SMT-1 Flashcards
Dunning et al. (2012) investigated thrust vs. Non-thrust mobilization for mechanical neck pain. What were the comparative percentage decreases in pain, disability and NNT?
Disability: 50.5% vs 12.8%
Pain: 58.5% vs 12.6%
NNT: 1.8 for disability, 2.3 for pain
Dunning et al, (2013) found what about cavitation sounds during their study?
They are bilateral >90% of the time, only slightly more like to occur ipsilateral to target side, with an average of 3-4 cavitations during initial manipulation and 6-7 total after B manipulation
Dunning et al. (2015) found that in patients with shoulder pain that have a negative Neer’s, what effect did 2 sessions of thoracic and rib manipulation have? Include effect size and GRC
Significant difference in SPADI (F=59.9) and NPRS (F= 63); difference remains significant (p<.05) through 3 month f/u
Effect size: d>0.8
GRC: +6.8 at 3 months
Dunning et al. (2016) compared cervical and thoracic mobilization with exercise to HLVAT for cervicogenic headache. What were the differences headache intensity (NPRS), headache frequency, headache duration, disability (NDI), and GRC at 1-week, 4-weeks, 3 months?
Improvements in NPRS, disability (NDI) compared to mobilization at 3-month f/u.
Improvements in headache frequency and headache duration at all time points
Improvements in GRC at 1 and 4 week f/u.
Mourad et al (2018) investigated lumbosacral manipulation sounds and found what?
Sounds were unilateral but no more likely to be target side than contralateral side. Mean number of cavitations was 5 (2-9 sounds).
Mourad et al. wrote up a case study on a patient with craniopharyngioma. What were the red flags that led him to refer her out?
- Recent onset of new type of headache
- Change in headache phenotype
- Rapid progression of Sx
- Neuro signs and Sx
- Worsening of Sx with valsalva
The ACP clinical guidelines recommend spinal manipulation with what level of evidence and strength of recommendation?
Low quality evidence, strong recommendation.
UK (NICE) guidelines of non-specific LBP include which manual Tx?
Up to 9 sessions of manual therapy including spinal manipulation over 12 weeks.
Up to 10 sessions of acupuncture over 12 weeks.
Haskins et al. (2012) concluded what after studying 25 LBP clinical prediction rules?
None were ready for clinical use due to non-existent or single arm validation and non-existent clinical impact phase
May & Rosedale (2009) reviewed existing LBP CPRs against established criteria and found what about the derivation and validation studies?
Derivation studies were mostly high quality, but none of the validation studies were. Most did not pass the lowest level of evidence hierarchy. Manipulation CPRs had limited and contradictory evidence of clinical utility.
Stanton (2010) and Haskins (2015) studied CPRs for readiness to apply them to LBP. They both concluded they were not ready for different reasons. What were they?
Stanton found studies used single arm design and therefore may just list prognostic indicators rather than treatment indicators.
Haskins (2015) found no studies to look at validation or impact analysis.
During C3/4 manipulations, Reggars (1996) found how many clicks will occur? Bolton (2007) found pops occurred on which side?
Average 2.5 cracks, popping contralateral side to applicator with rotation but either side with side bending.
How specific can we be with thoracic manipulation?
Herzog & Symons (2001): peak pressure pt moved 9.8 mm (probably not delivered to target segment)
Ross (2004) found 3.5 cm as avg error from target joint—more cracks=more accuracy
Bereznick (2002): 38.75 mm displacement on TPs, 33.25 mm for SPs during thoracic thrust if no skin lock
How accurate is lumbar manipulation?
Ross (2004): 5.29 cm avg error from target joint
Beffa & Mathews (2004): no correlation between target segment and cavitation—L5/S1 got L3-4, SIJ got L5/S1
Ernst& Canter (2006) SR of SRs said what about efficacy of HVLAT for LBP?
SMT superior to sham but not to other treatment
Bronfort (2004) found what level of evidence of SMT for LBP Tx?
Moderate evidence that SMT is superior to PT, HEP, and general medical care
The 2010 Cochrane review (Gross) of neck pain comparing manipulation to mobilization concluded what?
Moderate to low quality of evidence: manip same as mob for neck pain
Low quality: cervical manipulation alone may provide immediate short term relief and that thoracic manip>placebo
Smith & Bolton (2013) determined what clinical criteria can indicate need for cervical manipulation?
- Exclusion of serious conditions
- Manual exam for TTP
- Altered vertebral motion in the neck or upper thoracic region
However, they also concluded there are no good diagnostic rules
What 2 arguments does Cassidy (2012) make in favor of spinal manipulation for neck pain?
Evidence that it decreases pain (Hurwitz 2008, Leaver 2010) compared to placebo and is better than NSAIDs (Bronfort 2012)
No evidence that mobilization is safer
Michaleff (2012) investigated cost-effectiveness of SMT for neck pain and found what compared to GP, exercise, and other Tx?
Superior to GP: lower cost, higher recovery rate
Superior to exercise: cost effective and superior outcomes
SMT + GP care better than “other”
What are 8 benefits of applying a thrust?
- Facilitate movement
- Relieve pain
- Increase circulation
- Immediate neurophysiological reflex response (mm relaxation)
- Immediate strength increase
- Release entrapment (capsules, meniscoids)
- Powerful psychological effect
- Quicker than mobilization
What are the actual risks of spinal manipulation?
Margarey & Haldeman (2002): 1/50K to 1/5.85 million cervical manipulations
Cassidy (2008): cervical Complications 1/50K to 1 in 4M, association between chiro and VBA stroke less than PCP visits
Haldeman & Rubenstein (1992): lumbar <1/10M manipulations
Murphy (2010), Kerry & Taylor (2006) concluded there’s no benefit to screening for risk of VBA - what was the reasoning and what 6 tests are recommended instead?
VBI test not validated
Instead use:
1. CN exam and VOMS
2. BP testing
3. active signs of dissection
4. PMH of artherosclerosis (maybe)
5. US
6. functional CAD position tests
What is the comparative stress on VBA of HVLAT vs diagnostic testing/ROM? What is the level of force required to cause a dissection?
Symons (2002) SMT was 6.2% of resting length at OA level and 2.1% at C6 - mechanical failure occurs at 139-162%
SMT uses approx 1/9 the strain of a mechanical failure and equal or less strain as Dx/ROM testing
Wuest (2010) 2.3% strain during thrust vs 13% during PROM testing and 8.5% during VBI test
Thomas et al (2013) investigated blood flow during manipulations and found what?
No changes in flow during any neck position or manipulation/distraction—change in one vessel caused compensation in the others
What did Hutting (2013) conclude about the statistics for the VBI test?
Sensitivity 0-57%: high risk of false negatives
Specificity 67-100%: not helpful since a false positive is not dangerous for a patient with VBI
Which four cranial nerves are most impacted by a VBA/ICA dissection in progress? What other signs/Sx occur? Kerry & Taylor (2010), Thomas (2011)
Hypoglossal n., glossopharyngeal n., vagus n., accessory n.
ICA: Horner’s syndrome (82%), temporal/retro-orbital HA (75%), facial palsy (60%), ptosis (60%)
VA: occipital HA (85%), ataxia/balance (67%), dizziness (25%)
What are the 3 components AAMT argues should be added to a definition to distinguish HVLAT from mobilization?
- Thrust (short and fast)
- Audible pop
- Pt cannot prevent forces
Bonus: chiros add Paraphysiological range
What pre-manipulative tests are recommended for cervical spine?
- Lateral glide test (Fernandez-de-las-Penas 2005, Jull 1994)
- Flexion rotation test
What are the mechanics of a cervical manipulation (position, speed, acceleration, force)?
30 deg rot, 46 sidebend/sideshift, 2 deg flexion/ext
4.8 deg off barrier, 11 deg through barrier (Ngan), 13 deg displacement (Triano)
Time: 80-100 ms CS, 120-200 ms LS
Speed: 72 deg/s avg, 127 deg/s peak
Acceleration: 2183 deg/s/s
Force: peak 118N
Ngan 2005, Klein 2003, Herzog 1993, Tríanos & Schultz 1994
What is the difference between the preload force and peak force of a thoracic HVLAT?
10x increase (24 N to 238 N)
Herzog & Symons 2001
What evidence exists that joints move after manipulation?
Thoracic: Gal (1997) found 6-12 mm of anterior and 3-6 mm lateral translation from pre-load to post-thrust
SIJ: Hungerford (2004) found pts with pelvic pain rotated their WBing inominates anteriorly and translated inferiorly (opp for pain free individuals) suggesting asymmetry; Timgren & Soinila (2006) found restoration of pelvic symmetry after HVLAT w/ 15% relapse. Results independent of length of time pain had occurred.
How much did jaw opening increase after PA manipulation in neck pain patients (Mansilla-Ferragut 2009)?
3.5 mm
What is the amount of treatment indicated for neck pain that is acute vs. Chronic according to Bale & Newell (2005)?
Acute: 4 Tx, 3 weeks
Chronic: 4-10 Tx, 10 weeks
<7% required >10 Tx
What are three physiologic effects of SMT?
- Stimulate receptors in short and deep intervertebral mm (Bolton & Budgell 2006)
- Intervertebral disc diffusion (Beattie 2013)
- Increase afferent discharge of mechanoreceptors from disc, facets, mm, ligaments (Colloca 2004)
How did Indahl (1997) prove that lumbar multifidi are connected to discs?
1 mL injection into lumbar facet caused rapid reduction in multifidi EMG
Electrical stim to disc annulus stimulates mutlifidi
What are the 6 absolute contraindications to HVLAT? Include medical emergencies
- Vascular: CAD, aortic anuerysm >5 cm
- Bone: fracture, tumor, long-term corticosteroid, ankylosing spondylitis, true instability
- Neurological: cauda equina, cervical myelopathy
- Excessive/extreme pain
- Lack of clinical Dx
- Lack of patient consent
What are 5 relative contraindications to HVLAT?
- Disc herniation/prolapse
- Pregnancy (esp week 12 & 16)
- Osteoporosis/RA
- Spondylolysis, spondylolisthesis
- Advanced DJD, spondylosis
What are the Canadian cervical spine rules?
1+ high risk factor:
1. >65 yo
2. Paresthesias in the extremities
3. Dangerous mechanism (fall >1 m/5 stairs, axial load to head, MVA >60 mph or rollover or ejection, bicycle collision, ATV accident
AND
Pt unable to rotate neck 45 deg in each direction
Per Osmotherly & Rivett (2011), Why not use craniocervical instability tests?
Clinical tests have no established validity and “poor to unacceptable” inter-examiner reliability
What are five indications of craniovertebral instability?
- Occipital numbness
- Neck-tongue syndrome (1/2 of tongue goes numb with contralateral neck rotation
- Headache w/ sustained flexion
- Lump in throat during flexion
- Cord signs: Lhermitte’s (electrical feeling down back and limbs with vertebral flexion &/or ext), Romberg’s sign (balance w/ EC), Hoffman’s sign
What are the 5 tests in Laslett’s cluster and their statistics?
- Posterior thigh shear (thrust) test
- Gaenslen’s (perform B)
- ASIS distraction
- ASIS compression
- Sacral compression
3/6 91-94% sensitivity, 78-87% specificity
What are the 5 tests for SIJ pain provocation tested by Van der Wurff (2006) and their statistics?
- ASIS distraction
- ASIS compression
- Posterior thigh thrust
- Patrick’s sign (FABER)
- Gaenslen’s
3/5 85% sensitivity and 79% specificity
McGrath (2006) argued that the SIJ is impalpable for what 4 reasons?
- Depth of 5-7 cm under skin
- Inominate faces medically on sacrum
- 7 anatomical layers to palpate through
- Only 1-2 deg of motion in rotation and 1 mm of translation in any direction
What did Freburger & Riddle (2001) conclude about Inter-testing reliability, sensitivity, and specificity for SIJ positioning tests?
The standing/sitting flexion, Gillet’s, supine to sit, prone knee flexion and sacral spring all have poor inter-tester reliability, low sensitivity (0.46-0.49), and low specificity (0.38-0.64). Authors concluded we cannot palpate to find which “position” the SIJ is in.
Poor Inter-tester reliability was also found by Robinson (2007) and Holmgren (2007).
What did van der Wurff (2006) conclude about pain referral patterns for SIJ?
Fortin’s area (3cm horizontal x 10cm vertical) inferior to PSIS pain with the absence of tuber area (ischial tuberosity) pain indicates likely SIJ pain
What did Mens et al (1999) conclude about use of the ASLR in supine?
It validly demonstrates a step of 5mm at the upper margins of the pubic bones in pain patients caused by anterior rotation of inominate on symptomatic side and correlates STRONGLY with mobility of the pelvic joints in patients with pelvic pain.
What is the AAMT recommended best practice for SIJ clinical Dx?
- 3/5 tests (Laslett’s or van der Wurff)
- Fortin’s area
- ASLR
- Trigger points: BL54 (piriformis), BL23 (QL lat to L2)
What direction should you manipulate into for the SIJ?
It doesn’t matter (Clements 2001, Hartman 1997&2006, Stuge 2006)
What is are 6 goals of HVLAT to SIJ?
- Increase force closure/strength of QL, LM, glute Max
- Improve feed forward activation times
- Decrease pain
- Increase ROM
- Reduce disability
- Correct positional fault? (Contradicting evidence)
What is the evidence of use of stabilization exercises for SIJ pain?
Mens (2000): no improvement with stabilizing exercises vs control
Stuge (2004): improvement with stabilization, but patients also received SMT
Nilsson-Wikmar (1998), Dumas (1995): no difference between stabilizing exercise and no exercise
According to Holm et al (2002), Kavcic (2004), Stuge (2004, 2006), what muscles provide lumbopelvic stability?
All trunk mm—not just IO, TrA, LM
