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Context: Although spinal somatic dysfunction diagnosis is taught at all colleges of osteopathic medicine, few objective measures have been used to evaluate student accuracy., Objective: To assess the palpatory skills of osteopathic medical students in evaluating positional asymmetry in the transverse plane using static block transverse process and lumbar spine models., Methods: For this observational study, first-year osteopathic medical students completed 3 palpatory assessments using uncovered and covered block transverse process and lumbar spine models to simulate a range of positional asymmetries of the transverse processes. With use of logistic regression, 80%, 90%, and 95% thresholds were defined as the magnitude of asymmetry for which the predicted probability of students correctly determining the direction of asymmetry exceeded a specified amount (.80, .90, or .95)., Results: A total of 346 students completed the assessments. For the uncovered block transverse process model (assessment 1), students correctly identified the direction of asymmetry with .89 probability at 1 mm of asymmetry (80% threshold), .94 probability at 2 mm (90% threshold), and .95 probability at 3 mm (95% threshold). For the covered block transverse process model, students correctly identified the direction of asymmetry with .80 probability at 1 mm (80% threshold), .92 probability at 2 mm (90% threshold), and .98 probability at 3 mm (95% threshold) by the third assessment. For the uncovered lumbar spine model (assessment 2), students correctly identified the direction of asymmetry with .93 probability at 2 mm (80% and 90% thresholds) and .95 probability at 3 mm (95% threshold). For the covered lumbar spine model (assessments 2 and 3), students correctly identified the direction of asymmetry with .87 probability at 4 mm (80% threshold); 90% and 95% thresholds were not reached with the range of asymmetries tested., Conclusion: Most first-year osteopathic medical students were able to discern the direction of positional asymmetry of transverse processes on static models. Depending on the model type, student performance improved (block transverse process models) or declined (lumbar spine models) over time. Future studies should evaluate whether accuracy of palpating lumbar spine models translates to accuracy of palpating human lumbar spines., (© 2014 The American Osteopathic Association.)

Objective: Accurate localization of vertebral segments is crucial for many treatment procedures. The objective of this study was to determine accuracy of identification of lumbar spinous process levels by palpation., Methods: Three examiners independently identified the spinous processes of L1-L4 on 60 prone volunteers using multiple bony landmarks including the sacral base, L5, Tuffier's line, T12, and the 12th ribs. The spinous processes were marked with radiopaque skin markers. Location of marker placement and presence of anatomical anomalies were determined by posteroanterior lumbar radiographs. Accuracy of marker placement and interobserver reliability were assessed using weighted κ values. Generalized linear mixed models and Cochran-Mantel-Haenszel tests assessed the relationship of accuracy to training level, presence of anatomical anomalies, and participant characteristics., Results: Examiners identified a spinous process in 91% of vertebral assessments. Correct identification of vertebral level occurred 69% of the time (κ = 0.81; 95% confidence interval, 0.79-0.83). Faculty examiners were significantly more accurate in identifying the correct vertebral level than the resident examiner (67%-78% vs 51%, P ≤ .03). The presence of 12th rib anomalies decreased accuracy for all examiners (P ≤ .05), reducing accuracy from 74% to 55%. Accuracy was higher in male participants than in female participants (P = .01). Obesity significantly decreased accuracy (P = .0003) at L3 (50% vs 73%) and L4 (44% vs 72%)., Conclusions: Identification of lumbar spinous processes using multiple landmarks was more accurate than previously reported values. However, accuracy was dependent on examiner experience, presence of anatomical anomalies, and participant characteristics., (Copyright © 2011 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Context: Few studies have shown that diagnostic palpation is reliable. No studies have shown that the reliability of diagnostic palpatory skills can be maintained and improved over time., Objective: To investigate whether the reliability of selected palpatory tests used to identify lumbar somatic dysfunction was maintained during a 4-month period as part of a clinical observational study., Methods: Participants with low back pain and participants without low back pain, recruited from a rural Midwestern community, were examined during 6 separate sessions over a 4-month period. During each data collection session, two blinded examiners, who had previously completed comprehensive consensus training, evaluated the lumbar region with four tests: static segmental positional asymmetry of the transverse processes in the horizontal plane, tissue texture abnormalities, resistance to anterior springing on the spinous processes, and tenderness induced by pressure on the spinous processes. Detailed protocols for each test were defined during a previous comprehensive consensus training period and were not revised during the current study. To verify that established interobserver reliability was maintained throughout the clinical study, quality control sampling was performed on all data. When findings were inconsistent between the two examiners, focused consensus training was performed as a means of recalibration to understand why assessments were inconsistent. Interobserver reliability for determining the presence or absence of somatic dysfunction was assessed using kappa coefficients., Results: The study enrolled 64 participants, and 14 to 33 participants were examined per session. All four tests had acceptable interobserver reliability by the final data collection session. The test for static segmental positional asymmetry of the transverse processes in the horizontal plane had moderate to substantial reliability in all 6 sessions. The test for tissue texture abnormalities had moderate reliability in 5 of the 6 sessions. The test for resistance to anterior springing on the spinous processes had moderate reliability for 3 of the 6 sessions. The test for tenderness had substantial to almost perfect reliability for all 6 sessions. In general, interobserver reliability improved over time., Conclusions: Examiners were able to maintain and improve interobserver reliability of four lumbar diagnostic palpatory tests over a 4-month period.

Context: In the 1940s, osteopathic researchers suggested that paraspinal tissue abnormality was associated with spontaneous muscle activity, but few studies have since re-examined these reports., Objective: To determine whether abnormal motor activity plays a role in deep paraspinal tissues that appear abnormal to palpation., Methods: Using an observational study design, the PVG of participants with thoracic pain were palpated by two examiners for consensus on the most marked level of tissue abnormality. Dual fine-wire, intramuscular electrodes were inserted into the deep transversospinalis (multifidus, rotatores) muscles at the abnormal level and at two normal sites (above and below the abnormal level). Surface electrodes were placed over the erector spinae muscles adjacent to each intramuscular electrode site. Electromyography signals were recorded during initial prone resting, three maximal voluntary isometric contractions (MVIC), and a second prone resting. The area under the curve for a 2-second period was analyzed for each condition, and values were normalized and reported as a percentage of MVIC. Data were analyzed using a 2-factor repeated-measures analysis of variance., Results: Twenty-five participants with mean (SD) thoracic pain of 3.3 (1.9) on a 0 to 10 visual analog pain scale completed the study protocol. There were no statistically significant differences in normalized resting activity between the three intramuscular sites (P=.25) or between the three surface sites (P=.33). Substantial variability in normalized resting activity at each of the three intramuscular sites was evident (mean [SD] percent of MVIC: abnormal 7.83 [8.76]; normal 9.47 [8.45], 6.65 [7.39]). No statistically significant differences existed in the intramuscular EMG values between the two resting baseline periods (P=.10)., Conclusion: The lack of statistically significant differences between EMG activity at the abnormal and normal paraspinal sites suggests that factors other than muscle activity are responsible for the apparent abnormality of these tissues to palpation. Investigation of these regions for increased tissue fluid and inflammatory mediators is recommended.

Context: Few studies of inter- or intraobserver reliability have focused on evaluations of cranial strain patterns., Objective: To determine whether substantial intraobserver reliability can be achieved by osteopathic physicians (DOs) using common palpatory tests to diagnose cranial dysfunction., Methods: Forty-eight subjects were divided into three diagnostic groups, categorized as those with asthma, headaches, or neither asthma nor headaches (ie, healthy control group). Two blinded DO examiners separately evaluated approximately 8 subjects from each group (4 subjects per session), conducting diagnostic tests for cranial rhythmic impulse (CRI) rate, cranial strain patterns, and quadrants of restriction., Results: Overall, among the three diagnostic procedures, cranial strain patterns showed the highest intraobserver reliability (kappa=0.67). The highest intraobserver reliability was achieved in cranial strain patterns for the control group (kappa=0.82), followed by the headache (kappa=0.67) and asthma (kappa=0.52) groups. Diagnoses of the left anterior quadrant of restriction also showed substantial intraobserver reliability for the headache and control groups (kappa=0.60 and 0.61, respectively). Diagnoses of three quadrants of restriction showed moderate overall intraobserver reliability (kappa=0.44-0.52), while the left posterior quadrant had only fair overall intraobserver reliability (kappa=0.33)., Conclusion: Osteopathic physicians can obtain substantial intraobserver reliability when diagnosing cranial strain patterns in healthy subjects as well as those with asthma or headache. However, results are less promising for diagnoses of CRI and quadrants of restriction.

Context: Establishing reliable palpatory tests continues to be a critical, yet elusive, step in osteopathic medical research and evidence-based clinical practice., Objective: The authors investigated the interobserver reliability of common osteopathic palpatory tests used to evaluate the lumbar spine., Design and Methods: Subjects (N=119) were recruited from the faculty, staff, and students of Kirksville (MO) College of Osteopathic Medicine (KCOM) of A.T. Still University of Health Sciences. Three osteopathic medical examiners residency trained in neuromusculoskeletal medicine initially evaluated lumbar segments on subjects from one subgroup (n=42) in a blinded assessment. The examiners performed palpatory tests of tenderness and tissue texture changes, as well as--in three planes--vertebral positional asymmetry and motion asymmetry. Kappa statistics (kappa) were used to evaluate interobserver reliability. Following a period of consensus training, subjects from another subgroup (n=77) were evaluated in a blinded assessment for those palpatory tests that seemed most likely to produce reliable findings. The interobserver reliability was then re-evaluated., Results: During the initial evaluation of interobserver reliability, kappa ranged from -0.02 to 0.34, within the poor-to-fair reliability range. Following consensus training, reliability improved, rising into the moderate range for tissue texture changes (kappa=0.45) and into the substantial range for tenderness assessments (kappa=0.68). Reliability for positional asymmetry in the transverse plane (kappa=0.34) and rotational motion asymmetry (kappa=0.20) were improved but remained in the fair range., Conclusion: The authors concluded that consensus training improved the interobserver reliability of common osteopathic palpatory tests of the lumbar spine. In two of the four tests that were studied--tissue texture and tenderness--acceptable kappa values for clinical tests were achieved after consensus training.