Lumbar Segmental Instability Flashcards
Koppenhaver 2011: Study
TrA, IO, and LM muscles thickness assessed @ L4-5/L5-S1 using US imaging of muscles at rest and during submaximal contraction on day 1, 3, 4, and 1 week
Koppenhaver 2011: Results
contracted TrA and IO mm thickness decreased immediately after 1 SMT but were not significantly diff. from baseline after 3-4 days or @ 1 week
Conversely, LM mm thickness sig. increased @ 3 to 4 days immediately after 2 SMTs, but no diff. found after 1 SMT or at 1 week follow up
Koppenhaver 2011: results continued
changes in both TrA and IO thickness following SMT were transient/unrelated to whether pts experienced improved disability or not.
Only statistically sig. interaction occurred from baseline to 3-4 days immediately after 2 SMT in the LM @ L5-S1
Koppenhaver 2011: Conclusion
the change in contracted LM thickness @ 1 week only explained 7% of the variance in ODI scores.
Hancock 2007: SR of tests to identify disc, SIJ, or Facet joint as source of LBP
aim to determine diagnostic accuracy of tests available to clinicians to identify disc, ZJ, or SIJ as the source of LBP
+LR >2 or -LR <0.5 considered informative
Hancock 2007: studies included
41 total studies: 28 for disc, 8 for facet joint, 7 for SIJ
Hancock 2007: Background
The prevalence of these structures as source of LBP:
- Disc 39%
- Facet Joint 15%
- SIJ 13%
Hancock 2007: Appropriate Reference Test
Discography for discogenic pain (min 2 levels tested)
Intra-Articular Local Anesthetic Block for SIJ pain
Intra-Articular or medial branch blocks for Facet
Hancock 2007: discogenic results
3 features on MRI:
- High intensity zone
- Endplate Changes
- Disc Degeneration
Produced an informative +LR>2 in the majority of studies increasing probability of the disc as source of LBP
Centralization only clinical feature found to increase the likelihood as disc source of pain +LR 2.8
Hancock 2007: Results 2
absence of disc degeneration on mRI was only test found to reduce likelihood of the discs as source of pain -LR = .21
-5x more likely to NOT have a disc as source of LBP
Hancock FJ results 2007
none of individual tests that make up Revel’s criteria for facet joint pain were found to have informative +LRs
Hancock 2007: SIJ results
while using single PP SIJ tests were uninformative, when used in multi-test regimen was informative with +LR of 3.2 and -LR of .29
Lim 2011: Purpose
to compare pain and disability in individuals with persistent NS-LBP who were treated with Pilates exercises compared to min or other interventions
Lim 2011: # of RCTs and focus
7 RCTs investigating
- specific activation strategies
- dissociation of the hips; stabilization of pelvis
- core muscle training; TrA and LM
- Most studies used 8-12 tx sessions of Pilates based ex 1-2x per week over 6-8 weeks
Lim 2011 results
- Pilates based ex were no more effective than other forms of ex to reduce pain
- Pilates ex no more effective than min interventions or other interventions to reduce disability related to CLBP
Hancock 2008: independent eval of Childs CPR - Methods
Each of 239 pts status on Childs CPR was determined using 5 criteria baseline:
- < 16 days duration of current episode
- no symptoms distal to knee
- FABQ < 19 points
- at least on hypomobile segment on pA testing
- > 35 deg of Hip IR
Hancock 2008: SMT vs Non Thrust Mobs
97% of subjects who got SMT actually got non-thrust mobs and 5% got SMT
Hancock 2008 Results
- The CPR did not identify those pts who were more likely to respond to SMT
- The CPR performed no better than chance in identifying pts with acute, non-specific LBP most likely to respond to SMT
Hancock 2008 considerations
Loss to follow up only 2%, but was 30% in Childs
Even using 5/5 items in the CPR still remained statistically non-significant for all outcomes
Cleland 2009: validation of CPR using lat recumbent manip and supine lumbopelvic manip
Mean duration of symptoms = 50 days
Cleland 2009: Methods
- 2 sessions of HVT supine
- 2 sessions of HVT in side-lying
- 2 sessions of non thrust central PAs to L4 and L5
Thus did 240 central PAs to L4 and 240 central PAs to L5
- compared total of 480 non thrust mobs to a single HVLAT
Cleland 2009 exercises included in study
- all groups performed pelvic tilts (1x10 in clinic) and 3 x 10 @ home daily
- then all 3 groups received 3 sessions of exercises including:
- TrA hallowing
- Quadruped arm and leg extensions
- side support exercises
Cleland 2009 Results
- at 6 months 91.9%, 89.5%, 67.6% (p=.009)
- the study did not include a control group, therefore not able to determine is use of thrust on patients who are positive on the CPR would produce superior outcomes when compared to no tx at all.
Hayes 1989: Dx of LSI
found that 42% of asymptomatic subjects had at least 1 segment exceeding the instability thresholds on flexion/extension radiographs of lumbar spine
Dilitto et al 1995: believe the following for confirmatory data for LSI
- frequent recurrences of LBP participated by minimal perturbations
- lateral shift deformity in prior episodes of LBP
- short term relief of manipulation
- History of trauma
- Use of oral contraceptives
- improvements of symptoms with the use of brace in previous episodes
Maitland 1986; Paris 1985: exam findings
- the presence of a step off between SPs of adjacent vertebrae
- hypermobility on PPIVM or PAIVM testing of instability
Paris 85, Nachemson 85, Ogon 1997, O’Sullivan 2000
Aberrant motions such as instability catch:
- often occurring when returning from a flexed posture
- a sudden acceleration or deceleration of movement
- BUT aberrant motions have never been related to symptoms or abnormal movements in imaging studies
hence no concurrent validity to date
Clinical Dx of LSI “convention”
pain immediately upon sitting relieved through standing
through range pain (painful arc)
inability to stand erect without assistance of hands
reversal of lumbopelvic rhythm
Small jerks that occur intersegmental and hesitations during active motion.
Magee 1997: Prone Instability Test
+ if pain present in the resting position with lumbar PA compression but no pain while legs lifted and lumbar PA compression
no validity established
Delitto 1995: posterior shear test
produce a posterior force through the pts abdomen and anterior force with opposite hand through the pelvis (in standing)
test repeated at all lumbar levels
no validity established
Objective Indicators of LSI according to Paris (1985, 2003)
instability catch hypertrophied band horizontally step off on standing, disappears on lying shaking (juddering) on forward bending imbalance on single leg standing grade 5 or 6 on PPIVM
Spine Instability (2 categories)
- Radiologic: appreciable instability which reflects marked disruption of the passive osseous ligamentous constraints
Clinical Instability: more subtle and challenging to dx and involves neuromuscular system with inconsistent findings
Fusion if (Sonntag and Marciano 1995)
greater than 4 mm translation or 10 deg rotation and who have failed conservative tx
Subjective Indicators of LSI (According to Delphi Study)
Cook 2006: - 168 PTs identified as OCS or FAAOMPT
- Giving away of back giving out
- Self manipulator
- frequent bouts of or episodes of symptoms
Objective Indicators
Cook 2006:
- poor lumbopelvic control, including segmental hinging or pivoting
- juddering or shaking (poor neuromuscular control)
- decreased strength and endurance of local muscles at level of instability
Cook & Hegedus 2011: physical clinical tests for spinal dysfunction
examined Sn, SP, +/- LR of 14 stand alone clinical tests
For SCREENING: cut off Sn of 90 and -LR < .2
For DX: +LR > 5.0
No studies were found involving physical clinical tests for T spine
only the lateral glide test @C2-3 joint dysfunction was found as an effective Dx test
Cook & Hegedus 2011: 3 tests of lumbar conditions, 2 tests for screening
Diagnosis Tests:
- Centralization for discogenic pain
- Lumbar PAIVMs and PPIVMs dx for radiographic instability
- Percussion and supine sign for compression fx
Screening Tests:
- ER test yielded screening capacity for ZJ pain
-SLR demonstrated capacity for nerve root compression
Algarni 2011 SR: Passive Lumbar Extension Test
Sn: 84%
Sp: 90%
+ LR 8.8
thus PLE test may be an effective clinical test to dx structural LSI
What did Hicks 2005 say about CPR to stabilization exercises for LSI
- It is not possible to dx LSI clinically b/c of a lack of a true reference standard for confirmation
- The development of a valid method for identifying a sub-group of LSI would help clinicians determine which LBP pts are most likely to benefit from stabilization ex.
Flynn 2002: CPR for use of SMT in LBP
Random manipulations of non-radicular LBP results in 45% success rate (32/71 pts)
Flynn 2002 CPR
- Duration of sx < 16 days
- FABQ < 19
- Lumbar Hypomobility on spring test
- @ least 1 hip w/ >35 deg IR
- No sx distal to the knee
Flynn 2002 CPR: what was +
presence of 4/5 variables on the CPR increases the probability of success w/ manipulation from 45%-95% (+LR =24.28)
Flynn 2002 continued
- 3/5 has a probability of success of 68%, which is sufficient to warrant an attempt @ manipulation
- the 5 variable CPR applies only to the Chicago SI technique
Flynn 2002: conclusion
- study suggests pts with high level of fear avoidance beliefs about work activities are unlikely to respond to manipulation
- 45% of subjects had a successful outcome without any attempt @ prediction
- in other words randomly manipulating individuals with non-radicular LBP may result in success about 45% of the time
Flynn 2002: best variable to determine success with manipulation
duration of symptoms < 16 days i.e. more acute symptoms more likely to respond favorably
Flynn used only Chicago technique , therefore unknown whether other manip techniques would provide similar results
Cleland 2006: use of lumbar roll in LBP pts who satisfy CPR
case series N=12
mean age = 39, median duration of sx = 19 days
Cleland Results 2006
Mean reduction in disability (ODI) was 57%
11/12 pts (91.7%) had successful outcome w/in 2 tx using the lateral recumbent roll manipulation
Cleland 2006: Conclusions
the CPR identifies pts with LBP who are generally likely to benefit from any form of HVLA directed towards the Lumbar/SI region
Effects of MT are not specific to target vertebra:
Lee 2005:
- PA to C5 moves everything from occiput to T3
- PA to L3 moves everything from T10 to sacrum
Beffa & Mathews 2004:
- manipulation directed to L5 cavitated L3/4 more than 50% of the time, SMT to SIJ caused L5/S1 to cavitate more than 50% of the time
Ross 2004:
- only 46% of SMT techniques in the lumbar spine found to accurately produce clicks at the targeted spinal levels
Technique Choice not real important in NS-LBP
Chiradejnant 2003: specific technique selected by the treating clinician or randomly selected had no difference in any of the patient centered outcome measured
Haas 2003: manipulation directed towards segmental impairments vs. randomly selected manipulation achieved reduction in pain/stiffness among pts w/ mechanical neck pain
Oliphant 2004: SR on risks of HVT manipulation to the lumbar spine
worsened disc herniation or cauda equina syndrome was calculated to be less than 1 in 3.7 million manipulations
Bjorkman 1999: comparison of SMT and NSAID use
adverse events occur in 25% of pts and significant complications occur in 1%-4% of pts.
GI complications of NSAIDs cause more than 100,000 hospitalizations and an estimated 16,500 deaths in US each year.
Comparison of SMT to Lumbar Surgery
Cauda Equina Syndrome is reported as a sequela of lumbar surgery in .2-1% of patients
any complication rate is 3.7% including a 1.5% mortality rate
Conclusion of Risks of lumbar manipulation
Lumbar spine manipulation is 37,000 to 148,000 x safer than NSAIDS for the tx of LDH
Lumbar spine manipulation is 55,000-444,000x safer than lumbar surgery for LDH
Fritz 2005: evidence for support of HVLAT
baseline exam including PA mobility testing were categorized as having hypo/hypermobility and then treated for 4 weeks
Fritz 2005 : results
74% of subjects w/ hypomobility had a successful outcome with SMT ( P=.002)
16.7% of subjects with hypermobility had a successful outcome with manipulation (P=.014)
for pts with hypermobility, failure rates were 83% for manipulation and 22% for stabilization
SRs on manipulation
Assendfelt 2005
Bronfort 2004: moderate evidence that SMT has better short term efficacy than mob and detuned diathermy
Bronfort 2004: conclusion on Chronic LBP
moderate evidence that SMT w/ strengthening ex is similar in effect to prescription NSAIDs w/ exercise for pain relief in both short/long term
mod evidence that SMT/MOB is superior to PT and HEP for reducing disability long term
Mod evidence that SMT/MOB is superior to general medical practice and to placebo in short term; superior to PT in the long term for pt improvement
UK BEAM Trial 2004:
Results: Exercises alone achieved small benefit @ 3 months and no benefit @ 12 months
SMT alone = small but moderate benefit @ 3 months, and a small but significant benefit @ 12 months
SMT + Exercise = mod benefit @ 3 months and small but significant benefit @ 12 months
UK BEAM trial Conclusion
no diff btwn SMT alone and SMT + Ex groups @ 12 months; BOTH gave small but significant benefit
SMT over 12 week period produced statistically significant benefit relative to best care in general medical practice @ 3/12 months
SMT cost effective addition to best care for LBP in gen practice; manipulation alone gives better value for money than SMT + Ex
Giles and Muller 2003
manipulation achieved best results overall
concluded in pts with chronic spinal pain, manipulations if not contraindicated results in greater short term improvement than acupuncture or medication
Hammila 2002: RCT on SMT efficacy
SMT resulted in greater short/long term disability reduction than HEP or PT
SMPT was superior to PT for pain relief in the long term
Koes 1992: RCT on SMT
SMT or MOB have an advantage over general medical practice and placebo for severity of main complaint and perceived global improvement in long term
Burton 2000 RCT on SMT
SMT had a higher short term reduction in pain/disability for disc herniation than chemonucleolysis
Herzog 1991 RCT on SMT
found no significant difference btwn SMT, back education, and ex in pain/disability
Rubenstein CR 2011
in general there is high quality evidence that SMT has a small, statistically significant but not clinically relevant, short term effect on pain relief and functional status compared to other interventions in pts with CLBP
SMT as effective as other common therapies for CLBP, such as ex therapy, standard medical care or PT
Richardson 1992:
conclusion not supported by result.
- posterior pelvic tilt recruited EO more than 2x as much
- never measured TrA and LM
Mosley and Hodges 2007
no one has ever recorded the TrA and DM EMG activity simultaneously during an abdominal hollowing maneuver
MacDonald 2007
there is no evidence that TrA and DM co-contract or that co-contraction helps spinal stability
activity or training of DM does not require co-contraction of antagonists (TrA)
Hodges and Richardson 1996: Feed Forward activation delay of TrA
in pts with a > 18 mo hx of LBP
most obvious deficit in subjects with LBP was the significant delay btwn 50-450ms in the onset of TrA contraction
normals with 30ms feed forward
Richardson 1999:
Reflex Inhibition (RI) may cause changes in the timing of muscle activity. - RI produces a decreased activation level of the alpha motor neuron pool at the ventral horn
RI: Richardson 1999
25 cc of fluid on knee joint causes RI of VMO
55cc of fluid on knee joint causes RI of entire quad
RI linked to jt effusion, pain, ligament stretch, and capsular compression: lowering the excitability of the alpha motor neuron pool
Macedo 2009: MCE for CLBP: SR
MCE superior to minimal intervention and confers benefit when added to another therapy for pain at all time points and for disability at long term follow up. MCE not more effective than MT or other forms of ex
Macedo 2009: conclusion
MCE was not superior to MT, other forms of ex, or surgery
MCE was as effective at reducing pain and increasing QOL as less complex form of ex.
Stevens 2006:
need 70% MVC to promote strength trunk gains
Stevens 2006b
unlikely that abdominals (TrA/IO) reach 70% MVC during stability training
Brown, McGill 2006
conscious attempt to co contract specific muscles could be dangerous and decrease spine stability
Vera Garcia 2006
abdominal hollowing/bracing were worst of the stabilization maneuvers
Cholewicki 2002
can not contract TrA alone
Stanton 2004
swiss ball training core stability training was good at using core on ball, but no difference in running
Helewa 1999
strengthening abdominals did not prevent LBP
Nadler 2002
core strengthening did not decrease the occurrence in LBP in athletes
Core Stability Assumptions
- certain mm are more important for stabilization of spine, in particular the TrA
- weak abs lead to LBP
- strengthening absor trunk muscles can reduce LBP
- unique group of core mm working ind. of other trunk muscles
- strong core will prevent injury
- relationship btwn stability and LBP
Fast 1990: Pregnancy and LBP
a study of 318 pregnant women who were shown to have lost abilities to perform sit-up
no correlation btwn the sit-up performance and the presence of LBP
strength of abs not related to LBP
Leboeuf-Yde 2000
found weight gains and obesity are only very weakly associated with LBP
Marshall and Murphy 2006 on TrA timing issue
demonstrated that the TrA in CLBP pts had delayed onset timing
TrA FFA delay has been shown to improve 28% immediately following SMT to SIJ (Marshall and Murphy 2006)
Nadler 2002: spinal stability training
no significant advantage of core strengthening ex in reducing LBP occurrences in 257 collegiate athletes
Cairnes 2006: spinal stability training
no difference btwn specific stabilization ex and conventional PT for LBP management
Helewa 1999: spinal stability training
ab strengthening did not prevent LBP
Silfies 2007:
no significant diff. in repositioning errors or motion proprioception btwn athletes w or w/o hx of LB injury
Silfies 2007 Conclusion
poor trunk proprioception does not predispose athletes to low back injury
impaired trunk proprioception is not a risk factor for sustaining LB injury in athletes
Hides 1994
evidence of LM wasting ipsilateral to symptoms in pts with acute and sub acute LBP
LM atrophy found at the symptomatic segment on the side ipsilateral to symptoms, confined predominantly to that one vertebral level
Hides 1994 continued
Magnitude of btwn side diff. was 31% at the level of symptoms in LBP patients.
whereas in normals, difference was only 3% at the L4 level
changes occurred within 24 hrs of onset
Hides 1996: study
34 pts demonstrated LM atrophy of 25% at L5 level
L5 level showed greatest LM CSA atrophy btwn sides difference
Hides 1996: Conclusion
after 4 weeks LBP had subsided in all subjects regardless of group
the LM CSA in controls remained 16.8% less at most affected level and 14% less at 10 weeks
Hides 1996: most likely mechanism of decreased LM CSA
Reflex Inhibition
others: Pain inhibition and disuse atrophy
Kader 2000: LM atrophy and LBP
LM atrophy was present in 80% of pts with LBP on MRI study
Kader 2000: grades for atrophy
Mild <10%
Moderate <50%
Severe >50% loss
