Clinical Examination In Order To Diagnose Whether A Patient Has A Temporomandibular: Fill & Download for Free

SPORTS 'N KIDSCopyright January 2016 by Laurence E. Badgley, M.D.As a practicing generalist medical doctor for several decades, I have performed my share of sports physical exams of children. Often times, I have learned that contact sports are involved, and I have learned to perform these examinations with a sense of misgiving and regard that allowing children to play contact sports is a form of child abusive (see explanations below). It is one thing to encourage social development and to inure young males via certain rites of passage. It is another thing to meet them, at end of their passage, as permanently crippled adults. This is something I see all too frequently. I can explain the abuse phenomenon, but for best understanding of this volatile issue the reader needs to first learn some concepts about how the physical body functions (see below).OBSERVATIONS OF YOUTH SPORTSI was appalled the other day, when a 9 year old boy was brought for evaluation of a respiratory medical condition and extolled his enthusiasm for joining his school football team and receiving the padded uniform. He was obviously yearning to mimic older students and his heroes on national TV football extravaganzas. I made some cautionary comments and winked at his mother to learn her position about this matter. She messaged agreement, so I went on to tell him of the dangers he faced for permanent injury. Of course he was unimpressed by my comments. His mother understood, but she is not supported by her peers or society at large. The kid will probably play football. I had done my duty.THE DEVELOPING BODYThe musculoskeletal system and soft tissues, such as the ligaments, tendons, and muscles are not fully formed until the age at which most advanced societies regard youths to have gained majority status. While these tissues are developing tone and strength, intense and repetitive impacts should be avoided, with concern for permanent injury to soft tissues. The shoulder, low back, and knees are particularly exposed, and can be injured to the point of chronic disability.GLADIATOR SPORTSFootball is a barbarian sport. I cannot begin to tell you how many young people I have personally examined and found to be permanently damaged and suffering as the result of high school and college contact sports like football, basketball, and soccer. To call ice hockey a sport is an oxymoron. Rugby is for sado- masochists.My attitude is to leave adult sport professionals alone to gather their concussions, mental defects, and million dollar contracts. Just leave minor children alone when it comes to contact sports.FRAGILE BODIESA little known factor is involved in our national scandal of child sports abuse. About 15% of women and 1% of men inherit loose ligaments. The name of the tissue variation is "benign Hypermobility Syndrome." Another declination for this tissue variation is Joint Hypermobility Syndrome (JHS). This is a genetic variation that is passed between generations.Mother Nature imbues women with genes that determine ligament laxity, and to enhance childbirth. Indeed, women are more delicate issues of the Homo-sapiens stock than men.Ligaments hold the pelvic bones and contiguous low back bones together. Ligaments that are more expandable during passage of a new born through the birth canal are worthy of genetic selection concomitant with evolutionary struggles. About 15% of women inherit genes for JHS, and which potentiate pelvic joint laxity and ease of childbirth. However, there are certain significant downsides to having this genetic trait.FEMALE JOINTS ARE LOOSERWomen who have benign Hypermobility Syndrome (aka JHS) can, depending on their degree of athletic conditioning and toned musculature, suffer terrible menstrual cramps, "endometriosis-like" symptoms, daily headaches, Irritable Bowel Syndrome (both diarrhea and constipation types) Temporomandibular Joint Disorder (aka TMJ), Panic & Hyperventilation Attacks, Postural Orthostatic Tachycardia Syndrome (POTS), Frequency of Urination, Interstitial Cystitis, Chronic Low Back Pain, Daytime Fatigue, Cognitive Disarray, and Depression. The reasons that these associations are not well understood by the lay public has to do with orthodox physicians' ignorance about Joint Hypermobility Syndrome (JHS).FIBROMYALGIAThe genetic underpinnings of Fibromyalgia, which is the banner name for the above described symptom constellation, is "Hypermobility Syndrome." This genetic variation is most frequently found amongst women, who are the child bearers and who need flexible pelvises for birthing.Ligament integrity is important to tether major joints together while the joints move through their ranges of motion. If ligaments are too stiff, then joints do not readily move. The gorilla hobbles around because this animal does not even have pelvic sacroiliac joints, the large joints between the low back and pelvis.,TESTING FOR LOOSE JOINTSIn the clinic whenever I encounter men or women who complain of pain, I look for JHS. It takes only a minute to discover if the patient is hyper-flexible. I look for ability to use the fingers of one hand to grasp and fold the thumb of the other hand, which is flopped over at the wrist, down and back to touch the forearm of the hand-thumb being tested. If the thumb can touch or nearly touch the forearm, this is one demonstration that the person has loose ligaments.The next test is to fully extend the arm and open up the elbow as far as it can go; to see if the elbow opens more than 180 degrees. Overextension is another positive sign of JHS.Patients with flexible ligaments can easily bend over to touch the floor with finger tips or even their palms. Historically, people with JHS might tell you that they are "double jointed". As adults and with extra body mass, which is common with aging, many can no longer readily demonstrate super flexibility, and that is why you have to ask them what they were like as children. Could they bring their legs up to touch their ears? Could they lick their toes? Could they do the back bridge? There are no absolute measures and ranges involved here; these hypermobility tendencies are evidentiary for JHS.HISTORY OF LOOSE JOINTSPeople with JHS are the ones who tell you how they could do the splits, back bend, flips, and cartwheels as children. They were good gymnasts and cheerleaders. Even as adults they outshine all the others in yoga class; even without years of dedicated stretching. If asked, many of these women with JHS admit to fainting once or more in the past.By my estimates about 1 out of 7 (15%) women and 1 out of 100 (1%) men have the loose ligament JHS variation. These are only rough observations I have made within my clinic population, and I have no firm data to support these figures.The JHS trait is genetically determined and passes readily from mother to daughter. The predominance in women is explanatory why women have greater incidence of Fibromyalgia, and this phenomenon is discussed at length in a companion post "FIBROMYALGIA AND FEMALES." Loose ligaments potentiate ease of childbirth, but the trade off is potentiation to develop several chronic pain conditions.DISEASES AND SYMPTOMS RELATED TO LOOSE JOINTSI once did a survey of women who have "endometriosis" diagnosed by other doctors. I found that more that 50% reported being able to forcefully approximate their thumb to their forearm while the associated wrist was flexed.I have found loose ligaments highly associated with patient complaints and diagnoses as follows: daily headaches, Migraines, Temporomandibular Joint Disorder (sometimes called TMJ), Chronic Shoulder Pain, Thoracic Outlet Disorder, Panic Attacks, Gastroparesis, Irritable Bowel Syndrome (either diarrhea or constipation type), Frequency of Urination, Interstitial Cystitis, Chronic Low Back Pain, Dyspareunia, Chronic Sciatica, Endometriosis, and menstrual periods more painful than in other women. By and large, these symptoms reflect functional disorders absent confirmatory laboratory studies. A frustrating aspect of these disorders is that, for the most part, diagnoses of these disorders are made by evaluations that include in-depth history of the problem and an hands-on physical examination.DIFFICULTIES DISCOVERING LOOSE JOINTSLigaments and other soft tissues are radiolucent and cannot be readily imaged. In any case, most diagnostic imaging techniques provide static films of non-moving body parts. The disorders being discussed in this essay are functional ones, whereby soft tissues move abnormally in space and time. The best device to detect these disorders is a sensitive trained physician who knows how to touch tissues with great sensitivity and who knows what physical signs to look for; combined with excellent knowledge of anatomy and physiology. An educated in-depth history of the disorder must be taken to discover the mechanism of injury, which in turn gives clues to the soft tissue dysfunctions being evaluated.DYSAUTONOMIA SYMPTOMSMany of the symptoms being discussed herein arise from dysfunctions of the autonomic nervous system; impinged as a result of joint hypermobility. For insight about Dysautonomias, the reader is directed to my companion essay "DYSAUTONOMIAS AND FIBROMYALGIA - THE SUPER SYNDROME."HOW MEN GET LOOSE JOINTSAt this juncture, a question might be raised about why men, who have a lesser prevalence of JHS, develop some of the same symptoms and chronic pain syndromes as women. The answer is simple. Men tend to permanently loosen ligaments in work & motor vehicle accidents and in pursuit of extreme sports.Which brings us full around to the question that this essay attempts to answer. Do doctors fail to properly direct people away from sports that might permanently injure them?SOCIAL RESPONSIBILITIESThe answer is yes and no. Society sets the standards for human conduct. Society also ends up paying for those who become maimed, crippled, and non-productive. Doctors conduct their services only by invitations of society and individuals in search of solutions to their problems.My view is that many youths become permanently injured pursuing certain organized sports, which they should avoid. The problem is that no one is telling them this. Certainly not the communities they live in nor their school administrators. Football is obviously injurious even to those who do not have Joint Hypermobility Syndrome (JHS). Football becomes an immediate and veritable threat to those who have JHS. Extreme sports like skate and snowboarding, where falls onto the buttock are common, have created legions of permanently injured young males.One solution to the epidemic of sport injuries is to evaluate every child for JHS. If they have this tissue variation they should be directed away from sports where falls onto the buttocks are common. This would include advice against basketball and soccer. Young women who pursue cheerleading should not perform stunts where they go to the top of a pile and might fall. The paradox is that young women with JHS can be great gymnasts, but they are easily injured via falls onto their buttocks.People with JHS would likely make great swimmers, golfers, and fencers, and they should be encouraged to pursue sports like these and which require agility and which do not include uncoordinated falls onto the buttocks or back. Track and field sports are advised. In addition, these types of sports help people to develop muscle strength and tone, which compensates for their loose joints.Gladiator sports are for adults to decide for themselves whether they want to pursue these potentially injurious activities. When it comes to youths, it is up to their gurardians to protect these youths from injury. The guardians should be sensible at judiciously allowing and disallowing their charges to pursue physical sport activities. In order to make proper decisions about these matters, gurardians might need to consult with doctors. And doctors, who are mostly ignorant about JHS, need to improve their diagnostic skills in this area of physical examination. For example, when doctors detect a young person with scoliosis they should always have the person lie prone to see if the scoliosis remits in the lying position. Many cases of scoliosis are functional and due to loose ligaments and force of gravity when the person is upright. Loose joints and hyper-flexible spines do not need operations and metal fixative implants. They require compensatory development and tone of muscles that hold joints together against Gravity, which tends to pull joints apart. Yoga, tai chi, light weight lifting, aquatherapy, and swimming can be used to tone muscles.Some of the worst joint injuries I have ever seen were in women with JHS and who pursued martial arts. It is absolutely necessary for women with JHS to avoid martial arts that include impactful falls as part of the training regimen. Horseback riding is another activity which must be scrutinized because falls from 4 feet onto the buttocks can be dangerous for people with JHS.CONCLUSIONInherited Joint Hypermobility Syndrome is common. All children should be screened for this tissue variation. Those who have JHS should be counseled as to which sports are best for them. Now that this information has been presented by knowledgeable doctors, this information should be widely disseminated.Adult-supervised participation of minor children in contact sports should be recognized as a form of child abuse. The uneducated supervision of minor children with JHS in sports of any sort is child abuse.Laurence E. Badgley, M.D.Berkeley, CA@badgleylaurenceAt Google at Laurence Badgley G+