SMT-1 (Part 3) Flashcards
What is the only study showing that a “cracking” sound is unnecessary?
Just one study published twice by Flynn et. al (2003) & Flynn et al. (2006)
It was using the Chicago HVT targeting SIJ.
What study shows that OA HVLAT increases activity and improves mouth opening?
Masilla-Ferragut et al (2009) JMPT
n=37 women with chronic (>6 months) bilateral mechanical neck pain and active month opening of less than 40 mm.
Results: A single session of HVLAT to the right and left OA joint immediately significantly increased active mouth opening by 3.5 mm.
Explanation: Reduction of reflex inhibition, allowing the masseter muscle to relax and thus increase in mouth opening ROM.
What is the main reason why OA HVLAT increases activity and improves mouth opening?
Reduction of reflex inhibition allows the masseter muscle to relax and thus increases mouth opening ROM.
What do the results of Koppenhaver et al. (2011) show?
The thickness of the Contracted Transverse Abdominus (TrA) and Internal Oblique (IO) musculature decreased immediately after the initial spinal manipulation technique (SMT). Still, it was NOT significantly different from baseline after 3-4 days or at one week.
*Lumbar Multifidus (LM) thickness significantly increased at 3 to 4 days immediately after two sessions of SMT, but no differences were found immediately after one session of SMT or a 1-week follow-up (following two sessions of SMT)
What was the only statistically significant result from the Koppenhaver et al. (2011) show?
TrA and IO, muscle thickness changes, occurred from baseline to 3-4 days immediately after session two of SMT in the LM muscle at L5-S1. Changes to LM were only present for a few seconds at L5-S1 immediately after the second session of SMT on day 3 or 4.
What are the results of Boal & Gillette (2004) show?
*SMT may alter afferent input to the central nervous system and, as a result, alter reflex mechanisms and ascending and descending pain-modulation elements of the pain system.
- SMT causes the co-activation of both large-diameter A-beta and small-diameter A-delta, c-fiber mechanosensitive afferents, providing a counterirritant like tens, acupuncture, and vigorous deep massage.
- SMT as an effect on the dynamic cellular mechanism within neurons-Neuronal plasticity.
What is Neuronal plasticity?
*Behavior changes in the dorsal horn of neurons are influenced by previous events that contribute to persistent pain states (Lont long-term potentiation LTP or central sensitization) or the reverse (Long Term Depression LTD).
*Provides a mechanism that contributes to the amplification of synaptic transmission in nociceptive circuits (central sensitization), leading to central neuronal elements overreacting to normal input with persistent hyperexcitability.
What is the post-cavitation refractory period?
What study hold support for this?
Once the joint has been cavitated, it cannot be recavitated for 15-30 minutes.
- Unsworth et. al (1971)
- Sandoz (1996)
- Mierau et. al (1989)
- Watson et. al (1989)
- Brodeur (1995)
Importance of the Boal & Gillette (2004) study?
*Spinal Manipulation Technique reverses long-term potential with an already sensitized pain signaling system.
*SMT may preferentially activate small diameter Alpha delta fibers in the skin and deep tissue, providing input to the spinal cord neurons, causing “spinal” LTD (Long-Term Depression) or suppressed neuronal discharge in the dorsal horn.
- SMT provides sufficient forces to the paraspinal tissues to trigger activation of both A-delta and c-fibers mechanosensitive afferents, thus initiating LTD, which is responsible for reversing ongoing LTP (central sensitization) in dorsal horn that is likely participating in the generation of low back pain.
*LTD occurs quickly (within seconds to minutes) after afferent stimulation (SMT), and it has been observed to last for hours.
*The Long Term Depression mechanism is the explanation for the antinociceptive effect of various manual therapies, including SMT.
*LTD necessary to allow structures to assume and/or sustain normal biomechanics post-SMT.
*SMT may allow for normal (neuronal) activity, creating afferent input that decreases LTP and/or stimulates LTD.
*Spinal (dorsal horn cells) and supraspinal (brain)/ descending mechanisms appear to play upon and down-modulate nociceptive processing from LBP
The George, Bialosky & Bishop study (2006-2011) shows?
“temporal sensory summation” model, explaining the hypoalgesic mechanism post SMT.
Why 15-30 min post-cavitation refractory period?
Due to the presence of collapse gaseous fluid, which remains unresorbed in the joint. Upon attempted cavitation, this gas expands to prevent a sudden drop in intra-articular pressure. Thus, the cracking sound does not occur until all the gas in the join is completely resorbed (Sandoz 1969).
In what study investigated the side of the cracking with C3-4 HVLAT manipulations?
Bolton et al. (2007)
N of 20, by putting microphone in the skin
What are the results from the Bolton et al. (2007) study investigating the side of the cracking with C3-4 HVLAT manipulations?
- With C3-4 with the primary lever of ROTATION, it is more likely to occur on the CONTRALATERAL side of the applicator.
- C3-4 HVLAT with the primary lever of SIDE-BENDING, the popping was more likely to occur on the ipsilateral than the contralateral side to the applicator.
- The patient can’t even ID the side of cavitation.
Dunning et. (2013) al follow the Bolton et.al (2007) study:
What are the results from this study investigating the side of the cracking with C1-42 HVLAT manipulations?
Microphones were put on the C1 level.
Results:
1. HVLAT cavitations were bilateral event
- Cavitations were no more likely to occur ipsilateral than contralateral with respect to the primary application.
- Mean number of pops after bilateral HVLAT= 6.95
- Neither the patient nor the therapist could reliably determine the side of the cavitations.
What are the results from the study by Dunning et al. (2014) on the side and the number of cracks post CTJ post manipulation?
4:1 cracks ipsilateral: Contralateral post-CTJ manipulation
What was the validate study for CS pre-manipulation testing:
Lateral Glide Test (PAIVM) in the cervical spine.
-Fernandez De Las Penas et.al (2005)
N=25 patients with mechanical pain
Method: 2 PA cervical X-rays taken on each patient at the maximum end range of right and left lateral flexion.
Radiology results compared with blinded results of PT using C3-7 cervical lateral glide (PAIVM) test to diagnose the “hypermobile” segment and side of dysfunction.
The study has better reliability on C3 and C4 segments
Results: Intervertebral radiological motion at the hypermobile side was 3.44 mm less than the contralateral side at the dysfunctional segment
Main Result and Conclusion from Fernandez De Las Penas et.al (2005) study:
Results: Intervertebral radiological motion at the HYPERMOBILE side was 3.44 mm less than the contralateral side at the dysfunctional segment
Conclusion: The first study to provide evidence that the lateral gliding test for the cervical spine is comparable with radiological assessment for the diagnosis of hypomobility fromC3-7
Validation of the lateral glide test. Is possible to diagnose ZJ hypomobility with the test
Diagnostic criteria to justify a cervical manipulation.
What are the clinical criteria justifying spinal manipulative therapy for neck pain?
Based on Smith and Boton (2013) systematic review
Based on Smith and Boton (2013)
- 30 RCT’s involving mobilization or manipulation for neck pain.
*SUbjects:
-43% of patients treated had Acute and chronic mechanical neck pain
-10% of studies included with CGH
*Clinical criteria used to determine the need for neck manipulation in over half (63%) of the RCT.
1-Exclusion of serious conditions
2-Manual examination for tenderness on palpation
3-Altred vertebral motion in the neck or upper thoracic region is known to lack validity.
Conclusion of the Smith and Boton (2013) systematic review?
Highlights the Absence of reliable and valid diagnostic protocols to determine the need for spinal manipulation in persons presenting with non-serious, idiopathic, or whiplash-associated (grade II) neck pain.
What is the purpose of the study by Cook & Hegedus (2011)
Purpose:
*Diagnostic utility of physical clinical test for spinal dysfunction. Examine sensitivity and specificity, +LR and -LR of 14 stand-alone physical clinical tests.
*Test for SCREENING (Ruling out disorder). A cut-off sensitivity of -LR <0..20 is useful.
-LR= how much the odds of the disorder decrease when the test is negative
*Test for DIAGNOSIS (ruling in disorders). A cut-off +LR> or = 5.0 is useful. +LR= how much the odds of the disorder increase when the test is positive.
What are the results of the study by Cook & Hegedus (2011)?
^Results:
A. For TS: No test with adequate +LR and -LR
B. For CS:
-Diagnostic test (+LR) (ONLY): Lateral glide test for C2-3 facet dysfunction
-Screening test (-LR) (ONLY);
1. Prone unilateral/ central PA’s for fascet dysfunction
2. Spurling’s test for radiculopathy
-Neither screening nor diagnostic test
1. Upper limb tension test (ULTT)
2. C5-6 lateral glide test
C. For LS:
-Diagnostic test (+LR)
1. Centralization for discogenic pain
2. PAIVM’s and PPIVM for radiologic instability
3. Percussion and supine signs for compression fractures
-Screening test (-LR)
1. Extension-rotation test for facet pain
2. Straight Leg Raise for Nerve root compression
What are the conclusions of the study by Cook & Hegedus (2011)?
Conclusions:
Stand-alone physical clinical tests provide only marginal value in diagnosing spinal conditions.
Clusters of tests appear to provide more promising findings and assist clinical decision-making.
(example: Laslett CPR for SI Pain)
Should we abandon cervical spine manipulation for mechanical neck pain?
NO!
*Cassidy et al. (2012): when risk, benefit, and patient preference are considered, there is currently no preferred first-line therapy and NO evidence that mobilization is safer or more effective than manipulation.
*Hurwitz et. al (2008):
The international multidisciplinary task force endorsed manipulation as one of several first-line treatments for neck pain, whiplash, and related headaches.
*Leaver et al. (2010)
Manipulation, multimodal PT, neck exercise, and drugs (paracetamol) all had significant short-term effects on pain compared with placebo. Acupuncture and manipulation had significant short-term effects on disability compared with placebo.
*Bronfort et. al (2012)
Spinal manipulation is more effective for acute & subacute neck pain (short & long-term) than management with NSAIDs or paracetamol.
This is a study that determines the cost-effectiveness of SMt compared to other treatment options for people with spinal problems of any duration.
Michaleff et. al (2012) Systematic Review
- Results: SMT was superior to general practitioner (GP) care for neck pain regarding recovery and QOL. SMT was associated with lower total costs and higher rates of recovery. (Korthals de Bos et. al 2003)
*Two studies found SMT to be a more effective treatment option than an exercise program in terms of pain, recovery, and QOL. (Bosman et. al 2011, Korthals de Bos et. al, 2003)
*SMT is dominant compared with exercises for neck pain.
*Both trials found that SMT plus GP, rather than GP alone, was a more cost-effective treatment for LBP than GP care alone. (UK Beam trial, 2004; Williams et al., 2004)
*SMT plus GP care was a more cost-effective treatment than GP care plus exercise. (UK BEAM trial, 2004).
If I rotate the CS to the right, what side will it close?
The right side will close.
The same side will close with the rotation.
If I rotate the TS or LS to the right, what side will it close?
The right side will open.
Opposite of the CS.
The same side of the rotation will be open.
The Canadian Cervical Spine Rule has been develop to determine when radiographs of the CS are indicated in individuals with neck pain following trauma.
It has highly….
High Sensitivity. 100% Sensitive, lack specificity just 43%
It’s a most use tool for when evaluation an older individual with neck pain caused by trauma, PT should be alert for the presence of CS fx’s.
What was the Ross & Cheeks (2008a) case report about?
Detecting CS fracture and the Canadian CS rule:
In patients with neck pain caused by trauma, PT should be alert for the presence of cervical spine fractures, even if the initial radiographs are negative for a fracture.
- In the case report, did A-P, lateral, and open-mouth X-ray views. The patient declines any medical and PT intervention. After eight months, f/u patient had No pain, AROM was WNL pain-free, and no neurologic deficits.
*Importance of screening for underlying cervical spine fractures in patients with neck pain following trauma-acute and subacute (8 weeks post-injury).
