PART must be documented in which part of the SOAP notes?
Used to determine the contour, consistency, quality, and presence or absence of pain in the dermal, subdermal, and deeper “functional” tissue layers.
Soft Tissue Palpation
What layer consists of Skin?
What layer incorporates subcutaneous adipose tissue, fasciae, nerves, and blood vessels?
What layer consists of the muscles, tendons, tendon sheaths, bursae, ligaments, fasciae, blood vessels, and nerves?
Dermal layer palpation is used to:
Assess Temperature, Moisture, Motility, Consistency, and Sesitivity
What Ortho tests are used to checking for Spondylolysthesis?
What is the "Goal" of medicare PARTS?
To identify and define the specific dysfunctiion and specific tissues involved
Contraindications for adjusting the lumbar or pelvis:
Bone Destroying Pathology (cancer)
Inability to assume adjustment position
Cautions for adjusting:
Degenerative Joint Disease (DJD)
Medicare Relative Contraindications:
Articular hypermobility and circumstances where the stability of the joint is uncertain;
Severe demineralization of bone;
Benign bonetumors (spine);
Bleeding disorders and anticoagulant therapy; and
Radiculopathy with progressive neurological signs.
Medicare Absolute Contraindications
Acute rheumatoid arthritis and ankylosing spondylitis;
Unstable os odontoideum;
Infection of bones or joints
myelopathy or cauda equina syndrome;
Levels of Care: (4)
Patient management directed at normalizing body function and with anticipated syndrome improvement expected within a reasonably predictable period of time.
The goal of this care is to return the patient to pre-clinical status through education and treatment.
Therapeutic / Active Care
Duration and frequency of care guidelines are to assist the clinician in decision making based on the expectation of outcome for the uncomplicated case.
Not designed as a prescriptive or cookbook procedure.
A course of two weeks of each of two types of manual procedures ( four weeks total), after which in the absence of documented improvement, manual procedures are no longer indicated.
Adequate Trial of Care
Controlled trials or case series have been reported with ranges between 1 and 19 sessions of CMT lasting anywhere from one day to two months.
What is the average number of visits for a Florida workers compensation case:
Treatment Frequency: 2-5 treatments per wk for the first two wks, decreasing to 1-2 treatments per wk. Maximum treatment duration: 2-4 months
Aggressive intervention ( 3-5 sessions per wk. for 1-2 wks) may be necessary early.
Progressively declining frequency is expected to discharge of the patient.
Significant improvement within 10-14 days, three to five treatments per wk.
Typical range 5-18 visits.
Radiographic imaging is a two dimensional representation of a three dimensional structure.
Positive Ortho or Neuro Tests
Muscle pain with no improvement
New back pain
Air = Black
Fat = Black/Grey
Bone = Light Grey
Metal = White
Two adjacent vertebrae are fused from birth.
Failure of the normal segmentation process during 3-8 fetal weeks.
- No DDD
- Common at L4/L5
Narrowing at Blocked Vertebrae disc level:
Failure of the lateral
ossification centers to unite:
- Pedicles may appear slightly enlarged
- Not associated with scoliosis
Vertebral body normally develops from two lateral ossification centers. One of these center fails to grow forming a triangular deformity of the vertebral body.
- Associated with scoliosis
- Occur with blocked vertebrae
- Common in Upper Lumbar/Lower Thoracic
Overdevelopment of the L5 spinous process:
Knife Clasp Syndrome
- Hyperextension causes enlarged spinous process to invade sacral neural canal producing symptoms of acute low back
Abnormal development of neural arch caused by the failure of neural tube to close completely.
- Occulta (Bony Structure, Most Common)
- Vera (Neurological Involvement)
Occur in 20 % of population
- Lumbarization: 1st sacral assumes lumbar character
- Sacralization: last lumbar assumes sacral character
Small triangle shape bone that is adjacent to the anterior aspect of the vertebral body, usually anterior and superior.
- Not clinically significant
Vertebral end-plate depression.
Mostly posterior, but sometimes the entire length of the vertebral end-plate.
- Not clinically significant
Herniated disc material through the vertebral end-plate.
- Possibly due to Osteoporosis
lines are drawn from the upper vertebra to the center of the vertebra at the apex of the lateral curvature and from the center of the lower vertebra to the center vertebra.
lines are drawn across the superior endplate of the upper vertebra and the inferior endplate of the lower vertebra involved with the curvature. Perpendicular lines are then drawn.
Degrees of Scoliosis
0-20: Monitor every 2-3 months
40+: Recommend Surgery
The lines are draw along the superior endplate of L1 and the base of sacrum.
Perpendicular lines are drawn from the endplate and sacral lines.
The angle of the intersection is normally 50 to 60 degrees.
Lumbar Spine Lordosis
The forward displacement of one vertebrae over the one immediately below.
Divide the sacral base into four quadrants.
A line is drawn along the posterior surface of the L5 vertebra.
This line should not intersect the sacral base.
A vertical line is drawn from the center of L3 vertebral body inferiorly.
Normally the vertical line will pass through the anterior third of the sacral base.
Lumbar Gravity Line
- Anterior line indicates hyperlordosis.
- Posterior line indicates a hypolordosis.
Lumbar Intervertebral Disc Angles:
L1: 8 degrees
L2: 10 degrees
L3: 12 degrees
L4: 14 degrees
L5: 14 degrees
A line is drawn along the sacral base. Next drawn a horizontal line parallel to the edge of the film.
The inferior angle of the intersection is __________ angle.
-The average is between 27 and 56 degrees
A line is drawn along the sacral base. Next drawn a vertical line parallel to the vertical edge of the film. The inferior angle is __________ angle.
-The average is 53 degrees with a standard of 4
Why X-ray Analysis?
1.Finding potential subluxations
2.Understanding the anatomy to give the most appropriate adjustment
3.Developing the most appropriate management plan for the patient
How do you analyze lateral spinographs?
Look for biomechanical stress
Bottom of one vertebral segment
Soft tissue between
Top of the next vertebral segment '
How do you identify visible posteriority?
Interuption in George's Line
Intervertebral Foramin Encroachment
Sign of posteriority
Acute or Chronic
When segment has tipped laterally
List only the most inferior segment
Acute or Chronic
Indicates involved Motion Unit
Increased Density on X-Ray
Three or more adjacent vertebral bodies that exhibit visible posteriority
invagination of nuclear material into the body of the vertebra
Anterior displacement of a vertebrae in relation to the segment immediately below.
disruption of the pars interarticularis, uni or bi-laterally
without anterior displacement
Occurs most often at L5 level (67%)
C6 most common in cervicals
Incidence of spondylo is between 5-7%
Higher incidence occurs among males, Whites, Eskimos, Japanese and those involved in gymnastics, football, weightlifting, polevaulting, and diving.
Possible correlation to precocious weight
bearing posture (infant carriers and walkers)
Type 1: Congenital, developmental abnormalities of the neural arch resulting in deformity and anterior vertebral displacement
Type 2: Isthmic, defect of the pars interarticularis
Type 3: Degenerative, segmental instability secondary to advanced degeneration of the IVD and posterior joints
Type 4: Traumatic, acute fractures of the neural arch other than the pars
Type 5: Pathologic, osseous deformity secondary to local or systemic pathology. (Paget’s, Mets, Osteopetrosis)
Type 6: Iatrogenic spondylo or spondylolisthesis acquista, developed secondary to spinal surgery