Sample Test

SAMPLE COURSE

WELCOME TO A SAMPLE OF OUR COURSE CONTENT. THE MATERIAL HAS BEEN CHOSEN FROM FIVE DIFFERENT TOPICS SO YOU MAY EXPERIENCE THE DIVERSITY, QUALITY AND RELEVANCE OF OUR MATERIAL, WHICH HAS BEEN PREPARED TO BE CLINICALLY APPLICABLE TO YOUR PRACTICE. MODULES MAY ALSO INCLUDE GRAPHICS, TABLES, ONLINE DISSECTION, XRAYS, MRI, VIDEO, SLIDESHOW PRESENTATIONS, ETC.

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Choose a topic based on your interest and/or requirements.
Choose a course in that topic (educational objectives are listed.
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After reading the first section, you will find a test questions and a ten minute timer on the bottom of the page. You must wait until the ten minute time expires before answering. Please take the time to re-read the section, further expand on thought provoking assignments, etc.
After the ten minute timer expires,you may answer the question. If you are correct, you will be taken to the next section. If you are wrong, you will be shown the section again to review and answer again (the ten minute timer does not start again). You will not be taken to the next section unless you answer correctly.
Once you have successfully completed all 5 sections of a course, you will have the opportunity to interact with the instructor of that course by email. You will also immediately receive a Certificate of Completion by email. Please print and retain for your records.

A SAMPLE SECTION FROM OUR NUTRITION MODULES:

Resistance Exercise Can Reduce Blood Lipids

SOURCE: "Effects of Resistance Exercise and Body Mass Index on Lipoprotein-Lipid Patterns of Postmenopausal Women," Bemben, Debra A. and Bemben, Michael G. Journal of Strength and Conditioning Research, 2000, 14(1), 80-85
Neuromuscular Laboratory, Department of Health and Sport Sciences, University of Oklahoma, Norman, Oklahoma 73019

ABSTRACT: This study was designed to evaluate the effects of a 16-week Dynaband resistance exercise program and body mass index on the lipoprotein-lipid patterns of postmenopausal women aged 60-80 years. Eighteen Caucasian women ranging in age from 60-80 years with an average age of 72.9 were recruited for the study. They came from three senior nutrition sites in the Oklahoma City area. They were evaluated in regards to resting heart rate, blood pressure, skinfold measurements and circumferences, and fasting blood samples for lipoprotein assays. These were done both before and after the training program. The exercise program included a 10-minute warm-up followed by progressive resistance exercises 1-2 sets, 10-15 repetitions three times per week. Seven muscle groups were trained followed with by a 5-minute cool down. Results included no significant change in body weight, % body fat or waist to hip ratios. Strength improved for each of the muscle groups tested. Improvements in high-density lipoprotein cholesterol (HDL-C) concentrations and in the Total cholesterol/HDL-C ratio were observed after training. The HDL-C serum levels increased by 13%. Therefore the Dynaband exercise program was associated with improvements in HDL-C that were not accounted for by weight loss. The authors were not able to use a randomized control design for this study.

High levels of low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC) are associated with coronary heart disease. Elevated levels of high-density lipoprotein cholesterol (HDL-C) can provide protection against development of atherosclerosis. In postmenopausal women, HDL-C levels appear to be a more potent risk factor for CHD than LDL-C. It is generally accepted that aerobic exercise can have a beneficial effect on serum lipid profiles in people of any adult age. However the majority of data concerning resistance training on blood lipid profiles is unclear with studies revealing variable results. There are a variety of different mechanisms for exercise induced blood lipid alterations. Some of these include changes in body fat and body weight. Weight loss will increase HDL-C, decrease TC and LDL-C. Changes to where fat is distributed throughout the body also effects lipid profiles. Loss of abdominal fat and decreased hip to waist ratios are related to increased HDL-C. In general, exercise programs that do not cause a weight loss result in increased HDL-C but do not effect LDL-C and TC.

COMMENTS: Chiropractic physicians should recommend resistance weight training for their elderly patients. It has been routinely demonstrated that the elderly population could benefit from resistance training exercises. These exercises can strengthen muscles and improve coordination, thereby resulting in less slip and falls and subsequent hip fractures. They can also improve bone mineral density and improve an osteoporotic situation. Many chiropractic physicians are purchasing exercise equipment to use in the office for these reasons. Dynabands are inexpensive, can be used easily and at a safe intensity level and require no special facility. They are also less threatening to the elderly patient with no history of using fitness exercise equipment. Additional benefits that the elderly patient may receive are improved HDL cholesterol status and improved vascular circulation. One of the problems with the study was its relatively small patient population as well as the inability to have a randomized control design. However, the results do appear to be significant enough to recommend that Chiropractic physicians begin their elderly patients on resistance exercise programs and that even a simple dynaband program can have beneficial results beyond the musculoskeletal system.

QUESTION 1

Resistance exercise has been shown to:

A. Increase LDL-C levels

B. Increase HDL-C levels

C. Decrease LDL-C levels

D. Decrease total cholesterol levels

E. Both B and C

A SAMPLE SECTION FROM OUR XRAY MODULES:

Non-Responsive Hip Therapy? Consider Osteonecrosis

SOURCE: Khana, A. Jay MD, Yoon, Taek Rim MD, Mont, Michael A, MD, Hungerford, David S. MD, Bluenke, David A., MD, Ph.D. Osteonecrosis of the Hip, Radiology 2000; Oct. 217:188-192.

ABSTRACT: The purpose of this study was to design and evaluate a limited MR Imaging examination that is rapid and inexpensive in order to diagnosis osteonecrosis. The hypothesis was that a limited screening examination would be similar to a full MR exam in its ability to depict the presence and help in grading the extent of involvement of femoral head necrosis. There are two goals of MR evaluation. The first is to determine whether the disease is present and the second to determine the percentage of involvement of the femoral head weight-bearing surface In the study limited and full hip MR imaging examinations were performed in 179 hips of 92 patients with clinical suspicion of femoral head osteonecrosis. Two radiologists were used and the percent of femoral head weight bearing surface was evaluated. Both examinations were performed successfully in all the cases. The results indicated that agreement between full and limited MR examinations for the presence of osteonecrosis was 98.9%. This represents excellent agreement between the examinations. Therefore the time and dollar cost savings may allow the introduction of MR imaging earlier in the diagnosis of femoral head osteonecrosis. Because of the close agreement between the limited and complete MR examination, the cost savings of a limited examination should allow for more widespread use in patient care.

COMMENTS: Osteonecrosis, also referred to as avascular necrosis, is essentially ischemia of bone marrow and eventual death of trabecular bone. Treatment needs to be prior to the onset of subchondral fracture and cartilage damage. Early treatment is of extreme importance in terms of success. Therefore, the Chiropractic physician needs to be concerned with any patient who does not improve with conservative therapy to the hip when plain film radiographs are normal. Hip complaints are common in the Chiropractic office with many patients not even realizing that the hip is their source of pelvic and back pain. The diagnosis must be from a careful clinical history and examination with proper diagnostic imaging. Conventional plain film radiographs do not depict the disease until a substantial portion of the femoral head weight-bearing surface is involved. By the time it is detected on plain films the condition has progressed to the point where the majority of patients will need arthroplasty. MR imaging has been shown to be the most sensitive method of detecting the presence of femoral head osteonecrosis, especially at the early stages of the disease. It is more sensitive than nuclear bone scans. MR imaging demonstrates the bone marrow very clearly, which the red marrow is low in signal intensity and the fatty yellow marrow high in signal intensity. These are usually seen as focal, subchondral areas of abnormal signal intensity on the MR. A rim of low signal intensity that creates a ring-like appearance typically surrounds these lesions. Chiropractic physicians should consider ordering a limited MR examination with any hip patient who does not respond with conservative therapy even with normal plain film radiographs. These would demonstrate any early pathology of the hip as well as offer cost savings for the major insurance carriers.

REFERENCES: Yochum, Terry R.DC, DACBR and Rowe, Lindsay J. DC, DACBR. Essentials of Skeletal Radiology, Volume I, Williams and Wilkins, Baltimore. Second edition, 1996

QUESTION 2

Hip Osteonecrosis can be evaluated by various imaging techniques. Which would be the most beneficial in terms of cost effectiveness and accuracy for a local VA hospital to use?

A. Plain film radiographs

B. Full MRI examination

C. CT examination

D. Limited MRI examination

E. Limited CT examination

A SAMPLE SECTION FROM OUR NEUROLOGY MODULES:

Mechanoreceptor Control Of Shoulder Musculature

SOURCE: Maass, S, Baumann, K, Halata, Z. Department of Functional Anatomy, University of Hamburg: Topography of Corpuscular Mechanoreceptors in the Shoulder Joint Region of the Monodelphis Domestica. The Anatomical Record 263:35-40 2001

ABSTRACT: Mechanoreceptor control of the musculature of the shoulder joint, particularly as it relates to reflex and protective control was evaluated in the Monodelphis Domestica. This laboratory marsupial was chosen due to its close correlation with humans pertaining to its wide capability of movement and the utilization of its shoulder joint for holding of food and climbing. The Monodelphis has a very similar anatomy to humans with a shoulder girdle consisting of a scapula, clavicle and humerus. Its anatomy is also small enough to perform entire serial sectioning, unlike a primate whose shoulder joint is too large. Mice have typically been used in receptor studies, but the use of their upper extremity as compared to man differs greatly, namely, in that in mice the shoulder is a weight bearing joint.

The shoulder joints of the Monodelphis was completely serial sectioned and silver stained serial paraffin sections were evaluated by light microscope. Selected mechanoreceptors were studies under an electron microscope and reconstruction of mechanoreceptors by three-dimensional imaging was performed.

129 mechanoreceptors were found in the joint capsules and 77 were identified in the surrounding soft tissue. Most were small lamellated corpuscles while much smaller amounts of larger mechanoreceptors, namely Pacinean and Ruffini Corpuscles were identified. The types of mechanoreceptors found in the Monodelphis are principally the same as those seen in studies of human samples. Free nerve endings are found in a much denser distribution in the joint capsule and surrounding tissues, actually outnumbering the corpuscular receptors by approximately 10 times.

85% of the mechanoreceptors identified in this study were small lamellated corpuscles with myelinated afferent axons, in close proximity to the joint capsule. In the Monodelphis, large Pacinean corpuscles and Ruffini Corpuscles were found in small amounts, usually in the fibrous layer of the joint capsule. A large amount of Ruffini corpuscles were found in a semi quantitative study on human cadavers, and this was noted to likely be accounted for due to the thickness of the sections and staining technique.

The area where the rotator cuff links to the joint capsule was relatively devoid of mechanoreceptors, but there were large numbers of golgi tendon organs. Muscle spindles were found at a greater distance from the joint. The small amount of Ruffini Corpuscles that were identified was mainly in the area of the dense connective tissue in the axillary recess of the joint capsule. As they are slowly adapting receptors and they are located where predominantly a high degrees of should abduction would be needed to cause a receptor potential, they may be present more for reflexogenic protective purposes.

Previous studies on cats have shown that when articular afferents were electrically stimulated, a short latency reflex contraction of the biceps and deltoid muscle occurred suggesting that the marked density of lamellated corpuscles in the capsule may be to maintain stability and prevent subluxation or dislocation by monitoring muscular tone to maintain stability of the humeral head in the glenoid labrum

COMMENTS: It was noted in this study that there is a large amount of nociceptive receptors (free nerve endings) relative to mechanoreceptors in a joint. It was noted 10 times the amount of nociceptive receptors were present. Considering that one of the functions of joint mechanoreceptors is to inhibit pain from the nociceptive system, the maximum functioning of these receptors is quintessential. Appropriate muscular activity is normally maintained by Golgi tendon organs, muscle spindles and mechanoreceptors, but abnormalities of the shoulder via injury, degeneration, disuse, etc. can have quickly developing manifestations. It is now simply to understand why a simply capsulitis can proceed to an adhesive capsulitis if not properly treated. Any time the global range of motion of a joint is reduced, the potentiation to reach threshold of the mechanoreceptors in that joint is reduced, which can lead to a variety of sequelae. Receptor stimulation, by way of the 1b inhibitory interneuron produces decreased muscle spasm and the gamma motorneuron loop to improve tone is well documented in most basic texts on Neurology. Chiropractic manipulation is an excellent procedure to increase global range of motion and to maximally stimulation of mechanoreceptors.

This study identified the types and locations of mechanoreceptors found around the shoulder joint of the Monodelphis and correlated it well with the human shoulder. It was also suggested that due to the location and types of mechanoreceptors, it is likely that they play an important role in the control of joint movement. There is no doubt that joint mechanoreceptors play an important role in kinesthesia of the joint which leads to appropriate reflexogenic joint movements. Considering that the Chiropractor achieves results by affecting the nervous system via mechanoreceptors, it is an excellent study to review.

QUESTION 3

This study on the mechanoreceptors in the shoulder of the Monodelphis Domestica demonstrated:

A. A large amount of small lamellated mechanoreceptors in and about the joint capsule.

B. A relatively small amount of large corpuscular receptors.

C. A higher degree of nociceptive receptors than mechanoreceptors.

D. Mechanoreceptors about the shoulder are likely to play an important role in the joints movement.

E. All of the above.

A SAMPLE SECTION FROM OUR MANIPULATION/PT/REHAB MODULES:

Sacroiliac Manipulation And Anterior Knee Pain

SOURCE: Suter, Esther, PhD, McMorland, G, DC, Herzog, W, PhD and Bray, R, MD. Decrease in Quadriceps Inhibition After Sacroiliac Joint Manipulation in Patients with Anterior Knee Pain. JMPT, Volume 22, Number 3, March/April 1999, pages 149 - 153

ABSTRACT: Anterior knee pain is often associated with weakness and inhibition of the knee extensors, particularly the vastus medialis, resulting in imbalance in the activation patterns of the knee extensor groups, thus accelerating patellofemoral pain. Treatment protocols have included physical therapy/rehabilitation programs and even surgical intervention. However, the lack of full recovery has been related to strength deficits and the inability to achieve full recovery of the affected structures, often associated with persistent muscular inhibition. It has been suggested that muscular inhibition needs to be overcome before significant improvement in muscle strength and function can be achieved. This pilot study was performed to establish whether quadriceps inhibition in patients with anterior knee pain was affected by sacroiliac joint manipulation.

18 subjects with chief complaints of anterior knee pain participated in this study. Four had bilateral anterior knee pain, six had knee surgery and 11 had received physical therapy treatment. Before and after sacroiliac manipulation, torque, muscle inhibition, and muscle activation for the knee extensor muscles were measured during isometric contractions using a Cybex dynamometer, muscle stimulation and electromyography. The knee extensors were measured bilaterally. Muscular inhibition was measured at 10 - 15% higher than normal subject comparison. Sacroiliac evaluation was performed with active forward bending, motion palpation and the sit up test for sacroiliac dysfunction. A sacroiliac joint was deemed symptomatic if pain was present over the posterior superior iliac spine and if provocation tests, such as Yeoman's, sacral compression, and Patrick's FABER test, exacerbated discomfort over the PSIS. 12 of the patients demonstrated a symptomatic sacroiliac dysfunction whereas 6 demonstrated an asymptomatic sacroiliac dysfunction. The manipulation consisted of a high velocity, low amplitude thrust to the sacroiliac joint ipsilateral to the side of anterior knee pain. For those with bilateral anterior knee pain, the side of greatest subjective complaint was treated.

After correction of the sacroiliac dysfunction, an increase in knee extensor torque and a decreased in muscle inhibition were observed in the involved leg. Electromyographic activation of the vastus medialis was higher in the involved leg post manipulation.

Evidence suggests that the success of conservative treatment in restoring muscle function is limited in the presence of severe muscle inhibition. This is consistent with this study as most of the subjects had a history of incomplete recovery following surgery or physical therapy. This study demonstrates that chiropractic manipulation may be an alternative or as an adjunct in the treatment of anterior knee pain.

COMMENTS: This is a very interesting pilot study that will hopefully lead to further research. The relatively small size of this study must be expanded upon and future studies should be randomized, and double blinded. However, considering the incomplete recovery in many patients whom undergo surgical and physical medicine treatments, this study offers an interesting hypothesis as to why. There are two issues that present themselves when reviewing this data. The first is neurological, the later, biomechanical, but both have clinical ramifications.

The inhibition of the extensors of the knees is a neurological expression of a reduction of excitatory postsynaptic potentials, and/or an increase in the amount of inhibitory postsynaptic potentials affecting the anterior horn cells of the spinal column. A review of the simple reflex arc is appropriate at this point, which will lead us to therapeutic considerations.

For example, when eliciting a simple reflex, the tendon of the agonist muscle is struck with a reflex hammer. This will produce the following events at the spinal cord level. An excitatory postsynaptic potential occurs monosynaptically at the agonist muscle and a inhibitory postsynaptic potential (via and interneuron) occurs at the antagonist muscle. From review of this arc, one would conclude that electrical muscle stimulation applied to the knee extensors reduces inhibition of this area by creating excitatory postsynaptic potentials at anterior horn cells that affect the quadriceps muscle. From the results of the manipulation causing reduction in the inhibition of the knee extensors, further investigation as to whether stimulation of mechanoreceptors of the sacroiliac joint are specific to creating excitatory post synaptic potentials of the knee extensors would be of interest. The actual position of the lower extremity during the manipulation could have a dramatic effect as well, in that it would dramatically alter the manner in which fast stretch is applied to the knee extensors themselves.

Biomechanically, alterations in gait cycle can certainly lead to sacroiliac dysfunction. This, along with the muscular weakness that commonly is associated with joint injuries, can account for a majority of the increased muscular inhibition of the knee extensors. A mechanical consideration beyond the neurological inhibition needs to be identified, particularly if the clinician feels it may have caused the knee pain. Appropriate biomechanical analysis of the lower extremity should be performed, for example, to determine if an orthotic is appropriate, and to help determine what rehabilitative exercises are appropriate.

QUESTION 4

In regard to anterior knee pain and the sacroiliac joint:

A. Anterior knee pain is often associated with inhibition of the vastus medialis.

B. Sacroiliac manipulation can produce excitatory post synaptic potential of dorsal horn cells of the spinal cord to affect knee extensors.

C. Muscular inhibition may have to be overcome before more functional strength gains can occur.

D. Both A and C.

A SAMPLE SECTION FROM OUR PEDIATRIC MODULES:

Childhood Headaches And Adult Health

SOURCE: Fearon P and Hotopf M. Relation between headache in childhood and physical and psychiatric symptoms in adulthood: national birth cohort study. BMJ 2001; 322:1-6.

ABSTRACT: Headache is the most common somatic complaint in children. Researchers in this study wanted to determine if there were any associations between children who experience frequent headache and an increased risk of headache, physical or psychiatric symptoms for these people when they reach adulthood. Reports have previously shown an association between headache in childhood and several psychosocial factors such as depression in the mother, depression in childhood, social disadvantage, and coming from a family with a history of "painful conditions." Prior to this study, the long-term outcome of headache in childhood had not been examined.

Parents were interviewed when the participants were aged 7 (year 1965) and 11 (1969). On both occasions the parents were asked, "does your child suffer from frequent headache or migraine?" The presence of any mental illness in a family member was also determined. When the participant was aged 16 his or her parents were asked about their own health. At age 33 (1991) the participants were asked about the specific somatic symptoms of: backache, bad headaches, twitching of the face, head, or shoulders, indigestion, upset stomach, heart racing "like mad," pains in the eyes, rheumatism or fibrositis, and worries about health. Overall, 11,407 participants were interviewed at age 33.

Headache in childhood was associated with several psychosocial factors. According to this study, these factors include having a mother with a chronic physical illness that began before the participant was aged 11; mental illness in a family member; and separation from mother for periods of more than one week. Prospectively, children with frequent headache had an increased risk in adulthood of multiple physical symptoms, and psychiatric problems. Increased risk in adulthood of headache (odds ratio 2.22, 95% confidence interval 1.62 to 3.06), multiple physical symptoms (1.75, 1.46 to 2.10), and psychiatric morbidity (1.41, 1.20 to 1.66). Children with headache are at an increased risk of recurring headache in adulthood and may complain of other physical and psychiatric symptoms. Strategies for coping with psychosocial adversity in childhood may improve the prognosis in adulthood.

COMMENTS: Headache in children can be an ominous sign or an indication of postural or biomechanical problems. Whatever the cause, children who experience headache are at risk for continued headache or other physical or psychological manifestations into adulthood. This is the first study on the topic using prospectively collected population based data, which confirms that children with headache do not simply "grow out" of their somatic complaint and may also "grow into" others.

The findings of an association between both headaches in childhood and psychosocial factors and headache in childhood and adult morbidity may have implications for the health of today's children and their future wellbeing. The wide range of professionals to whom a child with headache may present, including chiropractors, should consider the possible role of underlying psychosocial factors in the child's symptoms. If such factors are present and amenable to change, it is possible that intervention may reduce the risk of the child developing symptoms as an adult. While this study does not directly address treatment of headaches as a means of preventing the development of symptoms in adulthood, it can be inferred that such treatment would likely have a beneficial effect.

Evidence shows that the prevalence of headache in childhood is increasing steadily in the developed world. As a result, there may well be a corresponding increase in somatic and psychiatric symptoms as today's children become adults and clinicians should be in a position to recognize this trend.

QUESTION 5

This study indicates that children with headache:

A. Usually do not have headaches by age 33.

B. Are at a greater risk for psychiatric and physical symptoms as adults.

C. Are more likely to come from divorced parents.

D. Have no connection to illnesses in adulthood.

E. Are unlikely to experience other physical symptoms.

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