Morgan Young

A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis.

OBJECTIVE The purposes of this study were to locate articles that assessed the reliability of static palpation of the spine and sacroiliac joints, to appraise the quality of these studies, and synthesize their results. METHODS A structured literature search was conducted of chiropractic and medical databases PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature from 1965 through October 2007. Reference sections were inspected for additional citations. Only peer-reviewed articles in English containing information about static palpation of the spine or sacroiliac joints were selected. The resulting studies were appraised for quality by both of the authors using a 6-point scale instrument developed to assess the quality of reproducibility studies. RESULTS The search generated 343 citations, and another 7 were harvested from the reference lists. After removing articles not meeting the inclusion criteria, 29 were retained. A total of 14 studies focused on the reliability of locating painful or tender points, 10 on the location of landmarks, and 5 on position or alignment of bone structures. A higher proportion of studies that assessed painful or tender points reported acceptable levels of reliability. However, there were no significant differences between methods of palpation when considering the proportions of high-quality studies that reported good reliability. Thus, no form of static palpation could be considered to be superior. CONCLUSION Reported indices of agreement were generally low. More of the pain palpation studies reported acceptable kappa levels, although no one method of palpation could be deemed clearly superior.

Spinal Motion Palpation: A Comparison of Studies That Assessed Intersegmental End Feel Vs Excursion

OBJECTIVE Spinal motion palpation (MP) is a procedure used to detect intersegmental hypomobility/hypermobility. Different means of assessing intersegmental mobility are described, assessing either excursion of the segments (quantity of movement) or end feel (quality of motion when stressed against the paraphysiological space). The objective of this review was to classify and compare studies based on method of MP used, considering that some studies may have used both methods. METHODS Four databases were searched: MEDLINE-PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature databases for the years 1965 through January 2007. Retrieved citations were independently screened for inclusion by 2 of the authors consistent with the inclusion and exclusion criteria. Included studies were appraised for quality, and data were extracted and recorded in tables. RESULTS The search strategy generated 415 citations, and 29 were harvested from reference lists. After removing articles that did not meet the inclusion criteria, 44 were considered relevant and appraised for quality. Fifteen studies focused on MP excursion, 24 focused on end feel, and 5 used both. Eight studies reported high levels of reproducibility (kappa = >or=0.4), although 4 were not of acceptable quality, and 2 were only marginally acceptable. When only high-quality studies were considered, 3 of 24 end-feel studies reported good reliability compared with 1 of 15 excursion studies. There was no statistical support for a difference between the 2 groupings. CONCLUSIONS A difference in reported reliability was observed when the method of MP varied, although it was not statistically significant. There was no support in the literature for the advantage of one MP method over the other.

The location of the inferior angle of the scapula in relation to the spine in the upright position: a systematic review of the literature and meta-analysis

Practitioners in several of the health care professions use anatomical landmarks to identify spinal levels, both in order to enhance diagnostic accuracy and to specifically target the site of intervention. Authoritative sources usually state the upright inferior scapular angle (IAS) aligns with the spinous process (SP) of T7, but some specify the T7-8 interspace or the T8 SP. The primary goals of this study were to systematically review the relevant literature; and conduct a meta-analysis of the pooled data from retrieved studies to increase their statistical power. Electronic searching retrieved primary studies relating the IAS to a spinal level, as determined by an imaging reference standard, using combinations of these search terms: scapula, location, landmark, spinous process, thoracic vertebrae, vertebral level, palpation, and spine. Only primary studies were included; review articles and reliability studies related to scapular position but lacking spinal correlations were excluded. Eight-hundred and eighty (880) articles of interest were identified, 43 abstracts were read, 22 full text articles were inspected, and 5 survived the final cut. Each article (with one exception) was rated for quality using the QUADAS instrument. Pooling data from 5 studies resulted in normal distribution in which the upright IAS on average aligns closely with the T8 SP, range T4-T11. Since on average the IAS most closely identifies the T8 SP in the upright position, it is very likely that health professionals, both manual therapists and others, who have been diagnosing and treating patients based on the IAS = T7 SP rule (the conventional wisdom), have not been as segmentally accurate as they may have supposed. They either addressed non-intended levels, or made numeration errors in their charting. There is evidence that using the IAS is less preferred than using the vertebra prominens, and may be less preferred than using the iliac crest for identifying spinal levels Manual therapists, acupuncturists, anesthesiologists, nurses, and surgeons should reconsider their procedures for identifying spinal sites in light of this modified information. Inaccurate landmark benchmark rules will add to patient variation and examiner errors in producing spine care targeting errors, and confound research on the importance of specificity in treating spinal levels.

Mapping intended spinal site of care from the upright to prone position: an interexaminer reliability study

BackgroundUpright examination procedures like radiology, thermography, manual muscle testing, and spinal motion palpation may lead to spinal interventions with the patient prone. The reliability and accuracy of mapping upright examination findings to the prone position is unknown. This study had 2 primary goals: (1) investigate how erroneous spine-scapular landmark associations may lead to errors in treating and charting spine levels; and (2) study the interexaminer reliability of a novel method for mapping upright spinal sites to the prone position.MethodsExperiment 1 was a thought experiment exploring the consequences of depending on the erroneous landmark association of the inferior scapular tip with the T7 spinous process upright and T6 spinous process prone (relatively recent studies suggest these levels are T8 and T9, respectively). This allowed deduction of targeting and charting errors. In experiment 2, 10 examiners (2 experienced, 8 novice) used an index finger to maintain contact with a mid-thoracic spinous process as each of 2 participants slowly moved from the upright to the prone position. Interexaminer reliability was assessed by computing Intraclass Correlation Coefficient, standard error of the mean, root mean squared error, and the absolute value of the mean difference for each examiner from the 10 examiner mean for each of the 2 participants.ResultsThe thought experiment suggesting that using the (inaccurate) scapular tip landmark rule would result in a 3 level targeting and charting error when radiological findings are mapped to the prone position. Physical upright exam procedures like motion palpation would result in a 2 level targeting error for intervention, and a 3 level error for charting. The reliability experiment showed examiners accurately maintained contact with the same thoracic spinous process as the participant went from upright to prone, ICC (2,1) = 0.83.ConclusionsAs manual therapists, the authors have emphasized how targeting errors may impact upon manual care of the spine. Practitioners in other fields that need to accurately locate spinal levels, such as acupuncture and anesthesiology, would also be expected to draw important conclusions from these findings.

Mathematical modeling of the socalled Allis test: a field study in orthopedic confusion

BackgroundChiropractors use a variety of supine and prone leg checking procedures. Some, including the Allis test, purport to distinguish anatomic from functional leg length inequality. Although the reliability and to a lesser extent the validity of some leg checking procedures has been assessed, little is known on the Allis test. The present study mathematically models the test under a variety of hypothetical clinical conditions. In our search for historical and clinical information on the Allis test, nomenclatural and procedural issues became apparent.MethodsThe test is performed with the subject carefully positioned in the supine position, with the head, pelvis, and feet centered on the table. After an assessment for anatomic leg length inequality, the knees are flexed to approximately 90°. The examiner then sights the short leg side knee sequentially from both the foot and side of the table, noting its relative locations: both its height from the table and Y axis position. The traditional interpretation of the Allis test is that a low knee identifies a short tibia and a cephalad knee a short femur. Assuming arbitrary lengths and a tibio/femoral ratio of 1/1.26, and a hip to foot distance that placed the knee near 90°, we trigonometrically calculated changes in the location of the right knee that would result from hypothetical reductions in tibial and femoral length. We also modeled changes in the tibio/femoral ratio that did not change overall leg length, and also a change in hip location.ResultsThe knee altitude diminishes with either femoral or tibial length reduction. The knee shifts cephalad when the femoral length is reduced, and caudally when the tibial length is reduced. Changes in the femur/tibia ratio also influence knee position, as does cephalad shifting of the hip.ConclusionThe original Allis (aka Galeazzi) test was developed to identify gross hip deformity in pediatric patients. The extension of this test to adults suspected of having anatomical leg length inequality is problematic, and needs refinement at the least. Our modeling questions whether this test can accurately identify aLLI, let alone distinguish a short tibia from a short femur.

Interexaminer Reliability of Seated Motion Palpation for the Stiffest Spinal Site

Objectives: The purpose of this study was to assess the interexaminer reliability of palpation for stiffness in the cervical, thoracic, and lumbar spinal regions. Methods: In this secondary data analysis, data from 70 patients from a chiropractic college outpatient clinic were analyzed. Two doctors of chiropractic palpated for the stiffest site within each spinal region. Each were asked to select the stiffest segment and to rate their confidence in their palpation findings. Reliability between examiners was calculated as Median Absolute Examiner Differences (MedianAED) and data dispersion as Median Absolute Deviation (MAD). Interquartile analysis of the paired examiner differences was performed. Results: In total, 210 paired observations were analyzed. Nonparametric data precluded reliability determination using intraclass correlation. Findings included lumbar MedianAED = 0.5 vertebral equivalents (VE), thoracic = 1.7 VE, and cervical = 1.4 VE. For the combined dataset, the findings were MedianAED = 1.1 VE; MAD was lowest in the lumbar spine (0.3 VE) and highest in thoracic spine (1.4 VE), and for the combined dataset, MAD = 1.1 VE. Examiners agreed on the segment or the motion segment containing the stiffest site in 54% of the observations. Conclusions: Interexaminer reliability for palpation was good between 2 clinicians for the stiffest site in each region of the spine and in the combined dataset. This is consistent with previous studies of motion palpation using continuous analysis.

Conservative Care of Pediatric Acquired Torticollis: A Report of 2 Cases

Objective: The purpose of this case report is to describe the conservative management of 2 cases of acquired torticollis in children under 3 years of age. Clinical Features: Both patients awoke with painful, stiff, twisted necks the day after play in a bouncy house. Range of motion was limited, and hypertonic muscles were palpated. Their neurologic and physical evaluation was consistent with a diagnosis of acquired torticollis of musculoskeletal origin. Intervention and Outcomes: Both children were treated with chiropractic care that consisted of light myofascial release, use of an Activator instrument, and home stretching. Patients improved in pain and range of motion immediately posttreatment and returned to normal ranges in 1 or 2 visits. Conclusion: Chiropractic care provided relief for these 2 young patients with acquired torticollis.