Spinal Palpation

This section was compiled by Frank M. Painter, D.C.
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Interexaminer Reliability of Seated Motion Palpation for the Stiffest Spinal Site
J Manipulative Physiol Ther. 2018 (Sep); 41 (7): 571–579 ~ FULL TEXT

More than half the time (54.3%) the examiners in this study agreed on the exact segment or at least the motion segment that was stiff in a given spinal region. The MedianAED for the combined dataset was 01.1 VE. This information supports high levels of interexaminer reliability for the SSS in each region of the spine and in the combined dataset. Reliability estimates based on absolute examiner differences were relatively higher and seemed to be more trustworthy than prior estimates based on discrete analysis and analysis with κ because the assessment method more closely resembled that used by clinicians in clinical practice. The reliability seen in this study is broadly consistent with previous studies of MP using continuous analysis.

The Reliability and Validity of Tests and Rules

Reliability and Validity of Clinical Tests to Assess the Anatomical Integrity
of the Cervical Spine in Adults with Neck Pain and its Associated Disorders:
Part 1- A Systematic Review from the Cervical Assessment and
Diagnosis Research Evaluation (CADRE) Collaboration

European Spine Journal 2017 (Sep); 26 (9): 2225–2241 ~ FULL TEXT

Little evidence exists to support the use of clinical tests to evaluate the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders. We found preliminary evidence to support the use of the extension-rotation test, neurological examination, Spurling's and the upper limb neurodynamic tests.

Validity and Reliability of Clinical Prediction Rules Used to Screen for Cervical
Spine Injury in Alert Low-risk Patients with Blunt Trauma to the Neck: Part 2.
A Systematic Review from the Cervical Assessment and Diagnosis
Research Evaluation (CADRE) Collaboration

European Spine Journal 2018 (Jun); 27 (6): 1219–1233 ~ FULL TEXT

Our review adds new evidence to the Neck Pain Task Force and supports the use of clinical prediction rules in emergency care settings to screen for cervical spine injury in alert low-risk adult patients with blunt trauma to the neck. The Canadian C-spine rule consistently demonstrated excellent sensitivity and negative predictive values. Our review, however, suggests that the reproducibility of the clinical predictions rules varies depending on the examiners level of training and experience.

Reliability and Validity of Self-reported Questionnaires to Measure Pain and
Disability in Adults with Neck Pain and its Associated Disorders: Part 3 -
A Systematic Review From the CADRE Collaboration

European Spine Journal 2019 (May); 28 (5): 1156–1179 ~ FULL TEXT

The evidence supporting the validity and reliability of instruments used to measure pain and disability is preliminary. Further validity studies are needed to confirm the clinical utility of self-reported questionnaires to assess pain and disability in patients with NAD. These slides can be retrieved under Electronic Supplementary Material.

Reliability and Validity of Clinical Tests to Assess Posture, Pain Location, and
Cervical Spine Mobility in Adults with Neck Pain and its Associated Disorders:
Part 4. A Systematic Review from the Cervical Assessment and
Diagnosis Research Evaluation (CADRE) Collaboration

Musculoskeletal Science & Practice 2018 (Dec); 38: 128–147 ~ FULL TEXT

We found little evidence to support the reliability and validity of clinical tests to assess head posture, pain location and cervical mobility in adults with NAD grades I-III. More advanced validity studies are needed to inform the clinical utility of tests used to evaluate patients with NAD.

Reliability and Validity of Clinical Tests to Assess the Function of the
Cervical Spine in Adults with Neck Pain and its Associated Disorders:
Part 5. A Systematic Review from the Cervical Assessment and
Diagnosis Research Evaluation (CADRE) Collaboration

European Journal of Physiotherapy 2019 (Jul 8); 1–32 ~ FULL TEXT

We found active shoulder tests reliable and valid to assess neck function in adults with NAD. Experts were found to have a higher inter-rater reliability compared to novice raters. The cranio-cervical flexion test and DCE test were also reported to be reliable and valid for the assessment of cervical muscle strength in NAD patients. Overall, the evidence is preliminary at best, supported by phase I and II validity studies from the Sackett and Haynes classification. [23] Clinicians must consider the preliminary nature of the evidence when considering the use of these tests in clinic. More than 10 years after the publication of the Neck Pain Task Force, we still know little about the reliability and validity of clinical tests used to assess cervical function, muscle strength, and endurance in adults with neck pain. At best the current literature provides preliminary evidence for the active shoulder tests, cranio-cervical flexion tests and the DCE test. Therefore, the clinical utility of these tests remains unknown. Future high-quality studies, particularly phase III validity studies, are needed to inform the use of these tests for the assessment of NAD in clinical practice and their utility for treatment recommendations.

The Reliability of Spinal Motion Palpation Determination of the Location of the Stiffest
Spinal Site is Influenced by Confidence Eatings: A Secondary Snalysis of Three Studies

Chiropractic & Manual Therapies 2016 (Dec 20); 24: 50 ~ FULL TEXT

Neither the confidence module nor the subtyping by spinal region should obscure this study’s central finding: Motion Palpation (MP) for the “stiffest spinal site” (SSS) in the combined dataset, when analyzed using continuous data and related statistical methods, is reliable and appears to identify a clinically relevant and tightly constrained location for the stiffest spinal site; and the variability of the measured interexaminer differences is low. Using a stringent criterion of agreeing on at least the motion segment including the SSS, the described continuous measures palpation protocol was reliable 60.2–77.0% of the time for the combined dataset, and was 90.2% reliable when both examiners were confident. These findings support the view of some authors who have expanded the field of examiner agreement using motion palpation to include nominated segments that are within one level of each other. [30, 41]

Interexaminer Reliability of a Multidimensional Battery of Tests
Used to Assess for Vertebral Subluxations

Chiropractic Journal of Australia 2016; 46 (1): 100–117 ~ FULL TEXT

In this study, high levels of interexaminer reliability were observed in each region of the spine when a multidimensional approach to detect vertebral subluxations was used. Since the combined MedAED for vertebral subluxations was 0.6VE, it can be stated with confidence that examiners usually agreed on at least the motion segment containing the most positive vertebral subluxation test indicators, and very frequently on the same segment. Vertebral subluxation assessment, when analyzed using continuous data, indicate much higher levels of agreement than has been heretofore associated with assessing agreement using discrete data and the Kappa statistic.

The Reliability of Lumbar Motion Palpation Using Continuous Analysis
and Confidence Ratings: Choosing a Relevant Index of Agreement

J Can Chiropr Assoc. 2016 (Jun); 60 (2): 146–157 ~ FULL TEXT

Our results raise the possibility that the present inventory of reliability studies performed in the manual therapy professions, by having used mostly discrete study designs (certainly for MP) may have underestimated clinically relevant examiner agreement, thereby unduly discouraging further research and clinician interest in such research. Moreover, depending solely on ICC calculations to assess interexaminer agreement may result in flawed conclusions, when the subject population is relatively homogeneous. Greater reliance on variance-insensitive statistical functions would mitigate against that possibility. Future studies designed to analyze subsets of the data should use enough subjects to result in credible conclusions.

Validity of Palpation of the C1 Transverse Process:
Comparison with a Radiographic Reference Standard

J Can Chiropr Assoc 2015 (Jun); 59 (2): 91–100 ~ FULL TEXT

Interexaminer agreement for radiometric analysis was "excellent." Stringent accuracy (marker placed ±4mm from the most lateral projection of the C1 TVP) = 57.1%; expansive accuracy (marker placed closer to contiguous structures) = 90.5%. Mean Absolute Deviation (MAD) = 4.34 (3.65, 5.03) mm; root-mean-squared error = 5.40mm.

Review Of Methods Used By Chiropractors To Determine The Site
For Applying Manipulation

Chiropractic & Manual Therapies 2013 (Oct 21); 21 (1): 36 ~ FULL TEXT
A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care-methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine-such as skin conductance or thermography-tend not to be supported by the available evidence.

Interexaminer Reliability of Cervical Motion Palpation Using
Continuous Measures and Rater Confidence Levels

J Can Chiropr Assoc. 2013 (Jun); 57 (2): 156–164 ~ FULL TEXT

For the entire participant pool, ICC [2,1] = 0.61, judged "good." MAD=1.35 cm, corresponding to mean interexaminer differences of about 75% of one cervical vertebral level. Stratification by examiner confidence levels resulted in small subgroups with equivocal results. A continuous measures study methodology for assessing cervical motion palpation reliability showed more examiner concordance than was usually the case in previous studies using discrete methodology.

Interexaminer Reliability of Thoracic Motion Palpation Using Confidence Ratings
and Continuous Analysis

J Chiropractic Medicine 2010 (Sep); 9 (3): 99–106 ~ FULL TEXT

The confidence level of examiners has an effect on the interexaminer reliability of thoracic spine MP, such that agreement is “good” when examiners are “very confident” in their calls and not above chance levels when at least one of them is not. Looking at the data set as a whole, unstratified by degree of examiner confidence, our results resemble those of other investigators, in that the index of agreement is low. Thus, we believe using continuous measures methodology, and defining subgroups according to the confidence of the palpators, is more capable than level-by-level discrete analysis of detecting interexaminer agreement. We also believe our analytic method better reflects what motion palpators, who presumably look for maximally fixated levels within a spinal region logically related to a patient complaint, actually do.

Motion Palpation Used as a Postmanipulation Assessment Tool for Monitoring
End-Feel Improvement: A Randomized Controlled Trial of Test Responsiveness

J Manipulative Physiol Ther. 2009 (Sep); 32 (7): 549–555 ~ FULL TEXT

The findings of this study showed that motion palpation of end-feel assessment appears to be a responsive postmanipulation assessment tool in the cervical spine for determining whether perceived motion restriction found before treatment improves after SMT. This observation may be limited to symptomatic participants.

Manual Examination of the Spine: A Systematic
Critical Literature Review of Reproducibility

J Manipulative Physiol Ther 2006 (Jul); 29 (6): 475–485 ~ FULL TEXT

Palpation for pain is reproducible at a clinically acceptable level, both within the same observer and among observers. Palpation for global assessment (GA) is reproducible within the same observer but not among different observers. The level of evidence to support these conclusions is strong. The reproducibility of motion palpation (MP), soft tissue changes (STC) and static palpation (SP) is not clinically acceptable. The level of evidence is strong for interobserver reproducibility of MP and STC, whereas no evidence or conflicting evidence exists for SP and intraobserver reproducibility of STC. Results are overall robust with respect to the predefined levels of acceptable quality. However, the results are sensitive to changes in the preset level of clinically acceptable reproducibility and to the number of included studies.

Diagnosis of Sacroiliac Joint Pain:
Validity of Individual Provocation Tests and Composites of Tests

Manual Therapy 2005 (Aug); 10 (3): 207–218 ~ FULL TEXT

Provocation sacroiliac joint (SIJ) tests have significant diagnostic utility. Six provocation tests were selected on the basis of previously demonstrated acceptable inter-examiner reliability. Two of four positive tests (distraction, compression, thigh thrust or sacral thrust) or three or more of the full set of six tests are the best predictors of a positive intra-articular SIJ block. When all six SIJ provocation tests are negative, painful SIJ pathology may be ruled out.

An Investigation into the Validity of Cervical Spine Motion Palpation
Using Subjects with Congenital Block Vertebrae as a 'Gold Standard'

BMC Musculoskelet Disord 2004 (Jun 15); 5 (1): 19 ~ FULL TEXT

This study indicates that relatively inexperienced examiners are capable of correctly identifying inter-segmental fixations (CBV) in the cervical spine using 2 commonly employed motion palpation tests. The use of a 'gold standard' (CBV) in this study and the substantial agreement achieved lends support to the validity of motion palpation in detecting major spinal fixations in the cervical spine.

Spinal Palpatory Diagnostic Procedures Utilized by Practitioners of
Spinal Manipulation: Annotated Bibliography of Content Validity
and Reliability Studies

J Can Chiropr Assoc 2003 (Jun); 47 (2): 93–109 ~ FULL TEXT

The diagnosis of spinal neuro-musculoskeletal dysfunction is a pre-requisite for application of spinal manual therapy. Different disciplines rely on palpatory procedures to establish this diagnosis and design treatment plans. Over the past 30 years, the osteopathic, chiropractic, physical therapy and allopathic professions have investigated the validity and reliability of spinal palpatory procedures. We explored the literature from all four disciplines looking for scientific papers studying the content validity and reliability of spinal palpatory procedures. Thirteen databases were searched for relevant papers between January 1966 and October 2001. An annotated bibliography of these articles is presented and organized by the type of test used.

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