Current Perspectives on Orofacial Pain • Innervation of trigeminal system (head, face, masticatory musculature, temporomandibular joint and associated structures). • Temporomandibular disorders (TMD) are the most prevalent orofacial pain conditions for which patients seek treatment. • Temporomandibular disorders include a number of clinical problems that involve the masticatory musculature, the temporomandibular joint (TMJ) or both. • Trigeminal neuropathic pain conditions can arise from injury secondary to dental procedures, infection, neoplasias, or disease or dysfunction of the cervical spine (Reyes, 2015). 22
The First Rib and Pain Referral • First Rib ‐ most superior of the twelve ribs. • Atypical rib and anatomical landmark. • It is one of the borders of the superior thoracic aperture • Innervation • Innervated by the first intercostal nerve. • The intercostal nerves are distributed chiefly to the thoracic pleura and abdominal peritoneum and differ from the anterior rami of the other spinal nerves in that each pursues an independent course without plexus formation. 23
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The First Rib and Pain Referral • So Many Attachments!! • Anterior scalene muscle: scalene tubercle • Middle scalene muscle: between groove for the subclavian artery and transverse tubercle • Intercostal muscles: from the outer border • Subclavius muscle: arises from the distal shaft and first costal cartilage • First digitation of the serratus anterior muscle • Parietal pleura: from the inner border • Costoclavicular ligament: anterior to the groove for the subclavian vein 25
How to Palpate the First Rib • The first rib is often noted as the most difficult rib to palpate. To palpate the first rib, find the superior border of the upper trapezius muscle and then drop off it anteriorly and direct your palpatory pressure inferiorly against the first rib. Asking a patient to take in a deep breath will elevate the first rib up against your palpating fingers and make palpation easier • https://youtu.be/zwDO_VXOItM • https://youtu.be/PrDZD1erucI 26
First Rib Pathology • Thoracic Outlet Syndrome ‐ compression of the neurovascular structures as they exit through the thoracic outlet (cervicothoracobrachial region) • The thoracic outlet is marked by the anterior scalene muscle anteriorly, the middle scalene posteriorly, and the first rib inferiorly. • The term ‘TOS’ does not specify the structure being compressed. 27
First Rib Pathology • TOS affects approximately 8% of the population and is 3 ‐ 4 times as frequent In woman as in men between the age of 20 and 50 years. • Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain (referred to the shoulder blade/chest and around shoulder) and sensory changes to limb threatening complications in severe cases 28
First Rib Pathology • Pancoast Tumor ‐ refers to a relatively uncommon situation where a primary bronchogenic carcinoma arises in the lung apex at the superior pulmonary sulcus and invades the surrounding soft tissues. • The most common symptoms at presentation are chest and/or shoulder pain, with arm pain being also common. Weight loss is frequently present 29
TOS Exercises • https://youtu.be/lnaxIFP2_yA • https://youtu.be/q0r5XfZ ‐ NXc • https://youtu.be/MpojqL ‐ B5pc • https://youtu.be/wz6KRl3YtqU • https://youtu.be/YQMpmJbpfgY 30
TOS Exercises • Literature synopsis of first rib mobilization: • While literature investigating manual therapy in the treatment of thoracic outlet syndrome is very limited, results show a manual depression of the 1st rib to be an easy, effective option in conservative management of thoracic outlet symptoms. 31
Causa Causation ion of of Balance Balance Di Disor sorder ers and and Vestibular ibular Rehabilit habilitation ion De Defined ned • Function • Statistics • Etiology • Gait Assessment • Balance Testing 32
Function of the Vestibular System • The vestibular system functions: • Detects motion of the head and maintains stability of images on the fovea of the retina • Vestibular ‐ ocular reflex • postural control during head motion (cervical), ‐ Minor 1998 • Vestibulo ‐ spinal reflex • The system is made up of 3 components: • Peripheral sensory apparatus (Picture next Slide) • Motion sensors that send info to the CNS (Vestibular nucleus complex and cerebellum) • Information on head velocity and linear acceleration • Central processor • The CNS • Processes signals to estimate head and body orientation in space • A mechanism for motor output • Info is sent to ocular muscles and the spinal cord in 3 reflexes: • Vestibulo ‐ ocular reflex (VOR) • Vestibulocollic reflex (VCR) • Vestibulospinal reflex (VSR) 33
• Hain 34
Function of the Vestibular System • VOR – generates eye movements • Enables clear vision while the head is in motion. • Stabilizes images on the retina • Elicits eye movement by stimulating the vestibular system (Nystagmus) • Nystagmus is rhythmic back and forth beating (VOR generates slow phase to keep eye focused) • When eye reaches max range; a Saccade (quick phase) in generated in Opposite direction to new target • VCR – acts on the neck musculature to stabilize the head • Reflex initiated by vestibular system. “Righting reflex” • VSR – generates compensatory body movement to maintain head and postural stability • Fall prevention and balance strategies • The performance of all 3 reflexes is monitored by the CNS and re ‐ adjusted accordingly by the cerebellum. – (Hain, T) • LAB – VOR Activity 35
Function of the Vestibular System • Statistics • Population based study in US reported that 24 ‐ 30% of older people >age 72 have dizziness (Iwasaki/Klaus) • Falls are the leading cause of hospital admission and accidental death in elderly population (Iwasaki) • Vertigo and unsteadiness causes a fear of falling. • This is a predictor for those who will suffer one or more subsequent falls. • Vestibular rehab significantly decreases the risk of falls in the elderly (Macias) • Age related decline of the vestibular system correlates with age related decrease in the number of vestibular hair cells and neurons (Iwasaki) • Mitochondrial anti ‐ ox (alpha lipoic acid and co Q10) may reduce age dependent hair cell loss in study (Iwasaki 2015) 36
Sensory and Motor Control Roles • Postural Control • Vestibulopathy, • Nystagmus Assessment • Involuntary movement of the eye • Balance Components • VOR – reflex where activation of Vestibular system causes eye movement • Bilateral vs. Central Loss 37
Po Postural Con Control • Postural control is the ability to control the body position in space. –Huang 2006 • Normal CNS involvement keeps the body in vertical postural alignment • Patients with affected vestibular function will lean, tilt, or shift toward the weaker side. • Patients will correct this with compensation strategies. • Patients immediately experience hypermetria (movement of a body part beyond its goal) after a vestibular hit • Ataxic with severe postural instability • Increased amplitude of both reactive and anticipatory postural responses 38
Postur ural al Con Control • Boundaries = Limits of stability. • Ankle strategy allows ~4 degrees backward and ~8 degrees forward on stable surface. • In vestibulopathy, responsive reactions are larger movements than are needed • Theory for vestibular hypermetria: • Reduced cerebellar inhibition of the spinal motor system • Loss of vestibular input reduces the inhibitory mechanism of Purkinje cells (in cerebellum) • Poor reactive synapses from the somatosensory system to the vestibular nucleus after loss of vestibular drive –Hurak 2009 39
Po Postural Con Control • Changes with age related to sensory systems include: • Reduced joint position sense • Reduced visual function • Decreased vestibular function • In elderly Shumway ‐ Cook reported a 40% reduction in lower body muscle strength compared to young and healthy pt • Altered muscle response organization • More frequent co ‐ activations of antagonist muscles • Elderly exhibited a decreased ability to react to external perturbations • Difficulty in sensory re ‐ weighting • Lastly “stance of elderly people is reported to be less stable with absent or altered proprioceptive, vestibular and visual information.” (Peterka) 40
Postur ural al Con Control • Normally, proprioceptive information regarding sensory data is congruent. • Eyes, ears and feet all contribute proportionally to body position in space and movement. • Sensory situations that are not congruent are: • Uneven or an altered surface • Modification or absence of vision 41
Po Postural Con Control • Postural Tests per Clinical Preference/Practice for goals and return of Postural Control Tracking • Sensory Organization Test (SOT) – objectively identifies abnormalities in varying three sensory systems • Modified Clinical Test of Sensory Interaction (mCTSIB) – derivative of SOT to provide objective evidence of sensory dysfunction • Dynamic Visual Acuity (DVA) – changes in visual acuity at head velocities (visited again in formal Eval Section) Highly reliable for Vestbular hypofunction • 10 ‐ 15 feet away from eye chart • Stability Evaluation Test (SET) – balance control measures of postural sway velocity on available test conditions (per clinic) • Others you may wish to employ after independent study or clinical opinion: • Motor Control Test, Adaptation Test, Limits of Stability, Gaze Stabilization test, Unilateral Stance, Sit to Stand 42
Po Postural Contro rol • 6 conditions of Postural Control • During more challenged environments, the CNS relies more on the vestibular system for fall prevention • Elderly studies on proprioception • Results in elderly showed a decline in amplitude of motor feedback. LAB – Rehab Tx 43
Cer Cervical al Scr Screen een and and Special Special Te Tests • Vertebral Artery Test • Cervical sidebend and rotation in slight extension • Chin on Hand testing to mimic Dix Hallpike positioning for clearance (picture 1) • Arms extended test watching for drooping of one arm, parasthesia, dizziness or nystagmus (picture 2 and 3) • Red Flags: diaphoresis, dysphasia, dysarthria, drop attacks, diplopia, high pain 44
Special Special Te Tests 45
Special Special Te Tests • Cervical Instability • Sharp Purser – assessment of transverse ligament. • 1. Forward flex head and support with hand or elbow, opposite hand on SP of C2. • 2. Soft end feel, clunk or reduction of symptoms with shear • 3.Positive test and ER call. • The test without head flexion is also an effective headache SNAG 46
Special Special Te Tests • Ligamentous Stability • Cranial Axis Lift • Transverse Ligament Assessment • 1. Supine • 2. Support occiput with fingers on posterior arch of atlas • 3. gently lift axis and atlas while preventing upper cervical flexion • 4. Negative test = hard end feel • 5. Excessive motion or soft end feel = positive test • Monitor for parasthesia and nystagmus 47
Special Special Te Tests • Ligamentous Stability • Atlas – Axis Shear Test for Transverse Ligament • One hand on C1 and one hand on C2 • Arms parallel to table • Press hands toward each other in a shear motion • Hard/Firm end feel is negative • Soft end feel = positive 48
Special Special Te Tests • Ligamentous Stability • Alar Ligament • Find C2 Spinous process • Passively sidebend the upper cervical spine • Passively rotate the upper cervical spine • Hard end feel = negative • Soft end feel or increased pain/spasm = positive test 49
Special Special Te Tests • Ligamentous Stability • Tectoral Membrane • 3 positions: • Gentle long axis traction in neutral • Add upper cervical spine flexion with traction • Keep position and block axis • An empty or soft end feel/lag = positive test 50
Upper Upper Quart Quarter Scr Screen een • Manual Muscle Testing • Cervical Spine • ROM • Compression • Distraction • Sensation • Dull • Sharp • Light Touch • Deep Tendon Reflex • Normal • Brisk • Absent • Diminished • Coordination • Finger to Nose • Heel Shin • Rapid Alternation • Finger Opposition 51
Scr Screening eening Lab Lab • Vertebral Artery • Transverse Ligament • Alar Ligament • Tectoral Membrane • UE Screen/ROM/MMT/Neuro 52
Ce Cervic icog ogenic ic Dizziness zziness • Cervicogenic dizziness may be a result of whiplash injury, other forms of cervical spine dysfunction, or spasms in the cervical muscles. Wrisley, 2000 • The diagnosis of cervicogenic dizziness is characterized by dizziness and dysequilibrium that is associated with neck pain in patients with cervical pathology • Cervicogenic dizziness is most often associated with flexion ‐ extension injuries and has been reported in patients with severe cervical arthritis, herniated cervical disks, and head trauma. In these patients, complaints of ataxia, unsteadiness of gait, or postural imbalance associated with neck pain, limited neck range of motion, or headache predominate, Wrisley 2000 53
Cervic icogenic ic Dizziness Dizziness • Pathophysiology • With strong connections between the cervical receptors and balance function, it is believed that injury or pathology of the neck may be associated with a sense of dizziness or disequilibrium, (Wrisley 2000) • Current theory is that cervicogenic dizziness results from abnormal input into the vestibular nuclei from the proprioceptors of the upper cervical region. (Wrisley 2000) • The interconnections between the cervical proprioceptors and the vestibular nuclei may contribute to a cyclic pattern, where the cervical muscle spasms contribute to dizziness; and dizziness contributes to muscle spasm, although the causal relationship is unclear. (Wrisley 2000) 54
Cervic icogenic ic Dizziness Dizziness • Cervicogenic dizziness is a diagnosis of exclusion • (ie, the diagnosis is usually based on the elimination of the other competing diagnoses, such as vestibular or central nervous system pathologies), (Wrisley 2000) • The neck torsion nystagmus test, or head ‐ fixed, body ‐ turned maneuver is considered by some to identify cervicogenic dizziness. • Test requires the head of the patient to be stabilized while the body is rotated underneath. • Theoretically, the neck proprioceptors are stimulated while the inner ear structures remain at their resting. Nystagmus is elicited in a positive test. • Determine if the patient with a chief complaint of dizziness or vertigo has neck pain, either at rest, with active neck movement, or with palpation of the neck musculature. • This step is important because, by definition, a diagnosis of cervicogenic dizziness is excluded in a patient without neck pain. (Wrisley 2000) 55
Cervic icogenic ic Dizziness Dizziness • Manual therapy is recommended treatment for cervicogenic dizziness directed at decreasing muscle spasms and trigger points of pain in the cervical musculature. • Treatment for cervicogenic dizziness: • Manual therapy to decrease the irritation on the cervical proprioceptors from muscle spasms and trigger points • Exercises with graded exposure to sensory inputs to improve the patient's use of vestibular and proprioceptive inputs for balance. • Eye exercises to improve the function of the vestibular ‐ ocular reflex. • Evidence shows the use of manual therapy/mobilization for cervicogenic dizziness showed improvement in postural stability, ROM, muscle tenderness and neck pain. Therefore manual therapy combined with vestibular rehab yielded good treatment outcomes (Lystad) 56
Vestibular ibular Hypofunction Hypofunction • Defined as postural instability, visual blurring with head movement and subjective complaints of dizziness • Results: Based on Strong evidence of benefit over harm • Clinicians should offer vestibular rehab to uni and bilateral vestibular hypofunction with impairments and limitations related to deficit • Clinicians should NOT include voluntary saccadic or smooth pursuit eye movements in isolation (without head movement) • Should be perscribed 3 x per day for gaze stability as at least one component of HEP • Based on expert opinion ‐ acute or subacute unilateral hypofunction may need 1 x per week for 3 sessions then HEP • Chronic unilateral 1x per week 4 ‐ 6 visits, Bilateral 1 x for 8 ‐ 12 V • Evidence derived: APTA Neurology section Clinical Practice Guidelines 57
Theories, Theories, In Interv rven entio tions, and and Ex Exer ercise cise Pre Prescription Vestibular Rehabilitation Therapy 58
Section Section Obj Objecti ctives es • 1. Understand the role and effectiveness of Vestibular Rehabilitation Therapy (VRT) on Unilateral/Bilateral Peripheral Vestibular Hypofunction. • 2. Review indications for VRT regarding Peripheral Vestibular Hypofunction including enhanced gaze stability, enhanced postural stability, improved vertigo, and improved ADL’s. • 3. Understand and apply interventions of adaptation, substitution, and habituation. • 4. Demonstration of progressive treatments of VRT to alleviate the primary and secondary problems caused by vestibular disorders. • 5. Demonstration and understanding of causation and manual treatment for cervical caused dizziness. • 6. Reference of outcomes and considerations for various conditions 59
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Ce Cervic icog ogenic ic Dizziness zziness • Possible result of cervical spine dysfunction including: • Whiplash injury • HNP • Forms of cervical spine dysfunction (Trauma/OA) • Spasms in the cervical muscles. (Wrisley, 2000) • Diagnosis • Characterized by dizziness and dysequilibrium • Associated with neck pain in patients with cervical pathology • True spinning vertigo is rarely associated with this syndrome • Presentation and Symptoms • Complaints of ataxia/unsteadiness • Headache • Postural imbalance associated with neck pain • Limited neck range of motion (Wrisley 2000) 62
Cer Cervic icog ogenic enic Dizziness Dizziness • Pathophysiology • Strong connections between the cervical receptors and balance function • Injury or pathology of the neck ‐ associated with a sense of dizziness or disequilibrium, (Wrisley 2000) • Current theory • Abnormal input into the vestibular nuclei from the proprioceptors of the upper cervical region. (Wrisley 2000) • Cyclic pattern • Cervical muscle spasms contribute to dizziness • Dizziness contributes to muscle spasm, although the causal relationship is unclear. (Wrisley 2000) 63
Vestibul ibular ar Hypof Hypofunction unction • Bilateral Vestibular Hypofunction • Reduction or loss of vestibular function • Difficulty walking in the dark or on uneven surfaces (Balance) • Decrease in the patient’s ability to see clearly during head movements. • Ototoxicity, meningitis, sequential vestibular neuritis, progressive disorders, autoimmune disorders, and neurofibromatosis. (usually idiopathic) • Oscillopsia ‐ Another problem for patients with bilateral vestibular loss is the visual blurring that occurs during head movements. Almost 70% of all patients with BVH complain of oscillopsia even after a course of gaze stabilization exercises. 64
Vestibul ibular ar Hypof Hypofunction unction • Unilateral Vestibular Hypofunction (UVH) • A condition in which one of the peripheral vestibular receptors or the vestibular portion of cranial nerve VIII (vestibulocochlear) is not functioning properly. • Oscillopsia during gaze activity or head movement • Postural Instability and Deconditioning • Causes: neuritis, labyrinthitis, perilymphatic fistula, and acoustic neuroma 65
Vestibular ibular Rehab habilit litation ion Ther Therap apy (VR (VRT) & Cer Cervic icog ogenic enic Di Dizzine zziness: ss: Theories, Theories, In Interven entio tions, ns, and and Ex Exer ercise cise Prescrip escriptio tion • Adaptation • Substitution • Habituation • Balance Retraining • Cervicogenic Dizziness • Manual Therapy • Treatments 66
Traditio aditional nal Re Rehab vs. vs. VR VRT • Therapeutic Exercise • Vestibular Rehab • Isometric Exercise • Exercise based program • Isotonics to reduce vertigo and dizziness, gaze instability • Resistive and imbalance with falls. • Can use Apps, programs and Metronome to set and document speed • Adaptation • Substitution • Habituation 67
VR VRT Trea eatmen tment Theori Theories es and and Ex Exer ercise cise Pre Prescription • Recovery • Healing and rehabilita � on opportuni � es → plas � city of the CNS • The brain is able to recalibrate (use other senses) • Compensation from incorrect signals sent to the vestibular system • VRT improved vestibular function, reduced dizziness, improved mobility, postural stability, and gaze stability with head movement (Tee) • BPPV • Evidence shows CRT and incorporated VRT is effective as a preventative measure and recovery (Hillier 2016) • Two stages • Acute Compensation (Adaptation and Substitution) • Brain recognizes signal are incorrect and shuts them off with a cerebellar clamp • Chronic Compensation (Habituation) • Brain is getting signal bilaterally and begins to “make sense” of it all. 68
Adap Adaptation tion • Indication: Gaze Instability category, lack of coordination of head and eye movements • Goal: Reduce error and restore VOR and VSR • ↓ Re � nal slip/blur or “error signals” through demands • Step 1 in recovery of symptoms during static positioning accomplished through the cerebellar clamp • Adaptation is the mechanism of recovery during the acute stage of compensation • Capability of the vestibular system to facilitate indefinite changes in the neuronal response to a stimulus via plasticity. • Performance of head movements while keeping a target (X1) (or 2 targets X2) in focus (Dye) • Eyes must be focused on a word or letter to effectively induce retinal slip 69
Sub Substitutio titution • Indication: Dysfunctional and non ‐ recovering vestibular system or to strengthen drive compensation for the partially functioning vestibular system. (all types of vestibular loss) • Goals: Strengthen the remaining sensory systems (oculomotor, somatosensory) or drive improvement into the other systems. • The substitution of alternative strategies to replace the lost or compromised function • Internal substitution • Most likely central pre programming the pt vision • To compensate for vestibular loss. • External substitution • Assistive devices, home modifications, lifestyle changes • Promotes the vestibular system removing visual cueing and changing somatosensory input (proprioceptive balance exercises) Creath 2002 70
Habi Habitua tuation ion • Indication: Motion provoking category • Goal: Rebalance tonic activity with the vestibular nuclei and reduce responsiveness to repetitive stimuli • Ability of brain to tune out a continuous repetitive tone (Dye) • Desensitization ‐ the more you feel your symptoms, the more likely the symptoms are to be suppressed. • One movement may improve (horizontal), but doesn't transfer to another (vertical). • Not appropriate for bilateral vestibular loss (Initially) * • At the beginning phase, sitting symptoms will resolve while standing symptoms will persist due to the continued cerebellar clamp • Balance signals turned off where the cerebellum reduces firing through the brainstem • Near the end of the acute stage of compensation, the cerebellar clamp will release allowing balance information from the vestibular system to transmit to the brain. • Study of postural re ‐ arrangement (Alessandrini) 71
Habitua Habituation ion • Chronic Stage of Compensation • Brain will receive bilateral signals and decode/re ‐ learn info • Correct any discrepancy between the two ears • The more signals the brain receives, the more it understands and interpret what the balance organs are relaying • Normal ADL movements will assist in compensation phase • Habituation and Gaze Stabilization exercises in 6 weeks improved DHI and MSQ outcome scores (Clendaniel) • Habituation through repetition of recovery to specific movements. • Begin to allow pts to encounter movements that caused symptoms to maximize compensation • Barriers to recovery: use of meds outside post acute phase. • They result in turning off signals and keep the brain clamp engaged 72
Sub Substitution titution Ex Exer ercises cises • Seated Treatment • 1. Hold 2 cards or targets • Keep visible when holding them straight • 2. Turn head and eyes to one target • 3. Turn eyes to opposite target then move head to the same direction • Repeat on the other side • 4. Manipulate speed, target distance, surface and background 73
Sub Substitution titution Ex Exer ercises cises • Exercise Advancement • 1. Unstable surface • 2. Vertical plane • 3. Single leg in seated (swiss ball) • 4. Walking • Backward, Sideways or Tandem • 5. Obstacles 74
Sub Substitutio titution Ex Exer ercises cises • Eyes Open/Establish “Neutral” • 1. Laser on bullseye target • 2. Close Eyes – rotate entire body/head away from target • 3. With eyes closed look back to where you feel target “neutral” • 4. Open eyes and test accuracy • 5. Repeat Bilaterally • Progression to standing • Progression to unstable (foam) 75
Adap Adaptation tion Ex Exer ercises cises • X1 and X2 Viewing – VOR exercises to improve gain and accuracy • X1 – Head movements in phase with a target. Held Target during movement • Card with lettering held at arm length, eyes focused on the letters • Move head side to side 30 degrees. Vertically or Horizontally • Move your head as fast as you can as long as the letter stays in focus • X2 – Head movement out of phase with target. Target and head both are moving opposite of each other • Card held with lettering at arm length, eyes focused on letters • Keep in focus, move as fast as possible 1 ‐ 5 minutes. • Vertical and horizontal. • Slower and smaller amplitude than x1 viewing ex. • Should not be performed until x1 viewing is mastered. 76
Adap Adaptation tion Ex Exer ercises cises 77
Adap Adaptation tion Ex Exer ercises cises • X1 Viewing with Wall Targets • Stand in view distance from target at wall (2 ‐ 3 ft) • Eyes remain focused on target (side to side/vertical) • Various Targets, pictures, distorted/busy patterned backgrounds • Advancement Progression (per response and tolerance) • Seated • Standing • Solid • Foam • Tandem • Step forward/step back • Step up/step down 78
Adap Adaptation tion Ex Exer ercises cises 79
Adap Adaptation tion Ex Exer ercises cises • Advanced X1 and X2 • Head piece resistance band/wall station • Promotion of cervical and postural stabilization • Movement of head against resistance up/down, side to side and side bending while performing X1 and X2 activity • Advancement in surface and positioning: • Solid Surface • Foam Surface • Swiss ball • Tandem • Walking • Stepping • Step ups/Down • Held Targets • Multiple Wall targets 80
Con Conver ergence nce and and Di Divergence ence • 2 Spatula each with a written letter or Number • Hold each at arm length apart • Bring objects to and from patient (one at a time) • Stagger objects and bring to and from patient • Busy background patterning • Search for 3D image in the picture • Same advancement protocol applies from adaptation section • Sitting • Standing • Stepping • Surface • Walking 81
Habitua Habituation ion Ex Exer ercises cises • Effective for Visual Vertigo • Oscillopsia, Motion sickness (sea sickness/car sickness) • Challenge Balance While focusing on noxious visual target • Use of Biofeedback – Body Stability • Laser or forehead flashlight • Do not let light/laser move while doing sts, walking, heel toe, squats • Standing activity Functional Tasks • Pointing and UE motions at target for location during movement • Progression: • Stable • Unstable / Wobble ‐ board • One leg • Multiple patterns/speed • Wii /ski/soccer/snowboard/tightrope/squat/lunge/leg ext • Eyes Closed • ADL Simulation • Obstacles • Carrying 82
Habitua Habituation ion Ex Exer ercises cises 83
Habitua Habituation ion Ex Exer ercises cises • Target Tracking During Movement • Standing ball toss and catch • Walking toss and catch • Pivot toss and catch • Trampoline toss and catch • Pickup and toss from ground • Stool rotation while focused on target • Stool roll forward and back while focused on target • Pinhole Glasses with Environment Advancement/Hardening • Peds – Hippotherapy or zoom ball (Astronaut program) 84
Ca Cawthorne wthorne and and Cook Cooksey sey Ex Exer ercises cises • Vestibular Therapy Exercise Theory • Eye exercises designed to gradually retrain the eye and body musculature • Uses vision and proprioceptive signals to compensate for loss. • Patients are encouraged to move into positions that provoke symptoms. • Exercises include: • Adaptation Exercises to improve VOR (gain) • Habituation Exercises (repeated head and visual movement) • Balance and Gait Exercises (static and dynamic) 85
Ce Cervic icog ogenic ic Ve Vertigo Trea eatmen tment • 1. Stabilization • 2. Postural Awareness/Coping • Ergonomic Modification • Forward Head • In pain phase, relief techniques (whole body turning) • 3. Flexibility and Stretching • 4. Manual Therapy • Manual Cervical Flexion in flexion • SNAGS • Ischemic Compression to trigger Points • UE Dry needling https://www.youtube.com/watch?v= ‐ thao1ElN7Q • Suboccipital release (OA release/OA rocking with distraction) • Instrument assisted soft tissue mobilization • 5. Joint mobilization/SNAGS • 6. Modalities 86
Ce Cervic icog ogenic ic Ve Vertigo Trea eatmen tment • Stabilization Exercises • Chin Tucks and Cervical Retraction • Planks and Superman’s • Arm movement in prone (head off of plinth) • Swiss Ball WITY • Chin Tuck with Ball on wall (advance with X1 Viewing) • Depression of swiss ball into table • Ball on wall CCW and CW • Sick Scapula (closed chain IR/ER with protraction/retraction on door) • Cervical Side bending into ball • Swiss ball pushups 87
Ce Cervic icog ogenic ic Ve Vertigo Trea eatmen tment • Cervical SNAG (picture 1 top left) • Brace forehead with one hand • Mobilize C1/C2 with opposite Hand • Extend Neck • Extension SNAG (picture 2 top right) • Thumbs at articular pillars • Glide into Facet Plane • Patient actively Extends neck (painless) • Work down into various levels • Rotation SNAG (picture 3 bottom left) • Thumb on thumb on unilateral articular pillar (unilateral if motion is restricted) • Glide into active patient rotation • Block joint into pain free zone • Work down into various levels • Thoracic Spine mobilization (picture 4 bottom right) • PA grade IV or V manipulation (prone) • Today’s demonstration of “fall back technique” • Supine active Foam Roller 88
Ce Cervic icog ogenic ic Ve Vertigo Trea eatmen tment 89
Lab Lab Tim Time!! !! • Use Examples • Think Clinic Equipment • Innovation • Application • Safety 90
Anatomy and Biomechanics of the Temporomandibular Joint • Background • 50 ‐ 75% of individuals have experienced or will experience a TMD problem • 33% have >1 persistent problem • F>M 2:1 • Cook, 2007 91
Anatomy and Biomechanics of the Temporomandibular Joint 92
Anatomy and Biomechanics of the Temporomandibular Joint • Disc Anatomy • Displacement is Anterior and Lateral • Bioconcave, A&P Innervated • Retrodiscal Area • Highly innervated, has synovial fluid • Prone to inflammation • Does not tolerate tensile forces or constant load (Cook, 2007) 93
Anatomy and Biomechanics of the Temporomandibular Joint • Ligaments • Lateral guide opening • Medial disc has lateral pterygoid attachments • Sphenomandibular and Stylomandibular • Suspend mandible • Muscles – see next slide 94
Anatomy and Biomechanics of the Temporomandibular Joint 95
Anatomy and Biomechanics of the Temporomandibular Joint 96
Anatomy and Biomechanics of the Temporomandibular Joint • Biomechanics • Movements: open, close, protrusion, retraction, lateral deviation • If rotating – condyle rolls with inferior portion of disc • If translating – condyle and disc move together 97
Anatomy and Biomechanics of the Temporomandibular Joint • Jaw Opening • First phase posterior roll – mandible moves inf/post • Late Phase transitions from rotation to ant/inf translation • Muscles involved: Lateral Pterygoid and Suprahyoid 98
Jaw Opening and Curves C-Curve S-Curve -This occurs secondary to -Occurs secondary to hypomobility due to an hypermobility due to poor internal derangement. neuromuscular control of -The mandible deviates to the muscles of the involved side during mastication. the mid-range of motion -Structures causing the before the jaw returns dysfunction can include back to the center. the masseter, temporalis, -In the example below, a disc, and lateral ligaments. C-curve is noted to the Right with the dysfunctional TMJ being on the Right. 99
Anatomy and Biomechanics of the Temporomandibular Joint • Biomechanics • Jaw Closing • Posterior/Sup translation then Anterior rotation • Muscles Masseter • Medial Pterygoid • Temporalis 100
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