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

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Abstract

Objective

Poor reproducibility of spinal palpation has been reported in previously published literature, and authors of recent reviews have posted criticism on study quality. This article critically analyzes the literature pertaining to the inter- and intraobserver reproducibility of spinal palpation to investigate the consistency of study results and assess the level of evidence for reproducibility.

Methods

Systematic review and meta-analysis were performed on relevant literature published from 1965 to 2005, identified using the electronic databases MEDLINE, MANTIS, and CINAHL and checking of reference lists. Descriptive data from included articles were extracted independently by 2 reviewers. A 6-point scale was constructed to assess the methodological quality of original studies. A meta-analysis was conducted among the high-quality studies to investigate the consistency of data, separately on motion palpation, static palpation, osseous pain, soft tissue pain, soft tissue changes, and global assessment. A standardized method was used to determine the level of evidence.

Results

The quality score of 48 included studies ranged from 0% to 100%. There was strong evidence that the interobserver reproducibility of osseous and soft tissue pain is clinically acceptable (κ ≥ 0.4) and that intraobserver reproducibility of soft tissue pain and global assessment are clinically acceptable. Other spinal procedures are either not reproducible or the evidence is conflicting or preliminary.

Section snippets

Definitions

Palpation was defined according to Bergmann and Petersen,1 and results of the original articles were analyzed according to the palpation procedure, using the following annotations: motion palpation (MP), static palpation (SP) (palpation for alignment and/or structure), osseous pain (OP) (pain generated from palpation of osseous structures), soft tissue pain (STP), soft tissue changes (STC), and global assessment (GA) (the latter was introduced to describe the use of 2 or more of the above

Results of the Literature Search

More than 900 publications were retrieved, and 48 original articles published between 1980 and 2005 were included according to the inclusion criteria.20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 In all 48 studies interobserver reproducibility were reported, and in 19 studies, intraobserver reproducibility was also reported (Appendix A, Appendix B,

Summary of Results

After reviewing studies dealing with reproducibility of manual palpation of the entire spine, including the SI joints, we found strong evidence for clinically acceptable reproducibility both within and between observers for palpation of osseous and STP and within the same observer for GA. Strong evidence for clinically unacceptable levels of reproducibility for intra- and interobserver MP and STC was found. Intraobserver reproducibility was consistently higher than interobserver

Conclusions

Palpation for pain is reproducible at a clinically acceptable level, both within the same observer and among observers. Palpation for 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 MP, STC, and 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

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    This study was funded by the Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark and the Foundation for Chiropractic Education and Research, grant no. 03-09-01.

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