy Techniques
Name some things that are injected into TP to help relieve them.
local anesthetics, corticosteroids, botox, opiates, ketorolac tromethamine (Toradol), sterile saline, bee venom, diazepam, Sarapin, dry needling
What types of OMT help relieve TP?
muscle energy, counterstrain, direct soft tissue/myofascial release, deep inhibitory pressure, percussion vibrator, correct the original segmental dysfunction that contains the TP
what outcomes can one expect after treating a TP?
1) total relief, 2)nearly total -mild, 3)step-like with repeated spraying, 4)no relief
name the abnormalities or cranial dysfunctions that cause various symptoms.
abnormal suture tension, abnormal dural tension, alteration of muscle origins and insertions, Cranial nerve entrapment and irritation, Alteration of arterial flow, reduction in venous drainage, alterations in CSF production, reabsorption and circulation
the first cranial nerve passes through what bone to serve its purpose?
olfactory nerve passes through the cribiform plate in the ethmoid bone
What are some symptoms that occur when CN1 is entrapped or irritated?
ansomia, hyperosmia, dysgeusia (can't taste)
name the bones that can be dysfunctional in an olfactory nerve entrapment or irritation.
Ethmoid, Frontal, sphenoid, nasal, vomer, maxillae
through what passage does the optic nerve take to get to the eye?
optic foramen in the lesser wing of the sphenoid
What are some symptoms that occur when CN2 is entrapped, compressed, or irritated?
blurry vision, visual dimming, photophobia
name the bones that can be dysfunctional in an optic nerve entrapment or irritation.
SPHENOID, occiput, parietal, temporal, frontal, ethmoid, zygoma, maxilla, and vomer
discuss the tract the oculomotor nerve takes to get to the eye.
midbrain over the anterior border of the tentorium at the petrous apex (where it is vulnerable to compression by external rotation of the temporal bone)--> then it passes through the cavernous sinus and exits the skull throught the superior orbital foramen between the lesser and greater wings of the sphenoid
What are some symptoms that occur when CN3 is entrapped or irritated?
eye twitching and/or a variety of ocular movement disorders
What bone dysfunctions can cause CN3 to be symptomatic?
problem between two wings of the sphenoid or any dysfunction of the sphenoid bone
discuss the tract the trochlear nerve takes to get to the eye.
off posterior midbrain --> through the anterior border of the tentorium (external rotation of the temporal bone can cause symptoms), then follows oculomotor nerve -->it passes through the cavernous sinus and exits the skull throught the superior orbital foramen between the lesser and greater wings of the sphenoid
What are some symptoms that occur when CN4 is entrapped or irritated?
weakness in the superior oblique muscle, diplopia, eye twitching
What dysfunctions cause symptoms for the trochlear nerve?
anything that tightens the tentorium - temporal external rotation; sphenoid or occipital dysfunctions
where do the muscles of the orbit attach?
onto a fibrous ring surrounding the optic nerve and attach around the optic foramen in the lesser wing of the sphenoid
what drains the orbit and what dysfunctions cause symptoms?
ophthalmic vein exits the optic foramen, then empties into the cavernous sinus. any dysfunctions of the sphenoid can create orbital venous congestion with resultant ocular pain, conjunctival injection, and swelling
What are some symptoms that occur when CN5 is entrapped or irritated?
trigeminal neuralgia, facial numbness, facial paresthesias, dental pain without dental dz, sinus pain without sinus dz, spasm or hypertonicity of the muscles of mastication, TMJ dysfunction
Discuss the tract of the trigeminal nerve.
pons--> over the petrous ridge beneath the anterior border of the tentorium --> 3 different branches go through the= V1: cavernous sinus --> superior orbital fissure --> supraorbital notch or foramen; V2: cavernous sinus --> inferior orbital fissure --> infraorbital notch in the maxilla, and V3: mandibular nerve --> foramen ovale passes b/w the tensor veli palantini and the lateral pterygoid muscles than enters the alveolar canal of the mandible.
Cranial nerve V1 is susceptible to dysfunctions of what bones?
frontal and sphenoid bones
Cranial nerve V2 is susceptible to dysfunctions of what bones?
sphenoid and maxilla
Cranial nerve V3 is susceptible to dysfunctions of what bones?
sphenoid, temporal, and mandible (temporal and mandible related to TMJ)
what commonly follows dental extractions?
trigeminal neuralgia
How will the symptom pattern differ when extracting lower vs. upper teeth in producing trigeminal neuralgia?
lower tooth pulled: neuralgia occurs on the opposite side; upper tooth pulled: neuralgia is on the same side as missing tooth; also,in trigeminal neuralgia, look for severly internally rotated temporal bones
How will a newborn act if there are birth injuries?
vomitting, excessive crying, colic, spasticity, sleeplessness, tremor, poor sucking and unable to latch onto nipple
What bone/s is/are usually involved in birth injuries?
sphenobasilar dysfunction or compression of the condylar parts of the occiput
Discuss the tract of the hypoglossal nerve.
brainstem--> hypoglossal canal(anterolateral to the occipital condyle) --> innervates the "midnight muscle"
what can cause a dysfunctional hypoglossal nerve?
compression of the condylar parts
explain the path of the vagus nerve.
brainstem --> exits cranium via jugular foramen (JF is in a suture b/w the occipital condyle and petrous temporal)
what can cause a dysfunctional vagus nerve?
any dysfxn of the suture containing jugular foramen can result in hyperparasympathecotonia. severe dysfxn can cause sufficient compression and cause sympathetic dominance - cuts out vagus/parasymp
Through what foramen does 85% of the blood entering the cranium leave?
jugular foramen
impingement of the jugular foramen can cause what?
general cerebral congestion, over distention of accessory circulation (Batson's Veins, Emissary Veins) and a wide range of cerebral, cervical, facial, and other symptoms.
What nerves utilize the jugular foramen to exit the cranium?
9,10,11 - glossopharyngeal, vagus, and accessory
discuss the course of the spinal accessory nerve.
originates from cervical spinal cord C1-C8 and enters the cranium via the foramen magnum and exits the cranium via the juglar foramen
irritation of CN11 can cause what?
congenital torticollis; if in an infant, compression can cause a floppy appearing baby that is unable to hold its head up at the appropriate age
how does an asthmatic hold his/her head?
they often show severe extension of the head with a high arched palate, creating nasal obstruction and mouth breathing
what OMT technique is used for an acute asthmatic attack?
CV-4; also, look for dysfunctions influencing the Vagus (hyperparasympathecotonia results in bronchoconstriction)
what 3 things can be caused by a dysfunctional temporal bone?
tinnitus, vertigo, and otitis media
in regard to tinnitus, what type of rotation of the temporal bone will cause the eustachian tube to OPEN and create a LOW pitched roaring tinnitus?
Externally rotated temporal bones cause the eust. to open and low pitched roaring tinnitus to occur
in regard to tinnitus, what type of rotation of the temporal bone will cause the eustachian tube to CLOSE and create a HIGH pitched roaring tinnitus?
INTERNALLY rotated temporal bones cause the eust. to CLOSE and and cause a HIGH pitched hum or ringing tinnitus to occur
if vertigo is due to cranial somatic dysfunction, it is often due to what?
dysfxn of temporal bone and associated cervical musculature; commonly one temporal bone is internal and the other is externally rotated
Internal rotation of the temporal bones tend to _____ the eustachian tube and cause what?
closed; high pitched tinnitus and chronic serous otitis media
External rotation of the temporal bones tend to open the eustachian tube and cause what?
low pitched tinnitus and a retrograde transit of food particles and liquids and result in recurrent acute otitis media
what dysfunctions are associated with migraines?
impaired jugular foramen and its venous drainage
where in the cranium does the internal carotid enter?
carotid canal in the temporal bone (the artery makes a right angle within the temporal bone)
where in the cranium does the vertebral artery enter and what does it carry?
foramen magnum and it carries sympathetic fibers to the posterior fossa region
what bone is rotated what way in epilepsy?
parietal bones are internally rotated
if epilepsy follows a head injury, cranial manipulation may be ____________.
do infantile seizures respond to cranial manipulation?
No, they don't respond, it is NOT indicated
cerebral palsy does not cause cranial somatic dysfunction but a co-existing cranial dysfunction may exist. should you treat it?
if you find a dysfxn treat it. if there is no improvement after about 3 months of weekly tx, there never will be...discontinue
Is treatment warranted with Post-concussion syndrome?
yes, it may improve dramatically; the closer tx is to the time of concussion, the better; if not working after 3 months of weekly tx; discontinue
What bones are possibly dysfunctional in sinusitis?
ethmoid, maxillae, vomer, sphenoid, zygoma, temporalis, frontal, and palatines
what time period after a stroke should you NOT do cranial manipulation?
you should not preform cranial OMT on a stroke victim for the 1st 3 weeks - may lower ICP and cause bleeding
Should you do cranial OMT on acute cerebral bleeds and infarcts?
What are the indications for cranial OMT?
1) presence of cranial somatic dysfunction; 2) absence of C/I to tx; 3) presence of symptoms which may resond to a cranial approach
What is the epidemiology of temporomandibular dysfunction? What effect does age have on TMJ dysfunction?
20% of pop'n has temporomandibular dysfunction (TMD); incidence of TMJ dysfunction increases with increasing age.
What are the agreed upon symptoms of TMJ dysfunction?
unilateral pain in or around the ear: pain may radiate to other areas of the head and neck, the pain increases during the day, the pain is exacerbated at mealtime.
list common symptoms of TMJ (not the most agreed upon, but generally accepted)
Tenderness of the masticatory muscles. Clicking or popping noises in the TMJ. the joint sound must be accompanied by pain. 50% of the population or more have "benign" TM Joint Sounds. Limited Range of Motion of the jaw; Lateral Deviation of the mandible on opening
What are regional sxs in the TMJ joint attributed to TMJ dysfunction?
TMJ joint clicking, popping, poor occlusal contact, crepitance, restricted range of motion, and pain.
What are regional sxs in the ear attributed to TMJ dysfunction?
conductive hearing loss, tinnitus, hissing, dizziness, vertigo, itching, pressure, fullness, earache, buzzing, stuffy sensation, loss of balance, otitis externa, and otitis media.
What are regional sxs in the eye attributed to TMJ dysfunction?
Nystagmus, eyelid twitching, diploplia, tearing, blurred vision, iritis.
What are pains attributed to TMJ dysfunction?
Headache, burning tongue, burning side of nose, shoulder, fingers, face, muscle tenderness, otalgia, burning throat, neck, arms, upper back, sinusitis, trigeminal neuralgia.
What are miscellaneous sxs of TMJ dysfunction?
dry mouth, difficulty swallowing, dyslexia, mental illness, parkinsonism, clicking of the teeth, sleep disorders, choking, snoring, nervousness, fatigue, speech difficulties, ADHD, bruxism, accelerated aging, periodontal disease, digestive disorders.
What are the big 6 types of TMJ dysfunction? aka What are the main factors involved in getting a TMJ dysfunction?
joint, teeth, muscles of mastication, cranium, cerival spine, psychological.
Describe normal TMJ mechanics?
with jaw slightly open one gets predominantly a hinge effect btw the condyle of the mandible and the articular meniscus. With full opening add to this a translatory gliding motion btw the meniscus and the temporal bone.
What is the normal opening range of motion of the mouth?
What is the normal ROM for symmetric lateral excursion of the jaw?
What is the normal ROM for protrusion of the jaw?
What is the normal ROM for retraction of the jaw?
highly variable from pt to pt
What could cause a loss of gliding motion of jaw?
articular meniscus may become adherent to the temporal bone with loss of the gliding motion.
what could cause a loss of hinge motion of jaw?
articular meniscus may become adjerent to the condyle of the mandible with loss of the hinge motion.
Describe location palpation and normal joint motion of the TMJ?
joint palpable placing index fingers in ear canals with pads facing anteriorly. pt instructed to open mouth slowly. Normally: smooth, synchronous, symmetric motion can be palpated in both joints simultaneously.
Describe abnormal movements felt on palpation? How would the pain associate to the restricted side?
an abnormal joint can be felt to move asymmetrically. often one joint is restrained in the temporal fossa while the other becomes hypermobile to compensate. often the pain occurs in the hypermobile joint structures while the real problem is on the OPPOSITE (restricted) side. Usu problem on side opposite pain and sxs.
Describe the pathophysiology of a typical whiplash injury of the meniscus? What type of OMM would be contraindicated in this pt?
typical whiplash injury can force the condyle of the mandible up against the articular eminence of the temporal bone and impact it into the meniscus. This also puts tremendous tension on the lateral pterygoid muscle and can result in stretching or rupture of the retrodiscal tissues. CAUTION: do not use traction for any reason.
What are two outcomes of the typical whiplash injury?
condyles can impact into the temporal bone's meniscus. then, the lateral pterygoid tenses and causes stretching or rupturing of the retrodiscual tissues. Stretching of the retrodiscal ligament then results in an anteriorly displaced meniscus with loss of condylar capture of the meniscus. The pt gets pain on opening the mouth and an opening "lock", a loss of ROM on opening with jaw deviation to the same side. Stretching or rupture of the pterygoid attachment to the meniscus can result in retrodisplacement of the meniscus. This causes pain on closing the mouth and a closing "lock", an inability to fully close the mouth.
What would the treatment be for situations where menisceal capture is lost? How long is the treatment window period, and what happens after that time?
Direct manipulation of the jaw to recapture the meniscus and guide it back into the fossa. This works within a short time (weeks) after loss of capture. If it is allowed to persist too long, fibrosis and shortening of soft tissue occurs and a surgical approach becomes the only option.
What is the normal joint space distance of the TMJ, and what does smaller distance indicate?
On plain x-ray the bone to bone distance across the TMJ measures 3mm. Smaller joint space indicates loss of capture of the meniscus or loss of articular cartilage.
What is the effect lacking of posterior teeth?
The posterior teeth are responsible for maintaining normal joint space in the TMJ. Loss of the posterior teeth without replacement will result in increased pressure across the joint and premature osteoarthritis.
What is the effect of the cusps of the teeth not meshing normally?
If the cusps of the teeth do not mesh normally, abnormal lateral and anterior-posterior gliding motions will be introduced. These additional motions can put stress on painful joint structures. They can also produce excessive stress on the muscles of mastication, and/or lead to the development of cranial somatic dysfunction.
What are the ligaments that the mandible hangs from?
In addition to the joint capsular structures, the mandible is suspended by two ligaments: stylomandibular ligament and sphenomandibular ligament.
What are the effects of anterior head carriage?
anterior head carriage increases the tension on the anterior strap muscles of the neck with attach to the hyoid bone and then to the mandible. This tends to pull the mouth open. Causes downward pull that is offset by temporalis, masseter, and medial pterygoid muscle pull upward. These muscles then become painful from overuse.
What is the function of lateral pterygoid? medial pterygoid muscles in motion of jaw?
lateral - jaw protrusion; medial - jaw closure.
What does trigeminal nerve supply?
sensory innvervation of the joint itself, capsule and ligaments. Motor supply to the muscles of mastication. sensory nuclues of the trigeminal extends out of the brain stem and down into the spinal chord. some 'authorities' place the lowest extent of the sensory nucleus anywhere from C3 to the C7 spinal chord levels.
What level of spinal dysfunction is associated with TMJ dysfunction?
cervical somatic dysfunction C3, C4, and C5 (midcervicals).
If the facial nerve is involved secondarily in a TMJ dysfunction, what would be seen? in a severely involved case? how different from bell's palsy?
Manifests as facial twitching or spasm of the mucles of facial expression. If severly involved, there may be weakness or drooping of the face on the side of involvement. This differs from Bells Palsy which is caused by swelling of the nerve within the facial canal of the temporal bone.
What muscle straightens the eustachian tube? And what are the effects of hypertonicity of this muscle?
Tensor valli palatini m. and hypertonicity results in prolonged opening of the eustachian tube. This can result in roaring tinnitus or recurrent middle ear infections due to retrograde passage of saliva and food particles up into the middle ear. The isthmus of the tube normally serves as a sort of valve to prevent this retrograde passage from occurring, closing the eustachian tube when the tensor valli palatini muscle relaxes.
What innervates the tensor valli palatini m. and what are effects of increased tone?
Innervated by a branch of the mandibular nerve, part of the trigeminal system. Increased trigeminal tone results in reflex hypertonicity of this muscle with prolonged opening of the eustachian tube.
What are psychological factors that contribute to generalized muscle hypertonicity?
anxiety, stress, depression
Define bruxism.
clenching or grinding of teeth. may be caused by pscychological stress causing severely dysfunctional cranium. Sometimes resolves once cranial restrictions are removed. Can be seen with anger - grinding teeth.
What are other conditions that can cause TMJ dysfunction?
it is a synovial joint and subject to all the dz of synovial joints (rhuematoid arthritis, etc.); muscles of mastication can be involved in muscular dz such as McArdle's dz and other rare muscle conditions; muscles are more commonly involved in diseases of the CNS neurologic origin. May manifest as jaw clonus. Clonus will occur in any muscle exhibiting spasticity of CNS origin
Muscle spasm may also arise as a result of which metabolic diseases?
hyperthyroidism, hypokalemia, hypocalcemia (produces muslce spasm in response to muscle percussion)
What is the Chvostek sign?
Hypocalcemia produces muscle spasm in respone to muscle percussion. sign of tetany. stimulate medial to the angle of the jaw
what is the leading cause of disability in adults >65 yo?
rheumatologic disease
define rheumatologic disease.
RD are acute and/or chronic conditions marked by MIP - muscle soreness and stiffness; inflammation; and pain in joints and associated structures.
define arthritis.
joint inflammation accompanied by pain, swelling, stiffness, and deformity
What's difference in Rheumatic disease and arthritis?
arthritis only affects joints; Rheumatic disease affects tissues and organs as well as joints
What's difference in Rheumatic disease and rheumatic arthritis?
rheumatic arthritis is a type of rheumatic disease; RA is an autoimmune disorder that involves multiple joints at the same time; pain is also worse in the morning
list some Rheumatic diseases.
osteoarthritis, rheumatoid arthritis, degenerative joint disease, ankylosing spondylitis, seronegative spondyarthropathies, Fibromyalgia, and Systemic Lupus Erythematosus, gout, bursitis, tendonitis, scleroderma, polymyositis (muscle inflam. and weakness), and polymyalgia rheumatica (involves muscle, tendons, ligaments, tissues around joints)
in terms of rheumatic diseases, which one is most common?
OA=15%; Fibromyalgia=2%; RA=1%, Ankylosing spondylitis=<0.4%; SLE= 0.015%
which rheumatic diseases are most common in women?
SLE 9:1; FM 9:1; RA 2-3:1; Scleroderma; the only ones that are men dominated are ankylosing spondylitis and gout
when thinking about the history of a rheumatic patient, you think about the pattern of involvement. what is the difference in migratory and progressive?
migratory is having pain subside in the joint before starting up in another joint; progressive is first joint stays painful while new joints become involved in the pain process
What are the major consequences of having a rheumatic disease?
DISUSE MUSCLE ATROPHY; INTERFERENCE WITH ADLs; pain, pain equivalents, numbness, muscle spasm, chronically increased muscle tone, depression
What do you do in a Physical exam when faced with a rheumatic disease?
passive joint motion testing; LABS: CBC, Chem panal, u/a, RF, ESR, ANA (possibly a synovial fluid exam and/or autoantibody and immune assay); X-RAYs, U/S, MRI, CT
What are some pitfalls of diagnosing a rheumatic disease?
RA pts can have a +ANA; ANA is anti-nuclear antibody which is + in autoimmune disorder(double stranded ANA is specific to SLE); Pts>60 y/o can be RF+ in absence of RA; ESR only tells you there is inflammation, not specific;
describe arthritis.
most common arthritis is osteoarthritis; it affects cartilage, involves weight-bearing joints, difficulty using a joint normally, warmth and redness in a joint
describe RA.
multi-systemic autoimmune inflammatory disease. primarily in the synovium and results in premature death; fatigue, low-grade fevers, mild to moderate anemia, pleural/pericardial effusions (serositis), multisystemic vasculitis
List the American College of Rheumatology's diagnostic criteria for RA.
a min. of 6 weeks of at least 4 of the 7: 1)morning stiffness for at least one hour, 2)simultaneous soft tissue swelling in 3 or more joint groups 3)radiographic evidence of RA bone erosions in the wrist and hands, 4)hands joints must be involved 5)+RF 6)rheumatoid nodules 7)symmetric joint involvement
Describe gout.
monosodium urate crystals get deposited in articular cartilage of joints and tendons; commonly affects males 1st MTP (big toe)
Name this seronegative spondyloarthropathy (-RF). most affects males' spines, +sacroilitis, +peripheral inflammatory arthritis, HLA-B27.
ankylosing sponkylitis - hips, shoulders, knees may also be involved; tendons and ligaments around bones and joints become inflamed
Name this potentially debilitating autoimmune disease. affects mostly women, attacks the body's cells and tissue, resulting in inflammation and tissue damage. polyarthritis with characteristic butterfly rash. can affect any part of the body but most often harms the heart, joints (hands, wrists, and knees most commonly), skin, lungs, blood vessels, liver, kidney, and CNS.
Systemic Lupus erythematosus
This disease involves chronic widespread musculoskeletal pain, stiffness, paresthesias, disturbed sleep, easily fatigued, with multiple painful tenderpoints.
What is unique in the rheumatic disease, Fibromyalgia?
there is no inflammation, connective tissue, or diagnostic muscle abnormalities
What can trigger Fibromyalgia?
Pathogenesis is unknown; triggered by emotional stress, infections and other medical illness, surgery, HYPOthyroidism, Trauma
What four diseases are associated with the HLA-B27 (not in OMM lecture - freebie)?
"PAIR" = Psorasis, Ankylosing Spondylitis, Inflammatory Bowel Disease, and Reiter's Syndrome
What 2 diagnosis overlap with the diagnosis of Fibromyalgia?
Chronic Fatigue Syndrome and Depression
List the co-morbid conditions with Fibromyalgia?
IBS, irritable bladder, headaches, dysmenorrhea, PMS, RLS, TMJ, non-cardiac chest pain
List the classification criteria for fibromyalgia.
history of widespread pain with all of the following: Pain in left and right side of the body, Pain above and below the waist, and Axial skeletal pain (in any of: cerivcal spine, anterior chest, thoracic spine, low back) Must also have pain on palpation of at least 11 of the 18 tenderpoints (there are 9, but it is bilateral): 1. occiput:suboccipital muscle insertion; 2)low cervical, anterior aspect of intertransverse space C5-C7; 3)trapezius, midpoint upper border; 4) supraspinatus, above scapular spine near medial border; 5)2nd rib; 6)lateral epicondyle; 7)gluteal, upper outer quadrant of butt; 8) greater trochanter 9)knee, medial fat pad
How do you treat Fibromyalgia?
1)improve quality of sleep with tricyclics (amitriptyline or nortriptyline); 2)next treat depression and anxiety (beware of non-compliance); 3)exercise prescription; 4)NSAIDs, partial improvement; 5)Tylenol, Tramedol for pain; 6) Gabapentin; 7)heat,massage, TP injection; 8) biofeedback, hypnotherapy, stress management 9)identify life stresses and discuss NOT Helpful or of little use: corticosteroids (not inflammatory) and opiate analgesics
What are the general treatments of Rheumatic Diseases?
NSAIDs (ibuprofen, naproxen sodium, aspirin - monitor s/e with aspirin), Corticosteriods, DMARDs (Disease modifying anti-rheumatic drugs), surgery, OMT
List the possible side-effects of NSAIDs.
GI toxicity or bleeding, Renal Toxicity (this is how most are eliminated), platelet dysfunction, hypersensitivity reactions
If a rheumatic disease pt is unresponsive to NSAIDs, what is the next step? also list this treatment's side-effects.
corticosteroid injections (good for neg long-term s/e), Orally - low dose of prednisone (5-20mg) then progress to 1-2mg/kg qd if needed. side-effects: adrenal suppression, immunosuppression, endocrine abnormalities (cushingnoid), M/S problems like osteopenia, steroid myopathy, ischemic bone necrosis, mental status changes, and ocular effects (can increase IOP and cause glaucoma)
What DMARD (tx for rheumatic diseases) is the most widely used and effective for long-term treatment of RA? list it's side-effects.
Methotrexate; s/e: hepatotoxicity, bone marrow suppression, oral ulcers, life-threatening pneumonitis (take 1mgqd of Folic acid to reduce methotrexate toxicity)
List the 3 DMARDS used to treat RA.
Methotrexate (MC used), Enbrel (recombinant TNF receptor inhibitor for severe RA), and cyclosporin (immunosuppressant for refractory RA).
What are the indications for tx an RA pt with Enbrel?
severe RA that is highly effective at controlling the symptoms and disease progression with a low toxicity; however, it is very expensive and potentially can induce cancer and infections
What are the side-effects of the immunosuppressant cyclosporin (used for tx refractory RA)?
renal tox, hypertension, liver dysfunction, and oncogenicity
in regard to rheumatic diseases and surgery, what devices give excellent results?
hip and knee prosthetic devices
List common OMT for Rheumatic diseases.
1)soft tissue OMT to periarticular tissues improves blood flow and decreases hypersympathetic activity; 2)segmental facilitation; 3)indirect stacking for tender, inflammed tissues; 4)Liver and Gallbladder pumps; 5)lymphatic drainage; 6)CV4 (also good for asthmatics); 7)non-weight-bearing compression of joint surfaces improves local nutrition and decreased stiffness (RA hallmark) 8) treat the GI system if affected by NSAIDs DO NOT do CERVICAL HVLA; there is a high incidence of weakened cruciate ligaments with potential pathologic subluxations
How is the prognosis for recovery for rheumatologic diseases?
there is NO CURE; treat symptoms, improve functioning, and improve sense of well-being with pharmacology and OMT
if the articular meniscus of the TMJ becomes adherent to the temporal bone one loses _________ motion. if the articular meniscus becomes adherent to the mandible's condyles, then you lose the _________ motion.
adherent to temporal bone - lose GLIDING (would be difficult to fully open mouth); adherent to condyle - lose HINGE (difficult to slightly open mouth)
when the jaw is slightly open, the normal motion is ___________. when the jaw if fully opened, the motion is _____________.
slighty open - hinge; fully open - gliding
a whiplash injury does what to the mandible and pterygoid muscles?
whiplash can force the condyles up against the articular eminence and impact them into the meniscus of the temporal bone; it can also stretch or rupture the retrodiscal tissues of the lateral pterygoid muscle
on a plain x-ray, if the distance across the TMJ measures less than 3mm there is either loss of __________ or loss of __________.
loss of capture or loss of articular cartilage
what TMJ problems can result in premature osteoarthritis, indicated by a beak appearance of the condyle?
torn or perforated meniscus and/or lack of posterior teeth without replacement
what 4 things will tend to pull the mouth open?
asthma, whiplash, and anterior head carriage (and of course, hatchet face due to myotonic dystrophy - another freebie)
an open eustachian tube can be caused by what factors?
hypertonicity of the tensor velli palatini muscle; external rotation of the temporal bone = all may cause a low-pitched roaring tinnitus and possibly lead to retrograde materials getting into middle ear and causing otits media
often the pain that occurs in TMJ occurs on the __________ while the real problem is on the ___________ (restricted) side.
hypermobile side; opposite (the joint that is restrained in the temporal fossa)