manual functional analysis

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