Middy Flashcards

1
Q

Cox’s first patient

A

1963

He did side posture and pt had to be carried out of his office, blew her disc, L4 disc surgery the next day

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2
Q

Who invented the original flexion distraction table?

A

John MCMannis

He was an osteopath. Dr. Cox says in Chiro school a Dr. Blackmore would take him to use this osteopathic table for acute LB pts.

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3
Q

Dr. Cox worked with _____ to make the first Chiro lumbar flexion distraction table.

Year?
Tables since then?

A

Mr Jim Barnes

1972, Barnes Chiro-Manis Table
1973 - 1984, Zenith-Cox table
2001, Distraction enterprise
2004, Track corporation
2007, Haven Innovation - Cox 8
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4
Q

What is Dr. Cox’s personal experience with disc herniations?

A

1981, removed post from ground, sudden LBP, next AM bent over and felt tearing in LB. Leg pain became unbearable. 3 wks later, Cauda Equina. L5/SS1 fragment, had micro-lumbar discectomy

1984, Cox’s wife developed C6 herniated disc making him expand into cervical spine

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5
Q

What is the difference between Cox and Intervertebral Disc Distraction (IDD)?

A

No specific level in IDD.

Cox is 1 specific vertebral level with applied force, IDD is a general traction throughout the entire spine

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6
Q

T/F

Research showed Cox to have side effects in clinical application of manipulation compared to other forms.

A

FALSE

JMPT, Parker College found almost NO side effects compared to Diversified, Thompson and Gonstead - to the doctor OR patient

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7
Q

What are the 4 effects of Cox flexion distraction?

A
  1. Increase disc space
  2. Increase IVF (up to 28%)
  3. decrease intradiscal pressure
  4. Restore facet joint physiologic ROM

…as found in federally funded research by Gudavalli

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8
Q

T/F

A significant increase in fiscal pressure is observed during flexion-distraction.

A

FALSE

a decrease in pressure (by almost 192mm/Hg)

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9
Q

T/F

Flexion-straction widens space available in the anterior vertebral region for neural elements.

A

FLASE

widens posterior regions - dorsal column

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10
Q

T/F

EMG activity increases with flexion-distraction and should be monitored by clinician during procedure

A

TRUE

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11
Q

Name some general effects of flexion-distraction in the lumbar spine

(There are 8)

A
  • increase posterior disc height
  • increase IVF
  • decrease intradiscal pressure
  • decrease disc protrusion and stenosis
  • stretched Lig. Flavum
  • Opens vertebral canal
  • increases metabolic transport into the canal
  • opens apophyseal joints

…and extension-distraction will do the complete opposite

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12
Q

Frequency of visits?

A

Daily!

until have improved by 50%, then every other day, 2x/wk, 1x/wk

No subjective/objective improvement in 30 days = consider additional testing (MRI, CT, EMG) refer to neuro/ortho

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13
Q

What is the quintessential clinical finding for referral?

A

Progressive deterioration of motor function

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14
Q

The disc is a 3 joint complex. What are the joints?

A

2 facet joints - synovial (diarthrosis)
1 disc - cartilaginous (amphiarthrosis)

  • PLL is dividing line between posterior column (Dorsal rami pain) and anterior column (Discogenic pain)
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15
Q

What are the four parts of the disc?

A
  1. Annulus
  2. Nucleus
  3. Cartilaginous endplate
  4. Water
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16
Q

T/F

The nucleus has a low concentration of proteogylcans

A

FLASE

high concentration

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17
Q

What are proteoglycans made of?

A

proteins and carbohydrates

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18
Q

T/F

Proteoglycans within the nucleus are negative which attract Na+/K+, which then attracts water and nutrients through osmosis.

A

TRUE

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19
Q

Type ____ collagen is found in the annulus fibrosis. What does it do?

A

Type I - withstand tensile forces, pull strength, are rigid, inflexible and inelastic

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20
Q

Type _____ collagen is found in the nucleus pulpous. What does it do?

A

Type II - resists compression

21
Q

What 3 cells are within the cartilaginous endplate, called the “Manufacturing Plant”?

A

fibroblasts, chondroblasts, osteoblasts

22
Q

Where are the cartilaginous endplates most permeable?

A

in the center, adjacent to the nucleus pulposus

23
Q

T/F

The highest concentration of water is in the nucleus which controls hydrostatic pressure within the disc

A

TRUE

*the greater the internal hydrostatic pressure, the more taught the fibers of the annulus

24
Q

The IVDs are responsible for ____%of the length of the vertebral column

A

25%

25
Q

Properties of annulus circumferential lamella…

A
  • 10-25 concentric rings
  • 60 degree angle to the coronal plane
  • oriented in opposite directions
  • thickness increases gradually from nucleus to annulus
  • collagen fibrils in a parallel arrangement
26
Q

Why are the collagen fibrils in the nucleus arranged in a more disorganized way?

A

more granular proteoglycans attached to mucopolysaccharide-proteins allowing water to bind

27
Q

The IVD is avascular after puberty. How does the disc receive nutrients?

A

capillary beds within the endplates allow passive diffusion driven by osmotic pressure. This is facilitated by spinal motion

28
Q

Define: Imbibition

A

profusion/absortion and retaining large amounts of water thru endplates

  • from proteoglycans and hydrodynamic gel attracting Na+/K+
29
Q

The dry weight of the nucleus is ____% of its wet weight

A

15%

30
Q

Each lumbar IVD is approximately _____ mm in height

A

10-12 mm

31
Q

T/F

Disc height is fully restored at night in the recumbent position through imbibition

A

TRUE

  • discs decrease in height throughout day from ADLs
32
Q

When a well hydrated disc is bisected, the nucleus will swell up. This is caused by intradiscal _______ pressure.

A

Hydrostatic

33
Q

T/F

Throughout the day, the disc will decrease in height because it is losing water and Na+/K+.

A

FALSE

  • looses water but retains Na+/K+, increasing electrolyte concentration, causes osmotic gradient allowing rapid re-hydration at night. This is passive diffusion driven by an osmotic gradient
34
Q

What are the 3 directions that cause IVD injury?

A
  1. Shear
  2. Torsion
  3. Long Axis distraction (Y-axis)
35
Q

Which vertebral movement is utilized in Cox? Why?

A

Long axis distraction, causes both directional fibers to become taut creating vacuum phenomenon, draws disc within itself

(Chinese Finger Puzzle)

36
Q

What is Elastin? Where is it located in the IVD?

A
  • a CT protein allowing tissue to resume shape after stretching and contracting
  • cross-bridges between the lamella acting like a glue

*5x more flexible than a rubber band

37
Q

Which segment has the greatest degree of flexion/extension in the lumbar spine?

A

L5/S1

*80-90% of F/E happen between L4-S1; 20-25% L4/L5 and 60-75% L5/S1

38
Q

During Flexion/Extension, the axis of rotation passes close to the nucleus in the ______ of the disc

A

posterior 1/3

39
Q

Most probable lumbar disc herniation between L3, L4 or L5?

A

*L4 - 49%
*L5 - 43%
L3 - 6%

40
Q

Beyond 3 degrees of rotation, what happens to the facets in the lumbar spine?

A

1 facet is jammed creating a shearing stress, the other facet is gapped creating a strain

Can lead to 1 avulsion/compression, 2 circumferential tear when the elastin gives way

41
Q

Etiology of disc herniations (8)

A
  1. Congenital (weak collagen fibers)
  2. Repetitive micro trauma
  3. Accumulated micro trauma
  4. Poor nutrition (can’t form correct protein/collagen matrix)
  5. Poor health habits (smoking, not working out)
  6. Biomechanics forces (Farfan)
  7. Autoimmune factors (leaking nuclear material causing leukocyte immune response)
  8. Biochemical changes (inflammatory cytokines, discogenic pain, phospholipase A2 and arachidonic acid)
42
Q

What are the 2 ways Farfan states IVDs can injure?

A
  1. rotation
  2. compression

**the facet is injured 1st, the disc 2nd

43
Q

A normal disc and withstand ____ degrees of torsion before failure.

A degenerated disc and withstand ____ degrees of torsion before failure.

A

23 degrees

14 degrees

44
Q

What is Farfan’s torsion test?

A

. Pt placed on pillow for slight hip flexion. Doc stabilizes pt ilium and rotates opposite ilium. Pain indicated rotational injury, do NOT do side posture

45
Q

T/F

Panjabi and White show the annulus bulges toward the convex side of the lumbar spine due to taut annular fibers.

A

FLASE

  • concave side buckles and blues, convex side draws inward
  • *because type I fibers in annulus are inelastic
    • nucleus displaces toward convex side because type II fibers
46
Q

Is there more intradiscal pressure created when sitting or standing?

A

Sitting

47
Q

Contained vs non contained disc lesion

A

contained - annulus partially torn but still restraining nucleus

non contained - annulus fully torn allowing nuclear material to leak, extrude, sequester

48
Q

4 types of annular tears

A
  1. concentric/circumferential/peripheral
  2. radial
  3. rim lesion (from disc to apophyseal ring)
  4. transverse