SEAT NUMBER: ……….… ROOM:..……………….

FAMILY NAME:………….....………………………….
This question paper must be returned.
OTHER NAMES:……..…….…………………..……..
Candidates are not permitted to remove any part
of it from the examination room.
STUDENT NUMBER:…..…….………..……………..

FORMAL EXAMINATION PERIOD: SESSION 1, JUNE 2022

Unit Code: CHIR8101

Unit Name: Clinical Chiropractic 1

Duration of Exam 2 hours (plus 10 minutes reading time)

(including reading time if applicable):

Total No. of Questions: 19

Total No. of Pages 14

(including this cover sheet):

GENERAL INSTRUCTIONS TO STUDENTS:

• Students are required to follow directions given by the Final Examination Supervisor and must refrain from communicating in any way with another student once they have entered
the final examination venue.
• Students may not write or mark the exam materials in any way during reading time.
• Students may only access authorised materials during this examination. A list of authorised material is available on this cover sheet.
• All watches must be removed and placed at the top of the exam desk and must remain there for the duration of the exam. All alarms, notifications and alerts must be switched off.
• Students are not permitted to leave the exam room during the first hour (excluding reading time) and during the last 15 minutes of the examination.
• If it is alleged you have breached these rules at any time during the examination, the matter may be reported to a University Discipline Committee for determination.

EXAMINATION INSTRUCTIONS:

Answer all question in this examination paper in the spaces provided.

This exam has 3 parts.

Part 1 Clinical chiropractic theory Q01-11 69 marks

Part 2 Chiropractic technique Q12-16 20 marks

Part 3 Chiropractic clinical reasoning Q17-19 21 marks

_________

TOTAL 110 marks

AIDS AND MATERIALS PERMITTED/NOT PERMITTED:

Dictionaries: No dictionaries permitted
Calculators: No calculators permitted
Other: Closed book – No notes or textbooks permitted

Copyright © Macquarie University. Copying or distribution of part or all of the contents in any form is prohibited.
PART 1 – Clinical chiropractic theory questions (material from lectures)

Q1. Consider the following paper from 2018:

The aim of the above trial was to investigate the effectiveness of chiropractic maintenance
care on pain trajectories for patients with recurrent and persistent low back pain. What did
Eklund et al conclude in this study? (5 marks)
Maintenance care was more effective than symptom-guided treatment in reducing the total no. of days over 52 wks with bothersome
___________________________________________________________________________
non-specific LBP but resulted in a higher no. of treatments. For selected patients with recurrent or persistent non-specific LBP who
___________________________________________________________________________
respond well to an initial course of chiropractic care, MC should be considered an option for tertiary prevention.
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Q2. (a) What does the term ‘transition point’ mean in Diversified chiropractic technique?
(1 mark)
Lecture 2.1
It is used to describe the position at which the adjustment is focused or targeted.
___________________________________________________________________________

(b) Why are we concerned about the transition point when setting up adjustments?
(3 marks)

___________________________________________________________________________
It is of great concern when setting up adjustments because they represent areas where the spine

undergoes significant biomechanical changes and potential stress concentrations.

___________________________________________________________________________

___________________________________________________________________________

2
Q3. (a) What is a radiculopathy? (1 mark)

Damage to the nerve root

___________________________________________________________________________

(b) List 6 causes of radiculopathy? (3 marks)

(you need 2 causes to get a mark, no half marks)
Compression Chemical radiculitis
___________________________________ ______________________________________
Tethering
___________________________________ ______________________________________
Infiltration

Over stretching Transection

___________________________________ ______________________________________

Q4. (a) Of the 3 types of thoracic outlet syndrome ATOS, VTOS and NTOS, which is the
most common and what does the abbreviation stand for? (1 mark)
___________________________________________________________________________

(b) Discuss the aetiology of the condition that you have named immediately above in
Q4(a) (3 marks)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

(c) Discuss the treatment and management of the condition that you have named
above in Q4(a) (3 marks)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Q5. Why do patients with headache seek chiropractic care? (4 marks)

There is a significant dissatisfaction with headache drug outcomes and side effects. Main
___________________________________________________________________________
reason for why sufferers cease/avoid medical treatments and why sufferers seek alternative
___________________________________________________________________________
headache treatment. Physical therapies are the most popular alternative treatment providers
___________________________________________________________________________
for headache globally.
___________________________________________________________________________

Lecture 4.2; pg 5 3
 Lecture 5.2; Pg 6

Q6. (a) In clinical practice ‘red flags’ are factors derived from a patient’s history and
clinical exam that are usually linked with a high risk of having a serious disorder. In
the context of clinical practice what are ‘yellow flags’? (2 marks)

Yellow flags are psychosocial indicators suggesting an increased risk of progression to long-term
___________________________________________________________________________

___________________________________________________________________________
distress, disability & potential drug misuse. They include the patient's attitudes and beliefs, emotions,
behaviours, and family and work place factors.
(b) FACTORWEB is an acronym that outlines known risk factors for long term
disability associated with soft tissue injury. Select 4 of the FACTORWEB letters and
state what risk factor the letter represents and give 2 examples of how this risk
factor may play a role in a clinical case. (8 marks)
F- Family; A- Attitudes & beliefs; C- Compensation issues; T- Treatment & diagnosis.
___________________________________________________________________________

Family can play a massive role on the patient. A great example of this would be when an
___________________________________________________________________________
overly protective partner/significant other (usually well-intentioned) who emphasises fear
___________________________________________________________________________

of harm or encourages the perception of injury as a catastrophe.

___________________________________________________________________________

___________________________________________________________________________

A for attitudes and beliefs. An example of this occurring would be when the belief that pain
___________________________________________________________________________
is harmful or that it indicates ongoing physical damage. This could cause fear of anything
___________________________________________________________________________

that leads to more pain and avoidance of activities that are expected to be painful.
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

FACTORWEB: Family; Attitudes & beliefs; Compensation issues; Treatment & diagnosis; Older/other occurrences of
injury; Return to work; Work; Emotions; Behaviours 4
Lecture 5.2; Page 11-20
Q7. Consider the following paper:

Lin et al. list 4 common problems in musculoskeletal (MSK) pain care. One of those common
problems was the overuse of surgery. What were the other 3 common problems and how
may you have an impact of those problems in your future clinical practice? (6 marks)
Overuse of imaging: Increase in exposure for patients that come into my future clinical
___________________________________________________________________________
practice which will have a greater impact on their well-being in the long-run (associated as harmful).
___________________________________________________________________________
Overuse of opioids: Early use of opioids has been associated with poorer outcomes in LBP care.
___________________________________________________________________________
Although it is best to limit it, there are an increasing number of people being prescribed to
___________________________________________________________________________
opioids related harms and by the time they see me at the clinic they would already be at an increased risk
___________________________________________________________________________

Failure to provide education and advice: Without being provided with the right guidance
___________________________________________________________________________
patient's well-being could continue to worsen.
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

5
Q8. (a) What is pain that persists beyond the expected time of tissue healing? (1 mark)
Chronic pain > 3 months ?
___________________________________________________________________________

(b) How does pain transition to the type of pain you have named above? (3 marks)
Pain transition is divided into 3 categories. Acute, sub-acute and chronic pain.
___________________________________________________________________________
Acute pain= Present for at least _________; Sub-acute pain= __________
___________________________________________________________________________
Chronic pain= _______________
___________________________________________________________________________

(c) What are some strategies that can be implemented in patients with the type of
pain you have named above at (a)? (4 marks)
Soft tissue therapies that help to address with muscular tension. These techniques can include massage, trigger point release,
___________________________________________________________________________
or instrument-assisted techniques to help with the tension. Exercise and rehabilitation is by providing a tailored program
___________________________________________________________________________
that is suitable to the patient's needs by starting off easy and slowly easing it's way as their are more improvements seen
___________________________________________________________________________
in the patient over a period of time. Patient education is another crucial aspect to it as it teaches patients how to best manage
___________________________________________________________________________
their pain as well as making the necessary modifications in their lifestyle. Chiropractic adjustments also can help with chronic
___________________________________________________________________________
pain although the amount of sessions and duration will be dependent on the patient's response to the treatment.
___________________________________________________________________________
If the adjustment has too much pressure for the patient to handle it is best to use small amounts of torsion and force if they
___________________________________________________________________________
are in a lot of pain. Good egs can include using a table drop instead of a BLR which requires a lot of torsion to the lower back
___________________________________________________________________________
and can cause a lot of discomfort to the patient.
___________________________________________________________________________

6
 Q9. Consider the following paper:

Joern et al. state in their background comments that “Benefits from low back pain
treatments seem to be related to patients changing their pain cognitions and developing an
increased sense of control.”
What did their study conclude about the experiences of patients with low back pain who
participated in the ‘GLA:D® Back’ education and exercise program? (8 marks)
A structured program of patient education integrated with exercises (GLA:D Back) for people
___________________________________________________________________________

___________________________________________________________________________
with chronic LBP was experienced very differently by different people. Our results suggest

that the impact of having participated in the program relate to how the content of the program
___________________________________________________________________________

___________________________________________________________________________
resonated with the individual patient's experiences and prior understanding of LBP. Not all

patients changed their understanding or came to internalise new understandings during a

___________________________________________________________________________

___________________________________________________________________________
10 wk program, however the results support existing evidence that an improved understanding

of what LBP may translate into people being less negatively affected.
___________________________________________________________________________

___________________________________________________________________________

Q10. Movements that occur in the pelvis at the sacroiliac joints and at the pubic symphysis
are said to be small but important. What would be the consequence of a more rigid than
natural pelvis? (3 marks)
Increasing the rigidity of the Pelvis can restrict normal range of motion at the SI joint & the pubic symphysis.
___________________________________________________________________________
This would limit mobility and can effect movements such as walking, bending, etc. Altered biomechanics:
___________________________________________________________________________
Pelvis plays a crucial role in transmitting forces and distributing load throughout the body during movement.
___________________________________________________________________________

___________________________________________________________________________
It can cause excessive strain or stress on other joints. Impaired shock absorption: IF the pelvis is excessively

rigid, it's ability to absorb and distribute forces may be compromised. Dysfunctional movement patterns:

7
Rigid pelvis can disrupt the coordination & sequencing of movement patterns. It may result in compensatory
movements or altered gait patterns to accommodate for restricted mobility. Pelvic pain or dysfunction: Excessive
rigidity in the pelvis can contribute to pelvic pain or dysfunction.
Open pack positioning: The open pack position refers to a joint position in which the joint surfaces have minimal contact with each other. It is the position where the
joint capsule and ligaments are relatively loose, allowing for more joint mobility. This position is less stable.
Closed pack positioning: Refers to a joint position in which the joint surfaces have maximum contact and congruency. It is the position where the joint capsule &
ligaments are under tension, providing maximal stability to the joint. This position typically occurs at or near the end range of motion. It is considered most stable
position at the joint..
Q11. Compare and contrast the open pack and the close pack position of the sacroiliac joint.
In your answer describe the position of the various joint components in each position, make
reference to ligamentous tension and joint congruency and relate your descriptions to
chiropractic clinical practice. (10 marks)

___________________________________________________________________________
Open pack positioning: Sacral extension with anterior innominate rotation. There is a lack of ligamentous tension and joint congruency

___________________________________________________________________________
It is also often at a fixed position in a patient with dysfunction. Closed pack positioning: Sacral flexion with posterior innominate rotation.

There is limited joint laxity and and joint congruency and this helps with having the joint being very well stabilised.
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

You may wish to draw diagrams below to help your answer:

8
 PART 2 – Chiropractic technique questions (material from tutorials)

Q12. Both of the following adjustments address a patient who presents with a restriction in
cervical rotation. Compare and contrast these adjustments with respect to the reason you
would choose to use a particular adjustment. (4 marks)

Cervical: Supine, Bilateral index contact, rotation Cervical: Sitting, Reverse, Rotation

I would choose to use ‘Cervical: Supine, Bilateral index contact, rotation’ because:

___________________________________________________________________________
-More control over the cervical spine and i am able to control the lock up even better

-It is also easier for the patient to relax

___________________________________________________________________________

___________________________________________________________________________

I would choose to use ‘Cervical: Sitting, Reverse, Rotation’ because:

-Patient may feel discomfort when lying down and is required to sit up for an adjustment
___________________________________________________________________________

- ___________________________________________________________________________

___________________________________________________________________________

Q13. Both of the following adjustments address a patient who presents with a restriction in
Sacro-iliac joint flexion. Compare and contrast these adjustments with respect to the reason
you would choose to use a particular adjustment. (4 marks)

Sacroiliac: FLR, Forearm contact, Ischial Sacroiliac: BLR, Pisiform contact, Flexion

I would choose to use ‘Sacroiliac: FLR, Forearm contact, Ischial’ because:

I would use this contact cause of a broader surface area which would be more comfortable for the patient.
___________________________________________________________________________
It is also a force generator because you are using the forearm contact instead of the Pisiform contact which doesn't
___________________________________________________________________________
generate as much force.
___________________________________________________________________________

I would choose to use ‘Sacroiliac: BLR, Pisiform contact, Flexion’ because:

I would use the short lever because it is more specific to the region over a broad contact.
___________________________________________________________________________
If the patient is smaller than me the long lever can be too much pressure for them. It is easier to control the force better
___________________________________________________________________________
with a smaller, localised position.
___________________________________________________________________________

9
You can talk about the effectiveness of the adjustment, the patient that you use it on, what it feels like to receive for the specificity of the adjustment

Q14. Both of the following adjustments address a patient who presents with a restriction in
thoracic flexion. Compare and contrast these adjustments with respect to the reason you
would choose to use a particular adjustment. (4 marks)

Thoracic: Prone, Hypothenar-heel, Flexion Thoracic: Prone, Crossed pisiform, Flexion

I would choose to use ‘Thoracic: Prone, Hypothenar-heel, Flexion’ because:

It is a broad contact so it allows me to use more force to the patient.
___________________________________________________________________________
Preferably wouldn't use this on a small patient cause it is a broad contact and it'll take up too many spinal segments
___________________________________________________________________________

___________________________________________________________________________

I would choose to use ‘Thoracic: Prone, Crossed pisiform, Flexion’ because:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Q15. Both of the following adjustment’s primary aim is to gap the Occ-C1 joint complex on
the side of the 1º contact using traction. Compare and contrast these adjustments with
respect to the reason you would choose to use a particular adjustment. (4 marks)

Occiput: Supine, Heel contact, Long axis traction Occiput: Sitting, Homolateral lift

I would choose to use ‘Occiput: Supine, Heel contact, Long axis traction’ because:
-Patient feels discomfort from sitting up and prefers lying down
___________________________________________________________________________
-Patient is a lot larger so sitting on a chair would make it harder for me to traction and follow the line of drive
___________________________________________________________________________

___________________________________________________________________________

I would choose to use ‘Occiput: Sitting, Homolateral lift’ because:

___________________________________________________________________________
Patient may feel uncomfortable lying down and would prefer to sit up against the chair

___________________________________________________________________________

___________________________________________________________________________

10
Q16. Compare and contrast:

Metatarso-cuboid: Prone/plantar-dorsal thrust

Navicular-cuneiform: Prone/plantar-dorsal thrust

In you answer clearly describe the primary contact points on both the practitioner and
patient, the counterpressure, the line of drive, and what you are trying to achieve
biomechanically with each adjustment. (4 marks)

Metatarso-cuboid: Primary contact: Web contact on the distal metatarso-cuboid joint. Localised flexion at the joint. Maintain
___________________________________________________________________________
counterpressure via maintaining heel contact on the couch. Inversion thrust is applied to gap the metarso-cuboid using a lever affect.
___________________________________________________________________________
Navicular cuneiform- Primary contact: Web contact of the medial hand on the superior medial aspect of the foot just distal to the
___________________________________________________________________________
cuneiform-navicular joint. Localised flexion then eversion at the joint. Counter pressure via maintaining heel contact on the couch.
___________________________________________________________________________
Non-recoil eversion thrust with both hands to cause further eversion.
___________________________________________________________________________

PART 3 – Chiropractic clinical reasoning questions (material from tutorials)

Q17. Fran is a 32-year-old female retail manager who presents to your office complaining of
a 3-month history of dull aching in her upper neck. She relates that work has been very
stressful lately and that she is putting in longer than usual hours changing the fitout of her
shop. She complains of mild headaches worse at the end of the day and relieved by rest.
Fran has suffered from migraines in the past and she confirms that these headaches are not
migraine.
List and explain your top 4 further clinical details and/or history questions that you would
like to ask. (2 marks)
1. Is their a referral of pain elsewhere around the body
___________________________________________________________________________
2. What would you scale the pain from 0-10?
___________________________________________________________________________
3. Any trauma that has occurred to the neck region as it would be a risk for VAD (Vertebral
___________________________________________________________________________

___________________________________________________________________________
artery dissection)

4. Do you smoke?
___________________________________________________________________________
5. Any other significant medical history?
___________________________________________________________________________

11
Q17. continued
Fran’s physical exam reveals the following findings (the motion palpation finding is at C3):

List 2 adjustment techniques to address these findings. (1 mark)

Occiput, supine, Cradle hold, Index contact, Lateral flexion (Scoop)
Adjustment 1 _______________________________________________________________
Cervical. B/L index contact, lateral flexion, contralateral open
Adjustment 2 _______________________________________________________________

Discuss which adjustment you would select to use in this case and give your clinical
reasoning for the decision. (2 marks)
Adjustment 1 because you will use traction instead of compression. This will help the patient
___________________________________________________________________________
to feel more comfortable if they have compression on the nerves which is causing a referral
___________________________________________________________________________
of pain.
___________________________________________________________________________

In what clinical scenario would you select the other adjustment? (2 marks)
Discomfort of having the practitioner hold against their chin or not feeling stabilized enough
___________________________________________________________________________
because the patient has a big head and it is difficult for a small practitioner like myself
___________________________________________________________________________
to handle the weight on my arms.
___________________________________________________________________________

Q18. Manny is a 27-year-old male who presents to your office complaining of a 2-day
history of sharp pain in his lumbar region on the left after a collision during a football match.
What clinical features would need to be present for you to refer Manny for diagnostic
imaging. (2 marks)

Change in reflex (hyporeflexia or hyperreflexia), sensory or motor loss (Can be tested using myotomes
___________________________________________________________________________
and dermatomes), suspected fracture near the Lumbar region and an increasing of intensity
___________________________________________________________________________

of the symptoms.
___________________________________________________________________________

12
 Q18. continued
Manny is cleared of any injury or condition that requires urgent medical management.
Manny’s physical exam reveals the following findings (the motion palpation finding is at L4):

Restriction in left lateral flexion and right rotation

List 1 long lever and 1 short lever technique to address these findings. (1 mark)

Lumbar: BLR, Forearm contact, Anterior-inferior (L4)

Long lever technique _________________________________________________________
Lumbar: BLR, Pisiform contact, Lateral flexion (L4)
Short lever technique _________________________________________________________

What additional clinical features would need to be present for you to suspect that some
intervertebral disc injury is a component of Manny’s presentation? (2 marks)

___________________________________________________________________________
Sensation or motor loss, positive SLR (neurodynamic test) & numbness or weakness.

___________________________________________________________________________

___________________________________________________________________________

If you suspected that Manny has a mild intervertebral disc component to his presentation,
what treatment would you choose to address his exam findings above? (2 marks)

-Close model adjustment: Aim is to close down the side of nuclear spread & force material back towards the centre
___________________________________________________________________________
-Distraction model adjustment: The aim is to create a combination of disc distraction via endplate separation with
___________________________________________________________________________
stabilized, controlled rotation to induce helicoid traction. The resultant effect is to draw the nuclear material back
___________________________________________________________________________
towards the centre.

Q19. Bernard is a 42-year-old proprietor of a used book shop. He has a dishevelled Looking untidy
appearance and appears to be attending your office begrudgingly on the insistence of his
friend Fran. Bernard appears to have injured his knee after a fall over a pile of books in his
poorly kept shop.
Discuss 3 yellow flags that you may be mindful of when taking his history. (3 marks)
-His attitude (Bernard attended the office begrudgingly); He also injured his knee after a fall
___________________________________________________________________________
(could potentially be something serious); it also mentions about his poorly kept workplace.
___________________________________________________________________________
(Yellow flags also consider work place factors).
___________________________________________________________________________

13
Yellow flags are psychosocial indicators suggesting an increased risk of progression to long-term distress,
disability & potential drug misuse. They include the patient's attitudes and beliefs, emotions, behaviours, and
family and work place factors.
Lecture 5.2; Pg 6
Q19. continued
Outline your physical examination procedure for Bernard’s injured knee. (4 marks)
-Asking for consent before beginning with the physical examination
___________________________________________________________________________

-Pay attention to how he walks before coming into the office room
___________________________________________________________________________
-Observe for any deformities, swelling, fasciculations, tremor, bruising or skin abnormalities and posture
___________________________________________________________________________
-Palpate the patient as well as the unaffected knee to see if there is a differentiation between both knees
___________________________________________________________________________
-Also check the patients range of motion for passive and active for the knee to see whether
___________________________________________________________________________

it has the ability to move within the standard range.

___________________________________________________________________________

14