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2009 Paulet Fryer Inter-Examiner Reliability of Palpation For Tissue Texture Abnormality in The
2009 Paulet Fryer Inter-Examiner Reliability of Palpation For Tissue Texture Abnormality in The
Research report
a r t i c l e i n f o a b s t r a c t
Article history: Background: Palpation of soft tissue changes is claimed to be important for osteopathic diagnosis and
Received 2 May 2008
treatment. Few studies, however, have examined the inter-examiner reliability for the detection of
Received in revised form
altered segmental paraspinal tissue texture.
9 July 2008
Accepted 11 July 2008 Objective: To determine the inter-examiner reliability of the identication of abnormal tissue texture in
the thoracic paraspinal region using palpation.
Keywords: Method: Ten nal-year osteopathic students examined the thoracic paravertebral gutter regions of ten
Reliability subjects presenting with a recent history of thoracic symptoms. Each examiner palpated each subject to
Palpation determine which of four predetermined areas exhibited the most obvious alteration or abnormality in
Muscle tissue texture. One week prior to the study, all examiners received consensus training to standardise the
Osteopathic medicine
method of palpation.
Manual therapy
Results: The inter-examiner agreement for the site with the most marked tissue texture change was fair
(k 0.26; Po 0.46; Pe 0.28; 95% CI 0.190.33). When only the rst ve assessments from each
examiner were analysed, the agreement improved slightly, but remained fair (k 0.32; Po 0.52;
Pe 0.30; 95% CI 0.160.47).
Conclusions: Inter-examiner reliability of palpation for abnormal tissue texture in the deep thoracic
paraspinal region was only fair. The inuence of either examiner fatigue or tissue change due to repeated
palpation appeared to be small. Although the practice of palpating for segmental tissue texture abnor-
malities without concurrent reports of tenderness from the patient is not typical of clinical practice, this
study suggests that assessment of texture change is complex and not highly reproducible between
examiners.
2008 Elsevier Ltd. All rights reserved.
1746-0689/$ see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijosm.2008.07.001
T. Paulet, G. Fryer / International Journal of Osteopathic Medicine 12 (2009) 9296 93
palpation. Of the TART criteria, however, only palpation for The reliability of palpation to detect the clinical features of
tenderness and pain provocation tests (reproduction of the somatic dysfunction is fundamental in establishing the concept of
patients familiar pain) have been demonstrated to have acceptable somatic dysfunction as a valid diagnosis. The inter-examiner reli-
reliability between different examiners.10,17,18 Poor inter-examiner ability of palpation for abnormal tissue texture of the thoracic
agreement has been reported for motion palpation10,17,18 and static paraspinal muscles has not yet been established, thus the aim of
spinal asymmetry.19,20 this study was to investigate the inter-examiner reliability of
Despite reports of poor reliability for motion palpation, some palpation for abnormal tissue texture at pre-determined areas in
studies suggest that it may potentially be reliable in some the thoracic spine between a group of nal year osteopathic
circumstances. Humphreys et al.21 reported that examiners could students.
detect the presence or absence of xation in the cervical spine
using motion palpation techniques in lateral exion and rotation in 2. Methods
patients with a congenitally fused vertebral segment. Landel et al.22
demonstrated good inter-examiner reliability for identifying the 2.1. Participants
least mobile lumbar segment using posterioranterior springing,
however, the validity of these ndings were questionable because Ten subjects (5 male and 5 female, age range 1923) were
they did not concord with intervertebral motion measured during recruited from the student population at Victoria University (VU),
the test using MRI. Melbourne, Australia, in response to posted notices. In order to be
In contrast to motion palpation, several studies investigating the included in this study, subjects were required to be over 18 years of
reliability of palpating spinal tenderness have shown good to age and have had an episode of mild thoracic spinal pain (less than
excellent reliability.10,17,18 Although tenderness and pain provoca- 4 on a 10 point visual analogue scale) or stiffness within the two
tion have been claimed to be a useful tool for identifying symp- weeks prior to testing. None of the participants were symptomatic
tomatic joints in the cervical spine,23 the validity of motion on the day of testing. Limiting inclusion to subjects with a recent
palpation and pain provocation to accurately distinguish symp- history of thoracic symptoms was thought to increase the possi-
tomatic from non-symptomatic joints has been disputed.24 Wide- bility of the subjects having regions of tissue texture abnormality
spread pain and referred tenderness are common clinical ndings and somatic dysfunction. Participants were excluded from the
and localised tenderness does not always reect the site of study if they suffered from severe thoracic pain, had any gross
pathology.25,26 However, reproduction of pain may not be the only spinal deformities, had a diagnosed pain syndrome such as bro-
clue for joint dysfunction. For example, Jull et al.27 have demon- myalgia, if palpation of thoracic tissues produced more than minor
strated that direct verbal reports of pain were not required for discomfort, or if they were unable to lay prone on a treatment
examiners to identify symptomatic joints in the cervical spine. couch for 20 min. Subject weight, height and prior thoracic pain
Osteopaths commonly palpate for tissue texture changes in history was not recorded, although no subject was visibly obese. In
three paraspinal regions: the medial paravertebral groove (PVG) or addition to the ten subjects, ten examiners (3 male and 7 female,
gutter, which is located between the spinous processes of the age range 2224) were recruited from the nal year osteopathy
vertebrae and the erector spinae muscles, the bulk of the erector student population at Victoria University. All participants signed
spinae, and the iliocostalis muscle bres overlying the angles of the informed consent forms and the procedures for this study were
ribs.4,28 Some authors claim that palpation of hypertonicity of the approved by the VU Human Research Ethics Committee.
deep fourth layer of paraspinal muscles (semispinalis, rotatores and
multidus) in the medial paravertebral groove is a cardinal sign of 2.2. Examiner training
somatic dysfunction.4,5 Segmental tissue texture changes are
reported to include abnormal hardness, bogginess, or ropiness of In order to minimise individual variation in the application of
the underlying paraspinal muscles.4,5 examination techniques, pre-test training in a standardised
Considering the proposed importance of palpation for para- examination procedure has been recommended.32,34 One week
spinal tissue texture abnormalities for the identication of somatic prior to the study, all examiners spent one hour with an experi-
dysfunction, this criterion should be established as a reliable and enced osteopath (Researcher 1) in an attempt to standardise the
valid nding. However, few researchers have investigated the palpation techniques and arrive at agreement as to the state of the
reliability of palpating tissue texture abnormalities, and those tissue under palpation. Examiners agreed to palpate the thoracic
studies available have reported only fair to poor reliability.10,17,29 PVG with the index and middle ngers using moderately deep
Regions in the thoracic PVG identied as abnormal using palpation pressure and a short longitudinal sliding motion (Fig. 2). Sites were
have been veried as having a lower mean pressure pain threshold determined as having abnormal texture if the alteration was
than surrounding normal tissues,30 and have been reported to palpated in the oor of the PVG. Texture abnormality at the lateral
display abnormally increased electromyographic activity,31 which border of the PVG (erector spinae bulk) was not considered.
suggests that palpation may be useful in identifying tissue abnor-
mality in the paraspinal region. 2.3. Experimental procedure
Natural variability in the texture of paraspinal muscles may act
as a confounding factor in reliability studies,30 and careful pre-test The ten subjects were positioned prone on treatment couches
training may minimise the effects of individual examiner inter- arranged in a large room, and were assigned a letter from A to J. In
pretations of different tissue texture changes. Studies that have each subject, Researcher 1 identied four areas within the thoracic
used pre-test consensus training or training in a standardised PVG region and marked each with a line just lateral to the PVG (so
examination procedure suggest that training improves the agree- that repeated palpation in the PVG would not remove the mark)
ment of ndings between examiners palpating tissue texture with a skin pencil (Fig. 1). There was an attempt to include at least
changes related to spinal dysfunction or the presence of myofascial one area of increased tissue texture tone, judged by Researcher 1 as
trigger points.32,33 Additionally, inter-examiner reliability of pal- relatively hard, lumpy or boggy. The remaining areas were
patory examinations has been reported to be slightly higher using marked at random, with two marked areas on each side of the
symptomatic subjects,17 and so the use of subjects with a degree of spine. The four areas were labelled from superior to inferior as
symptoms may assist with establishing diagnostic reliability. numbers 14. The subjects were instructed not to talk to the
94 T. Paulet, G. Fryer / International Journal of Osteopathic Medicine 12 (2009) 9296
3. Results
4. Discussion
Table 1
2.4. Statistical analysis Guidelines for interpreting kappa values36
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