Why Would a Manual Therapist Need to Read X-rays!?!??

How many times has a patient walked through your door, handed you her beautiful X-ray and asked you to make sense of it?

If you're like me and many others- I would hazard to guess that for years your use of X-rays has consisted of lifting those radiolucent films up to the overhead light, squinting your eyes a bit, then contorting your head left and then right, squinting some more.  Then ultimately resigning yourself to asking the patient if they just so happened to also have the radiologist's radiology summary report.  



Don't worry.

The problem is that many of us were never taught much regarding the reading of X-rays in school.  But if we take the time to learn more about radiology, we can learn some of their impressive benefits in assisting with evaluation and treatment of our patients.

But, as a patient asked me just this week-

"Is there really any benefit to paying $100 for an X-ray?"


Well, specifically let's discuss her case- 


The Advantages of Using Cervical X-rays for Orofacial Pain


My patient, [Ms. M] has presented with persistent constant daily retroorbital and temporal region headaches for roughly 10 years.  She has visited a chiropractor, massage therapist and has had migraine injections on a regular basis throughout.  She is an intensely driven small business owner and finds herself getting 4-5 hours of sleep a night and feeling like she's a failure if her health stops her from achieving her goals.  Progress has been slow and she has significant upper cervical dysfunction.  

I recently spoke to her about having open mouth A/P and lateral cephalometric X-rays taken.  Her response wasn't totally unexpected-

"What exactly will cervical X-rays do for me?"


My response-



Specificity.


"Specificity" as it relates to orofacial manual therapy treatment has a number of advantages.   Let's examine these:


1.   AVOIDING ERRORS-  

I certainly didn't say this to her, but I believe this reason is very important.  As manual therapists we depend on our hands to feel for bony positioning and joint motion.  It's one of our greatest skills.  But it should come as no surprise that of the 5 senses, the sense we as human beings depend on most in life- is vision.  There is power in seeing exactly how each vertebra is aligned and rotated.  As we all know- each vertebra of the cervical spine can be flexed, extended, rotated left or right, side bent left or right, and even displaced and shifted forward or back.  AND- also how much are each vertebra moved into these positions.  Maybe you feel that a vertebra is stuck flexed forward, but its just the vertebra below extended backwards.  In this way, we can look to confirm what our fingers are feeling to avoid errors.  Although errors might be unlikely, the next two interrelated reasons are reason enough to request X-rays when progress is inconsistent-


2.  ACCELERATING RECOVERY

3.  IDENTIFYING THE UNEXPECTED

Maybe you didn't feel the instability of a vertebra when shifting forward.  In a very dysfunctional spine there can be a number of multi segmental dysfunctions.  Did you address one problem, only to miss another?  If you did, perhaps the patient is getting better, but still not progressing as quickly as it could.  The ability to accelerate the patient's recovery and to identify the unexpected are in my opinion the best reasons to recommend cervical X-rays.  


4.  FEEDBACK

How often do our patients require some reassurance?  We all do.  In those instances, it can be so helpful to a patient to see their problems/progress right before their eyes.  Let's say a patient has been seen for 2 months- they feel better, but some of their symptoms still persist- occasional discomfort or stiffness.  We've all seen patients that have pain, but have difficulty evaluating their own progress.  

How often have we asked to see if a patient is improving- "What's your pain level on a scale of 0-10.  And your patient answers with frustration- "I don't know- but it still hurts!"  

Having the visual proof to show a patient their progress and reassure them there is improvement goes a long way towards having patient's "buy-in" to their progress.  Let's face it, "fear" is often times a big obstacle for a patient to overcome in order for them to finally accept that they are feeling some relief and improvement.  It never hurts to have visual proof to document your progress to the patient.  Every veteran therapist knows how key patient "buy-in" is.


5.  MARKETING

If you have before and after X-rays of your patient you will have a physician referral for life!  Why?  A picture is worth a thousand words!




But why not just have a radiologist read the X-ray?

Well, certainly because radiologists don't specialize in movement dysfunction!  Yes, radiologists are concerned with diagnoses.  Is there stenosis?  Is there DJD?  Maybe.  But what does this tell us about the cause of those things?  Obviously movement restrictions or hyper mobility will contribute to some of these problems- but maybe the problem hasn't advanced enough to see the degeneration yet.  Maybe the cause of midcervical degeneration is a stuck AA joint a few levels above the problem.  Unfortunately, a radiology report just won't share those intimate little details with us.

Also, the more we understand radiology the more we can assist the X-ray tech in his positioning and the choice of X-rays to be taken.  Do we need the patient in perfect upright cervical postures if they spend 8 hours a day slumped in front of the computer and that is the only time that get their headaches?  Does the patient only get their pain when in extended neck postures?  Maybe then recommending a cervical extension stress X-ray would be most helpful.  But only through your improved understanding of radiology is this possible.



So if you don't have knowledge about radiology, where can you go to learn more?

So if you think you're ready to nibble into the field of radiology and its potential impact into your manual therapy evaluation & treatment, here are 2 excellent resources-

1. Fundamentals of Musculoskeletal Imaging by Lynn N. McKinnis


 I can't recommend this book enough.  Very practical and user-friendly for the physical therapist.  This is where I recommend anyone interested should turn.  Highlights all the important areas on the subject looking at each individual area of treatment- TMJ, cervical, thoracic, lumbar, knee, etc.

2.  St Augustine's course- Applied Musculoskeletal Imaging for Physical Therapists

I have not taken this particular course, but I have been instructed on the topic by a St Augustine instructor, Mark Strickland in Austin, TX.  Very knowledgable, very practical information.  I'd imagine this course is much the same.


So, have you personally found X-rays to be helpful in your manual therapy evaluation and treatment?  If so, comment and let me know.  I'm always interested in how many physical therapists utilize diagnostic imaging and if so, are there any ways that they particularly find them useful.  

More on this in a future post regarding how to read upper cervical spine X-rays!

The Walter White of TMD??

Yep.  Meet...  the Lateral Pterygoid.  



The lateral pterygoid is intimately involved in your oral function.  If you move your jaw forward or side-to-side your lateral pterygoid is involved in this motion.  Since chewing is not a straight up and down motion like a hinge, but rather a circular type motion when viewing your mouth from the front, the lateral pterygoid contributes to this important daily activity.

Quite simply, this muscle lying beneath your cheek and attaches to the disc and the mandibular condyle laterally and the sphenoid bone medially.  It acts to pull the jaw and disc forward and medially (towards the center of your face).

When your Mouth starts "Breaking Bad"

So what happens when the Lateral Pterygoid does it's best Walter White impersonation and starts "Breaking Bad"?

In the popular Fx show, whether it was lying to a guillible Jesse or even his own family, we could always count on Mr White to have a special knack for causing some sort of friction in his relationships.  The lateral ptyergoid has this same annoying tendency.  Under normal circumstances, much like Mr White, a high school chemistry teacher- the lateral pterygoid is harmless.  But power- as it always does- corrupts the most harmless of intentions. 

The unconscious mind at night can struggle to cope with a day's worth of pent of frustration.  Whether it's rocky relationships or rush hour traffic our minds and bodies find ways to cope.  This can easily lead to your mouth clenching or even teeth grinding or bruxing.  Your mouth, and specifically the lateral pterygoid, is positioned to forcefully move the jaw back and forth which it does fervidly during bruxing causing an abundance of friction.   With this repeated activity, the LP can cause pain and spasm- eventually causing all around it to feel the pain of its progressive breakdown.   

Was there ever a time when the duplicitous MWhite didn't lie?  He was as shifty a character as I've seen.  Well, the lateral pterygoid is a shifty one too.

What to Do About You-Know-Who

When the lateral pterygoid spasms, it can shift the bottom jaw forward separating the back teeth.  This is characteristic of a lateral pterygoid spasm.  How then to get this muscle to relax again?  It will benefit from dry needling and stretching.    Stretching can be performed effectively by jaw depression and retrusion.  I personally was surprised at how specific this stretch felt.  Often times this can be an effective stretch after the jaw is placed in a protruded position for a period of time- like when a splint positions the jaw forward. An ARA or anterior repositioning appliance is one of the splints that aims to move the jaw forward.  The lateral pterygoid can adaptively shorten over time. 

Dry needling the lateral pterygoid involves needling between the mandibular condyle and coronoid process of the mandible.  The muscle is not able to be palpated due to its depth.  It generally is accepted to lie deep within the jaw attached to the sphenoid at roughly 40 mm deep.   It's also interesting to note that the lateral pterygoid can refer to the sinuses just below the eye.  Sometimes soreness below the eye from lateral pterygoid pain can be easily misinterpreted as sinusitis or sinus infections.

The next time you see a mouth that's creating friction and you suspect its behavior seems just a little too shifty-

Don't forget to consider the lateral pterygoid- the Mr White of Orofacial Pain.

So you have jaw pain and nothing quite seems to do the trick.  You've tried your dentist, you have a mouth splint, you've taken meds and by now you may even be considering jaw surgery surgery, orthodontics or equilibration.  Whoa!  Before you consider any drastic steps, maybe it's time to consider another possibility first.  Why don't we have our friend below teach us a little about how that thing that attaches our head to our shoulders- the neck- can contribute to TMJ or Jaw Pain.

1.  MUSCLES-
Neck muscles often refer pain to your face and your head.  At least a half dozen neck muscles- the sternocleidomastoid, trapezius, digastricus, semispinalis cervicus, splenius capitis, splenius cervicus among them- are just a few of the tongue-twisting muscular contributors to TMJ pain.

2.  TrigeminoCervical Complex.

Your head and neck have a center for incoming pain signals that…  gets a little confused at times.  Sometimes it can't tell just where your pain is coming from!  This confusion is due to a common neurological connection that each share called the TrigeminoCervical Complex.  Pain in your jaw is unfortunately sometimes perceived by this complex as pain in your neck- or vice versa- neck pain can be perceived as jaw pain.

3.  Scoliosis or Neck Misalignment-

If your head is tipped sideways, how do you ever expect to keep your mouth straight when chewing up and down??  If your head isn't screwed on straight, there's no way your mouth alignment can remain straight either. If your mouth isn't aligned vertically symmetrical, than one side is working differently than the other and this asymmetry can begin to tax the jaw.


4.  Poor Posture-

A head that is craned forward will often compress the tissues just below the back of the skull.  This area is inundated with tiny blood vessels and nerves.  If the vessels and nerves are pinched by this compression, they will refer pain to your face, head and jaw.

Also, the tissue in the front of the neck is taut.  It pulls the jaw backwards and downwards causing increased pressure on the sensitive areas around your TMJ.  The downward force from your taut neck tissue must be counteracted by muscles to hold the jaw up.  The masseters and temporalis muscles- the muscles depended upon to close your mouth- are elected for this task and they quickly become irritated at having to volunteer their overtime services. 

By correcting any of these dysfunctional neck issues, you can significantly alleviate your TMJ or jaw pain- likely avoiding a much more costly and involved medical intervention.  So next time you have jaw pain- don't let it become a pain in the neck!