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MOTION PALPATION

MISCONCEPTIONS

Introduction

Spinal motion palpation is an integral diagnostic procedure that has been widely used by manual therapy practitioners to diagnose spinal dysfunction. It is frequently used to locate primary areas of joint restriction, asymmetries in spinal level and intersegmental hypomobility and hypermobility. It helps determine whether a patient needs spinal manipulation, and, if so, where to apply the thrust (Bergmann and Peterson 2010). Motion palpation is also performed to detect functional changes in other regions (e.g., shoulder or hip) related to the spine. In addition, a recent study among physiotherapists in Australia reported that around 98 per cent of the respondents were using manual palpatory tests to take treatment decisions (Abbott et al. 2009).

Over the last century, various palpatory techniques have been developed to detect different degrees of motion restriction at the spinal level. However, the clinical utility of these palpation techniques in the assessment of spinal dysfunction has been controversial (Walker et al. 2015). Although proponents of manual therapy consider it to be a valid and reliable indicator of spinal abnormalities, a majority of studies have found it to be unreliable due to low indices of agreement (Cooperstein and Young 2016; Haneline et al. 2008; Huijbregts 2002; Walker et al. 2015). Because the reliability of an examination tool is a prerequisite for its clinical utility, the use of motion palpation to guide treatment interventions is questionable.

This chapter is therefore written to improve our understanding concerning the validity and reliability of spinal motion palpation.

Intrarater and interrater reliability of motion palpation

In the context of spinal motion palpation, reliability refers to the degree of consistency in the diagnostic outcomes when it is repeated under identical conditions. Intrarater reliability is the degree of agreement obtained by the same rater across two or more trials using the same procedure. Interrater reliability is the relative consistency of agreement among two or more raters concerning the outcomes of the same procedure (Watkins and Portney 2009).

Over the past decades, a large body of research has been conducted to determine the reliability of motion palpation. However, the reliability estimates have been reported to vary widely from study to study (Walker et al. 2015). The literature investigating the intrarater reliability using κ values suggested the degree of agreement to be moderate. On the other hand, the interrater reliability of motion palpation has been found to be poor, often the agreement at near chance levels (Haneline et al. 2008). Huijbregts (2002) proposed that this higher intra- than interrater reliability might be due to incorrect detection of the vertebral level by the raters at which motion restriction was identified. Nyberg and Russell Smith (2013) stated that a therapist’s primary focus during motion palpation might also be responsible for the low level of agreement between raters. They suggested that some therapists might solely concentrate on the degree of spinal displacement while others might be more focused on assessing the velocity of the displacement.

Systematic reviews done to assess the quality of motion palpation studies have found significant statistical and methodological shortcomings in the majority of these studies (Stochkendahl et al. 2006; van Trijffel et al. 2005). In a recent systematic review by Haneline et al. (2008), it was found that only 4 out of 44 retrieved articles were of acceptable quality. Some of the common methodological flaws in these studies included poor patient selection, inexperienced raters, use of irrelevant rating scales and low levels of reproducibility. Moreover, in most of the earlier studies, therapists were not allowed to detect different degrees of spinal stiffness, which obviously affected the level of agreement between them (Cooperstein and Young 2016). However, despite these limitations, the majority of high-quality studies have reported poor interrater reliability of motion palpation. The level of interrater agreement is usually found to be no better than chance.

Here are some of the most likely reasons for the low reliability of motion palpation:

• differences in palpatory testing procedures

• inaccurate interpretation of motion abnormality at the segmental level

• incorrect identification of spinal landmarks

• anatomical difference between patients.

Alternatively, Cooperstein and Young (2016) opined that significant interrater agreement could be achieved with motion palpation if continuous analysis is performed and the findings are stratified by therapist confidence. They suggested that instead of performing the segmental level-by-level evaluation to identify spinal stiffness, therapists should focus on finding the stiffest site and use their confidence as a surrogate measure to determine the degree of spinal stiffness. Bracht et al. (2015) also suggested that the therapist’s lack of confidence with the test result might be a variable affecting the interrater agreement.

Reliability of osteopathic motion palpation tests

The osteopathic approach of motion palpation adheres to the principles of Fryette’s Laws, which is a set of three laws that serve as guiding principles for osteopaths to differentiate between spinal dysfunctions. These laws suggest that the existence of a somatic dysfunction in one plane of the spine will negatively affect vertebral motion in all other planes (DiGiovanna, Schiowitz and Dowling 2005). The first two laws assume that when one or more vertebrae are out of alignment, the vertebral movement will be toward the side that has more freedom of movement. For example, according to the first law, if there is an asymmetry in the position of T3 and T4 vertebrae, side bending to the right will cause a simultaneous horizontal rotation to the left. In brief, these laws imply that the vertebra has a natural tendency to position itself opposite to the side with less mobility (Nelson and Glonek 2007).

Studies done to understand the mechanical dysfunctions of vertebrae have reported a decrease in spinal joint movement in patients with low back pain (LBP). Passias et al. (2011), whose aim was to quantify abnormal vertebral motion, found greater segmental hypermobility and hypomobility in discogenic LBP patients compared with asymptomatic normal subjects. Furthermore, although Snider et al. (2008) did not find a significant difference between chronic LBP and non-LBP groups for the incidence of static rotational asymmetry, they reported a greater asymmetry in chronic LBP patients than those without LBP. These findings further highlight the significance of identifying rotational asymmetry and the potential of some palpatory tests that can detect asymmetrical vertebral position.

Osteopaths frequently use a motion palpation test to identify the rotational asymmetry of the vertebrae in the transverse plane. The vertebral rotation test is usually performed to detect whether there is asymmetry in the vertebral position and to determine the severity of somatic dysfunction. So far, only a few studies have investigated the intra- and interrater reliability of palpatory tests that assess rotational vertebral asymmetries (Degenhardt et al. 2005, 2010; Holmgren and Waling 2008). However, the findings of these studies are contradictory and do not suggest motion palpation as a reliable test to identify vertebral asymmetry. Recently, to confirm the results of earlier studies, Bracht et al. (2015) assessed the rotational movement asymmetry of the lumbar vertebrae using a motion palpation test in order to determine its intra- and interrater reliability. Similar to previous authors, they also found low inter- and intrarater agreement of the motion palpation test used. Taken together, it can be said that the reliability of palpatory tests for the assessment of vertebral rotational asymmetry is questionable.

Conclusion and recommendations

Motion palpation tests have a wide clinical use in manual therapy. However, since the reliability of these tests has been questionable, clinicians should follow the current clinical recommendations for the assessment of spinal dysfunction. Based on the conclusions made by the studies reviewed, we developed the following suggestions for therapists:

• Have a qualitative approach. When assessing a patient, the therapist should focus more on the quality of motion with end-range spinal motions than the quantity of movement in the palpated segments. This is because it is clinically more important to detect the presence of a motion abnormality than the exact segmental level at which the abnormality was found. The therapist’s decision to provide a spinal manipulation largely depends on whether there is a motion restriction at the spinal level and the symptoms reproduced with the palpation test. Huijbregts (2002) suggested that incorrect identification of the segmental level with abnormality might be a possible explanation for the low interrater agreement. Moreover, the systematic review by Haneline et al. (2008) found that studies that reported fair agreement favoured the qualitative or passive palpation method more than the quantitative approach.

• Consider using pain provocation tests. In addition to using a more passive motion palpation test, the therapist should focus on pain response with provocation of the involved spinal segments. Pain provocation tests have been shown to demonstrate higher levels of reliability than motion palpation for identifying spinal dysfunction and instability (Hicks et al. 2003; Malanga, Landes and Nadler 2003; Telli, Telli and Topal 2018). On the other hand, Nyberg and Russell Smith (2013) suggested that the use of a passive palpation technique would help improve the therapist’s tactile perception and ability to discriminate spinal motion behaviour.

References

Abbott, J.H., Flynn, T.W., Fritz, J.M., Hing, W.A., Reid, D. and Whitman, J.M. (2009) ‘Manual physical assessment of spinal segmental motion: Intent and validity.’ Manual Therapy 14(1), 36–44.

Bergmann, T.F. and Peterson, D.H. (2010) Chiropractic Technique: Principles and Procedures. St Louis, MO: Elsevier Health Sciences.

Bracht, M.A., Nunes, G.S., Celestino, J., Schwertner, D.S., França, L.C. and de Noronha, M. (2015) ‘Inter- and intra-observer agreement of the motion palpation test for lumbar vertebral rotational asymmetry.’ Physiotherapy Canada 67(2), 169–173.

Cooperstein, R. and Young, M. (2016) ‘The reliability of spinal motion palpation determination of the location of the stiffest spinal site is influenced by confidence ratings: A secondary analysis of three studies.’ Chiropractic and Manual Therapies 24(1), 50.