Reliability and validity of a palpation technique for identifying the spinous processes of C7 and L5

Manual Therapy 14 (2009) 409–414

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Original Article

Reliability and validity of a palpation technique for identifying the spinous processes of C7 and L5 Roar Robinson a, b, *, Hilde Stendal Robinson c, Gustav Bjørke b, Alice Kvale a a

University of Bergen, Department of Public Health and Primary Health Care, Section for Physiotherapy Science, Bergen, Norway Hans and Olaf Physiotherapy Clinic, Oslo, Norway c University of Oslo, Faculty of medicine, Institute for nursing and health sciences, Oslo, Norway b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 16 May 2007 Received in revised form 5 June 2008 Accepted 29 June 2008

The objective was to examine inter-tester reliability and validity of two therapists identifying the spinous processes (SP) of C7 and L5, using one predefined surface palpation procedure for each level. One identification method made it possible to examine the reliability and the validity of the procedure itself. Two manual therapists examined 49 patients (29 women). Aged between 26 and 79 years, 18 were cervical and 31 lumbar patients. An invisible marking pen and ultraviolet light were used, and the findings were compared. X-rays were taken as an objective measure of the correct spinal level. Percentage agreement and kappa statistics were used to evaluate reliability and validity. The best inter-therapist agreement was found for the skin marks. Percentage agreement within 10 mm and 20 mm was 67% and 85%, respectively. The inter-tester reliability for identifying a radiological nominated SP by palpation was found to be poor for C7 and moderate for L5, with kappa of 0.18 and 0.48, respectively. The results indicated acceptable inter-therapist surface palpation agreement, but the chosen procedures did not identify the correct SP. This indicates that the procedures are not precise enough. Future reliability studies should test other non-invasive palpation procedures, both individually and in combination, and compare these with radiological investigation. Ó 2008 Elsevier Ltd. All rights reserved.

Keywords: Palpation procedure Reliability Validity Spinous process

1. Introduction The ability to palpate a spinous process (SP) is considered to be a basic skill and a prerequisite for other manual therapy techniques (Jull, 1986; Downey et al., 1999, 2003). If physiotherapists are unable to locate the same SP by palpation, it would be unreasonable to assume that other spinal manual therapy techniques have better reproducibility (Billis et al., 2003). For a variety of reasons, colleagues often examine the same patient, yet often their findings differ or are conflicting. Several studies have assessed the reliability of palpation tests for locating bony landmarks in the lumbar and sacral spine (Burton et al., 1990; Keating et al., 1990; Byfield et al., 1992; Simmonds and Kumar, 1993; McKenzie and Taylor, 1997; O’Haire and Gibbons, 2000; Harlick et al., 2007). Studies of static palpation of the L5 SP have shown acceptable intra-tester reliability, but generally poor inter-tester reliability (Burton et al.,1990; Breen,1992; Russell,1993;

* Corresponding author. Hans og Olaf fysioterapi A/S, Torggt 16, N – 0181 Oslo, Norway. Tel.: þ47 22993177; fax: þ47 22203019. E-mail address: [email protected] (R. Robinson). 1356-689X/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2008.06.002

Simmonds and Kumar, 1993). Some studies have demonstrated a trend for better agreement when using highly experienced physiotherapists specialised in manual therapy (Byfield et al., 1992; Jull et al., 1994; Downey et al., 1999; Billis et al., 2003). However, a systematic review of the reliability of spinal palpation for diagnosing back and neck pain concluded that neither the examiners’ education nor their experience improved reliability (Seffinger et al., 2004). In contrast to this, a recently published study by Harlick et al. (2007) concluded that inter-therapist variability had a greater effect on accuracy than any patient-defined factor. Due to common anatomical variations of the spine, advised palpation procedures may fail (Lewit, 1985; Grieve, 1994). The assumption that SPs are points rather than having a surface area (Burton et al., 1990; Simmonds and Kumar, 1993) might influence palpation results. McKenzie and Taylor (1997) attempted to correct this source of error and included an average surface area for each of the SPs of L1–L5. They examined 13 cadavers and found that the height of the SPs ranged from 16.4 to 20.4 mm and the width from 7.4 to 9.4 mm. Harlick et al. (2007) measured the height of the SPs on L1–L5 by means of X-ray and reported the mean height of L5 to be 14.1 mm. They suggested a mean SP height of 18.3 mm as level of acceptance for agreement.

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Binkley et al. (1995) had six orthopaedic physiotherapists to examine the mobility of the lumbar spine of 18 patients. The examination included identification of an arbitrary marked SP, and agreement on numbering this SP was found to be low. With no predefined method, they demonstrated inter-rater agreement only within 1.4 segments. Downey et al. (1999) reported a kappa of 0.69 and a weighted kappa of 0.92 for three pairs of therapists palpating the appropriate levels in the lumbar spine. If physiotherapists are unable to identify the same level, treatment and evaluation may be applied to the wrong level. Hence, there is no need to use weighted kappa. McKenzie and Taylor (1997) reported a lower overall kappa, even though they used the same palpation method as Downey et al. (1999). Christensen et al. (2002) studied the thoracic spine using the term expanded agreement; which also included the neighbouring segment. They argued that pain does not come from one segment, but from an area. However, we find this problematic, particularly when therapists use palpation to identify and treat symptomatic spinal levels, and also when evaluating patient progress. The literature on the topic is sparse, and with conflicting levels of intra- and inter-tester reliability it is difficult to argue for palpation as a reliable assessment tool. Najm et al. (2003) claimed that most research results are not comparable, due to variability in the tests, terminology, design, methodology, and statistical analyses utilised. Such inconsistencies make it difficult to rate the value of reliability studies and the results of effect studies. Furthermore, to our knowledge, no former studies have reported inter-tester reliability results for C7 identification. Although a wide variety of studies have related to radiological examination of the spine, very few have investigated either the reliability or the validity of locating SPs by palpation in relation to X-ray (Harlick et al., 2007). Hence, earlier studies might have shown satisfactory reliability, but the wrong spinal level may nevertheless have been palpated. Consequently; validity cannot be examined without confirmation. Postural assessment instruments and radiographic measurement are suggested as valid and reliable objective tools for identifying spinal levels (Haldeman et al., 1993; Troyanovich and Harrison, 1999). The SPs of C7 and L5 are easily identified on X-rays and are considered accurate if standard procedures are followed (A. Høiseth radiologist, personal communication 2004). Accordingly, we decided to use X-ray as the gold standard for identifying SPs, as used in a recently published study (Harlick et al., 2007). The main purpose of this study was to examine the inter-tester reliability of experienced manual therapists (MTs) using a predefined surface palpation technique to identify the SPs of C7 and L5, and to verify whether the markings were at the correct SP by means of X-ray (concurrent validity). We wanted to test the actual procedures described in textbooks and taught in physiotherapy schools. Hence, the focus was not to optimise the MTs’ possibilities of identifying the correct SP, but to evaluate the procedure itself. Allowing more than one procedure for each segment would have made this impossible. The amount of subcutaneous fat varies among patients and might influence palpation results (Harlick et al., 2007). Accordingly, we also decided to investigate whether patient’s body mass index (BMI) and gender influenced the findings. 2. Methods In clinical practice, the SPs of C7 and L5 are commonly used key points for identifying cervical and lumbar levels, respectively, before starting motion assessment (Magee, 2002). Guidelines for clinical identification of segmental levels are based on published descriptions (Hoppenfeld, 1976; Lewit, 1985; Grieve, 1994; Magee,

2002). In this study, C7 SP was identified through an assisted movement of the cervical spine into extension, where the C6 SP appears to move anterior (or ‘‘disappear’’) and C7 is thus the first cervical SP remaining stationary during the movement (Lewit, 1985; Magee, 2002). L5 was identified as the first SP under an imaginary line connecting the two iliac crests (Hoppenfeld, 1976; Lewit, 1985; Magee, 2002). The MTs used these procedures, among others, in their clinical practice. They attended three training sessions with the researcher to test the procedure details, including standard positioning of the participant, palpation, use of marking pen, blinding, and time consumption. Twelve healthy volunteers were tested, but no X-rays taken. The Regional Committee for Medical Research Ethics, Western Norway, provided formal ethical approval for this study. 2.1. Testers The participating MTs had between16 and 18 years in practice since completing the Norwegian postgraduate qualification in manual therapy (IFOMT standards). One radiologist with 30 years experience examined all the X-rays. 2.2. Subjects Patients referred to a particular radiology institute in Oslo, Norway, for X-ray examination of either their cervical or lumbar spine, were invited to participate in the study. Patients who had undergone surgery in the area of interest were not invited. If the MTs could neither identify the iliac crests properly nor palpate the SP in question, the patients were excluded. Cervical patients who could not maximally extend the lower cervical spine were also excluded. Information regarding diagnosis, age, gender, height and weight was collected. 2.3. Testing procedure Prior to radiographs, each participant was examined separately and in random order by both of the two MTs (GB and HSR). For practical reasons, examination was conducted in a different room to the X-ray table. Lumbar patients were examined in side lying (the same position in which the X-rays were subsequently taken). Cervical patients had their X-rays taken in the standing position, but the palpation procedures were performed with the participant seated. Reliability: Each MT palpated the SP in question and marked the position on the skin with a pen containing ink visible only under ultraviolet light, thus making it possible to blind the result for the next tester. The method has been utilised in previous studies (Burton et al., 1990; Simmonds and Kumar, 1993; McKenzie and Taylor, 1997; Downey et al., 1999; Billis et al., 2003). The researcher (RR) measured the distance between the marks using a hand held calliper and an UV lamp. Validity: To visualize the marks on X-rays, one small magnet was taped on each skin mark (Accu-Band, Magnetic Plaster, Gauss, Ito co., Ltd). The X-rays were taken and examined according to standard procedures with one anterior–posterior picture and one lateral projection; no extra X-rays were taken for the study. The outlines of the vertebrae were inspected on the X-rays, and lines were drawn perpendicular to the skin when defining the sector for C7 (L5). The area between two lines defined the sector (Figs. 1 and 2); line one midway from the lower demarcation of the C6 (L4) and the upper demarcation of C7 (L5) to the skin and line two from the upper demarcation of Th1 (S1) and the lower demarcation of C7 (L5) to the skin. The markers (magnets) were inspected and noted as being within or outside the sector. The

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results were reported as positive or negative identification of the actual SP marked by each of the therapists. 2.4. Statistical analysis SPSS version 12.0 was used. The percentage agreement was calculated as a measure of reliability between the two therapists, firstly based on skin markings alone and secondly on X-ray identification of the magnets and the SPs. To evaluate palpation precision, we defined and used three levels of agreement: marking at the same point (0 mm), within 10 mm and within 20 mm, respectively. These distances are within formerly reported sizes of the SPs (McKenzie and Taylor, 1997; Harlick et al., 2007). Kappa statistics were not used, since no contingency (2  2) table could be made with this data format. However, when the palpation marks were compared with the gold standard (X-ray), Cohen’s kappa (k) was used to calculate agreement between the two testers, the marks being either within or outside the sector. k effectively discounts the proportion of agreement expected by chance, and ranges in values from 1 to þ1 (Landis and Koch, 1977). Both inter-tester reliability and concurrent validity could be examined using these calculations. We also split the participants into three groups according to their BMI and used the Kruskal–Wallis test to compare the palpation results for the groups to see if BMI influenced the results. 3. Results Fig. 1. The identification sector of C7 on the X-ray was defined as: the area between one line drawn from a midpoint between the upper demarcation of C7 SP and the lower demarcation of C6 SP, and another line drawn from the midpoint between the lower demarcation of C7 SP and upper demarcation of Th1 SP, the lines being perpendicular to the skin.

The 52 patients (aged 26–79 years) who were asked to participate included 20 cervical and 32 lumbar patients. All participants were examined twice prior to radiographs, one patient was excluded because one magnet had fallen off and two patients did not meet the inclusion criteria. The study sample thus contained 49 patients; 18 cervical patients (8 females), and 31 lumbar patients (21 females) (Table 1). 3.1. Reliability: therapist agreement on skin marks The therapists had marked the same point in 18 out of 49 patients (37%). The agreement increased to 33 (67%) and 40 (82%) of 49 patients for markings within 10 and 20 mm, respectively. When the results for C7 and L5 were analysed separately, we found corresponding results (Tables 2 and 4). 3.2. Validity: therapist agreement examined on X-rays The magnets’ positions were examined using two X-ray projections; the anterior–posterior projection was used to check that both magnets were in place, and the lateral projection to evaluate the position of the magnets in relation to the defined sector. The two MTs identified the correct SP in a total of 25 (51%) and 24 (49%) of 49 participants, respectively. C7 was correctly identified in 10 (55%) and 13 (72%) participants, respectively. There was agreement between the two MTs in 8 (44%) out of 18 cervical participants. For 3 (17%) of the cervical participants, both MTs

Table 1 Demographic data. Demographic data

Fig. 2. The identification sector of L5 on the X-ray was defined as: the area between one line drawn from a midpoint between the upper demarcation of L5 SP and the lower demarcation of L4 SP, and another line drawn from the midpoint between the lower demarcation of L5 SP and the upper demarcation of S1 SP, both lines being perpendicular to the skin.

Age, range (mean) Women Normal weight (BMI 18.5–24.9) Overweight (BMI 25–29.9) Obese (BMI >30)

Cervical

Lumbar

n ¼ 18

n ¼ 31

Total n ¼ 49

26–79 (53.6) 8 7 7 4

26–79 (49) 21 14 12 5

26–79 (50.7) 29 21 19 9

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Table 2 Agreement between the two therapists, according to skin marks only.

C7 (n ¼ 18) L5 (n ¼ 31) Total (n ¼ 49)

Total agreement (%)

Agreement within:

0 mm

10 mm

20 mm

7 (39) 11 (35) 18 (37)

11 (61) 22 (71) 33 (67)

14 (78) 27 (87) 40 (82)

The results are presented within three levels of agreement, 0 mm, 10 mm, and 20 mm, to permit determination of the degree of palpation precision.

marked outside the sector (Table 3). Kappa was 0.18 (95% CI; 0.25 to 0.62) for identifying C7 SP. L5 SP was correctly identified by the two MTs for 15 (48%) and 11 (36%) participants, respectively. There was agreement between the MTs in 9 (29%) out of 31 participants. For 14 (45%) participants, both MTs had marked outside the sector (Table 3). Kappa was 0.48 (95% CI: 0.18–0.78) for identifying L5 SP. For 15 participants, one MT marked within and the other outside the sector (Table 3). For 7 of these 15, the distance between the marks was <20 mm. We also compared the palpation results for the participants when categorised according to international BMI classification (WHO, 1995; Seidell and Flegal, 1997) (Table 1). The Kruskal–Wallis test indicated no significant difference in distance between the MTs skin marks in the three different BMI groups (p ¼ 0.2). Neither height or weight nor gender influenced the results. 4. Discussion In this study, the best agreement between two experienced MTs was found when skin markings were compared. Agreement was 67% and 85% for agreement levels within 10 mm and 20 mm, respectively. Inter-tester reliability as determined by X-ray sector definition was found to be poor for identifying C7 SP, yet moderate for identifying L5 SP. Previous studies have used small sample sizes, and included both healthy volunteers and patients (Downey et al., 1999; Billis et al., 2003). In the present study, two therapists examined 18 cervical and 31 lumbar patients, all recruited at the same X-ray institute. Although somewhat small, our sample is heterogeneous, representing the patient population in a clinical setting, similar to that of Harlick et al. (2007) who recruited 75 patients and distributed them among five physiotherapists. A recent review on manual examination of the spine found poor reproducibility and questioned the utility of manual examination procedures in spinal diagnosis altogether (Stochkendahl et al., 2006). The present study was performed in accordance with their recommendations concerning blinding and randomisation procedures, and included standardisation and training sessions to enhance internal validity. Acceptable agreement also depends on the circumstances. In the present study, the testers were experienced MTs. They worked in the same setting and attempted to optimise agreement by using the required procedures for testing and marking. Thus, poorer agreement might be expected in an ordinary clinical setting or between different medical specialists. In clinical practice the identification procedure for SPs might be based upon the use of several identification procedures. However, in this study the purpose was not to optimise the identification of the SPs, but to evaluate one palpation procedure at each level. In our view, more studies should focus on evaluating the reliability and validity of individual procedures used in clinical practice. The next step would be to examine a cluster of the best procedures to find the best combination for identifying the SP in question. Whether inadequate reliability will result in imprecise treatment cannot be inferred from our study.

Table 3 Agreement between the two testers with X-ray results for 49 participants, split for C7 and L5. C7

N ¼ 18

MT 2 Within sector (%)

Outside sector (%)

Total

MT 1

Within sector Outside sector Total

9 (29) 2 (6) 11 (35)

6 (19) 14 (45) 20 (65)

15 (48) 16 (52) 31 (100)

L5

N ¼ 31

MT 2

MT 1

Within sector Outside sector Total

Within sector (%)

Outside sector (%)

Total

8 (44) 5 (28) 13 (72)

2 (11) 3 (17) 5 (28)

15 (48) 8 (44) 18 (100)

The table shows that for 17 participants both MTs marked inside sector and in 17 both marked outside sector. In 15 participants one MT marked outside and the other inside sector. Sector refers to the demarcation of the SP (see Figs. 1 and 2).

4.1. Identifying C7 The results suggest that there is agreement between MTs, but they fail to identify the C7 SP. This indicates poor validity for the used identification method. The therapists agreed on 12 participants out of the 18 examined, but the C7 SP was correctly identified in only 8 (44%). This could be attributable to the MTs, the participants or the procedure itself. The procedure for identifying C7 SP requires that the patient extend the cervical spine. As some of the participants were likely to be apprehensive about extending their cervical spine due to pain, stiffness, or both, this might have influenced the results. A combination of other palpation techniques, including counting the cervical SPs from occiput to C7, might have improved the results. However, this would have disqualified us from the possibility of evaluating this particular procedure. The description of the procedure in textbooks says nothing about precision (Hoppenfeld, 1976; Lewit, 1985; Grieve, 1994; Magee, 2002). The study was conducted in the X-ray institute during working hours, and we could not occupy the X-ray lab for our examinations. Hence, the procedure was carried out in an adjoining room. Repositioning in the X-ray lab might have interfered with posture and neck position, and hence influenced the palpation results. However, we concluded that this would be of little importance at the C7 level. We had some unexpected problems in demarcating the C7 SP on the X-ray and in defining the sector. C7 SP is longer than the neighbouring SPs and points both dorsally and caudally. Both the dorsal part and the distal tip of C7 then define the palpation zone. The dorsal part was often 2–3 times longer than the tip of the SP as visualized on the X-rays (Fig. 1). In some participants, the tip of the C6 SP almost covered the dorsal, proximal part of the C7 SP in a manner similar to a roof tile. This could have confused the MTs, since the best bony contact for palpation might not have been the tip of the C7 SP. Using X-rays to confirm identification of the C7 SP might then be less precise than expected. More research is needed to further investigate this phenomenon. 4.2. Identifying L5 L5 was identified as the first SP lying under an imaginary line between the iliac crests. There might be uncertainty concerning the level at which this line crosses the spine. The amount of subcutaneous tissue and difficulties in compressing the skin overlying the iliac crest could displace the line. Differences in the size of the iliac crests, both within and between individuals, have also been reported (Grieve, 1994). One earlier study has concluded that comparing iliac crest heights using observation and palpation was

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Table 4 Distribution of participants at each mm distance between skin marks for the two testers. Distance between skin marks, in mm

Level

C7 (n ¼ 18) L5 (n ¼ 31)

Mean (SD)

0

2

3

4

5

6

7

8

9

10

11

13

14

15

17

18

19

20

21

24

25

28

32

34

9 (10) 8 (10)

7 11

1 1

0 2

0 2

0 1

1 1

1 1

0 2

0 1

1 0

0 1

1 0

1 0

0 1

0 1

0 1

0 1

1 0

1 0

1 1

2 0

0 1

0 1

0 1

Mean distance between skin marks was 9 mm (SD 10) and 8 mm (SD 10) for C7 SP and L5 SP, respectively.

unreliable (Mann et al., 1984). According to Lewit (1985) and Grieve (1994), the horizontal or vertical position of the sacrum between the two iliac bones also varies: this is called ‘‘high’’ or ‘‘low’’ pelvis, respectively, relative to the spinal column (Lewit, 1985; Grieve, 1994). Two of our participants were on X-ray classified by the examining radiologist as having a ‘‘horizontal sacrum’’ and neither of the two MTs had palpated the correct SP. Owing to methodological differences, it is difficult to compare our results with earlier studies. Levels of the spine, positioning, inclusion criteria as well as sample sizes vary from study to study. We wanted to carry out examinations in the same positions as the X-rays were taken, and used side-lying position in the lumbar identification. This was done to minimize errors due to postural changes. The position was, however, the same for both testers and should not interfere with inter-tester results. Harlick et al. (2007) allowed the physiotherapists to use their preferred clinical assessment technique for palpating and identifying the lumbar SPs, while other studies used prone position (Simmonds and Kumar, 1993; Binkley et al., 1995). Different positions may affect the spine and the inter-vertebral position; this in turn might influence palpation accuracy. The analyses of the X-rays in this study showed variation in the size of L5 SP, consistent with the results of McKenzie and Taylor (1997) and Harlick et al. (2007). The location of L5 SP has been described in the literature as being very deep compared with L4 SP (Ebraheim et al., 1999), and L4 SP can be very prominent compared to L5 SP (Lewit, 1985; Grieve, 1994; Billis et al., 2003). Interestingly, the radiologist described L5 SP as lying very deep in four of our participants, but no measurements were made to confirm this. Both MTs marked the same skin spot in these participants; however, they missed the correct spinal level. 4.3. Reading the X-rays The same experienced radiologist, together with the researcher (RR), examined all X-rays on the testing day. The SPs were identified on the X-rays according to standard radiological definitions. There was no validation procedure between the palpation and the X-ray prior to the study, which might have improved the results. Only one former study where X-ray was used as the gold standard has been available for comparing results (Harlick et al., 2007). Their methodology was different from ours, in that the therapists were allowed to choose palpation procedures and that accuracy was evaluated differently. However, no correlation was observed between the palpation procedure used and accuracy, and they concluded that therapist variability had the greatest effect on accuracy in connection with palpation of the L1, L3 and L5 SPs. We did not find that BMI influenced the results. The study population contained few obese participants (18%) (Table 1), and the BMI distribution is representative of the distribution in the general Norwegian population (Directorate for Health and Social Affairs, 2004). 5. Conclusion The best inter-tester agreement was found when distances between skin marks were compared independently of the X-rays.

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