J Manipulative Physiol Ther. 2008 (Oct); 31 (8): 616626 ~ FULL TEXT
Michael T. Haneline, DC, MPH, Robert Cooperstein, MA, DC, Morgan Young, DC, Kristopher Birkeland, BA
Palmer College of Chiropractic West,
San Jose, California 95134, USA.
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.
Key Indexing Terms:
Palpation, Chiropractic, Spine, Vertebra, Sacroiliac Joint
From the FULL TEXT Article:
Motion palpation (MP) of the spine and sacroiliac joints is a diagnostic procedure used by chiropractors and manual therapists to detect intersegmental hypomobility/hypermobility. It is used in determining where to apply a manipulative thrust or mobilization. However, the validity of MP of the spine and sacroiliac joints has not been established [1, 2] and studies of its reliability have generally reported low indices of agreement.  Previous literature reviews on the reliability of MP have reported κ values suggesting only slight interexaminer reliability and moderate intraexaminer reliability. [4-8]
Different means of assessing intersegmental motion have been described that assess either the excursion of the segments or their end feel.  Some, in addition, look at pain provocation. Motion palpation of excursion is also known as quantitative or active palpation, whereas MP of end feel is also known as qualitative or passive palpation. Excursion depicts the quantity of movement of the examined segments within the normal range of motion (ROM), whereas end feel refers to the quality of motion when the segments are taken to their extremes of ROM and then stressed by the examiner against the paraphysiological space. The objective for the MP examiner is to detect gross movement of the segments during excursion and/or their relative stiffness when the segments are stressed at the extremes of normal ROM. Authors in MP studies that used qualitative assessment have not consistently described their methods clearly enough to determine whether they used the end-feel method as we describe it or rather evaluated joint play within an ROM short of the end range. In our study, we had no choice but to lump such studies together, as more similar in method to each other than to the excursion method.
To our knowledge, no reviews have assessed whether there were differences in reliability according to whether the end-feel or excursion methods were used. The objective of this literature review was to classify the studies as to which method of MP was used, allowing for the possibility that a study may have used both methods at the same or at different segments.
Previous literature reviews on spinal MP have, in general, pointed to a lack of support for the procedure. Troyanovich et al  called for abandoning the procedure on this basis. Dishman  reported on only a few MP interexaminer reliability studies, concluding that the procedure was supported by the literature. However, it was not a systematic review and all of the cited studies merely reported percentage of agreement between examiners. Another review by Haas  concluded that the chiropractic literature at that time could not substantiate claims about the reliability of any of the diagnostic instrumentation or palpatory procedures commonly used by chiropractors, including MP. Breen  reviewed the literature on physical examination techniques used by chiropractors, finding their reliability to be lacking. He suggested that, in addition to establishing observer reliability, studies should be designed that pay attention to issues of validity by incorporating the use of gold standards. A review by Panzer  concluded that most previous MP studies had reported marginal to poor interexaminer and good to moderate intraexaminer reliability. Stochkendahl et al  reviewed studies that investigated the reliability of manual examination methods, including a number of MP reliability studies. The authors concluded that the procedure was not clinically acceptable.
In agreement with other reviews on the reproducibility of spinal MP, [2, 3, 8, 44, 92, 93] the overall results of this review point to a low degree of reproducibility among the included studies, with intraexaminer reliability generally faring better than interexaminer reliability. Thus, in a clinical context, one method would not be preferred over the other. Furthermore, if MP is used in clinical practice, the procedure should be accompanied by complementary tests that have established reliability and validity.
It is noteworthy that so many articles were located while searching the reference sections of the included studies and reviews on MP. We were able to uncover an additional 29 articles using this process, which, when combined with those found in the database searches, is more than any other MP review to date. This experience was similar to that of Murphy et al,  who were still able to locate an additional 11 citations via manual searches and content experts, after searching 13 databases on the reliability of spinal palpation procedures.
We searched 4 biomedical databases using diverse search terms and also gleaned a number of references from the included articles. Nonetheless, it is possible that some relevant citations may have been missed.
We have attempted in this review to compare the reported reliability of studies that used MP excursion vs end feel. However, when combining the results of reliability studies, one must consider that this exercise is fraught with a number of difficulties.  Some examples include the following: studies commonly used dissimilar interpretations of what the calculated κ values meant (eg, 0.4 is judged satisfactory in one study, whereas another study requires ≥0.5), studies used examiners with different experience levels, and some studies used symptomatic and others asymptomatic subjects. Furthermore, the included studies often used somewhat different methods of MP, used dissimilar study designs, included diverse populations, and reported different reliability indices. These difficulties have resulted in an overall study heterogeneity that makes direct comparison difficult.
Studies of MP are inherently prone to error because, even if the examiners agree on the level of hypomobility, there is a significant chance they will unknowingly differ in their identification of the level of palpated segments, even when they agree on the location of fixation. For instance, Billis et al  reported on the interexaminer reliability of simply locating the C5, T6, and L5 spinous processes by palpation, which was low at all spinal levels. Some researchers have attempted to ameliorate this problem by collapsing segmental data into regions, although Haas  criticized this practice because it inflates reliability. An example of a study that attempted to control for disagreement about the level being palpated was Maher et al,  who had the examiners locate and mark the spinous process of the target vertebra by consensus. They thought that the marking procedure may have contributed to the reported relatively high interexaminer reliability, artificially increasing reliability estimates, because the target level must be located independently in clinical practice. Huijbregts  suggested that the reason intraexaminer MP studies have on average reported higher indices of agreement than interexaminer studies may be related to the difficulty of identifying spinal levels between examiners.
Some of the operational definitions of the palpation procedures that were given in the various articles were vague, which sometimes made it difficult to ascertain the actual method of palpation that was used. In our classification of studies as having used the end-feel method, we reluctantly lumped together procedures that assessed joint movement at the end ROM and those that assessed joint play (ie, posteroanterior stiffness springing short of end range). The 2 methods are in some respects discrete, as they assess somewhat different aspects of joint integrity, although they both involve applying pressure and judging the tissue's response.
A major limitation in attempting to determine the preference of one type of MP over the other is the lack of evidence concerning the validity of the 2 types. It should also be noted that, to actually determine whether one type of MP is more reliable than another, it will be necessary to conduct a study that involves a head-to-head comparison of independent tests.
The reliability of both the excursion and end-feel MP methods was, for the most part, found to be meager in this review, given that the reported κ values of most studies were below 0.4. When only considering high-quality studies, there did not appear to be any advantage of one method of MP over the other. In light of the findings of Marcotte et al, [78, 79] future MP reproducibility studies, at least those involving the cervical spine, may benefit by controlling the kinematics of palpation between examiners. Studies should also be more careful to describe their methods, for ease of classification as excursion, end feel, or joint play palpation.
Two forms of spinal MP may be described, one assessing joint end feel and the other excursion of the intervertebral joints.
The reported reliability for both methods of spinal MP is generally low.
The proportion of studies that reported good reliability favored the end-feel method over excursion, although differences were not statistically significant.
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