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Structural Approach to Patient Care II - Extremities
(Methods 7 Selective) - 33678


 

 
Joseph Sweere, DC
1.0
22.5
1.0
2.0

This class provides NWHSU term 7 chiropractic students with an easily understood, highly reliable structural approach to clinical assessment and the application of specific manual adjustive care for the clinical afflictions of the upper and lower extremities. The class will be primarily a hands-on laboratory experience which will include appropriate explanation, discussion and observation of the fundamentals involved that form the rationale for this approach to chiropractic extremity care.

A variety of specific manual and soft tissue extremity techniques will be discussed, demonstrated and practiced by class participants.  
Please select from the list on the right.

The Institution-wide learning goals define the common ground that unites the programs within the university. They are purposefully broad so that the various colleges and schools can continue to develop their unique identities through varying ways in which the goals are met.

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    Graduates will demonstrate a willingness to recognize the values of others while maintaining one’s own integrity, and act ethically and professionally in all endeavors.
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  5. Service to the Community
    Graduates will understand and value the benefits of service to the community.
  6. Influence of Mind, Body and Spirit on Health
    Graduates will recognize the inter-relationship of the mind, body and spirit and the influence of extrinsic factors on an individual’s health.
  7. Critical Thought and Knowledge Acquisition
    Graduates will acquire, appraise and apply scientific information. Graduates will contextually organize and synthesize relevant information to address an issue or problem.
  8. Competence in one's Discipline
    Graduates will demonstrate competence of appropriate depth and scope for one's discipline.

Course Objectives
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  1. Systematically evaluate human subjects for the presence or absence of structural faults within the upper and lower extremities of the human frame and resultant disturbances within the nervous system with special emphasis on the evaluation for subluxation within the extremities.
  2. In conjunction with their previous training in the clinical and chiropractic sciences they will be able to develop a rational plan for the clinical management of human extremity disorders.
  3. Arrive at an appropriate differential diagnosis through physical, neurological, orthopedic/structural/postural/radiographic/imaging and appropriate laboratory means complimented and directed by a thorough and comprehensive history.
  4. Determine whether the patient would be an appropriate candidate for chiropractic care, referred for allopathic medical care (or other health discipline management) or be co- managed with chiropractic and through one or more health care practitioners of other discipline(s).
  5. Apply the specific methods, adjustive procedures and chiropractic techniques described and demonstrated in the lecture and lab portions of the class, utilizing the Northwestern Health Sciences University Methods Department P.A.R.T.S. Acronym to identify and validate the presence of subluxations and related structural aberrations and pathomechanical consequences.
  6. Possess a clear understanding of a logical, scientifically defensible and practical basis for the practice of chiropractic and have sufficient skills to be able to apply a definitive, goal- directed rationale for case management based on the principles of physics and engineering.
  7. Understand the basis for the methods taught with sufficient conviction that they will be capable of teaching others, including their patients, other health care providers, third party payers, legal advisors, governing bodies and the public in general.
  8. Practice chiropractic in a holistic manner wherein the doctor recognizes that: a human is more than the sum of its individual parts; the human experience has a physical, emotional and spiritual component; optimal health is a manifestation of harmony between the body, mind and spirit; the patient and the doctor are considered equals; the patient is involved in all decisions regarding their care and the patient is primarily responsible for his/her own health.
Materials
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A. Required Text(s):

LEARNING AID:
Two hour DVD recording. Structural Approach to Clinical Case Management - Extremities. J. Sweere. NWHSU bookstore - $4.00


B. Recommended Text(s):

NONE


C. Required Materials for Lab:

NONE
Assignments
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  1. Practice learned techniques on student patients under T-7's care
  2. Attendance at all Lecture and Laboratory Sessions and Demonstrations
Attendance
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Attendance at all laboratory sessions is required.
More than three absences will result in an unsatisfactory grade.
Grading Criteria
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This elective class will be graded on a Pass/Fail basis. In lieu of Midterm and Final examinations a series of four 10-question quizzes will be provided at the end of various three hour sessions. Successful students will have demonstrated their knowledge and skill level with a minimum average of 70% correct answers on written quizzes, and will be capable of accurately assessing and executing the majority of manual adjustive procedures and soft tissue techniques demonstrated and practiced during the course of the term.

Guaranteed grades are as follows:

A = PASS/FAIL
B = N/A
C = N/A
D = N/A
F = N/A
Course Competencies
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COGNITIVE DOMAIN


  1. Identify and reduce the residual subluxation(s) of the cuboid, medial and intermediate cuneiform bones of the foot, and assess and treat the coincidental residual effects of strain of the origins of the posterior tibial and anterior tibial muscles which result from the most common type of ankle sprain (inversion and plantar flexion).
  2. Provide manual and related conservative care for a variety of disorders of the human foot and ankle mechanism as follows:
    • Observe for physical evidence of malfitting shoes
    • Provide measurement of the feet utilizing the Brannock Device to determine as close as possible a correct shoe fit
    • Observe for the presence or absence of Pes Planus
    • Observe for, and by utilizing a simple wood ruler or other straight edge, demonstrate objective evidence for the presence or absence of pronation and/or suppination of each of the ankle mechanism
    • Identify and reduce a medially subluxated talus in the pronated ankle syndrome
    • Identify and reduce an inferiorly subluxated navicular, most commonly found in conjunction with a subluxated talus in the ankle pronation syndrome.
    • Identify and reduce a posterior/superior subluxation of the calcaneus which is commonly found in patient's with plantar fasciitis and/or heel spurs
    • Identify and reduce a laterally subluxated great toe (hallux valgus) at the phalangeal/metatarsal junction
    • Identify and reduce extension malposition/fixations of the 2nd, 3rd, 4th and 5th toes at the phalangeal/metatarsal junctions, commonly associated with metatarsalgia
    • Observe the correct use of a metatarsal pad for assistance with the clinical management of metatarsalgia
    • Observe for the potential for fungal infection of the feet and provide patient instructions for an effective conservative approach to managing this disorder
    • Observe for the potential for ingrown toenails and provide patient instructions for the management and prevention of recurrences of this disorder
    • Observe for the potential for plantar warts and provide patient instructions for an effective conservative approach to managing this disorder
  3. Evaluate and provide care of the knee joint for a variety of mechanical and related soft tissue disorders including:
    • External and internal derangement
    • Osteochondritis dessicans
    • Chondromalacia patellae
    • Quadriceps, tensor fascia lata, adductor muscle shortening, myofascial fibrositis, contracture requiring manual and/or mechanical muscle stripping and stretching techniques
  4. Evaluate for the presence of the four most common forms of bursitis in the region of the hip joint.
  5. Identify and treat a potential trigger point within the muscular aspect of the tensor fascia lata which is causally related to a variety of referred sciatic nerve mimicking pain patterns to the lower spine, ipsilateral sacroiliac joint, groin and lower limb.
  6. Evaluate the sartorius muscle for its potential role in chronic medial knee symptoms.
  7. Evaluate the piriformis muscle to learn its potential role in sciatic nerve symptoms.
  8. Perform and interpret the combined Linder, Soto-Hall and Sitting Von-Becterew test for nerve root entrapment disorders.
  9. Perform the "big four" series of tests to help identify the potential lesion in acute and/or semi-acute mechanical back pain syndromes.
  10. Identify and treat a significant trigger point within the origin of the infraspinatous muscle which may be casually related to anterior shoulder pain and referred pain and parasthesia through the brachial plexus, particularly the median nerve dermatome into the wrist and fingers (often mimicking carpal tunnel syndrome.)
  11. Identify and treat a significant trigger point within the terres major muscle which may be causally related to triceps muscle and posterior elbow syndromes.
  12. Identify and reduce a posteriorly subluxated proximal ulna which is causally related to local elbow and a variety of upper extremity symptoms.
  13. Identify and reduce a postero-laterally subluxated proximal radius which coexists with radio- humeral bursitis/lateral epicondylitis ("tennis elbow").
  14. Identify and adjust the carpal bones of the wrist, with particular emphasis on the carpal tunnel and the adjustment of the capitate
  15. Identify and treat a patient with loss of abduction capacity of the shoulder joint (adhesive capsulitis/partially frozen shoulder) which may be the result of a superior/lateral adhesion/fixation or subluxation of the proximal head of the humerus in its relationship to the glenoid cavity.
  16. Perform and teach patients the Codman's and modified Codman's exercise program for shoulder rehabilitation.
  17. Perform and teach patients how to use the "Therabee" exercise and rehabilitation device for the upper extremity.
  18. Evaluate and treat patients who demonstrate temporo-mandibular joint syndrome with a combination of manual and soft tissue techniques, combined with lifestyle considerations.
  19. Identify and treat a significant trigger point within the sternocleidomastoid muscle which may be causally related to supraorbital, retroorbital, infraorbital or temporal headache syndromes including migraine and cluster.
  20. Evaluate and treat lumbar spondylolisthesis utilizing a unique adjustive maneuver applied to the involved vertebral segment.


Conditions:
STRUCTURAL AND PATHOLOGICAL SYNDROMES AND CONDITIONS
Students will be able to make case management decisions regarding common structural and pathological conditions based on their understanding of the following information regarding each condition: (See key on the following page for the description of codes.)

Clinical Condition Etiology & Epidem Patho-
physiology		 Nat. Hist & Course Exam Diag Rx & Mgmt
Subluxation (extrem) 2 2 2 1,2,3,4,6 1,2,3,4,5
Pes Planus 1 1 1 1,2,3 1,7
Corns/Callouses 2 2 2 1,2,3,4 1,5
Plantar's Warts 2 2 2 1,2,3,4 1,2,3,5,7
Athlete's Foot 3 3 3 1,2,3,4 1,3,5,7
Ingrown Toenails 2 2 2 1,2,3,4 1,5,6,7
Bunion/Hallux Valgus 2 2 2 1,2,3,4 1,2,3,4,5,7
Pes Cavus 1 1 1 1,2,3 1,7
Ankle pronation 2 2 2 1,2,3,4 1,5,7
Ankle sprain 2 2 2 1,2,3,4,6 1,2,3,4,5,7
Knee Derangement 2 2 2 1,2,3,4 1,2,3,4,5,7
Chondromalacia Patella 2 2 2 1,2,3,4 1,2,3,4,5,7
Bursitis; Hip Region 2 2 2 1,2,3,4 1,2,3,4,5,7
ESIL's nodes 2 2 2 1,2,3,4 1,2,3,4,5,6,7
Leg-Length Inequality 3 3 3 1,2,3,4,6,7 1,5,7
Spondylolisthesis 2 2 2 1,2,3,4,6 1,2,3,4,5,7
Tensor Fascia Lata Syndrome 3 3 3 1,2,3,4 1,2,3,4,5,7
Sartorius Syndrome 2 2 2 1,2,3,4 1,2,3,4,5
Piriformis Syndrome 1 1 1 1,2,3,4 1,2,3,4,5
Infraspinatous Syndrome 3 3 3 1,2,3,4 1,2,3,4,5
Terres Major Syndrome 2 2 2 1,2,3,4 1,2,3,4,5
Adhesive Capsulitis (frozen shoulder) 2 2 2 1,2,3,4 1,2,3,4,5
Lateral Epicondylitis 2 2 2 1,2,3,4 1,2,3,4,5
Pronator Terres Syndrome 2 2 2 1,2,3,4 1,2,3,4,5
Orbital/Temporal Headache Syndrome 2 2 2 1,2,3,4 1,2,3,4,5,7
Temporo-mandibular Joint Syndrome 2 2 2 1,2,3,4 1,2,3,4,5,6,7

Elaboration of Coding Definitions Regarding Conditions

The following codes refer to the depth of coverage for Etiology and Epidemiology; Pathophysiology, and; Natural History and Course:

0. No coverage or content
1. Introduction, without test items
2. Moderate class discussion and/or handout material, with test items
3. Extensive discussion/demonstration and/or handout material and test items

For Examination and Diagnosis, the following numbers indicate which aspects of exam and diagnosis of each condition are taught/presented in this course:

  1. Presenting symptoms
  2. History findings
  3. Exam findings
  4. Chiropractic findings
  5. Lab findings
  6. Imaging findings
  7. Special test findings


For Treatment/Clinical Management, the following numbers indicate which aspects of treatment and management of each condition are taught/presented in this course:

  1. Chiropractic
  2. Physiological therapeutics
  3. Nutritional considerations
  4. Exercise/Activity/Restrictions
  5. Lifestyle Management
  6. Medical
  7. Other
  8. Guidelines (published)


PSYCHOMOTOR DOMAIN


CLINIC EVALUATION SKILLS
Students will be able to conduct an appropriate structure/function evaluation for patients presenting with a wide variety of clinical syndromes.

ADJUSTIVE SKILLS
Students will also be able to select and properly employ the following treatment techniques for patients who present with a wide variety of structurally related clinical syndromes:

  1. Position the patient in the the most appropriate posture(s) the patient should be positioned in for the optimal delivery of the adjustive reduction of each subluxation that is presented, whether prone, supine, side-posture or sitting or combinations thereof with refinements of each position based on the structural adjustive model presented by the instructor.
  2. Assume the most appropriate posture(s) for the doctor to be positioned in relation to the patient's body to optimize the doctor's adjustive efficiency, accuracy and effectiveness with an overall aim to optimize the doctor's strength/leverage and to preserve the doctor's energy and wear and tear on his/her body parts.
  3. Apply physical forces which address absolute and predetermined line(s) of drive to effectively reduce extremity subluxation(s) with an emphasis on the application of mechanical "torque" when more than one translation from normal exists in a given subluxation finding.
  4. Execute and deliver the specific adjustive reduction of extremity subluxations based on optimal patient relaxation response, patient/doctor position, line(s) of drive/vectors of forces involved, gentle, firm, slow, passive movement of the joint mechanism through appropriate planes of motion until all tissue slack is taken up and follow through with sufficient specifically directed gentle force to reduce the malpositioned (subluxated) joint surfaces.
  5. Employ appropriate and accurate digital contact(s) to muscle and fascia to identify (and treat) active trigger points by replication of predictable and reproducible patterns of symptom(s) presentation.

In addition, students will be able to advise and instruct patients regarding various therapeutic and primary and secondary/tertiary prevention considerations for the conditions presented. These may include:

  1. Lifestyle and nutritional factors including special dietary supplementation
  2. Psychosocial and attitudinal factors
  3. Occupational exposure and ergonomic factors
  4. Exercise and stretching techniques
  5. Shoe fit/selection, beds, pillows, sleep postures
  6. Stress management
  7. Holistic health care orientation and patient responsibility


AFFECTIVE DOMAIN


Students will demonstrate maturity, integrity, intellectual curiosity, objective reasoning, respect, courtesy, compassion and professionalism at all times, both in lectures and labs, and will be able to apply the history, physical examination and treatment interventions demonstrated and discussed in this course with any appropriately chosen patient while demonstrating those same qualities.
Weekly Calendar of Learning Objectives
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Week Dates Topics/Learning objectives
Week 1 --

Introduction to Extremity Case Management

Students are introduced to a specific method of adjusting the subluxated great toe, phalanges, as indicated; as well as the cuboid, intermediate and medial cuneiform bones of the foot, which are a common residual of the most common variety of ankle sprain that being a combination of inversion and plantar flexion. They are also introduced to the presence of trigger points within the bellies and attachments of the tibialis anterior and tibialis posterior, which also commonly result from inversion/plantar flexion ankle sprains.
Students are taught a simple method of documenting the presence or absence of ankle pronation or ankle suppination, being able to quantify this phenomenon in degrees away from normal. Students will observe a simple method for evaluating for and reducing a medially subluxated talus and inferiorly, subluxated navicular which are commonly encountered in patients with pronation of the ankle.

A demonstration of simple and effective reduction of subluxations of the great toe and the metatarsal phalangeal joints will be provided.

Discussion will feature slides and case presentations of common foot disorders, including bunions, corns, callouses, plantar fasciitis, pes planus, pes cavus, metatarsalgia, heel spurs, short achilles tendons, talipes equinovarus, ingrown toenails, fungal infections, plantar's warts and Morton's foot.

Students will continue to provide specific adjustive care to their chosen partner based on the structural model they have now become acquainted with.

Week 2 --

Students will be shown how to utilize the "Brannock" device for measuring foot size and proper fitting of shoes, including a variety of physical factors which indicate that a patient's shoes do not fit properly.

A demonstration will be provided of an effective method of adjusting the calcaneus, talus, the navicular and medial cuneiform; along with discussion of the clinical management of plantar fasciitis and heel spurs.

A demonstration will be provided of an effective means of adjusting the distal and proximal fibula.

A volunteer student patient will be assessed for indications of instability and/or signs of derangement of the knee joint. A test will be shown to assist in the identification of chondromalacia patellae.

The sartorius muscle will be evaluated for its potential for causing chronic medial knee symptomatology, especially as a residual in patients who have undergone medial knee compartment derangement.

Muscle "stripping" of the lower extremity musculature will be demonstrated with relevant clinical discussion provided.

Students will continue to provide specific adjustive care to their partner based on the structural model they have now become acquainted with, which will now include lower extremity evaluation and care.

Ten question quiz will be given
Week 3 --

The second discussion from the Predisposing Factors manual will be on the topic of limb-length inequalities. Idiopathic and acquired varieties, including those due to trauma as well as disease will be demonstrated on slides showing actual patients with a variety of symptom presentations. Suggestions for using heel lifts and heel and sole lifts will be part of the discussion.

A review of the evaluation for the four common types of bursitis in the region of the hip joint, groin and buttocks, including superficial trochanteric, deep trochanteric, ilio-pectineal and ischial, will be described and demonstrated on a volunteer subject. Differential diagnosis, theories of etiology, mechanisms of insult and clinical symptoms and pain referral patterns and presentations of each will be described. A variety of therapeutic interventions will be described and demonstrated.
Week 4 --

A demonstration of and evaluation for the presence of a significant trigger point within the belly of the muscular component of tensor fascia lata will be conducted with the assistance of student volunteers. The sciatic nerve mimicking pain referral patterns of this syndrome will be reviewed and demonstrated among symptomatic students.

Students will continue to provide specific adjustive care to their partner and will include evaluation and care of the lower extremities.

A ten question quiz will be given

Week 5 --

This week will be devoted to the common afflictions of the hip joint in children and early adolescence. Legg-Calve' Perthe's Disease (Coxa Plana) and Slipping of the Femoral Capitus (Coxa Vara) will be demonstrated on slides and discussed from a clinical standpoint. Age of onset, theories of etiology, differential diagnosis, radiographic findings, radiographic views required, need for referral and co-management will be reinforced, with special emphasis on accurate differential diagnosis during the early clinical presentation.

Students with chronic anterior shoulder pain will be solicited and a demonstration of a significant trigger point which occurs within the origin of the infra-spinatus muscle with referral to this region of the shoulder joint. Commonly this trigger point will also refer pain and/or parasthesia into the brachial plexus and relate to typical shoulder-arm-hand syndromes including the carpal tunnel syndrome.

A demonstration of the reduction of a superiorly and laterally subluxated humerus will be provided which commonly restricts comfortable abduction of the upper extremity at the shoulder. This condition is involved with adhesive capsulitis (frozen shoulder).

A demonstration of Codman's and modified Codman's exercise for shoulder rehabilitation will be shown to the class.

Students will continue to provide specific adjustive care to their partner and will now also include evaluation and care of the shoulder and upper extremities.
Week 6 --

A demonstration of a trigger point within the belly of the terres major muscle will be provided, which refers pain into the region of the triceps and to the posterior aspect of the elbow joint.

A demonstration will be provided for the reduction of a posteriorly subluxated ulna, as well as a postero-laterally subluxated radius for elbow disorders. The proximal radius subluxation is causally related to lateral epicondylitis/radio-humeral bursitis (tennis elbow).

A demonstration will be provided for the evaluation and treatment of a significant trigger point within the origin or belly of the pronator terres muscle at the elbow which is causally related to symptoms of medial nerve entrapment disorders including carpal tunnel syndrome.

A demonstration will be provided of a general manipulative reduction of adhesions/fixations of the wrist joint.

A demonstration of a specific manual adjustment of the wrist joint for the presence of a subluxated capitate bone in the management of Carpal Tunnel Syndrome.

A demonstration of the use of the Therabee exercise device which is used for strengthening the upper extremity.

A demonstration of two approaches to the effective reduction of general adhesions and joint fixations of the wrist, as well as the specific reduction of subluxation of the lunate and the base of the thumb.

A demonstration will be provided for the evaluation and treatment of a significant trigger point within the sternocleidomastoid muscle which is causally related to supraorbital, infraorbital, retrorbital and temporal headaches. An associated reflex point at the base of the great toe will also be demonstrated.

Students will continue to provide specific adjustive care to their partner and will now include lower and upper extremity clinical management as indicated.

Ten question quiz will be given
Week 7 -- Class discussion and demonstration regarding the chiropractic case management of temporo-mandibular joint syndrome will be provided. Common predisposing factors and lifestyle considerations will be included along with recommendations regarding referrals to dentists/oral surgeons who are appropriately trained to most effectively co-manage these disorders.
Week 8 -- -
Week 9 -- -
Week 10 -- -
Week 11 -- -
Week 12 -- -
Week 13 -- -
Week 14 - -
Week 15 -- -
Please Note
This schedule of lecture and lab topics and quizzes and exams may be changed during the course of the trimester as circumstances require. Whenever possible, such changes will be announced in class before the date and time in question. You are responsible for anything that transpires during lectures and labs, even when you are unable to attend. In the event that you miss a class session, make sure you check with a classmate about any announcements or schedule changes which may have been made. Makeup exams are allowed only according to the policies described in the current student handbook, which is available in the Student Affairs office.
Maintained by Northwestern College of Chiropractic
Last updated: 16 August, 2005
 

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