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What are 6 causes of subluxations?

Single traumatic event.
Repetitive microtrauma.
Uncoordinated movement.
ADL's with unstable spine.
Reflex from visceral disease.


What are the myopathic components of the subluxation that is causing pain?

Shearing b/w msl fibers irritate nociceptors.
Sustained load at the msl. attachments cause pain.


What is the broken door hinge analogy?

Hypo or hypermobility results in a shift of the axis of rotation in the motion unit resulting in abnormal loads and irritation of tissue.


What is the misalignment analogy?

A misaligned tire has a shifted axis of rotation causing uneven wear and faster wear on the tire.


How does hypomobility in one joint affect the mobility of another joint?

Hypomobility may cause hypermobility in other joints.
(hypermobility causes abnormal loads and joint irritation).


What are the immediate effects of hypomobility?

A restricted joint probably doesn't hurt, but what is causing the restriction may be generating pain (msl spasm, trapped meniscoid, co-existing injury).


What are the intermediate effects of hypomobility?

Pain due to wear and tear on local tissue from shifted axis of rotation or pain from compensatory altered motion in other joints in the same motion unit or compensations in other joints.


What are the longterm effects of hypomobility?

Pain from degenerative tissue breaking down b/c of lack of local circulation of synovial fluid.


What can long standing hypomobility of a joint lead to?

Degeneration of the joint.


Based on an animal model, how many weeks of fixation lead to degenerative changes?

4-8 weeks.


Animal model: After 8 weeks of joint fixation, were the changes in the joints reversible?

The changes didn't appear to be reversible.


What are the 5 proposed musculoskeletal effects of adjusting?

1) Suppress both local and referred pain.
2) Reduce msl spasm.
3) Restore segmental/global mobility.
4) Activate inhibited msls.
5) Restore proper proprioceptive input.


Why does adjusting cause a reduction of msl spasms?

Likely a reflex from stimulation of second order neurons in the spinal cord. (not from stretch on the msl).


What are the 3 proposed ways that adjusting restores segmental/global mobility?

1) Temporary increase in motion due to changes in synovial fluid.
2) Gap joints and break down adhesions.
3) Releasing entrapped meniscoid fragment.


What are deep referred pain syndromes also known as?

Somatic referred pain or scleratogenous pain.


What is it called when a patient with irritated joints or msls in the next feels pain or other symptoms spreading out over their shoulders, between their shoulder blades, and even into their arms even though there is no pinched or injured nerve?

Deep referred pain syndrome.


What is the convergence-projection theory?

Peripheral pathways converge.
Common central pathway is facilitated.
Central sensitization occurs.
Hypersensitivity and spontaneous pain projects into scleratomes.
(See first 3 slides on page 5 for an example).


What kind of syndromes involve nerve root damage?

Radicular syndromes.


When do radicular syndromes occur?

When the nerve root is compressed or irritated or both.


What does an irritated nerve root cause?

Pain, paresthesia, increased sensitivity.


What does a compressed or torn nerve root cause?

Loss of function: loss of senstion, strength or reflex.


What are radicular symptoms? (from the history)

Dermatomal pain.
Pain may be sharp or electrical.
Dermatomal paresthesia.
Reports of subjective numbness or weakness.


What are radicular signs? (from the physical)

Positive tension tests suggest nerve root irritation.
SLR: pain/paresthesia must radiate past the knee for hard positive.


What are the 2 questions to ask to help interpret a soft positive in a tension test?

Was the quality of the nerve tension pain nerve pain?
Is there any other evidence that the nerve is damaged in any other way whatsoever?


What do neurological deficits suggest?

Compression/cell damage.
(Atrophy, loss of motor strength, Depressed DTR, Sensory loss).


What are the symptoms of deep referred pain? (from the history)

Diffuse pain.
Less likely to cross the knee/elbow.


What are the signs of deep referred pain? (from the physical)

Negative tension tests.
No neuro deficits.


In most back pain, what is the mechanism involved?

Stimulation of nerve ending in the affected structure.
("Nerve root compression is in no way involved").k


What makes nerve roots vulnerable?

Less tissue protection.
More sensitive to compression and irritation.
More sensitive to ischemic changes.


Compression: How is AP velocity and amplitude effected?

Reduced at site of injury.


Compression: Is velocity change permanent or temporary?



Compression: Is amplitude change more temporary or permanent?

More permanent.


Compression: Is rapid onset or slow onset more damaging?

Rapid onset is more damaging.


Does acute compression of normal NR cause pain?

Usually not.


What does NR compression cause?

Numbness, paresthesia, weakness.


irritation + minimal compression = ?

Radicular pain.


Are smaller or larger fibers more susceptible to compression?



Does 10 mmHg at 2 sites have more effect on AP's than 50 mmHg at 1 site?

10 mmHg at 2 sites.


How much of the IVF is taken up by the NR and its sheaths?



What is the rest of the IVF filled with?

Connective and adipose tissue.


How likely is it that severe compression signs are due to subluxation syndromes alone?

Very unlikely.


How likely is it that mild compression signs are due to subluxation syndromes alone?

Not likely.


T/F: Radiating pain is usually due to irritated nerve roots.

False. Radiating pain is Not usually due to irritated nerve roots.
(Nerve tension test will usually be negative).


What should you first think if a patient presents with dermatomal pain/paresthesia and positive nerve tension test?

Chemical/mechanical irritation from disc herniation, osteophytes, stenosis, or tumors.


What are some chemical irritants that may be associated with joint dysfunction?

1) From the disc: Glycoproteins, lactic acid.
2) From local inflammation: H+ ions.
3) nerve root adhesions.


What is the co activation model?

Manipulation acts as a "counter-irritant" closing the pain gate.
It activates multiple pools of tissue r/c's composed of both mechanoreceptors (short term inhibition) and nociceptors (longer term inhibition).
May help block central sensitization.


What is contracture?

Abnormal, usually permanent shortening of tissues.


What is allodynia?

Pain d/t a stimulus that usually does not provoke pain.


What is radiculopathy?

Refers to a set of conditions in which one or more nerves is affected and doesn't work properly. Can result in pain, weakness, numbness, or difficulty controlling specific muscles.


What are WDR neurons?

Convergence neuron whose cell bodies are located in the dorsal horn. Responsive to all somatosensory modalities (thermal, mechanical, chemical stimuli).


A patient complains of low back pain that radiates into the posterior thigh and complains of numbness in the right foot. Physical exam reveals light tough and pain sensation are diminished over the symptomatic foot; ankle muscles test 4/5 on the symptomatic side; DTR's are +2. Nerve tension tests aggravate the pain as far as the calf.

Radicular syndrome, specific evidence of BOTH root compression and irritation.


A patient has pain that radiates into the groin and over the quadriceps; there are no neurological deficits; nerve stretch tests produce no symptoms.

Deep referred pain syndrome.


A patient complains of subjective numbness in his toes as well as low back pain radiating to the foot. The SLR reproduces the pain, but only as far as the calf. There are no neurological deficits.

Radicular syndrome, specific evidence of root irritation.


A patient presents with low back pain and right anterior thigh pain. The femoral stretch test creates a sharp pain along the front of the thigh but it does not cross the knee; the patellar DTR is +2, The patient has trouble resisting knee extension; there is no loss of sensation.

Radicular syndrome, specific evidence of BOTH root compression and irritation.


Pain radiates from the neck to the elbow. Shoulder depression and the brachial stretch test cause symptoms to the forearm. The biceps reflex is 0; shoulder abduction is mildly weak. The patient has no loss of sensation with routine "dull-sharp" and cotton ball testing.

Radicular syndrome, specific evidence of BOTH root compression and irritation.


What factors increase the development of degenerative joint disease (osteoarthritis)?

Shift in axis of rotation.
Long standing hypomobility.


What are the 4 components of subluxation syndrom?

Kinesiologic, myopathic, neurologic, and static malposition.


What is the working definition of subluxation syndrome?

A joint lesion which may be associated with poor mechanical function, either local or referred pain, along with adverse effects on the nervous system and its target organs.