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CHIR13008 WORKBOOK

Resources, PowerPoints, lecture notes. Online only and


discussed in Zoom sessions.
Answer questions and case studies.

Activity or practical classes 2X2 hours per week


Face to face

Up to 2 hours tutorial per week. Zoom.


2 hours is allowed however the class may take less than 2
hours depending on case study discussions.
Important notes

1. Read the assessment requirements, portfolio


instructions will be given in week 4.

2. There is a lot of content in Weeks 2,3,5,6,7, 9


and 10. Weeks 4 and 8 are considered
review, reflection and ‘catch up’. There will
be minimal new material for weeks 4 & 8.
Weeks 11 and 12 are review weeks. We will
perform a practice examination in these last
2 weeks.

3. The Zoom sessions are going to be recorded


and placed on Moodle each week.

4. OSCE cards will be given in Week 7. The


OSCE (practical assessment) will be given in
week 12.

5. Reading Week is April 15th - April 21st. No


classes.
Week

Tutorial up to 2 hrs
Lecture topics Prac class – 2X2 Weebly Submissions
Face to face
(recordings/PowerPoints) hrs

Online only Face to face

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

3.5 Review content under Lumbar spine, hip


the ‘lecture’ icon. and pelvis

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

5.3 Review content under and static


‘lecture icon’. palpation

5.3 MSK testing


Thoracic spine and
ribs

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

6.2 Rib motion


and static
palpation

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.

Practice cards for 7.2 Case Study 3 and


OSCE 4 Developing a
differential diagnosis
and likely diagnosis

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)

Practice cards for


OSCE

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

10 MSK condition 5: Spinal 10.1 Case history: Review week. Answer


Spondylolisthesis manipulative taking. Simulation all quiz questions and
techniques (incl for a spinal condition submit to Weebly by
Review anatomy and
ribs) according to associated with 27/5/19
biomechanics associated
GORP scoliosis
with this condition. Clinical
signs and symptoms in
Practice cards for Submit finished group
10.2 Case Study 6.
addition to pathomechanics
OSCE. video to Weebly
Developing a
differential diagnosis
and likely diagnosis

11 Review and reflection Revision. Practice Revision Revision


Cards for OSCE
No new material. Answer practice exam
12 Review and reflection Revision. Practice Revision Revision
Cards for OSCE
No new material.
WEEK 1

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

By the conclusion of this week, you will be able to:

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 the resources in Moodle

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.

Lecture notes and PowerPoints

Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.

Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.

Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.

via Zoom

QUESTIONS: WEEK 1. To be completed by the 17th


March
The Diagnostic Process, 3 joint complex and 3 phases of degeneration.
1. Describe the diagnostic triage in the classification of pain.
2. What questions do you think would elicit ‘red flags’ for the musculoskeletal system?
3. What questions do you think would elicit ‘yellow flags’?
4. During physical examination: what does GORPOMNICS stand for?
5. Describe the anatomy of the 3-joint complex.
6. Describe the 3 phases of degeneration.

WEEK 2

2. Answer all quiz


2.1 Clinical evaluation of 2.1 Spinal
2.1 Case history questions and submit
pain (pathophysiology of manipulative
taking to Weebly by 25/3/19
pain, simple (referred pain) techniques and
verses complicated pain observation 2.2 Go through the
(radicular pain). (postural analysis, clinical forms for
range of motion case history taking
2.2 Case history:
active and passive, 2.2 Practice cervical
Introduction and
palpation static MSK testing
application.
and motion) ‘ORP’
2.3 Physical Examination.
of GORP.
GORP OMNICS what does it
stand for? 2.2 MSK testing of
the cervical
spine. Validity
and specificity.

Objectives
By the conclusion of this week, you will be able to have an understanding of the following:

1. Understand how to perform a case history.


2. Understand the pathophysiology of pain
3. Introduce GORPOMNICS as a mnemonic for physical examination procedure.
4. Understanding the interpretation/ validity and reliability where indicated and perform
the cervical MSK tests.

Readings:

Refer to the resources in Moodle

Differential Diagnosis and Management for the chiropractor 5th ed. Barlett and Jones Learning. Read
pages 8 and 9 on referred pain.

Lecture notes and PowerPoints

Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.

Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.

Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.

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?

Complete the following table:

Associated signs and Referred symptoms Radicular symptoms


symptoms.

Symptoms likely to be
subjective or objective?

Describe the pain (sharp or


dull)
What are the causes of
referred and radicular
symptoms?

Describe the distribution of


symptoms?

Are there typically neurological


findings?

Are there tension signs?

Which is classified simple


(uncomplicated) or complex
(complicated)

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

Muscles (trigger points)

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 Axial Compression

Cervical distraction test

Cervical Flexion
Compression test

Cervical Rotation
Compression test

Cervical Lateral Flexion


Compression test

Cervical Maximal
Compression test

Shoulder Depression test

Shoulder abduction test


(Bakody’s)

Valsalva test

LLermittes sign

Brachial plexus tension test

Cervicogenic dizziness

Adson’s test

Halstead test (reverse


adson’s)

Wright’s test
(hyperabduction)

Costoclavicular test

Provocation elevation test


(Roos)
Allen’s test
WEEK 3

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:

1. Making a diagnosis and clinical impression (working diagnosis)


2. How to develop a prognosis
3. Introduction to clinical reasoning and developing a differential diagnosis
4. How to do a ‘report of findings’ (ROF)

Readings:

Refer to the resources in Moodle


Lecture notes and PowerPoints

Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.

Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.

Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.

via Zoom

QUESTIONS: WEEK 3. To be completed by the 1st of


April

How to make a Diagnosis

1. Summarise how you would make a likely diagnosis or ‘tissue’ in lesion.


2. Summarise how you would make clinical impression. Draw a conceptual map to explain
3. Summarise how you would make a prognosis.
4. Summarise how you would perform a report of findings. Outline key points.
5. Outline an algorithm outlining the diagnostic process using the headings below:
i. Prognosis
ii. Case history taking
iii. Clinical impression
iv. Refer for an x-ray
v. Treatment management plan
vi. Developing a differential diagnosis
vii. Report of findings
viii. Referral to another health care provider

Clinical Reasoning (refer to the PowerPoint slides ):

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.

Lumbo-pelvic MSK tests


Test INTERPRETATION/WHAT TISSUE STRUCTURE DOES THIS TEST LOAD? For you to
complete

Squat test

Lumbar Kemps test

Djerine’s triad
(Valsalva, cough,
sneeze)

Flip or Bechterew’s
test

Straight leg raising


test (SLR)

Well straight leg


raising test (WSLR)

Braggard’s test

Bowstring’s test

Bonnet’s test

Kernigs test

Sign of the buttock

Slump test

Milgrams test

Sacral thrust
(Springing the sacrum)

SIJ distraction

SIJ compression

Thigh thrust

Gaenslen

Nachlas test (prone


knee bending
Ely’s test

Yeoman’s test

Lumbar springing test

Stoop test

Hoover test

Trendelenberg’s test

Patrick Fabere test

Rotational deformities

Thomas test

Test for true leg


length

Ober’s test

Pelvic Rock test

Homer pheasant test

Schober test

Bicycle test of Van


Felderen

Summarise the Characteristics of the following

Compression injury to Nerve root Nerve trunk Peripheral nerve Spinal cord
nerve tissue symptoms compression entrapment compression
WEEK 4

Review and reflection 4.1 Case history


4.1 Mock OSCE for 4.1 Review week.
taking with and
No new material. feedback.
without the Students to form groups
4.2 Practice all MSK clinical form. of four for video
testing to-date 4.2 Practice all MSK assessment.
testing to-date

Objectives

This is review, reflection and catch-up week.

Readings:

There are no further readings for this week.

Lecture notes and PowerPoints

Review, reflection and catch-up

Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.


Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.

via Zoom

There are no questions for week 4. Review only.

Week 5

5.1 Spinal Answer all quiz


5.1 Case history:
5.1 MSK condition 1: questions and submit to
manipulative taking. Simulation of
Myofascial pain syndromes. Weebly by April 15,
techniques and myofascial syndrome.
Review anatomy and 2019
observation 5.2 Case Study 1:
biomechanics associated with
(postural analysis, Developing a
this condition. Clinical signs
range of motion differential diagnosis
and symptoms in addition to
active and passive, and likely diagnosis.
pathomechanics
palpation static and
motion) ‘ORP’ of

5.2 Review of Stages of GORP.

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:

1. The pathomechanics of myofascial syndrome including clinical signs and symptoms of


Myofascial trigger points (MTPs)
2. The stages of ligamentous healing
3. The stages of muscle injuries (muscle strains).
Readings:

Refer to the resources in Moodle

Lecture notes/recordings and PowerPoints

Study the lecture notes, listen to the recording and study the PowerPoints under the lecture
icon.

Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.

Up to 2 hours tutorial on Zoom


Refer to schedule on Moodle.

via Zoom

WEEK 5, CASE STUDY 1: TO BE COMPLETED PRIOR TO


THE TUTORIAL.

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.

Jack has been diagnosed with tension headaches.

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 Axial Compression

Cervical distraction test

Cervical Flexion Compression


test

Cervical Rotation
Compression test

Cervical Lateral Flexion


Compression test

Cervical Maximal
Compression test

Shoulder Depression test

Shoulder abduction test


(Bakody’s)

Valsalva test

LLermittes sign

QUESTIONS: WEEK 5. To be completed by the 8th April


1. In general, what are the treatment objectives for a muscle strain?
2. Discuss the criteria by which a patient may require surgical repair for muscle strain.
3. Describe muscle contusions.
4. What is the difference between a intermuscular haematoma and intramuscular
haematoma?
5. Summarise the classification of muscle strains
6. Summarise the prognostic indicators for muscle injury.
7. Outline the signs and symptoms/clinical features of acute Lumbar Muscle strain
8. What are the main differences between an acute and chronic lumbar sprain strain?
9. What is the difference between myofascial pain syndrome and muscle strains?
10. From the ppts (Myofascial syndrome): Have a look at slide 9 and indicate how this exercise
might help low back pain patients.
11. From the ppts (Myofascial syndrome): Describe upper and lower cross syndrome.
12. Develop an ‘illness script for chronic lumbar sprain/strain.
13. What is a trigger point? Complete the table below.

Healing and Classification of Ligaments and Tendon Sprains: Quiz questions

1. What are the factors influencing ligaments and tendons?


2. Summarise the ‘classification of connective tissue injury.
3. Outline the 4 phases of inflammatory reaction.
4. What are the treatment principles for most soft tissue injuries?

Complete an ‘illness script’ for the following muscle trigger points :

Gluteus medius Supraspinatus

Sternocleidomastoid (SCM) Splenius capitus

Gastrocnemius Quadratus lumborum

Longissimus Iliopsoas

Extensor carpi radialis Deltoid

Pectoralis Major Subscapularis

Serratus anterior Gluteus maximus

Splenius Cervicus Suboccipitals

Levator scapulare Upper trapezius

Infraspinatus Piriformis

Temporalis Gluteus Minimus

Tensor Fascia Lata


Thoracic MSK Testing

Test INTERPRETATION/WHAT TISSUE STRUCTURE DOES THIS TEST LOAD? For


you to complete

Slump test

Passive Scapular
approximation

Percussion

Rib fracture screen

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.

6.2 Rib motion and


static palpation

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:

1. The typical aetiology for facet problems.


2. The signs and symptoms of facet syndrome.
3. The grading of ligamentous strains.
4. The 4 phases of healing of soft tissue injuries.
5. The gait cycle and what ‘normal’ looks like.
Readings:

Refer to resources in Moodle.


Differential Diagnosis and Management for the Chiropractor: Protocols and algorithms. Souza,
Thomas A 5th Edition. Read page 104 on facet syndrome of the cervical spine. Page 214 on facet
syndrome.

Lecture notes/recordings and PowerPoints

Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.
Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.

Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.

via Zoom

WEEK 6, CASE STUDY 2: TO BE COMPLETED PRIOR TO


THE TUTORIAL
Joe 21-year-old single male teacher.

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.

Lumbar Kemps test

Djerine’s triad (Valsalva, cough, sneeze)

Flip or Bechterew’s test

Straight leg raising test (SLR)

Well straight leg raising test (WSLR)

Braggard’s test

Bowstring’s test

Bonnet’s test

Kernigs test

Sign of the buttock

Slump test

Milgrams test

Sacral thrust (Springing the sacrum)

SIJ distraction

SIJ compression

Thigh thrust

Gaenslen

Nachlas test (prone knee bending

Ely’s test

Yeoman’s test

Lumbar springing test

Stoop test
Hoover test

Trendelenberg’s test

QUESTIONS: WEEK 6. To be completed by the 29th April


Facet ‘syndrome’

1. Write an illness script for facet syndrome.


2. Describe the pathomechanics of facet syndrome.
3. What are the signs and symptoms of facet syndrome.
4. The thoracic spine is the least mobile area of the spine. True or false. Explain your answer.
5. The thoracic spine has limited capacity to compensate or accommodate for postural and
dynamic distortions. True or false. Explain your answer.
6. Draw a conceptual map outlining the typical history and aetiology.
7. Does a facet problem give neurological signs?

The Gait Cycle

1. Describe the gait cycle.


2. The stance phase is 40% of the gait cycle and the swing phase is 60%. True or false.
3. What are the definitions of the following:
a. Stride Length
b. Step Length
c. Step width
d. Foot angle
e. Cadence
4. When examining the motion in the sagittal plan, which joint undergoes the most angular
motion?
5. Describe the typical gait for a post-stroke patient.
6. At what phase of the gait cycle do the quadriceps activate?
7. At what phase of the gait cycle do the hamstring muscles activate?
8. List the 7 principles of gait assessment.
9. List 2 causes for excessive inversion (supination)
10. List 3 causes for excessive eversion.
11. List 4 causes for limited knee flexion.
12. List 2 causes for excessive hip flexion.
13. List 2 causes for contralateral pelvic drop
Week 7

MSK condition 3: ‘Simple’ pain 7.1 Case history:


71. Spinal (incl ribs) Answer all quiz
associated with the Hip, Sacro- taking. Simulation SI
manipulative questions and submit to
iliac joint and coccyx jt. hip or coccyx
techniques Weebly by 7/5/19
condition.
according to GORP
7.2 Case Study 3 and 4
7.2 Practice cards Developing a
for OSCE differential diagnosis
and likely diagnosis

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:

Refer to resources in Moodle.


Differential Diagnosis and Management for the Chiropractor: Protocols and algorithms. Souza,
Thomas A 5th Edition. Read page 169 on the sacro-iliac joint. Page 391-404 on the hip joint. Read
page 216 on sacroiliac sprain and subluxation.

Lecture notes/recordings and PowerPoints

Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.

Practical Class (2X2 hr):


Compulsory attendance. Refer to technique schedule.

Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.

via Zoom

WEEK 7, CASE STUDY 3 and 4: TO BE COMPLETED


PRIOR TO THE TUTORIAL.
Case Study 3

Robert is a 30-year-old solicitor.

Presenting Complaint

Robert complains of right hip pain.

History of 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

Robert walks into your office with no visible limitations.

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.

Patrick Fabere test is negative

Right Sign of Buttock test reproduces the pain in the right hip

Right Ober’s 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.

Shoulder examination: Unremarkable. Pain cannot be reproduced during your consultation.

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

i. His hip pain


ii. His shoulder pain

Case Study 4

Joey is a 45-year-old computer programmer

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.

Nachlas and Ely’s: Unremarkable

Lumbar Compression/distraction: Unremarkable.

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

Lumbar Kemps test

Djerine’s triad (Valsalva, cough,


sneeze)

Flip or Bechterew’s test

Straight leg raising test (SLR)

Well straight leg raising test (WSLR)

Braggard’s test

Bowstring’s test

Bonnet’s test

Kernigs test

Sign of the buttock

Slump test

Milgrams test

Sacral thrust (Springing the sacrum)

SIJ distraction

SIJ compression

Thigh thrust

Gaenslen

Nachlas test (prone knee bending

Ely’s test

Yeoman’s test

Lumbar springing test


Stoop test

Hoover test

Trendelenberg’s test

QUESTIONS: WEEK 7. To be completed by the May 7th

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)

Sacro-Iliac joint and coccydynia

1. What conditions potentially can give pain in the sacro-iliac joint?


2. What are the characteristic clinical features of a sacro-iliac joint sprain?
3. Describe the ligaments that support the sacro-iliac joint.
4. Describe the mechanics of the sacro-iliac joint during movement.
5. Does the sacro-iliac joint fuse as we get older? Explain your answer.
6. What are the signs and symptoms of sacro-iliac syndromes.
7. Is pain from the sacro-iliac joint referred or radicular? Explain your answer.
8. What orthopaedic tests would confirm a problem in the sacro-iliac joint?
9. Describe the signs and symptoms for coccydynia?
10. What are the causes of coccydynia?
Week 8: Review, reflection and Catch-up

Review and reflection


8.1 Spinal (incl ribs) Review week. No
8.1 Case history:
No new material. questions this week.
manipulative taking. Simulation for a
techniques spinal condition
according to GORP. (selected from that
Mock OSCE studied to-date)

Practice cards for


OSCE

Objectives

This is review, reflection and catch-up week.

Readings:

There are no further readings for this week.

Lecture notes and PowerPoints

Review, reflection and catch-up

Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.


Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.

via Zoom

There are no questions for week 8. Review only.

Week 9

MSK condition 4: Scoliosis


9 Spinal Answer all quiz
9.1 Case history:
manipulative questions and submit to
taking. Simulation for a
techniques (incl ribs) spinal condition Weebly by 20/5/19

according to GORP associated with


scoliosis
Practice cards for
OSCE 9.2 Case Study 5.
Developing a
differential diagnosis
and likely diagnosis
Objectives

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:

Refer to resources in Moodle.


Differential Diagnosis and Management for the Chiropractor: Protocols and algorithms. Souza,
Thomas A 5th Edition. Read page 135 to 156 on Scoliosis.

Lecture notes/recordings and PowerPoints

Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.

Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.

Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.

via Zoom
QUESTIONS: WEEK 9. To be completed by the 20th of
May
Scoliosis and Scheuermann’s disease

Categorise the symptomatology of thoracic pain (there are 3 categories).

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

according to GORP questions and submit to


spinal condition
Weebly by 27/5/19
associated with
Practice cards for scoliosis
OSCE.
10.2 Submit finished
10.2 Case Study 6.
group video to Weebly
Developing a
differential diagnosis
and likely diagnosis

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:

Refer to resources in Moodle.


Differential Diagnosis and Management for the Chiropractor: Protocols and algorithms. Souza,
Thomas A 5th Edition. Read pages 215 and 216 on spondylolisthesis

Lecture notes/recordings and PowerPoints

Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.

Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.


Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.

via Zoom

WEEK 10, CASE STUDY 6: TO BE COMPLETED PRIOR TO


THE TUTORIAL.
Presenting Complaint:

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.

Muscle testing in the lower extremities: normal

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

Lumbar Kemps test

Djerine’s triad (Valsalva, cough,


sneeze)

Flip or Bechterew’s test

Straight leg raising test (SLR)

Well straight leg raising test (WSLR)

Braggard’s test

Bowstring’s test

Bonnet’s test

Kernigs test

Sign of the buttock

Slump test

Milgrams test

Sacral thrust (Springing the sacrum)

SIJ distraction

SIJ compression

Thigh thrust

Gaenslen

Nachlas test (prone knee bending

Ely’s test

Yeoman’s test

Lumbar springing test


Stoop test

Hoover test

Trendelenberg’s test

QUESTIONS: WEEK 10. To be completed by the 27th


May
State true or false to the following, explain your answers in each case.

1. Spondylolisthesis caused by a defect in the pars interarticularis invariably causes symptoms.

2. Spondylolisthesis may interfere with childbirth

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.

6. Prone manipulative procedures are recommended for all types of 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.

Please answer the following questions.

1. What is the difference between spondylolisthesis and spondylolysis?


2. What is the difference between an isthmic spondylolisthesis and a degenerative
spondylolisthesis?
3. Describe an iatrogenic spondylolisthesis?
4. Explain the biomechanical effects of spondylolisthesis?
5. Is there instability with spondylolisthesis?
6. Are the always symptoms associated with spondylolisthesis. Describe the typical symptoms
if they are present.
7. What are the clinical signs of spondylolisthesis?
8. What conditions/syndromes may result from spondylolisthesis?
9. Describe the general chiropractic approach to managing spondylolisthesis?
10. Is spondylolisthesis always associated with nerve root irritation and compression? Explain
your answer.
11. Describe the type of spondylolisthesis below. What clinical signs and symptoms could
possibly occur as a result? Do you think a patient with this spine always has symptoms?

Week 11

Review and reflection Revision. Practice Revision Revision


Cards for OSCE
No new material. Answer practice exam

Readings:
This is a review week

Lecture notes/recordings and PowerPoints

Study the lecture notes, listen to the recording and study the PowerPoints under the lecture icon.

Practical Class (2X2 hr):

Compulsory attendance. Refer to technique schedule.

Up to 2 hours tutorial on Zoom

Refer to schedule on Moodle.


via Zoom

Week 12

OSCE Week OSCE Week Revision Revision

No new material