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Tutorial up to 2 hrs
Lecture topics Prac class – 2X2 Weebly Submissions
Face to face
(recordings/PowerPoints) hrs
1 1.1 Course profile, Spinal 1.1 What is EBP 1.1 Answer all quiz
assessment expectations for manipulative What if there is no questions and submit
the practical, written techniques and evidence? to Weebly by 18/3/19
assessment and the observation
1.2 Is it black or
portfolio. (postural analysis,
white? Are we OK
1.2 The diagnostic triage. range of motion
with uncertainty?
1.3 General approach to active and passive,
1.3 Discuss the
MSK testing palpation static
concept of ‘cause’
1.4 Red and yellow flags of and motion) ‘ORP’
and ‘effect’ in
musculoskeletal pain of GORP.
chiropractic
1.5 Anatomy of the 3 joint
practice. Where
complex and its clinical
does subluxation
significance.
fit? Does it fit at all?
1.6 Three phases of
degeneration
1.7 General approach to
MSK testing and all
PowerPoints under lecture
icon.
2 2.1 Clinical evaluation of 2.1 Spinal 2.1 Case history 2. Answer all quiz
pain (pathophysiology of manipulative taking questions and submit
pain, simple (referred pain) techniques and to Weebly by 25/3/19
2.2 Go through the
verses complicated pain observation
clinical forms for
(MSK pain Lecture radicular (postural analysis,
case history taking
pain). range of motion
2.2 Practice cervical
active and passive,
2.2 Case history:
MSK testing
palpation static
Introduction and
application.
2.3 Physical Examination. and motion) ‘ORP’
GORP OMNICS what does it of GORP.
stand for?
2.2 MSK testing of
2.4 Review PowerPoints
the cervical
under ‘lecture icon’.
spine. Validity
and specificity.
3 3.1 Making a diagnosis and 3.1 Spinal 3.1 Case history: 3.1 Answer all quiz
clinical impression (working manipulative taking questions and submit
diagnosis) techniques and 3.2 Practice MSK to Weebly by 1/4/19
3.2 How to develop a ‘tissue observation testing Lumbar
in lesion’, prognosis and (postural analysis, spine, hip and pelvis.
likely diagnosis. range of motion
3.3 Report of findings (ROF). active and passive,
What is it and how is this palpation static
performed? and motion) ‘ORP’
3.4 Introduction to clinical of GORP.
reasoning. How to make a
differential diagnosis. 3.2 MSK testing
4 Review and reflection 4.1 Mock OSCE for 4.1 Case 4.1 Review week.
feedback. history taking
No new material. Students to form
with and
4.2 Practice all groups of four for
without the
MSK testing to- video assessment.
clinical form.
date
4.2 Practice all MSK
testing to-date
5 5.1 MSK condition 1: 5.1 Spinal 5.1 Case history: Answer all quiz
Myofascial pain syndromes. manipulative taking. Simulation of questions and submit
Review anatomy and techniques and myofascial to Weebly by April 15,
biomechanics associated observation syndrome. 2019
with this condition. Clinical (postural analysis, 5.2 Case Study 1:
signs and symptoms in range of motion Developing a
addition to pathomechanics active and passive, differential
palpation static diagnosis and likely
and motion) ‘ORP’ diagnosis.
of GORP.
5.2 Review of Stages of
Ligamentous Healing. 5.2 Rib motion
6 MSK condition 2: Facet 6.1 Spinal 6.1 Case history: Answer all quiz
Syndrome in the manipulative taking. Simulation of questions and submit
cervical/thoracic and techniques and facet syndrome. to Weebly by 29/4/19
lumbar spines (facet observation
capsulitis and synovitis) (postural analysis, 6.2 Case Study 2.
range of motion Developing a
Review anatomy and
active and passive, differential diagnosis
biomechanics associated
palpation static and likely diagnosis.
with this condition. Clinical
and motion) ‘ORP’
signs and symptoms in
of GORP.
addition to pathomechanics
6.3 Gait
Examination. The
‘G’ of GORP
7 MSK condition 3: ‘Simple’ 7. Spinal (incl ribs) 7.1 Case history: Answer all quiz
pain associated with the manipulative taking. Simulation SI questions and submit
Hip, Sacro-iliac joint and techniques jt. hip or coccyx to Weebly by 7/5/19
coccyx according to GORP condition.
8 Review and reflection 8.1 Spinal (incl 8.1 Case history: Review week. No
ribs) manipulative taking. Simulation questions this week.
No new material.
techniques for a spinal condition
according to (selected from that
GORP. Mock OSCE studied to-date)
9 MSK condition 4: Scoliosis 9 Spinal 9.1 Case history: Answer all quiz
manipulative taking. Simulation questions and submit
Review anatomy and
techniques (incl for a spinal condition to Weebly by 20/5/19
biomechanics associated
ribs) according to associated with
with this condition. Clinical
GORP scoliosis
signs and symptoms in
addition to pathomechanics
Practice cards for 9.2 Case Study 5.
OSCE Developing a
differential diagnosis
and likely diagnosis
Week
Face to face. Up to
Lecture topics Activity Prac class Weebly Submissions
2 hours
(recordings/PowerPoints – 2X2 hrs
1 1.1 Course profile, Spinal 1.1 What is EBP. 1.1 Answer all quiz
assessment expectations for manipulative What if there is no questions and submit
the practical, written techniques and evidence? to Weebly by 18/3/19
assessment and the observation
1.2 Is it black or
portfolio. (postural analysis,
white? Are we OK
1.2 The diagnostic triage. range of motion
with uncertainty?
1.3 General approach to active and passive,
1.3 Discuss the
MSK testing palpation static
concept of ‘cause’
1.4 Red and yellow flags of and motion) ‘ORP’
and ‘effect’ in
musculoskeletal pain of GORP.
chiropractic
1.5 Anatomy of the 3 joint
practice. Where
complex and its clinical
does subluxation
significance.
fit? Does it fit at all?
1.6 3 phases of
degeneration
1.7 General approach to
MSK testing.
Objectives
1. Understand the expectations for this unit including assessment requirements: portfolio,
written exam and practical assessment.
1. Understand the purpose of on-campus activities. Anatomy of the 3 joint complex and the
clinical significance
2. Understand how to perform a physical examination using GORPOMNICS
3. Reference standard for MSK testing.
4. Understanding the meaning of ‘red’ and ‘yellow’ flags.
5. Understand the diagnostic triage.
Readings:
Refer to readings in unit profile. Differential Diagnosis and Management for the Chiropractor:
Protocols and algorithms, Souza. Thomas 5th Ed, Jones and Bartlett Learning 2016. Read page 22
(general approach to MSK testing). Page 174 and 176: Red flags in MSK pain. Page 165: the 3 joint
complex.
Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.
via Zoom
WEEK 2
Objectives
By the conclusion of this week, you will be able to have an understanding of the following:
Readings:
Differential Diagnosis and Management for the chiropractor 5th ed. Barlett and Jones Learning. Read
pages 8 and 9 on referred pain.
Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.
via Zoom
QUESTIONS: WEEK 2. To be completed by the 25th
March
1. What does the mnemonic ‘LODCTRRAPPA” stand for? When is it used?
2. Describe what is meant by a systems review.
3. What does VINDICATE stand for? When is it used?
4. What is the definition of pain?
5. What is the difference between acute, sub-acute and chronic pain?
6. Describe chronic pain? What is sensitisation?
7. Why would chronic pain syndrome be considered to be more challenging to manage as
opposed to acute pain?
8. Is a true compression to a nerve root common? Is there more or less pain characteristically
with a true compression?
9. Describe what happens when you have a compression injury of nerve tissue?
10. Describe the difference between dermatomes, sclerotomes and myotomes..
11. Describe the characteristics of paraesthesia.
12. Describe the differences between nerve root pressure and nerve trunk pressure.
13. Describe the differences between spinal cord pressure and peripheral nerve pressure.
14. In general, how would you relieve peripheral nerve pressure?
15. Describe the characteristics of bone pain.
16. What are tension signs?
17. What is the difference between an injury from the muscle, ligament and tendon?
Symptoms likely to be
subjective or objective?
Complete the following table for pain sensitive structures in the spinal cord:
Pain sensitive Is this What is the typical type What is the typical
structure/tissue tissue/structure of pain: simple or type of pain: complex
uncomplicated or complicated
Pain sensitive.
(referred pain) (radicular pain)
Yes/No
Yes/No
Yes/No
Facet joints
Facet capsule
Intervertebral disc:
Nucleus pulposis
Intervertebral disc:
annulus
Ligaments
Spinal cord/nerve
root/peripheral
nerve/nerve trunk
Cervical Testing
NAME OF TEST INTERPRETATION/WHAT TISSUE STRUCTURE DOES THIS TEST LOAD? For you
to complete
Rust sign
Cervical Flexion
Compression test
Cervical Rotation
Compression test
Cervical Maximal
Compression test
Valsalva test
LLermittes sign
Cervicogenic dizziness
Adson’s test
Wright’s test
(hyperabduction)
Costoclavicular test
3.1 Making a diagnosis and 3.1 Spinal 3.1 Answer all quiz
3.1 Case history:
clinical impression (working manipulative questions and submit to
taking
diagnosis) techniques and Weebly by 1/4/19
3.2 Practice MSK
3.2 How to develop a observation testing Lumbar spine,
prognosis. (postural analysis, hip and pelvis.
3.3 Report of findings (ROF). range of motion
What is it and how is this active and passive,
performed? palpation static and
3.4 Introduction to clinical motion) ‘ORP’ of
reasoning. How to make a GORP.
differential diagnosis.
3.2 MSK testing
Lumbar spine, hip
and pelvis
Objectives
By the conclusion of this week, you will be able to have an understanding of the following:
Readings:
Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.
via Zoom
1. Clinical reasoning errors often can occur as a result one of four areas. List these 4 areas.
2. What clinical process contributes to ‘data gathering’?
3. What clinical process contributes to faulty data processing or faulty metacognition?
4. Describe the 2 frameworks that lead to effective clinical reasoning. Draw a simple
conceptual map.
5. What is an ‘illness script’ and how does it assist the four areas in your response to question
1.
6. What is meant by a hypothesis driven physical exam?
7. Describe metacognition and how this assist the reasoning process
8. Describe 3 different types of cognitive bias.
Squat test
Djerine’s triad
(Valsalva, cough,
sneeze)
Flip or Bechterew’s
test
Braggard’s test
Bowstring’s test
Bonnet’s test
Kernigs test
Slump test
Milgrams test
Sacral thrust
(Springing the sacrum)
SIJ distraction
SIJ compression
Thigh thrust
Gaenslen
Yeoman’s test
Stoop test
Hoover test
Trendelenberg’s test
Rotational deformities
Thomas test
Ober’s test
Schober test
Compression injury to Nerve root Nerve trunk Peripheral nerve Spinal cord
nerve tissue symptoms compression entrapment compression
WEEK 4
Objectives
Readings:
via Zoom
Week 5
Ligamentous Healing.
5.2 Rib motion and
static palpation
5.3 MSK testing
Thoracic spine and
ribs
Objectives
By the conclusion of this week, you will be able to have an understanding of the following:
Study the lecture notes, listen to the recording and study the PowerPoints under the lecture
icon.
via Zoom
Case study 1
Jack is a 40-year-old labourer who has decided to change his career. He has decided to enrol into
University and has been undertaking his studies now for around two years. Jack now presents to
you with headaches which seem to be worse with studying. Upon taking the case history, he
mentions his mother suffers the same problem.
ASSUME ALL OTHER EXAMINATION AND CASE HISTORY FINDINGS ARE UNREMARKABLE.
1. List the statements (clues) in the case history that aligns with the diagnosis of tension
headaches. Use the script concordance.
2. The above case history is incomplete. What further questions or what information
would you need to acquire?
3. List the muscles (trigger points that are likely to refer pain to the head leading to
tension headaches?
Test For case study 1 indicate the likely outcome for the
following tests. Is it likely to be positive or negative?
Discuss false positives and negatives.
Cervical Rotation
Compression test
Cervical Maximal
Compression test
Valsalva test
LLermittes sign
Longissimus Iliopsoas
Infraspinatus Piriformis
Slump test
Passive Scapular
approximation
Percussion
Adam’s forward
bending
Ott Sign
Chest Expansion
Beevor’s sign
Abdominal reflex
Maigne’s syndrome
test
Discussion.
Is the person with the cervical x-ray on the right more likely or less likely to suffer myofascial pain in
the neck. Explain your answer
Week 6
Chest
6.1 Spinal 6.1 Case history:
MSK condition 2: Facet
manipulative taking. Simulation of 6.1 Answer all quiz
Syndrome in the
techniques and facet syndrome. questions and submit to
cervical/thoracic and lumbar
observation Weebly by 29/4/19
(postural analysis,
spines (facet capsulitis and range of motion 6.2 Case Study 2.
synovitis) active and passive, Developing a
palpation static and differential diagnosis
motion) ‘ORP’ of and likely diagnosis.
GORP.
6.3 Gait
Examination. The ‘G’
of GORP
Objectives
By the conclusion of this week, you will be able to have an understanding of the following:
Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.
Practical Class (2X2 hr):
via Zoom
Presenting Complaint:
Joe complains of severe low back pain with intermittent radiations to the left posterior thigh. The
pain does not extend below the left knee. The pain is more pronounced upon rising in the mornings
and on standing after long periods. The pain is somewhat relieved by rest. This complaint is of 4
days duration and came on suddenly after pulling back one of his pupils who was falling while doing
gymnastics. There has been no previous history of low back pain. He has been taking anti-
inflammatory drugs with temporary relief.
Physical Examination
Observation: Hyperlordosis of the lumbar spine. There is muscle spasm in the mid-thoracic area
which appears as a ‘pottengers saucer’.
Palpation: Static joint springing reveals tenderness at the L5,S1 level. On motion palpation L5, S1 is
restricted in right rotation and left lateral flexion. The right sacro-iliac joint is restricted into flexion.
T4-8 are restricted into flexion and right rotation.
Lumbar ROM: Lateral flexion to the left is painful on the left side around the L5 level.
ASSUME ALL OTHER EXAMINATION AND CASE HISTORY FINDINGS ARE UNREMARKABLE.
USING ONLY THE INFORMATION IN THE ABOVE CASE HISTORY AND PHYSICAL EXAMINATION
ANSWER THE FOLLOWING QUESTIONS:
1. List the statements (clues) in the case history that aligns with the diagnosis of facet
syndrome. Use the script concordance.
2. What is as a ‘pottenger’s saucer’
3. The above case history is incomplete. What further questions or what information would
you need to acquire?
4. Do you think Joe has referred or radicular pain?
5. Based on the given information from the case history and physical examination, do you think
Joe has a muscle strain, ligamentous strain or facet problem. Is it possible Joe has a
combination of these problems?
From the diagram below, which lumbar spine is more likely to suffer facet problems. Why?
Test For Case study 2 indicate the likely outcome for the
following tests. Is it likely to be positive or negative?
Discuss false positives and negatives.
Braggard’s test
Bowstring’s test
Bonnet’s test
Kernigs test
Slump test
Milgrams test
SIJ distraction
SIJ compression
Thigh thrust
Gaenslen
Ely’s test
Yeoman’s test
Stoop test
Hoover test
Trendelenberg’s test
Objectives
By the conclusion of this week, you will be able to have an understanding of the following:
1. Understand ‘simple’ pain associated with the hip, sacro-iliac joint and coccyx.
Readings:
Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.
via Zoom
Presenting Complaint
There has no previous history of hip pain, and his medical history is unremarkable. He reports a
gradual onset of pain that started approximately two months ago and is now felt more often, whereas
before he would feel it only when lying down on his right side. Robert, unfortunately, cannot recall
any incident that may have caused his hip pain. He rates it at a level of 5/10, describing it as being
very sore and tender.
He also mentions that he occasionally gets pain in his right shoulder, which is not related to
movement or physical activity. This shoulder pain has been present for about six months.
Physical Examination
Active right hip ROM: 30 degrees of abduction with pain, 20 degrees of external rotation with pain.
All other ranges of motion of the right hip are normal.
Lumbar ROM: Flexion is reduced by 50% due to hamstring tightness. All other movements are
unremarkable.
Muscle strength: 4/5 on the abductors and external rotators; other muscles are normal.
Right Sign of Buttock test reproduces the pain in the right hip
Palpation: Robert exhibits increased tenderness on the right greater trochanter with slight tenderness
on the middle portion of the buttock on the right side.
1. List the statements (clues) in the case history that aligns with the diagnosis of hip pain. Use
the script concordance.
2. The above case history is incomplete. What further questions or what information would you
need to acquire?
3. Based on the given information from the case history and physical examination, do you think
Robert has a hip problem, facet syndrome or muscle strain? Give reasons for your answer.
4. For the above case history alone, give 3 possibilities (differential diagnoses) for his hip pain.
Explain each answer.
5. Your colleague thinks that Robert as an ischiogluteal bursitis (weaver’s bottom). Do you agree
with your colleague?
6. Using the information from the above case history and physical examination, what is the more
likely diagnosis for
Case Study 4
Presenting Complaint:
Joey presents to your office with right low back pain which occasionally radiates into the right
buttock.
History of Presenting Complaint and Onset: The pain had been present for three weeks. It started
one day after he played a game of golf. He has no history of back pain, and he denies any medical
history of significance. X-rays are unremarkable.
Aggravating Activities
Running, prolonged fast walking of more than a mile. When the symptoms are at its worst, he is
unable to stand or walk without pain. Joey also finds it difficult to stand from a seated position.
When the pain is present, he is unable to sleep, waking him as he rolls over in bed.
Physical Examination
Observation: Standing on the right foot reproduced his pain in the right low back area. He also has
a right flat foot.
Trunk extension was full range but reproduced his pain. All other movements were pain-free and
full range.
Neurological: Unremarkable.
SLR: Full range but mildly painful in the right low back at 70 degrees.
Standing on the right leg only reproduced the pain in the right low back however, if the sacro-iliac
joints were supported (as in supported Adams or the belt test) the pain disappeared.
NB If the question incorporates ‘Based on the information in the case history and/or physical
examination’ assume that all other tests are unremarkable.
1. List the statements (clues) in the case history that aligns with the diagnosis sacro-iliac pain.
Use the script concordance.
2. The above case history is incomplete. What further questions or what information would
you need to acquire?
3. Based on the given information from the case history and physical examination, do you think
Joey has a sacro-iliac problem, hip problem, facet syndrome or muscle strain? Give reasons
for your answer.
4. For the above case history alone, give 3 possibilities (differential diagnoses) for his back and
buttock pain? Explain each answer.
5. What other tests would you like to perform?
6. Joey presents with the x-ray below: Would this change your diagnosis?
Test For Cases 3 and 4 indicate the likely outcome for the
following tests. Is it likely to be positive or negative?
Discuss false positives and negatives.
Squat test
Braggard’s test
Bowstring’s test
Bonnet’s test
Kernigs test
Slump test
Milgrams test
SIJ distraction
SIJ compression
Thigh thrust
Gaenslen
Ely’s test
Yeoman’s test
Hoover test
Trendelenberg’s test
Hip joint
1. When standing, both femoral heads take minor compressive loads. If the load increases
through hip what could this be attributed to?
2. List the major muscles and bursae of the hip joint.
3. What is the nerve supply of the hip joint? Describe the referral pattern?
4. Describe what is meant by femoral neck retroversion and femoral neck anteversion.
5. List the soft tissue structures that can refer pain to the hip (Posterior, anterior and medial)
Objectives
Readings:
via Zoom
Week 9
By the conclusion of this week, you will be able to have an understanding of the following:
Understand the pathomechanics and clinical signs and symptoms that can develop from
scoliosis.
Readings:
Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.
via Zoom
QUESTIONS: WEEK 9. To be completed by the 20th of
May
Scoliosis and Scheuermann’s disease
1. The thoracic spin is less mobile compared with the lumbar and cervical spines? Why?
2. Why is ‘systems review’ in the case history so important in a patient with thoracic pain?
3. ‘The underlying causes of somatic dysfunction in the thoracic spine can be significantly
different from the causes in the lumbar and cervical areas’. Why?
4. What are the other synonyms of Scheuermann’s disease?
5. List the clinical features of Scheuermann’s disease.
6. What are the pathological and radiological features of Scheuermann’s disease?
7. What is the general treatment for someone with Scheuermann’s disease?
8. Name and explain the different types of scoliosis.
9. What the clinical characteristics of a patient with Scheuermann’s disease?
10. What are the clinical characteristics of a patient with a non-structural scoliosis (functional
scoliosis)?
11. What are the most common causes of functional scoliosis?
12. Name and explain the different types of structural scoliosis?
13. Outline the typical examination procedure for scoliosis.
14. In general, what is the treatment or management of scoliosis?
15. Outline the examination routine for thoracic spine examination.
16. What type of scoliosis is likely to be present below? Would you be able to straighten this
curve?
Week 10
MSK condition 5:
Spinal manipulative 10.1 Review week.
Spondylolisthesis 10.1 Case history:
techniques (incl ribs) taking. Simulation for a Answer all quiz
Objectives
By the conclusion of this week, you will be able to have an understanding the different types of
spondylolisthesis and the related clinical signs and symptoms.
Readings:
Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.
via Zoom
A 46-year-old man presents to your office complaining of severe low back pain which
radiates down the posterior aspect of the right leg to the ankle. This complaint started one
month ago after lifting heavy boxes at work.
Past History:
He said he had fallen through a ceiling three years ago but did not injure his low back
although he had previously experienced intermittent low back pain. Walking up the steps
aggravated the low back pain as did coughing. On awakening in the morning, he
experienced low back pain. Heat was of no help. Cold aggravated the low back pain, so he
wore a low back support belt during the winter months to keep his lower back warm. He had
been treated with rest, NSAID’s and analgesics which had given him some relief and this was
followed by physiotherapy treatment. He returned to work approximately two weeks later
but found that his back was too painful for working, so he stopped.What further pertinent
questions would you ask this patient?
1. Your colleague thinks that this 46 year old has a facet problem at L5/S1. Do you agree with
your colleague? Explain your answer.
2. Using the information from the above case history, give 3 differential diagnoses for this
patient’s complaint? Explain your answer.
Physical Examination
Palpation: tenderness throughout the lumbosacral spine and in the right buttock centrally.
SLR was to 90 degrees bilaterally before he experienced low back pain on right SLR.
Deep tendon Reflexes: The right patella and achilles reflexes was reduced to 1.
Imaging Review
A plain film radiograph showed a grade 3 spondylolisthesis of L5 on S1 with bilateral pars defects.
The L5-S1 intervertebral disc was narrowed and there were anterior osteophytes adjacent to it on
the L5 and S1 bodies.
I. Using the information from the above case history, physical examination and x-rays, what is
your likely diagnosis? Explain your answer.
II. Using only the information from the above case history and physical examination what
factors may pre-dispose or complicate this diagnosis (‘tissue in lesion’).
Test For Case 10 indicate the likely outcome for the following
tests. Is it likely to be positive or negative? Discuss false
positives and negatives.
Squat test
Braggard’s test
Bowstring’s test
Bonnet’s test
Kernigs test
Slump test
Milgrams test
SIJ distraction
SIJ compression
Thigh thrust
Gaenslen
Ely’s test
Yeoman’s test
Hoover test
Trendelenberg’s test
3. Neurological signs, caused by the slip of one vertebra on the other may require
decompression of the nerve root and fusion of the affected vertebral segments.
4. Spinal manipulation has shown to be less effective with referred pain syndromes such as
sacro-iliac joint or posterior joint syndromes than in nerve root entrapment syndromes i.e.
dynamic lateral recess stenosis or central canal stenosis.
5. Manipulation is less effective for low back pain patients with degenerative spondylolisthesis
than those with grade 2 isthmic spondylolisthesis.
7. For all types of spondylolisthesis, with the correct manipulative procedure, it is possible to
replace the displace segment to its original position.
8. Manipulation using the spinous process for leverage is of little benefit for an isthmic
spondylolisthesis.
Week 11
Readings:
This is a review week
Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.
Week 12
No new material