1] Advanced Manual Therapy Techniques

Question 1

HVLA thrusts are often accompanied by

Answer 1

Cavitations

Question 2

3 types of pain

Answer 2

Acute, subacute, chronic

Question 3

What is expected motion loss in a patient with restricted capsular mobility atthe Left L2/L3facet?

Answer 3

Capsular restriction at lumbar limits upslides and gapping.

Left L2/L3 facet would be restricted in flexion, right SB and left rotation.

Question 4

Absolute contraindications for manips in lumbar

Answer 4

Bone weakening patho
Neurological symptoms
Vascular issues
Severe pain that wont let them get into position
Lack of patient consent

Question 5

Neuro sx that are absolute contraindications

Answer 5

Cord compression
Cervical myelopathy
Nerve root compression with increasing neuro deficits
Cauda equina compression

Question 6

Vascular issues that are absolute contraindications

Answer 6

CAD or vertebrobasilar insufficiency
Aortic aneurysms
Blood disorder (hemophilia)
Using anticoagulants

Question 7

Relative contraindications for lumbar manips

Answer 7

History of intervertebral disc injury
Pregnancy 
Ligamentous laxity/hypermobility 
Advantaged DJD
Vertigo 
Psychological dependence on joint manip

Question 8

Some transient adverse effects that might happen after manip

Answer 8

Increased local pain or discomfort 
Stiffness
Headache
Tired/fatigue
Radiating pain
DNV
Tinnitus

Question 9

Serious adverse effects after manip

Answer 9

HNP
Fractures 
Vertebral artery dissection
CVA
Cauda equina syndrome
Spinal cord compression
Death

Question 10

3 effects of manual therapy

Answer 10

Psychological
Mechanical
Neurophysiological

Question 11

What is a psychological effect of manual therapy?

Answer 11

We have found their pain and can reproduce it so this strengthens the THERAPEUTIC ALLIANCE - possible placebo effect

Question 12

Mechanical effects of MT

Answer 12

Stretching
Snap intra-articular adhesions
Release entrapped meniscoid tissue within facets
Increase ROM

Question 13

What are some neurophysiological effects of MT?

Answer 13

Endogenous pain relief

Less muscles guarding and inhibition and sensitivity to pain

Question 14

Mid cervical flexion

Answer 14

Both facets upslide

Question 15

Mid cervical extension

Answer 15

Both facets downslide

Question 16

Mid cervical right SB

Answer 16

L facet upslide

R facet downslide

Question 17

Left sidebend mid cervical motion

Answer 17

Left downslide

Right upslide

Question 18

Mid cervical right rotation

Answer 18

Left upslide

Right downslide

Question 19

Mid cervical left rotation

Answer 19

Left downslide

Right upslide

Question 20

Lumbar flexion

Answer 20

Both facets upslide

Question 21

Lumbar extension

Answer 21

Both facets downslide

Question 22

Lumbar right SB

Answer 22

Left up

Right down

Question 23

Left SB

Answer 23

Left down

Right up

Question 24

Lumbar right rotation

Answer 24

Left compress

Right gap

Question 25

Lumbar left rotation

Answer 25

Left gap | Right compress

Question 26

Coupled motion of Upper cervical spine

Answer 26

Rotation and SB happen in opposite directions

Question 27

Coupled motions of mid cervical

Answer 27

Rotation and SB occur to SAME side

Question 28

Coupled motion of thoracic and lumbar

Answer 28

In neutral/extended: rotation and SB in opposite directions In flexed: rotation and SB happen in same direction

Question 29

How do you do facet apposition locking

Answer 29

Put the spine in position thats opposite to the normal coupled motions

Question 30

How would you lock mid cervical coupled motions?

Answer 30

SB and rotate to opposite side

Question 31

When SB and rotation happen to the opposite sides like in neutral position of lumbar and thoracic, how do you lock?

Answer 31

Put them in SB and rotation to the same side

Question 32

What conditions do you screen for during the interview

Answer 32

CAD VBI Cauda equina compression

Question 33

What 3 conditions do you want to rule out before doing manips?

Answer 33

Cervical arterial dysfunction Cervical instability CES

Question 34

Signs and Sx of cervical arterial dysfunction

Answer 34

``` Occipital and one sided headache Ataxia Ptosis Facial palsy 5 D’s 3 Ns ```

Question 35

What are the 5 D’s

Answer 35

``` Dizzy Drop attacks Diploplia Dysarthria Dysphagia ```

Question 36

What are the 3 N’s

Answer 36

Numbness Nausea Nystagmus

Question 37

Meta analysis by Mitchell noted significant decreased blood flow in VA with ?

Answer 37

Contralaterla end range rotation

Question 38

Risk factors for craniocervical artery dissection

Answer 38

``` Recent minor trauma HTN Hypercholesterolemia Smoking TIA/CVA Vertigo Paresthesia ```

Question 39

In pts with cervical instability, you want to rule out?

Answer 39

RA Down’s syndrome S/p trauma or falls

Question 40

What would a pt with cervical instability say?

Answer 40

That they cant hold their head up or that they feel the need to wear a collar

Question 41

Other signs and Sx of cervical instability

Answer 41

Bilateral paraesthesias Weakness Other signs of cord compression Midline muscle guarding or tender

Question 42

3 tests for cervical instability

Answer 42

Canadian c spine rules for fracture Sharp-purser for transverse lig Alar ligament stress test

Question 43

What do you do if they are + for cervical instability through testing

Answer 43

Refer to imaging

Question 44

Causes for cauda equina syndrome

Answer 44

``` HNP Trauma Tumor Fracture Stenosis Infection ```

Question 45

Signs and symptoms of cauda equina syndrome

Answer 45

``` LBP Urinary incontinence or retention Fecal retention/incontinence Paresthesias in saddle distribution Motor or sensory loss in B/LLEs Gait Dysfunction ```

Question 46

If CES suspected

Answer 46

Immediately refer for medical work up/imaging

Question 47

Lumbar manip CPR guidelines (5)

Answer 47

``` Symptoms less than 16 days No Sx below knee FABQ work subscale less than 19 Hip IR more than 35 deg atleast 1 side 1 hypomobility lumbar segment ```

Question 48

Recommendations for neck pain with mobility deficits

Answer 48

Acute: should thoracic manip and may cervical manip/mob - weak evidence Subacute: may thoracic manip and cervical manip/mob- weak evidence Chronic: multimodal approach - mod evidence