Week 2

Question 1

According to Boal and Gilette 2004, how does SMT reduce pain?

a) Restores the position or biomechanics of the affected segment
b) Attenuates the release of algesic agents
c) Mechanotransduction
d) A and B

Answer 1

D) A and B

SMT restores the position or biomechanics of the affected segment and attenuates the release of algesic agents

Question 2

How does SMT alter afferent input to the CNS?

a) Restores homunculus representation
b) Alter reflex mechanisms
c) Alter ascending and decending pain modulating elements of the pain system
d) B and C

Answer 2

D) B and C
SMT alters reflex mechanisms and ascending/descending pain- modulating elements of the pain system

Question 3

How does SMT produce a counter-irritant effect?

a) Co-activation of both large diameter A-beta, small diameter A-delta and C-fiber mechanosensitive afferents
b) Histamine reaction
c) Periaqueductal Areas
d) all of the above

Answer 3

A) Co-activation of both large diameter A-beta, small diameter A-delta and C-fiber mechanosensitive afferents

Question 4

Neuroplasticity:

a) Behavioral changes in dorsal horn neurons influenced by previous events
b) Contributes to persistent pain states (long-term potential LTP or central sensitization)
c) Provide mechanics that contribute to amplification of synaptic transmission that lead to central neuronal elements overacting to normal input with hyper-excitability
d) All of the above

Answer 4

d) All of the above
neuronal plasticity: behavioral changes in dorsal horn neurons influenced by previous events, contributing to persistent pain states (long-term potential LTP or central sensitization)
Provide mechanics that contribute to amplification of synaptic transmission that lead to central neuronal elements overacting to normal input with hyper-excitability

Question 5

SMT:

a) Induce neuroplasticity which reverse (long-term depression LTD)
b) Activate small diameter A-delta fibers in skin and deep tissues, providing input to spinal cord neurons causing LTD or suppressed neuronal discharge.
c) Changes central/supraspinal synaptic targets in the brain resulting in central suppression and decrease pain
d) All of the above

Answer 5

D)All of the above

Question 6

Long Term Depression with SMT:

a) Due to preferential activation of small diameter A-Delta fibers in skin and deep tissues
b) Decrease LTP previously established by C-fibre activation of these same dorsal horn neurons
c) Similarly with acupuncture thus, position of needle may not be critical, suggesting spinal cord/central mechanism
d) All of the above

Answer 6

D) All of the above

Question 7

Long-term Depression with SMT occurs within seconds and can last for hours.

True or False

Answer 7

True

Question 8

Neuroplastic changes occuring with SMT offers possible explanation of the its mechanical anti-nociceptive effects.

True or False

Answer 8

True

Question 9

In George et all 2006 investigation :

a) Focused on the immediate hypoalgesic effects of lumbar SMT on thermal pain sensitivity in asymptomatic subjects.
b) Subjects then rated their delayed (“second”) pain after the first, third, and fifth heat pulses (believed to be Cfibre mediated)
c) Direct measure of windup is not feasible in humans - temporal summation (second c-fibre pain) is indirect measure
d) All of the above

Answer 9

D) All of the Above George 2006 Study investigated immediate hypoalgesic effects of lumbar SMT on thermal pain sensitivity in asymptomatic

Subjects rated “first” pain they felt (believed to be primarily mediated by input form ADelta fibres)

Subjects then rated their delayed (“second”) pain after the first, third, and fifth heat pulses (believed to be Cfibre mediated)

Wind up results from tonic (constant) peripheral nociceptive c-fibre input and is an example of central sensitization that occurs within dorsal horn cells

1. direct measure of windup is not feasible in humans - temporal summation (second c-fibre pain) is indirect measure

Question 10

First pain response is trasmitted through:

a) B-Delta fibers
b) Interneurons
c) C-Fibers
d) A- Delta fibers

Answer 10

d) A- Delta fibers

Question 11

Temporal Summation ( secondary pain) is transmitted through:

a) B-Delta fibers
b) Interneurons
c) C-Fibers
d) A- Delta fibers

Answer 11

c) C-Fibers

Question 12

Wind-up is a phemomen:

a) Due to constant peripheral nociceptive c-fiber input
b) An example of central sensitization that occurs within dorsal horn cells
c) Can only be measured indirectly by temporal summation (C-fiber pain)
d) All of the above

Answer 12

D) All of the above

Wind up results from tonic (constant) peripheral nociceptive c-fibre input and is an example of central sensitization that occurs within dorsal horn cells

direct measure of windup is not feasible in humans - temporal summation (second c-fibre pain) is indirect measure

Tonic activation of these dorsal cells induces a central hyperalgesia mediated at the spinal cord level, such that subsequent pain stimulus of standard amplitude are incorrectly relayed as increased in intensity

Question 13

In Bialosky 2008 study on the neurophysiological effects of SMT, 60 non-LBP subjects were divided into what 3 groups?

a) Body size - ectomorphic, endomorphic, mesomorph
b) Expectations - Positive expectation, negative expectation, neutral expectation
c) Educationa - High-school, College, Post-graduate
d) None of the above

Answer 13

b) Expectations - Positive expectation, negative expectation, neutral expectation

• Positive: told SMT was very effective in treating LBP and expect your perception of heat pain to be reduced
• Negative: told SMT is ineffective in treating LBP and expect your perception of heat pain to be worsened
• Neutral: told SMT has unknown effects for treating LBP and heat painperception

Question 14

In Bialosky 2006 study:

a) the plantar surface of the non- dominant foot using a train of ten consecutive heat pulses of less than one second duration at an inter- stimulus frequently of .33 Hz (temporal summation)
b) The positive group showed significant decrease while the negative group showed a significant increase
c) Concludes that hypoanalgesia associated with SMT may be influenced by expectation
d) All of the above

Answer 14

D) All of the above

Question 15

In Bishop 2011, the study measured regional pain modulation after SMT on:

a) TMJ for A-delta and gastrocnemius for C-fiber
b) Thenar eminence and medial longitudinal arch of the foot for C-fiber
c) Volar forearm and posterior aspect of upper calf for first-pain for A-Delta
d) B and C
e) A and B

Answer 15

d) B and C

Subjects rated first pain A-delta from thermal stimuli applied to volar forearm and posterior aspect of upper calf. Then subjects rated second pain C-fiber from thermal stimuli applied to thenar eminence and medial longitudinal arch of the foot.

Question 16

In Bishop 2011, the study measured regional pain modulation after SMT using the what interventions:

a) SMT in upper thoracic
b) Cervical exercises DNF with CCFT
c) Control group rested in supine for 10 min
d) A and B
e) All of the above

Answer 16

d) A and B

• upper thoracic SMT
• cervical exercises DNF with CCFT
• control group rested in supine for 5 min

Question 17

In Bishop 2011 on regional pain modulation after SMT

a) No significant changes for any group
b) SMT group experienced a decrease in temporal sensory summation (2nd pain)
c) Immediate inhibition or decrease in temporal sensory summation after SMT BUT only in healthy subjects.
d) All of the above
e) None of the above

Answer 17

d) All of the above
70. Results: no significant changes for any group
71. Changes in thermal stimuli ratings: no significant changes for any group
72. What group experienced a decrease in temporal sensory summation (2nd pain)? SMT group
73. What did this prove? Immediate inhibition or decrease in temporal sensory summation after SMT BUT was only used in healthy subjects.

Question 18

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”, one of the conclusions is that mechanisms behind SMT and its effectiveness been proven.

True or False.

Answer 18

False

74. Have the mechanisms behind SMT and its effectiveness been proven? Bialosky et al 2009 says no.

Question 19

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”, assessment of the biochemical effects are reliable.

True or False

Answer 19

False.

75. According to Bialosky et al 2009, are biomechanical effects assessment reliable? No

Question 20

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”, joint techniques lack:

a) Contraindications for pregnant women
b) Precision because forces are dissipated over a large area
c) Skilled learning because anyone can do them
d) None of the above

Answer 20

b) Precision because forces are dissipated over a large area
76. What do joint techniques lack? Precision because forces are dissipated over a large area

Question 21

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Are nerve-biased techniques specific to a single nerve?

Yes or No

Answer 21

No

77. Are nerve-biased techniques specific to a single nerve? No

Question 22

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Does the choice of technique affect the outcome?

Yes or No

Answer 22

No

78. Does the choice of technique affect the outcome? No

Question 23

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Have lasting structural changes been identified?

Answer 23

No

79. Have lasting structural changes been identified? No

Question 24

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Have existing studies directly observed the central or peripheral nervous system?

Answer 24

No

80. Have existing studies directly observed the central or peripheral nervous system? No

Question 25

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Stimulation of the dorsal periaqueductal grey (dPAG) was suggested by whom?

a) Wright 1995
b) George 2006
c) De las Penas 2005
d) Dunning 1991

Answer 25

a) Wright 1995
81. Stimulation of the dorsal periaqueductal grey (dPAG) was suggested by whom? Wright 1995.

Question 26

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Who suggested the lessening of temporal sensory summation (TSS) in dorsal horn cells following SMT?

a) Wright 1995
b) George 2006
c) De las Penas 2005
d) Dunning 1991

Answer 26

b) George 2006
82. Who suggested the lessening of temporal sensory summation (TSS) in dorsal horn cells following SMT? George et al 2006

Question 27

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

What 3 categories does Bialosky et al 2009 use for neurophysiologic mechanisms?
a) Homunculus, Spine, First order Neurons

b) biological, social, psychological
c) nociceptive, neuropathic, nociplastic
d) peripheral, spinal, suprspinal

Answer 27

d) peripheral, spinal, suprspinal
83. What 3 categories does Bialosky et al 2009 use for neurophysiologic mechanisms? -peripheral mechanisms
- spinal mechanisms -supraspinal mechanisms

Question 28

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”, peripheral mechanisms events consist of

a) MSK injuries produce an inflammatory response in the periphery that influences both healing and pain processing.
b) Dorsal horn, Dorsal root ganglia, sensory afferents
c) Achetylcholine, Calcium, ATP, Na-K pump alterations
d) None of the above

Answer 28

84. Peripheral mechanisms: MSK injuries produce an inflammatory response in the periphery that influences both healing and pain processing.

Question 29

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Spinal mechanisms consists of changes blood levels of inflammatory products:

a) Substance-P, beta endorphins, found by Boal and Gilette 2004
b) Acetylcholine, Na-K Pump, ATP, Nitrous Oxide found by Butts 1998
c) Glutamate, Calcium, Serotonin found by Dunning 2014
d) None of the above

Answer 29

a) Substance-P, beta endorphins, found by Boal and Gilette 2004
85. Spinal mechanisms: SMT changes blood levels of inflammatory products such as substance-P, beta endorphins, found by Boal and Gilette 2004

Question 30

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Who speculated that SMT bombards the CNS with sensory input from the muscle and joint proprioceptors?

a) Bialosky et al
b) George et al
c) Pickar and Kang 2006
d) Hong and Lew 2001

Answer 30

c) Pickar and Kang 2006
86. Who speculated that SMT bombards the CNS with sensory input from the muscle and joint proprioceptors? Pickar and Kang 2006

Question 31

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

How does SMT indirectly implicate a SC-mediated effect?

a) Temporal summation
b) Wind-up
c) Hypoalgesia by dec in motoneuron pool
d) Muscle spindle activation causing changes in muscle activity

Answer 31

c) Hypoalgesia by dec in motoneuron pool
87. How does SMT indirectly implicate a SC-mediated effect? Hypoalgesia caused by afferent discharge decreasing motor neuron pool activity, causing changes in muscle activity.

Question 32

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Supraspinal mechanisms are:

a) Influencing pain experience by activities in the anterior cingulate cortex, amygdala, Periaquiductal gray (PAG, primary control center for descending pain inhibition), rostral ventromedial medulla (RVM)
b) Act on ascending pathways as second order neurons
c) Ascending pathways from substantia gelatinous, spinothalamic tract and cortical radiation
d) All of the above

Answer 32

Supraspinal mechanisms are:

a) Influencing pain experience by activities in the anterior cingulate cortex, amygdala, Periaquiductal gray (PAG, primary control center for descending pain inhibition), rostral ventromedial medulla (RVM)

Question 33

In Bialosky et al’s 2009 article “ The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model”,

Supraspinal mechanisms are:

a) Grouped as supraspinal descending inhibition or descending pain inhibitory systems (DPIS)
b) Supported by findings in Malisza 2003 study
c) None of the above
d) A and B

Answer 33

d) A and B

1. Grouped as supraspinal descending inhibition or descending pain inhibitory systems (DPIS)
2. Direct support for supraspinal mechanism of action of MT (Malisza 2003)

Question 34

Oliphant et al 2002 found what ratio of worsening of lumbar spine with SMT?

a) 1/5 million
b) 2/1.5 million
c) 1/3.7 million
d) 2/2.6 million

Answer 34

c) 1/3.7 million

Question 35

Which is not an absolute contraindications for SMT:

a) CAD, anyeurysm
b) > 20 day Corticosteiord use
c) Radiculopathy and neurogenic pain
d) Cauda equina and myeopathy

Answer 35

c) Radiculopathy and neurogenic pain

Question 36

Absolute contraindications for SMT includes:

a) lack of patient consent or clinical diagnosis
b) osteoporosis or spondylosis
c) cervical radiculipathy
d) None of the above

Answer 36

a) lack of patient consent or clinical diagnosis

Question 37

Relative contraindications for SMT:

a) disc herniation or prolapse
b) spondylolysis/spondylolisthesis
c) advanced DJD
d) all of the above

Answer 37

d) all of the above

91. Relative contraindications for SMT:
    - disc herniation or prolapse

• pregnancy
• osteoperosis, RA
• spondylolysis/spondylolisthesis
• advanced DJD

Question 38

Force needed to break the “fixation” of a joint after it is focused?

a) Cervical 160 N
b) Cervical 180 N
c) Cervical 150 N
d) Cervical 145 N

Answer 38

c) Cervical 150 N

Question 39

Force needed to break the “fixation” of a joint after it is focused?

a) Lumbar 500 N
b) Lumbar 150 N
c) Cervical 500 N
d) Thoracic 150 N

Answer 39

a) Lumbar 500 N

Question 40

Force needed to break the “fixation” of a joint after it is focused?

a) Cervical 500N
b) Thoracic 500 N
c) Lumbar 150 N
d) Lumbar 550 N

Answer 40

b) Thoracic 500 N

Question 41

Combined leverage technique (Locking):

a) Attempts to remove all mobility from adjacent segments
b) Force to be applied only at target sgment
c) Uncomfortable, traumatic, unsafe
d) All of the above

Answer 41

d) All of the above

Question 42

Momentum-induced technique (Focusing):

a) Placing as little tension as possible through adjacent segments
b) Target segment is at the point of maximum focus of forces
c) Attempts to remove all mobility from adjacent segments; force to be applied only at target sgment
d) A and B

Answer 42

d) A and B

Focusing

place little tension as possible through adjacent segments

target segment is point of maximal force

less traumatic, usually not uncomfortable

accel, velocity

Question 43

How long is the post-cavitation refractory period?

a) 5-10 min
b) 10-15 min
c) 15-30 min
c) 5-30 min

Answer 43

c) 15-30 min