OPP 2 PIAT Study Guide Written Exam 3 Spring 2024 PDF

OPP 2 PIAT Study Guide Written Exam 3 Spring 2024  Osteopathic Concepts For ANY disease state, the patient must be STABLE before performing OMT*** The sicker/weaker/more injured a patient is, use gentler techniques (examples include rib raising, BLT, MFR...

OPP 2 PIAT Study Guide Written Exam 3 Spring 2024  Osteopathic Concepts For ANY disease state, the patient must be STABLE before performing OMT*** The sicker/weaker/more injured a patient is, use gentler techniques (examples include rib raising, BLT, MFR, soft tissue, etc.) Somatic dysfunction can occur anywhere in the body at Sympathetics levels Paraysmpathetic levels Soma (not autonomic related) Viscerosomatic reflexes occur at Sympathetics levels Parasympathetics levels Facilitated segments ONLY occur at Sympathetics **** Know your sympathetic levels, parasympathetic levels. If sympathetic is not in your answer choices, see if a parasympathetic level to that organ is present (lot of people tend to forget about the parasympathetics). For example, upper (proximal) ureters sympathetically are T10-T11, and the parasympathetic innervation is vagus (so OA, AA (C1), C2 can affect the upper (proximal) ureters.  Important Concepts Most commonly used form of contraction in muscle energy is isometric contraction Translation to the right=left side-bending, translation to the left=right side-bending C3,4,5 keeps the diaphragm alive. C3,4,5 innervation to thoracoabdominal diaphragm Soft Tissue techniques are DIAGNOSTIC as well as THERAPEUTIC Feather’s Edge refers to perceived quality of motion at the RESTRICTIVE BARRIER Indication for HVLA is a distinct, solid barrier. Need a firm end-feel Sympathetic innervation to the Head and Neck: T1-T4 Upper cervical area and sacrum are connected by dural connections AA (C1 on C2) accounts for 50% of the cervical spine’s rotational motion OA (C0 on C1) accounts for 50% of the cervical spine’s flexion/extension motion Spurling test assesses for neural foraminal narrowing Sternocleidomastoid muscle will rotate and sidebend the neck in opposite directions Occiptomastoid suture dysfunction can cause nausea and vomiting Avoid upper cervical direct manipulation (HVLA, articulatory, etc.) on upper cervical spine in rheumatoid arthritis, Down Syndrome, ligamentous instability Somatic Dysfunction Somatic dysfunction is an impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements. Diagnosed by T.A.R.T. T: Tissue Texture Changes A: Asymmetry R: Restriction of motion T: Tenderness Always named for the way it likes to go In axial spine, the reference point is the superior/anterior aspect of the vertebra Not all somatic lesions are somatic dysfunctions. Fractures, sprains, degenerative processes, and inflammatory processes are not somatic dysfunctions.  5 Osteopathic Models Biomechanical (structural, postural) Anatomy of muscles, spine, extremities; posture, motion OMT directed toward normalizing mechanical somatic dysfunction, structural integrity, physiological function, homeostasis Neurological Emphasizes CNS, PNS and ANS that control, coordinate and integrate body functions Proprioceptive and muscle imbalances, facilitation, nerve compression disorders, autonomic reflex and visceral dysfunctions, brain/CNS dysfunctions Respiratory/circulatory Emphasizes pulmonary, circulatory and fluid (lymphatic, CSF) systems Lymphatic techniques Metabolic/Nutritional Regulates through metabolic processes Behavioral (psychobehavioral) Focuses on mental, emotional, social and spiritual dimensions related to health and disease  Palpating Somatic Dysfunction ACUTE CHRONIC Recent history (injury) Long-standing Sharp or severe localized pain Dull, achy diffuse pain Warm, moist, sweaty skin Cool, smooth, dry skin Boggy, edematous tissue Possible atrophy Erythematous Fibrotic, ropy feeling tissue Local increase in muscle tone, Pale/skin pallor contraction, spasm, increased muscle spindle firing Decreased muscle tone, contracted muscles, sometimes flaccid Normal or sluggish ROM Restricted ROM May be minimal or no somatovisceral effects Somatovisceral effects more often present “Old is cold, hot is not” Look to see if the underlying cause of a patient’s presentation has been long standing. They might complain of something recently but have had a condition going on for months prior to their complaints therefore making it a chronic issue. For instance, fatigue may be due to a slow GI blood lose over many months. Remember a visceral problem will not give you a firm end feel, but a rubbery end feel  Fryette Law 1 ¡ When side-bending is attempted from N neutral (anatomical) position, rotation of vertebral bodies follows to the opposite direction. ¡ Typically applies to a group of vertebrae (more than two) ¡ Occurs in a neutral spine (no extreme flexion or extension) NO SAGITTAL COMPONENT ¡ Side-bending and rotation occur to opposite T2-6 RRSL sides ¡ Side-bending precedes rotation ¡ Side-bending occurs towards the concavity T2-6 N RRSL of the curve ¡ Rotation occurs towards the convexity of the curve ¡ Diagnosed as a Type I dysfunction T2-6 N SLRR Fryette Law 2 ¡ When side-bending is attempted from non- F neutral (hyperflexed or hyperextended) position, rotation must precede side-bending to the same side. E ¡ Typically applies to a single vertebra ¡ Occurs in a non-neutral spine (flexion or extension of spine present) SAGITTAL COMPONENT ¡ Side-bending and rotation occur to same sides ¡ Rotation precedes side-bending T4 E RLSL ¡ Rotation of the vertebra occurs into the concavity of the curve ¡ Diagnosed as a Type II dysfunction T4 E SLRL ¡ May be described as traumatic injury T4 E SRL 8  Orientation of Orientation of Superior Facets Inferior Facets Region Facet Orientation Mnemonic Region Facet Orientation Mnemonic Cervical Backward, BUM Cervical Anterior, Inferior, AIL Upward, Medial Lateral Thoracic Backward, BUL Upward, Lateral Thoracic Anterior, Inferior, AIM Medial Lumbar Backward, Medial BM /BUM Backward, Lumbar Anterior, Lateral AL/AIL Upward, Medial Anterior, Inferior, Lateral Reflexes somatosomatic reflex, localized somatic stimuli producing patterns of reflex response in segmentally related somatic structures. For example, rib somatic dysfunction from an innominate dysfunction. somatovisceral reflex, localized somatic stimulation producing patterns of reflex response in segmentally related visceral structures. For example, triggering an asthmatic attack when working on thoracic spine. viscerosomatic reflex, localized visceral stimuli producing patterns of reflex response in segmentally related somatic structures. For example, gastritis affecting musculature. viscerovisceral reflex, localized visceral stimuli producing patterns of reflex response in segmentally related visceral structures. For example, pancreatitis and vomiting, or myocardial infarction and vomiting  Sympathetic levels Head and Neck: T1 – T4 Appendix: T10 – T11 Heart: T1/T2 – T5/T6 Kidneys: T10 – T11 Respiratory: T1/T2 –T6/ T7 Adrenal Medulla: T10 Esophagus: T2 – T8 Upper Ureters: T10 – T11 Upper GI Tract: T5 – T9 Lower Ureters: T12 – L1 – Stomach, Liver, Gall Bladder, Spleen, Bladder: T12 – L2 Pancreas, Duodenum Gonads: T10 – T11 Uterus & Cervix: T10 – L2 Middle GI Tract: T10 – T11 Erectile tissue: T11 – L2 – Pancreas, Duodenum, Jejunum, Ileum, Prostate: T12 – L2 Ascending colon, Right Transverse Colon, Kidney, Upper Ureter, Gonads Arms: T2 – T8 Legs: T11 – L2 Lower GI Tract: T12 – L2 – Left Transverse Colon, Descending Colon, Sigmoid colon, Rectum, Prostate, Bladder, Lower Ureter Vertebrae will rotate towards the side of the dysfunction Cholecystitis will have T5-T9 rotating right Gastritis will have T5-T9 rotating left Sympathetic levels Parasympathetic levels Heart: T1 – T5 Heart: OA, C1, C2 (Vagus) Lungs: T1 – T6 (T2-T7) Lungs: OA, C1, C2 (Vagus) Stomach: T5 – T9 Stomach: OA, C1, C2 (Vagus) Gallbladder: T5 – T9 Gallbladder: OA, C1, C2 (Vagus) Upper/Proximal Ureters: T10 – T11 Upper/Proximal Ureters: OA, C1, C2 (Vagus) Lower/Distal Ureters: T12 – L1 Lower/Distal Ureters: S2 – S4 Prostate: T12 – L2 Prostate: S2 – S4 Vertebrae will rotate towards the side of the dysfunction Cholecystitis will have T5-T9 rotating right Gastritis will have T5-T9 rotating left Parasympathetic Levels Vagus Nerve (OA, AA, C2) Trachea, esophagus, heart, lungs, liver, gallbladder, stomach, pancreas, spleen, kidneys, proximal ureter, small intestine, ascending colon, and transverse colon up to the splenic flexure S2-S4 Distal to the splenic flexure of the transverse colon, descending colon, sigmoid colon, rectum, distal ureter, bladder, reproductive organs, and external genitalia. Variations: Ovaries & Testes Vagus Nerve S2-S4  Collateral Ganglia Sympathetic Pre-ganglionics - T5 through L2: Greater Splanchnic (T5-T9), Lesser Splanchnic (T10-11), Least Splanchnic (T12), Lumbar Splanchnic (L1-L2) nerves Celiac Ganglion (T5-T9) Post-ganglionic to: Distal Esophagus, Stomach (epigastric), Liver, Gallbladder (cholecystitis), Spleen, portions of Pancreas, proximal Duodenum (foregut) Superior Mesenteric Ganglion (T10-T11) Post-ganglionic to: Portions of Pancreas, Duodenum, Jejunum, Ileum, Ascending Colon, Proximal 2/3 of Transverse Colon. (midgut); Adrenals, Gonads, Kidneys, upper ½ Ureter Inferior Mesenteric Ganglion (T12-L2) Post-ganglionic to: Distal 1/3 Transverse Colon, Descending Colon, Sigmoid, Rectum (hindgut); lower ½ Ureter, Bladder, Prostate Genitalia Sympathetic Innervation Greater Splanchnic Nerve (T5-9) Synapses at the Celiac Ganglion Stomach, Liver, Gall Bladder, Pancreas, Parts of Duodenum Lesser Splanchnic Nerve (T10-11) Synapses at the Superior Mesenteric Ganglion Small Intestines and Right Colon (appendix is found here) Least Splanchnic Nerve (T12) and Lumbar Splanchnic Nerve (L1-2) Synapses at the Inferior Mesenteric Ganglia Innervates the Left Colon and Pelvic Organs  Sympathetic Innervation: Chapman’s Reflexes 5th IC space Right: Liver Left: Stomach Acid (gastritis/may raise red flag to NSAID use) 6th IC space Right: Liver, Gallbladder Left: Stomach Peristalsis (delayed stomach emptying time) 7th IC space Right: Pancreas (glucose, amylase, lipase) Left: Spleen Tip of right 12th rib: appendicitis McBurney’s point  Chapman Reflex Points Adrenal glands Anterior: 1” lateral and 2” superior to umbilicus ipsilaterally Posterior: intertransverse spaces of T11 and T12 ipsilaterally midway between spinous and transverse processes Kidneys Anterior: 1” Lateral and 1” Superior to Umbilicus Ipsilaterally Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of T12-L1 Urinary Bladder Anterior: Umbilical Area (Periumbilical) Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of L1-L2 Urethra Anterior: Along superior margin of the pubic ramus about 2 cm lateral to the symphysis Posterior: L3 transverse processes Appendix Anterior: Tip of the right 12th rib Posterior: At the transverse process of T11/T11 intertransverse space Cervical Spine SD Diagnosis - Major Minor Diagnosis Motion Motion OA FB/BB Side-slipping SXRY Flexion Rotation With or without Extension Sagittal Component AA Rotation Wobble RX C2-C7 Sidebending Slight SXRX Rotation Translation Usually with FB/BB Sagittal Component Palpatory Experience Check static landmarks Dx TP closer to TP closer to Deep Occipital Shallow Mastoid Mandible Shelf Occipital (can grab Shelf more of the skull) SLRR Left Right Right Left SRRL Right Left Left Right  Cervical Spine OA (occipitoatlantal joint) side-bends to one side and rotates to opposite. Also Flexes and Extends in a rocking motion (Type I like) AA (atlantoaxial joint) primarily rotational C2-C7 rotate and side-bend to same side (“typical vertebrae”) (Type II like) Cervical superior facets: BUM (Backwards, Upwards, Medial) Can be also described as Posterior, Superior, Medial Cervical spine follows Fryetteʼs III principle; does not follow Fryetteʼs I or II principles Anterior Cervical CS Points Tender Point Location Treatment Position Acronym Anterior Cervical 1 Mandible=Posterior aspect Markedly rotated away RA of the ascending ramus of the mandible at the level of the earlobe Transverse process=Lateral aspect of the transverse process of C1 Anterior Cervical 2-6 On the anterolateral Flexed, side-bent away, F SARA aspect of the rotated away corresponding anterior tubercle of the transverse process Anterior Cervical 7 On the clavicular Flexed, side-bent toward, F STRA attachment of the SCM rotated away Anterior Cervical 8 At the sternal attachment Flexed, side-bent away, F SARA of the SCM on the medial rotated away end of the clavicle  Posterior Cervical CS Points Tender Point Location Treatment Position Acronym PC1 inion On the inferior nuchal line, lateral Marked Flexion F St Ra to the inion Fine tune with side-bending toward, rotating away PC1 occiput On the inferior nuchal line at the Extended E Sa Ra splenius capitis (midway between Slight side-bending and rotation the inion and mastoid) away as needed PC2 occiput On the inferior nuchal line at the Extended E Sa Ra attachment of semispinalis capitis Slight side-bending and rotation away as needed PC2 midline spinous process On the superior or superior lateral Extended, side-bent away, rotated E SARA aspect/tip of the spinous process away of C2 PC3 midline spinous process On the inferior or inferolateral Flexed, side-bent away, rotated F SARA aspect/tip of the spinous process away of C2 PC4-PC8 midline spinous process On the inferior or inferolateral Extended, side-bent away, rotated E SARA aspect of the tip of the spinous away process. Remainder of tender points follow this pattern. PC3-PC7 lateral On the posterolateral aspect of the Extended, side-bent away, rotated E SARA articular process associated with away the dysfunctional segment Counterstrain: Steps of Treatment Assess the “this is a 10” pain level Maintain finger contact at all times (NOT PRESSING FIRM constantly, only monitoring!)(***continuous monitoring) this is to monitor tension, not to treat Find the position of comfort Retest by pressing with contact finger This is a passive treatment Hold it for 90 seconds (that’s the time for ALL counterstrain points, including ribs) monitor tension and response Return patient to neutral position SLOWLY!! Recheck pain level should be a 3 or less The only time you press firmly is when finding the point, repositioning the point. All other times you are keeping you contact finger on point to just monitor location. Jugular Foramen Formed by Temporal Bone and Occiput, which make the occipitomastoid suture CN IX, X, and XI exit from the jugular foramen (formed by occipitomastoid suture) CN XI (the spinal accessory nerve) is involved with torticollis. There is usually compression at the occipitomastoid suture/jugular foramen CN X is involved with vomiting Vagus nerve originates in the brainstem and exits through the jugular foramen. The jugular foramen is formed from the occipitomastoid suture, which is made up from the temporal bone and the occiput. So, dysfunction affecting the vagus nerve could come from occipitomastoid suture compression. Indirect and Direct treatment If INDIRECT treatment used: exaggerate/augment the dysfunction If DIRECT treatment used: engage the barrier/reverse the dysfunction Indirect Technique Somatic dysfunction is exaggerated or augmented Somatic dysfunction is taken the way it likes to go Restrictive barrier is disengaged Dysfunction is taken into position of injury Uses inherent forces Uses a compressive, tractional, or torsional component Direct Technique Somatic dysfunction is taken the way it does not like to go Restrictive barrier is engaged Uses external forces  Examples of Indirect Techniques Counterstrain Facilitated Positional Release (FPR) Balanced Ligamentous Tension Technique (BLT) Functional Technique Myofascial Release (may also be direct) Cranial (may also be direct) Still Technique (combined indirect and direct) Examples of Direct Techniques Myofascial Release Soft tissue Articulatory Muscle Energy High velocity, low amplitude (HVLA) Springing Myofascial Release (may also be indirect) Cranial (may also be indirect) Still Technique (combined indirect and direct) FPR Body part in NEUTRAL position COMPRESSION applied to shorten muscle/muscle fibers (some cases may have TRACTION instead) Place area into EASE of motion (INDIRECT) for 3-5 seconds Return body part to neutral THIS TECHNIQUE IS INDIRECT!!!!  FPR For example, if C2 is extended, rotated right, side-bent right, you would: Place neck in a neutral position (flatten spinal curve) Add a compressive force Then take C2 into extension, right rotation and right side-bending Still Technique Tissue/joint placed in EASE of motion position (augments the somatic dysfunction) Compression (or traction) vector force added Tissue/joint moved through restriction (into and through the restrictive barrier) while maintaining compression (or traction) and force vector THIS TECHNIQUE GOES FROM INDIRECT TO DIRECT!!!! Still Technique For example, if C2 is extended, rotated right, side-bent right, you would: Beginning of Still Technique: C2 E RR SR End of Still Technique: C2 F RL SL There are many ways to ask how to diagnose C2 and once you figure out the diagnosis you can answer the treatment questions, for example: C2 does not translate well to the right and becomes more symmetrical in extension C2 translates easier to the left and becomes more asymmetrical in flexion Both of these give you the diagnosis of C2 E RR SR OA Diagnosis, HVLA and ME Set Up OA diagnosis: A deep sulcus on the right would indicate that the OA is rotated right A deep sulcus on the left would indicate that the OA is rotated left OA ME and HVLA set up are identical If you have an OA with a deep sulcus on the left which is worse in extension, you would assume the dysfunction is OA F SR RL To set this up for ME or HVLA you would have to side-bend OA to left and rotate OA to the right  Muscle Energy Technique Postisometric Relaxation Reciprocal Inhibition Procedure Procedure - Dysfunctional Structure Positioned at Feather Edge of Direct - Dysfunctional Structure Positioned at Feather Edge of Barrier Direct Barrier (Positioning is in All Three Planes of Motion) (Positioning is in All Three Planes of Motion) - Physician Continuously Monitors Dysfunction - Physician Continuously Monitors Dysfunction - Patient is Instructed to GENTLY Push AWAY From the Barrier - Patient is Instructed to GENTLY Push TOWARD the Barrier - Physician Resists Patient’s Effort for 3 - 5 Seconds - Physician Resists Patient’s Effort for 3 - 5 Seconds - Patient is Instructed to Relax - Patient is Instructed to Relax - Physician Repositions Patient to Feather Edge of New Barrier - Physician Repositions Patient to Feather Edge of New Barrier - Repeat 3 - 5 Times or until Maximum Improvement - Repeat 3 - 5 Times or until Maximum Improvement - Passively Reposition to Neutral After Last Effort - Passively Reposition to Neutral After Last Effort - Recheck Area of Dysfunction for Change - Recheck Area of Dysfunction for Change Cervical HVLA Set Up Examples C2 E RL SL: Rotational correction emphasis Rotate C2 to the right (this automatically side-bends C2 to the right) Metacarpal phalangeal joint is positioned over POSTERIOR aspect of C2 left articular pillar Lock out C3-C7 by side-bending those segments to the left C2 E RL SL: Side-bending correction emphasis Side-bend C2 to the right (this automatically rotates C2 to the right) Metacarpal phalangeal joint is positioned over LATERAL aspect of C2 right articular pillar Lock out C3-C7 by rotating those segments to the left Indications and Contraindications Remember indications and contraindications for techniques For example, if a patient is too young or is not able to follow commands, you can not do techniques such as muscle energy If a patient has lax ligaments such as Rheumatoid Arthritis or Trisomy 21, you do not want to do HVLA, or ANY type of articulatory techniques in the upper cervical spine. Remember Still Technique is an articulatory technique. Would use a gentle technique such as myofascial release Neurological Exam of UE Root Sensation Motor Reflex C4 Shoulder None None C5 Lateral Elbow Biceps Biceps C6 Thumb, Wrist Extensors Brachioradialis Index Finger C7 Middle Finger Triceps Triceps C8 Ring Finger, Wrist Flexors None Pinky T1 Medial Elbow Interossi None Deep Tendon Reflexes Grade Definition Injury 4/4 Brisk w/clonus UMN injury 3/4 Brisk 2/4 Normal 1/4 Decreased 0/4 Absent LMN injury Muscle Testing Grade Definition 5 FROM + Gravity + Full Resistance 4 FROM + Gravity + Some Resistance 3 FROM + Gravity + No Resistance 2 FROM with Gravity eliminated 1 Slight Contractility 0 No Contractility Trigger Points Sternocleidomastoid muscle (SCM) refers pain lateral to and behind the eye Splenius Capitus muscle refers pain to the vertex of the head  Cervical Somatic Dysfunction Pain @ Vertex Vertex - Sternocleidomastoid (pain around eye) - Splenius Capitis (pain on vertex) Sternocleidomastoid Splenius Capitis Sternal Head Clavicular Head X = Tender Point  Cervical Somatic Dysfunction Occipital Pain Occiput - Sternocleidomastoid (Both Heads) - Multifidi Muscles (Cross 1-4 Vertebrae to Reach Spines of C2-L5) - Semispinalis Muscles - Suboccipital Muscles Multifidi Semispinalis Cervicis & Capitus Suboccipitals X = Tender Point Thoracoabdominal Diaphragm Must evaluate neurological influence versus biomechanical influence Neurologically: Phrenic Nerve/C3, C4, C5 Biomechanically: Where the thoracoabdominal diaphragm attaches: lower ribs, thoraco-lumbar junction, T10-L3 are examples. Triggerbands (TB) Body language: sweeping motion with the fingers Verbal Description: burning, pulling, tethering, restricted motion, tightness Key words: “pulls”, “heard it snap” TB Treatment Recognize body language to support triggerband Find discrete starting point and ending point that is painful Use thumb tip to “iron out” twisted fascial band Treat the entire pathway, partial treatment may allow TB to reform May need to treat more than once Herniated Trigger Points (HTP) Body Language: pushes with fingers or fist into non jointed area Verbal Description: aching or tightness in soft tissue Key Words: “feels tight”, “stiff”, or “pinches’ HTP Treatment Observe patient gesture indicating HTP Palpation of HTP Verification of most tender area Reduction of protruding tissue below the fascial plane Palpation for firm residual edges of protrusion through the fascial plane Tuck any remaining edges under fascial plane HTP Treatment Painful to treat Reduction of herniated tissue below the level of fascial plane with tip of thumb. An increase in pain, or sensation of sharp, pinching pain at the reduction site should prompt the practitioner to search for and reduce any tails of fascia. Continuum Distortions (CD) Body language: points to one or more spots of pain Verbal description: hurts in one spot Key word: just that one spot CD Treatment Very tender! Reduction of shifted continuum material by application of pressure from tip of thumb Pay attention to angle of patient finger when pointing to CD. The angle is important for reduction of CD in treatment. Folding Distortions (FD) Body language: places hand over a joint; cupping area Verbal description: aches deep in the joint, feels unstable Key words: unstable, changes with the weather, FD Treatment Should be PAINLESS! Recreates the mechanism of injury Cylinder Distortions (CYD) Body language: squeezes or rubs with hands Verbal description: pain that wakes me up; comes and goes; numbness, tingling, paresthesias Key words: weakness, feels numb, “weird”, “spaghetti legs” CYD Treatment Not painful to treat Recognize body language of distortion The gesturing hand may not contact the body Verbal description: bizarre, difficult to explain; may jump from one body area to another. May report pain of unusual intensity. Treatment of separate coils via manual techniques and/or assistive devices  Tectonic Fixations (TF) Body language: difficulty moving joint, looks and feels stiff Verbal description: feels like it’s stuck; feels like it needs to pop Key words: stiff, tight “in joints” TF Treatment Recognize may NOT have specific body language for the distortion May attempt self mobilization (ie “crack my neck and feels good” Restore the gliding quality of the affected tissue The only distortion that the application of heat may help (Must move after!) If pain then address other distortions first ie TB, HTP, CD Side effects of treatment Pain/ discomfort during treatment Erythema of the skin Bruising Hemorrhagic petechiae Rebound tenderness Relative contraindications to FDM Poor doctor/patient rapport Bleeding disorders Open wounds Hematomas Skin infections Previous stroke Osteomyelitis Pregnancy (abdomen or pelvis Vascular diseases treatment) Arteriosclerosis Infectious arthritis Collagen vascular disease Aneurysms Edema phlebitis  Good luck!!!! For ANY clarifications, please refer back to the Lecture/Lab material for clarification of any concepts Please review cervical spine diagnosis, treatment set up, indications/contraindications, etc. All concepts are cumulative: for example, Fryette principles, direct/indirect technique set up, etc. Thank you for being a great class!!!!