Lecture 1

Objectives
Summarize current trends in tobacco use
Nicotine Use Disorder = Nicotine Dependence
Manifests by more intense effect at first use of day; reduction in nausea and
dizziness with repeated use; well-defined withdrawal symptoms; 80% want to
stop but less than 5% do
Nicotine-Induced Disorder = Nicotine Withdrawal & Nicotine-Related Disorder NOS
Dysphoric mood; insomnia; irritability; frustration and anger; anxiety; difficulty
concentrating; restlessness and impatience; decreased HR; increase appetite and
weight gain
Precontemplation "I like to smoke." Introduce ambivalence: I can tell that you like to
smoke. Is there any down-side?"
Contemplation "I like to smoke, but I know I need to quit." Emphasize ambivalence
"How do you and others think your life will be better after you've quit smoking?
Preparation "I'm ready to quit." Resist the Righting Reflex and explore how THEY will
do it. So, have you thought of a 'quit day' what will that be like? Do you anticipate
future high risk times for use?
Action "I'm not smoking, but I still think about smoking from time to time." Explore
solutions to specific relapse triggers "How can you deal with your desire to smoke in
those situations?"
Maintenance "I used to smoke." Solidify patient's commitment to a smoke-free life
"This would be a good time to share your experience with other people."
The younger you are when you begin to smoke, the more likely you are to be an
adult smoker
Although 70% of smokers say they want to quit and about 40% try to quit each
year, only 4% to 7% succeed without help
Assessing Nicotine Addiction using the "Four Cs" Test
Compulsion ( desire to use chemical overwhelms thoughts) Do you ever smoke
more than you intend? Have you ever neglected a responsibility because you
were smoking, or so you could smoke?
Control (controlled use of chemical)
Have you felt the need to control how much you smoke but were unable to do
so easily? Have you ever promised that you would quit smoking and bought a
pack of cigarettes that same day?
Cutting down (and withdrawal symptoms)
Have you ever tried to stop smoking? How many times? For how long?
Have you ever had any of the following symptoms when you went for a while
without a cigarette: agitation, difficulty concentrating, irritability, mood swings?
If so, did the symptom go away after you smoked a cigarette?
Consequences (denial or acceptance)
How long have you known that smoking was hurting your body? If you continue
to smoke, how long do you expect to live? If you were able to quit smoking
today and never start again, how long do you think you might live?
Smoking is the single greatest avoidable cause of disease and death
Secondhand smoke exposure causes disease and premature death in children and adults
who do not smoke
Children exposed to secondhand smoke are at an increased risk for sudden infant death
syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma.
Smoking by parents causes respiratory symptoms and slows lung growth in their
children
Exposure of adults to secondhand smoke has immediate adverse effects on the
cardiovascular system and causes coronary heart disease and lung cancer
The scientific evidence indicates that there is no risk-free level of exposure to
secondhand smoke
Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to
secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and
ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke
Quantify the results for nicotine treatments
Pharmacotherapy
Placebo 13.8%
First-line agents
Bupropion SR 24.2%
Nicotine gum (614 wk)
Nicotine inhaler
Nicotine lozenge (2 mg)
Nicotine patch (614 wk) 23.4%
Nicotine nasal spray
Varenicline (2 mg/day) 33.2%
Second-line agents
Clonidine 25%
Nortriptyline
Combination therapy
Patch (>14 weeks) + ad lib nicotine
Nicotine patch + bupropion SR 28.9
Nicotine patch + nortriptyline
Nicotine patch + nicotine inhaler
Discuss first line treatments
Bupropion SR (Zyban) inhibits the reuptake of dopamine and norepinephrine
in the central nervous system and may function as a nicotinic receptor
antagonist
Contraindicated in pts with seizure disorder, anorexia/bulemia, using another
formulation of bupropion, recent Mao use, abrupt cessation of BZDs or etoh
Nicotine Gum
Nicotine Inhaler
Nicotine lozenge
Nicotine nasal spray
Nicotine patch
Vareniclinepartial acetylcholine receptor agonist selective for alpha/beta
acetylcholine receptor
Indicated in most cases except when medically CI or in specific
populations where there is insignificant evidence of effectiveness
Partial agonist activity induces modest receptor stimulation that
attenuates the symptoms of withdrawal, and inhibits the surges of
dopamine release believed to be responsible for the reinforcement and
reward associated with smoking
Lecture 2
Review and describe the structural and functional anatomy of the thoracic spine and rib
cage.
o 12 T vertebrae, 12 pairs of ribs, and 1 sternum
o Mild kyphotic curve
o Vertebrae increase in size as you move caudally
o Protects vital organs
o Assists with respiration
o Movement
o Connections with neck, head, abdomen, pelvis, upper and lower extremities
o Vertebral units: 2 adjacent vertebrae, their joints, and the intervertebral discs
o Spinal unit: two vertebrae and associated soft tissues
o Divisions
Upper: T1-T4
Middle: T5-T9
Lower: T10-T12
o Sternal Notch: T2
o Sternal Angle: T4
o Xiphoid: T9
o Umbilicus: L3-L4
o Spine of scapula: T3
o Inferior Angle of scapula: T8/T7
o Thoracic Inlet
Anatomical: T1, Rib1, sternal manubrium
Functional: T1-4, ribs 1 and 2, manubrium
Review Fryettes principles and how they apply to the thoracic spine.
o 1: when sidebending id attempted from neutral, rotation of vertebral bodies
follows to opposite directions; primary weight bearing is on vertebral bodies
(NS
x
R
Y
)
o 2: when sidebending is attempted from non-neutral, rotation must precede
sidebending to the same side; facet structures determine the motion
characteristics (E/F R
x
S
x
)
o 3: motion introduced in one plane limits and modifies motion in the other planes
Demonstrate both a screening and segmental evaluation of the T spine.
o Lateral
o Trunk Rotation: if less than 90
0
there is a restriction
o Upper trunk side-bending
Upper T-spine: CT jn
Lower T-spine: AC jn
o Forward/backward bending: note ability of the SP to approximate and separate
o TART changes
Explain and review anterior and posterior landmarks in the thoracic region.
Describe the motion characteristics of the T spine.
Describe the rule of 3s and how this is helpful in identifying a segmental level.
o Rule of 3s (spinous processes)
1-3: same plane
4-6: tip is halfway between itself and vertebrae below
7-9: tip is in plane with TP of lower vertebrae
10-12: similar to T9 but eventually regress to resemble lumbar spine
Lecture 3
Recognize the difference between true vs. false ribs as well as typical vs. atypical ribs.
o True Ribs (1-7): attach directly to sternum via costochondral cartilage
o False Ribs (8-10): attach via synchondroses to costochondral cartilage of rib 7
o Floating: (11-12): dont attach to the sternum at all
Identify the motion characteristics predominant in each rib group.
o Pump-handle: 1-5
o Bucket-handle: 6-10
o Caliper: 11-12
Recognize and explain the types of rib somatic dysfunction and how to screen and
diagnose.
o Inhalation SD pump handle/bucket handle/caliper
o Exhalation SD pump handle/bucket handle/caliper
o Superior subluxations
o A/P subluxations
Explain the role of the diaphragm in breathing mechanics and its relationship to the
spine.
o Efficient contraction relies on using the abdominal viscera as a fulcrum and the
verticality of the muscle in relations to the chest wall as a lever
Identify the key rib to be treated in inhalation and exhalation somatic dysfunction.
o Treat highest rib in exhalation SD
o Treat lowest rib in Inhalation SD
Review treatment techniques for ribs: indirect and direct (ME).

Lecture 5
Review the basic pathophysiology of the respiratory system and the horizontal
diaphragms
o Partial distention of air sacs: shallow, rapid respirations (viscerosomatal reflex by
carotid body to ^ rate of respiration
o Elevated pCO
2

Describe the sympathetic innervation of the respiratory system
o Goblet cells (thick sticky mucous)
o Initial dilation of bronchi
o Vasoconstriction
Loal hypoperfusion
Epithelial hyperplasia
Describe the parasympathetic innervation of the respiratory system
o Ciliated cells (thin nasal secretions)
o Edematous alveoli
Herring-Brewer Reflex: cant tell is alveoli are distended with air of
inflammatory fluidlimited diaphragmatic excursion
o Carotid Body
Signal for more O
2
increased diaphragmatic rate
Describe the lymphatics of the respiratory system
o Chronic lymphatic congestion
Poor oxygenation of cells
Increased infection
Describe a lymphatic treatment for URI
o Rib-raising, thoracic inlet, thoracolumbar, thoracoabdominal diaphragm
Review and describe lymphatic pumps