OrthoFinal

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OrthoFinal
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  1. LBP is responsible for ____% of all lost workdays in the US
    25%
  2. loss or abnormality of physiological, psychological or anatomical structure or function---I can't bend over cause my back hurts
    impairment
  3. the inability to engage in age-specific, gender-related and sex specific roles in a particular social context and physical environment---I cant get a job cause of my back pain
    disability
  4. impairment rates have remained largely ____over recent years
    stable
  5. disability rates have ______ exponentially
    grown
  6. worst combination: (general spine info)
    perception that LBP episode is work-related plus the absence from work for more than 2 weeks.
  7. risk factors for back pain:
    age
    peaks for men in their 50s

    increases after 50 in women
  8. risk factors for bak pain:
    level of physical fitness
    better, less likely to have LBP
  9. risk factors for back pain:
    cigarette smoking
    more likely to have LBP and last longer (decreased blood flow)
  10. risk factors for back pain:
    jobs that subject the individual to vibration (fatigue of collagen)
    truck driver
  11. risk factors for back pain:
    jobs
    low job satisfaction
  12. pathomechanical basis of back pain tx
    link impairments to functional deficits (pain with flexion)

    foundation of PT diagnosis

    identify poorly tolerate physiological stresses

    tx is designed to avoid thoses stresses
  13. pathoanatomical basis of back pain tx
    anatomical structure at fault (herniated disc)

    gives anatomical context in which tx occurs
  14. positives of pathomechanical basis
    do not rely on unsubstantiated diagnosis related to examiner bias

    goal in function change, tx related to functional change

    allow for tx without specific anatomical diagnosis
  15. negatives of pathomechanical basis
    no structural framework to make decisions

    importance of constant eval of tx

    lessens ability to give pt a direct "this is what is wrong with you"
  16. positives of pathoanatomical basis
    gives you a frame of reference to make decisions

    able to give patient a clear explanation of what is wrong with them
  17. negatives of pathoanatomical basis
    80-90% of disabling LBP cannot be given a precise anatomical diagnosis

    different professionals will give different diagnoses

    if you follow "correct" tx for a diagnosis that might not be right and you could miss what would really help pt
  18. segments:
    cervical
    thoracic
    lumbar
    sacral
    coccygeal
    • C-1-7
    • T-1-12
    • L-1-5
    • S-1-5
    • Coccygeal-1-4
  19. what does sacralization mean?
    L5 is fused with sacrum
  20. what does lumbarization?
    S1 not fused with sacrum
  21. cervical and lumbar have what kind of curve?
    lordosis (convex anterior)
  22. thoracic, sacral and coccygeal have what kind of curve?
    kyphosis (convex posterior)
  23. these spinal curves do what for the spine?
    increase flexibility

    help with shock absorbing

    maintain stability at IV joints
  24. what causes cervical curves?
    entirely disc shape (cervical vertebral bodies are shorter anteriorly than posteriorly)
  25. what causes thoracic curve?
    vertebral bodies are wedged shaped

    disc is equal height
  26. what causes lumbar curve?
    mostly disc

    lumbar vertebral bodies are shorter anteriorly than posteriorly
  27. components of anterior vertebral body
    body and disk
  28. components of posterior vertebral arch
    pedical, facets, transverse process, lamina, spinous process
  29. differences of vertebrae:
    cervical
    uncinate processes

    foramina trasversarii
  30. difference of vertebrae:
    thoracic
    articular facets for the ribs
  31. difference of vertebrae:
    lumbar
    mamillary bodies-attachment of multifidi muscles
  32. anterior portion of the motion segment:
    weight bearing
    • 85%
    • body consists of spongy bone

    cartilaginous end plates btwn disk and body

    body has ability to deform and act as shock absorber
  33. when shifting weight what is involved with flexion, then what happens with extension?
    flexion--disk (increased during WB)

    extension--facets (decreased during WB)
  34. posterior portions of the motion segment:
    weight bearing
    • 15%
    • increased in extension, decreased in flexion

    articular facets covered in hyaline cartilage
  35. what is the pars interarticularis?
    spot where lamina takes origin from the pedicle

    (dog in the sagittal plane)
  36. what is spondylolysis?
    fracture of pars interarticularis

    (decapitated dog)
  37. zagopoophyseal joints
    consists of cartilaginous surface, fluid filled capsule

    capsule and synovium may be redundant have meniscal folds that can become trapped btwn articulating surfaces
  38. C1-C2 facet
    transverse plane

    much rotation
  39. C3-C7 facet orientation
    45d from transverse plane and parallel to frontal plane

    gradually changing to perpendicular to the transverse plane remaining parallel to frontal plane

    allows for flexion, extension SB, and rotation
  40. thoracic spine orientation
    60d from transverse plane and 20d to the frontal plane

    lateral aspect of the facet tipped anterior

    upper thoracic and lower thoracic are termed (transitional)

    motion limited by ribs
  41. lumbar spine orientation
    90d to transverse plane and 45d to the frontal plane

    lateral aspect of facet tipped posterior

    allows flexion, extension, and SB, almost no rotation
  42. gross facet asymmetry is present in approx ____% of the normal, pain free population
    20%
  43. facet joint coupled motions--freyettes law

    cervical
    SB and rotation to SAME side
  44. IV disk
    none between C1 and C2 and occiput and C1

    make up 20-33% of total vertebral height

    greater disk height, lower body height = more ROM
  45. 3 components of disks
    nucleus pulposus

    annulus fibrosis

    cartilaginous endplate
  46. nucleus pulposus info

    extension versus flexion
    extension causes disk to move ANTERIORLY

    flexion causes disk to move POSTERIORLY
  47. nucleus pulposus info

    normal weight bearing
    normal weight bearing equally distributed over disk
  48. nucleus pulposus info

    degeneration/dehydration
    with degeneration or dehydration of disk, WB shifts to outer area of disk that happens to be innervated

    not good
  49. do extension/flexion exercises aid in re-hydrating the disk, equalizing pressure
    EXTENSION
  50. outer 1/3 of annulus fibrosus is ______&________ which can be a source of pain and inflammation
    innervated and vascular
  51. if annulus has been torn and goes thru repair process vascularity and innervation can creep _____ causing it to be more _____than normal
    inward

    central
  52. healthy disk:

    flexion causes anterior annulus to _____

    nucleus to move _____(ant/post)
    annulus compresses

    nucelus moves posterior
  53. healthy disk;

    flexion causes posterior annulus to _____ and tighten resisting the motion of the nucleus
    elongate
  54. with rotation or torsion the disk is ____(compressed/elongated)
    compressed
  55. what makes up the intervertebral foramen:

    superior and inferior border
    pedicles
  56. what makes up the intervertebral foramen:

    posterior border
    capsule of facet

    ligamentum flavum
  57. what makes up the intevertebral foramen:

    anterior border
    dorsum of the intervertebral disk

    posterior longitudinal ligament
  58. anterior longitudinal ligament:

    where does it connect to?

    what does it resist?

    is it innervated?
    narrow band from occiput and broadens as it descends from C3 to sacrum

    resists hyperextension

    richly innervated
  59. posterior longitudinal ligament

    where does it connect to?

    connect to annulus? vertebral bodies?

    innervated?
    occiput to the sacrum, posterior surface of the vertebral bodies, anterior aspect of the neural canal

    attached to annulus, not vertebral bodies

    richly innervated
  60. ligamentum flavum:

    segmental or continuous?

    where does it go from?

    what does it do?

    when is it most taught? (flex/ext)
    segmental

    runs from lamina from C2-S1

    helps retract capsule of facets so it doesnt get caught in facet joint

    remains taught in extension
  61. what are the 3 layers of the thoracolumbar fascia?
    anterior, posterior, middle
  62. thoracolumbar fascia arises from?
    transverse and spinous processes that blend with quadratus lumborum and transverse abdominal
  63. contraction of ____ _____ muscles tightens thoracolumbar fascia so it functions as part of an active mechanism for pulling the vertebrae posteriorly and controllin shear during lifting
    erector spinae
  64. on full flexion back muscles are silent and fascia is.....
    resister against further flexion
  65. on extension from fully flexed position, _____ ____ and _____ act in concert with the thoracolumbar fascia to initiate extension
    glute max and hamstrings
  66. the thoracolumbar fascia plus abdominal muscles help do what to the vertebral column?
    stabilize
  67. facet joint capsules
    have 2 layers

    innervated and vascularized
  68. what 3 structures are not pain producing (innervated)?
    spinal cord, nucleus pulposus, inner annulus
  69. latissimus dorsi does what to the lumbar spine?
    stabilizes the lumbar spine
  70. glute max stabilizes the spine along with what else?
    thoracolumbar fascia
  71. activity of the lumbar spine muscles is low in relaxed ____and alternates with low levels of activity during ___ ___
    standing

    body sway
  72. there is a small ___ (incr/decr) in activity of lumbar muscle in sitting
    increase
  73. during flexion from standing to sitting, ____ and _____ are active until full flexion is reached then they are quiet
    glutes and erectors
  74. ______are very powerful low back extensors
    multifidi
  75. ______ _____ attachements at L4 and L5 gradually turn into the iliolumbar ligament in your teens
    quadratus lumborum
  76. what is neutral spine?
    not full posterior pelvic tilt
  77. beginning spinal stabilization exercises
    hip hinging

    mass mmt patterns

    sitting UE/LE progressions

    bridging

    beginning squat

    advanced sqaut
  78. ADLs progression in stabilization

    hip hinging
    hip hinging

    sitting

    sit to stand

    stand to sit
  79. mass mmt patterns in beginning stabilization
    supine

    sidelying

    prone

    prone on elbows

    all 4s

    kneeling

    1/2 kneeling

    stance
  80. intermediate stabilization program
    all 4s

    advanced bridging

    wall slides

    swiss ball
  81. advanced stabilization program
    practice holding for longer periods

    use weights
  82. type of disk bulge:

    no bulge
    protrusion
  83. type of disk bulge:

    bulge but outer annulus remains intact
    prolapse
  84. type of disk bulge:

    annular fibers disrupted, nuclear material still in 1 piece
    extrusion
  85. type of disk bulge:

    free nuclear material present
    sequestration
  86. type of disk bulge:

    nucleus breaks thru inner annular rings, finally reaching the innervated and vascular portion of the disk. no bulge noted
    intra-diskal derangement
  87. peripherlization = _____

    centralization= ______
    bad


    good
  88. generally...what is postural syndrome?
    intermittent pain brought on by adoption of a position that is stressful for too long a time period
  89. characteristics of postural syndrome (6)
    • slow onset
    • intermittent pain
    • prolonged stress
    • age 30 or under
    • sedentary
    • diffuse non-specific pain that gets worse as day goes on
  90. on exam...postural syndrome will present with

    no....
    deformity, loss of mmt, pain on mmt, radicular symptoms
  91. tx for postural syndrome
    maintain perfect posture for 10 days

    must correct muscular imbalances
  92. how are dysfunctions named?
    named for what you can't do...

    example...can't extend? = extension dysfunction
  93. characteristics of dysfunction (5)
    • stiffness, sharp pain towards end range
    • intermittent pain
    • decr ROM
    • over 30 am
    • pain worse in AM
  94. on exam of dysfunction
    • poor posture
    • deformity not common
    • always loss of mmt
    • pain at end range
    • when you stretch it it hurts, when you left off its fine
    • no radicular sx
  95. tx of dysfunction
    • might take 4-6 weeks
    • stretch to cause some discomfort
    • 10 reps 10 times a day good start
  96. what is derangement syndrome?
    symptom arising from motion segment

    aka disk bulge
  97. characteristic of derangement (7)
    • sx sudden or gradual
    • insidious onset
    • constant pain that incr/decr with certain postures/motions
    • pain thru range (before resistance) ACUTE
    • early 40s
    • may be worse in AM
    • may have radicular sx
  98. large derangements feel better when.....
    lying down
  99. small derangement feels better when.....
    slightly active
  100. on exam for derangement
    • have deformity
    • centralization of sx
    • decrease ROM
  101. with posterior-posterior/lateral bulges _____(flex/ext) might be VERY limited and painful (no _____periph/central of sx)

    _____(flex/ext) will be painful (possibly limited) does cause peripheralization of sx
    extension

    peripheralization

    flexion
  102. with flexion if symptoms peripheralize suggests a what...?
    DISK problem (derangement)
  103. with extension if symptoms peripheralize suggests a what...?
    STENOSIS
  104. classic posterior/lateral disk
    lateral shift--most shift away from disk bulge, but can depend on axillary or shoulder

    decrease lordosis

    painful thru range extension, centralizes sx

    flexion peripheralizes sx
  105. tx of derangement
    reduction

    maintainence of reduction

    recovery of function

    prevention of recurrence
  106. requirements for having an unstable spine (4 characteristics)
    1. average SLR ROM 91d or more

    2. + prone instability

    3. + aberrant movements

    4. less than 40 yrs
  107. disk generally presses on nerve root of segment ( at/below/above)
    below

    L1 on L2 root, L2 on L3 root
  108. large posterior disk bulge at L4 can do what
    can include all nerves in cauda equina and can result in bowel/bladder sx
  109. when symptoms are worse with sitting suggests?
    deformation of the spine/disk (flexion)
  110. when symptoms are worse with standing?
    extension/ wt on facets or extension dysfunction (extension)
  111. do you do a scanning exam on every back patient?
    YES!!
  112. lumbar myotome:
    L2
    L3
    L4
    L5
    S1
    S2
    • L2=hip flexion
    • L3=knee extension
    • L4=ankle dorsiflexion
    • L5=great toe ext
    • S1=plantar flex/eversion
    • S2=knee flexion
  113. lumbar dermatomes
    • L1 groin
    • L2 medial thigh
    • L3 medial patella
    • L4 medial malleoli
    • L5 top of foot
    • S1 lateral border of foot
    • S2 behind knee
  114. what is the SI compression test?
    push down on ASIS for 60 secs
  115. what is the SI distraction test/
    patient sidelying, push down on iliac crests for 60 secs
  116. standing ROM:
    flexion
    extension
    SB
    rotation
    flex-40-60d

    ext- 20-35d

    SB 15-20d

    rotation 3-18d
  117. what are aberrant movements?
    look for hitching or odd non uniform movements

    indicative of unstable segment(s)
  118. what is prone instability test?
    prone PA glide contracting back extensors raising legs

    if less painful when contracting back extensors + sign
  119. standing (static) may be painful
    prone lying --may be painful
    extension in prone--pain at end range that dissipate quickly no peripheralization
    repeated ext in prone--pain at end range that dissipate quickly no peripheralization

    this explains what?
    extension dysfunction
  120. flexion in standing--pain during (peripher sx)
    flexion in sitting--pain during (peripher sx)
    repeated flex it sittin--pain during (peripher sx)
    prone lying--may be pain (central sx)
    ext in prone-pain during limited
    repeated ext in prone --pain during limited (central sx)

    this explains what?
    posterior-lateral derangement
  121. describe acute, severe LBP
    patient complains/condition so severe that we cannot adequately evaluate it
  122. exam for acute/severe LBP
    • make sure bowels/bladder ok
    • make sure the pain is constant and unchanging
  123. acute/severe LBP contraindications/precautions
    do not cause increase in pain after tx

    NO PERIPHERALIZATION OF SX!!
  124. inflammatory stage of acute/severe LBP characteristics (6)
    • protect body mechanics
    • anti-inflams
    • grade 1 and 2 osteo/artho kinematic mobs
    • PROM within pain free range
    • gentle strengthening
    • general conditioning
  125. describe a muscular strain
    definite history of trauma-they know they did it at the time
  126. AROM and muscle strain
    limited, possibly in both directions

    TOWARD action of the muscle because of pain with contraction

    LIMITED away from action of muscle due to pain with stretch
  127. PROM and muscle strain
    pain with stretch
  128. management of muscle strain
    do not cause overall increase in symptoms with or after tx

    NO PERIPHERALIZATION of sx
  129. disk derangement:

    flexion produces______(periph/centr)

    extension produces _____ (periph/centr)
    flexion.......peripheralization


    extension...........centralization
  130. management of extension dysfunction
    • proper posture
    • prone on elbows
    • add belt fixation
    • add PA mobs
  131. management of flexion dysfunction
    • proper posture
    • supine knees to chest
    • ab strength
  132. (reduction of derangement)

    --correcting the deforomity
    decrease lordosis (prone lying with stomach on pillows)

    lateral shift (prone lateral shift)
  133. if you have a shoulder bulge which side do you side bend to?
    AWAY
  134. if you have an axillary bulge which side do you side bend to?
    TOWARD!!
  135. (reducing the derangement)

    --start with extension (flexion for ant. bulge)
    prone lying

    prone lying in ext

    press ups
  136. (reducing the deranagement)

    --progressions if not improving
    therapist ext mobs

    over corrective lateral shift in prone if posterior lateral
  137. (maintenance of reduction)

    completed after derangement is reduced-pain free or near pain free
    proper posture/body mechanics

    reduce prone press ups, standing ext
  138. (recovery of function)

    after symptoms are very stable, symptom free for 3-5 days
    lumbar stabs

    flex dysfunction? gentle supine to knee to chest no periph of sx
  139. (prevention of recurrence)
    contd education, posture, general fitness
  140. what is the hallmark sign of a facet capsular strain?
    sudden, unexpected trauma to the lumbar spine often including a rotational component with acute symptoms that resolve to include increase end range pain with the same motion of the facets
  141. with a facet strain there is pain:

    on the R side with ______(SB/rotation)

    on the L side with ______(SB/rotation)
    R side with SB


    L side with rotation
  142. what is spondylolisthesis?
    failure of the pars interarticularis and forward slipping of the vertebrae
  143. _____(ant/post) element slips forward, spinous process might go forward somewhat and you will feel and indentation where spinous process is supposed to be
    anterior
  144. management of spondylolisthesis
    NO EXTENSION EXERCISES!!!!

    flexion could help manage sx
  145. lumbar spinal stenosis

    (bilateral/unilateral)

    central canal produces _______ symptoms

    intervertebral foramen produces _______symptoms
    central canal......BILATERAL


    intervertebral foramen ...........UNILATERAL
  146. symptoms of lumbar stenosis
    • extension makes symptoms worse
    • flexion makes symptoms better

    lumbar pain that might include nagging leg pain
  147. management of lumbar stenosis
    • educate on body mechanics
    • flexion exercises
    • address weak abs/tight hip flexors
  148. what is ankylosing spondylitis?
    progressive joint sclerosis and ligamentous ossification which 1st appears in the SI joints and later spread to the lumbar and thoracic spine and rib cage
  149. how does ankylosing spondylitis present?
    • between 20-35 yrs old
    • vague lower back pain and stiffness
  150. management of ankylosing spondylitis
    • patient education
    • firm bed
    • exercise upper back in extension
  151. does the C1 vertebrae have a body?
    no
  152. where does the body of C1 go?
    turns into the odontoid process of C2
  153. rotation past ____d may lead to kinking of the contralateral vertebral artery

    ipsilateral vertebral artery will kink at _____d rotation
    50 contra


    45 ipsil
  154. what direction do the superior facets face?
    upward and backward
  155. what direction do the inferior facets face?
    downward and forward
  156. because of the placement of the facets in the cervical spine this causes rotation and side bending in what direction?
    SAME DIRECTION
  157. nucleus is generally more ______ant/post in the disk when compared to lumbar spine
    anterior
  158. what is the capsular pattern of the cervical spine?
    side flexion and rotatation equally limited

    extension
  159. a tight capsule on R is most limited in what?
    SB on R

    rotation on R

    extension
  160. what are the cervical mytomes?
    • C1, C2=neck flexion
    • C3-neck SB
    • C4-shoulder elevation
    • C5-should abduction
    • C6-elbow flexion
    • C7-elbow extension
    • C8-thumb extension
    • T1-adduction of hand intrinsics
  161. what are the cervical dermatomes?
    • C3-clavicale
    • C4-top of shoulder
    • C5-distal lateral bicep
    • C6-tip of thumb
    • C7-tip of middle finger
    • C8-tip of little finger
    • T1-distal tricep
    • T2-axilla
  162. when do you do a shoulder clearing?
    only do if sx are at shoulder or below
  163. what is the sharp purser test?
    flex the head, web space of PTs hand goes on C2, feel clunk = positive
  164. what is the anterior shear test?
    supine and bring head up and forward

    + test = (B) symptoms down arms

    sliding occurs if transverese ligament torn or dens fractures
  165. Right side pain with right SB and right rotation suggest inability of the facet on painful side to glide _______(downward or upward)
    downward
  166. right side pain with left SB and left rotation can suggest inability of the facet on the painful side to glide _____(upward/downward)
    upward
  167. pain on right side that increases with right side bending and left rotation can suggest what?
    impingement of capsule of facet or painful facet joint surfaces themselves
  168. cervical flexion with palpation---no change
    repeated flexion--no change
    cervical ext with palpation --incr in pain no periph ERP
    repeated ext--incre in pain no periph ERP
    coupled motion toward painful side--incr pain no periph ERP
    coupled motion away painful side--incr pain no periphe ERP

    suggests what?
    R side facet dysfunction (superior cant glide down)
  169. cervical flex with palpation--R upper trap pain PDM
    repeated flex--incr cervical R upper trap PDM
    cervical ext with palpation--cervical pain PDM
    repeated ext--cervical pain decr r upper trap PDM
    couple motion toward pain side--cervical R upper trap pain PDM
    coupled motion away --no change

    suggests what?
    R posterior derangement
  170. what is acute facet impingement?
    sudden, unexpected trauma to the C spine often including a rotational component with acute symptoms that resolve to include increase ERP with SB TOWARD PAINFUL SIDE AND ROTATION AWAY FROM PAINFUL SIDE
  171. treatment for acute facet impingement
    attempt to dislodge the impingement
  172. what ribs articulate with a single vertebra?
    1, 10, 11, 12
  173. ribs ______articulate with 2 adjacent vertebrae and intervening intervertebral disc
    ribs 2-9
  174. T1 facet position
    superior facet faces up and backward

    inferior facet faces down and forward
  175. T2-T11 facet position
    superior facet face up, back and slightly lateral

    inferior facet face down, forward and slightly medial
  176. Rule of 3's:

    T1, T2, T3
    spinous processes AT SAME LEVEL AS BODY
  177. Rule of 3's

    T4, T5, T6
    spinous processes ANGLE DOWN AND ARE LOCATED 1/2 BETWEEN LOWER VERTEBRAE

    example (T4 spinous process half way between T4 and T5)
  178. Rule of 3's

    T7, T8, T9
    spinous processes are located ONE FULL VERTEBRAE BELOW

    example (T7 located in same plane at T8)
  179. Rule of 3's:

    what do T10, T11, T12 do?
    T10...follows suit with T7-T9 one full vertebrae below

    T11 follow suit with T4-T6 halfway between vertebrae

    T12 follows suit with T1-T3 at same level as body
  180. noraml, developmental, asymptomatic small invasions of the vertebral body by the nucleus protruding superiorly.

    most common in lower thoracic and upper lumbar spine
    Schmorl's Nodes
  181. Scheuermann's Disease is what?
    Where spinous processes become very sharp over time

    occurs between 13-16
  182. if there is a problem with the upper thoracic do you do cervical or lumbar myotomes?

    if there is a problem with lower lower do you do cervical or lumbar myotomes?
    UPPER----CERVICAL


    LOWER----LUMBAR
  183. what is levator scapulae syndrome?
    stiff neck and have difficulty with rotation, SB, flexion

    patient will complain of thoracic pain near the upper scapular region

    (rotation and SB to the R affected by L levator scapulae)
  184. if unilateral levator syndrome: will have _____SB and rotation ______ and flexion

    extension will be full
    decrease

    away
  185. if bilateral levator syndrome: will have bilateral ______in SB and rotation
    decrease
  186. rib disorder:

    elevated/exhalation restriction
    rib will not descend with exhalation

    past trauma

    pain usually posterior

    pain with full exhalation
  187. rib disorder:

    depressed/inhalation restriction
    rib will not ascend with inhalation

    pain with full inhalation
  188. what is nutation?
    top of sacrum goes forward
  189. what is counternutation?
    top of sacrum goes backward
  190. when the ilium goes anterior it is also referred to as ____
    counternutation
  191. when the ilium goes posterior it is also referred to as _____
    nutation
  192. patient history for SI joint issue:

    unilateral pain ______ SI joint

    if symptoms are periph/central means SI joint issue
    @ or below SI joint and peripheralization
  193. if you have a hypo right PSIS what does this mean?

    think vorlauf
    right ilium rotated early
  194. if you have a hyper right PSIS what does this mean?

    think vorlauf
    right side doesnt move because of laxity of joint
  195. what is the 1st verse and chorus of the MU fight song?
    1st verse: old missouri, fair missouri, dear old varsity, our hearts that fondly love thee, here's a health to thee

    • chorus: Proud art thou in classic beauty,
    • Of thy noble past;
    • With thy watchwords, Honor, Duty,
    • Thy high fame shall last.

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