SMT-3 Flashcards
Savolainen (2004) found improvements in what parameter of neck pain in those with HVLA treatment vs. Exercise?
Worst pain — overall pain and average pain the same
Cleland (2007) allocated neck pain patients to thoracic NTM or SMT and found significant differences in what between-group parameters after 48 hours?
NDI (10.3% better), NPRS (2.03 points)
Gonzalez-Iglesias (2009) treated neck pain patients with HVLAT and/or electro thermal Tx and compared NPRS, NPQ (disability), and ROM. What were the initial results? We’re they maintained at 2 week follow up in his second study?
Mean between group differences:
2.3 points on NPRS
8.5 points on NPQ
8.4 deg LR, 9.6 deg RR
Pain and disability results maintained, ROM not reported
What were the primary 3 limitations of the Cross et al (2011) systematic review of thoracic HVLAT for mechanical neck pain?
- No inclusion of chronic patients
- Longest f/u was 6 months
- RCTs were limited and performed by the same authors
Lau (2011) studied chronic neck pain patients and treated with either SMT and/or infrared, as well as exercises. What were the results for differences between groups regarding pain and disability immediately and at 6 month f/u?
Insignificant for pain (1.2/10 diff) at both time points.
Significant for disability (8.86/36 immediately, 6.03/36 after six months) at both time points.
Dunning et al (2012) compared thrust and non-thrust mobilization of cervical and thoracic spine for neck pain and found what changes in DNF strength (in mmHg) and C1-2 rotation?
DNF: 3.4 mmHg (vs. 1.2 mmHg)
C1-2 rotation: 8.4 deg R (vs 3.5 deg), 5.9 deg L (vs. 2.5 deg)
In Koppenhaver’s (2011) study of LM thickness after SMT, why can we conclude that LM thickness was unrelated to disability? What percentage of variance in ODI scores was explainable by LM thickness?
The multifidi changes were transient and only related to 7% of variance in ODI score
Hancock et al (2007) reviewed tests to identify sources of pain. What 3 criteria on MRI were useful for ruling in a disc as pain source? What clinical feature was useful for ruling in disc?
MRI: 1. high intensity zone, 2. Endplate changes, 3. Disc degeneration (all 3= +LR > 2)
Clinical: centralization (+LR 2.8)
Hancock et al (2007) reviewed tests to identify sources of pain. What tests were useful for determining facet as pain source? What about SIJ?
Facet: none
SIJ: multi-test regimens (+LR= 3.2, -LR=0.29). no single test was informative
Why do Hancock (2008) and Cleland (2009) fail to reliably confirm or deny use of a CPR for lumbar SMT?
Hancock used NTM and reduced symptom duration from 27 to 5 days from original CPR study by Childs (2004), and Cleland compared 1 thrust to 480 CPAs and did not use a control group.
What is the evidence/best practice for diagnosing lumbar segmental instability?
Passive lumbar extension test (Alquarni 2011)
Sn=84%
Sp=90%
+LR=8.8
What does Cook et al (2006) identify as 3 subjective and 3 objective signs of clinical lumbar segmental instability?
Subj:
1. “Giving way”
2. Self-manipulation
3. Frequent bouts or episodes of Sx
Obj:
1. Poor lumbopelvic control (segmental hinging, pivoting)
2. Poor coordination, inc. juddering or shaking
3. Decreased strength and endurance of local mm
Which 3 tests and 2 screens did Cook & Hegedus (2011) determine to be of use in diagnosing LBP?
Tests:
1. Centralization for disc pain
2. Lumbar PIVMs for radiologic instability
3. Percussion for compression fx
Screens:
1. ER test for ZJ pain
2. SLR for nerve root compression
What did Flynn et al (2002) find to be the most likely predictor of positive and negative outcome from HVLAT for LBP?
Positive: Duration < 16 days
Negative: FABQ > 19
What are the 5 components of Flynn’s (2002) CPR for Lumbar HVLAT?
- Duration of Sx <16 days
- FABQ < 19
- Lumbar hypo mobility on spring testing
- At least one hip with >35 deg ER
- No Sx distal to knee
In Cleland’s (2006) validation study of Flynn’s CPR for HVLAT of LBP, what percentage of patients had a successful outcome? What was average decrease in ODI?
91.7% within 2 Tx, avg 57% reduction in disability, but it was only a case series
What did Oliphant (2004) calculate as the risk of worsening disc herniation or caída equina syndrome?
1 in 3.7 million manipulations
What is biomechanical specificity suspect, particularly with SMT?
Manual therapy is non-specific!
Lee (2005): C5 mob moves O-T3, L3 moves T10-sacrum
Ross (2004): only 46% of lumbar manips are accurate
Chiradejnant (2003): randomly selected technique performed as well as specific one
Haas (2003): random as good as specific for neck pain
Using the best evidence, lumbar manipulation in how much safer than NSAIDs? Than surgery?
37K to 148K times safer than NSAIDs
55K to 444K times safer than surgery
According to Fritz (2005), what is the success rate of HVLAT for patients with hypomobility? What was the success rate of stabilization for patients with hypermobility?
74% of hypomobile subjects responded to manipulation (vs. 16.7% of hypermobile subjects)
78% of hypermobile subjects responded to stabilization (vs. 17% of hypomobile subjects)
The UK BEAM trial found what level of improvement with low back pain in patients with exercise, SMT, or SMT + exercise at 3 and 12 months?
Exercise: small benefit 3 months, no benefit at 12 mos
SMT: small-mod benefit at 3 months, small at 12 mos
SMT + exercise: moderate benefit at 3 months, small at 12 mos
SMT + exercise only slightly better than SMT alone - except for fear avoidance
Giles & Muller (2003) investigated manipulation, medication, and acupuncture and found what?
Manipulation achieved best overall results (50% improvement in ODI and VAS, 38% on NDI, 47% on SF-36)
Rubenstein (2011) did a Cochrane review of SMT concluded what?
High quality evidence suggests no clinically relevant difference between SMT and other interventions for improving pain and function.
What does MacDonald (2007) say about spinal stability?
There is no evidence that TrA and DM co-contract, or that co-contraction helps spinal stability. EMG studies do not show DM as tonically active during any posture.
What does Richardson (1999) conclude may be the reason for the delayed TrA contraction seen with limb movements in Hodges & Richardson (1998)?
Reflex inhibition producing a decreased activation level of the alpha MN pool at the ventral horn
What did Macedo et al (2009) conclude about motor control exercise vs. minimal intervention for LBP?
Manual therapy and general exercise were more effective than motor control exercise
What evidence suggests core stability is a myth?
70% MVC (Max voluntary contraction) needed for strength gains (Stevens 2006) but abdominals do not reach this during “stability” training (Stevens 2006). Abdominal hollowing does not improve stability (Brown 2006, Vera-Garcia 2006), and the TrA cannot contract alone (Cholewicki 2002). Additionally, abdominal strength does not prevent LBP (Helewa 1999, Nadler 2002).
Hides (1994, 1996) demonstrated that multifidi strengthening reduced likelihood of back pain recurrence by what amount?
Patients recovered in four weeks regardless of group, but 30% recurrence in LM group vs. 80% recurrence in controls. Multifidi recovery was not spontaneous in controls despite pain remission, did occur with LM group.
Kader (2000) found what percentage of LBP pts showed multifidi atrophy on MRI? How many had no other findings?
80% — about half had no other findings, even with root or leg pain!
What is the Danneels (2001) protocol for LM strength?
3 exercises: QP leg extensions, trunk lifting from prone, B leg lift in prone
3x/week for 10 weeks
70% 1RM (15-18 reps)
2 second lift/lower with 5 second isometric for each rep
Kjaer et al. (2007) found what MRI finding correlated with severity of LBP?
Fatty infiltration of lumbar multifidi mm
Mayer (2005) studied use of T2 signal to determine muscle recruitment with exercise programs. What exercise routine did researchers find was most effective for recruiting lumbar extensor muscles, and which muscles were most recruited?
The multifidus showed the greatest increase, followed by erector spinae, then QL.
Roman chair, 75 deg flexion to 15 deg extension, 3 sets x10 reps, 2 sec concentric and 2 sec eccentric phases, 60s rest between sets, 40 MVC (minimize alternate mm recruitment)
Koumantakis (2005) gave both groups exercises, one with stabilization-specific exercise and the other with heavy extensor/flexor exercises, and came to what conclusions?
Patient engagement through safe exercising and NOT particular types of exercises may be the key component for successful LBP mgmt. General exercise was more effective than stabilization training.
What is the pain adaptation model? What is the evidence for it?
Pain results in loss of motor control, not the other way around.
Pain alters proprioception: Capra & Ro (2000)
Pain alters motor control: Hodges & Moseley, Holm (2002), Arendt-Nielsen (1995)
Pain alters muscle spindle sensitivity: Matre (1998)
What are Laslett’s (2006) 3 features that rule out ZJ pain?
- Negative extension rotation test
- Dominance of midline pain
- Presence of centralization
Wilde (2007) interviewed a panel of experts and found what sign was regarded as most likely to indicate ZJ pain?
Localized unilateral LBP (94%)
Santilli (2006) compared treatment of HLVAT and mobilization for disc protrusion and sciatica (5x/week up to four weeks) and found what changes in pain presence, number of painful days, and MRI findings at 6 month f/u?
HVLAT was 28% pain-free in back (vs. 6%) and 55% pain-free in leg (vs. 20%)
HVLAT had 23.6 days of pain (vs. 27.4), 13.9 of which where mod-severe (vs. 17.9)
No changes in MRI for either group
