Week 3 Case Questions

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CHIR13009
Professional Chiropractic Practice 2
WORKBOOK
TERM 2, 2020
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CHIR13009 WORKBOOK
Lecture Icon in Moodle: Resources, PowerPoints, lecture notes.

Online only and discussed in recorded Zoom sessions.
Answer questions and case studies.
Activity Icon:
Practical classes
2X2 hours per week
Face to face on campus
Tutorial Icon:
1hour tutorial per week.
By Zoom.
case study discussions.
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Detailed Schedule
Week Lecture Topics Practical Class Session Weebly Submissions

1 1.1 Introduction and Practical Skills: 1.1 Answer all quiz questions
expectations for the unit and submit to Weebly by
1.3 Cervical and Lumbar Spine
20/7/20
1.2 Chiropractic Assessment Instability Tests, Psychomotor
and Management for Skills
Degeneration of the Spine:
Spondylolisthesis, Ankylosing
Spondylitis, Osteoarthritis
2 2.1 Assessment and Practical Skills: 2.1 Answer all quiz questions

Management of Scoliosis and submit to Weebly by
2.2 Thoracic Spine Practical
27/7/20
-Psychomotor Skills
2.3 Thoracic Spine Examination
Practical- Scoliosis
3 Practical Skills:
3.1 UMNL vs LMNL
3.1 Answer all quiz questions
3.3 Pathological Reflexes 3.4 Practical Examination of and submit to Weebly by
3/8/20
UMNL vs LMNL and
Pathological reflexes, Tone,
Spasticity, Clonus
3.5 Practical Lumbopelvic

Psychomotor Skills
4 4.1 Assessing the Practical Skills:

4.1 Answer all quiz questions
Cerebellum and Basal and submit to Weebly by
4.4 Assessing Cerebellar,
Ganglia 110/8/20
Posterior Column-
4.2 Assessing Posterior Proprioception Multimodal
Column Sensations
4.3 Vertigo and Dizziness
5 5.1 Cranial Nerve General Practical Skills: 5.1 Answer all quiz questions
Examination and submit to Weebly by
5.4 Cranial Nerves (I, II, III, IV
19/8/20
5.3 Cranial Nerves (I, II, III, IV and VI) Examination
and VI) Examination
5.2 Headaches
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STUDY BREAK
6 6.1 Cranial Nerves (V, VII, Practical Skills: 6.1 Answer all quiz questions
VIII, IX, X, XI, XII) and submit to Weebly by
6.3 TMJ Management including
Examination 31/8/20
Adjustments
6.2 TMJ and Facial
6.4 TMJ and Facial
pain Conditions
Examination
6.3 TMJ Management
6.5 Examination of Cranial
including Adjustments
Nerves (V, VII, VIII, IX, X, XI,
XII)
7 Practical Skills: 7.1 Answer all quiz questions

7.1 Introduction to Vital Signs
and submit to Weebly by
7.2 Assessment of Mental 7.1 Examination of Vital Signs
Status 7/9/20
7.4 Shoulder Practical
Psychomotor Skills
8 8.1 Introduction to Injury Practical Skills: 8.1 Answer all quiz questions
Prevention and Management and submit to Weebly by
8.4 Practical Common Injuries-
14/9/20
8.2 Injury Management and Head and Trunk
Sports First Aid
8.3 Common Injuries- Head

and Trunk
9 Practical Skills –
Review 9.1 Answer all quiz
9.1 Post-Surgical questions and submit
Management of 9.3 Orthopedic to Weebly by 21/9/20
Examination of patient
Orthopedic Post-Surgical 9.2 Submit portfolio
conditions 9.4 Knee Practical by 5 pm 18/9/20 via
(Elective Psychomotor Skills TurnitIn in Moodle
Surgery)
9.2Management
of Lower Limb
(Elective
Surgery)
10 Practical Skills
10.1 Management of
Lower Limb 10.1 Answer all quiz
Orthopedic Trauma 10.2 Orthopedic Examination questions and submit to
Weebly by4/10/20
Post Trauma
10.4 Ankle and Foot Practical
Psychomotor Skills
11 Review Review
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12 None
13 FINAL OSCE
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CHIR13009 Week 1 Synopsis – 13th – 19th July2020
Overview 1.0
The overview for this week includes an Introduction to CHIR13009 PCP2:

The beginning lectures will give a breakdown of the assessment tasks and criteria in this
unit as well as what are some of the needs in a neurological history and significant signs
and symptoms seen with various patient’s presentations.
Most, if not all, of the lectures will have corresponding recordings (videos) that may add
further emphasis or insight into material presented. Please remind the students to ensure
that they listen to the recordings as well as going through the lecture material prior to the
practical class each week. You can lead them in your own personal reflection and/or
discussion about why they are important to them as they commence clinical chiropractic
and the importance in practice for neurological conditions.
The students will be given information on the required textbook readings via Reading List
found at the top of your Moodle page.
Readings and Videos: 1.05
Resources and readings will be given via Reading List.
 Bergmann, T. Chiropractic Technique, Principles and Procedures, 3rd Edition (2010)

pages, 174-177, 142- 143, 211- 213, 386- 388 Cervical Spine: Fig 5-82, 5-85, Fig 5-87.
Cervicothoracic Spine: Fig 5-169, Fig 5-170
 Magee D, Orthopedic Physical Assessment, 6th Edition (2014), pages 148- 152, 195-198,
606-610
 Souza T. Differential Diagnosis and Management for the Chiropractor, Protocols and
Algorithms, 5th Edition. 2016, pages 9- 14, 217-222, 1128-1129
Theoretical Lecture Material: 1.1
The first lecture given in CHIR13009 will be a Lecture 1.1 Introduction and the
expectations in this unit. This will be followed by a Lecture 1.2 Chiropractic
Assessment and Management for Degeneration of the Spine:
Spondylolisthesis, Ankylosing Spondylitis and Osteoarthritis
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Tutorial or On-Campus Activity: 1.2
During the first session, there needs to be an introduction of tutors and students. First
practical session of the on-campus activity will involve introductions and clarification of
expectations in this unit, including the assessments. If they are not familiar with you, take
a few minutes to run through your own introduction and experience here before coming to
CQUniversity, so that they can learn to appreciate our diversity.
It may be necessary to review the Lab induction instructions given by Yvonne Warburton.
Appropriate dress and hygiene expected in chiropractic lab sessions (personal hygiene,
washing hands and tables etc.); and in the importance of obtaining consent prior to
commencement of touching/testing/care.
Practical Lab Skills Development: 1.3
In 1st hour orthopedic examination practice
The main focus for this practical lab session, will be for tutors to run through instability
tests for the cervical and lumbar spine as per the PowerPoint presentation. 1.2
Chiropractic Management and Assessment for Degeneration of the Spine.
Tutors are to review the videos with the students and have students perform the Instability
tests on their partners, rotating with other students in the room.
Cervical Instability Tests
• Lateral Flexion Alar Ligament Stress Test

• Anterior Shear or Sagittal Stress Test
• Atlantoaxial Lateral Shear Test
• Rotational Alar Ligament Stress Test
• Transverse Ligament Stress Test
Lumbar Spine Instability Tests
• One leg Standing (Stork Standing) Lumbar Extension Test

• Passive Lumbar Extension Test
• Prone Segmental Instability Test
• Test of Anterior Lumbar Spine Instability
• Test of Posterior Lumbar Spine Instability
• Modified Schober’s Method
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In 2nd hour Psychomotor Skills practice
Go through the mechanics/rationale of psychomotor skills for the Cervical and Cervico- Thoracic
spine. These have all be taught previously so should not spend too much time on this activity.
• Cervical Spine
Supine:
• Supine Hypothenar/Occiput Lift Fig 5.82 (P. 174)
• Supine Index Atlas Push Fig 5-85A (P. 176)
Sitting:
• Sitting Index/Occiput Lift. Fig 5.87 (P. 177)
Prone:
• Thumb/spinous Push. Fig 5-169A, B, C (P. 211-212)
• Hypothenar/ Transverse Push (Combination Move) Fig 5-170 A, B
(P. 213)
 1. The orthopedic tests listed in the practical PowerPoint

 2. The technique procedures listed in the practical PowerPoint; all are
examinable. Pay attention to the indications for the orthopedic tests and the
indications for the techniques as these will also be examined in the theory
examination.
 VIEW THE BERGMAN VIDEOS TO REVIEW OUTSIDE OF CLASS.
CASE STUDY AND QUESTIONS: To be completed by the 19 July

Week 1 Case 1: Ben
Presenting Complaint:
Ben complains of left sided neck pain with intermittent radiations to the left deltoid. The pain does
not extend below the left elbow. The pain seems to be aggravated by extended periods of computer
work. This complaint is of 4 days duration and came on suddenly after jumping a fence to catch his
dog. There has been no previous history of neck pain except it feels stiff every now and then. He
has been taking anti-inflammatory drugs with temporary relief.
Physical Examination
Observation: Upper cross syndrome with muscle hypertonicity in left cervical paraspinal muscles
and left deltoid.
There is a ‘C’ scoliosis apex at T7,8 to the left (levoscoliosis)
Cervical ROM: Lateral flexion to the left is painful around the C5,6 level.
Palpation: The right sacro-iliac joint is restricted into flexion. T4-8 segments are restricted into
flexion and right rotation. C5-7 is stiff and restriction in all directions
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Right cervical maximum compression testing is positive for pain on the left side at C5,6 level. Right
shoulder depression testing is positive for the left side at C5,6
Questions
1. What further pertinent questions would you ask this patient?
2. Based on the given information from the case history, what are your differential diagnoses?
Give reasons for each diagnosis given.
3. What tests have been omitted in order to eliminate or confirm your list of differential
diagnoses mentioned in question 2?
4. Using only the information from the above case history and physical examination, what is the
likely diagnosis?
5. Give a clinical impression (working diagnosis) from the information above.
6. Using only the information stated above, how would you treat/manage Ben?
7. Refer to the x-ray and indicate whether your treatment would change.
http://www.pivonkahealth.com/tag/cervical-arthritis
NAME OF TEST For Cases 1 indicate the likely outcome for the following
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tests. Indicate whether it is likely to be a true positive, false

positive, true negative, false negative
Rust sign
Cervical Axial
Compression
Cervical
distraction test
Cervical sidebend
Compression test
Cervical Rotation
Compression test
Cervical Maximal Already performed

Compression test
Shoulder Already performed
Depression test
Shoulder
abduction test
(Bakody’s)
Valsalva test
Lhermitte’s sign
Brachial plexus
tension test
Cervicogenic
dizziness
Allen’s test
Wright’s test
(hyperabduction)
Adson’s test
Halstead test
(reverse adson’s)
Costoclavicular
test
Provocation
elevation test.
For the ‘likely diagnosis’ for case 1 complete the following table:
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General Questions: Test your knowledge!!! 

1. A 58-year-old female presents with pins and needles in the first 3 digits of the right hand.
There is no cervical pain.
i. Is this pain likely to be coming from the spinal cord, nerve root, nerve trunk or
an entrapment of a peripheral nerve? Explain your answer.
ii. Give a list of differential diagnoses starting from the most likely.
2. Sally is 34 years old with 4 children. She suffers intermittent pins and needles to the back of
the leg to the foot. The pins and needles are aggravated by sitting and occasionally occurs
at night. The symptoms can be traced. Sally also experiences low back pain.
Is Sally likely to be suffering referred or radicular pain? Explain your answer. Using ONLY
this information give an aetiology for Sally’s symptoms.
3. Using your physical examination procedures differentiate between the following conditions:
iii. Piriformis myalgia with pain down the posterior aspect of the right leg to the
knee.
iv. L5-S1 capsular strain referring pain down the right leg.
4. What musculoskeletal (MSK) conditions can give this pain distribution?

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Study Guide Questions: 1.4
Each week, sample study questions will be provided to encourage them to keep up to date
with the expected knowledge and to appreciate the types of questions and/or material they
will be expected to know for the final written examination. The answers can be discussed in
the ZOOM sessions at designated times during the term. This will give them an
opportunity to work through your resources.
Name of Test Interpretation/ what is a positive test and what

tissue and structures are loaded?
Lateral Flexion Alar Ligament Stress Test
Anterior Shear or Sagittal Stress Test
Atlantoaxial Lateral Shear Test
Rotational Alar Ligament Stress Test
Transverse Ligament Stress Test
One leg Standing (Stork Standing) Lumbar

Extension Test
Passive Lumbar Extension Test
Prone Segmental Instability Test
Test of Anterior Lumbar Spine Instability
Test of Posterior Lumbar Spine Instability
Modified Schober’s Method

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CHIR13009 Week 2 Synopsis – 20th- 26th July 2020
Overview 2.0
The focus for this week will be to present lectures on Assessment and Management of
Scoliosis.
 Bergmann, T. Chiropractic Technique, Principles and Procedures, 3rd Edition (2010) pages,
174-180, 217-226 Thoracic Spine: Fig 5-175B, Fig 5-177, Fig 5-181E, Fig 5-185A, B
 Magee D, Orthopedic Physical Assessment, 6th Edition (2014), pages 515- 519
 Souza T. Differential Diagnosis and Management for the Chiropractor, Protocols and
Algorithms, 5th Edition. 2016, pages 135- 156
The first lecture this week will be 2.1 Assessment and Management of Scoliosis . This will
be followed by a lecture 2.2 on Thoracic Spine Psychomotor Skills.
This week’s activity will be for tutors to discuss a challenging case scenario and to see if
they can come up with a clinical impression and treatment plan for this patient.
However, your tutors may choose to speak about a case from their own personal ‘files’ that
challenged them – ideally with a scoliosis patient. Please take only 15-20 minutes of the
practical session.
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This week will be 2.1 Assessment and Management of Scoliosis . This will be followed by
a lecture 2.2 on Thoracic Spine Psychomotor Skills.
During the practical sessions for week 2
Name of Test Interpretation/ what is a positive test and what tissue

and structures are being tested?
Adams Forward Bend Test
Alli’s Test
Cobb Angle
Risser Sign
Sternal Compression Test
Ott Sign
Chest Expansion Test
Percussion
Schepelmann’s Sign
Alli’s Test – Galeazzi’s Sign
Rigid Kyphosis Sign

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Go through the mechanics/rationale of psychomotor skills for the Thoracic spine. These have all be
taught previously should not too much time will be spent on this activity.
In the lab, you will do the following:
 Thoracic Spine
 Prone:
 Bilateral Hypothenar Transverse Push (Crossed Bilateral) Fig 5-175B (P. 216)
 Unilateral Hypothenar /Transverse Push Fig 5-177 (P. 218)
 Supine:
 Opposite Side Thenar /Transverse Drop Fig 5-181E (P. 222)
 Standing:
Thenar Transverse Push Fig 5-185A, B (P. 225)

 2. The technique procedures listed in the practical PowerPoint; all are examinable. Pay
attention to the indications for the orthopedic tests and the indications for the techniques
as these will also be examined in the theory examination.
CASE STUDY AND QUESTIONS: To be completed by the 26 TH July
Week 2 Case: CHIR13009 (Tutor Copy)
14-year-old Female with Adolescent Idiopathic Scoliosis and Back Pain
History
The patient is a 14-year-old female with complaints of scoliosis and back pain. She is greater than 2
years post-menarche and has no medical problems. She is engaged in typical activities for an
adolescent female including netball and skateboarding.
The back pain is primarily located in the mid-thoracic region. The pain is increased by her sporting
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activities and absent at rest. The pain has been present for 1 year. She is unhappy with her body
alignment and appearance as her shoulder appear imbalanced with (rib cage and breast
asymmetry). She reports that she feels “ugly”
Examination
Patient is a healthy-appearing adolescent with near ideal body weight. The right shoulder is slightly
higher with minimal waist- line asymmetry. Scoliometer of the thoracic curve is 15° and the lumbar is
8°. There is no clinical leg-length discrepancy. The skin has no abnormalities, and the neurological
assessment is normal.
Radiographic Examination
Cobb angle 54 degrees in the thoracic spine and lumbar spine 48 degrees with a Risser 5. Side
bending curve 15 degrees and lumbar curve 24 degrees.
Previous Treatment
The pain has not responded to prescribed exercises from physiotherapist. This involved
strengthening exercises for the core low back muscles for 3 months.
Diagnosis
Adolescent Idiopathic Scoliosis
Questions
1. Using the information in the case history and physical examination, give a clinical impression.
2. What is the prognosis for this patient?
3. Discuss how you would manage/treat this patient.
4. Is this patient a candidate for conservative care, bracing or surgical correction, if so why?
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The results of this case will be discussed in your tutorial by your tutors.
Selected Treatment
The patient underwent a Posterior Spinal Fusion T4-T12.
Post-treatment Images
Immediate Post-operative Images
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2-year Post-operative Images

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The questions for this week will focus on the assessment and treatment of scoliosis.
Case Study Question1:

Tammy is a 23-year-old woman who has a structural scoliosis with a single C curve
having an apex at T7. Describe your assessment plan before beginning treatment.
How would you measure the curve which is 28 degrees and the amount of rotation?
Management would be to refer for x-rays if she has not got them already. Would also
like to check underlying pathology and to ask questions of first detection. Plan of
treatment would be undertaken and discussed with the patient. Starting with preventing
curve progression through STT on the apex side of the curve, manipulation at the base
and top of where the curve starts, SSE, improve aesthetics via postural correction.
Rotational aspect can be assessed through Nash-moe method looking at the pedicles.
Measuring the curve you’d find the vertebrae superior to the apex with the greatest
angle and same with the inferior vertebrae then assess the Cobb angle.
True/ False Questions

Q1. Functional scoliosis involves rotation and malformation of vertebra?
F
Q2. The majority of idiopathic scoliosis’s will be progressive?
F
Q3. When assessing for scoliosis it is important to view the patient doing a forward
bending movement in all three planes?
T
Q4. A scoliometer is an instrument used to measure trunk inclination?
T
Q5. There is a correlation between nursing posture of an infant and the
development of a scoliosis curve?
T
Q6. Patients with idiopathic scoliosis may initially report fatigue in the lumbar region
after prolonged sitting or standing
T
Q7. Most idiopathic scoliosis curves are convex to the right in the thoracic spine and
to the left in the lumbar spine, so that the right shoulder is higher than the left.?
T
Q8. A subtle scoliosis (less than 10-15 degrees) in the lower thoracic and lumbar
spine are easily missed on postural exam due to coupled motion?
T
Q9. Adolescent scoliosis rarely improves spontaneously and typically halt only one
skeletal maturity has been reached (17- 19 years)
T
Q10. Name 4 predictors of progression for idiopathic scoliosis
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- Risser sign
- Female
- Age when menarch
- Age of diagnosis
Q11. Complete the table below
Infantile Juvenile Adolescent

Ages 0-3 3-10 10-17
Sex male females Female
Progressive Yes can be Yes If get to
and highly 20degrees
if it is most likely
progressiv to become
e progressive
especially
in females
Radiographic >20 follow If >20
follow up up needed degrees
needed when
Q12. Name (3) three orthopedic tests that would be considered when assessing a patient
with a scoliosis? Adams forward bending, Alleys and schpamms sign.
Q13. When measuring the severity of a scoliosis which (3) three radiographic evaluations
would be undertaken or referred for to be taken?
Full spine AP, Lateral spine and lateral flexion
Q14. Do primary or double curves form more deformity?
Double curve due to a primary cure developing in the womb in the fetal
position for birth. Double curves generally develop after birth and can cause
more deformities
Q15. According to the literature what (3) three factors exist that may lead to a greater
chance of progression? Females adolescence, structural curve with rotational component
and menarche
Q16. What should the clinician be asking when considering the correct management
approach to an idiopathic scoliosis? Is it progressive?
Q17. Would girls who are at pre-menarche or menarche with curves in the 20° to 40° range have
the greatest chance of success with bracing. Yes/No
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Q18. According to the literature how long should bracing be required for during the day to have the
best outcome and what factors may contribute to this success.
21 hours
Q19. What management approaches have been shown to be effective in the management of
compensatory scoliosis
STT, SSE, bracing, exercise focusing on abdominal strengthening and strengthening of
muscles on convex side and stretching muscles on concave side
Q20. When should a patient be referred for orthopedic surgery with an idiopathic scoliosis?
>45 degrees
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CHIR13009 Week 3 Synopsis –27th July- 2nd August 2020
Overview 3.0
The lectures this week will focus on the introduction to pathological reflexes assessment and
descriptions associated with UMNL vs LMNL.
Bergmann. T. Chiropractic Technique, Principles and Procedures, 3rd Edition (2010) Lumbar
Spine pages 261, Fig 5-259A, Sacrum pages 275- 277 Fig 5-283, Fig 5- 285A
Fuller, Geraint. Neurological Examination Made Easy, 6th Edition", Churchill Livingstone
Gloucester, UK, Elsevier Ltd. 2019:
 Upper Motor Neuron Lesions pages 39, 110 accessory nerve 109, arms 118, brainstem 150-
151, findings 148, legs 130, limbs 117, mixed 110, 150 mouth examination 104, reflexes
145, 147
 Lower Motor Neuron Lesion pages 110, findings 148, limbs 117, mixed 110, 150, mouth
examination 104
 Tone pages 113, 115- 117
 Clonus pages 144- 145
 Vizniak N.A. Orthopedic Assessment 1st Edition, pages 104, 108- 111
The lectures this week we will look at Lecture 3.3 introduction to the pathological
reflexes (most common Babinski). There are four (4) listed for the lower limb and only
two (2) for the upper limb. There will be a review of the neuroanatomy to differentiate
between an Upper Motor Neuron (UMNL) and a Lower Motor Neuron lesion in the
Lecture 3.1 Upper Motor Neuron vs Lower Motor Neuron.
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UMNL LMNL
Muscle power
Muscle wasting
Muscle Tone
Reflexes
Babinski Response
Presence of
fasciculations
During the practical sessions for week 3, you will run the 3.1 UMNL vs LMNL presentation
which you should have watched the recording before this session. The presentation
includes demonstrations on each of the pathological reflexes and provides a broad
overview of the tests.
Once you have reviewed the videos and/or questions, you will practice performing these
tests with each other and recording any findings in your clinical notes for each student
tested.
You will have the opportunity to perform on 3-4 other students if possible. If time permits,
include a review of the upper limb (sensory, motor, reflexes and nerve tension tests).
In the lab, you will perform the following
• Lower Limb
• Babinski
• Chaddock’s
• Gordon’s
• Oppenheim’s
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• Upper Limb
• Hoffman’s
• Tromner’s
Perform on 3-4 other students if possible, to assess Tone and Clonus and discuss
hyperreflexia and spasticity using the examples at the end of presentation.
Go through the mechanics/rationale of psychomotor skills for the Thoracic spine. These have all be
taught previously should not too much time will be spent on this activity.
In the lab, you will do the following:
Lumbar Spine:
Sitting:
 Hypothenar/ Mammillary or Spinous Push Fig 5-259A (P. 261)
Side Posture:
 Hypothenar/Sacral Base Push (PS sacrum) Fig 5-283 (P. 275)
 Hypothenar/Ilium Sacral Apex (PI Ilium or AI Sacrum) Fig 5- 285A (P. 277)

CASE STUDY AND QUESTIONS: Lecture 4. To be completed by the 2 nd August
Week 3: Case 3 Sally
Presenting Complaint
Sally is a 53-year-old receptionist. She is assisted into your office by her husband as she is
struggling with walking. She suffers sharp and shooting pain in her lower back on her left side
which radiates down the left posterior-lateral aspect of the left thigh to the left calf. The pain does
not extend to the left foot when questioned.
Onset and history of presenting complaint.
The pain commenced suddenly when making the bed that morning. She gets relief from lying down
but struggles to stand up after resting for some time. Sally has admitted that she has had a few
episodes of low back pain previously which she ignored since the pain simply disappeared - she
thought the same would happen now. She contributed the pain to long hours of sitting at work and
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lack of physical activity.

Sally is overweight with a lack of muscle conditioning but says her health is generally ok. Her
bowels are a ‘bit all over the place’ although she suffers no pain in her abdomen. She loves the odd
drink every now and then and smokes 2 packets of cigarettes a week. She is happily married
however states that her husband is not well as he has been diagnosed with prostate cancer.
Her family history reveals that her grandfather passed away from bowel cancer 10 years ago. There
is high blood pressure in the family but that’s all she can recall. She mentions also that she feels
tired lately on a constant basis.
QUESTIONS
1. What further information would you seek from Sally?
Can she recall a specific event that could have brought this event on? Ask if she has had any
scans MRI/x-ray due to chronic smoking. Since she also mentioned about her bowel being all
over the place ask follow up questions. When did the changes in the bowels occur? Can you
recall anything that may have consequence in this? Have you been to a doctor about bowel
problems or as a checkup due to family history of bowel cancer? Have you seen a
chiropractor or anyone else for this issue? Did it help?
2. Using only the information in the case history above, list the possible causes of Sally’s back
and leg pain? Explain your answer in each case
Due to the nature of Sally’s history examination pain is likely to be complicated.
Piriformis entrapment
Strain/sprain (not likely)
L4/5 intervertebral disc herniation: Due to the sharp shooting pain and it is consistent with the
specific dermatomes of L4-5
L5-S1 spinal stenosis (possible, more likely to be bilateral pain)
3. According to each differential as outlined in question 2, indicate the strength of the following
statements (from the case above) to the respective differential:
a. “She suffers sharp and shooting pain in her lower back on her left side which radiates
down the left posterior-lateral aspect of the left thigh to the left calf. The pain does not
extend to the left foot when questioned”
Piriformis entrapment: Normally more of sensory disruption rather than the pain she is
feeling. The pattern of piriformis entrapment is generally posterior leg pain rather than
posterior lateral leg pain.
Strain/Sprain: distribution of pain could be consistent with possible distribution of pain
for a strain of the multifidus muscle, but this case is more of a complicated situation.
L4/5 disc herniation: Radicular pain is associated with the specific distribution of the
nerve roots of L4/5
L5/S1 canal stenosis: dynamic lateral recess stenosis (hasn’t been done yet) If done
the more lateral the more likely it would affect the nerve above.
b. “She contributed the pain to long hours of sitting at work and lack of physical activity”.
Piriformis entrapment: Sitting would make condition worse (not likely pain)
L4,5 intervertebral disc herniation/bulge: Flexed position sitting causes the pain
L5,S1 spinal stenosis: If she slouches opens the IVF depending on how she is sitting
A sprain/strain: more complicated pain due to

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c. “The pain commenced suddenly when making the bed that morning”
L4,5 intervertebral disc herniation/bulge (bending shearing and torsion is consistent)
Piriformis entrapment: not typical for this condition.
A sprain/strain: injury is generally more severe and doesn’t match with the findings
4. For your examination, the aim is to eliminate and confirm your differential diagnoses. From
the tests you have learnt so far, design an examination plan for this patient. Use
GORPOMNICS according to sitting, standing, supine and prone routine.
According to Standing, sitting, supine, prone routine

Gait
Observation
Active and passive range of motion
Static and motion palpation
Ortho tests (see table)

Muscle testing: not necessary NA
Neuro tests: Yes, for lower limb SMR Yes lower limb SMR
Investigations: MRI, CT
Systems: Abdominal exam for bowel (Supine) Abdominal exam (bowel)
Test (only mentioned for true positives)
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Squat test Yes standing
Lumbar Kemps test yes decreases IVF
Lumbar Vertical compression test Yes disc not reliable
Slump test Yes

Dejerine’s triad (Valsalva, cough, sneeze) Yes disc lesion
Flip or Bechterew’s test Yes for Disc
Straight leg raising test (SLR) Yes DIcs
Well straight leg raising test (WSLR) Yes disc
Bilateral straight leg raising test NA
Braggard’s test yes disc
Bonnet’s test yes to prove or disclaim piriformis
Bowstring’s test yes Disc if needed don’t want over test the patient
Kernig’s/Brudzinski’s test yes for spinal stenosis
Milgram’s test Yes stenosis and disc
Nachlas test (prone knee bending No
Ely’s test No
Yeoman’s test No
Lumbar springing test Yes for location
Trendelenburg’s test No
Patrick Fabere test Yes (for length of pelvic stabilizers
Sign of the Buttock Piriformis entrapment
Thomas test Check psoas
Belt test or supported Adam’s NO
Ober’s test NO
33
Study Guide
Questions: 3.4
The questions for this week will focus on UMNL/ LMNL and pathological reflexes.
Questions
Q1. An L5 disc pathology can lead to weakness of which muscle?
a. Peroneus longus
b. Quadriceps
c. Extensor hallicus longus
d. Gluteus maximus
Q2. Which of the following would be evident with an UMNL?

a) hyporeflexia
b) spasticity
c) flaccidity
d) fasciculations
Q3. If you detect ankle clonus in a patient, where is the location of the lesion?
a) Ankle
b) Spinothalamic tract
c) Nerve root
d) Corticospinal tract
Q4. What is tone?
Q5. What is the difference between spasticity and rigidity?

34
CHIR13009 Week 4 Synopsis – 3rd_ 9th August 2020
Overview 4.0
The lectures this week will focus on the 4.1 Introduction to Cerebellum, Coordination and
Posterior Column Assessment as well as 4.2 Vertigo and Dizziness followed by 4.3 Cerebellar
and Posterior Column examinations
 Fuller, Geraint, Neurological Examination Made Easy, 5th Edition, Churchill Livingstone
Gloucester, UK, Elsevier Ltd. 2019 Cerebellum pages 36, 39, 173 – 186
 Magee. D, Orthopedic Physical Assessment, 6th Edition (2014), pages 194- 195
 Souza.T. Differential Diagnosis and Management for the Chiropractor, Protocols and
Algorithms, 5th Edition. 2016, pages 611- 634
 Vizniak N.A. Orthopedic Assessment 1st Edition, pages 102-105
The lectures this week we will look at the Lecture 4.1 Assessing the Cerebellum and Basal
Ganglia followed by Lecture 4.2 Assessing the Posterior Columns.
4.3 Lecture Dizziness and Vertigo is discussed with a recording from the previous unit coordinator
Assoc Prof Sharon Eaton. The final presentation is 4.4 Assessing Cerebellar, Posterior Column-
Proprioception and Multimodal sensations .
35
tested. You will have the opportunity to perform on 3-4 other students
In the lab, you can have the students perform the following
4.2 Dizziness and Vertigo
 Practice Dix Hallpike Test

 Epley manoeuvre for BPPV
 Fitz- Ritson Test
Then have students complete the following table:
What tract demonstrates the following action responsibility?
Action Tract
Responsible for coordination
Carries vibration
Carries pain and temperature
Responsible for balance reflexes
Conveys two-point discrimination
Responsible for muscle tone
Carries voluntary motor
Responsible for speech
Responsible for gait

36
Responsible for posture
Hot and cold
Finger placement
Rapid hand movement
Muscle testing
Finger to nose test
Two pins
37
In 2nd hour orthopedic examination practice
During the 2nd hour of the practical sessions for week 4, you will watch the videos in the 4.4
Assessing Cerebellum and Proprioception presentation as a review that you should
have watched before this session. These nine (9) videos focus on assessing cerebellum.
Once you have watched and reviewed the videos and/or questions, practice the
following:
i. Evaluate for cerebellum specific for muscle control (truncal dystaxia)
iv. Evaluate for Coordination – Upper Limb

a) Finger to nose
b) Finger to nose to examiner’s finger.
c) Fingers approximating but not touching
d) Overshooting
a. Postural tremor
b. Intention tremor
e) Dysdiadokokinesia
Evaluate for Coordination – Lower Limb

a. Heel to shin
b. Toe to finger
c. Figure eight test
Assess for cerebellar function
1. Test Gait (Fuller Chapter 4)

2. Assess upper limbs (Fuller pp 173-174)
a. Finger –nose test
b. Repeated movements
3. Assess lower limbs (Fuller p 174)
a. Heel-shin test
b. Tapping feet
4. Assess Trunk (Fuller p 174)
In the lab, the students can perform the following:

38
i. Evaluate the lateral spinothalamic tracts

a. Pain and temperature
b. Compare adjacent sides and with the opposite side of the
body
c. Temperature (use warm and cool)
ii. Evaluate the posterior columns

a. Romberg’s test
b. Proprioception (use 3rd or 4th fingers or toes)

c. Vibration
d. Fine touch
iii. Evaluate the corticospinal tracts

e. Observe posture
f. Hyperactivity of LMN
g. Babinski
h. Loss of superficial reflexes
iv. List the typical symptoms for cerebellar disease.
v. What type of sensation is carried in the lateral spinothalamic tract?

39
CASE STUDY AND QUESTIONS: To be completed by the 9th August

Week 4: Case 4: Amber
Amber is a 36-year-old hairdresser
2-year history of intermittent right arm pain. Over the last 3 months it has progressed in severity
and had become bilateral.
History of Presenting Complaint
The pain would occasionally awaken her at night and was associated with numbness, tingling and
paranesthesia’s. She did not report any color changes, hyperhidrosis, swelling or trauma. She also
denied other symptoms such as joint pain, dry eyes, dry mouth, alopecia, photophobia.
Her past medical history was negative as was her family history.
System review elicited a chronic problem with constipation, with occasional diarrhea. This was
occasionally associated with low abdominal pain, which improved with defecation or passing flatus.
These symptoms have been present for many years.
Amber is a well-built woman. Her vital signs were normal and there was no rash. There was full
range of motion of all her joints, without any swelling, redness, or warmth. Her lungs were clear, her
cardiovascular and neurological examination were normal (including cranial nerves). Abdominal
examination was unremarkable. Laboratory studies including complete blood cell count, erythrocyte
sedimentation rate and urinalysis were all normal. A chest x-ray and cervical spine films were also
normal. An EMG and nerve conduction velocity testing were normal.
Questions for Case 4

5. What other further pertinent questions should you ask this patient?
6. For the above case history alone, what are your differential diagnoses for:
a. Her arm pain?
b. Her bowel complaints?
7. Do you think all the tests performed in the physical examination above were necessary? Explain
your answer.
8. Using the information in the case history and physical examination, what is the more likely
diagnosis from the list of differential diagnoses mentioned in question 2.
9. Using only the information in the case history and physical examination, give a clinical
impression.
10. What is the prognosis for this patient?
11. Discuss how you would manage/treat this patient.
12. An x-ray of Amber showed a cervical rib. Do you think this is the cause of Amber’s symptoms?
Do you think a cervical rib would have any impact Amber’s management plan?
40
http://learningradiology.com/notes/chestnotes/cervicalrib.htm
NAME OF TEST For the likely diagnosis in Case 4 indicate the likely outcome
for the following tests. Indicate whether it is likely to be a
true positive, false positive, true negative, false negative
Rust sign
Cervical Axial Compression
Cervical distraction test
41
Cervical sidebend
Compression test
Cervical Rotation
Compression test
Cervical Maximal
Compression test
Shoulder Depression test
Shoulder abduction test
(Bakody’s)
Valsalva test
Lhermitte’s sign
Brachial plexus tension test
Cervicogenic dizziness
Allen’s test
Wright’s test
(hyperabduction)
Adson’s test
Halstead test (reverse
adson’s)
Costoclavicular test
Provocation elevation test.
QUESTIONS
1. Describe TOS. What is it?
2. Complete an illness script for TOS.
3. What structures/tissues are involved in TOS?
4. What are the typical signs and symptoms of TOS?
5. What type of ‘sports’ or ‘activities’ predispose to TOS?
6. What is the difference between Raynaud’s syndrome and Raynaud’s phenomenon?
7. What are the 2 suspected mechanisms of TOS? Describe how each of these ‘mechanisms
can lead to symptoms?
8. How would you manage TOS (as a chiropractor)?
9. What peripheral nerve distribution is most common in TOS?
10. What are the causes of Brachial Neuritis?
11. How is Brachial Neuritis generally managed?
1. Which of the following is NOT typically a symptom for cerebellar disease?

a. Weakness
b. Ataxia
c. Diplopia
42
d. Atrophy
2. What type of sensation is carried in the lateral spinothalamic tract?

a. Light touch
b. Vibration
c. Pain
d. Position
3. What is stereognosis?
a. Inability to alternate hand movements
b. Inability to hear out of both ears equally
c. Ability to recognise familiar objects placed in one’s hand
d. Inability to identify symbols drawn on the skin
4. Explain the clinical significance of signs elicited when testing for meningeal
irritation.
a. Nuchal rigidity (inability to flex the neck forward due to rigidity of the neck
muscles)
b. +ve Kernig’s and Brudzinski’s signs. (Orthopaedic tests) – causes
irritation of motor nerve roots passing through inflamed meninges
REVIEW QUESTIONS to test your general knowledge 

DIFFERENTIAL DIAGNOSIS EXERCISE
With the following statements, give a list of possible differential diagnoses. List and discuss all
possibilities with your fellow classmates and tutor. Please assume that all other aspects of the case
history are unremarkable.
1. A 35-year-old jogger who suddenly feels pain in the right calf muscle. The pain is sharp and
does not radiate. There are no other signs and symptoms.
2. A 4- year-old suffers an ache in the right deltoid. He is also suffering cholecystitis
3. A 47-year-old suffers low back pain after painting a high ceiling. The pain is located over
L4,5 and does not radiate.
4. A 37-year-old suffers immediate pain after overstretching during a tennis match. The pain is
felt over L5-S1 and radiates to the left buttock.
5. A 50-year-old suffers pain in the right arm. The patient traces the pain down the outer aspect
of the arm to the thumb. The pain is sharp and shooting.
6. 25-year-old patient suffers pins and needles down the posterior aspect of the right leg. The
pins and needles are worse on sitting.
7. A 29-year-old female patient suffers a generalized low back pain. The back pain is worse
when she suffers dysmenorrhea
8. Refer to the diagrammatic C/T scan below. If this was at L4-L5 level what are your most
likely symptoms? What type of herniation is represented by the diagram below?
43
http://www.spinesurgeon.nyc/conditions-treated/cervical-
myelopathy/herniated-disc
44
CHIR13009 Week 5 Synopsis – 10th – 16th August 2020
Overview 5.0
The lectures this week will focus on 5.1 Cranial Nerves General Examination and Lecture 5.2
Headaches and the practical Lecture 5.3 Cranial Nerve I, II, III, IV and VI Examination
 Fuller, Geraint, "Neurological Examination Made Easy, 6th Edition", Churchill

Livingstone Gloucester, UK, Elsevier Ltd. 2019 ISBN 978-0-7020-7627-5; pages
43 – 87
 Watch Lecture 5.3 Cranial Nerve I, II, III, IV and VI Examination

Within the presentation be attentive to the following videos that are embedded for
the students to practice and become familiar with.
 “Practical Eye Movement Terminology”

 “Practical Cranial Nerve Examination – do I, II, III, IV and VI”
 “Practical Cranial Nerve I”
 “Practical Cranial Nerve II Visual Fields”
 “Practical Cranial Nerve II Peripheral Vision
 “Practical Cranial Nerve II Visual Acuity”
 “Practical Eye Saccades”
 “Practical Cranial Nerve II Pupillary Light Reflex”
 “Practical Cranial Nerve III, IV, VI Fields of Gaze”
 “Practical Cranial Nerve III, IV, VI Accommodation”

45
The lectures this week will focus on the structural and functional overview of the cranial
nerves and the components of the physical examination necessary to effectively assess
this region of neurology. The lectures this week will focus on
5.1 Cranial Nerves General Examination and Lecture 5.2 Headaches and the practical
5.3 Cranial Nerve I, II, III, IV and VI Examination

Take this opportunity to talk about the ‘cardinal positions of gaze’ and how to
assess cranial nerves III, IV and VI. Ask the student to comment on the correspond
muscles and nerves (according to the diagram attached).
1. What are the six positions to which the normal eye may turn?
a. Straight nasal -
b. Up nasal -
c. Down nasal -
d. Straight temporal -
e. Up temporal -
f. Down temporal -
2.Which muscles do which movement?

a. Straight nasal -
b. Up nasal -
c. Down nasal -
d. Straight temporal -
e. Up temporal –
f. Down temporal -
46
https://medical-dictionary.thefreedictionary.com/cardinal+position+of+gaze
Please run the nine (9) videos (they are all relatively short and hopefully don’t take up
too much time). These videos give a broad overview of Cranial Nerves: I; II, III, IV and
VI. The last video is a review of assessment using Macleod’s version.
Once you have shown and reviewed the videos and/or questions, have the students
practice the following: In the lab, you can have the student practice the following:
i. Evaluate Cranial Nerve I

ii. Evaluate Cranial Nerve II
General observation for symmetry, eye position and

eyelids Check pupils:
iii. Evaluate Cranial Nerve III
iv. Evaluate Cranial Nerves III, IV and VI
CASE STUDY AND QUESTIONS: To be completed by the 16 th August

Case 5 Joe is a 35-year-old male.
Neck pain and occasional headaches. The neck pain was intermittent and aching in nature. This
began over the last 10-15 years. Since this time, he had adjustments every week at least twice a
week by a chiropractor in Tasmania. Now in Sydney, he wants to have an adjustment which
involves a position of rotation and then a strong twist into further rotation and traction. The patient
was insistent that the adjustment be performed.
47
Palpation: Hypermobility throughout the cervical spine. There was marked hypertonicity throughout
the cervical spine and shoulders bilaterally. There was normal neurology, orthopaedic tests and
physical examination findings.
1) What is the likely diagnosis? Give reasons for your answer.
2) Does this sort of adjustment described have dangers? Please explain the mechanisms
involved.
Case 5b Alison 70-year-old female
Alison presents to you with recurrent headaches. She has suffered from various types of
headaches since adolescence. She admits that stress appears to bring the headaches on, and that
they are sometimes accompanied by feelings of dizziness and nausea.
Previous investigations over the years never revealed any pathology, and she was regularly
reassured by her medical practitioner that ‘they were nothing to worry about’.
History of Presenting Complaint:

She smoked 10 cigarettes per day from the age of 16 to 60 years of age but has not smoked since.
She drinks occasionally but she says that it is not to excess.
She also complains of recent a 2-month history of occasional pain between the scapulae, which
seem to occur when she goes shopping, or after a large meal. The pain is mild and does not seem
too troublesome.
She denies any other health problems or past trauma and has not had any operations. She did
suffer a whiplash injury after a heavy rear end motor vehicle collision some 20 years ago which
caused pain for a couple of months. She takes no medications apart from Nurofen (ibuprofen) and
Nurofen Plus (ibuprofen plus codeine), which she uses to control here headaches.
1. What other further pertinent questions would you ask Alison.

2. Using ONLY the information in the above case history, give 3 likely differential diagnoses for
a. Her headaches
b. Her interscapular pain
Explain your answer in each case.
3. What do you need to examine?
Physical Examination.
Alison is tall and slightly overweight and walks with slightly hunched shoulders.
Vitals: Pulse rate/min = 62, Respiratory rate/min =10, Blood pressure/mm Hg = 150/95,
Height (cm) = 175, Weight (kg) = 85, BMI 27.7, Temperature (degrees) = 36.1
Her neck ROM is limited to left rotation by about 35% with minimal pain. Cervical extension is
uncomfortable at the extreme of range limited by 50%. Orthopaedic, UMN and LMN tests are
negative.
Interscapular region: tightness of rhomboids and trapezius.
Abdomen: Soft, non-tender, no masses.
4. Using ONLY the information above do you think Alison is suffering from:
 Cervicogenic headaches
 Classic migraine
 Cluster headaches
 Common Migraine
 Subdural hematoma
(Not likely or more likely)
5. What are possible causes of her interscapular pain? Why?

48
6. Do you think it was necessary to take vital signs? Are the vital signs normal/abnormal?
7. Do you think an abdominal exam is necessary or do you think this is ‘over examining the
patient’?
8. If this patient was diagnosed with common migraines, what is your proposed treatment/plan
of management?
9. How would you manage her interscapular pain?
General Questions
1. Give the 2 categories for headaches and give examples for each.
2. List the ‘red flags’ for headaches.
3. Give a list of the differential diagnoses of non-primary causes of headaches.
4. Differential between tension headaches and classic migraine headaches.
5. Give a list of triggers that could lead to classic migraines?
6. How would you manage a patient with classic migraine headaches?
7. Describe the clinical presentation for cervicogenic headaches?
8. Describe the clinical presentation for cluster headaches?
9. Describe the clinical presentation of hypertension headaches?
10. Describe the clinical presentation for temporal arteritis?
Types of Headaches
Write an illness script for each headache including those demonstrated in the diagram
below.
49
https://www.youtube.com/watch?v=3mF1hvIAcoo

50
The questions for this week will focus on components of cranial nerves I, II, III IV
and VI.
1. What kind of information is found in the ventral root of a spinal nerve?
2. Which of the following cranial nerves carries SSA information?
a. CN II
b. CN III
c. CN V
d. CN VII
3. Which procedure is NOT typically done in the clinical evaluation of cranial nerve
III?
a. Observe eyelid position
b. Pupillary response to light
c. Accommodation
d. Testing visual fields
4. A patient complains of light sensitivity. He will most likely have a

problem with which cranial nerve?
a. Optic
b. Oculomotor
c. Trochlear
d. Abducens
51
CHIR13009 Week 6 Synopsis – 24th – 30th August 2020
Overview 6.0
The lecture this week will focus on the 6.1 Cranial Nerves (V, VII, VIII, IX, X, XI, XII) 6.2 TMJ and
Facial Pain followed by 6.3 TMJ Management- including Adjustments and practical 6.4 TMJ and
Facial Examination
 Bergmann. T. Chiropractic Technique, Principles and Procedures, 3rd Edition (2010)

TMJ pages, 291- 294, Fig 6-19, Fig 6-21, Fig 6-22, Fig 6-24, Fig 6-25
 Fuller, Geraint, Neurological Examination Made Easy, 6th Edition, Churchill Livingstone
Gloucester, UK, Elsevier (2019), pages 92 – 103 and 104- 110
 Magee. D, Orthopedic Physical Assessment, 6th Edition (2014), pages 234- 243
 Souza.T. Differential Diagnosis and Management for the Chiropractor, Protocols and
Algorithms, 5th Edition. (2016), TMJ pages 105- 116, Facial pain pages 961-968
 Vizniak N.A. Orthopedic Assessment 1st Edition (2019), pages 124- 131, 157
Within the 6.1 Cranial Nerves V, VII and VIII, IX, X, XI, XII Examination and 6.5 Examination of
Cranial Nerves V, VII, VIII, IX, X, XI, XII presentations you will see the following video resources
please review these found on Moodle in Week 6
1. Review videos “Practical Cranial Nerve V Sensory”
2. Review videos “Practical Cranial Nerve V Motor”
3. Review videos “Practical Cranial Nerve VII Motor”
4. Review videos “Practical Cranial Nerve VII Sensory”
5. Review videos “Practical Cranial Nerve VIII Auditory Acuity

6. Review videos “Practical Cranial Nerve VIII Hallpike”
52
7. Review videos “Practical Cranial Nerve VIII Fukuda”
8. Review video “Practical Cranial Nerve IX, X”
9. Review video “Practical Cranial Nerve XI”
10. Review video “Practical Cranial Nerve XII”
The lectures this week will focus on the 6.1 Cranial Nerves V, VII and VIII, IX, X, XI,
XII Examination followed by 6.2 TMJ Conditions and Lecture 6.3 TMJ
Management including adjustments.
Weber’s test: sound lateralizes to impaired ear unilateral conduction

i.e. bone conduction (BC) better than air deafness
conduction (AC)
Rinne’s test: BC longer than AC
Weber’s test: sound localizes to good ear i.e. unilateral sensorineural
AC better than BC. deafness
Rinne’s test: AC lasts longer than BC
Using this information, what can you conclude from the following results?
Rinne’s test Weber test
Left ear
Right ear
Patient 1 BC > AC Localizes to left ear
AC > BC
Patient 2 AC > BC Localizes to left ear
AC > BC
Patient 3 AC > BC Localizes to right ear
BC > AC
Patient 4 AC > BC Localizes to right ear
AC > BC
The activity is a quick review of the actions that can manifest in a patient’s history
53
that would help the students suspect a cranial nerve involvement. Run through the
list, randomly, and ask the students to be able to name which one is responsible for
that symptom.
Condition Condition
Bell’s Palsy Sticking out tongue?
Scent with eyes closed Cardinal field of gaze?
Hoarseness Mittelmeyer test?
Gag checks Rinne test?
Torticollis Swallowing
Snellen Chart Tests Hot or cold test tubes?
Trigeminal Neuralgia Weber test?
Diplopia Sour tastes tests?

54
Practical Lab Skills Development: TMJ Examination
Using the 6.4 TMJ Examination Practical as a guide on what to do have the students perform the
following
i. Evaluate the TMJ motion palpation
ii. Perform TMJ clearing test
iii. Evaluate TMJ ROM
iv. Evaluate TMJ – palpation
v. Evaluate mandibular motion

55
Practical Lab Skills Development: 6.5 Cranial Nerves Examination
Using the 6.5 Examination of Cranial Nerves V, VII, VIII, IX, X, XI, XII as a guide on what to do
have the students perform the following:
i. Evaluate Cranial Nerve V

ii. Evaluate Cranial Nerve VII
iii. Evaluate Cranial Nerve VIII
Assess the Trigeminal nerve CN V

• Test Motor function
• Observe - any wasting?
• Assess muscle power of temporalis, masseter and pterygoids
• Jaw jerk
Test Sensory function CN V
• Test light touch and pinprick in each division on both sides
• V1 : forehead
V2 : cheek
V3 : lower lip
• If abnormal, test temperature

• Test corneal reflex
Task 1: Assess the facial nerve CN VII
Check facial symmetry

Ask patient to perform certain facial expressions – check ability and symmetry
close eyes tightly
show teeth
Whistle
look up
Task 2: Test hearing CN VIII
1. Gross hearing test: cover 1 ear, make sound near the other ear.
2. Perform Rinne’s test
3. Perform Weber’s test
Task 3: Test Balance CN VIII

56
1. Test heel-toe walking (tandem walk)

2. Test nystagmus
3. Perform the Head impulse test
4. Perform Hallpike’s test
In the lab, perform the following:
i. Evaluate Cranial Nerves VIII

1. Gross hearing test: cover 1 ear, make sound near the other ear.
2. Perform Rinne’s test
3. Perform Weber’s test
i. Evaluate Cranial Nerve VIII

1. Rhomberg Test
2. Fakuda Test
3. Test heel-toe walking
4. Test nystagmus
5. Perform the Head impulse test
6. Perform Hallpike’s test
ii. Evaluate Cranial Nerve IX, X

1.Uvula Reflex
2.Observe soft palate
3. Gag Reflex
4.Swallow Test
5. Taste (posterior 1/3 of the tongue)
iii. Evaluate Cranial Nerve XI
Inspect. Palpate and Muscle test SCM and Trapezius
iv. Evaluate Cranial Nerve XII

1.Inspect tongue
2.Tongue movement

57
Go through the mechanics/rationale of psychomotor skills for the TMJ. These have all be taught
previously should not too much time will be spent on this activity.
In the lab, you can do the following:
TMJ:
Supine:
 Bilateral Thumb/Mandibles; Long Axis Distraction Fig 6-19 (P. 291)
Seated:
 Reinforced Palmer/ Distal Mandibles; Anterior to Posterior Glide Fig 6-22 (P. 293)
Supine:
 Reinforced Thumb Proximal Mandible: Lateral to Medial Glide Fig 6-24
(P. 294)
Seated:
 Thenar/Proximal Mandibles: lateral to Medial Glide Fig 6-25 (P. 294)

CASE STUDY AND QUESTIONS: To be completed by the 12 th September.

Week 6: Case 6: Joe
Joe is a 60-year-old who works in IT.
Joe presents with neck and right jaw pain of 3 weeks duration. The patient also complained of
headaches in the temporal area which have been present for the last 6 weeks. Within the last 2
weeks the intensity of the headaches has increased. These headaches are worse in the mornings.
The quality of the pain (of the headaches) is dull, throbbing, diffuse and aching. The headaches are
intermittent and may last up to 2-3 hours.

He was driving home from work when another car ran a red light and struck his car on the left front
fender. He was wearing a seat belt, had some prior warning that the accident was going to occur,
and braced himself but was still thrown violently against his seat belt. His sunglasses flew off his
head. Estimated impact velocity was about 40 km/hr. Extensive damage was done to the front end
and the left front fender. The patient was able to get out of the car and take information from
58
witnesses but by the next morning he had developed severe midline neck pain and an inability to
move his right shoulder without discomfort.
 Joe is an obese male.
 Vitals: pulse 80/min, normal volume; BP 160/95; respiratory rate 18/min; Temp 36.9
 Cervical ROM: He demonstrates limited forward flexion and incomplete extension of the
cervical spine. There is decreased motion on right rotation. Cervical range of motion is
otherwise full.
 The upper extremities demonstrate normal contours and no atrophy.
 There is no point tenderness along the right acromial border.
 Passive range of motion of the right shoulder is comfortable except on forward flexion beyond
90 degrees where there is pain in the acromial region.
 Upper extremity sensory and motor tests reveal no deficits. Supination of the forearm
against resistance (Yergason’s tests for bicipital tendinitis) is painless.
 TMJ examination revealing a translation to the right and difficult placing 3 fingers in his
mouth. There is crepitus and muscles spasm on palpation of masseters and temporalis
X-rays
Cervical and shoulder x-rays are unremarkable.
Questions
1. Describe the mechanism of the neck pain and its relationship to the findings.
2. How do you explain the lack of pain initially followed by severe pain later?
3. What injuries of the neck and shoulder might occur in this type of accident, and how would they
be ruled in/out?
4. Does he have hypertension? Explain your answer.
5. What signs would you look for, in order to determine if he has any complications related to his
elevated blood pressure. For each sign named, explain the pathology which it is related to.
6. What are the possible causes for his headaches? Do you think that they may be related to?
a. His recent MVA?
b. His elevated blood pressure?
7. How would you treat/manage this patient if he presented to your office

59
The questions for this week will focus on components of a cranial nerve and
A
TMJ assessment.
1. Which branches of the trigeminal nerve supply each region in the

image below?
B
A:
B:
C:
C
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1. Complete the following table:
Examination Finding Nerve(s) involved

Wasting/weakness of
temporalis and masseter
muscles
Weakness of jaw opening

– jaw deviates to side
Loss or diminished jaw
reflex
Loss of corneal reflex –

neither eyes blink
2. What is the possible cause of each of the following?
a. pain in the distribution of either V1, V2 or V3 when touching that area
b. pain, vesicle formation and hyperaesthesia in the region of V1, V2 or V3
The questions will now focus on components of cranial nerve IX, X, XI and XII
structure, function and significance of the findings.
3.Consider examination of the pharynx. Complete the following table:
Finding Possible significance

Uvula moves to one side
Uvula does not move on

saying ‘ahh’ or gag
4.Consider examination of the larynx. Complete the following table:

When asking patient to cough, it is
of gradual onset
‘Bubbly’ voice
Swallowing is followed by
coughing
Hoarse voice
5.Consider examination of the spinal accessory nerve. Complete the following

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table:

Weakness of
sternocleidomastoid and
trapezius on the same side
Weakness of sternocleidomastoid
and trapezius on the same side,
plus
ipsilateral loss of gag reflex and
uvula deviation
Weakness of ipsilateral
sternocleidomastoid and
contralateral trapezius
Unilateral delayed shoulder
shrug
Bilateral wasting and weakness of
sternocleidomastoid
Unilateral sternocleidomastoid
abnormalities
Abnormal head position and

hypertrophy of neck muscles
6.Undertake some research of neurological disorders and name a condition associated with
each of the cranial nerve provided.
Neurological Disorders Name

CN V
CN VII
CN VIII
C5-T1
C5-6
C7-8
T1
7. What is the difference between mandibular deviation and mandibular deflection when
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assessing the TMJ joint?
8. What are the articular surfaces in the TMJ joint covered by in order to reduce the effects of
compressive forces placed upon it.
9 Name the ligamentous structures in the TMJ joint
10. How does the disc stay on the condyle while moving?
11. The muscles of mastication include
true or false
12. The upper TMJ joint is a sliding joint (ginglymus)
13. The disc of the TMJ joint is avascular and derives its nutrition from the synovia?
14. The TMJ motion of depression is generated by the contraction of temporalis, masseter
and medial pterygoids?
15. What kind of head position may cause the mandible to close differently than it should,
thus causing mal- occlusion?
16. What are some of the symptoms that can occur with forward head posture and TMJ mal
occlusion?
17. What is the cause of the noises heard in the TMJ like (popping, snapping, clicking)?
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CHIR13009 Week 7 Synopsis 31st August - 6th September 2020
Overview 7.0
The lecture this week will focus on the introduction to 7.1 Introduction to Vital Signs Listen to the
recording followed by the 7.2 The Assessment of Mental Status found on Moodle in Week 7.

Review less common shoulder adjustments pages 309- 314, Fig 6-59, Fig 6-60, Fig 6-62,
Fig 6-65, Fig 6-66
 Fuller. G., Neurological Examination Made Easy, 6th Edition (2019), Mental State pages
20- 24
Review the lecture 7.1 Introduction to Vital Signs as within the presentation you will see the
following video resources please review these found on Moodle in Week 7
Review video: “Pulse Rate”
Review video: “Respiration Rate”
Review video: “Measurement of Blood Pressure”
The lectures this week will focus on the introduction and examination of Vital Signs including the
Measurement of height, weight, temperature, Palpation of pulse, Measurement of respiratory rate
and Measurement of blood pressure.
64
Review video Pulse Rate

Review video Respiration Rate
Review video Measurement of Blood Pressure
Your tutor will demonstrate how vital signs are examined.

You will now practice taking the vital signs of your colleagues
 Measure temperature height and weight of your colleagues

 Measure radial pulse on a number of your colleagues and note rhythm and rate
 Measure respiration rate on a number of your colleagues
 Measure Blood pressure on a number of your colleagues
tested.
You will have the opportunity to perform on 3-4 other students if possible.
In the lab, you can have the students perform the following:
Examination Why is it done? What type of abnormalities can be

component found? What is a common cause of
each abnormality identified?
Measure height and
weight
Assess radial pulse
Measure blood
pressure
Measure temperature
Measure respiratory
rate
65
Go through the mechanics/rationale of psychomotor skills for the shoulder. These have all be taught
previously should not too much time will be spent on this activity.
In the lab, you can do the following:
Shoulder:
Glenohumeral Joint:
Sitting:
 Reinforced Palmer Olecranon: Anterior to Posterior Glide Fig 6-59 (P. 309)
Supine:
 Index/Distal Clavicle: Superior to Inferior Glide Fig 6-60 9 (P. 310)

 Hypothenar/ Distal Clavicle with Distraction Anterior to Posterior Glide Fig 6-62 (P.
310)
Sternoclavicular Joint
Supine:
 Hypothenar/ Proximal Clavicle with Distraction: Anterior to Posterior Glide Fig 6-65 (P.
311)
 Covered Thumb / proximal Clavicle; Superior to Inferior Glide Fig 6-66 (P.312)
CASE STUDY AND QUESTIONS: To be completed by the 6 th September

Week 7: Case Study Tim
45-year-old male
Tim a 45- year-old male presents to your office suffering low back and left leg pain. The back pain
was felt centrally and was intermittent.

The symptoms occur with fast walking for more than 15 minutes, prolonged standing, and occur
occasionally at night. The leg pain is posterior and is described as an ache rather than a sharp
pain. The leg pain generally starts just after the onset of the back pain. Walking, sitting or flexing
the trunk eased the pain, usually in about 15 minutes.
The pain in the low back and leg have been present for about 3 years. There is no known cause or
onset. The symptoms are progressively getting worse particularly over the last 4 months. He had
tried various medications and chiropractic treatment all without relief. He had been well previously
with no signs or symptoms of arthritis and there was no history of trauma. His past medical history
66
was unremarkable.
The patient appeared fit. His pulses of the lower limb were normal. The lumbar spine was
hypolordotic. The patient is thin. All lumbar movements were generally stiff with little extension
occurring in the spine. Most of trunk extension was the result of hip flexion. Flexion was better but
he was only able to reach to his knees. Lateral flexion was restricted by 40% in both directions with
a slight ache in the lower back on left lateral flexion (right lateral flexion was painless). Rotation to
the left was restricted by 60% with low back pain. Right rotation was only slightly restricted (30%)
and painless. None of the movements reproduced the pain in the left leg. SLR, Nachlas and Ely’s
were negative. There were no neurological deficits. Palpation to the lumbar spine was painless but
restricted in all lumbar segments. Compression and distraction testing were negative or
unremarkable.
Questions:
1. Do you think this patient has vascular or neurogenic claudication/ Explain your answer.
2. Run through the GORPOMNICS physical examination that would eliminate and/or confirm
whether this patient is suffering from vascular claudication or neurogenic claudication.
3. Refer to the diagram below. Does this represent central stenosis or lateral recess stenosis?
Would there be neurological signs present? Explain your answers.
http://ddjointpain.weebly.com/neurogenic-claudication.html
Test For Case 7 indicate the likely outcome for the
following tests. Indicate whether it is likely to
be a true positive, false positive, true
negative, false negative
Squat test
Lumbar Kemps test
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Lumbar Vertical compression

test
Slump test
Djerine’s triad (Valsalva,
cough, sneeze)
Flip or Bechterew’s test
Straight leg raising test (SLR)
Well straight leg raising test
(WSLR)
Bilateral straight leg raising
test
Braggard’s test
Bonnet’s test
Bowstring’s test
Kernig’s/Brudzinski’s test
Milgram’s test
Nachlas test (prone knee
bending
Ely’s test
Yeoman’s test
Lumbar springing test
Trendelenburg’s test
Patrick Fabere test
Sign of the Buttock
Thomas test
Belt test or supported Adam’s
Ober’s test
From the ‘likely diagnosis’ for Cases 7, complete the following table:
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General questions on Vascular and Intermittent claudication
1.From the information in the above case history and physical examination, what is the most likely
diagnosis?
2. Which of the following tests/assessments typically differentiates between neurogenic

claudication and vascular intermittent claudication?
3. Spinal stenosis typically occurs in patients whose lumbar spines are:
4. Dynamic lateral recess stenosis more typically occurs in:
5. The most common causes of developmental or acquired spinal stenosis are:
6. Which of the following enables the clinician to differentiate between an intervertebral disc
herniation and spinal stenosis
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7. Fixed central stenosis is usually associated with:
8. Dynamic lateral recess stenosis may be associated with:
9. A congenitally small spinal canal:
10. The pain from lateral recess stenosis is usually:
A patient presents with neurogenic claudication. An x-ray is taken of L5-S2 shown below. Discuss
the mechanism by which this person may have a diagnosis of neurogenic claudication.
http://headbacktohealth.com/Retrolisthesis.html

The questions for this week will focus on Vital Signs assessment.
Answer the following questions on this topic:
Q1. Name the 4 measurements which comprise the ‘vital signs’
Q2. State if the following are True or False:
a. Body temperature is usually lower early in the morning, compared to the evening
70
b. Using a tympanic membrane thermometer is preferable to other methods in a child with a

suspected ear infection.
c. When measuring pulse and respiratory rate, it is best to count for 15 seconds then multiply by
4.
d. The pulse rate is usually higher in a newborn than in a child.
e. The most common cause of an irregularly irregular pulse is atrial fibrillation.
f. A pulse which is very strong and forceful is usually denoted as 1+
g. The average respiratory rate generally increases from birth to adulthood.
h. The average blood pressure generally increases from birth to adulthood
Q3. When taking the pulse, the 3 major measurements you need to do are
Q4. The level of blood pressure is determined by cardiac output, blood volume and
Q5. The apparatus used to measure blood pressure is called a
Q6. What are the 8 domains that are considered and assessed when conducting a Mental State
Exam?
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Q7. After viewing the video what is your assessment of John. Report using the 8 MSE
domains.
72
CHIR13009 Week 8 Synopsis 7th –13th September 2020
Overview 8.0
The lecture this week will focus on the 8.1 introduction to Injury Prevention and Management
and the 8.2 Injury Management Sports First Aid seen in chiropractic practice. This is followed by
8.3 Common Injuries- Head and Trunk. Our thanks to Dr Crystal Kean and Dr Joshua Guy, B Sp
Ex Sc (Hons), PhD, AFHEA Lecturers in Exercise and Sport Sciences School of Health, Medical and
Applied Sciences for providing this information.

Review Elbow pages 322- 325 Fig 6-91, Fig 6-92, Fig 6-93, Fig 6-95, Fig 6-98, Fig 6-99, Fig
6-100, Fig 6-101 and Review Wrist and Hand: pages 334- 337 Fig 6-126, Fig 6-127, Fig 6-
128, Fig 6-130, Fig 6-131, Fig 6-132, Fig 6-133, Fig 6-134
 Magee. D, Orthopedic Physical Assessment, 6th Edition (2014), Trauma pages 86- 108
 BJSM Online First, published on April 26, 2017 as 10.1136/bjsports-2017-097506SCAT5
The lectures this week will focus 8.1 introduction to Sporting Injuries and the 8.2
Injury Management Sports First Aid seen in chiropractic practice. This will be
followed by 8.3 Common Injuries Head and Trunk
73
 Perform the on-campus activity for week 8A.
You will read the SCAT5 SPORT CONCUSSION ASSESSMENT TOOL — 5TH EDITION
You will have the opportunity to work in a small group with other students if possible and
revise the document with your tutor. (NO MORE THAN 1 HOUR)
Elbow:
Sitting:
 Web/Distal Humerus, Forearm Grasp Pull; Long Axis Distraction Fig 6-91
(P. 322)
 Calcaneal/Proximal Ulna Forearm Stabilization Medial to Lateral Glide Fig 6-92 (P. 322)
 Calcaneal/Proximal Radius Forearm Stabilization Lateral to Medial Glide Fig 6-93 (P.
323)
 Thumb / Radius Push, Distal Forearm Grasp; Posterior to Anterior Glide in Pronation
Fig 6-95 (P. 323)
 Thumb- Index/ Olecranon Push; Posterior to Anterior Glide in Full Extension Fig 6-98
(P. 324)
Supine:
 Bimanual Grasp/Distal Humerus with Knee Extension; Long Axis Distraction Fig 6-99
(P. 325)
 Web/ Proximal Ulna Push with Knee Extension; Medial to Lateral Glide Fig 6-100 (P.
325)
 Web/ Proximal Radius Push with Knee Extension; Lateral to Medial Glide Fig 6-101 (P.
325)
Go through the mechanics/rationale of psychomotor skills for the Elbow and Wrist. These have all be
taught previously should not too much time will be spent on this activity. In the lab, you can have
them do the following:
74
Wrist and Hand:
Supine or Sitting:
 Bimanual Thumb- Index Radius and Ulnar Shear; Anterior to Posterior and Posterior to
Anterior Glide Fig 6-126 (P. 334)
 Reinforced Hypothenar/ Radius; Medial to Lateral Compression Fig 6-127 (P. 334)
 Hand Grasp Pull with Forearm Stabilization; Long Axis Distraction Fig 6-128 (P. 335)
 Bimanual Grasp/ Distal Forearm Hand; Medial to Lateral or Lateral to Medial Tilt Fig 6-
130 (P. 336)
 Bimanual Grasp/ Distal Forearm Hand; Anterior to Posterior or Posterior to Anterior
Glide Fig 6-131 (P. 336)
 Reinforced Thumbs/ Carpals; Anterior to Posterior and Posterior to Anterior Glide Fig
6-132 (P. 337)
 Bimanual Thumbs Digits/Metacarpals; Anterior to Posterior and Posterior to Anterior
Glide Fig 6-133 (P. 337)
 Thumb Index Grasp/Metacarpophalangeal (or Interphalangeal) with Hand Stabilization;
Long Axis Distraction; Internal or External Rotation; Anterior to Posterior or Posterior
to Anterior Glide; Lateral to Medial or Medial to Lateral Glide Fig 6-134 (P. 337)

 Perform the on-campus activity for week 8B.
Week 8 Case Study 8 Allan
Allan is a 30-year-old financial planner.
Allan fell on his left shoulder during a game of basketball. The pain in his left shoulder occurred
immediately after the incident.
An x-ray taken at the time showed no evidence of fracture. Over the next one month, the pain
worsened: the pain was now in his entire left arm as well as his shoulder. He described the pain as
a burning and throbbing quality with tenderness and coolness of the left hand and wrist. He also
75
noted that his skin had become shiny and he had difficulty holding objects such as a pen or kitchen
utensils. Typing also caused pain in the left arm and shoulder. There is no history of past illness or
familial arthritis and he had been on no medications.
Allan appears tired and a little pale.

Vitals:
Pulse rate was 90/min, regular, and strong. Respiratory rate 16/min; BP 120/75
There was pallor of the conjunctiva, but not the palmar creases.
On examination, the skin of the left arm was slightly shiny compared with the right arm. Swelling
and oedema were also present. The left arm was hypersensitive to touch. His radial pulses and
capillary filling were symmetrical and normal.
Questions
1. What other further pertinent questions should you ask this patient?
2. For the above case history alone, what are your differential diagnoses?
3. Outline an examination routine that would eliminate or confirm your differential diagnosis
mentioned in question 2.
4. Using only the information from the above case history and physical examination, what is the
likely diagnosis:
a. For his upper limb problem

b. For his other physical signs
Explain your answer.
The questions for this week will focus on sporting injuries and the management of
common sporting injuries. Refer to the literature in the Reading List for week 8 to answer
the following questions.
1. What definitions can be found to define What is a sports injury?
2. Why is Sports Injury Prevention Important?
3. Explain the difference between intrinsic and extrinsic risk factors that affect the
aetiology and mechanisms of an injury.
Intrinsic Risk Factors Extrinsic Risk Factors

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Skeletal alignment Nature of Task
Muscle strength Intensity of performance
Muscle endurance Frequency of performance
Joint flexibility Environment
Joint alignment Equipment
Bone mineral density Level of participation
Previous injury Rules
Muscle activation patterns
Body mass
Psychological factors
4. List the SMA (Sports Medicine Australia) general injury prevention principles.
5. Review the literature and think about the sports that you may play and the injuries you see.
– What are common injuries in your sport?
– What are potential risk factors?
– What are the mechanisms of the injury?
6.What are the signs and symptoms of soft tissue injuries?
7.What are the management guidelines for a hard tissue injury
8.What are the Sign and Symptoms of a Concussion?
9.What does DRSABCD stand for?
10.What is the TOTAPS injury protocol?

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CHIR13009 Week 9 Synopsis – 14th – 20th September 2020
Overview 9.0
The lectures this week will focus on the introduction to 9.1 Post- Surgical Management of
Orthopedic Conditions (Elective Surgery) Our thanks to Dr Crystal Kean and Dr Joshua Guy, B
Sports Exercise Science (Hons), PhD, AFHEA Lecturers in Exercise and Sport Sciences School of
Health, Medical and Applied Sciences for providing this information.

Review knee pages 360- 364 Fig 6-191. Fig 6-192, Fig 6-193, Fig 6-194, Fig 6-195, Fig 6-
196, Fig 6-197, Fig 6-198, Fig 6-199, Fig 6-200, Fig 6-201, Fig 6-202 and Fig 6-203.
 Magee. D, Orthopedic Physical Assessment, 6th Edition (2014), pages 1088- 1096, 1099-
1101
The lectures this week will focus on lecture 9.1 Introduction to Post Surgical
Management of Orthopedic Conditions (Elective Spinal Surgery) and which will
be followed by 9.2 Management of Lower Limb (Elective Surgery) and then 9.3
Orthopedic examination of patient Post-Surgical) and 9.4 Practical Knee
Psychomotor Skills.
78
Femorotibial Supine:
 Bi Manual Grasp/ Proximal Tibia with Knee Extension; Long Axis Distraction Fig 6-191
(P.358)
 Reinforced Web/Proximal Tibia Push; Anterior to Posterior Glide in Flexion Fig 6-192
(P. 359)
 Bimanual Grasp / Proximal Tibia with Knee Extension; Internal or External Rotation in
Extension Fig 6-193 (P. 360)
 Hypothenar/ Proximal Tibia with Leg Stabilization; Medial to Lateral Glide Fig 6-194
(P.361)
 Knee Hypothenar/Proximal Tibia with Leg Stabilization; Lateral to Medial Glide Fig 6-
195 (P. 361)
Femorotibial Prone:
 Reinforced Mid-Hypothenar (knife-edge) Proximal Tibia Pull; Posterior-to-Anterior

Glide in Flexion Fig 6-196 9 (P. 361)
 Bimanual Grasp/Distal Tibia with Knee Thigh Stabilization; Internal or External
Rotation in Flexion Fig 6-197 (P. 362)

Go through the mechanics/rationale of psychomotor skills for the Knee. These have all be taught
previously should not too much time will be spent on this activity. In the lab, perform the following:
Patellofemoral Supine:
 Bimanual Web/Patella; Superior Medial-to-Inferior Lateral Glide; Superior Lateral-to-

Inferior Medial Glide; Inferior Medial-to-Superior Lateral Glide; Inferior Lateral-to-
Superior Medial Glide Fig 6-198 (P. 362)
Tibiofibular Supine:
 Index/proximal fibula, palmar ankle push; posterior-to anterior glide in flexion Fig 6-
199 (P. 363)
 Reinforced thumbs/proximal fibula; anterior-to-posterior glide in flexion Fig 6-200 (P.
363)
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Tibiofibular Prone:
• Reinforced mid-hypothenar (knife-edge)/proximal fibula pull; posterior-to-anterior

glide in flexion Fig 6-201 (P. 364)
Tibiofibular Side Posture:
• Reinforced mid-hypothenar (knife-edge)/proximal fibula push; inferior-to-superior

glide in eversion Fig 6-202 (P. 364)
• Reinforced mid-hypothenar (knife-edge)/proximal superior fibula push; superior-
to-inferior to glide in inversion Fig 6-203 (P. 364)


Week 9 Case 9 Stan
Stan is 40-year-old male who is referred to you by his physician.
Stan presents to your office with severe pain and paranesthesia in the anterolateral aspect of his left
thigh.
The pain and paranesthesia extend from an area just lateral to the right anterior superior iliac to the
anterolateral aspect of the thigh just above the knee of the right leg. The pain had been present for
two weeks and had followed unaccustomed physical activity (he cleaned his basement out). He felt
the pain the same evening when he stood up after watching TV for an hour or so. There was no low
back pain. An x-ray and CT scan were taken of his lumbar spine; both were negative.
Stan has just been diagnosed as a Diabetic type II. He has a pendulous abdomen.
Any unguarded movement caused severe leg pain. He was only comfortable in lying but he was
able to move about slowly and carefully.
The patient’s medical history was unremarkable. He does not smoke and drinks alcohol on social
occasions.
1. The physician’s diagnosis was L4,5 facet synovitis. Do you agree with this diagnosis?
Explain your answer.
2. Give a differential diagnosis for Stan’s symptoms. What is the likely diagnosis?
3. What areas would you examine and why?
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4. Using only the information in the case history, is it possible that Stan's symptoms could result
from the following:
a. Meralgia paraesthetica
b. Myofascial pain syndrome
5. From your likely diagnosis in question 2, how would you treat Sam?
6. Sam is a little overweight (see a picture below). Do you think this has any impact on your
management of the patient?
For the likely diagnosis in case 9, complete the following table:

Test For Case 9 indicate the likely outcome for the following tests.
Indicate whether it is likely to be a true positive, false positive,
81
true negative, false negative
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
Kernig’s test
Sign of the buttock
Slump test
Milgram’s test
Sacral thrust
(Springing the
sacrum)
SIJ distraction
SIJ compression
Thigh thrust
Gaenslen’s
Adam’s Belt test
Nachlas test
(prone knee
bending
Ely’s test
Yeoman’s test
Lumbar springing
test
82
.
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2. Explain the difference in post- operative management for a patient who has had a
discectomy vs laminectomy?
3. Under what conditions do you suspect a spinal injury?
4. When is the Canadian C- Spine rule not applicable?
5. If a patient receives a cervical spine fracture and is not suitable for surgery what
precautionary management is recommended?
6. Visit https://surgeryreference.aofoundation.org/ and answer the following

questions.
A. Co fractures/Occipital condyle fractures are typically the result of motor vehicle

accidents. T/ F
B. Clincial findings may include:Tenderness in the posterior craniocervical transition, dysphagia

hoarseness and numbness in the anterior parts of the ear? T/F
C. Anterior arch injuries are in general hyperflexion injuries. These are normally stable and treated
with a soft collar under close observation. T/F
D. Burst fractures are axial load injuries resulting in both anterior and posterior ring fractures. T/F
E. With a suspected cervical spine injury, the cervical spine should be immobilized in a hard collar.
A cervical spine injury should be suspected in anyone with impaired level of consciousness, with a
high velocity injury, or in anyone with neck pain. T/F
F. In a basic neurological assessment the level of consciousness should be assessed using the
Glasgow coma score. T/F
7. What is seen in the xray below and what does it indicate?

84
8. With a total hip replacement (THR) what precautions should be adhered to in

recovery?
9. What are some of the complications to be aware of with a total knee

replacement (TKR)?
10. What is an indication for an ACL reconstruction?

85
CHIR13009 Week 10 Synopsis 21st –27th September 2020
Overview 10.0
The lectures this week will focus on the 10.1 Management of Lower Limb Orthopedic Trauma
followed by 10.2 Orthopedic Examination Post Trauma. Thanks to Tanya Palmer
Physiotherapy Clinical Education Coordinator & Physiotherapy Lecturer (Cardiorespiratory) for
providing this material

Review Foot and Ankle: pages 371- 379, Fig 6-221, Fig 6-222, Fig 6-223, Fig 6-224, 6-225,
Fig 6-227, Fig 6-228, Fig 6-229, Fig 6-232, Fig 6-233, Fig 6-234, Fig 6-236, Fig 6-237
 Fuller. G. Neurological Examination Made Easy, 6th Edition 2019, Standard Neurological
Exam pages 215- 216
The lectures this week will focus on lecture 10.1 Introduction to Post Trauma
Management which will followed by 10.2 Orthopedic Examination post Trauma. This
is followed by 10.3 Whiplash and Torticollis

86
In the lab, the students can perform the following:
Tibiotalar Supine:
• Bimanual Reinforced Interphalangeal Grasp/Anterior Talus Pull; Long-Axis

Distraction Fig 6-221 (P. 373)
• Reinforced Webs/Anterior Talus Push Anterior-to-Posterior Glide Fig 6-222 (P.
373)
• Reinforced Middle Interphalangeal/Talus Pull; Lateral to-Medial Glide (eversion) or
Medial-to-Lateral Glide (inversion) with Long-Axis Distraction Fig 6-223 (P. 373)
• Web/Talus, Mid-Hypothenar (knife-edge)/Calcaneus; Long-Axis Distraction with
either inversion or eversion Fig 6-224 (P. 374)
Tibiotalar Prone:
• Reinforced Webs/Talus Push; Posterior-to-Anterior Glide Fig 6-225

(P. 374)
Subtalar Prone:
• Reinforced Web/Calcaneus; Long-Axis Distraction Fig 6-226 (P. 375)

• Interlaced Bimanual Grasp/Calcaneus; Lateral-to-Medial Glide; Medial-to-Lateral
Glide; Anterior-to-Posterior Glide; Posterior-to-Anterior Glide Fig 6-227 (P. 375)
Tarsometatarsal Prone:
• Hypothenar/navicular (cuneiforms) with forefoot distraction; plantar-to-dorsal

glide Fig 6-229 (P. 376)
Tarsometatarsal Supine:
• Reinforced middle interphalangeal/cuneiform (navicular, cuboid) pull; anterior-to-

posterior glide Fig 6-232 (P. 376)
Intertarsal Supine:
• Bimanual webs/tarsals; long-axis distraction Fig 6-233 (P. 377)
Intermetatarsal Supine:
• Bimanual thenar/metatarsal grasp shear; anterior-to-posterior and posterior-to-

anterior glide Fig 6-234 (P. 378)
Metatarsophalangeal Supine
• Thumb index grasp/phalanx; long-axis distraction Fig 6-236

(P. 379)
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First Metatarsophalangeal Supine:
• Web metatarsal/finger grasp phalanx; medial-to-lateral glide with pendular

distraction Fig 6-237 (P. 379)
You will be given a few sample OSCE cards and take at least 1 hour to run through as
many of these as possible. They likely will be the ‘same’ as in the final OSCE (due to
lack of choices!!), but it is good for them to practice, nonetheless.
CASE STUDY AND QUESTIONS: To be completed by the 27th September.
Week 10: Case 10 David is a 7-year-old boy.
David is in obvious distress with severe posterior neck pain on the right side (around C2-3) of less
than one-day duration. The pain did not radiate to the extremities.

The pain started upon waking this morning (3 hours ago). The previous day he had been wrestling
with his pet dog but cannot remember any particular incident that caused the problem. He did not
go to school today he is in too much pain. He has had no history of neck pain or any medical
history of significance.
Vitals:
PR-100/min
RR – 20/min
BP – 100/60
Temp – 38.3 C
This is an otherwise healthy normal boy.
His neck was side flexed and rotated to the right. David’s head was twisted slightly upward and to
the left.
There was cervical lymphadenopathy on the right side.
Cervical ROM: Left rotation – pain-free full range, right rotation and left lateral flexion produced
severe neck pain. Lateral flexion to the right was full range with moderate neck pain.
Questions
a. What other further pertinent questions should you ask this patient?
b. For the above case history alone, what are your differential diagnoses?
c. Are these vital signs normal for a 7-year-old boy?
d. From the above physical examination, what tests have been omitted in order to eliminate and
confirm your differential diagnosis mentioned in question 2.
e. What else do you need to examine in order to determine the possible cause of his fever and
lymphadenopathy?
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f. Using the information from the above case history and physical examination, what is the
more likely diagnosis. Explain your answer. Does it explain all of his symptoms and signs?
g. How would the signs and symptoms of acute torticollis differ from that of neck tongue
syndrome?
h. Could the lymphadenopathy and fever related to his neck pain?
i. Discuss the treatment/management for this patient.
j. Discuss the prognosis for this patient.
k. Name and describe the different types of torticollis.
l. Discuss the aetiology of acute torticollis.
m. Differentiate between childhood and congenital torticollis
n. Discuss the chiropractic management of acquired adult torticollis.
o. What are the causes of Vertigo?
p. Describe the Fitz-Ritson test. What is the purpose of this test?
q. Describe the Hall Pike test. What is the purpose of this test?
r. Describe Postural hypotension.
s. What are the signs and symptoms of BPPV?
The questions for this week will focus on components of Management Post Trauma
1. What is myositis ossificans and why is it important to monitor?

2. Why does a fracture of the neck of the femur #NOF have such a high mortality rate and what
factors contribute to this injury?
3. What is the role of the health care provider in early management of trauma?
4. What complications can arise following a hip fracture?
5. What are the risk factors for post-operative delirium?
6. How does post-operative delirium present?
7. What are the aims of #NOF treatment?
8. What functional outcomes does a physiotherapist look for with #NOF?
89
CHIR13009 Week 11 Synopsis – 28th September – 4th October 2020
Overview 11.0
There will be no lectures this week to allow for any review of material from this term.
None this week.
There will be no lectures this week to allow for any review of material from this term.
None as will be reviewing for final OSCE
Please run the fourteen (14) videos with the focus on assessing cerebellum as well as a
quick run through of all the cranial nerves. These videos give a broad overview of
Cranial Nerves and the cerebellum.
Once you have shown and reviewed the videos and/or questions, have the
students practice the following:
You will be given a few sample OSCE cards and take at least 1 hour to run through as
many of these as possible. They likely will be the ‘same’ as in the final OSCE (due to
lack of choices!!), but it is good for them to practice.

90
None this week.

91
CHIR13009 Week 12 Synopsis – 5th- 11th October 2020
Overview 12.0
There are no lectures this week since it is preparing for the final OSCE.
None this week.
The final ZOOM session will attempt to address any questions before
the final OSCE and On-Line Exam.
There is no scheduled On-Campus Activity as there will be the

conducting of the Final OSCE. (yet to be determined)
Revision
Nothing for this week.

Week 3 Case Questions

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1

Lecture Icon in Moodle: Resources, PowerPoints, lecture notes.

Week Lecture Topics Practical Class Session Weebly Submissions

2 2.1 Assessment and Practical Skills: 2.1 Answer all quiz questions

3.5 Practical Lumbopelvic

4 4.1 Assessing the Practical Skills:

4.3 Vertigo and Dizziness

7 Practical Skills: 7.1 Answer all quiz questions

8.3 Common Injuries- Head

CHIR13009 Week 1 Synopsis – 13th – 19th July2020

The overview for this week includes an Introduction to CHIR13009 PCP2:

Readings and Videos: 1.05

Resources and readings will be given via Reading List.

 Bergmann, T. Chiropractic Technique, Principles and Procedures, 3rd Edition (2010)

Theoretical Lecture Material: 1.1

Tutorial or On-Campus Activity: 1.2

Practical Lab Skills Development: 1.3

In 1st hour orthopedic examination practice

Cervical Instability Tests

• Lateral Flexion Alar Ligament Stress Test

Lumbar Spine Instability Tests

• One leg Standing (Stork Standing) Lumbar Extension Test

In 2nd hour Psychomotor Skills practice

 1. The orthopedic tests listed in the practical PowerPoint

CASE STUDY AND QUESTIONS: To be completed by the 19 July

tests. Indicate whether it is likely to be a true positive, false

Cervical Maximal Already performed

General Questions: Test your knowledge!!! 

4. What musculoskeletal (MSK) conditions can give this pain distribution?

Study Guide Questions: 1.4

Name of Test Interpretation/ what is a positive test and what

Lateral Flexion Alar Ligament Stress Test

Anterior Shear or Sagittal Stress Test

Atlantoaxial Lateral Shear Test

Rotational Alar Ligament Stress Test

Transverse Ligament Stress Test

One leg Standing (Stork Standing) Lumbar

Passive Lumbar Extension Test

Prone Segmental Instability Test

Test of Anterior Lumbar Spine Instability

Test of Posterior Lumbar Spine Instability

Modified Schober’s Method

CHIR13009 Week 2 Synopsis – 20th- 26th July 2020

Readings and Videos: 2.05

Resources and readings will be given via Reading List.

Theoretical Lecture Material: 2.1

Tutorial or On-Campus Activity: 2.2

Practical Lab Skills Development: 2.3

During the practical sessions for week 2

In 1st hour orthopedic examination practice

Name of Test Interpretation/ what is a positive test and what tissue

Adams Forward Bend Test

Sternal Compression Test

Chest Expansion Test

Alli’s Test – Galeazzi’s Sign

Rigid Kyphosis Sign

In 2nd hour Psychomotor Skills practice

In the lab, you will do the following:

 1. The orthopedic tests listed in the practical PowerPoint

 VIEW THE BERGMAN VIDEOS TO REVIEW OUTSIDE OF CLASS.

CASE STUDY AND QUESTIONS: To be completed by the 26 TH July

Week 2 Case: CHIR13009 (Tutor Copy)

14-year-old Female with Adolescent Idiopathic Scoliosis and Back Pain