Influence of Transverse Process Landmark Localization on Palpation Accuracy of Lumbar Spine Models.

CONTEXT: Accurate determination of transverse process displacement in the horizontal plane requires accurate transverse process landmark localization followed by accurate discrimination of asymmetry by the examiner's palpating digits. OBJECTIVE: To determine whether the accurate localization of transverse process landmarks influences overall accuracy of asymmetry determination in third-year osteopathic medical students evaluating covered lumbar spine models. METHODS: A class of third-year osteopathic medical students was split into 2 groups and asked to determine whether the right transverse processes of covered lumbar spine models were anterior or posterior relative to the left transverse process. The marked model group (group A) was provided covered models with black dots on the fabric covers over the transverse process landmarks, while the covered models given to the students in the unmarked model group (group B) had no markings. Both groups were asked to assess asymmetry differences from L1 to L5 on 2 models. Landmarks were randomized for asymmetry (ranging from 2 mm to 6 mm) and direction (anterior or posterior on the right side). The number of correct responses was modeled as a binomial random variable in a generalized linear model to compare the effects of marked vs unmarked models on accuracy of palpation. The predicted probability of correctly determining the direction of the asymmetry and 95% CIs were calculated. RESULTS: The probability of correctly identifying the direction of asymmetry was 0.89 (95% CI, 0.87-0.91) for group A and 0.74 (95% CI, 0.71-0.78) for group B, a 15 percentage point difference (OR, 1.2; 95% CI, 1.1-1.3; P<.001). Assuming accurate perception of digit asymmetry and accurate localization of landmarks are independent and correct answers are given only if both events occur, then students were more likely to accurately perceive digit asymmetry (0.89) than accurately localize landmarks (0.83=0.74/0.89). Overall, more students accurately identified the direction of asymmetry when the right transverse process was anterior (0.87; 95% CI, 0.84-0.90) than when it was posterior (0.81; 95% CI, 0.77-0.84) (OR, 1.6; 95% CI, 1.2-2.1; P=.001). CONCLUSIONS: Student palpation accuracy was better when transverse process landmark localization was provided on the lumbar spine models than when it was not. Students were more likely to accurately perceive digit asymmetry than accurately localize the landmarks. Improving palpation accuracy requires developing educational methods to improve both accurate landmark localization and accurate digit asymmetry perception.

Laser Doppler flowmetry in manual medicine research.

Laser Doppler flowmetry (LDF) is commonly used in combination with reactivity tests to noninvasively evaluate skin sympathetic nerve activity and skin microvascular function. In manual medicine research, LDF has been used as a marker for global peripheral sympathetic nervous system function, but these results should be considered with caution because skin sympathetic nerve activity physiology is often overlooked. Another limitation of LDF in manual medicine research is the processing of LDF recordings. Two methods have been suggested: the time-domain analysis and the frequency-domain analysis. Standardization is required for data collection and processing in either domain to accurately interpret these changes in skin blood flow that occur after manual procedures. For physiologic studies using LDF, the authors recommend the use of noninvasive reactivity tests (positive controls) to evaluate the different mechanisms involved in overall skin blood flow changes and to compare the magnitude of these changes with those specifically elicited by manual procedures.

Changes in rat spinal cord gene expression after inflammatory hyperalgesia of the joint and manual therapy.

CONTEXT: Mobilization of a joint affects local tissue directly but may also have other effects that are mediated through the central nervous system. OBJECTIVE: To identify differential gene expression in the spinal cords of rats with or without inflammatory joint injury after manual therapy or no treatment. METHODS: Rats were randomly assigned to 1 of 4 treatment groups: no injury and no touch (NI/NT), injury and no touch (I/NT), no injury and manual therapy (NI/MT), and injury and manual therapy (I/MT). We induced acute inflammatory joint injury in the rats by injecting carrageenan into an ankle. Rats in the no-injury groups did not receive carrageenan injection. One day after injury, rats received manual therapy to the knee of the injured limb. Rats in the no-touch groups were anesthetized without receiving manual therapy. Spinal cords were harvested 30 minutes after therapy or no touch, and spinal cord gene expression was analyzed by microarray for 3 comparisons: NI/NT vs I/NT, I/MT vs I/NT, and NI/NT vs NI/MT. RESULTS: Three rats were assigned to each group. Of 38,875 expressed sequence tags, 755 were differentially expressed in the NI/NT vs I/NT comparison. For the other comparisons, no expressed sequence tags were differentially expressed. Cluster analysis revealed that the differentially expressed sequence tags were over-represented in several categories, including ion homeostasis (enrichment score, 2.29), transmembrane (enrichment score, 1.55), and disulfide bond (enrichment score, 2.04). CONCLUSIONS: An inflammatory injury to the ankle of rats caused differential expression of genes in the spinal cord. Consistent with other studies, genes involved in ion transport were among those affected. However, manual therapy to the knees of injured limbs or to rats without injury did not alter gene expression in the spinal cord. Thus, evidence for central nervous system mediation of manual therapy was not observed.

Assessing palpation thresholds of osteopathic medical students using static models of the lumbar spine.

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.

Influence of manual therapy on functional mobility after joint injury in a rat model.

CONTEXT: Animal models can be used to investigate manual therapy mechanisms, but testing manipulation in animal models is problematic because animals cannot directly report their pain. OBJECTIVE: To develop a rat model of inflammatory joint injury to test the efficacy of manual therapy in reducing nociception and restoring function. METHODS: The authors induced acute inflammatory joint injury in rats by injecting carrageenan into the ankle and then measured voluntary running wheel activity in treated and untreated rats. Treatments included manual therapy applied to the ankle and knee of the injured limb and several analgesic medications (eg, morphine, ketorolac, prednisone). RESULTS: Intra-articular injection of carrageenan to the ankle produced significant swelling (diameter of the ankle increased by 64% after injection; P=.004) and a robust reduction in voluntary running wheel activity (running distance reduced by 91% compared with controls; P<.001). Injured rats gradually returned to running levels equal to controls over 10 days. Neither manual therapy nor analgesic medications increased running wheel activity relative to untreated rats. CONCLUSION: Voluntary running wheel activity appears to be an appropriate functional measure to evaluate the impact of an acute inflammatory joint injury. However, efforts to treat the injury did not restore running relative to untreated rats.

Retrospective medical record review of an osteopathic manipulative medicine hospital consultation service.

CONTEXT: In the first half of the 20th century, nearly all osteopathic physicians used osteopathic manipulative medicine (OMM) in the care of hospitalized patients. Over the past few decades, however, inpatient OMM care has declined and is more commonly provided by OMM specialists. OBJECTIVE: To retrospectively evaluate the details of a specialty-level OMM inpatient consultation service. METHODS: Inpatient OMM consultations that took place at Northeast Regional Medical Center in Kirksville, Missouri, between July 1998 and March 2008 were identified from billing records. Consultations were reviewed for demographic information, admission location, postoperative status, intensive care unit and mechanical ventilation usage, admission and discharge diagnoses, consultation reasons and final diagnoses, areas of somatic dysfunction treated and types of osteopathic manipulative treatment (OMT) techniques used, and hospital length of stay (LOS). RESULTS: A total of 1509 OMM consultations were identified (580 for male patients [38%]; 929 for female patients [62%]; mean [SD] age, 54 [31] years [range, 0-99 years]), representing 11% of all inpatient consultations. Of these, 1372 consultations (91%) were initiated in the inpatient acute care facility, 87 (6%) in the inpatient acute rehabilitation facility, and 50 (3%) in the skilled nursing facility. Further, 265 consultations (18%) were for postoperative patients, 187 (12%) were for patients in the intensive care unit, and 54 (4%) were for patients receiving mechanical ventilation at the time of the consultation. The most common admission diagnoses were hypertension, routine newborn care, lower respiratory infection, chronic obstructive pulmonary disease, and gastrointestinal symptoms. The most common reasons for OMM consultation were chest/rib pain, spinal pain, lower respiratory infection (adjunctive treatment), cranial asymmetry, and infant feeding disorder. The most common types of OMT techniques used were myofascial release, balanced ligamentous tension, muscle energy, soft tissue, and inhibition. The mean (SD) LOS was 5.7 (3.3) days (range, 0-48 days), while the mean (SD) number of days the patient received OMT was 3.1 (2.2) days. CONCLUSION: Medical records reviewed in the current study revealed that OMM consultations were ordered primarily for musculoskeletal complaints, respiratory problems (adjunctive treatment), and newborn care. A variety of OMT techniques were used. Further retrospective study is warranted to determine if OMM had an effect on LOS.

Preventative osteopathic manipulative treatment and the elderly nursing home resident: a pilot study.

CONTEXT: Elderly nursing home residents are generally in poor health. Many residents report pain on a daily basis, few are independent in their activities of daily living, and most take a large number of medications. OBJECTIVE: To investigate the benefits elderly nursing home residents may receive from preventative osteopathic manipulative treatment (OMT) designed to optimize structure and function and enhance their bodies' homeostatic mechanisms. METHODS: Volunteer nursing home residents were randomly assigned to 1 of 3 groups: (1) OMT, (2) light touch (LT), or (3) treatment as usual (TAU). The OMT group received an OMT protocol twice per month for 5 months, for a total of 10 visits. The LT group received a light-touch protocol meant to simulate OMT at the same frequency as the OMT group. The TAU group received no intervention. Participant health information from Minimum Data Set assessments was monitored during the study, along with hospitalizations, emergency room visits, and outpatient procedures. The nursing home personnel and the participants' attending physicians were blinded to treatment group assignment. RESULTS: Twenty-one participants completed the study: 8 in the OMT group, 6 in the LT group, and 7 in the TAU group. The OMT and LT groups had fewer hospitalizations (P=.04) and decreased medication usage (P=.001) compared with the TAU group. CONCLUSION: Twice monthly OMT and LT protocols reduced the number of hospitalizations and decreased medication usage in elderly nursing home residents.

Palpatory accuracy of lumbar spinous processes using multiple bony landmarks.

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.

Low back pain, somatic dysfunction, and segmental bone mineral density T-score variation in the lumbar spine.

CONTEXT: Identifying objective measures that correlate with somatic dysfunction palpatory findings will aid in establishing clinical relevance of the findings and provide outcome measures for future studies. OBJECTIVE: To investigate the association of altered segmental lumbar vertebral mechanics (ie, somatic dysfunction) as assessed by palpation with bone mineral density (BMD) T-score variability in participants, some with chronic low back pain (CLBP) and others without low back pain (LBP). METHODS: Individuals with CLBP and individuals without LBP were examined by 2 blinded examiners for the presence or absence of paraspinal tissue texture abnormalities, vertebral rotational asymmetry, anterior motion restriction, and tenderness from L1 to L4. All participants then received a dual-energy x-ray absorptiometry scan of the lumbar spine. Bone mineral density T scores were compared between the CLBP and non-LBP groups. RESULTS: Sixty-three individuals (16 CLBP, 47 non-LBP) participated in the study. Lumbar segments with perceivable rotational asymmetry had higher mean BMD T scores (95% confidence interval [95% CI]) than lumbar segments with no asymmetry (0.5 [0.4-0.7] vs -0.2 [-0.6 to 0.2], respectively; P=.002). Additionally, lumbar segments with anterior motion restriction had higher mean BMD T scores (95% CI) than lumbar segments with no motion restriction (0.6 [0.4-0.7] vs 0.1 [-0.2 to 0.3], respectively; P=.03). Participants with CLBP demonstrated higher regional mean lumbar BMD T scores (95% CI) than those without CLBP (0.9 [0.6-1.1] vs 0.3 [0.2-0.5], respectively; P<.001). After accounting for sex and body mass index, vertebral segments with rotational asymmetry (in non-LBP participants only) and vertebral segments with motion restriction had higher mean BMD T scores than vertebral segments with no asymmetry or motion restriction. CONCLUSION: Participants with CLBP had significantly higher lumbar BMD than participants without LBP. The presence of rotational asymmetry or motion restriction was associated with elevated BMD at the affected vertebrae.

Maintenance and improvement of interobserver reliability of osteopathic palpatory tests over a 4-month period.

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.

The immediate effect of individual manipulation techniques on pulmonary function measures in persons with chronic obstructive pulmonary disease.

BACKGROUND: The use of manipulation has long been advocated in the treatment of chronic obstructive pulmonary disease (COPD), but few randomized controlled clinical trials have measured the effect of manipulation on pulmonary function. In addition, the effects of individual manipulative techniques on the pulmonary system are poorly understood. Therefore, the purpose of this study was to determine the immediate effects of four osteopathic techniques on pulmonary function measures in persons with COPD relative to a minimal-touch control protocol. METHODS: Persons with COPD aged 50 and over were recruited for the study. Subjects received five, single-technique treatment sessions: minimal-touch control, thoracic lymphatic pump (TLP) with activation, TLP without activation, rib raising, and myofascial release. There was a 4-week washout period between sessions. Protocols were given in random order until all five techniques had been administered. Pulmonary function measures were obtained at baseline and 30-minutes posttreatment. For the actual pulmonary function measures and percent predicted values, Wilcoxon signed rank tests were used to test within-technique changes from baseline. For the percent change from baseline, Friedman tests were used to test for between-technique differences. RESULTS: Twenty-five subjects were enrolled in the study. All four tested osteopathic techniques were associated with adverse posttreatment changes in pulmonary function measures; however, different techniques changed different measures. TLP with activation increased posttreatment residual volume compared to baseline, while TLP without activation did not. Side effects were mild, mostly posttreatment chest wall soreness. Surprisingly, the majority of subjects believed they could breathe better after receiving osteopathic manipulation. CONCLUSION: In persons with COPD, TLP with activation, TLP without activation, rib raising, and myofascial release mildly worsened pulmonary function measures immediately posttreatment relative to baseline measurements. The activation component of the TLP technique appears to increase posttreatment residual volume. Despite adverse changes in pulmonary function measures, persons with COPD subjectively reported they benefited from osteopathic manipulation.

Interobserver reliability of osteopathic palpatory diagnostic tests of the lumbar spine: improvements from consensus training.

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.