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Methods > Methods 5-Final > Flashcards

Methods 5-Final Flashcards

1
Q

Motions of the rib cage

A

-Pump handle
-Bucket Handle
-Caliper
-Torsion

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2
Q

Thoracic movements

A

-Flexion/Extension (Mostly)
-Lateral Bending
-Axial Rotation

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3
Q

Scheuermann’s Disease

A

-D/t growth plate trauma during adolescence
-Schmorl’s Nodes=Evidence of nuclear disc extrustions
-Wedging of >5* in three consecutive segments
-Midthoracic (75% of the time)/Thoracolumbar (25%)

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4
Q

Scheurmann’s disease typically affects:

A

Young male (13-17yo) & female gymnasts

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5
Q

Scheurmann’s Disease will typically structurally involve:

A

-Exaggerated cervical/lumbar lordosis
-Hyperkyphotic thoracic spine

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6
Q

Scheuremann’s Disease: Management

A

-Soft tissue/gentle mobilization
-Address during adolescence/brace (>60) sometime
-Address functional overuse
-Surgery: May be considered at >70 w/ pain
-Kyphosis <60* will most likely resolve in adulthood

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7
Q

Costochondritis: Observation

A

Antalgia, shallow breathing, anterior rib
pain at the costosternal articulation (usually ribs 2-5)

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8
Q

Costochondritis:ROM

A

-Bucket and/or pump handle restriction
-Arm abduction limited d/t pain

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9
Q

What ortho can you use for costochondritis?

A

Schepelmann’s

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10
Q

Costochondritis: Active Treatment

A

-Light stretching
-Avoid exacerbating activity
-Focused breathing

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11
Q

Costochondritis: Home Care

A

-Bromelain: 500mg 3x/day
-Curcumin
-Heat

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12
Q

Costochondritis: Referral

A

-Massage therapy
-Anesthetic or corticosteroid

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13
Q

Costochondritis: Passive Treatment

A

-Chiropractic adjustments
-Muscle work
-Moist heat
-Laser

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14
Q

Causes of intercostal neuritis

A

*Herpes Zoster
-Tumors
-Ruptured discs/bone spurs
-Diabetes
-Rib motion dysfunction

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15
Q

Ortho for Intercostal neuritis

A

Schepelmann’s sign produces pain on the concave
side

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16
Q

During intercostal neuritis, what should you do if herpes zoster is suspected?

A

Wear gloves

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17
Q

Intercostal neuritis: Supplements

A

-B1, B2, B6, B12 & pantothenic acid given together
-Zinc

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18
Q

Intercostal neuritis: Active treatment

A

-Thoracic and core stability
-Posture
-Breathing exercises

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19
Q

Intercostal Neuritis: Passive Treatment

A

-Adjust (be careful of shingles lesions)
-US, EMS, Laser

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20
Q

Intercostal Neuritis: Co-Management

A

-Injections: Anesthetic (Xylocaine or Lidocaine)
-Analgesics, NSAIDS
-Acupuncture & Acupressure
(NO proven cures)

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21
Q

Idiopathic Scoliosis is influenced by:

A

-Family History
-Female patients w/ curves >30*

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22
Q

Idiopathic scoliosis can be corrected to some degree with:

A

Lateral flexion

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23
Q

How does Idiopathic scoliosis affect ROM?

A

Decrease in ROM of trunk and pelvis

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24
Q

Idiopathic scoliosis: Ortho

A

Adam’s Position

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25
Q

Are there any neuro findings with idiopathic scoliosis?

A

No

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26
Q

Congenital Scoliosis includes:

A

Club foot/foot deformities

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27
Q

Spina bifida includes:

A

Patches of hair along the spine

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28
Q

Neurofibromatosis includes:

A

Cafe au lait spots or patches

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29
Q

Idiopathic Scoliosis: PARTS

A

-Pain in areas of the rib
-Asymmetry both globally as well as joint level

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30
Q

A cobb angle of _____ is considered scoliosis

A

> 10 degrees

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31
Q

Active treatment of Idiopathic Scoliosis: Strengthen muscles of _______/Stretch muscles of ____

A

Convexity; Concavity

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32
Q

With idiopathic scoliosis is contraindicated to adjust into a ________

A

Concavity

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33
Q

TOS: Cause/Risk

A

-Repetitive activity, Poor posture, pregnancy

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34
Q

Most cases of TOS are:

A

Neurogenic

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35
Q

TOS involves what musculature

A

Scalene, 1st rib, pectoralis

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36
Q

TOS: Presentation

A

-Pain/numbness tingling into 4th/5th digit that worsens with activity
-Neck/shoulder pain
-Thenar atrophy
-Diminished grip strength
-Hand/arm swelling
-Pallor or dislocation of the hand

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37
Q

In TOS, imaging is used to rule out:

A

Cervical Rib

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38
Q

TOS Treatment: Active

A

-Stretch Scalenes, pectoralis
-Radial and ulnar nerve flossing

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39
Q

TOS: Home Care

A

Bruegger’s relief*, heat, avoid sleep posture with elevated arm, postural awareness

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40
Q

TOS responds well to:

A

Chiropractic care

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41
Q

Adhesive Capsulitis: Phases

A

-Acute: Moderate to severe pain that limits ROM
-Middle: Less pain but lifting arm & internal/external rotation is severely restricted
-Final: Slowly increased ROM

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42
Q

Adhesive capsulitis often resolves in:

A

2-3 years

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43
Q

Adhesive Capsulitis: Stages

A

-Freezing
-Frozen Stage
-Thaw

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44
Q

Cause of adhesive capsulitis

A

-Unknown
-Slight increase if diabetic, hyperthyroid, COPD
-Inflammation leads to fibrosis

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45
Q

Adhesive Capsulitis: Risk Factors

A

-Age: 45 to 60 years old
-Gender: Women (70%)
-Prolonged immobility, previous injury, surgery
-Diabetes mellitus, hypothyroid

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46
Q

Adhesive capsulitis: Diagnosis

A

-Loss of Shoulder ROM: External and Abduction
-Orthopedic Tests: Mazion shoulder

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47
Q

Adhesive Capsulitis: Treatment (Phase 1)

A

Phase 1: Avoid aggressive adjustments;Focus on mobilization/pain relief & laser. Exercises: Isometric or Codman’s exercises

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48
Q

Adhesive Capsulitis: Treatment (Phases 2/3)

A

-Adjust and mobilize shoulder
-Codman’s and isometric exercises

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49
Q

Impingement Syndrome:Causes

A

-Narrowing of the space between the acromion process and head of the humerus
-Examples: Subacromial spurs, osteoarthritic spurs, variations in shape of the acromion

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50
Q

Variations in acromion process

A

-Type 1: Flat (normal)
-Type 2: Gently curved
-Type 3: Hooked (will lead to more issues)

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51
Q

Impingement Syndrome: Signs/Symptoms

A

-Pain, weakness at night sleeping on affected shoulder
-ROM limited by pain
-Painful arc during forward elevation (60-120*)
-Passive movement appears painful with downward force @ the acromion

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52
Q

Impingement Syndrome: Active Care

A

Isometric to Isotonic exercises, beginning with shoulder slightly abducted

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53
Q

What adjustments are best for impingement syndrome?

A

S-I adjustments of the glenohumeral joint
-I-S adjustments of the sternoclavicular joint

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54
Q

What disorders of the hand/wrist/elbow are most prominently seen in clinic?

A

Lateral Epicondylitis & Carpal Tunnel Syndrome

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55
Q

Lateral Epicondylitis: M99 Codes

A

M77.11(Right elbow), M77.12 (Left elbow)

56
Q

Lateral Epicondylitis: Causes/Risk Factors

A

-Overuse injury
-Age: Late 30s-Early 60s
-Desk Work

57
Q

Lateral Epicondylitis: Signs/Symptoms

A

-Tenderness along the lateral border of the elbow
-Pain when picking up objects while pronated
-Reduced grip strength
-Provoke pain when palpating the lateral elbow
-Hypertonicity of the forearm
-Radiating pain into the forearm

58
Q

Lateral Epicondylitis: MSR would show

A

Motor strength weakness w/ wrist extension and grip

59
Q

Lateral Epicondylitis: PARTS

A

-Tenderness over tendons of extensor carpi radialis brevis
-Asymmetry/diminished mobility of the radial head
-Hypertonic forearm muscles

60
Q

Orthos for Lateral Epicondylitis

A

Kaplan’s, Mills, Cozens

61
Q

Lateral Epicondylitis: Home Treatment

A

-Avoid excessive/repetitive twisting at the wrist
-Ice Pack: Outside of the Elbow
-Brace

62
Q

Lateral Epicondylitis: Passive Treatment

A

-Soft tissue release/IASTM
-Laser
-Manipulation

63
Q

Lateral Epicondylitis: Complications

A

-Recurrence of the injury with overuse
-Rupture of the tendon with repeated steroid injections

64
Q

What kind of adjustments should be used for lateral epicondylitis?

A

P-A glide of the radial head

65
Q

Cubital Tunnel Syndrome: ICD Code

A

G56.30-Lesion of the ulnar nerve, unspecified upper limb

66
Q

Cubital tunnel Syndrome is influenced by which movements?

A

Shoulder abduction, elbow flexion, and wrist extension

67
Q

Cubital Tunnel Syndrome: Signs/Symptoms

A

Wartenburg Sign: Pinky finger abducts, difficulty with opposition

68
Q

Cubital tunnel syndrome: Diagnosis

A

-History: Recurrent elbow flexion or pressure
-Observation: Wartenburg Sign
-ROM: Limited by elbow flexion

69
Q

Cubital Tunnel Syndrome: Exam

A

Parts: Pain over the posterior and medial elbow
-MSR: Weak flexor digitorum profundus, paresthesia along the ulnar distribution of the hand

70
Q

Cubital Tunnel Syndrome: Orthopedic Tests

A

Froment’s Test, Tinels sign of the elbow, elbow flexion test

71
Q

Cubital Tunnel Syndrome: Grade I

A

Mild lesions with paresthesia (ulnar nerve), feeling of clumsiness in the affected hand. NO WASTING OR WEAKNESS of the intrinsic muscles

72
Q

Cubital Tunnel Syndrome: Grade II

A

Intermediate lesions with WEAK INTEROSSEI and MUSCLE WASTING

73
Q

Cubital Tunnel Syndrome: Grade III

A

Severe lesions with paralysis of the interossei and a MARKED WEAKNESS OF THE HAND

74
Q

Cubital Tunnel Syndrome: Special Tests

A

-EMG
-NCS
-Asymptomatic: Medical subluxation of the ulnar nerve

75
Q

Cubital Tunnel Syndrome: Treatment

A

-Passive: ST mobilization, adjustments
-Active: Progressively strengthen flexors
-Home: Reduce elbow flexion
-Medical comanagement: PT, surgical placement of nerve

76
Q

Adjustments for Cubital Tunnel

A

-P-A glide of the ulna into extension
-A-P glide of the ulna
M-L glide of the elbow in supine position

77
Q

Carpal Tunnel Syndrome: ICD Codes

A

-ICD-9354.0
-IDC-10G56.0

78
Q

Carpal Tunnel Syndrome: Signs/Symptoms

A

-Pain, tingling, numbness in the hand and forearm (median nerve distribution)
-Weakness with wrist and finger flexion
• Frequently dropping things
• Prolonged or repetitive wrist flexion

79
Q

CTS: Exam

A

• MSR
• PINCH AND GRIP STRENGTH WEAK OR DIMINISHED, PARESTHESIA ALONG THE MEDIAN NERVE, REFLEX – N/A

• PARTS
• PAIN NOTED OVER THE CARPAL TUNNEL REGION
• ASYMMETRY OF THE TRAPEZIUM, TRAPEZOID AND CAPITATE
• LOSS OF A-P OR P-A SEGMENTAL MOTION
• TONE – HYPOTONICITY OF OPPONENS POLLICIS BREVIS, FLEXOR POLLICUS BREVIS AND ABDUCTOR POLLICUS BREVIS

• SPECIAL TESTS
• X-RAY
• ELECTROMYOGRAM
• NERVE CONDUCTION STUDY

80
Q

CTS: Orthopedic Tests

A

Tinels sign (Wrist), Phalen’s Test, Reverse Phalens Test

81
Q

Carpal Tunnel: Adjustments

A

LAD of intercarpal joint
-P-A/A-P of the intercarpal joint
-A-P/P-A of distal radioulnar joint
-A-P/P-A of carpals

82
Q

Dequervains Tenosynovitis: ROM

A

ROM
• LOSS OF FLEXION, EXTENSION OR RADIAL DEVIATION AT THE WRIST
• LOSS OF THUMB FLEXION/EXTENSION, ABDUCTION/ADDUCTION AND OPPOSITIO

83
Q

Dequervains: Ortho

A

Finkelsteins

84
Q

Dequervains: MSR

A

• WEAKNESS AND REPRODUCTION OF PAIN WITH RESISTED THUMB EXTENSION
• POSSIBLE PARESTHESIA
• DIMINISHED BRACHIORADIALIS REFLEX

85
Q

DeQuervains: PARTS

A

• PALPATORY TENDERNESS NOTED OVER THE BASE OF THE THUMB
• ASYMMETRY/Loss of segmental motion OF THE SCAPHOID, TRAPEZIUM OR FIRST CARPAL
• OVERLY FIRM/HARD DORSAL COMPARTMENT

86
Q

When would you use X-Ray with potential Dequervains Case

A

Rule out OA or RA

87
Q

Dequervains: Treatment

A

Passive: IASTM, mobilization of the wrist
-Active: Gentle wrist stretches, ROM
-Home: Ice, Nsaids

88
Q

Dequervains: Adjustments

A

LAD of the metacarpalphalangeal joints

89
Q

Legg-Calve Perthes Disease: Causes/Risk

A

• Sometimes trauma?
• Subcapital fx
• Posterior hip dislocation
• Boys age 4-9
• Not genetic

90
Q

Legg-Calve Perthes: Signs/Symptoms

A

• Painless limp or waddling gait
• Mild pain in the affected hip
• Limited hip ROM
• Hip stiffness that restricts movement
• Ipsilateral Knee pain
• Persistent thigh or groin pain
• Wasting of muscles in the upper thigh
• Apparent shortening of the leg, or legs of unequal length

91
Q

Stages of LCP

A

1) Initial- loss of blood supply
2) Fragmentation/resorptive phase
3) Re-ossification
4) Healed

92
Q

LCP: Examination

A

History (rule out)
• Compression fractures
• Infection
• Endocrine disorders
• Clotting disorders

Observation
• Limping, muscle atrophy, leg length

93
Q

LCP: ROM

A

Range of Motion
• Limited internal rotation and abduction

94
Q

LCP: Orthopedic Tests

A

Leg Length Measurement, Trendelenburg Sign

95
Q

LCP: PARTS

A

PARTS
– Palpatory tenderness over the femur head
– Asymmetry and leg length discrepancy
– Loss of segmental ROM at the hip
– Hypotonicity or atrophy of the quadriceps

• Special Tests
– X-ray or MRI
– Labs

96
Q

LCP: MSR

A

MSR
– Sensory is equal and WNL
– Reflexes equal and WNL
- Weak hip muscles especially internal rotators and ABductors.

97
Q

LCP: DDx

A

Unilateral: Inflammatory
• Septic arthritis, Toxic synovitis, Juvenile RA

Bilateral: Dysplasia
• Spondyloepiphyseal dysplasia, Metaphyseal dysplasia

Systems: Endocrine
• Hypothyroidism

98
Q

LCP: Treatment (Active)

A

Active
– Balance training, Gait training, ROM exercises ,Strength training

Home
– Minimize weight bearing, restrict aggravating activities, Traction (PM), Ice/Heat

Co management
• Bracing to keep the femoral head abducted
and internally rotated & Pain medications

99
Q

What kind of cast can you use with LCP

A

Petrie Cast

100
Q

Subtrochanteric Bursitis: Orthos

A

– Ober’s
– Patrick’s
– Leg length

101
Q

Subtrochanteric Bursitis Ddx: MSR

A

– Internal and external rotation weak due to pain
– Sensory - equal bilateral light touch
– Lower extremity reflexes - 2/2

102
Q

Subtrochanteric Bursitis DDx: PARTS

A

– Pain over the greater trochanter and bursa
– Asymmetry R vs L femur
– Loss of internal rotation and external rotation
– Hypertonic IT band

103
Q

Subtrochanteric Bursitis: Special Tests

A

– X-ray rule out bone spurs, arthritis
– MRI

104
Q

Subtrochanteric Bursitis: Active Tx

A

– Stretching the IT and hip abductors
– Isometric glute strengthening

105
Q

Subtrochanteric Bursitis: Passive Tx

A

– Adjust the hip, ilium, sacrum dependent on leg length.
– Adjust above and below: pelvis, knees, ankles, feet – Avoid side posture (Bergmann figure 6-155)
– Ultrasound (Pulsed ultrasound if chronic)
– EMS

106
Q

Osteitis Pubis: ICD

A

ICD-10 M85.30 UNSPECIFIED

107
Q

Osteitis Pubis is common in:

A

• Athletes- runners or kicking activities
• Exercise intensity
• Direct compressive or distractive injury
• Often from a sudden forced adduction injury
• Repetitive side-foot kicking

108
Q

Osteitis Pubis: Signs/Symptoms

A

• Adductor pain
• Lower abdominal pain
• Clicking sensation
• Pain walking, running, kicking, etc

109
Q

Osteitis Pubis: Observation

A

– Limping gait, difficulty rising from a chair/car
– ROM: Weak hip aDDuctors and flexors
– Local pain with resisted adduction

110
Q

Osteitis Pubis: Orthopedics

A

– Compression ASIS joints toward one another
– Spring test: apply direct pressure over the pubic rami approximately 3cm from midline

111
Q

Osteitis Pubis: PARTS

A

– Pain with palpation over the pubic symphysis
– Asymmetry of pubic rami
– Loss of PA motion
– Spasm of the piriformis, adductors

112
Q

Osteitis Pubis: MSR

A

– Motor weakness due to pain
– Sensory & Reflexes WNL

113
Q

Osteitis Pubis: Special Tests

A

– Gait evaluation
– X-ray, MRI, CT

114
Q

Osteitis Pubis: Active Tx

A

-Strengthening of the hip flexors, adductors, abdominal muscles, hamstring and quadriceps
-Dynamic muscular stabilization technique

115
Q

Osteitis Pubis: Home

A

– Avoidance of side-foot kicking and bilateral adduction maneuvers until pain and inflammation is reduced. A slow return to activity is recommended
– Heat or ice

116
Q

Osteitis Pubis: Passive Tx

A

– Adjust the pelvis and pubic symphysis.

117
Q

Osgood Schlatter: Presentation

A

• Young athlete (Runners, jumpers, etc)
• More common in male athletes
• Worse with activity
• Pain/swelling and tenderness at tibial tuberosity
• Due to repetitive stress on the tibial apophysis by the patellar tendon
• RARE to have avulsion of the apophysis

118
Q

Sinding-Larsen-Johansson Syndrome

A

• Involving the patellar tendon and the lower margin of the patella
• Also called Juvenile Osteochondrosis of the patella

119
Q

Osgood-Schlatter Disease Diagnosis

A

• OBSERVATION – PAINFUL, RED LUMP INFERIOR TO THE PATELLA
• ROM – PAIN INFERIOR TO THE PATELLA WITH RESISTED EXTENSION
• MSR: WEAKNESS DURING RESISTED KNEE EXTENSION D/T PAIN
• PATELLAR REFLEX INTACT BUT SITE MAY BE PAINFUL

120
Q

Osgood-Schlatter Disease: PARTS

A

• PALPATORY PAIN AT THE POINT OF INSERTION
• ASYMMETRY OF PATELLA, FIBULA AND TIBIA ASSESSED. PALPATORY BUMP OVER THE TIBIAL TUBEROSITY
• PATELLAR TRACKING, FIBULA AND TIBIA
• HYPERTONICITY OF THE QUADRICEPS, SCAR TISSUE OF THE TENDON

121
Q

X-Ray would be used with suspected Osgood-Schlatter if a ______ is suspected

A

Avulsion Fracture

122
Q

Osgood-Schlatter Disease: Active Tx

A

• STRETCH THE QUADRICEPS AND HAMSTRING

123
Q

Osgood-Schlatter Disease: Passive Tx

A

• PER THE PARTS EXAM FINDINGS
• AVOID ADJUSTING OVER THE ACUTE AREA AS IT IS CONSIDERED A POTENTIAL AVULSION FRACTURE (SCOPE OF PRACTICE)
• LASER

124
Q

Prepatellar Bursitis: Causes/Risk Factors

A

Housemaid’s Knee

125
Q

Pre-patellar Bursitis DDx

A

HISTORY
• ACTIVITIES/OCCUPATION
• SIGNIFICANT PAIN WHEN KNEELING
• STIFFNESS AND PAIN WITH WALKING

OBSERVATION: RUBOR, CALOR, EDEMA

ROM – GENERALLY PRESERVED

• ORTHOPEDIC TEST: PATELLAR GRINDING TEST – PAIN ON TOP

126
Q

Prepatellar Bursitis Diagnosis: MSR

A

• MOTOR – PAINFUL 5/5
• SENSORY – NAF
• REFLEXES – WNL (2/4) MAY BE PAINFUL

127
Q

Prepatellar Bursitis Ddx: PARTS

A

• PALPATORY DOLOR (PAIN) NOTED
• ASYMMETRY BETWEEN RIGHT AND LEFT PATELLA
• PATELLAR TRACKING PROBLEM D/T TUMOR (SWELLING)
• EDEMA AND BOGGINESS OVER THE SWOLLEN AREA

128
Q

Prepatellar Bursitis: Tx

A

• THE TREATMENT OF ANY BURSITIS DEPENDS ON WHETHER OR NOT IT INVOLVES INFECTION

ASEPTIC PREPATELLAR BURSITIS
• ICE COMPRESSES, REST, AND ANTI-INFLAMMATORY AND PAIN MEDICATIONS.
• OCCASIONALLY, IT REQUIRES ASPIRATION OF THE BURSA FLUID.
• CBC - ASPIRATED TO IDENTIFY THE MICROBES
• ANTIBIOTIC THERAPY

129
Q

Prepatellar Bursitis: Passive Care (Acute)

A

• ASSESS & ADJUST ABOVE/BELOW
• ADJUST THE KNEE: IF there is Patellar tracking disorder
• TAPE THE KNEE FOR COMPRESSION AND/OR LYMPHATIC DRAINAGE

130
Q

Prepatellar Bursitis: Chronic (Active Care)

A

ACTIVE CARE (ONCE PAIN AND SWELLING HAS REDUCED)
• ISOMETRIC CONTRACT OF HAMSTRINGS/ QUADS
• LEG EXTENSION AND LEG CURLS
• FUNCTIONAL EXERCISES– SQUATS, ETC.

• HOME – ANTI INFLAMMATORY DIET, HEAT/ICE PUMP

131
Q

Prepatellar Bursitis: Passive Care (Chronic)

A

• PULSED ULTRASOUND
• GENTLE MANIPULATION OF THE PATELLA

132
Q

Meniscus Tear: History

A

HISTORY OF TRAUMA (YOUNGER) OR DEGENERATION(AGE RELATED)
• PAIN
• STIFFNESS
• SWELLING OFTEN MAIN COMPLAINT
• CATCHING OR LOCKING OF THE KNEE
• SENSATION OF KNEE INSTABILITY
• ROTATIONAL INJURY OF KNEE (PLANT AND TWIST)
• LIMITED ROM

133
Q

Meniscus Tear: Observation

A

• NOT A LOT OF BRUISING FROM PURE MENISCUS TEARS DUE TO LACK OF BLOOD SUPPLY (ALSO SPEAKS TO HEALING). HOWEVER, CAN HAVE SWELLING DUE TO SYNOVIAL FLUID REACTION
• LIMPING GAIT

134
Q

Meniscus Tear: Examination

A

• ROM: LIMITED FLEXION AND EXTENSION

• PARTS: PAIN ALONG THE JOINT LINE, IF LOCKED - LIMITED ROM AND CLICKING NOTED, SWELLING

• MSR: NO ABNORMAL FINDINGS

• MRI: CORRELATE WITH CLINICAL FINDINGS; FALSE POSITIVES – ASYMPTOMATIC TEAR WITH OTHER PATHOLOGY CAUSING SYMPTOMS

135
Q

Meniscus Tear: Orthopedic Tests

A

McMurrays, Apley’s Compression Test, Bounce Home

136
Q

Meniscus Tear Treatment

A

• ACTIVE: FOCUS ON ROM, GAIT, PROPRIOCEPTION, MUSCLE STRENGTH

• HOME CARE: AVOID AGGRAVATING ACTIVITY, HYALURONIC ACID

• CO-MANAGEMENT: PT, NSAIDS, SURGERY

137
Q

Meniscus Tear Treatment: Passive

A

• STABLE TEARS WITH LESS THAN 1CM DAMAGE
• ADJUST TO PATIENT’S TOLERANCE: INDUCE LAD OR GAPPING

Methods (15 decks)

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