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Experiences of intervertebral motion palpation in osteopathic practice – A qualitative interview study among Swedish osteopaths
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Journal of Bodywork & Movement Therapies (2016) xx, 1e8
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths Niklas S. Sposato, DO, MSc a,b,*, ˚, CNS, RN, PhD, MSNc c,d Kristofer Bjersa a
Scandinavian School of Osteopathy, Gothenburg, Sweden The Institute of Orthopaedic Medicine, Gothenburg, Sweden c Division of Nursing Science, Department of Medical and Health Sciences, Linko¨ping University, Linko¨ping, Sweden d Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden b
Received 29 February 2016; received in revised form 4 May 2016; accepted 6 May 2016
KEYWORDS Intervertebral motion palpation; Clinical reasoning; Osteopathy
Summary 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. ª 2016 Elsevier Ltd. All rights reserved.
* Corresponding author. Skandinaviska Osteopatho ¨gskolan, Kapellplatsen 4, 411 31, Gothenburg, Sweden. Tel.: þ46 73 99 55 100. E-mail address: [email protected] (N.S. Sposato). http://dx.doi.org/10.1016/j.jbmt.2016.05.008 1360-8592/ª 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Sposato, N.S., Bjersa ˚, K., Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/ j.jbmt.2016.05.008
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Introduction As part of a manual medicine tradition, osteopathic practitioners are concerned with the diagnosis and treatment of pain syndromes and dysfunctions related to the musculoskeletal system (World Health Organization (WHO), 2010). Pathophysiological changes to musculoskeletal structures are perceived in osteopathic medicine as potentially responsible for both active and passive movement dysfunctions and may subsequently be assessed by active and passive diagnostic methods. Assessment of passive movement includes peripheral and axial (intervertebral) motion palpation (Trew, 2005). Intervertebral motion palpation (IMP) is one of the main assessment methods in osteopathic medicine practice and is used to identify segmental dysfunction, i.e., intervertebral joint hypomobility or hypermobility (Haneline et al., 2008; Juel and Wallgren, 2003). This assessment method can be used with different foci, such as assessing joint play (quality of passive gliding movements) (Lewit and Rosinab, 1999; Maitland and Kawchuk, 1997; White iii and Panjabi, 1978), range of motion (quantity of movement) (Levangie and Norkin, 2011; Maitland and Kawchuk, 1997) or endfeel (the quality of the elastic barrier) (Lakhani et al., 2009; Maitland and Kawchuk, 1997). Studies suggest that IMP may be a valid method for assessing intervertebral hypomobility (Haas et al., 2003; Hansen et al., 2006; Hazle and Nitz, 2012; Lakhani et al., 2009; Lewit and Rosinab, 1999; Quack et al., 2007; Shaw et al., 2012; Snodgrass et al., 2008). However, to our knowledge, no study has included more than one possible palpable quality, i.e., no comparisons have been made between end-feel qualities and/or quality of joint play in the final results. Quack et al. (2007) compared quantitative range of motion (ROM) test results with expert physical diagnosis results, and a study by Lakhani et al. (2009) assessed both end-feel and joint play but reported results only concerning end-feel. Studies using both manual and some form of apparatus indicate to various extents that motion palpation may be used to assess variations in intervertebral mobility. Two independent studies suggest that assessment accuracy is increased when less force is applied (Hazle and Nitz, 2012; Lewit and Rosinab, 1999). However, the amount of force applied was not further presented other than as an internal comparison between the participants (Hazle and Nitz, 2012). Another study confirmed palpable findings via ultra-sound, partially based on positional findings, as tissue depth from the surface was compared to a manually diagnosed posterior transverse process, both pre and post treatment (Shaw et al., 2012). In addition, published research articles during the last 15 years that studied IMP in relation to a therapeutic intervention mainly used high velocity low amplitude (HVLA) manipulations as the treatment method of choice (Haas et al., 2003; Hansen et al., 2006; Shaw et al., 2012). Research on clinical decision-making in general and on IMP in particular is very limited in osteopathic medicine practice. Thomson et al. (2014) have presented results on diagnostic reasoning in a study on osteopathic medicine practitioners, and Esteves and Spence (2014) have
N.S. Sposato, K. Bjersa ˚ researched and published results on palpatory diagnosis development in relation to neuroanatomical and neurophysiological adaptation. However, to the knowledge of the present authors, no studies have been published on the experiences of IMP in osteopathic practice. Although IMP is considered a general diagnostic tool in osteopathic practice, little is known about practitioners’ experience and use of this technique. The aim of this study was thus to explore osteopathic practitioners’ experiences of clinical decision-making and intervertebral motion palpation as a diagnostic tool for planning and evaluating osteopathic interventions.
Method Design This interview study was done as part of a Master thesis project in osteopathic medicine at Dresden International University. The design was semi-structured interviews, and the analysis process was performed using inductive content analysis as described by Elo and Kynga ¨s (2008).
Participants A convenient sample of Swedish osteopathic practitioners (D.O; Diploma in Osteopathy) with a connection to Swedish osteopathic education was approached in the spring of 2015 with both verbal and written information about the study. In total, nine were approached and eight accepted participation. The inclusion criteria were five or more years of clinical experience as a D.O, clinical practice including a variety of therapeutic osteopathic techniques, and regular use of intervertebral motion palpation as an assessment method. Written informed consent was collected before inclusion. In total, eight D.Os were included. Demographics are shown in Table 1.
Data collection Semi-structured interviews were used for data collection. The interviews were conducted between February and April
Table 1
Informants demographics (n Z 8).
Mean years of clinical 9 (range 5e22) experience Gender Place of work
Academic qualifications
5 males 3 females All informants worked in private clinical practice 7 of the informants were involved in osteopathic educational institutions as lecturers or clinical tutors All informants held undergraduate degrees in osteopathy (B.Sc., D.O.)
Please cite this article in press as: Sposato, N.S., Bjersa ˚, K., Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/ j.jbmt.2016.05.008
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Experiences of intervertebral motion palpation 2015, lasting a mean of 43 min (range 30e60 min), and were audiotaped and transcribed verbatim by the first author (NS). No dependent relationship existed between interviewer and respondent. An interview guide was used, starting with the question “what is your view of intervertebral motion palpation?” The informants selected the location for the interviews; five interviews were conducted at osteopathic clinics and three in private homes. Initially, a pilot interview was conducted to test the initiation question and to gain experience of descriptions of this issue. Data from this pilot interview are not included in the analysis and results.
Analysis All interviews were conducted, transcribed and analyze processed in Swedish. Both author were active individually and joint during each step of the analysis. Credentials of the authors was MSc in Osteopathy and visiting lecture in osteopathy (NS) and PhD in Medicine as well as university lecture with several previous scientific publications using interview and content analysis (KB). No software program was used during analysis. Interview text was the body of data. Hence, a qualitative content analysis with an inductive approach was made, guided and inspired by the steps described by Elo and Kynga ¨s (2008): - Data analysis began with carefully and repeatedly reading the transcribed text in order to gain an overview of the contents and to reach a comprehensive understanding of the data content. - Secondly, text units that corresponded to the aim of the study could then be identified and highlighted. This open coding was done with a naı¨ve and inductive approach towards both the interview text and the aim. - Thirdly, the text units selected where condensed to become more manageable; meaning units. These meaning units were in the form of larger citations. - Next step was to arrange the meaning units into clusters and arranging them into headings and further grouping the headings in to different shades of the same aspect. This resulted in codes. - The fifth step consisted of comparison of differences and similarities of the codes, making unique categorisations of the codes in to larger aspects of the aim of the study.
3 (World Medical Association, 2013). Ethical review and approval were given in the Master thesis project by Dresden International University, which is also in line with the Swedish legislation for research in higher education (SFS 2003: 460; Prop.2007/08:44; Law 2003:460). The informants were provided verbal and written information and gave their written consent to participate before being included in the study. Participation could be discontinued at any time during the interview sessions. All data have been and are being treated safely and confidentially.
Results The analysis of the texts from the eight interviews resulted in three categories and eight subcategories, see Table 2.
Strategic decision-making IMP was used to strategically plan patients’ care. By combining general aspects of the patient’s health together with hypotheses from explicit signs and symptoms, the IMP assessment was evaluated on the basis of possible findings of dysfunctions. This, as well as the perceived choice of intervention, led to the comprehensive therapeutic planning. All informants stated an uncertainty as to how they justified specific choices from an evidence-based perspective. Rather, decisions were based on empirical rationale, clinical vigilance and information gained from professional authorities such as in education or from colleagues. Therapeutic considerations The informants expressed a hierarchy in the decisionmaking. Initially, the patient’s preconditions regarding general aspects such as age, gender, level of physical activity and previous or current pathological conditions were evaluated. This also included some form of assessment of the patient’s psychological state. Risk-benefit factors as potential risks of interventions in contrast to potential benefits were expressed as a fundamental part of the decision-making process. ‘If the patient is older, I tend to think that at least part of the restriction is due to degenerative changes.’
This resulted in the sub-categories. - The final step consisted of abstraction and finding autonomous and unique categories that truly described the data response to the aim of the study on a general, overall level. The category represented the most abstract understanding (Elo and Kynga ¨s, 2008). Exemplifications of the analysis process are presented on the left side of Table 2.
Ethical considerations This study was an interview study with its ethical foundations in the Declaration of Helsinki for human research
‘There is an obvious difference between a 13-year-old gymnast and an 80-year- old former truck driver. Both the diagnostic process and the treatment will be adapted to the person rather than to the local dysfunction.’
‘I prioritize general risk/benefit factors over type of dysfunction when I choose what technique to apply.’ Clinical experience and decision-making The informants experienced a clinical development from a structured diagnostic routine towards an intuitive diagnostic and therapeutic methodological approach over
Please cite this article in press as: Sposato, N.S., Bjersa ˚, K., Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/ j.jbmt.2016.05.008
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N.S. Sposato, K. Bjersa ˚ Table 2
Analysis process exemplification and Results structure.
Exemplification from analysis process
Results
Meaning units
Codes
Sub categories
Categories
‘I prioritize general risk/benefit factors over type of dysfunction when I choose what technique to apply’ ‘If the patient is older, I tend to think that at least part of the restriction is due to degenerative changes.’ ‘As the years go by you don’t overthink so much, you become more confident with what you do and that it works out well.’ ‘If it acts like a cat, looks like a cat and if you have seen a cat before, chances are that you will assume that what you have in front of you is in fact a cat.’ ‘You should do what you do best, that’s why I mostly choose an indirect technique.’ ‘Motion palpation is an important and valuable part of manual therapy, perhaps even the most important diagnostic tool regarding intervertebral motion dysfunction.’ ‘When I test the end-feel passively I try to determine whether the sensation is stiff or elastic, and if there is pain associated to any motion. I primarily focus on pain reproduction.’ ‘I use intervertebral motion palpation as part of my routine to find out where the spinal dysfunction is located rather than what is dysfunctional in the motion segment. ‘The best possible scenario is when hypomobility in the active tests correlates with passive motion palpation findings regarding segmental levels.’ ‘I more commonly choose techniques for the treatment of passive structures. I think that possibly that has to do with the sensation that it is easier to diagnose dysfunction in these structures.’ ‘The tendency is for me to choose a technique to treat the passive structures of the joint and perhaps recommend some form of exercise for any related muscular
Risk/Benefit Cause of restriction
Therapeutic considerations
Strategic decisionmaking
Diagnostic confidence Pattern recognition
Clinical experience and decision making
Clinical competence
Personal preferences
Motion palpation for motion dysfunction
General diagnostic value
Qualitative modalities of motion palpation Location of motion dysfunction
Application
Correlation of clinical findings
Clinical implementation
Therapeutic correlations Therapeutic differentiation
Treatment based on perceived articular dysfunction
Diagnostic usability of IMP
Treatment applicability of IMP
Please cite this article in press as: Sposato, N.S., Bjersa ˚, K., Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/ j.jbmt.2016.05.008
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Experiences of intervertebral motion palpation
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Table 2 (continued ) Exemplification from analysis process Meaning units dysfunction.’ ‘I consider whether the dysfunction is acute or more chronic and tend not to choose to treat with HVLA if the problem has been more long lasting, at least not initially.’
Results Codes
Sub categories
Temporal considerations regarding tissue texture changes
Treatment based on time and location
time. In addition, different diagnostic procedures were described as being unevenly weighted depending on the individual patient’s preconditions during assessment, as some patients were diagnosed primarily by the results of a physical examination while others were diagnosed mainly by the information retrieved from the patient’s history. ‘As the years go by you don’t overthink so much, you become more confident with what you do and that it works out well.’ ‘It’s when the problems do not resolve that you have to sit down and really think the case through.’ ‘As I try to verbalize what I do and why, I find myself somewhat unsure of whether my choices can be properly justified or if my clinical work has become more of an automatic process. In any case, my patients seem to get better.’ The informants experienced that, over time, they became more and more able to differentiate between various conditions based on what could be described as diagnostic cues, as specific sentences or behavioral patterns of the patient that correlated to a specific condition and that the informants had come across before. ‘If it acts like a cat, looks like a cat and if you have seen a cat before, chances are that you will assume that what you have in front of you is in fact a cat.’ ‘I wouldn’t say that I consciously reflect on whether it is an intra- or extra- articular dysfunction. I guess that I have a pretty good idea about what is wrong based on the case history. I then only use motion palpation to confirm the precise site of dysfunction.’ The informants stated the importance of being able to engage in the craftsmanship of the profession as they progressed in their clinical practice. However, it was also stated that this was done without a continuous reflection on one’s own practice. The use of intuition was expressed as an important factor in successful learning. The importance of clinical specificity was also experienced as varying from case to case. ‘You need to be able to rely on your hands and let go of your intellect and vice versa.’
Categories
‘There are cases when it really matters what you treat and that you are extremely specific, whilst in other cases it only matters that you treat.’ Personal preferences Clinical preferences were not only affected by the general diagnostic considerations. The informants’ personal experiences of treatment played an important role, both regarding perceived therapeutic results and in regard to how the informants themselves preferred to be treated. Further, the informants excluded or included certain interventions on the basis of their own physical ability and practical skills. ‘As an undergraduate student I hurt my lumbar spine when practising HVLA so I don’t really want to use that technique on anyone else.’
‘You should do what you do best, that’s why I mostly choose an indirect technique.’
‘I am rather small so I rarely choose HVLA.’
Diagnostic usability of IMP Several experiences were found about the understanding and use of IMP as a valid and reliable assessment method. The informants all stated how they incorporated IMP into their daily practice and the extent to which they found the method valuable. General diagnostic value IMP was perceived by the informants as an important diagnostic assessment method and was used in most clinical cases to detect intervertebral motion dysfunction and reproduce pain symptoms that derived from the spine. ‘Motion palpation is an important and valuable part of manual therapy, perhaps even the most important diagnostic tool regarding intervertebral motion dysfunction.’ Application IMP was applied with different foci. All informants used IMP to assess different modalities such as range of motion (ROM), joint-play and end-feel and to reproduce pain.
Please cite this article in press as: Sposato, N.S., Bjersa ˚, K., Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/ j.jbmt.2016.05.008
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N.S. Sposato, K. Bjersa ˚
Different aspects of IMP were emphasized as being the primary objective. Some informants presented their use of IMP as a hierarchy, where all of the modalities presented above were included but given different clinical values. Others applied IMP considering one or two modalities or the site of dysfunction. ‘Quantity of motion is my first objective, after which I try to assess the quality of motion in terms of end-feel and joint-play.’
‘When I test the end-feel passively I try to determine whether the sensation is stiff or elastic, and if there is pain associated to any motion. I primarily focus on pain reproduction.’
‘I use intervertebral motion palpation as part of my routine to find out where the spinal dysfunction is located rather than what is dysfunctional in the motion segment.’ IMP was also considered to be an equally important diagnostic method in itself regardless of what was assessed. However, it was perceived as more or less easy to attain relevant information from the test on the ground of factors such as the patient’s size, age or ability to follow instructions. Clinical implementation None of the informants used IMP as an isolated assessment method. Instead, it was described to be incorporated in a broader diagnostic routine, where the information gathered from the history taking and general active testing procedures provided the basis for passive IMP. The passive application of IMP served to confirm or refute information from the patient’s history and the active mobility testing, both regarding the specificity of the dysfunctional area and how the said motion segment was dysfunctional, i.e., the perceived qualitative changes in the motion segment. ‘The best possible scenario is when hypomobility in the active tests correlates with passive motion palpation findings regarding segmental levels.’
Treatment based on perceived articular dysfunction When using IMP, the informants generally reacted to segmental dysfunction with a firm end-feel, which led to a local treatment approach that was aimed at the passive structures of the motion segment, i.e., passive mobilization with or without impulse. In most (but not all) cases, when the informants considered the local segmental dysfunction to be caused by a muscular deficit, treatment tended to become more general and prone to more variation. ‘I more commonly choose techniques for the treatment of passive structures. I think that possibly that has to do with the sensation that it is easier to diagnose dysfunction in these structures.’
‘The tendency is for me to choose a technique to treat the passive structures of the joint and perhaps recommend some form of exercise for any related muscular dysfunction.’ Treatment based on time and location Time and localization were also experienced as important factors. This was described as the choice of any given treatment in correlation to whether a dysfunction had been present for a longer or shorter period of time, if pain was reproduced, and what structures were thought to be involved. ‘I consider whether the dysfunction is acute or more chronic and tend not to choose to treat with HVLA if the problem has been more long lasting, at least not initially.’
‘It is important to achieve joint cavitation when the joint-play is firm and unyielding and pain is reproduced on palpation.’
‘I think that it is important to affect the hydrostatic pressure in the synovial fluid.’
Discussion ‘If the patient’s presenting complaint has to do with excessive muscular loading, I find it reasonable to expect a more springy end-feel on palpation.’
Treatment applicability of IMP IMP was used as a general method, not as a rule matched with a certain treatment or a certain diagnosis. However, some general areas were found relevant to consider in translating IMP findings to treatment. It was also observed and stated by the informants that a retrospective analysis brought on by the interview itself was made during this study concerning the treatment applicability of IMP. The informants had not previously actively reflected on the use of IMP as an aspect in the choice of intervention.
This study indicates that Swedish osteopathic practitioners consider IMP to be an important assessment method from a general perspective, and that the method is utilized with different foci including range of motion (ROM), joint-play, end-feel qualities and pain reproduction. However, a degree of inconsistency was observed in perceived IMP findings and subsequent treatment. As part of a person-centred approach to health care the informants stressed the importance of an individually adapted treatment plan. Patient-centerdness in osteopathy has been discussed as problematic in stating definition and content (Thomson et al., 2013). In this study, clinical findings were considered along with the patients potential inclinations toward certain therapeutic modalities, which is supported in previous osteopathic personcentered Swedish research as a vital factor towards good
Please cite this article in press as: Sposato, N.S., Bjersa ˚, K., Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/ j.jbmt.2016.05.008
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Experiences of intervertebral motion palpation practice and patient outcome (Fahlgren et al., 2015). At the same time the informants in this study stated that they preferred and carried out certain forms of treatment more often than others, regardless of their perceived sense of the specific IMP finding. This difference between IMP findings and treatment could to a certain extent be attributed to the way that the informants incorporated IMP findings in a larger diagnostic process, but also to their personal beliefs about the efficacy of their preferred techniques. Clinical reasoning and clinical decision-making processes are dynamic, and the quality of the practitioner’s clinical reasoning and subsequent decision-making are limited by parameters such as discipline specific knowledge, general clinical experience and method specific experience (Gong et al., 2013; Hazle and Nitz, 2012; Jones, 1992; Klein, 2011; Sabini et al., 2013). Further, the perception of evidence based practice among Swedish osteopathic practitioners are unknown, but affect both clinical decision making as well as choice of assessment and treatment. This is an important issue for further research. Although research in the field of clinical decision-making in osteopathic medicine practice is limited, there are publications on the topic in adjacent health care professions (Klein, 2011; Riva et al., 2010). These studies indicate that clinical decision-making is inter-professional, which is also supported by this study and by research on diagnostic reasoning involving osteopathic practitioners (Thomson et al., 2014). Two common routes of clinical decision-making processes can be identified: the hypothetico-deductive model, where information obtained from the various stages in a diagnostic process is challenged and thereafter included or excluded in order to formulate a specific diagnosis, and a so called recognition primed decision model (Klein, 2011; Thomson et al., 2014). The intuitive diagnostic procedure is where an experienced clinician is able to process information on several levels and arrives at a diagnostic conclusion (Esteves and Spence, 2014; Jones, 1992; Thomson et al., 2014). A process of this kind, by definition, requires a fair amount of clinical experience. The way that the informants in this study interpreted and connected the different pieces of information from their diagnostic routine to each other and subsequently decided how to treat their patients could be attributed to the ability to recognize specific clinical features as diagnostic cues, i.e., diagnosis by pattern recognition. Diagnosis based on recognition requires two parameters in order to become relevant: a setting that has a sufficiently high level of regularity in order to become predictable and the preconditions that an individual is able to learn through repetitive practice (Kahneman and Klein, 2009). An expert opinion or intuitive decision that is based on these parameters can be considered to be knowledge-based and therefore reasonable to consider in a clinical context (Kahneman and Klein, 2009). IMP along with other musculoskeletal diagnostic methods can be thought of in a systematized manner and thereby provide regularity such that the practitioner, through practice, becomes skilled. Scientific data on the correlation between IMP diagnosis and treatment are, as far as the authors have been able to tell from recent studies, limited to HVLA manipulation and
7 undefined motion restriction (Haas et al., 2003; Hansen et al., 2006; Shaw et al., 2012). As of now, IMP can therefore be considered to be a rather blunt assessment method with regard to therapeutic intervention. The informants in the study at hand confirmed through their incorporation of IMP results in clinical practice that the method is still insufficiently understood and therefore possibly not utilized to its full diagnostic potential.
Limitations In this study, a semi-structured interview design was considered to be appropriate for illustrating how the experienced osteopaths clinical decision-making and utilize IMP as part of a multifaceted diagnostic process. A phenomenographic design could possibly have been a more appropriate study design based on its roots and aims regarding pedagogical and educational perspectives. This study indicated that these were important perspectives for osteopathic diagnosis, as learning is a key factor for diagnostic reasoning, as well as IMP usage and interpretation. Only eight Swedish osteopaths participated in this study, which may have affected the diversity and numbers of experiences negatively. However, it is not in the aim or design of this study to draw any general conclusions. The article by Tong et al. (2007) was used to elevate the general trustworthiness of the study by applying suitable item from the checklist appropriate to this study design. A further way of strengthening the trustworthiness of the study could have been to let the informants examine the analysis process and the result. Due lack of resources, this was not possible during this study. The authors declare that no known dependent relationship existed between the informants and the authors during the study. But, all informants were involved in osteopathic education, which might have colored the interviews and the informants’ answers. However, this is always an issue when this type of design is used.
Clinical implications The results of this study may be used in: Clinical education as a basis for discussions of the developmental stages in clinical decision-making. Hypothetico-deductive models for diagnosis and treatment may be refined in order to provide a structure upon which clinical decisions based on pattern recognition may be developed. Professional discussions at a clinic or on national bases among manual practitioners that include IMP in their practice. As demonstrated and argued for above, IMP is only a part of a broader, person-centered approach to assessing patients’ holistically affected ill-being.
Conclusion This study indicates that IMP findings were considered relevant in cases where they confirmed a preconceived idea that was based on the diagnostic process as a whole.
Please cite this article in press as: Sposato, N.S., Bjersa ˚, K., Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/ j.jbmt.2016.05.008
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8 However, the study also suggests that, in cases where IMP findings did not confirm other findings, the results the method gave were disregarded in favor of other diagnostic results and in favor of personal preferences regarding the choice of treatment method. The limited understanding of the clinical correlation to variations in intervertebral motion palpation qualities leaves a great deal of room for personal interpretations. Further studies on core subjects such as intervertebral motion palpation, as well as other manual diagnostic techniques are essential since these subjects in many ways define the role and purpose of osteopathic medicine in modern health care systems.
Competing interests Both authors declare that they had no competing interest or economical gain of performing and publishing this study, and that they were free to interpret the results in a strict scientific manner.
Authors’ contribution NS conceived the idea for the study. Both authors contributed to the design and concept. NS managed the data collection. Both authors analyzed and interpreted the data, constructed and revised the manuscript for logical content and approved the final version.
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N.S. Sposato, K. Bjersa ˚ Jones, M.A., 1992. Clinical reasoning in manual therapy. Phys. Ther. 72, 875e884. Juel, N.G., Wallgren, G.A., 2003. Ortopedisk Medicin. Studentlitteratur, Lund, Sweden. Kahneman, D., Klein, G., 2009. Conditions for intuitive expertise: a failure to disagree. Am. Psychol. 64, 515e526. Klein, G., 2011. Critical thoughts about critical thinking. Theor. Issues Ergon. Sci. 12, 210e224. Lakhani, E., Nook, B., Haas, M., Docrat, A., 2009. Motion palpation used as a postmanipulation assessment tool for monitoring endfeel improvement: a randomized controlled trial of test responsiveness. J. Manip. Physiol. Ther. 32, 549e555. Levangie, P.K., Norkin, C.C., 2011. Joint Structure and Function: a Comprehensive Analysis. FA Davis, Philadelphia. Lewit, K., Rosinab, A., 1999. Why yet another diagnostic sign of sacroiliac movement restriction? J. Manip. Physiol. Ther. 22, 154e160. Maitland, M.E., Kawchuk, G.N., 1997. Towards the quantification of end-feel for the assessment of passive joint motion. Phys. Ther. Rev. 2, 217e226. Quack, C., Schenk, P., Laeubli, T., Spillmann, S., Hodler, J., Michel, B.A., Klipstein, A., 2007. Do MRI findings correlate with mobility tests? an explorative analysis of the test validity with regard to structure. Eur. Spine J. 16, 803e812. Riva, J.J., Lam, J.M., Stanford, E.C., Moore, A.E., Endicott, A.R., Krawchenko, I.E., 2010. Interprofessional education through shadowing experiences in multi-disciplinary clinical settings. Chiropr. Osteopathy 18, 31. Sabini, R.C., Leo, C.S., Moore, A.E., 2013. The relation of experience in osteopathic palpation and object identification. Chiropr. Man. Ther. 21, 38. Shaw, K.A., Dougherty, J.J., Treffer, K.D., Glaros, A.G., 2012. Establishing the content validity of palpatory examination for the assessment of the lumbar spine using ultrasonography: a pilot study. J. Am. Osteopath. Assoc. 112, 775e782. Snodgrass, S.J., Rivett, D.A., Robertson, V.J., 2008. Measuring the posteroanterior stiffness of the cervical spine. Man. Ther. 13, 520e528. Thomson, O.P., Petty, N.J., Moore, A.P., 2013. Reconsidering the patient-centeredness of osteopathy. Int. J. Osteopath. Med. 16, 25e32. Thomson, O.P., Petty, N.J., Moore, A.P., 2014. Clinical decisionmaking and therapeutic approaches in osteopathyea qualitative grounded theory study. Man. Ther. 19, 44e51. Trew, M., 2005. Human Movement: an Introductory Text, fifth ed. Churchill Livingstone, Edinburgh/New York. Tong, A., Sainsbury, P., Craig, J., 2007. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int. J. Qual. Health Care 19, 349e357. White iii, A., Panjabi, M., 1978. The basic kinematics of the human spine: a review of past and current knowledge. Spine 3, 12e20. World Health Organization (WHO), 2010. Benchmarks for Training in Traditional/complementary and Alternative Medicine - Benchmarks for Training in Osteopathy. World Health Organization, Geneva. World Medical Association, 2013. Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA - J. Am. Med. Assoc. 310, 2191.
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Journal of Bodywork & Movement Therapies (2016) xx, 1e8
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Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths Niklas S. Sposato, DO, MSc a,b,*, ˚, CNS, RN, PhD, MSNc c,d Kristofer Bjersa a
Scandinavian School of Osteopathy, Gothenburg, Sweden The Institute of Orthopaedic Medicine, Gothenburg, Sweden c Division of Nursing Science, Department of Medical and Health Sciences, Linko¨ping University, Linko¨ping, Sweden d Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden b
Received 29 February 2016; received in revised form 4 May 2016; accepted 6 May 2016
KEYWORDS Intervertebral motion palpation; Clinical reasoning; Osteopathy
Summary 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. ª 2016 Elsevier Ltd. All rights reserved.
* Corresponding author. Skandinaviska Osteopatho ¨gskolan, Kapellplatsen 4, 411 31, Gothenburg, Sweden. Tel.: þ46 73 99 55 100. E-mail address: [email protected] (N.S. Sposato). http://dx.doi.org/10.1016/j.jbmt.2016.05.008 1360-8592/ª 2016 Elsevier Ltd. All rights reserved.
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Introduction As part of a manual medicine tradition, osteopathic practitioners are concerned with the diagnosis and treatment of pain syndromes and dysfunctions related to the musculoskeletal system (World Health Organization (WHO), 2010). Pathophysiological changes to musculoskeletal structures are perceived in osteopathic medicine as potentially responsible for both active and passive movement dysfunctions and may subsequently be assessed by active and passive diagnostic methods. Assessment of passive movement includes peripheral and axial (intervertebral) motion palpation (Trew, 2005). Intervertebral motion palpation (IMP) is one of the main assessment methods in osteopathic medicine practice and is used to identify segmental dysfunction, i.e., intervertebral joint hypomobility or hypermobility (Haneline et al., 2008; Juel and Wallgren, 2003). This assessment method can be used with different foci, such as assessing joint play (quality of passive gliding movements) (Lewit and Rosinab, 1999; Maitland and Kawchuk, 1997; White iii and Panjabi, 1978), range of motion (quantity of movement) (Levangie and Norkin, 2011; Maitland and Kawchuk, 1997) or endfeel (the quality of the elastic barrier) (Lakhani et al., 2009; Maitland and Kawchuk, 1997). Studies suggest that IMP may be a valid method for assessing intervertebral hypomobility (Haas et al., 2003; Hansen et al., 2006; Hazle and Nitz, 2012; Lakhani et al., 2009; Lewit and Rosinab, 1999; Quack et al., 2007; Shaw et al., 2012; Snodgrass et al., 2008). However, to our knowledge, no study has included more than one possible palpable quality, i.e., no comparisons have been made between end-feel qualities and/or quality of joint play in the final results. Quack et al. (2007) compared quantitative range of motion (ROM) test results with expert physical diagnosis results, and a study by Lakhani et al. (2009) assessed both end-feel and joint play but reported results only concerning end-feel. Studies using both manual and some form of apparatus indicate to various extents that motion palpation may be used to assess variations in intervertebral mobility. Two independent studies suggest that assessment accuracy is increased when less force is applied (Hazle and Nitz, 2012; Lewit and Rosinab, 1999). However, the amount of force applied was not further presented other than as an internal comparison between the participants (Hazle and Nitz, 2012). Another study confirmed palpable findings via ultra-sound, partially based on positional findings, as tissue depth from the surface was compared to a manually diagnosed posterior transverse process, both pre and post treatment (Shaw et al., 2012). In addition, published research articles during the last 15 years that studied IMP in relation to a therapeutic intervention mainly used high velocity low amplitude (HVLA) manipulations as the treatment method of choice (Haas et al., 2003; Hansen et al., 2006; Shaw et al., 2012). Research on clinical decision-making in general and on IMP in particular is very limited in osteopathic medicine practice. Thomson et al. (2014) have presented results on diagnostic reasoning in a study on osteopathic medicine practitioners, and Esteves and Spence (2014) have
N.S. Sposato, K. Bjersa ˚ researched and published results on palpatory diagnosis development in relation to neuroanatomical and neurophysiological adaptation. However, to the knowledge of the present authors, no studies have been published on the experiences of IMP in osteopathic practice. Although IMP is considered a general diagnostic tool in osteopathic practice, little is known about practitioners’ experience and use of this technique. The aim of this study was thus to explore osteopathic practitioners’ experiences of clinical decision-making and intervertebral motion palpation as a diagnostic tool for planning and evaluating osteopathic interventions.
Method Design This interview study was done as part of a Master thesis project in osteopathic medicine at Dresden International University. The design was semi-structured interviews, and the analysis process was performed using inductive content analysis as described by Elo and Kynga ¨s (2008).
Participants A convenient sample of Swedish osteopathic practitioners (D.O; Diploma in Osteopathy) with a connection to Swedish osteopathic education was approached in the spring of 2015 with both verbal and written information about the study. In total, nine were approached and eight accepted participation. The inclusion criteria were five or more years of clinical experience as a D.O, clinical practice including a variety of therapeutic osteopathic techniques, and regular use of intervertebral motion palpation as an assessment method. Written informed consent was collected before inclusion. In total, eight D.Os were included. Demographics are shown in Table 1.
Data collection Semi-structured interviews were used for data collection. The interviews were conducted between February and April
Table 1
Informants demographics (n Z 8).
Mean years of clinical 9 (range 5e22) experience Gender Place of work
Academic qualifications
5 males 3 females All informants worked in private clinical practice 7 of the informants were involved in osteopathic educational institutions as lecturers or clinical tutors All informants held undergraduate degrees in osteopathy (B.Sc., D.O.)
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Experiences of intervertebral motion palpation 2015, lasting a mean of 43 min (range 30e60 min), and were audiotaped and transcribed verbatim by the first author (NS). No dependent relationship existed between interviewer and respondent. An interview guide was used, starting with the question “what is your view of intervertebral motion palpation?” The informants selected the location for the interviews; five interviews were conducted at osteopathic clinics and three in private homes. Initially, a pilot interview was conducted to test the initiation question and to gain experience of descriptions of this issue. Data from this pilot interview are not included in the analysis and results.
Analysis All interviews were conducted, transcribed and analyze processed in Swedish. Both author were active individually and joint during each step of the analysis. Credentials of the authors was MSc in Osteopathy and visiting lecture in osteopathy (NS) and PhD in Medicine as well as university lecture with several previous scientific publications using interview and content analysis (KB). No software program was used during analysis. Interview text was the body of data. Hence, a qualitative content analysis with an inductive approach was made, guided and inspired by the steps described by Elo and Kynga ¨s (2008): - Data analysis began with carefully and repeatedly reading the transcribed text in order to gain an overview of the contents and to reach a comprehensive understanding of the data content. - Secondly, text units that corresponded to the aim of the study could then be identified and highlighted. This open coding was done with a naı¨ve and inductive approach towards both the interview text and the aim. - Thirdly, the text units selected where condensed to become more manageable; meaning units. These meaning units were in the form of larger citations. - Next step was to arrange the meaning units into clusters and arranging them into headings and further grouping the headings in to different shades of the same aspect. This resulted in codes. - The fifth step consisted of comparison of differences and similarities of the codes, making unique categorisations of the codes in to larger aspects of the aim of the study.
3 (World Medical Association, 2013). Ethical review and approval were given in the Master thesis project by Dresden International University, which is also in line with the Swedish legislation for research in higher education (SFS 2003: 460; Prop.2007/08:44; Law 2003:460). The informants were provided verbal and written information and gave their written consent to participate before being included in the study. Participation could be discontinued at any time during the interview sessions. All data have been and are being treated safely and confidentially.
Results The analysis of the texts from the eight interviews resulted in three categories and eight subcategories, see Table 2.
Strategic decision-making IMP was used to strategically plan patients’ care. By combining general aspects of the patient’s health together with hypotheses from explicit signs and symptoms, the IMP assessment was evaluated on the basis of possible findings of dysfunctions. This, as well as the perceived choice of intervention, led to the comprehensive therapeutic planning. All informants stated an uncertainty as to how they justified specific choices from an evidence-based perspective. Rather, decisions were based on empirical rationale, clinical vigilance and information gained from professional authorities such as in education or from colleagues. Therapeutic considerations The informants expressed a hierarchy in the decisionmaking. Initially, the patient’s preconditions regarding general aspects such as age, gender, level of physical activity and previous or current pathological conditions were evaluated. This also included some form of assessment of the patient’s psychological state. Risk-benefit factors as potential risks of interventions in contrast to potential benefits were expressed as a fundamental part of the decision-making process. ‘If the patient is older, I tend to think that at least part of the restriction is due to degenerative changes.’
This resulted in the sub-categories. - The final step consisted of abstraction and finding autonomous and unique categories that truly described the data response to the aim of the study on a general, overall level. The category represented the most abstract understanding (Elo and Kynga ¨s, 2008). Exemplifications of the analysis process are presented on the left side of Table 2.
Ethical considerations This study was an interview study with its ethical foundations in the Declaration of Helsinki for human research
‘There is an obvious difference between a 13-year-old gymnast and an 80-year- old former truck driver. Both the diagnostic process and the treatment will be adapted to the person rather than to the local dysfunction.’
‘I prioritize general risk/benefit factors over type of dysfunction when I choose what technique to apply.’ Clinical experience and decision-making The informants experienced a clinical development from a structured diagnostic routine towards an intuitive diagnostic and therapeutic methodological approach over
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Analysis process exemplification and Results structure.
Exemplification from analysis process
Results
Meaning units
Codes
Sub categories
Categories
‘I prioritize general risk/benefit factors over type of dysfunction when I choose what technique to apply’ ‘If the patient is older, I tend to think that at least part of the restriction is due to degenerative changes.’ ‘As the years go by you don’t overthink so much, you become more confident with what you do and that it works out well.’ ‘If it acts like a cat, looks like a cat and if you have seen a cat before, chances are that you will assume that what you have in front of you is in fact a cat.’ ‘You should do what you do best, that’s why I mostly choose an indirect technique.’ ‘Motion palpation is an important and valuable part of manual therapy, perhaps even the most important diagnostic tool regarding intervertebral motion dysfunction.’ ‘When I test the end-feel passively I try to determine whether the sensation is stiff or elastic, and if there is pain associated to any motion. I primarily focus on pain reproduction.’ ‘I use intervertebral motion palpation as part of my routine to find out where the spinal dysfunction is located rather than what is dysfunctional in the motion segment. ‘The best possible scenario is when hypomobility in the active tests correlates with passive motion palpation findings regarding segmental levels.’ ‘I more commonly choose techniques for the treatment of passive structures. I think that possibly that has to do with the sensation that it is easier to diagnose dysfunction in these structures.’ ‘The tendency is for me to choose a technique to treat the passive structures of the joint and perhaps recommend some form of exercise for any related muscular
Risk/Benefit Cause of restriction
Therapeutic considerations
Strategic decisionmaking
Diagnostic confidence Pattern recognition
Clinical experience and decision making
Clinical competence
Personal preferences
Motion palpation for motion dysfunction
General diagnostic value
Qualitative modalities of motion palpation Location of motion dysfunction
Application
Correlation of clinical findings
Clinical implementation
Therapeutic correlations Therapeutic differentiation
Treatment based on perceived articular dysfunction
Diagnostic usability of IMP
Treatment applicability of IMP
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Table 2 (continued ) Exemplification from analysis process Meaning units dysfunction.’ ‘I consider whether the dysfunction is acute or more chronic and tend not to choose to treat with HVLA if the problem has been more long lasting, at least not initially.’
Results Codes
Sub categories
Temporal considerations regarding tissue texture changes
Treatment based on time and location
time. In addition, different diagnostic procedures were described as being unevenly weighted depending on the individual patient’s preconditions during assessment, as some patients were diagnosed primarily by the results of a physical examination while others were diagnosed mainly by the information retrieved from the patient’s history. ‘As the years go by you don’t overthink so much, you become more confident with what you do and that it works out well.’ ‘It’s when the problems do not resolve that you have to sit down and really think the case through.’ ‘As I try to verbalize what I do and why, I find myself somewhat unsure of whether my choices can be properly justified or if my clinical work has become more of an automatic process. In any case, my patients seem to get better.’ The informants experienced that, over time, they became more and more able to differentiate between various conditions based on what could be described as diagnostic cues, as specific sentences or behavioral patterns of the patient that correlated to a specific condition and that the informants had come across before. ‘If it acts like a cat, looks like a cat and if you have seen a cat before, chances are that you will assume that what you have in front of you is in fact a cat.’ ‘I wouldn’t say that I consciously reflect on whether it is an intra- or extra- articular dysfunction. I guess that I have a pretty good idea about what is wrong based on the case history. I then only use motion palpation to confirm the precise site of dysfunction.’ The informants stated the importance of being able to engage in the craftsmanship of the profession as they progressed in their clinical practice. However, it was also stated that this was done without a continuous reflection on one’s own practice. The use of intuition was expressed as an important factor in successful learning. The importance of clinical specificity was also experienced as varying from case to case. ‘You need to be able to rely on your hands and let go of your intellect and vice versa.’
Categories
‘There are cases when it really matters what you treat and that you are extremely specific, whilst in other cases it only matters that you treat.’ Personal preferences Clinical preferences were not only affected by the general diagnostic considerations. The informants’ personal experiences of treatment played an important role, both regarding perceived therapeutic results and in regard to how the informants themselves preferred to be treated. Further, the informants excluded or included certain interventions on the basis of their own physical ability and practical skills. ‘As an undergraduate student I hurt my lumbar spine when practising HVLA so I don’t really want to use that technique on anyone else.’
‘You should do what you do best, that’s why I mostly choose an indirect technique.’
‘I am rather small so I rarely choose HVLA.’
Diagnostic usability of IMP Several experiences were found about the understanding and use of IMP as a valid and reliable assessment method. The informants all stated how they incorporated IMP into their daily practice and the extent to which they found the method valuable. General diagnostic value IMP was perceived by the informants as an important diagnostic assessment method and was used in most clinical cases to detect intervertebral motion dysfunction and reproduce pain symptoms that derived from the spine. ‘Motion palpation is an important and valuable part of manual therapy, perhaps even the most important diagnostic tool regarding intervertebral motion dysfunction.’ Application IMP was applied with different foci. All informants used IMP to assess different modalities such as range of motion (ROM), joint-play and end-feel and to reproduce pain.
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Different aspects of IMP were emphasized as being the primary objective. Some informants presented their use of IMP as a hierarchy, where all of the modalities presented above were included but given different clinical values. Others applied IMP considering one or two modalities or the site of dysfunction. ‘Quantity of motion is my first objective, after which I try to assess the quality of motion in terms of end-feel and joint-play.’
‘When I test the end-feel passively I try to determine whether the sensation is stiff or elastic, and if there is pain associated to any motion. I primarily focus on pain reproduction.’
‘I use intervertebral motion palpation as part of my routine to find out where the spinal dysfunction is located rather than what is dysfunctional in the motion segment.’ IMP was also considered to be an equally important diagnostic method in itself regardless of what was assessed. However, it was perceived as more or less easy to attain relevant information from the test on the ground of factors such as the patient’s size, age or ability to follow instructions. Clinical implementation None of the informants used IMP as an isolated assessment method. Instead, it was described to be incorporated in a broader diagnostic routine, where the information gathered from the history taking and general active testing procedures provided the basis for passive IMP. The passive application of IMP served to confirm or refute information from the patient’s history and the active mobility testing, both regarding the specificity of the dysfunctional area and how the said motion segment was dysfunctional, i.e., the perceived qualitative changes in the motion segment. ‘The best possible scenario is when hypomobility in the active tests correlates with passive motion palpation findings regarding segmental levels.’
Treatment based on perceived articular dysfunction When using IMP, the informants generally reacted to segmental dysfunction with a firm end-feel, which led to a local treatment approach that was aimed at the passive structures of the motion segment, i.e., passive mobilization with or without impulse. In most (but not all) cases, when the informants considered the local segmental dysfunction to be caused by a muscular deficit, treatment tended to become more general and prone to more variation. ‘I more commonly choose techniques for the treatment of passive structures. I think that possibly that has to do with the sensation that it is easier to diagnose dysfunction in these structures.’
‘The tendency is for me to choose a technique to treat the passive structures of the joint and perhaps recommend some form of exercise for any related muscular dysfunction.’ Treatment based on time and location Time and localization were also experienced as important factors. This was described as the choice of any given treatment in correlation to whether a dysfunction had been present for a longer or shorter period of time, if pain was reproduced, and what structures were thought to be involved. ‘I consider whether the dysfunction is acute or more chronic and tend not to choose to treat with HVLA if the problem has been more long lasting, at least not initially.’
‘It is important to achieve joint cavitation when the joint-play is firm and unyielding and pain is reproduced on palpation.’
‘I think that it is important to affect the hydrostatic pressure in the synovial fluid.’
Discussion ‘If the patient’s presenting complaint has to do with excessive muscular loading, I find it reasonable to expect a more springy end-feel on palpation.’
Treatment applicability of IMP IMP was used as a general method, not as a rule matched with a certain treatment or a certain diagnosis. However, some general areas were found relevant to consider in translating IMP findings to treatment. It was also observed and stated by the informants that a retrospective analysis brought on by the interview itself was made during this study concerning the treatment applicability of IMP. The informants had not previously actively reflected on the use of IMP as an aspect in the choice of intervention.
This study indicates that Swedish osteopathic practitioners consider IMP to be an important assessment method from a general perspective, and that the method is utilized with different foci including range of motion (ROM), joint-play, end-feel qualities and pain reproduction. However, a degree of inconsistency was observed in perceived IMP findings and subsequent treatment. As part of a person-centred approach to health care the informants stressed the importance of an individually adapted treatment plan. Patient-centerdness in osteopathy has been discussed as problematic in stating definition and content (Thomson et al., 2013). In this study, clinical findings were considered along with the patients potential inclinations toward certain therapeutic modalities, which is supported in previous osteopathic personcentered Swedish research as a vital factor towards good
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Experiences of intervertebral motion palpation practice and patient outcome (Fahlgren et al., 2015). At the same time the informants in this study stated that they preferred and carried out certain forms of treatment more often than others, regardless of their perceived sense of the specific IMP finding. This difference between IMP findings and treatment could to a certain extent be attributed to the way that the informants incorporated IMP findings in a larger diagnostic process, but also to their personal beliefs about the efficacy of their preferred techniques. Clinical reasoning and clinical decision-making processes are dynamic, and the quality of the practitioner’s clinical reasoning and subsequent decision-making are limited by parameters such as discipline specific knowledge, general clinical experience and method specific experience (Gong et al., 2013; Hazle and Nitz, 2012; Jones, 1992; Klein, 2011; Sabini et al., 2013). Further, the perception of evidence based practice among Swedish osteopathic practitioners are unknown, but affect both clinical decision making as well as choice of assessment and treatment. This is an important issue for further research. Although research in the field of clinical decision-making in osteopathic medicine practice is limited, there are publications on the topic in adjacent health care professions (Klein, 2011; Riva et al., 2010). These studies indicate that clinical decision-making is inter-professional, which is also supported by this study and by research on diagnostic reasoning involving osteopathic practitioners (Thomson et al., 2014). Two common routes of clinical decision-making processes can be identified: the hypothetico-deductive model, where information obtained from the various stages in a diagnostic process is challenged and thereafter included or excluded in order to formulate a specific diagnosis, and a so called recognition primed decision model (Klein, 2011; Thomson et al., 2014). The intuitive diagnostic procedure is where an experienced clinician is able to process information on several levels and arrives at a diagnostic conclusion (Esteves and Spence, 2014; Jones, 1992; Thomson et al., 2014). A process of this kind, by definition, requires a fair amount of clinical experience. The way that the informants in this study interpreted and connected the different pieces of information from their diagnostic routine to each other and subsequently decided how to treat their patients could be attributed to the ability to recognize specific clinical features as diagnostic cues, i.e., diagnosis by pattern recognition. Diagnosis based on recognition requires two parameters in order to become relevant: a setting that has a sufficiently high level of regularity in order to become predictable and the preconditions that an individual is able to learn through repetitive practice (Kahneman and Klein, 2009). An expert opinion or intuitive decision that is based on these parameters can be considered to be knowledge-based and therefore reasonable to consider in a clinical context (Kahneman and Klein, 2009). IMP along with other musculoskeletal diagnostic methods can be thought of in a systematized manner and thereby provide regularity such that the practitioner, through practice, becomes skilled. Scientific data on the correlation between IMP diagnosis and treatment are, as far as the authors have been able to tell from recent studies, limited to HVLA manipulation and
7 undefined motion restriction (Haas et al., 2003; Hansen et al., 2006; Shaw et al., 2012). As of now, IMP can therefore be considered to be a rather blunt assessment method with regard to therapeutic intervention. The informants in the study at hand confirmed through their incorporation of IMP results in clinical practice that the method is still insufficiently understood and therefore possibly not utilized to its full diagnostic potential.
Limitations In this study, a semi-structured interview design was considered to be appropriate for illustrating how the experienced osteopaths clinical decision-making and utilize IMP as part of a multifaceted diagnostic process. A phenomenographic design could possibly have been a more appropriate study design based on its roots and aims regarding pedagogical and educational perspectives. This study indicated that these were important perspectives for osteopathic diagnosis, as learning is a key factor for diagnostic reasoning, as well as IMP usage and interpretation. Only eight Swedish osteopaths participated in this study, which may have affected the diversity and numbers of experiences negatively. However, it is not in the aim or design of this study to draw any general conclusions. The article by Tong et al. (2007) was used to elevate the general trustworthiness of the study by applying suitable item from the checklist appropriate to this study design. A further way of strengthening the trustworthiness of the study could have been to let the informants examine the analysis process and the result. Due lack of resources, this was not possible during this study. The authors declare that no known dependent relationship existed between the informants and the authors during the study. But, all informants were involved in osteopathic education, which might have colored the interviews and the informants’ answers. However, this is always an issue when this type of design is used.
Clinical implications The results of this study may be used in: Clinical education as a basis for discussions of the developmental stages in clinical decision-making. Hypothetico-deductive models for diagnosis and treatment may be refined in order to provide a structure upon which clinical decisions based on pattern recognition may be developed. Professional discussions at a clinic or on national bases among manual practitioners that include IMP in their practice. As demonstrated and argued for above, IMP is only a part of a broader, person-centered approach to assessing patients’ holistically affected ill-being.
Conclusion This study indicates that IMP findings were considered relevant in cases where they confirmed a preconceived idea that was based on the diagnostic process as a whole.
Please cite this article in press as: Sposato, N.S., Bjersa ˚, K., Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/ j.jbmt.2016.05.008
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MODEL
8 However, the study also suggests that, in cases where IMP findings did not confirm other findings, the results the method gave were disregarded in favor of other diagnostic results and in favor of personal preferences regarding the choice of treatment method. The limited understanding of the clinical correlation to variations in intervertebral motion palpation qualities leaves a great deal of room for personal interpretations. Further studies on core subjects such as intervertebral motion palpation, as well as other manual diagnostic techniques are essential since these subjects in many ways define the role and purpose of osteopathic medicine in modern health care systems.
Competing interests Both authors declare that they had no competing interest or economical gain of performing and publishing this study, and that they were free to interpret the results in a strict scientific manner.
Authors’ contribution NS conceived the idea for the study. Both authors contributed to the design and concept. NS managed the data collection. Both authors analyzed and interpreted the data, constructed and revised the manuscript for logical content and approved the final version.
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Please cite this article in press as: Sposato, N.S., Bjersa ˚, K., Experiences of intervertebral motion palpation in osteopathic practice e A qualitative interview study among Swedish osteopaths, Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/ j.jbmt.2016.05.008