passive compression the bilaminar zone is examined for poorly adapted areas. Translation and traction serve to test the capsule and ligaments.
The examination always begins with passive compression (Bumann and Groot Landeweer 1996b). The rationale of the examination is based upon elicitating pain by loading various joint structures in different directions. In healthy joints, these manipulations are never painful (Palla 1986, Bumann and Groot Landeweer 1992, Curl and Stanwood 1993, McNeill 1993, Hesse 1996), because under physiological conditions the lateral ligament, acting as a motion-limiting structure, prevents injury to the bilaminar zone.
However, if the lateral ligament becomes overextended, pain sensations can emanate from the bilaminar zone because of its rich innervation (Scapino 1991a, b) or from various parts of the capsule. During passive compression the muscles of mastication are not active and are not loaded. Because the disk and the joint surfaces are not innervated, they can be ruled out as sources of pain that can be repeatedly provoked. Therefore pain that can be provoked through posterior (retrusive) and/or posterosuperior compression is evidence of inflammation in one or more areas of the temporomandibular joint (Palla 1992, McNeill 1993, Bumann and Groot Landeweer 1996b). The high level of diagnostic reliability of passive compression has been demonstrated in clinical studies (Lobbezoo-Scholte et al. 1994, de Wijer et al. 1995).
If the dynamic tests for evaluating a patient’s joint surfaces produce pain, then no diagnostically useful information can be gained through applying superiorly directed pressure during the same appointment.
Pain patients are able to report current pain with relative exactness (Cousins 1989. Bell 1991, Stacey 1991. Hewlett et al. 1995) and their reports can be useful in making a differential diagnosis. Seven passive compression tests are available and these are carried out in a definite sequence for ergonomic efficiency. Following each manipulation the patient is asked if pain occurred and if so, whether it was the same as that previously experienced or if it was elicited only by the momentary loading. In this way, as with the joint surface problems, three conditions of the bilaminar zone can be described:
• Adaptation (condition green): no history of pain and no pain evoked by compression.
• Compensation (condition yellow): no history of pain, but pain can be provoked repeatedly by passive compressions.
• Decompensation (condition red): history of pain, and individual pains can be provoked by compressions.
The three possible conditions of the tissues are noted in the patient’s chart with color coding:
• All painful symptoms fall under the term capsulitis in the tissue-specific diagnosis.
• “Conditions yellow” are designated as compensated capsulitis
• “Conditions red” are designated as decompensated capsulitis.
Finally, the exact loading vector, which indicates the direction of compression, is added to the diagnosis. For example, a finding of “condition yellow” pain resulting from posterolateral compression would give the diagnosis: decompensated capsulitis with a posterolateral loading vector. In this case, during clarification of the contributing factors (see p. 124) we would look for one or more causes for the posterolateral force on the involved condyle.
• “Condition green” indicates either that the relationships in the bilaminar zone are physiological or that there is perfect adaptation to nonideal conditions. Even if the morphology is completely different from normal, there is no pressing medical indication for treatment. This has been confirmed over the long term through a series of basic studies (Pereira et al. 1996a, b).
177 Possible endfeels with traction and protrusion
Under physiological conditions the movements of the temporomandibular joint, with the exception of jaw closure, are limited by ligaments and therefore produce a “hard ligamentary endfeel.” A number of structural changes can be responsible for different pathological endfeels. Above all else, muscle shortening and capsule shrinkage have the greatest therapeutic relevance because they can impose restrictions on the treatment.
After the bilaminar zone, the joint capsule and ligaments are tested specifically by means of translation and traction manipulations (Bumann and Groot Landeweer 1996b). These techniques serve on the one hand to determine if pain can be provoked, and on the other hand to evaluate the so-called “endfeel.” There is a relatively high correlation between the findings by various examiners (de Wijer et al. 1995).
The specialized structure of the ligaments with their dense connective tissue and parallel collagen fibers provides high tensile strength (Gay and Miller 1978). Ligaments can be stretched by approximately 5-8% of their original length. This slight elasticity prevents irreversible damage to the ligaments themselves while still effectively limiting condylar movements and thereby protecting much more sensitive structures (Griffin et al. 1975. Sato et al. 1996).
The joint capsule exhibits fewer parallel fibers and is composed of different types of collagen. It is more elastic than the ligaments. The principle of collecting, documenting, and interpreting the signs and symptoms is exactly the same as for the passive compression tests. Pain within the joint capsule occurs only with inflammatory changes and is transmitted to the central nervous system by type-IV receptors (Wyke 1972, 1979; Clark and Wyke 1974). Various neuropeptides such as NA and SP effect the release of prostaglandins, which in turn elevate the sensitivity of the pain receptors (Levine et al. 1986, Lotz et al. 1987).
Конец ознакомительного фрагмента.
Текст предоставлен ООО «ЛитРес».
Прочитайте эту книгу целиком, купив полную легальную версию на ЛитРес.
Безопасно оплатить книгу можно банковской картой Visa, MasterCard, Maestro, со счета мобильного телефона, с платежного терминала, в салоне МТС или Связной, через PayPal, WebMoney, Яндекс.Деньги, QIWI Кошелек, бонусными картами или другим удобным Вам способом.
