Palpatory tests in manual therapies: an international survey on osteopathic clinical practice.

OBJECTIVES: The primary aim of the study is to explore the knowledge and use of palpatory tests in detecting somatic dysfunction, the second is to assess the knowledge about the inhibitory tests among osteopathic practitioners in Italy, England, and France. METHODS: A quantitative survey was conducted, between March and May 2021, through the administration of a semi-structured questionnaire. The participants had to answer 8 questions. RESULTS: A total of 2,223 e-mails were sent: 423 manual therapy professionals participated in the survey. Subsequently, only the responses of the 385 osteopaths (280 Italian, 23 French and 82 British) were included in the data processing; the 38 excluded were physiotherapists and chiropractors. The most significative outcomes for the total sample were found to: years of working experience and knowledge of a palpatory test that allows to discriminate two dysfunctional anatomical structures was significant with a χ2=12.509 (p-value <0.006); 68.5% answered in the affirmative to this last question. It was found that less work experience is associated with knowledge of a palpatory test to discriminate two dysfunctional structures. The correlation between years of work experience and knowledge of the inhibitory test was explored with the result being statistically significant (p-value <0.001). 64.4% know and use the inhibitory test. 39.1% base the inhibitory test on tissue change. CONCLUSIONS: The clinical practice of Italian and French professionals, makes possible to establish the hierarchy between two somatic dysfunctions with respect to English sample. The osteopaths reported a wider use of the tissue change parameters rather than pain reported by the patient. Furthermore, more than half of the sample-based their discriminatory test on the musculoskeletal and fascial systems. There is a vast knowledge of the inhibition test among osteopaths.

Accuracy of Palpation Procedures for Locating the C1 Transverse Process and Masseter Muscle as Confirmed by Computed Tomography Images.

OBJECTIVE: The purpose of this study was to examine the accuracy of palpation methods for locating the transverse processes of the first cervical vertebra and masseter muscle using radiographic images as the gold-standard method and the association between personal characteristics with the observed accuracy. METHODS: This was a single-blinded, diagnostic accuracy study. Ninety-five participants (49 women, 58 ± 16 years of age) were enrolled in this study. A single examiner palpated the neck and face region of all participants to identify the transverse processes of the first cervical vertebra and masseter muscles bilaterally. In sequence, participants underwent a multislice computed tomography scan for assessment of the superimposed inner body structure. Two radiologists assessed the computed tomography images using the same criteria and were blinded regarding each other's assessment and the anatomic landmarks under investigation. The palpation accuracy was calculated as the proportion of the correctly identified landmarks in the studied sample. The correlation of the palpation outcome (correct = 1; incorrect = 0) with age, sex (male = 1; female = 0), and body mass index was investigated using the point-biserial correlation coefficient. RESULTS: The right and left transverse processes were correctly located in 76 (80%) and 81 (85%) participants, respectively, and bilaterally in 157 events (83%), as evaluated by the consensus of the 2 radiologists. The masseter muscles were correctly localized bilaterally in 95 of 95 (100%) participants. Body mass showed statistical evidence of a weak, positive correlation with the correct location of the transverse processes of the first cervical vertebra at the right body side (r = .219; 95% confidence interval, 0.018-0.403; P = .033). CONCLUSION: Palpation methods used in this study accurately identified the location of the first cervical vertebra spinous processes and the masseter muscles.

Inter-rater Accuracy and Reliability of a Palpation Protocol of the C7 Spinous Process Comprising a Combination of 3 Traditional Palpation Techniques.

OBJECTIVE: The purpose of this study was to determine the accuracy and intrarater reliability of a palpatory protocol based on a combination of 3 palpatory methods to identify both the C7 spinous process (C7 SP) and the factors that affect the errors and inaccuracy of palpation. METHODS: Twenty-five women between the ages of 18 and 60 years were submitted to a palpation protocol of the C7 SP, and a radiopaque marker was fixed on the skin at the possible location of the vertebrae. A radiograph and a photograph of the cervical spine were obtained in the same posture by a first rater. A second rater performed the same palpation protocol and took a second photograph. The accuracy and measurement error of the palpation protocol of C7 SP were assessed through radiographic images. The inter-rater reliability was estimated by the interclass correlation coefficient and assessed using photographs of each rater. The Pearson's correlation coefficients (r), the Fisher exact test, and the χ2 test were used to identify the factors associated with the error and inaccuracy of palpation. RESULTS: Accuracy of the C7 palpation was 76% with excellent reliability (interclass correlation coefficient = 0.99). There was a moderate correlation between weight and the measurement of palpation error (r = -0.6; P = .003). One hundred percent of inaccuracy palpation was related to the increased soft-tissue thickness (P = .005) in the cervical region. CONCLUSION: The palpation protocol described in this study was accurate and presented excellent reliability in identifying the C7 SP. Increased weight and dorsocervical fat pad were associated to error and palpation inaccuracy, respectively.

Craniocervical Posture Assessed With Photogrammetry and the Accuracy of Palpation Methods for Locating the Seventh Cervical Spinous Process: A Cross-sectional Study.

OBJECTIVE: The purpose of this study was to compare craniocervical posture assessed by photogrammetry using 2 distinct palpation methods for locating the spinous process of the seventh cervical vertebra (C7SP). METHODS: This cross-sectional study was conducted in 2 phases. In phase I (n = 42), the assessor's accuracy in locating the C7SP using the flexion-extension and the modified thorax-rib static methods was compared to radiography. In phase II (n = 68), the craniocervical posture was analyzed with photogrammetry after palpation using the 2 methods. Neck pain intensity and disability were also determined. RESULTS: The accuracy in locating the C7SP was higher using the modified thorax-rib static method (67%, 95% confidence interval [CI], 55-79) compared to the flexion-extension method (38%, 95% CI, 26-50, P = .016). Lower values of the craniocervical angle were obtained with the flexion-extension method than the modified thorax-rib static method (mean difference = -1.1°, 95% CI, -1.6 to -0.6, P < .001). However, both palpation methods resulted in similar classifications of participants as with or without forward head posture (P = .096). Weak correlations were observed between the craniocervical angle and neck pain intensity (ρ = -0.088 and -0.099, respectively) and disability (ρ = -0.231 and -0.249, respectively). CONCLUSION: Craniocervical angles obtained using palpation methods with different accuracies were different, although the magnitude of the difference was insufficient to lead to different classifications of a forward head posture in adults with mild neck pain and disability. Craniocervical posture was weakly correlated with neck-pain intensity and disability.

The interrater reliability of static palpation of the thoracic spine for eliciting tenderness and stiffness to test for a manipulable lesion.

Background: Despite widespread use by manual therapists, there is little evidence regarding the reliability of thoracic spine static palpation to test for a manipulable lesion using stiffness or tenderness as diagnostic markers. We aimed to determine the interrater agreement of thoracic spine static palpation for segmental tenderness and stiffness and determine the effect of standardised training for examiners. The secondary aim was to explore expert consensus on the level of segmental tenderness required to locate a "manipulable lesion". Methods: Two experienced chiropractors used static palpation of thoracic vertebrae on two occasions (pragmatic and standardised approaches). Participants rated tenderness on an 11-point numerical pain rating scale (NPRS) and raters judged segmental stiffness based on their experience and perception of normal mobility with the requested outcomes of hypomobile or normal mobility. We calculated interrater agreement using percent agreement, Cohen's Kappa coefficients ( κ ) and prevalence-adjusted bias-adjusted Kappa coefficients (PABAK). In a preliminary study, an expert panel of 10 chiropractors took part in a Delphi process to identify the level of meaningful segmental tenderness required to locate a "manipulable lesion". Results: Thirty-six participants (20 female) were enrolled for the reliability study on the 13th March 2017. Mean (SD) age was 22.4 (3.4) years with an equal distribution of asymptomatic (n = 17) and symptomatic (n = 17) participants. Overall, the interrater agreement for spinal segmental stiffness had Kappa values indicating less than chance agreement [ κ range - 0.11, 0.53]. When adjusted for prevalence and bias, the PABAK ranged from slight to substantial agreement [0.12-0.76] with moderate or substantial agreement demonstrated at the majority of spinal levels (T1, T2 and T6 to T12). Generally, there was fair to substantial agreement for segmental tenderness [Kappa range 0.22-0.77]. Training did not significantly improve interrater agreement for stiffness or tenderness. The Delphi process indicated that an NPRS score of 2 out of 10 identified a potential "manipulable lesion". Conclusion: Static palpation was overall moderately reliable for the identification of segmental thoracic spine stiffness and tenderness, with tenderness demonstrating a higher reliability. Also, an increased agreement was found within the mid-thoracic spine. A brief training intervention failed to improve reliability.

How type and number of training sessions influence the reliability of palpation.

INTRODUCTION: Accurate and reliable palpation is needed to identify anatomical landmarks as well as to assess motion and dysfunctions. Although different trials suggested that training might increase reliability of palpation, the poor dependability of the examined tests may show the need to review the teaching methods to improve palpatory accuracy? The aims of this study were: METHODS: 82 examiners with different years of experience were enrolled from AIMO institute. Two different type of training sessions were performed (individual and group training). A total of 5 training sessions were performed during 5 weeks and 5 different models with a similar BMI were used. A uni-variated statistical analysis was used to evaluate the main effect of type and number of trainings, a multi-variated analysis was used to verify cross-effects. RESULTS: Overall results show moderate reliability for the correct detection of the position of the heel lift (Random probability being 33%, GT = 58.6% and SIPS = 57.1%, both P-value < 0.001). No difference was shown between the types of training (p-value GT = 0.503, p-value PSIS = 1) and no overall improvement was shown after the first training (P-value(GT) = 0.25, P-value(PSIS) = 0.96). The professional group improved the reliability during the training sessions starting from substantial reliability and ended with an almost perfect reliability (P-value GT = 0.0029, P-Value PSIS<0.001). Whereas the 3rd 4th and 5th showed a decreased performance. CONCLUSIONS: Type of training sessions seems not to influence reliability of palpation accuracy. The improvement of reliability during the training sessions seems to be related to the experience of examiners, which plays an important role in reliability and the learning experience.

Differences of Cutaneous Two-Point Discrimination Thresholds Among Students in Different Years of a Chiropractic Program.

OBJECTIVES: The aim of this study was to investigate if there were differences in the two-point discrimination (2-PD) of fingers among students at different stages of a chiropractic program. METHODS: This study measured 2-PD thresholds for the dominant and nondominant index finger and dominant and nondominant forearm in groups of students in a 4-year chiropractic program at the International Medical University in Kuala Lumpur, Malaysia. Measurements were made using digital calipers mounted on a modified weighing scale. Group comparisons were made among students for each year of the program (years 1, 2, 3, and 4). Analysis of the 2-PD threshold for differences among the year groups was performed with analysis of variance. RESULTS: The mean 2-PD threshold of the index finger was higher in the students who were in the higher year groups. Dominant-hand mean values for year 1 were 2.93 ± 0.04 mm and 1.69 ± 0.02 mm in year 4. There were significant differences at finger sites (P < .05) among all year groups compared with year 1. There were no significant differences measured at the dominant forearm between any year groups (P = .08). The nondominant fingers of the year groups 1, 2, and 4 showed better 2-PD compared with the dominant finger. There was a significant difference (P = .005) between the nondominant (1.93 ± 1.15) and dominant (2.27 ± 1.14) fingers when all groups were combined (n = 104). CONCLUSIONS: The results of this study demonstrated that the finger 2-PD of the chiropractic students later in the program was more precise than that of students in the earlier program.

Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders.

BACKGROUND: The sacroiliac joint (SIJ) has been implicated as a potential source of low back and buttock pain. Several types of motion palpation and pain provocation tests are used to evaluate SIJ dysfunction. OBJECTIVE: The purpose of this study was to investigate the relationship between motion palpation and pain provocation tests in assessment of SIJ problems. DESIGN: This study is Descriptive Correlation. METHODS: 50 patients between the ages of 20 and 65 participated. Four motion palpation tests (Sitting flexion, Standing flexion, Prone knee flexion, Gillet test) and three pain provocation tests (FABER, Posterior shear, Resisted abduction test) were examined. Chi-square analysis was used to assess the relationship between results of the individuals and composites of these two groups of tests. RESULTS: No significant relationship was found between these two groups of tests. CONCLUSIONS: It seems that motion palpation tests assess SIJ dysfunction and provocative tests assessed SIJ pain which do not appear to be related.

Experiences of intervertebral motion palpation in osteopathic practice - A qualitative interview study among Swedish osteopaths.

BACKGROUND: Assessment in manual therapy includes quantitative and qualitative procedures, and intervertebral motion palpation (IMP) is one of the core assessment methods in osteopathic practice. The aim of this study was to explore osteopathic practitioners' experiences of clinical decision-making and IMP as a diagnostic tool for planning and evaluation of osteopathic interventions. METHOD: The study was conducted with semi-structured interviews that included eight informants. Content analysis was used as the analytical procedure. RESULT: In total, three categories emerged from the analysis: strategic decision-making, diagnostic usability of IMP, and treatment applicability of IMP. CONCLUSION: The study indicated that IMP was considered relevant and was given particular importance in cases where IMP findings confirmed clinical information attained from other stages in the diagnostic process as a whole. However, IMP findings were experienced as less important if they were not correlated to other findings.

Locating the Seventh Cervical Spinous Process: Development and Validation of a Multivariate Model Using Palpation and Personal Information.

OBJECTIVE: The aim of this study was to develop and validate a multivariate prediction model, guided by palpation and personal information, for locating the seventh cervical spinous process (C7SP). METHODS: A single-blinded, cross-sectional study at a primary to tertiary health care center was conducted for model development and temporal validation. One-hundred sixty participants were prospectively included for model development (n = 80) and time-split validation stages (n = 80). The C7SP was located using the thorax-rib static method (TRSM). Participants underwent chest radiography for assessment of the inner body structure located with TRSM and using radio-opaque markers placed over the skin. Age, sex, height, body mass, body mass index, and vertex-marker distance (DV-M) were used to predict the distance from the C7SP to the vertex (DV-C7). Multivariate linear regression modeling, limits of agreement plot, histogram of residues, receiver operating characteristic curves, and confusion tables were analyzed. RESULTS: The multivariate linear prediction model for DV-C7 (in centimeters) was DV-C7 = 0.986DV-M + 0.018(mass) + 0.014(age) - 1.008. Receiver operating characteristic curves had better discrimination of DV-C7 (area under the curve = 0.661; 95% confidence interval = 0.541-0.782; P = .015) than DV-M (area under the curve = 0.480; 95% confidence interval = 0.345-0.614; P = .761), with respective cutoff points at 23.40 cm (sensitivity = 41%, specificity = 63%) and 24.75 cm (sensitivity = 69%, specificity = 52%). The C7SP was correctly located more often when using predicted DV-C7 in the validation sample than when using the TRSM in the development sample: n = 53 (66%) vs n = 32 (40%), P < .001. CONCLUSIONS: Better accuracy was obtained when locating the C7SP by use of a multivariate model that incorporates palpation and personal information.

Locating the Seventh Cervical Spinous Process: Accuracy of the Thorax-Rib Static Method and the Effects of Clinical Data on Its Performance.

OBJECTIVES: The aim of this study was to assess the thorax-rib static method (TRSM), a palpation method for locating the seventh cervical spinous process (C7SP), and to report clinical data on the accuracy of this method and that of the neck flexion-extension method (FEM), using radiography as the gold standard. METHODS: A single-blinded, cross-sectional diagnostic accuracy study was conducted. One hundred and one participants from a primary-to-tertiary health care center (63 men, 56 ± 17 years of age) had their neck palpated using the FEM and the TRSM. A single examiner performed both the FEM and TRSM in a random sequence. Radiopaque markers were placed at each location with the aid of an ultraviolet lamp. Participants underwent chest radiography for assessment of the superimposed inner body structure, which was located by using either the FEM or the TRSM. RESULTS: Accuracy in identifying the C7SP was 18% and 33% (P = .013) with use of the FEM and the TRSM, respectively. The cumulative accuracy considering both caudal and cephalic directions (C7SP ± 1SP) increased to 58% and 81% (P = .001) with use of the FEM and the TRSM, respectively. Age had a significant effect on the accuracy of FEM (P = .027) but not on the accuracy of TRSM (P = .939). Sex, body mass, body height, and body mass index had no significant effects on the accuracy of both the FEM (P = .209 or higher) and the TRSM (P = .265 or higher). CONCLUSIONS: The TRMS located the C7SP more accurately compared with the FEM at any given level of anatomic detail, although both still underperformed in terms of acceptable accuracy for a clinical setting.

Cross friction algometry (CFA): Comparison of pressure pain thresholds between patients with chronic non-specific low back pain and healthy subjects.

UNLABELLED: Palpation is widely used to assess muscular sensitivity in clinical settings but still remains a subjective evaluation. This cross-sectional study assessed a newly developed cross-friction algometry making palpation measurable. The objective was to investigate the reliability of pressure pain thresholds obtained using Cross-Friction Algometry (CFA-PPTs) measured at the level of Erector spinae and Gluteus maximus central muscle parts, and to compare the CFA-PPTs between patients with chronic nonspecific low back pain (nCLBP) and matching healthy subjects. PARTICIPANTS: Patients presenting nCLBP to GP's and send into a Pain Center and healthy subjects recruited via university ad valvas & flyers distribution. OUTCOME MEASURES: 30 patients with nCLBP were measured for cross-friction algometry. Other evaluations consisted of the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI). RESULTS: The inter- and intra-reliability were tested and found to be sufficient. The mean CFA-PPT values of the Erector spinae at levels T8, T10, L1 & L3 and the Gluteus maximus of the nCLBP group were significantly lower (p ≤ 0.001) when compared to the CFA-PPT values of the healthy group. The greatest difference (-58%) was found at L1 Erector spinae level and at the superior part of the Gluteus maximus measuring point (-59%). Within the group of patients with nCLBP it was surprising to notice that there was no significant correlation between all the reference points measured using CFA-PPTs and the outcomes of the VAS and ODI scores. CONCLUSIONS: With the aid of CFA, the importance of local muscular disorder in the lumbar part of the Erector spinae and Gluteus maximus in patients with nCLBP is obviously demonstrated, but also reveals the very large inter-individual differences in muscular fibrosis sensitivity and/or pain behavior in daily life. This possibly re-opens the debate on which influences can be put forward as the most important: the central or the peripheral sensitization system.

Evidence - The intraoral palpability of the lateral pterygoid muscle - A prospective study.

The intraoral palpability of the inferior caput of the lateral pterygoid muscle has been a matter of ambiguity because of its topography. Thus, none of the recently published studies has provided reliable proof of the possibility of digital intraoral palpation, although palpation of the muscle is part of most of the examination catalogs for clinical functional analysis and functional therapy. Digital muscle palpation was performed intraorally on five preparations after exposure of the infratemporal fossa and visualization of the lateral pterygoid muscle. Direct digital palpation of the lateral pterygoid muscle was seen in all five cases. The successful palpation was carried out and approved during laterotrusion to the examined side (relaxation). While opening and closing the mouth (contraction) the muscle is palpable. In real-time kinematic measurements (MRI) an impression of the lateral caput of the left lateral pterygoid muscle of a 30-year-old control male person was found up to 6mm. Electromyographic detection by direct signal conduction with concomitant palpation is possible. The injection electrode tested in situ in the muscle was felt transorally with the palpating finger. The intraoral palpability of the inferior caput of the lateral pterygoid muscle is verified. The basic requirement for successfully palpating the lateral pterygoid muscle is the exact knowledge of muscle topography and the intraoral palpation pathway. After documented palpation of the muscle belly in cadaverous preparations, MRI and EMG also visualized palpation of the lateral pterygoid muscle in vivo. The palpation technique seems to be essential and basically feasible.

Quantification of Motion Palpation.

CONTEXT: The palpation of motions is at the heart of the practice of foreign-trained osteopaths. When practicing osteopathic manual therapy (care provided by foreign-trained osteopaths) in the cranial field or osteopathic cranial manipulative medicine, the palpation of small motions (several tens of micrometers) is a key process. However, to the authors' knowledge, the smallest detectable motion has not been identified. OBJECTIVE: To quantify motion detection capacity by passive palpation. METHODS: Participants were instructed to hold a mechanical device containing a micrometric actuator between their hands and report when they felt motion while 6 series of 27 random motions were generated by the actuator. After each series, if a participant succeeded or failed to detect motion with a confidence level of greater than 98%, the motions in the next series were set to a smaller or larger magnitude, respectively. After 6 series, the individual motion detection capacity was recorded. Statistical significance was set at P=.02. RESULTS: A total of 21 participants were selected, comprising 14 osteopaths and 7 nonosteopaths. The average performance of the sample was 148 µm. Thirteen participants (62%) perceived motions of 200 µm or less, and 7 participants (33%) detected motions of 50 µm or less with bare hands. Osteopathic training did not notably affect the performance. Osteopaths were twice as likely to claim detection of nonexisting motions than to miss existing ones, whereas nonosteopaths were equally subject to both types of errors. CONCLUSION: The data show human passive palpatory sensitivity to be in the range of several tens of micrometers. This range is comparable to that reported for calvarial motion (10-50 µm).

Validation of palpatory methods for evaluating anatomical bone landmarks of the cervical spine: a systematic review.

OBJECTIVE: The aim of this study was to systematically review the literature for validity of palpatory procedures for evaluating anatomical bone landmarks in the cervical spine. METHODS: A systematic search of electronic databases identified observational studies assessing validity and/or accuracy regarding evaluation of anatomical bone landmarks of cervical spine palpatory procedures. The databases used in the search included the US National Library of Medicine of the National Institutes of Health (MEDLINE/PubMed), the Regional Library of Medicine (Bireme), the Scientific Electronic Library Online (SciELO), the Physiotherapy Evidence Database (PEDro), the Latin American and Caribbean Health Sciences Literature database (LILACS), the Cochrane Library, and Coordination of Personnel Improvement of Higher Education (CAPES/Brazil). Data were extracted by a primary reviewer, and 2 independent reviewers used a critical appraisal tool to estimate the quality of the retrieved studies. The results were synthesized qualitatively within the Quality Assessment of Diagnostic Accuracy Studies criteria. After completing the synthesis and scoring, the reviewers applied classifications such as "low," "fair," and "good." RESULTS: The initial search yielded 69860 articles. After selection criteria were applied, 5 studies satisfied the eligibility criteria. Three studies verified the validity of the manual palpatory procedure, and 2 studies correlated the findings of the palpatory procedures with other measured results. According to Quality Assessment of Diagnostic Accuracy Studies criteria, 3 studies presented good methodological quality, and 2 presented fair methodological quality. Studies demonstrated an accuracy range from 51% to 87.8%. CONCLUSION: There are few studies that evaluate the validity of manual palpatory procedures for examining boney landmarks of the cervical spine. The 5 that were found showed fair to good methodological quality. However, we note that there may be poor external validity due to the sampling heterogeneity of these studies.

Tapping but not massage enhances vasodilation and improves venous palpation of cutaneous veins.

This paper investigated whether tapping on the median cubital vein or massaging the forearm was more effective in obtaining better venous palpation for venipuncture. Forty healthy volunteers in their twenties were subjected to tapping (10 times in 5 sec) or massage (10 strokes in 20 sec from the wrist to the cubital fossa) under tourniquet inflation on the upper arm. Venous palpation was assessed using the venous palpation score (0-6, with 0 being impalpable). Three venous factors-venous depth, cross-sectional area, and elevation-were also measured using ultrasonography. The venous palpation score increased significantly by tapping but not by massage. Moreover, all 3 venous measurements changed significantly by tapping, while only the depth decreased significantly by massage. The three venous measurements correlated significantly with the venous palpation score, indicating that they are useful objective indicators for evaluating vasodilation. We suggest that tapping is an effective vasodilation technique.

Strain counterstrain technique to decrease tender point palpation pain compared to control conditions: a systematic review with meta-analysis.

BACKGROUND: Strain counterstrain (SCS) is an indirect osteopathic manipulative technique that uses passive positioning to relieve tender point (TP) palpation pain and associated dysfunction. OBJECTIVE: The purposes of this systematic review with meta-analysis were to 1) determine the pooled effect of SCS on TP palpation pain compared to a control condition and 2) assess the quality of the overall evidence. DATA SOURCE: A search conducted using the MEDLINE with AMED, PUBMED, CINAHL, and SCOPUS databases for publications from January 2002 and April 2012 yielded 29 articles for eligibility screening. STUDY SELECTION: Included studies were limited to randomized control trials comparing TP palpation pain after isolated SCS treatment compared to control conditions assessed with a visual analog scale. Other study designs or manipulative treatments were excluded. DATA EXTRACTION: Two reviewers adhered to a predetermined study protocol following current Cochrane Collaboration recommendations to independently extract the data with standardized extraction forms and assess studies for methodological quality and determine risks of bias. RESULTS: Five randomized control trials were included for qualitative and quantitative analysis. The pooled effect of SCS was a reduction of TP palpation pain (p < 0.001, 95% CI -0.291 to -0.825). The overall evidence quality was low: while all studies met at least 8 of 12 methodological quality criteria, most were low quality. CONCLUSIONS: This systematic review and meta-analysis found low quality evidence suggesting that SCS may reduce TP palpation pain. Future studies with larger samples of better quality studies with patient populations that assess long-term pain, impairment, and dysfunction outcomes could enrich the literature.