Second Version, January 99
An Informative Quiz about Academic Research News
from the Field of Manual Medicine
In the following quiz you are asked to take guesses as to the outcomes of some scientific studies. These include publications in journals like SPINE, Lancet, New England Journal of Medicine, or even Scientific American, which tend to orient themselves on the methodological standards of what is now often called ‘evidence based medicine’. Additionally they contain information from the ‘3rd Interdisciplinary World Conference on Low Back and Pelvic Pain’ which is oriented around the same standards.
It is suggested that you fill out the whole quiz – most likely by taking brave guesses on several of the questions – before looking at the correct solutions at the end. This way you will have the advantage of having two kinds of pleasurable learning experiences:
- AHA experiences ("Aha, this is new and unexpected to me. What an interesting surprise! ")
- YEAH- experiences ("Yeah, I knew it! My guess was right. I am glad those guys have done all this work to prove my assumption in scientific terms.")
So sharpen your pencil, write down your best guesses, and be ready for some nice AHAs and YEAHs at the end. Ready?
1) Assymetry and Back Pain
A study published in 'SPINE' in 1985 examined structural symmetry along the coronal plane among freshman women. The researchers used the following 3 parameters:
- A) elevation of one shoulder,
- B) elevation of one hip,
- C) deviation of the spine from the midline of the body.
25 years later a questionnaire was sent out to the same people, asking them among other things about whether and how often they have been experiencing low back pain. Which of those 3 parameters (A, B, C) do you suspect to have shown a significant correlation with subsequent reports of chronic low back pain?
2) Results of Surgery
A long term follow up study of 280 back pain patients in Sweden (published in 1983) compared those that were treated with surgery with those that continued without surgery. Which of the following were their reported results:?
- The surgery group had the faster pain relief
- The non-surgery group had the faster pain relief
- After 4 years as well as after 10 years the non-surgery group reported less pain.
- After 4 years as well as after 10 years the surgery group reported less pain.
- After 4 years as well as after 10 years there was no difference among the 2 groups.
3) What creates Tinnitus ("ringing in the ear")?
Recently (in early 1998) several studies were published in medical journals on the physiological changes in the head and neck region before, during and after tinnitus perceptions. They studied with state of the art imaging measurements what happens anatomically when these patients hear their disturbing sounds. Make a guess as to their findings:
(1 to 2 correctly checked choices are possible here)
- A) Slightly before and during the sound perceptions the nerve conduction of the 8th cranial (acoustic) nerve is diminished. The reasons for this were left unclear, yet they speculated it could be due to some mechanical impingement upon this nerve along its path via the temporal bone, or also lack of nutrition in the area of the inner ear.
- B) It is all happening in the inside of the brain. No physiological or anatomical changes outside the brain are involved that can explain the difference between quiet moments and intense ringing perceptions in these patients.
- C) In about 60% of the patients a lack of circulation in the small arterial blood supply to some areas in the inner ear could be demonstrated with fluoroscopic Doppler-ultrasound imaging. Whereas circulation in these areas was significantly better during symptom-free quiet times in these patients.
- D) No physiological or neurological changes have so far been able to be detected to explain the generation of these sounds.
4) Acupoints in Fascia
In 1995 a study was published which showed that at least 82% of the acupuncture points are topographically identical with ‘fascial perforation points’. At these points the deep layer of the superficial fascia ( ‚Fascia profunda‘ in American anatomy) is always perforated by a small triad of nerve, artery and vein. (See Heine, H., Functional Anatomy of Traditional Chinese Acupuncture Points, Acta Anat., 152, 1995). Now in December 1998 a surgical follow up study was published in which acupoints in 103 patients with chronic shoulder-, arm-, or neck-pain were surgically inspected and operated (Bauer, J., Heine, H., Biologische Medizin, 6.12.98).
Which of the following would you think are true:
- A) They could demonstrate that the triad of perforating vein, nerve and artery were regularly ‘strangulated’ in most of the acupoints of the painful region by an access amount of collagen fibers around these openings.
- B) In surgically opening those strangulated openings a bit, most of the patients experienced significant improvements (i.e. less pain).
- C) They did operate these perforation points in order to give the triad more room, yet no significant pain improvements resulted from that.
- D) None of the above is true. The researchers found that the fascial openings were of usual size, yet some of the perforating vessels looked thinner than usual at these points.
Open question for discussion:
Assuming your answers are correct, what consequences of these findings would you suggest for our practical work?
5) Lumbar disk anomalies
In 1994 a study of magnetic resonance imaging (MRI) of the lumbar spine of 98 people without backpain was published in the New England Journal of Medicine (Vol.331, No.2). In their results they distinguished between the following 5 disk conditions:
2) bulge (circumferential symmetric extension of the disk beyond the interspace)
3) protrusion (focal or asymmetric extension of the disk beyond the interspace),
4) extrusion (more extreme extension of the disk beyond the interspace, with a base that is narrower than the diameter of the extruding material itself or without a
connection between the material and the disk of origin).
5) Nonintervertebral disk anomalies, such as facet arthropathy or Schmorl Nodes,
were also documented.
What were their findings?
- A) Over half of these pain free people had a bulge at least at one level of the lumbar spine.
- B) More than one fourth had a herniated disk (protrusion or extrusion).
- C) Clear extrusions were very rare (below 2%)
- D) Budges and/or protrusions were found in altogether only a quarter of the people
- E) Nonintervertebral disk anomalies were found in more than 40% of the people.
- F) Bulges and intervertebral were very common (each above 30%). Yet clear protrusions or extrusions were rather rare (below 20%).
Assuming your guesses are correct, what consequences do these findings have for dealing with an acute backpain client whose x-rays (or MRI) show a corresponding clear disk anomaly at the lumbar spine?
6) Scientific American article (Aug.98) on Low-Back Pain
This science news magazine (with a worldwide circulation of over 800 000) featured an article on the current state of ‘evidence based medicine’ research about low back pain in its cover story. Which of the following claims did they make?
- A) The combined costs of back pain-related medical care and disability compensation may reach $50 billion in the US.
- B) A study revealed a connection between stressful life events and occurrences of back-pain.
- C) A study comparing treatment outcomes found no differences in recovery times among patients who saw chiropractors, family doctors or orthopedic surgeons.
- D) Patients with acute back pain who continue routine activities as normally as possible do better than those who try either bed rest or exercise.
- E) Last statement is wrong. For patients with acute back pain (as well as well as chronic back pain patients) active exercise is still the best.
- F) Injections of cortisone like drugs into the facet joints seems to be more effective than injections with saline solutions, yet not in all patients.
- G) Chiropractic adjustments seem to be able to offer short term help for acute back pain. Yet whether it can impart long term pain relief remains unclear.
- H) Most specialists now agree that disk surgery is appropriate when there is a combination of a definite disk hernia on an imaging test, a corresponding pain syndrome, and a signs of nerve root irritation.
- L) For patients with a herniated disk, spontaneous recovery is the rule.
Studies reported at the World Conference on Low Back
and Pelvic Pain
7) Arthrokinetic Reflex
When the supraspinal ligament was artificially stretched with a metal needle (in cats and humans) there was a tonus increase in the multifidus at the same level. This was called the arthrokinetic reflex which supposedly could explain some of the local back muscle spasms in back pain patients.
A) In these experiments a prolonged ligamentous deformation resulted in
prolonged activity in the multifidus (indicating a more robust neurological and mechanical synergy between muscles and their ligaments)
B) In these experiments the ligamentous deformation lead to a muscular
tonus change increase of only a few seconds duration. Then adaptation settled in and a new or increased ligamentous irritation was needed to continue the muscular activity.
8) Muscular Support for the Sacroiliac Joint
The following muscles have been shown to be active in healthy people for providing an increased ‘force closure’ of the sacrolilac joints in standing:
- A) Piriformis?
- B) Gluteus maximus?
- C) Transversus abdominis?
- D) External abdominal oblique?
- E) Internal abdominal oblique?
And some related insights:
- F) Studies show a 6 times higher likelihood for pelvic pain during pregnancy whenever high level of relaxin can be detected in the blood.
- G) Crossing legs in sitting increases the tonus of the internal abdominal oblique muscle.
9) Muscular lumbar stabilization
EMG studies of healthy people versus back pain patients have shown that during lifting (or other more strenuous trunk movements) an orchestrated tonus increase of the following muscles tends to provide a helpful stabilization for the position of the lumbar vertebrae.
Make a guess which muscles belong to this group.
- A) Multifidus?
- B) Iliocostalis lumborum and longissimus lumborum?
- C) Quadratus lumborum?
- D) Transversus abdominis?
- E) Diaphragm?
- F) Pelvic floor?
- G) Rectus abdominis?
10) Radiostereometric analysis of sacroiliac motion
Radiosteriometric analysis (RSA) is today the most used and most exact method in orthopedic research for small movements. It was recently applied to measure the mobility of the sacroiliac joint (SIJ) in the following way: tantalum balls with a diameter of less than 1 mm were implanted from a posterior approach into the pelvic bones, geometrically well spread in the 3-D space into the iliac bones and the sacrum, respectively. Measurements with two telescopic roentgen units for simultaneous horizontal and vertical exposure were then processed by a computer. Subjects had enough space to move around freely in front of the films. Movements between the sacrum and each ilium were measured in the Standing Hip Flexion Test (also named Gillet’s test, which is frequently used for analyzing SIJ mobility: patient stands on one leg and draws the other knee up towards the chest). Twenty-two patients were examined which had been diagnosed as having a sacroiliac problem (by 2 leading manual therapists independently from each other).
What were their true findings?
- A) The amount of iliac rotations was sometimes different on both sides. Largest rotation was a posterior rotation of the ilium in relation to the sacrum of up to 4 degrees. Minimum was less than 1 degree. Mean rotation was 2,3 degrees. Backwards motion was 2 mm average. Conclusion of the researchers: the difference in SIJ movement can be in the range of a palpable size. Yet apart from the view cases with larger movement range, such palpation requires a very sensitive and skilled hand in most patients.
- B) Rotations were equal on both sides with a range between 0,1 and 1,8 degrees and an average of 0,2 degrees. Backwards motion was only 0,2 mm on average. Conclusion of the Swedish researchers: palpation of such small movements seems impossible.
- C) When a standard orthopedic ‘pelvic belt’ was worn to increase the force closure of the sacroiliac, no significant reduction of the SIJ motion was seen.
- D) With a pelvic belt the amount of SIJ motion was reduced significantly in most of the patients.
11) Treatment Success Rates
Let’s assume the following: a fellow therapist that you know has done some statistics on her newly developed treatment method for acute low back pain. She states that
- with her randomized clientele, after one treatment already 75% get significantly better. (Her treatments are spaced 4 weeks apart; and she measures 'success' by the ability of the clients to return to their regular work).
- For the remaining 25% she claims to have clear success with a series of up to 8 more monthly treatments, ...
- except for a small group of altogether only 8% of all patients, who remain painful even 6 months after the onset and who she suspects might have psychological (instead of biomechanical) causes.
- Would you tend to believe these statistics?
- How would you expect your own current success rates to compare with those reported by your colleague.
- And where do you think are the average treatment statistics (of conventional orthopedic back care) in relation to both?
12) True or False?
- The pain threshold tends to get slightly higher (i.e. person can tolerate pain better) when a compassionate friend is also in the room.
- Stretching and strengthening exercises both tend to enhance the metabolism of the moved tissues.
- Acupuncture seems to be more effective in chronic than in acute low back-pain.
Are you ready for this??
Remember that only after marking down your own guesses on paper you will have the pleasure of clear AHA or YEAH experiences now.
- No correlation among any of those parameters.
- Study published in: Spine 1985; 10:10: 872-877
- Yet when it comes to the effectiveness of therapeutic treatments (which is a different question!) P.Greenman reports positive results of heel lift therapy to increase sacral symmetry in the treatment of acute low back pain.
- A, E.
- B (details in the article ‘Research News on Tinnitus’ on my webpage
- A, B Yet before jumping to premature conclusions, compare with the
neuroreflexotherapy research of Kovacs, as described in the article:
"Report from the World Congress of Low Back and Pelvic Pain’
5) A, B, C, E Details under ‘Disk hernia or protrusion as cause for low back pain?’
on same webpage
- A, B, C, D, G, L
(H not correct, since additionally fulfillment of the following criteria is
required: "failure to respond to six weeks of non-surgical treatment")
7) A Which gives this reflex a more robust and potentially important
function.. (Details of this and the following questions are in my conference report at same webpage, or - even better - at the conference book referenced there).
8) A, C, E, F
Crossing legs in sitting decreases the tonus of the int. abd. obl.
9) A, D, E For the pelvic floor this is also assumed, but not yet proven via EMG.
10) B, D
- The reported statistics are identical with the ‘spontaneous recovery rates’ in acute low back pain people, as measured by how soon the patients are able to return to work, even if they have no treatment at all. (According to Spitzer et.al. 1987 the percentage of sick in leave in relation to pain onset duration since onset: after 7 days - 80%, after 4 wks - 26%, after 7 wks - 17%, after 12 wks 13%, after 24 wks 8%.).
12) B Pain threshold gets lower (person more pain sensitive).
Acupuncture more effective in acute than in chronic low back pain.
By limiting this selection to only those studies which have met the current standards of 'evidence based medicine' it is not implied that their results and conclusions are always infallible. It is of course also possible that some studies outside of these standards might contain different and even more relevant information for our field.