SMT 3 Manual: Part 1

Question 1

Dunning

Answer 1

2012: 107 patients with neck pain of any duration. Treatment by 7 PT’s at 7 different clinics. Did:
1. Upper cervical (C1/C2) and upper thoracic HVLAT
2. Upper cervical and upper thoracic grade IV PA’s
Looked at outcomes at baseline and 48 hours after treatment.
1. HVLAT group had greater reductions in disability (50.5%) and pain (58.5%) than non-thrust (12.8% and 12.6%)
2. Significantly greater increase in passive C1/C2 right rotation (8.4 vs. 3.5 degrees) and left rotation (5.9 vs. 2.5 degrees) in HVLAT vs. mob
3. HVLAT group experienced significantly greater improvements in motor performance of deep cervical flexors (3.4 mmHg) compared to non-thrust (1.2 mmHg).

Question 2

Richardson studies

Answer 2

Several studies have demonstrated activity of abdominal and paraspinal muscles during an abdominal hollowing maneuver but Richardson (1990, 1992, 1999, and 2000) measured only sEMG for ES, not LM and TrA as reported. They said abdominal hollowing or bracing produced more effective pattern for lumbar stabilization that posterior pelvic tilt but posterior pelvic tilt recruited the external oblique more than twice as much as hollowing or bracing in both sitting or crook-lying. They never measured TrA or LM and never actually made a measurement of spinal stability.

Question 3

Gonzalez-Iglesias (Study 1)

Answer 3

2009: Subjects with acute neck pain less than 1 month. All treatments done by 1 PT and patients allocated to:
1. 3 sessions of thoracic HVLAT in sitting (1x/week) and 6 electro-thermal treatments over 3 weeks
2. 6 sessions of electro-thermal treatments over 3 weeks
HVLAT group had greater reductions in both neck pain and disability at 1 week after discharge. Difference between groups: 2.3/10 NPRS and 8.5/36 for NPQ [Northwick Park Neck Pain Questionnaire])

Question 4

Lau

Answer 4

2011: Patients with chronic neck pain allocated to:
1. 8 sessions supine thoracic HVLAT (2x/week) and infrared radiation over painful site
2. 8 sessions infrared
Both groups go isometrics, stretching, and AROM. Between group differences for pain not different but change scores for disability were on NPQ at immediate and 6 month f/u.

Question 5

Hayes

Answer 5

(1989) Found 42% of asymptomatics had at least 1 segment exceeding the instability thresholds on flex/ext radiographs of lumbar spine (high false positives)

Question 6

Cook and Hegedus

Answer 6

(2011): Looked at Sn, Sp, +LR, and -LR or 14 stand alone physical clinical tests. For screening a cut-off Sn of 90 and -LR of less than 0.2 necessary. For diagnosis a +LR of 5.0 or greater considered useful. No studies found matching inclusion criteria for thoracic spine. 5 clinical tests for cervical spine identified. Only lateral glide for C2-C3 dysfunction was found as effective diagnostic test. Prone UPA/CPA and Spurling’s effective as screening tools, not diagnosis. ULTT and C5-C6 lateral glides not effective for screen/diagnosis. Examined 10 tests for lumbar spine. 3 tests useful for diagnosis. Centralization diagnostic for discogenic pain (Laslett 2005), lumbar PAIVM’s and PIVM’s diagnostic for radiologic instability (Fritz 2005, Abbott 2005), percussion and supine sign diagnostic for compression fracture. Extension/rotation good screen for facet pain, SLR test good for nerve root compression.

Question 7

CPR for SMT in LBP

Answer 7

Flynn (2002): 71 patients with non-radicular LBP. Random HVLAT resulted in 45% success rate. CPR:
1. <16 days
2. FABQ (Work Subscale) <19
3. Lumbar hypomobility with spring testing
4. At least one hip > 35 degrees IR
5. No symptoms distal to the knee
Presence of 4/5 increased probability of success from 45% to 95% with +LR of 24.38. 3/5 has probability of success of 68%. Only applies for Chicago technique. Works 45% no matter what. The single best predictor of success was duration <16 days. Cleland (2006) tried to validate with n=12 for lumbar roll and Childs (2004) for 131 patients.

Question 8

Results of non-specific manual therapy

Answer 8

1. Chiradejnant (2003): Patients with LBP who received 1 session of mobilization to lumbar spine with specific or randomly selected technique had no difference in any of the patient-centered outcome measures
2. Haas (2003): Manipulation directed towards segmental impairments versus randomly selected HVLAT achieved similar reductions in pain and stiffness among patients with neck pain

Question 9

Pilates for LBP

Answer 9

Lim 2011: Compared Pilates to minimal/other interventions for persistent LBP for pain and disability. Used specific activation strategies of glutes, dissociation of hips, stabilization of pelvis, and TrA/LM training.

1. Pilates no more effective than other forms of exercise for pain
2. Pilates no more effective than minimal/other interventions for disbility.

Question 10

Hancock (Part 1)

Answer 10

2007: Systematic review of tests to identify disc, SIJ, or facet as source of LBP. Positive LR >2 or negative LR <0.5 were considered informative. Prevalence of each of these structures as source of LBP estimated at:
-Disc: 39%
-Facet: 15%
-SIJ: 13%
For studies to be included they had to have appropriate reference test (discography, SI joint blocks, intra-articular or medial branch block for facet)
1. 3 features on MRI (high intensity zone, end plate changes, and disc degeneration) increased probability of disc being LBP source
2. Centralization was only clinical feature found to increase likelihood of disc (+LR 2.8) and was uninformative in absence of centralization
3. Absence of disc degeneration was only test found to reduce likelihood of disc as source of pain (-LR 0.21, or 5x more likely not to have disc as pain generator)
4. Revel’s criteria for facet was not information
5. Multi-test regimen for SI joint pain was information with +LR of 3.2 and -LR of 0.29
6. No test for facet appears informative

Question 11

Safety of HVLAT vs NSAID’s/Surgery

Answer 11

1. Using the best available evidence, lumbar HVLAT is 37,000 to 148,000 times more safe than NSAID’s for treatment of LDH.
2. Lumbar spine HVLAT is 55,000 to 444,000 safer than lumbar surgery for treatment of LDH
3. Meanwhile, neither NSAID’s or surgery have been proven to be more effective in treatment of LDH than SMT (Oliphant 2004)

Question 12

Bronfort

Answer 12

(2004): 31 LBP trials with 5,202 participants.
Acute LBP conclusion: Moderate evidence that SMT has better short term efficacy than spinal mobilization and detuned diathermy.
Chronic LBP conclusion:
1. Moderate evidence that SMT with strengthening is similar in effect to prescription NSAID’s with exercise for pain relief in both short and long term
2. Moderate evidence that SMT/mob is superior to PT and home exercise for reducing disability in long term
3. Moderate evidence that SMT/mob is superior to general practice medical care and to placebo in short-term, and superior to PT in long term for patient improvement

Question 13

RCT’s of SMT efficacy

Answer 13

1. Bronfort (1996): Combo HVLAT and exercise similar in effect to combo of NSAID’s and exercise
2. Hemmila (2002): HVLAT resulted in greater short and long term disability reduction than home back exercise or PT, manipulation was superior to PT for pain relief in long-term.
3. Koes (1992): SMT or mob have an advantage over general medical practice and placebo for severity of main complaint and perceived global improvement in long term
4. Burton (2000): SMT had higher short-term reduction in pain and disability for disc herniation than chemonucleolysis
5. Herzog (1991): Found no significant short-term differences between STM, back education, and exercise in pain and disability

Question 14

Krauss

Answer 14

2008: Upper thoracic HVLAT vs. no intervention for those with neck pain. Looked at right and left cervical ROM and neck pain at end range with faces scale. Significant improvement in cervical rotation ROM to both sides. No difference in pain for right and left rotation but if subjects had pain with rotation in both directions then there was significant difference with right rotation but not left.

Question 15

TrA and LM Co-Contraction

Answer 15

Mosely and Hodges (2007). No one has ever recorded TrA and DM EMG activity simultaneously during abdominal hollowing maneuver.

Question 16

NSAID’s

Answer 16

1. Adverse events occur in 25% of patients and significant complications occur in 1-4% of patients (Bjorkman 1999)
2. GI complications due to NSAID’s cause more than 100,000 hospitalizations and an estimated 16,500 deaths each year (Graumlich 2001)

Question 17

Rubenstein

Answer 17

(2011) : Effectiveness of mob or manip for CLBP.
1. Low quality evidence SMT is not more effective than inert interventions or sham HVLAT for short-term pain relief or function
2. High quality evidence SMT has small, statistically significant but no clinically meaningful short-term effect on pain and function, when compared to other interventions
3. High quality evidence suggests there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with CLBP
4. Results of this review demonstrate SMT appears to be as effective as other common therapies prescribed for CLBP, such as exercise therapy, standard medical care, or PT.

Question 18

Hancock (Part 2)

Answer 18

(2008) Assessed external validity of Child’s 2004 CPR. Child’s original CPR was in U.S. Air Force facilities. This was a secondary analysis of Hancock (2007) RCT of 239 patients that got SMT or placebo (detuned ultrasound) 2-3x/week for up to 4 weeks. Each of the 239 patietns were assessed on the orginal 5 criteria at baseline (<16 days, no symptoms distal to knee, FABQ < 19, at least 1 hypomobile lumbar PA, >35 degrees hip IR). Participants who met 4/5 were positive for CPR.
1. Review of patient records revealed 97% of subjects who got “SMT” actually got non-thrust mobs and only 5% got HVLAT
2. The CPR did not identify those patients who were more likely to respond to SMT
3. The CPR performed no better than chance in identifying patients with acute, non-specific LBP most likely to respond to SMT
4. Childs (2004) was only 1 thrust vs. Hancock (2007) 8-12
5. Loss to f/u was 2% with Hancock and 30% with Childs
6. Even 5/5 items in CPR was statistically non-significant for all outcomes

Question 19

Gonzalez-Iglesias (Study 2)

Answer 19

2009: Subjects with acute neck pain less than 1 month. All treatments done by 1 PT and patients allocated to
1. 3 sessions of manipulation to “middle” thoracic spine in sitting (1x/week) and 5 sessions of electro-thermal
2. 5 sessions of electro-thermal over 3 weeks
HVLAT group had greater improvements in pain, disability, and cervical ROM at 2 and 4 weeks. Difference between groups 16.8/100 mm at 2 weeks and 26.5/100 mm at 4 weeks. 8/36 points on NPQ at 2 weeks, no data available at 4 weeks.

Question 20

Assessment tools for spine instability

Answer 20

O’Sullivan (2000) and Cook (2006) state there is a current lack of reliable and valid clinical assessment tools for diagnosis of spine instability.

Question 21

Cleland (2005)

Answer 21

Split subjects with neck pain into 2 groups:
1. Thoracic HVLAT
2. Placebo pre-manipulation hold
Defined neck pain as non-specific pain in area of CT junction, not the neck itself. Thoracic group had 15.5/100 mm reduction in pain 48 hours after treatment and placebo had 4.2/100 mm decrease. This 11.3 mm reduction in pain barely meets upper bound limit for MCID of 9-11 mm.

Question 22

O’Sullivan and Instability

Answer 22

(2000): Giving way, slipping out, or locking

Question 23

Cleland (2009)

Answer 23

Tried to validate Child’s HVLAT CPR. Took 112 patients with 4/5 of Child’s criteria. Randomly assigned to 1 of 3 manual therapy groups and then 3 exercise sessions.
1. 2 sessions supine HVLAT (didn’t choose level and got 4 attempts)
2. 2 session sidelying HVLAT (Chose level)
3. 2 sessions of non-thrust CPA’s to L4 and L5 (240 each level)
Exercises included pelvic tilts, TrA hollowing, quadruped arm/leg extensions, side support exercises.
1. No differences in disability for supine and sidelying thrusts at any follow up point (1 wk, 4 wk, 6 mo.)
2. Significantly better for disability with each thrust compared to mobs at 1 wk, 4 wk, and 6 mo.
3. No difference between pain for all 3 groups at 6 months
4. Study didn’t include a control group though so not able to determine if this is superior to no treatment for those positive on CPR.

Question 24

Manual therapy not specific

Answer 24

1. Lee (2005): PA to L5 moves everything from occiput to T3
2. Beffa and Matthews (2004): more than 50% of time L5/S1 HVLAT cavitated L3/L4 and SIJ cavitated L5/S1
3. Ross (2004): Only 57/124 HVLAT’s to lumbar spine were accurate

Question 25

Cross

Answer 25

2011: Literature review looking at effects of thoracic HVLAT. Concluded thoracic HVLAT may provide short-term improvements with acute or subacute neck pain but literature is weak and results may not be generalizable.
1. All 6 RCT’s only included acute or subacute neck pain
2. No study had outcomes longer than 6 months
3. There was a limited number of RCT’s which limited generalizability.

Question 26

Alqarni

Answer 26

(2011): Systematic review. The majority of clinical tests routinely employed to diagnose structural lumbar segmental instability demonstrated only limited ability to do so. The majority of tests had high specificity but low sensitivity. However, the passive lumbar extension test may be useful to diagnose structural LSI. It’s done to ~30 cm while providing from traction to LE’s. Positive test is pain that disappears on return to starting position. Sn 84%, Sp 90%, +LR 8.8.

Question 27

Delitto (1995)

Answer 27

Believed the following to be confirmatory data for LSI:

1. Frequent recurrences of LBP precipitated by minimal perturbations
2. Lateral shift deformity in prior episodes of LBP
3. Short term relief with manipulation
4. History of trauma
5. Use of oral contraceptives
6. Improvement of symptoms with use of brace in previous episodes

Question 28

Paris and Maitland

Answer 28

The presence of a step-off between spinous processes of adjacent vertebrae and/or hypermobility of PPIVM and PAIVM testing are indicative of instability (Paris 1985; Maitland 1986)

Question 29

UK Beam Trial

Answer 29

(2004) : 1334 patients with LBP (1/2 had >90 days) across UK. SMT delivered by chiros, osteopaths, and PT’s. Main outcome was Roland Morris at 3 and 12 months.
1. Exercise alone achieved a small benefit at 3 months and no benefit at 12 months
2. SMT alone achieved a small to moderate benefit at 3 months and a small but significant benefit at 12 months
3. SMT combined with exercise achieved a moderate benefit at 3 months and a small but significant benefit at 12 months. Thus, no difference between SMT alone and SMT plus exercise at 12 months.
4. Relative to “best care” in general medical practice, mean disability improved by this factor at 3 month and then 12 month for SMT, SMT/exercise, and exercise (1.6, 1.9, 1.4 and 1.0, 1.3, 0.0)
5. Concluded that SMT over a 12 week period produced statistically significant benefits relative to best care in general medical practice at both 3 and 12 months
6. SMT is a cost effective addition to best care for back pain
7. Manipulation alone gives better value for money than manipulation followed by exercise

Question 30

Aberrant motion

Answer 30

Often occurs returning from a flexed posture and is:
1. Sudden acceleration or deceleration of movement (OR)
2. Movement outside primary plane of movement
Has never been related to symptoms or abnormal movements in imaging studies, hence, no concurrent validity

Question 31

Manipulation validation study

Answer 31

Cleland (2006): Case series with 12 patients had 4/5 criteria on CPR. Used lumbar roll and mean number of days was 7 between 1st visit and re-exam on 3rd visit. Mean reduction on ODI was 57%. 11/12 had successful outcome within 2 treatments exceeding >50% reduction in ODI. Can’t infer cause-effect relationship between HVLAT and ODI because this is a case series (Level IV evidence). Need RCT to compare different HVLAT techniques. He concluded though that the CPR identified patients with LBP who are generally likely to benefit from any form of HVLAT towards lumbar or SIJ region.

Question 32

Cook

Answer 32

(2006): 168 PT’s identified as OCS or FAAOMPT. 3 delphi rounds designed to select specific and objective identifiers of LSI.
Subjective:
1. “Giving way” or back “giving out” ranked as the subjective factor most related with LSI
2. Self-manipulator
3. Frequent bouts or episodes of symptoms
Objective:
1. Poor lumbopelvic control, including segmental hinging or pivoting with movement, as well as poor proprioceptive function ranked as objective factors most related to LSI
2. Poor coordination/neuromuscular control, including juddering and shaking
3. Decreased strength and endurance of local muscles at the level of segmental instability

Question 33

Spine instability categories

Answer 33

1. Radiologic: instability which reflects disruption of passive osseo-ligamentous constraints (static flex and ext radiographs)
2. Clinical Instability: more subtle and challenging to diagnose and involves the neuromuscular system with inconsistent findings during traditional radiographs (Cook 2006)
   Fusion reserved for patients with excessive motion (greater than 4 mm translation or 10 degrees rotation) and who have failed a trial of conservative treatment (Sonntag and Marciano 1995)

Question 34

Lumbar surgery complications

Answer 34

Cauda equina syndrome is reported as a sequela of lumbar surgery in 0.2 to 1% of patients (Henriques 2001, Kardaun 1990). Any complication rate is 3.7% and this includes a 1.5% mortality rate.

Question 35

Giles and Muller

Answer 35

(2003): Compared medication, needle acupuncture, and SMT for chronic spinal pain (neck or LB) >13 weeks. Manipulation achieved best overall results.
Conclusion: In patients with chronic spinal pain, manipluation, if not contraindicated, results in greater short-term improvement than acupuncture or meds.

Question 36

Savolainen

Answer 36

2004: Subjects with neck/shoulder pain got personal exercise program from PT or 4 thoracic HVLAT’s by PT at 1 week intervals. No significant differences found at 6 and 12 months between groups but thoracic HVLAT group reported significantly lower level of perceived “worst” pain at 12 month follow up.

Question 37

CPR for stabilization

Answer 37

Hicks (2005)

Question 38

Sillevis

Answer 38

2010: Patients with neck pain got single T3/T4 HVLAT or 3 second chest compression but no thrust. Measured pupil diameter with goggle apparatus and pain before and after. Pupil receives innervation from ANS exclusively. No statistically significant difference in VAS or pupil diameters between groups.

Question 39

Fritz

Answer 39

(2005) : RCT of 131 patients with LBP. Baseline exam including PA mobility testing and were categorized as having hypomobility or hypermobility in lumbar spine and then treated for 4 weeks.
1. 74% of subjects with hypomobility had successful outcome with manipulation
2. Only 16.7% of subjects with hypermobility had successful outcome with manipulation
3. For patients with hypermobility, failure rates were 83% for manipulation and 22% for stabilization

Question 40

Cleland (2007)

Answer 40

60 subjects allocated to non-thrust mob CPA’s for 30 sec to T1 - T6 levels vs. supine upper and middle thoracic thrust manipulations. HVLAT had:

1. Greater short-term reductions in disability and pain
2. Mean between group change in NDI was 10.03% in favor of HVLAT (MCID for NDI is 7)
3. Mean between group change in NPRS scores was 2.03 (MCID for NPRS is 1.3)