Div 1 EXAM 1
thigh thrust
-pt. supine with hips flexed to 90° -examiner applies posterior force through femurAt multiple angles.Of abduction and adduction..Reproduction of Buttocks pain
•LUMBAR ROM = 10-15 degrees (2.5 per lumbar joint) -Impaction of the zygapophyseal joints protects the IVD by limiting tension to the annulus fibrosis -Lumbar articular cartilage must compress up to 60% to allow just 3 degrees of segmental motion -Lumbar Facets are mostly sagittal (pic) •Facets interlock resisting lumbar rotation and minimizing stress & injury to the lumbar disc -Lumbar ROM & IVD Injury •Microscopic failure of Annular fibers > 3 degrees of axial rotation •Full macroscopic failure of annular fibers @ ___degrees
12
Combined flexion and extension L1-2 _____degrees L2-3 14 degrees L3-4 _____ degrees L4-5 16 degrees L5-S1 17 degrees AMA Guides to Impairment : Normal lumbar flexion = 60+ degrees uNormal lumbar extension = ______+ degrees
12, 15, 25
low back pain diagnosis •Evidence of social/psychological distress that could amplify/prolong pain •"5 categories of innapropriate/non-organic signs correlating to other indicators of psychological distress:" * 1.Innappropriate tenderness + superficial/widespread pain 2.Pn on simulated axial loading (S-I pressure on pts head) & spinal rotation (shoulders and hips move together) 3."Distraction Signs" (ex. Inconsistent performance b/w seated and supine SLR) 4.Regional strength and sensation disturbances inconsistent with nerve root innervation patterns 5.Overreaction during the physical exam •NOTE: Positive findings in at least _____/5 categories suggests psychological distress5
3
patients position example Patient Position: lSP= RSP= Pts. Hips & shoulders should be _________ & ___________ Pts knees slightly ______. Feet of edge of table. Pt should be within ____ of the front edge of the table. You can measure by having them move up to your ______.
3 inches. fist.
ankylosing spondylitis •5 SCREENING QUESTIONS FOR AS: •Morning stiffness? •Discomfort improves with exercise? •Onset before 40yoa? •Did symptoms begin slowly? •Has the pain persisted for a minimum of 3 months? ***____ or more yes answers = + screening test result •If the pt answers 'yes' to at least 4/5 of the screening questionsà+ for AS •Predictive value of a + screening test is typically low for very rare conditions •Sensitivity and specificity vary from one study to another •How accurate is the screening? •Accurate enough to look for signs of AS during the physical examination •Schober test: to quantify decrease in flexion •Decreased flexion is equally common in pts w/ chronic LBP/spine tumors •Spine flexion is of limited diagnostic value (for AS) •Spinal ROM very useful in locating spinal fixations, planning, & monitoring physical therapy
4
Combined lumbar flexion and extension = sagittal plane rotation = 15 degrees/segment Includes 2-3mm sagittal plane translation in each direction (normal) If this exceeds ______ mm à clinical joint instability (Penjabi and White) IAR = instantaneous axis of rotation Flexion - superior vb slides and tilts forward as the inferior facets move superiorly IAR for flexion = anterior IVD (see fig) Disc compressed anteriorly and stretched posteriorly Extension - approximation of facets IAR for extension = posterior IVD (see fig) uDisc compressed posteriorly and stretched anteriorly
4.5
cancer summary •Patient history is most useful in detecting underlying cancer (compared to PE) •>_____ yoa •History of Cancer - M/C metastases from breast lung and prostate •Unexplained weight loss •Pain > one month •Pain not improved by conservative therapy •Pain _____ relieved by bed rest
50, not
systemic disease - cancer •Cancer is the M/C systemic disease affecting the spine •Accounts for <1% of back pain •Important risk factors: •Age>____ yoa •History of cancer *consider cancer until proven otherwise •Unexplained ______ loss •Pain lasting longer than one month/fail to improve with conservative therapy •Pain not relieved by ______ rest
50, weight, bed
-ADEQUATE (acceptable) Reactions= transient episodes (probably a normal product of manual therapy& mobilization or stimulation of periarticular soft tissues) •Onset __-12 hrs •Mild subjective symptoms •Local soreness •Tiredness •Headache •No decrease in work capacity •duration< 2 days with spontaneous remission
6,
-EXCEEDING reactions= characterized by more pronounced discomfort •Onset ____-12 hours •Objective worsening of signs and symptoms •Interferes with work, ADL's •Duration> ___ days with spontaneous remission
6, 2
One-side lateral flexion approximately 6 degrees each side per segment L1-2 6 degrees L2-3 6 degrees L3-4 ____degrees L4-5 6 degrees L5-S1 3 degrees uAMA Guides to impairment list normal lumbar lateral flexion = _______+ degrees
8, 25
lThoracic's - TVP's except ___ & PI which is a body ref. as viewed laterally via x-ray lLumbar's - Vertebral Body/Mammillary processes lPelvis - Innominate (ilium-PSIS, ischium, pubes) lSacrum - Sacral base lCoccyx - Position of apex of coccyx
AI,
Functions of the lumbar spine
Bears the weight of the body Allows movement
P2P= pocket 2 pocket Fencer's stance straddling pts. flexed leg with good posture/ dr.'s front leg against the table Dr. shifts weight to their front leg to bring their hip (back leg) up to the pts hip by sliding up thigh to thigh lDr. rotates their pelvis towards HOT dropping their ASIS to contact the pts hip lThis causes the dr. to pivot : §LSP: 10:00à11:00 & RSP: 2:00à1:00 Dr. allows pt to roll with and towards them as drs. back foot returns to floor in _______ stance Use pocket 2 pocket to roll pt. approximately _____ ˚ without losing tension from pin lDrs. torso and lower body in line Ex. Dr. facing 11:00 should have legs in line @ 5:00
Bowler's, 45
Pathological neutral - The NZ has been shown to increase with:
Degeneration (joint & disc) Surgical injury Repetitive cyclic loads High-speed trauma
Lumbar spinal canal Supports and protects spinal cord and nerve roots (cord ends at ____)From the conus ______ proximally to the cauda equina distally Ensheathed in 3 meninges Filum terminale tethers to coccyx Dural sac: sheath of dura mater surrounding sc and cauda equine Stabilized by ________ ligaments They connect the dural sac to PLL
L2, medularis, hoffman,
Right Lateral Flexion with Left Rotation Lumbar and upper thoracic Transition change at _______ (ipsilateral coupling) uIncreased torsional stress uClinical Instability Degenerative changes
L4/5
•Patients have the right to know about any risks of significant harm (complications) & other treatment options before consenting to examination and care -The patient must understand the nature of the procedure(s) to be performed -They must give " written, verbal, or implied consent." •Consent must be documented in the pts. Health record •Malpractice/Assault & Battery: If Dr. treats/performs diagnostic evaluation without documented informed consent
NEED CONSENT
Sacral thrust
Patient is prone.Examiner delivers an anterior directed thrust over the sacrum.Re -production of pain
Distraction
Patient is supine.Examiner applies posterolateral Directed pressure To bilateral ASIS.Reproduction of pain
Gaenslen's Test
Patient sidelying at edge of table while holding bottom leg in maximal hip and knee flexion (knee to chest). Stand behind the patient and passively extend hip of upper most limb. This places stress on SIJ associated with upper most limb. (+) TEST: pain in SIJ
Compression
Patients sidelying.Examiner compresses polish with pressure applied over the iliac crestDirected at the offices iliac crest.Reproduction of symptoms
•IVD herniation with nerve root irritation •
Spinal stenosis •Anatomic anomalies •Underlying systemic disease •Visceral disease
What is a tic?
Sudden, rapid, recurrent, nonrhythmic motor movement or vocalization
Most patients that present with disc herniation(s) are ________ years old. a. 30-50 b. over 50 c. 50-70 d. 40-60
a. 30-50
Which of the following patient presentations demonstrate an antalgic gait? a. A patient with left sciatica leans to the right when walking to decrease pain/sciatica symptoms b. A patient with left sciatica leans to the right to stretch the lumbar musculature on the left. c. A patient with left sciatica leans to the left when walking to decrease pain/sciatica symptoms d. A patient with left sciatica leans to the left to stretch the lumbar musculature on the left.
a. A patient with left sciatica leans to the right when walking to decrease pain/sciatica symptoms
Mrs. Covidia presents to your office complaining of "left hip pain" that has been constant for the past few days. When asked to point to the pain, she places her hand over her left sacroiliac joint. Upon visual inspection/static palpation, you notice that the right leg is long compared to the left leg and the left PSIS is tender and more prominent than the right. Motion palpation reveals a left sacroiliac extension restriction with a hard end-feel when motioning the left ilium P-A. Which of the following is the most likely listing for these findings? a. AGR L-Ilium b. AGR R-Ilium c. R-SB-P d. L-SB-P
a. AGR L-Ilium
Mrs. Covidia presents to your office complaining of "right hip pain" that has been constant for the past few days. When asked to point to the pain, she places her hand over her right sacroiliac joint. Upon visual inspection/static palpation, you notice that the left leg is long compared to the right leg and the right PSIS is tender and more prominent than the left. Motion palpation reveals a right sacroiliac extension restriction with a hard end-feel when motioning the right ilium P-A. Which of the following is the most likely listing for these findings? a. AGR R-Ilium b. L-SB-P c. AGR L-Ilium d. R-SB-P
a. AGR R-Ilium
Mrs. Smith arrives at your office with an exacerbation of right sacro-iliac pain. During motion palpation you detect a hard end-feel when palpating P-A on the right PSIS as compared to the left. Which of the following is the correct motion restriction listing? Choose the best answer. a. AGR R-Ilium b. PGR R-Ilium c. R-AS Ilium d. CRRLOA
a. AGR R-Ilium
Mrs. Smith arrives at your office with an exacerbation of right sacro-iliac pain. During motion palpation you detect a hard end-feel when palpating P-A on the right PSIS as compared to the left. Which of the following is the correct motion restriction listing? Choose the best answer. a. AGR R-Ilium b. R-AS Ilium c. PGR R-Ilium d. CRRLOA
a. AGR R-Ilium
Which of the following conditions require referral to a vascular surgeon? a. Aneurysm b. Osteopenia c. Tumors d. Space occupying lesions
a. Aneurysm
When setting up on a patient for a lumbar rotation side posture adjustment, it is important to position your patient _________. a. Approximately 3 inches from the front edge of the table b. Approximately 3 inches from the back edge of the table c. In the middle of the table with their feet hanging off of the caudal end of the table. d. Approximately 6 inches from the front edge of the table
a. Approximately 3 inches from the front edge of the table
When adjusting a P-I Ilium in side posture, the tissue pull should be mostly ______. a. I-S b. M-L c. L-M d. S-I
a. I-S
Upon examination/palpation of your patient's sacrum, you detect an RRROA. What is the correct contact point for the correction of this restriction using the side posture set up taught in lab? a. L-SB b. R-SA c. L-pisiform/hypothenar d. R-SB e. R-pisiform/hypothenar
a. L-SB
You detected a LRR of L3 while motion palpating your patient. What is the appropriate CP/SCP, in other words you should use your _______ on the (patient's) _______? a. L-pisiform/hypothenar on the R-mammillary process of L3 b. L-pisiform/hypothenar on the L-mammillary process of L3 c. R-pisiform/hypothenar on the R-mammillary process of L3 d. R-pisiform/hypothenar on the L-mammillary process of L3
a. L-pisiform/hypothenar on the R-mammillary process of L3
The knee flexors are a group of muscles stimulated by a single spinal nerve, ____. a. L5 b. L4 c. S1 d. L3
a. L5
You have detected an RRR-L3, which of the following is the correct SCP, as taught in Diversifed 1? a. Left mammillary of L3 b. Right aspect of the spinous process c. Left aspect of the spinous process d. Right mammillary of L3
a. Left mammillary of L3
Give directions starting from the spinous process of the involved segment to the mammillary process. ISS=interspinous space SP= spinous process a. One ISS superior and lateral 1/2" b. One SP inferior and lateral 1/2" c. One ISS inferior and lateral 3/4" d. One SP superior and lateral 3/4"
a. One ISS superior and lateral 1/2"
If a patient presents to your office with LBP and a history of successful removal of a malignant melanoma 6 months ago, which of the following is the most appropriate action? a. Order imaging before adjusting to assess for a malignant neoplasm of the spine. b. After completing the physical exam, perform soft tissue work on the patient to see if they have a decrease in pain following the treatment as this is an indication that the LBP is probably mechanical in nature. c. Refer the patient to a dermatologist, as they may be having referred pain from other melanomas d. After completing the physical exam, adjust the patient to see if they have a decrease in pain following the adjustment as this is an indication that the LBP is probably mechanical in nature.
a. Order imaging before adjusting to assess for a malignant neoplasm of the spine.
A new patient presents to your office reporting bilateral LBP L1-L2 which began one week ago immediately after he fell off of a step ladder (from two feet off the ground) while replacing a light bulb. He describes landing on his feet as if he had jumped off the ladder. He immediately felt a sharp pain in his low back which has been getting worse since it began. He cannot find any positions which afford him any comfort. The patient is a well nourished 48 year old male with a history of diabetes and prostate cancer. He reports that he was given a cancer-free diagnosis following the removal of his prostate 5 years ago. Which of the following is the most appropriate action following examination, given this patients history? a. Order imaging to assess for a malignant neoplasm. b. Adjust the patient as you suspect a lumbar sprain/strain injury. c. Order imaging to assess for an osteoporotic compression fracture. d. Order imaging to assess bone and soft tissue as you suspect spinal stenosis.
a. Order imaging to assess for a malignant neoplasm.
Forceful manipulation is contraindicated in patients with ________. a. Osteoporosis b. Sacroiliac syndrome c. Clotting disorders d. Facet syndrome
a. Osteoporosis c. Clotting disorders
Which of the following types of cancer are the 3 most likely to metastasize to the spine? MACA (there are 3 correct answers) a. Prostate cancer b. Breast cancer c. Skin Cancer d. Lung cancer
a. Prostate cancer b. Breast cancer d. Lung cancer
When palpating/springing left to right on the spinous process of L4, you perceive a "hard end-feel". When palpating/springing right to left on the spinous process of L4, you perceive a "springy end-feel". What SCP should you contact to correct this restriction with a side posture set up as learned in Diversified lab? a. R-mammillary process of L4 b. L-mammillary process of L4 c. L-mammillary process of L5 d. R-mammillary process of L5
a. R-mammillary process of L4
When you set up to adjust a RRR-L3, the patient should be in _____. a. RSP b. LSP
a. RSP
Mrs. Jones, an otherwise healthy 32 year old female, returns to your office 6 weeks after delivering a healthy baby boy. She explains that she had a c-section procedure to deliver the baby after 18 hours of difficult labor. She reports mid line back pain at the thoracolumbar junction which began a few hours after giving birth and has been getting worse since it began. Her pain is currently 7/10 on a pain scale. She also reports that she thinks she may have a sinus infection since she has been running a low grade fever for the past few weeks. Upon examination, you detect severe muscle spasm and tenderness from T8 to L5 bilaterally. Given this patient's history, which of the following is the most appropriate diagnosis? a. Spinal infection b. Fractured coccyx c. Lumbar sprain/strain d. Spinal stenosis
a. Spinal infection
In patients with spinal/disc degeneration, osteophytes may form at the superior and inferior endplates. a. True b. False
a. True
Regarding informed consent: Prior to any evaluation or treatment, a doctor must always inform patients of potential complications and any risk of significant harm from said evaluation or treatment. a. True b. False
a. True
When a patient has contraindications to HVLA adjusting/manipulation, you may still be able to mobilize the joint. a. True b. False
a. True
Mrs. Covidia is a well nourished 58 year old female who presents to your office complaining of low back pain. You notice that her gait is very unsteady as she walks in your office. When you ask the patient how long she has been feeling unsteady, she explains that it began with the onset of low back pain when she was leaning forward pick up her bag off of the front floor board of her car a few days ago. Which of the following is the most appropriate action? a. Unsteady gait is a red flag for LBP. Proceed with caution being careful not to aggravate the patient's condition during the physical exam. b. Explain to the patient that unsteady gait is a typical finding in patient's with cancer and refer to an oncologist. c. Explain to the patient that unsteady gait is a typical finding in patient's with compression fractures and refer out for orthopedic consultation. d. Explain to the patient that she should feel more steady after the adjustment and removal of nerve interference.
a. Unsteady gait is a red flag for LBP. Proceed with caution being careful not to aggravate the patient's condition during the physical exam.
A new patient, Mr. Jones, presents with bilateral LBP from L3-L5 and tenderness over the SI joints bilaterally. Upon examination/palpation of the sacrum, you detect a RRLOA. How might you have detected this motion restriction? a. While palpating P-A on the right sacral base b. While palpating P-A on the right sacral apex c. While palpating P-A on the left sacral base d. While palpating P-A on the left sacral apex
a. While palpating P-A on the right sacral base
When setting the pelvis for a lumbar rotation restriction, which of the following is true? a. You should let the patients' leg slide across your thigh as you rotate their pelvis anteriorly preventing abduction and adduction of the patient's hip. b. You should adduct the patient's hip as you rotate the pelvis anteriorly to create maximum tension. c. You should pull the patient's hip that is contacting the table posteriorly as you set the pelvis. d. You should abduct the patient's hip as you rotate the pelvis to prevent the patient's leg from being pressed into the side of the table.
a. You should let the patients' leg slide across your thigh as you rotate their pelvis anteriorly preventing abduction and adduction of the patient's hip.
Regarding coefficients of friction of synovial joints, the kinetic coefficient of friction is _______ the static coefficient of friction. a. much lower than b. equal to c. slightly higher than d. much higher
a. much lower than
You have detected a "hard end-feel" when springing a lumbar spinous process right to left and a "springy end-feel" when springing left to right on the same spinous process. Which of the following is the correct patient position? a. right side-lying position b. left side-lying position
a. right side-lying position
The most common symptom of disc herniation is _____. a. sciatica b. local burning pain c. bowel and/or bladder disturbances d. muscle weakness
a. sciatica
Lumbar radiculopathy is typically ______. a. unilateral b. caused by leg pain c. bilateral d. accompanied by bowel/bladder incontinence
a. unilateral
spinal infections •Acute spinal infections are _______ contraindications to HVLA thrusts. Ex: •Osteomyelitis •Septic discitis •TB of the spine •LBP caused by spinal infection - incidence .01% •Usually _________ (pt w/ discogram) •Presence of fever: high specificity (SPIN: specificity + rules in) history of •UTI •Catheters •Skin infections •Injection sites •IV drug users •** One of these sites identified in 40% of pts presenting with spinal infection
absolute, bloodeborne
•Always inform patients of ANY risk of significant harm -Even though most risks are not significant •CVA following cervical manipulation -Most studies actually show a higher incidence (1 in 100,000)of spontaneous VBA dissection than of post-manipulative VBA dissection (1-2 per 1,000,000) •NCMIC reports a significant number of malpractice suits are filed due to a lack of informed consent -What is a material & significant risk is not clear •up to the courts to decide in each case •Contact an attorney specializing in health care law in the area you practice for ________ on standards for obtaining informed consent
advice.
•Complication= problem that occurs _______ a procedure is performed -Serious injuries from adjustive therapy are very uncommon -May be associated with new tissue damage -May require a change in therapeutic approach (Table 4-1) -Most are resultant from misdiagnosis or improper technique •Awareness of Complications/Contraindications & Sound Diagnostic Assessment help prevent injuries -Ranges from mild increase in local discomfort to serious permanent neurological complications/death -"The best available evidence indicates that chiropractic care is an effective option for patients with mechanical spine pain and is associated with a very ______ risk of associated serious adverse events"
after, low
•______ is the top cause of herniated discs. Your spine ages with you—and after years of use, spinal structures begin to weaken. As you get older, the water content and elasticity of the nucleus pulposus decreases. That's why herniated discs are most common in people who are between _________ years old.1
aging, 30 and 50
radiating pain •L5: postero-lateral thighs wrapping around to the ______ foreleg •L4: lateral-anterior thighs wrapping around to antero_____ foreleg
anterior, medial,
•Absolute Contraindications= disorders that contraindicate _____ form of thrust manipulation •Relative Contraindications= potential contraindications depending on severity/stage of disorder & it's pathological process -Many contraindications to adjust are relative -May require modifications to treatment -Use CAUTION in applying adjustive therapy, consider: •Pts. Age/state of health •Nature of potentially complicating pathologic condition •Stage of disorder, stage of development State of remission or exacerbation
any,
Antalgic Gait occurs when the patient avoids putting weight on one leg due to pain. A patient with left sciatica would lean ______ from the involved side (lean towards the right) to avoid putting weight on the left leg.
away.
We can use the orthogonal system to describe lumbar motion. For example, right lumbar rotation could also be described as ________. a. -θZ b. -θY c. +θY d. +θZ
b. -θY
According to the 2017 Clinical Practice Guidelines from the American College of Physicians (found at the end of the disc PowerPoint), physicians are recommended to advise patients of alternative treatments such as chiropractic for which of the following conditions? Choose the best answer. a. Acute LBP b. Acute, Subacute, and Chronic LBP c. Acute and Subacute LBP d. Chronic LBP
b. Acute, Subacute, and Chronic LBP
When should you pull your patient off of their shoulder (the one contacting the table)? a. At the beginning of the set up, before you flex their top leg (the one closest to the ceiling) b. After you set the pelvis c. Before you set the pelvis d. After you go "pocket to pocket"
b. After you set the pelvis
Which of the following are red flags for cancer? MACA a. Pain that is relieved when recumbent b. Age over 50 years old c. Pain at night while trying to sleep d. Weight loss after beginning a regular exercise program e. Pain that lasts longer than 30 days
b. Age over 50 years old c. Pain at night while trying to sleep e. Pain that lasts longer than 30 days
Since it is safe to adjust a healthy joint, once you have correctly identified a subluxation/motion restriction, it is safe to adjust that subluxation/motion restriction. a. True b. False
b. False
One of the main differences between "acceptable" and "exceeding reactions" is that exceeding reactions _____. a. Do not resolve spontaneously b. Interfere with work/ADL's c. Have a shorter duration d. Have a more rapid onset
b. Interfere with work/ADL's
When palpating/springing right to left on the spinous process of L4, you perceive a "hard end-feel". When palpating/springing left to right on the spinous process of L4, you perceive a "springy end-feel". What SCP should you contact to correct this restriction as learned in Diversified lab? a. R-mammillary process of L5 b. L-mammillary process of L4 c. L-mammillary process of L5 d. R-mammillary process of L4
b. L-mammillary process of L4
Upon examination of your patient's sacrum, you detect a RRLOA. What is the correct contact point for the side posture set up taught in lab? a. L-calcaneal b. L-pisiform/hypothenar c. R-calcaneal d. R-pisiform/hypothenar
b. L-pisiform/hypothenar
LBP can be caused by which of the following conditions? Choose the best answer. a. Systemic conditions b. LBP can be caused by musculoskeletal, visceral, and systemic conditions. c. Visceral conditions d. Musculoskeletal conditions
b. LBP can be caused by musculoskeletal, visceral, and systemic conditions.
A new patient arrives at your office complaining of local LBP which began one week ago after carrying 12 pieces of plywood up the attic stairs to deck his attic. When asked to point to the location of pain, he covers his low back bilaterally with both hands and explains that he only gets relief when he lays down. Patient examination reveals lumbar hypolordosis, and taut and tender fibers bilaterally L1-L5 with bilateral erector spinae spasm in the lumbar region. Based on this information, you are thinking this patient may have a ______. a. Spinal infection b. Lumbar sprain strain injury c. Lumbar malignant neoplasm d. spinal stenosis
b. Lumbar sprain strain injury
Which of the following are potential complications from manipulating a patient with late stage osteoarthritis according to table 4-1 from the textbook? a. Wallenberg syndrome b. Neurological compromise c. Vertebral artery dissection d. Unresponsiveness to pain e. Hemorrhage
b. Neurological compromise
A test with high sensitivity means that __________. a. Patients who test negative for a condition are less likely not to have the condition. b. Patients who test negative for a condition are more likely not to have the condition. c. Patients who test positive for a condition are more likely to have the condition. d. Patients who test positive for a condition are less likely to have the condition
b. Patients who test negative for a condition are more likely not to have the condition.
Which of the following describes a transient episode of an increase in a patients symptoms that later resolve spontaneously? a. Relative Contraindication b. Reaction c. Absolute Contraindication d. Complication
b. Reaction
Conditions that have the potential to contraindicate manual adjusting depending on the severity/stage of the condition are called _______. a. Actual contraindications b. Relative contraindications c. Real contraindications d. Absolute contraindications
b. Relative contraindications
When setting up for a side posture adjustment on a lumbar left rotation restriction, your patient complains that their right thigh is being "smashed into the edge of the table". Which of the following choices is the most likely cause of the patients discomfort? a. The patient's shoulders were NOT stacked at the beginning of the set up. b. You adducted the patient's hip as you were setting the pelvis. c. The patient's hips were NOT stacked at the beginning of the set up. d. You positioned your patient too close to the edge of the table. e. You abducted the patient's hip as you were setting the pelvis.
b. You adducted the patient's hip as you were setting the pelvis.
A 30 year old female, a new patient, arrives at your office complaining of sharp bilateral local LBP which began approximately two weeks ago. The pain is intermittent bothering her several times per day. While taking a patient history, you discover that your patient does not drink water... ever. She says she just doesn't like water and she drinks tea and sodas instead. When you ask about constitutional symptoms giving specific examples, you discover that your patient has also been experiencing painful urination. Thinking about the "big picture" and based on the patient history above, it is important to consider that your patient's low back pain may be _____. a. caused by a disc herniation. b. a referred pain from the kidneys. c. a referred pain from the prostate. d. referred pain from an abdominal aneurysm.
b. a referred pain from the kidneys.
You have detected a "hard end-feel" when springing a lumbar spinous process left to right and a "springy end-feel" when springing right to left on the same spinous process. Which of the following is the correct patient position? a. right side-lying position b. left side-lying position
b. left side-lying position
When performing an HVLA adjustment, you must breech the ________. a. elastic and anatomic barriers b. physiologic and elastic barriers c. plastic zone d. physiologic barrier only
b. physiologic and elastic barriers
When your patient is in RSP, they are laying on their ______. a. back b. right side c. left side
b. right side
When you find a RRR L3, you would expect to feel more joint restriction when palpating ________ on the spinous process. a. left to right b. right to left
b. right to left
Which of the following types of disc pathology are the most severe/degenerative? a. prolapse b. sequestration c. extrusion d. dehydration
b. sequestration
Patient Position For all techniques, how one positions the patient is very important. Not only for delivery of the adjustment but also for patient comfort for receiving the adjustment. "It's all in how you tee up the _____." Because of this, the equipment for optimal positioning becomes very important. It is under this heading that we will also describe appropriate table adjustments.
ball
myotomes •Upper Extremities: •C5 - Deltoid and _____ (C6 too) •C6 - Wrist Extensors •C7 - Triceps / _______ Flexors / Finger Extensors •C8 - Finger Flexors •T1 - Finger ABduction / Finger ADduction
biceps, wrist,
Anatomical reference points for dynamic spinal listings Mo-palp = ______ reference Dynamic orthogonal = _____ reference
body, body.
When using orthogonals to describe lumbar lateral flexion, left lateral flexion is ________. a. +θZ b. +θY c. -θZ d. -θY
c. -θZ
Spinal stenosis can result from hypertrophic degenerative changes of the _____. Choose the best answer. a. IVD's, facets, and TVP's b. IVD and facets c. IVD's, facets and ligamentum flavum d. IVD's, spinous process, and TVP's
c. IVD's, facets and ligamentum flavum
Which of the following motions occur during normal lumbosacral extension? a. L5 extends as the sacral base extends. b. L5 extends as the sacral apex glides anterior. c. L5 extends as the sacral base flexes. d. L5 flexes as the sacral base extends.
c. L5 extends as the sacral base flexes.
The listing: RRTA describes the same restriction as a _______. a. Counter-rotation restriction b. RRROA c. Nutation restriction d. CRRTA
c. Nutation restriction
A test with high specificity means that __________. a. Patients who test negative for a condition are less likely not to have the condition. b. Patients who test negative for a condition are more likely not to have the condition. c. Patients who test positive for a condition are more likely to have the condition. d. Patients who test positive for a condition are less likely to have the condition
c. Patients who test positive for a condition are more likely to have the condition.
Mobilization occurs between which two barriers? a. Elastic and Anatomic b. Elastic and Plastic c. Physiologic and Elastic d. Physiologic and Plastic
c. Physiologic and Elastic
Your patient is complaining of local "right hip pain" which is exacerbated by sitting for more than 30 minutes. When asked to point to the pain, the patient places their hand over their right sacroiliac joint. Inspection/static palpation reveals tenderness around the entire right SI joint and a left short leg as compared to the right. You also detect a hard end-feel when palpating the right sacral base anteriorly. Which of the following is the most likely listing? Make sure your answer has the correct letters for the abbreviated listing. a. RRRROA b. RRRLOA c. RRLOA d. RRROA
c. RRLOA
Which of the following are not consistent with complications from adjustive therapy? a. Misdiagnosis/improper technique is a common cause of complications from adjustive therapy b. Complications range from mild increase in local pain to permanent neurological deficits and in rare cases even death. c. Serious injuries are fairly common d. May be associated with new tissue damage
c. Serious injuries are fairly common
When an intervertebral disc weakens/degenerates, part of the disc can tear resulting in a disc herniation. What part of the disc typically tears/degenerates allowing herniation? Choose the best answer (anatomical name). a. circumferential fibrosis b. central pulposis c. annulus fibrosis d. nucleus pulosis
c. annulus fibrosis
PROM should always be _____________ AROM. a. less than b. equal to c. greater than
c. greater than
Antalgic posture is frequently observed in patients with which type of disc herniation? a. central or midline b. medial or posteromedial c. lateral or posterolateral d. none of the above
c. lateral or posterolateral
Pain originating from the lumbar facets _________. a. does not radiate b. typically radiates down the leg to the foot c. may radiate into the buttocks and thighs d. frequently causes sciatica
c. may radiate into the buttocks and thighs
When an intervertebral disc weakens/degenerates, part of the disc can tear allowing discal material to escape the normal boundaries of the disc. What part of the disc herniates through the outer layer ? Choose the best answer (anatomical name). a. central pulposis b. circumferential fibrosis c. nucleus pulosis d. annulus fibrosis
c. nucleus pulosis
The adjustment occurs in the ___________. a. mobilization zone b. neutral zone c. paraphysiological space d. plastic zone
c. paraphysiological space
How should the right ilium move during right sacroiliac flexion? a. anterior-inferior b. posterior-superior c. posterior-inferior d. anterior-superior
c. posterior-inferior
A new patient reports to your office complaining of constant LBP bilaterally L1-L5 with pain in both SI joints which began approximately one year ago insidiously. She also reports bilateral thoracic pain and pain that travels from her low back up into her thoracic spine and into both arms. When you attempt to palpate the lumbar spine your patient cannot tolerate light pressure stating that it is too painful and jumping off the table with even light pressure. Taking this into consideration, you should consider _______. a. your patient has prostate cancer b. your patient probably has cancer c. your patient may be experiencing psychological distress that may be causing/amplifying her pain. d. your patient may have ankylosing spondylitis
c. your patient may be experiencing psychological distress that may be causing/amplifying her pain.
1st barrier is called physiologic and represents the end of A-ROM. 2nd barrier is called elastic and represents the end of P-ROM. 3rd barrier is called anatomic or anatomical and represents the end of joint motion that causes no permanent damage to the structures that limit or "_______" motion and are important to joint stability.
check.
IAR for Lateral Flexion = IVD opposite side of lateral flexion Vertebra tilts and slides towards the concavity Structures compressed on the side of convexity uFacets approximate uDisc uStructures stretched on the side of ______ uFacets separate uDisc uLigamentum flavum, intertransverse ligament, capsular ligaments
convexity.
compression fractures •Common in patients with osteoporosis (included under 'systemic diseases') •Red Flags •Osteoporosis •Corticosteroid usage •>70yoa •>50yoa •History of trauma •Long term ________ usage?- very high specificity (.99) •Treat as a compression fracture until proven otherwise • •Is there a history of trauma? Yes + LBP = 85% specific for comp fracture •Low sensitivity -Most patients with a history of compression fracture do not have history of trauma •high specifictyà + rules in •Low sensitivityà - does not rule out
corticosteroid
We can use the orthogonal system to describe lumbar motion. For example, left lumbar rotation could also be described as ________. a. -θY b. -θZ c. +θZ d. +θY
d. +θY
When using orthogonals to describe lumbar lateral flexion, right lateral flexion is ________. a. -θZ b. +θY c. -θY d. +θZ
d. +θZ
Which of the following may irritate a nerve root? a. decreased blood supply to the nerve root b. mechanical pressure from a bulging/herniated disc c. chemical changes d. All of the choices are correct
d. All of the choices are correct
Which of the following is true regarding musculoligamentous injuries? a. They are a common cause of LBP b. They are caused by tearing and or stretching of soft tissues. c. They can result from faulty biomechanics. d. All of the choices are correct.
d. All of the choices are correct.
Which of the following represents appropriate treatment for a musculoligamentous injury? a. Limit motion to decrease inflammation b. Exercises that reproduce the patient's pain... no pain no gain. c. Referral to an orthopedist since chiropractors cannot treat musculoligamentous injuries. d. Gentle stretches and/or exercises as long as they do not exacerbate the patient's symptoms
d. Gentle stretches and/or exercises as long as they do not exacerbate the patient's symptoms
You have detected a R-SB-PS during an examination of your patient's sacral biomechanics. Which of the following is the correct contact point for the side posture set up taught in lab? a. L-SB b. R-SB c. R-pisiform/hypothenar d. L-pisiform/hypothenar
d. L-pisiform/hypothenar
Mr. Smith arrives to your office complaining of bilateral low back pain (LBP). When asked to point to the pain, he places both of his hands on his low back covering the entire lumbar spine. Upon visual inspection/static palpation of the lumbar spine, you observe a hypolordosis with an increase in muscle tonicity bilaterally. The patient's right leg appears short as compared to the left leg when lying prone. Motion palpation reveals a hard end feel when palpating left to right on the spinous process of L2, while motioning the spinous right to left reveals a springy end-feel. Which of the following is the most likely listing? a. LP-L3 b. RP-L3 c. RRR-L2 d. LRR-L2
d. LRR-L2
Your patient is experiencing lumbo-sacral pain intermittently. Upon examination/palpation you notice that the patient has a hypolordosis and tenderness over the entire sacral base and L5 bilaterally. You also find a posterior sacral base with a hard end-feel when motioning the sacral base P-A. Choose the correct CP for correcting this restriction using the side posture set up taught in lab. a. R-calcaneal if your patient is in left side posture b. R-pisiform/hypothenar if your patient is in right side posture c. L-pisiform/hypothenar if your patient is in right side posture d. R-calcaneal if your patient is in right side posture
d. R-calcaneal if your patient is in right side posture
Mr. Smith arrives to your office complaining of bilateral low back pain (LBP). When asked to point to the pain, he places both of his hands on his low back covering the entire lumbar spine. Upon visual inspection/static palpation of the lumbar spine, you observe a hypolordosis with an increase in muscle tonicity bilaterally. The patient's right leg appears short as compared to the left leg when lying prone. Motion palpation reveals a hard end feel when palpating right to left on the spinous process of L2, while motioning the spinous left to right reveals a springy end-feel. Which of the following is the most likely listing? a. LRR-L2 b. LP-L3 c. RP-L3 d. RRR-L2
d. RRR-L2
Mr. Smith arrives to your office complaining of bilateral low back pain (LBP). When asked to point to the pain, he places both of his hands on his low back covering the entire lumbar spine. Upon visual inspection/static palpation of the lumbar spine, you observe a hypolordosis with an increase in muscle tonicity bilaterally. The patient's right leg appears short as compared to the left leg when lying prone. Motion palpation reveals a hard end feel when palpating right to left on the spinous process of L2, while motioning the spinous left to right reveals a springy end-feel. Which of the following is the most likely listing? a. RP-L3 b. LRR-L2 c. LP-L3 d. RRR-L2
d. RRR-L2
What does "pocket to pocket" mean? a. The doctor's front pocket should approximately line up with the patient's front pocket b. The doctor's front pocket should approximately line up with the patient's front pocket c. The doctor's back pocket should approximately line up with the patient's back pocket d. The doctor's front pocket should approximately line up with the patient's back pocket
d. The doctor's front pocket should approximately line up with the patient's back pocket
A new patient presents to your office with chronic LBP (VAS 8/10) which began approximately 3 months ago and has been getting worse since it began. The patient is a 38 year old female with a history of breast cancer. She has been seeing a massage therapist for the past 6 weeks and although she experiences a slight decrease in pain (from VAS 8/10 to VAS 7/10) following a massage, the relief only lasts 1-2 hours. You should be suspect that ______ may be causing your patient's pain. Choose the best answer. a. a sprain strain b. facet syndrome c. osteomyelitis d. a malignant neoplasm
d. a malignant neoplasm
Typical causes of disc herniation include _______. a. a sudden increase in intrathecal pressure b. poor biomechanics c. age related degeneration d. all of the choices.
d. all of the choices.
What does LRR stand for? a. little rotation restriction b. left right restriction c. left restricted rotation d. left rotation restriction
d. left rotation restriction
Which of the following are NOT among the most common reactions to adjustive therapy (according to the study referenced in your text and the notes)? a. radiating discomfort b. mild increase in local pain c. fatigue d. radiating numbness
d. radiating numbness
When performing a side posture adjustment to correct a lumbar rotation restriction as taught in the lab, it is important to maintain tension on the patient's shoulder in which direction? a. posteriorly b. superiorly c. toward the ground d. superiorly and posteriorly
d. superiorly and posteriorly
•Reactions= transient episodes of increased symptoms that resolve spontaneously (Dvorak's def) -No worsening of underlying condition or new iatrogenic injury -Normal vs adverse reactions •Normal reactions= minor increase in ______ -commonly occurs in patients who have been successfully treated Adverse reactions= more significant discomfort & temporary or permanent impairment (less common/complication
discomfort,
LRR = Left Rotation Restriction RRR = Right Rotation Restriction RLFR = Right Lateral Flexion Restriction LLFR = Left Lateral Flexion Restriction AGR = Anterior Glide Restriction PGR = Posterior Glide Restriction RRROA = Rotation Restriction around Right Oblique Axis RRLOA = Rotation Restriction around Left Oblique Axis CRRROA = Counter-Rotation Restriction around Right Oblique Axis CRRLOA = Counter-Rotation Restriction around Left Oblique Axis RRTA = Rotation Restriction around Transverse Axis CRRTA = Counter-Rotation Restriction around Transverse Axis
diversified listings outlined.
Your patient is complaining of bilateral sacroiliac joint pain with tenderness over the SI joints bilaterally and right lower lumbar area. Upon examination/palpation you find a rotation restriction around the transverse axis. Choose the correct SCP for the side posture set up taught in lab. a. middle of the sacral apex b. right sacral base c. R-calcaneal d. middle of the calcaneal e. middle of the sacral base
e. middle of the sacral base
lumbar ranges of motion ________ ________ (most flexible motions of lumbar spine) 75% of trunk flexion and extension from lumbar region (flexion 2Xs' extension) First 60 degrees of trunk flexion from the lumbar spine (pelvis stabilized by glutes and hamstrings) uLumbar lateral flexion (moderate flexibility) Lumbar rotation (limited)
flexion and extension,
cavitation After the one breeches the elastic barrier the joint should cavitate. This is the pop or crack that one customarily hears. This an air mass (usually nitrogen) rushing back in to a closed space created by a joint that has had a significant loss of motion (for many reasons) and has formed a vacuum. Think in terms of a suction cup or 2 pieces of glass held together by a small amount of _______
fluid.
•A weakened disc goes through a series of stages (4) before it reaches herniation occur suddenly or slowly over time •In the first 2 stages, the nucleus pulposus _______ yet broken through the annulus fibrosus. The third and fourth stages, however, represent _____ herniations.
hasn't, complete.
CES (Cauda equina syndrome) •Caused by a midline disc _______ @ the L3, L4, or L5 IVD •Symptoms: paralysis, weakness, pain, reflex changes, bowel/bladder disturbances -Bilateral radiculopthies with distal paralysis of lower limbs, sensory loss in the _____ distribution, & sphincter paralysis indicative of CES -Adjustment CONTRAINDICATED -SURGICAL EMERGENCY •13 cases of CES (in 80 years of literature) apparently caused by __________ therapy -An additional 16 cases resulted from MUA -D.C. & ER doc did not take appropriate action in most cases (CES is very rare) •Lack of prompt appropriate treatment à increase in frequency of serious complications & residual impairment -Incidence of CES from manipulative therapy: 1 in 4 million - 1 in 100 million
herniation, sacral, manipulative,
position example Patient Position Set the patient's pelvis Rotate pelvis anteriorly without Abducting or Adducting the _____ Gently pull Pt. off shoulder (the one resting on the table) IH: Position pts. Humerus ______ to mid axillary line NOT X chest +Y to oblique +Y distraction P2P= pocket 2 pocket Take care to keep the Pt. close to the front edge of table lMaintain tension throughout the set up (spring) Load & Hold/ don't loose the potential energy you created
hip, anterior,
Line Of Drive LOD covers not only the direction of the force generator but also ______ the force is being generated. Line of correction and vector is sometimes used to describe these entities. In a motion model LOD is determined with physical methods, by Mo-palp (excursion &/or end feel). A diminishment or restriction to normal motion is felt for and then HV-LA force is applied to break through that restrictive barrier.
how.
•Broberg used a theoretical disc model to study how IVD's respond to compression, shear, bending, and axial rotation -IVD stiffness increases sig. with axial load -Bending, shear & axial rotation only constitute a risk of annular fiber rupture in combination with very high axial loads (compression) •Most studies were done on cadavers, some after removing the posterior elements (results vary study to study) •**The IVD may respond VERY differently when there is associated disc herniation/motion segment _________
instability.
•A sudden increase in _______ pressure may push the nucleus pulposis through the annulus fibrosis •Coughing & sneezing cause a sudden increase in intrathecal pressure •Valsalva maneuver=ortho test •Ask patient to "bear down" to increase intrathecal pressure •may aggravate/reproduce symptoms •Do you think constipation could aggravate a patient's symptoms?
intrathecal
functional anatomy of typical lumbar vertebrae Lumbar vertebra are large _______ shaped (wider side to side) Lumbar pedicles Short and strong Vertebral notches Superior notch shallow inferior notch deeper Lamina Short, broad, and strong Spinous Processes ______ and broad uTVP's uLong, slender and flat (considered frail) ___ longest Articular Processes Large, thick and strong Superior articular process: concave and faces posteromedially Inferior articular processes: convex and face anterolaterally Mamillary process: bump on the posterior-superior edge of the _____ articular process Facet orientation: changes from mostly _______ to more coronal from L1-L5 Limits rotation but Allows for more flexion and extension Facet functions: Facets carry 18% of axial load à 3% in extension Is facet syndrome more common in hypo or hyper-lordosis? Facet + capsule: as much as 45% of torsional strength IVD's Nucleus midline and slightly posterior Disc height to body height ratio = 1:3 Allows increased motion Better resistance to axial forces d/t preload state Nucleus pulposis absorbs water generating hydrostatic pressure à inc stability of the disc
kidney, thick, l3, superior, sagittal
lumbar curve The lumbar lordosis developes as a baby begins to sit up (9-12 mos.) Lordosis usually well developed by 18 months from standing Begins at L1/2 and increases at each level caudally Apex _____disc ______ degrees = normal lumbar lordosis Measuring from superior endplate of L1 to the inferior endplate of L5 uLordosis is affected by sacral base angle (SBA) Anterior pelvic tilt à increased lordosis à increased SBA Increases forces absorbed by the facets Posterior pelvic tilt à decreased lordosis à decreased SBA Increases forces absorbed by the IVD (dec. ability of the spine to absorb compressive forces
l3/4, 20-60
•Sciatica (S1-S5): buttocks à posterior legs à ________ ankles
lateral,
abbreviations R = right L = left L = lateral as 2nd character A = anterior P = posterior P = pelvis usually spelled out I = inferior S = superior L-S= lumbosacral SB= sacral base SA= sacral apex AI= anterior-inferior ASB= anatomical snuff box ILA= inferolateral aspect LSP= left side posture = _____ side down*** lRSP= right side posture = ______ side down***
left, right.
CoF The nice thing about joint surfaces is their very ____ "Coefficients of Friction" (CoF). This becomes a very forgiving system when we apply it to developing our manipulative skills. This gives us some latitude when we are not exactly aligned with the joint surfaces.
low
•Risk of serious complications from Lumbar Manipulation is extremely ______ p. 103 -<1 case/yr ??(lack of documentation of complications/may be higher?) -Forces measured during L-P manipulation = forces baggage handlers experience •Forces determined to be below injury threshold •Reported Complications of Lumbar Manipulation -Disc-related -Diagnostic error -Vascular complications due to thrombosis -Osteoporotic fracture -Manipulation of patient on anticoagulant therapy -Rib fracture -Inguinal/abdominal hernia -unknown
low,
The space created between the physiologic barrier and the elastic barrier or the space created between the different distances attained with A-ROM & P-ROM is where we perform _________. This is an aspect of joint motion that one can not do to them self or by them self. It requires outside assistance and therefore is passive in nature. We use this area (work with in this space) to increase ROM when we can not, for some reason, perform the preferred HV-LA.
mobilization,
spinal stenosis •________ of the central spinal canal and/or... •Narrowing of the lateral recesses of the spinal canal (n. roots run inferiorly) •Can result from hypertrophic degenerative changes in the •IVD, ligamentum flavum, and facets prevalence unknown •Some of the more serious anomalies are not in the L-P region •Dens hypoplasia, unstable os odontoideum, basilar invagination, Arnold Chiari, etc4 •Most lumbopelvic anamolies cause _________ contraindications or none •Scoliosis - asymptomatic or symptomatic (severe) •Spondylolisthesis - asymptomatic or symptomatic (severe) •Spatulated TVPS •Sacralization of L5 •Spina Bifida/ diastematomyelia (split cord) depends on severity4
narrowing, relative,
nerve root irritation •Direct Compression (mechanical pressure) •Chemical changes •Neuroischemia •Viral infection: • ______ causes inflammation of the nerves
neuritis,
Midline neutral (neutral axis) - A longitudinal line in a long structure where normal axial stresses are zero when the structure is subjected to bending. That is to say there are ____ "stresses" imposed upon the soft tissue components about the joint
no
Contraindications to & Complications of Adjustive Therapy •" Clinical corroboration of subluxation/dysfunction syndromes is ______, in and of itself, an indication for adjustive therapy." -You, the doctor, must determine: Is it SAFE to adjust? -Just because a patient has subluxation/dysfunction, does not mean that adjustive therapy is appropriate for that patient -Spinal dysfunction may be concomitant with contraindications to some forms of manual therapy
not
•Though bulging discs and herniated discs sound synonymous, they are _____. •A bulging disc is when the nucleus pulposus presses on the annulus fibrosus and bulges the disc, but it doesn't ______ through. •A true herniated disc occurs only when the nucleus pulposus breaks through the annulus fibrosus and ______ the disc.
not, break, escapes,
Dynamic Listings Mo-palp - Motion Palpation (excursion & end-feel) Dynamic Orthogonal (same system but written in terms of reduced movements) Along - is used to state someone or something is moving in ____ direction. Linear, translation. About /Around- used of movement to or among many ______ places or in no particular direction, all around or on all sides (such as around an axis), in rotation or succession, about a point or around a point (a point in space).
one, different.
what are problems with TIC?
other things affect them.
Static Model- Vertebrae stuck in space. Will not return to neutral. Can go further "______" with in it's normal range of motion. Dynamic Model- Restricted with in it's normal range of motion. Will return back to it's ________ position.
out, neutral
pain not relieved by bed rest •High Sensitivity - Neg test rules _____- (SNOUT) •If a patient's pain IS relieved by bedrest = Neg test •High sensitivity = good at identifying patients ______ the Dz = more true negatives •Pain that IS relieved by bedrest (neg test) good at predicting no cancer •High sensitivity means a negative test more accurate (than if test had low sensitivity) •Low Specificity - Positive test rules ___ (SPIN) •If a patient's pain is NOT relieved by bedrest = Positive test •Low specificity = not as good at identifying patients ______ the Dz = More false + •pain not relieved by bedrest is experienced by many pts w/o Cancer Low specificity means that a positive test is less accurate (than if the test had high specificity
out, without, in, with,
adjustment Central to chiropractic wellness and left unanswered is whether an adjustment as such has a unique role in wellness care over and above its role as a treatment therapy lThis is also mirrored by Vernon's four staged practice management paradigm: lReduction of ____- lRecovery of function lRehabilitation lReinforcement
pain.
hvla The best and most efficient way to breach the elastic barrier is through a high velocity (speed), low amplitude (small depth) force. Analogy: pulling a band aid off. Once this is done we move in to a new space between the elastic barrier and the anatomical barrier called the ____________ space. The joint motion, at this point is greatly increased.
para physiological.
l1 Health is the natural state of the individual, and the natural tendency of the body is to maintain or restore that health l2. Health is an expression of biological, psychological, social and spiritual factors, and disease and illness is multi-causal l3. Optimal health is unique for any single individual, and the individual also bears some responsibility for their health - the practitioner is simply a facilitator of health l4. There is a fundamental and central role for the structure and function of the neuro-musculo-skeletal system in the maintenance of good health and combating disease
philosophys of wellness has 4 principles
myotomes •Lower Extremities: •L3 - Hip Flexors •L4 - Knee Extensors •L5 - Knee Flexors •S1 - ________ Flexors
plantar
•When done suddenly or with poor posture, even normal movements can cause a herniated disc. Twisting in your office chair too quickly or lifting a heavy bag of groceries might seem harmless, but they can weaken your spinal discs—especially if you regularly use ______ body mechanics.
poor.
-REVERSIBLE complications= the pathological condition associated with the complication is reversible •Onset within 2 days •Requires diagnostic/therapeutic interventions •Tissue damage •**patient can return to ____-occurrence status -IRREVERSIBLE complications •Onset within 2 days •Requires diagnostic/therapeutic interventions •_______ tissue damage and impairment result
pre, permanent.
lumbar kinetics in flexion Lumbar Flexion uInitiated by concentric contraction of ______ / abdominals Psoas initiates when femur fixed uAbdominals initiate when pelvis is fixed uControlled by eccentric contraction of the erector spinae mm. First 60˚ - Pelvis locked by gluteus maximus and hamstrings Pelvis rotates 30˚more @ hips when when trunk weight exceeds ability of mm. to lock pelvis Full Flexion (L-P): trunk is supported by ligaments and passive muscle tension
psoas.
Lumbar Lateral Flexion Coupled Motion Patterns: Can't bend a curved rod without some rotation (physics principal) Lateral bending should be primarily controlled by eccentric contraction of the ______ ____ Inserts posterior to the IAR (posterior 1/3 IVD) Type 1 = normal coupled motion is thought to occur due to normal control of the eccentric contraction of the quadratus lumborum Lateral flexion combined with opposite side body rotation (spinousà concavity) Opposite of cervical and thoracic (upper)
quadratus lumborum,
specificity and sensitivity •Highly sensitive test: more likely a - test is really - for a condition •Highly specific test: more likely + test is really + for condition •For example: • Temp > 98.6o à sick patient •High sensitivity (less false negatives) / Low specificity (more false positives) •Temp >102o à sick patient •Low sensitivity: for example sick pts with a temp of 101o (more false negatives) •High specificity: for example most pts with a temp >102o are ______ sick (less false +)
really
musculoligamentous injuries •Lumbar strain/sprain (acute/chronic) •One of the M/C cause of LBP •Muscles, tendons, fascia, ligaments, joint capsule, etc. •Partial tearing/stretching of soft tissues above due to: •Trauma/overuse/improper use (poor posture) • Diagnosis based on: •MOI (___________), location of pain, & exclusion of nervous system injury and other systemic diseases •Research shows that prolonged bedrest slows ______ •Low Back Pain due to soft tissue injury: •_______ Pain on Palpation (POP) mild to severe •No paresthesia (exceptions) •No muscle weakness in legs or feet •Paraspinal muscle spasm (may be excruciating) •Usually relieved by rest / ________ by motion •May begin immediately or gradually after trauma (usually w/in 24hrs) •X-rays may be indicated to rule out _______ (esp. high velocity trauma) MRI to visualize soft tissues •Chiropractic Care: HVLA may be contraindicated if severe/acute •Although exacerbated by motion, preventing motion is counterproductive •Limiting motion à decreases muscle strength and flexibility & circulation •Gentle stretching and exercise _______ treatment • Resolve the injury more efficiently by using motion to increase circulation and flexible healing •If gentle stretching/exercise increase pts symptoms STOP
recovery, local, exacerbated, fracture, preferred,
•Contraindication= problem identified b4 the procedure is performed -Potential to cause harm/injury à procedure not advised (serious injuries very uncommon) -May worsen associated disorder (instability) -If procedure may delay life-saving treatment (cancer) •Adjustive therapy (if not contraindicated) can give significant pain relief & improve quality of life for cancer patients -**PALLIATIVE CARE MUST BE CONCOMITANT CARE W/ DR. TREATING MALIGNANCY** -Some conditions may contraindicate thrusting forms of manipulative therapy •May be able to use other forms of manual therapy (mobilization) •May be able to adjust other areas (improve quality of life) • -May be Absolute or _____ contraindications
relative.
-Bogduk studied excessive rotation with flexion (fig 4-7) •Flexion is presumed to tense the annular fibers •In flexion, the inferior & superior articular processes don't limit segmental ______ as much •IAR shifts from the central posterior 1/3 of the disc (A) to the impacted/compression facet (B) Fig 4-7 A-B -New IAR @ compression facet allows excessive motion (superior vertebra pivoting about new IAR) à shear & torsion on contralateral facet »Fractures of the impacted facet- fig 4-7 (C) »Capsular tears or avulsion fractures of the contralateral facet (C) »annular circumferential discal tears- fig 4-7 (D)
rotation,
lumbar rotation One-side rotation approximately 2 degrees each side per segment L1-2 2 degrees L2-3 2 degrees L3-4 2 degrees L4-5 2 degrees L5-S1 1 degrees _______ facets limit rotation Facets separate on side of rotation IAR for Rotation = posterior IVD (not central like pic) Coupled Flexion and Extension Aka Sagittal Plane Rotation When rotating/lateral bending from a flexed or extended posture: Spine à neutral posture uFlexed spine à rotation/lateral flexion à extension uExtended spine à rotation/lateral flexion à flexion
sagittal.
•Many herniated discs are asymptomatic •May be found from MRI or CT scan for an unrelated problem •Symptomatic disc herniations •________- Most common symptom •Radiating pain, numbness, or tingling • Dermatomes can vary •Muscle weakness •Bowel/bladder incontinence- CES
sciatica,
•Some patients may need surgery. Herniated discs can cause significant pain. In fact, they are the most common cause of ________. Though surgery isn't typically needed for herniated discs, there are times when it is the best option.
sciatica,
Segmental Contact Point SCP refers to where the contact point is placed so as to deliver the adjustment and therefore to effect change within that _______. You are being taught a short lever, direct technique. We will therefore be as specific as possible in describing the segmental contact positions.
segment,
SCP= mammillary process of involved segment \ See charts for other SCP's RRR/LP: SCP= L-mammillary LRR/RP: SCP=R-mammillary SCP must be secure and capable of receiving thrust without ______ lNOTE: You cannot put your index finger on your pisiform (of the same hand) You MUST pick up your index finger before using your CP to tissue pull to the SCP
slipping,
diagnosing low back pain- big picture •Evidence of systemic disease or visceral disease, anatomic anomolies? •Pt. history/exam •Constitutional Symptoms •Evidence of neurologic compromise (lumbar disc herniation, stenosis, CES)? •Assess motor, reflex, and sensory function •Evidence of social/psychological stress that could amplify/prolong pain •Decrease pain inhibition _________ amplification serves the patients needs for economic survival and maintenance of self-esteem •Illness behavior
somatic,
cancer red flags •How likely a patient is to have or not have a condition based on test is dependent on the accuracy of the test •In this case, the test is a question regarding the patient's health history •If a test is positive it indicates the patient has the condition (current cancer) •Positive Test= LBP + Hx Cancer •If a test is negative it indicates the patient does NOT have the condition (current cancer) •Negative Test= LBP + NO Hx Cancer •80% of patients with a malignant spinal neoplasm are >50yoa •History of cancer - *consider it cancer until proven otherwise •Specificity = likelihood that a positive test is really positive •Specificity=.98 •Sensitivity=.31 •M/C source of spinal malignancy= breast, _______, and prostate •Unexplained weight loss •Pain > 1 month •Failure to improve with conservative therapy
specificity and sensitivity, lung
One can over come those entities that limit motion about the elastic barrier by ever increasing tension until the joint releases (cavitates). lOr, a better (preferred) way is to breach the elastic barrier via a HV-LA thrust or impulse. This is done by _____ and is a demonstration of Bernoulli's principle. With speed one can over come the ____ that restricts its motion.
speed, CoF
lAnatomical reference points for static listings lACA-M = Radiographically determined vertebral body reference. Malposition - extension malposition, etc. lPGF = Palpatory & radiographically determined _______ reference. Instrumentation used also. lStatic Orthogonal = Palpatory & radiographically determined vertebral ______ reference (Roentgenometrics). lNational Diversified = lOcciput - condyles lC1 - TVP's lC2-7 - Articular pillars
spinous, body
Indifferent Hand IH refers to what the other hand &/or arm is doing and therefore contributing to the adjustment. You will find some reference as to its position, tissue slack (if any) and action. This is sometimes referred to as the _____ or support hand but that would be a reference as to its action. IH: Position pts. Humerus anterior to mid axillary line NOT X chest l+Y to oblique +Y distraction
stabalization
anatomical barrier We can breech this barrier in degrees (plastic zone). These are usually graded. There are plastic changes of tissues about the joint that occur initially before total separation &/or permanent damage. Changes to this barrier effect future joint ________.
stability.
Doctor Positioning lThis is broken up (usually) into position & stance. Position covers where the doctor will be relative to the position of the patient. Some techniques will require the doctor to start in one position and then transition to another during the delivery of the adjustment. Stance covers what the doctor looks like when they get into the position to deliver the adjustment. This stance is the most ______ position one can be in for adjustment delivery. Long fencer's stance to set pelvis Dr.'s front foot under knee Keep back straight After P2P, Drs. torso and lower body in line: l Ex. Dr. facing 11:00 should have legs in line @ 5:00 Dr. final position on target-'hammer' contacting 'nail' Dr. maintains good posture w/ sup leg against table & inf leg _______
stable, straight.
full joint movement Is that motion attained through complete and un-encumbered motion with assistance (passive) up to that joints anatomical barrier. To get from the elastic barrier to the anatomic barrier requires a force that exceeds the ______ of those things (capsular, fluid & surface tension etc.) that normally restrict joint motion creating that elastic barrier
stength.
Neutral zone - The initial phase of ROM is called the neutral zone (NZ) and is usually quite small. An exception to the rule is the atlanto-axial joint (C1-2) where the NZ makes up 75% (30 degrees) of the total ROM for Y axis motion (40-45). Therefore the NZ can be thought as the free-play or "______" of the motion segment or joint laxity around the neutral position. NZ continued - Also described as the displacement between the neutral position and the initiation point (beginning) of spinal resistance to physiological motion. Translatory and rotatory neutral zones are expressed in meters and degrees, respectively. The neutral zone can be expressed for each of the six degrees of freedom. NZ continued - Starting from the neutral position, there is large deformation due to application of a small load. After this "easy" deformation, again called "free-play" or "joint play", there is increasing resistance offered by the tissue. Thus, the motion that takes place between the neutral position (mid-line) and the beginning of significant resistance is the NZ
stop.
LOD/VEC Spring the joint lLoad & Hold: Maintain tension (eccentric contraction of the triceps) as you drop Practice slowly lowering hands with partner pushing down on hands Dr. should be facing 11:00 or 1:00 with back ______(not twisted) and legs in line (5:00 or 7:00)
straight.
Static Listings ACA-M (American Chiropractic Association - Medicare) PGF (Palmer-Gonstead-Firth) National Diversified (ND) Static Orthogonal (right-handed cartesian orthogonal coordinate system, X-Y-Z)
systems of static listings
•Herniated Disc •When a disc weakens, the annulus fibrosis can ______, allowing the nucleus pulposus to slip outside of the disc and into the spinal canal or IVF
tear.
IVD & Facet degeneration •May cause radiating pain if degeneration causes nerve root impingement •IVD bulging/herniated into IVF •Facet hypertrophy (severe expanding into IVF) •https://www.spine-health.com/video/facet-joints-video •Facet pain referral to: • Buttocks and posterior ______
thighs
Contact Point CP refers to some aspect of the doctors body (hand, knee, forearm etc.) or appliance (tool, block, fulcrum etc.) that is used to and through which the adjustment is delivered. This will usually be further divided into t_______or pull used in the placement of the contact point and its action after it has been placed (what it is going to do when it gets there?). Dr.'s pisiform/ proximal hypothenar of inferior hand Chiropractic hand position to protect your pisiform lWrist extension & ______ flexion with lHypothenar muscle should be contracted Use your pisiform proximal hypothenar to remove tissue slack with a L-M tissue pull (a little I-S but mostly L-M) lCP should remain stable after tissue pull (don't wiggle around, you might slip off SCP)
tissue slack, mcp,
•More recent studies show that the facet joints and posterior ligaments are the main structures resisting _______ in the lumbar spine -Adams & Hutton used a cadaver to show that the facets resist lumbar rotation before IVD •Compressed facet was the first structure to give at the limit of rotation •Articular cartilage and soft tissues showed significant injury b4 significant stress was transferred to the IVD •Also showed that the disc is more vulnerable to ______ injuries -Flexion is NOT inhibited by the facets -Excessive flexion à disruption of the posterior annulus »Esp. when coupled with rotation, lateral bending, and axial loading (overweight) »Pts. Say "I just bent over to pick up a Kleenex"
torsion, flexion,
lumbar ivd injury •Does Lumbar rotation damage the IVD or do the lumbar facets limit rotation protecting the IVD's from "undue torsional stress"? -Farfan postulated " 90% of the torsional strength of a lumbar motion segment is provided by the disc & facet joints with the annulus providing the majority of the __________ resistance." •Stages of IVD injury: -1. Circumferential separation of annular fibers -2. Radial fissures develop -3. Internal disruption of the disc 4. Possible disc protrusions/herniations
torsional
Red flags for low back pain •Unsteady when standing or _______ •Difficulties passing/controlling _______ or bowels or numbness in either area •A previous history of ______ or osteoporosis •Back pain accompanied by unexplained _______ loss or fever •________ disorder
walking, bladder, cancer, weight, bleeding,
belt test
•BELT TEST AKA Supported Adam's Test •Indications: •Helps differentiate between Lumbar spine pathology and Sacroiliac (SI) joint pathology. •Procedure: •Standing patient is instructed to bend forward and touch toes with knees straight and return to standing. •Examiner then stabilizes the patient's pelvis with hands and patient's sacrum with examiner's lateral thigh. •Patient is instructed to repeat motion of touching toes. •Interpretation (based on biomechanical logic, but little published evidence): •*By supporting the patient's pelvis & Sacrum the examiner should effectively prevent motion at the sacroiliac joint, thus eliminating it as a potential pain generator during supported forward flexion. •*No pain with support, pain without support Sacroiliac joint pathology •Pain with both supported & unsupported flexion Lumbar spine pathology
systemic disease
•Cancer - primary or metastatic •Spinal Infections •Ankylosing Spondylitis
Most common non-surgical treatments for herniated discs
•Chiropractic treatments •Alternative treatments •Drugs and medications (last resort) •Exercise •Physical therapy
SACROILIAC JOINT SYNDROME
•FINDINGS: •LOCAL PN/TENDERNESS •LEG LENGTH INEQUALITY •POSSIBLE GAURDED GAIT •PALPATION OF MISALIGNMENT OR RESTRICTED MOTION/JOINT PLAY (HARD END FEEL) •POSTURAL ABNORMALITIES •https://www.physio-pedia.com/Sacroiliac_Joint_Syndrome •ORTHOPEDIC TESTS: •BELT TEST TO DIFFERENTIATE BETWEEN LBP AND SI PN- not much evidence available, not included in test cluster
SACROILIAC JOINT SYNDROME - HISTORY
•LOCAL PAIN MAY RADIATE INTO THE LB AND BUTTOCKS (pain patterns are variable) •PN IS DULL ACHE TO SHARP AND STABBING •PROVOCATIVE: •WEIGHT BEARING •SITàSTAND •MOTION/WALKING •PELVIC FLEXION/EXTENSION •PALLIATIVE: RECUMBENCY (LAYING DOWN)
PI ILIUM (ANT GLIDE RESTRICTION)
•MORE COMMON •STANDING (SAME FINDINGS ON SIDE OPPOSITE AS ILIUM) •LOW CREST AND PSIS à MAY CAUSE IPSILATERAL LUMBAR SCOLIOSIS •HIGH ASIS •SHORT LEG PRONE OR SUPINE •DECREASED PRONE THIGH EXTENSION •PSIS MORE PRONOUNCED •PN IN LOWER HALF OF SI •PRONE SACROILIAC EXTENSION PALPATION/MOBILIZATION (Ilium should flex as SB extends) •FLEXION RESTRICTION OF THE ILIUM •STABILIZE CONTRALATERAL SACRAL APEX & MOTION PàA ON PSIS •DECREASED MOTION/HARD END-FEEL
SACROILIAC JOINT SYNDROME/Dysfunction
•PAIN ARISING FROM SACROILIAC JOINT / JOINT CAPSULE •SOME STUDIES SHOW SI IS THE SOURCE OF LBP IN UP TO 50% OF CASES •CHARACTERIZED BY ABERRANT MOTION OF THE SACROILIAC JOINT •HYPOMOBILITY •LIGAMENTOUS LAXITY (CAN LEAD TO MISALIGNMENT) •PREGNANCY •TRAUMA -SPRAIN/STRAIN WITH SIGNIFICANT TRAUMA (SI LIGAMENTS ARE VERY STRONG) •MAY HAVE COMPENSATORY CONTRALATERAL RESTRICTION OF MOTION •LEG LENGTH INEQUALITY •SI JOINTS FUSE WITH AGE (MALE>FEMALE) OR SURGICALLY
AS ILIUM (POSTERIOR GLIDE RESTRICTION)
•STANDING (SAME FINDINGS ON SIDE OPPOSITE PI ILIUM) •HIGH CREST AND PSIS à MAY CAUSE CONTRALATERAL LUMBAR SCOLIOSIS •LOW ASIS •LONG LEG PRONE OR SUPINE **MUST DETERMINE IF SHORT LEG IS PI ILIUM OR IS LONG LEG AS ILIUM •INCREASED PRONE THIGH EXTENSION COMPARED TO OTHER SIDE •PSIS LESS PRONOUNCED •PN IN LOWER HALF OF SI •PRONE SACROILIAC FLEXION PALPATION/MOBILIZATION (Ilium should extend as SB flexes) •EXTENSION RESTRICTION OF ILIUM (PSIS) decreased post-inferior glide •LIFT ASIS AàP WHILE MONITORING THE SACRAL SULCUS FOR DECREASED MOTION/HARD END-FEEL •DECREASED MOTION/HARD END-FEEL
