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Research and treatment bulletin
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International Journal of Osteopathic Medicine 12 (2009) 38e43 www.elsevier.com/locate/ijosm
RESEARCH AND TREATMENT BULLETIN Section Co-ordinator: Paul Blanchard The British School of Osteopathy, Research Centre, 275 Borough High Street, London SE1 1JE, UK
The problems of diagnosis e recent research Nicholas Lucas, University of Western Sydney, Australia While the focus is largely on diagnostic accuracy, there is an increasing awareness of the need to investigate the reliability of diagnostic tests. Poor reliability adversely affects the accuracy of diagnostic tests. If the accuracy of the test is not known, reliability is the only indicator we have to designate if the test is useful. There are a number of recent reliability studies of particular relevance to osteopaths; the first three report poor reliability outcomes, and the last two report good outcomes. Hickey et al.1 report on the reliability of observation for shoulder girdle dysfunction. In a well-designed study, 9 subjects with shoulder girdle pain and 11 subjects without shoulder girdle pain were videotaped whilst performing shoulder flexion, abduction, and scapular plane abduction. These video recordings were independently viewed by 11 manipulative (musculoskeletal) physiotherapists with graduate qualifications and a minimum of 5-years clinical experience. The physiotherapists were asked to rate each subject at three levels; (1) whether they thought the subject was symptomatic; (2) if symptomatic, which shoulder was the symptomatic shoulder; and (3) to identify the abnormalities of movement that indicated that the shoulder was symptomatic. The results are surprising. Only 58% of 220 responses regarding the symptom status of the subject were correct. While 71% of patients with left shoulder complaints were correctly identified, only 30% of patients with right shoulder complaints were correctly identified. In terms of agreement between physiotherapists, the kappa estimate for all subjects was only k 0.23. For the identication of abnormal movement, only ve subjects had two or more physiotherapists agree. In another well-designed study, Sedaghat et al. report on the reliability of a clinical grading system (Wisbey-Roth
International Journal of Osteopathic Medicine
grading system) of motor control for patients with low back pain based on the assessment of the activation and recruitment of transversus abdominis and lumbar multifidus.2 The assessment and rehabilitation of these muscles roared into popularity after it was demonstrated that abnormal firing patterns and atrophy of groups of muscles occurs soon after the first onset of low back pain. Countless practitioners now use this model for treatment and the phrase ‘core stability’ will be well known to many osteopaths. Thirty-four subjects with chronic low back pain were recruited for this study, and were assessed by four physiotherapists and one sports medicine physician. The experience of the assessors ranged from 3 years to 20 years and each reported that they frequently assessed the motor control of the transversus abdominis and lumbar multifidus in private practice. Four of the five assessors had at least 12 months experience in the assessment of motor control. In addition, the assessors met twice and carried out three pilot trials prior to the study in order to establish agreement about the assessment protocol. The estimated reliability of the assessors ranged from k 0.01 to k 0.56 with an average weighted k of 0.26. The authors conclude that the grading system they evaluated should not be used to exchange meaningful information and make recommendations for improving the reliability of the assessment of motor control. In the last of the three papers, Kim et al.3 report on the reliability and accuracy of landmarks of the pelvis to identify spinal levels. It is commonly taught that the superior aspect of the iliac crest is in the same plane as the L4 spinous process. In my experience, students in the early years of osteopathic education are frequently required to carry out this procedure in practical examinations of surface palpation and lumbar spinal techniques. However, this procedure lacks both reliability and accuracy. Sixty patients were assessed by four examiners with at least three years clinical experience in musculoskeletal medicine. A straight vertical line was drawn over the midline of the patient’s spine. For reliability, examiners
were required to mark the most superior aspect of the iliac crest bilaterally. A straight transverse line was then drawn between the two marks. The point at which that line bisected the vertical midline was also marked as the reference point. Reliability was estimated as the amount of discrepancy between the reference points obtained by each examiner, which ranged from 0.5 cm to 1.5 cm, with an average discrepancy of approximately 0.94 cm. In order to assess the accuracy of this test, a further 72 patients were examined. Radio-opaque markers were applied to the skin to indicate the superior aspect of the iliac crests bilaterally, and anteroposterior plain film radiographs of the lumbar spine were then taken of each patient. Transverse lines were drawn between the two radiopaque markers on each of the obtained radiographs, and the spinal level at which the line bisected the midline was identified. The data was reported in the form of frequency distribution of spinal levels at which the transverse line bisected the midline. The spinal levels estimated by the iliac crest method as confirmed by plain film imaging ranged from the L2-3 interspace to the L5 spinous process. In 10 out of 72 patients, the L4 spinous process was correctly identified; nine were correctly identified as the L4-5 interspace; and seven as the L5 spinous process. Collectively, these studies demonstrate that the reliability and accuracy of commonly used diagnostic and assessment procedures cannot be assumed. Experienced physiotherapists were not able to reliably identify which subjects had painful shoulders, which shoulder was symptomatic, or which movements were abnormal. Clinicians experienced in assessment of the motor function of the transversus abdominis and lumbar multifidus did not reach acceptable levels of agreement. Lastly, the method of using the iliac crest to identify the L4 spinous process has poor accuracy. Thankfully, it’s not all doom and gloom, as these last two articles demonstrate. The Stork test is a well-known assessment procedure for the assessment of pelvic arthrokinematics and load transfer. Hungerford et al. investigated the reliability of the Stork test when used on the support side.4 The procedure requires the patient to lift one leg into 90 degree of hip and knee flexion, whilst remaining standing on the contralateral leg (support side). Typically, the motion between the sacrum and innominate bone of the ‘lift’ leg is monitored; however, in this study the movement between the sacrum and innominate bone of the support leg was monitored. The test was considered abnormal if the PSIS on the support side was observed to move cephalad. Thirty-three subjects were examined by three physiotherapists. The subjects were either asymptomatic or had back or leg pain. When subjects were rated using a two-point scale (positive or negative) the reliability was good, with
International Journal of Osteopathic Medicine
kappa ranging from k 0.67 to k 0.77. When raters were asked to nominate if the PSIS moved cephalad, caudad or remained stationary, reliability was moderate (k 0.59). Lastly, in a large and important study conducted across 27 sites in the UK, McCarthy et al. investigated the reliability of the clinical tests and questions recommended in international guidelines for the assessment of low back pain.5 At each site (hospital), two physiotherapists independently assessed consecutive patients who presented with low back pain. Each assessment was conducted on the same day using a proforma-guided examination, and consisted of 50 clinical tests and questions. Each physiotherapist received only a one-hour explanation of the examination guide but had no specific training on how to perform the clinical tests. Two hundred and ninety five patients were examined by 54 physiotherapists. Of the 50 clinical tests and questions, only 14% obtained kappa estimates of less than k 0.40, with the remaining 86% achieving ‘fair’ reliability (k > 0.4). Given the modest training of each physiotherapist and the multitude of sites at which the study was conducted, this is a surprising but welcome outcome. Of course, it would have been more encouraging to see the majority of tests obtaining reliability greater than k 0.6; however this study provides evidence that the clinical assessment of patients with low back pain as recommended by international guidelines is useful. It is likely that the reliability of each test can be improved with increased training and standardisation between assessors. Osteopaths are frequently reminded that when it comes to somatic dysfunction, we are to find it, fix it, and leave it alone. Studies of diagnostic accuracy and reliability help us to understand how useful physical examination tests are for the purpose of ‘finding it’. We also use diagnostic tests to indicate if we have ‘fixed it’. Research into diagnostic procedures is inherently osteopathic, and is, in many ways, the new frontier. The challenge remains as to how best to incorporate the evidence into osteopathic practice and education. References 1. Hickey BW, Milosavljevic S, Bell ML, Milburn PD. Accuracy and reliability of observational motion analysis in identifying shoulder symptoms. Man Ther 2007;12: 263e70. 2. Sedaghat N, Latimer J, Maher C, Wisbey-Roth T. The reproducibility of a clinical grading system of motor control in patients with low back pain. J Manipulative Physiol Ther 2007;30:501e8. 3. Kim HW, Ko YJ, Rhee WI, Lee JS, Lim JE, Lee SJ, et-al. Interexaminer reliability and accuracy of posterior superior iliac spine and iliac crest palpation for spinal level estimations. J Manipulative Physiol Ther 2007;30:386e9.
4. Hungerford BA, Gilleard W, Moran M, Emmerson C. Evaluation of the ability of physical therapists to palpate intrapelvic motion with the Stork test on the support side. Phys Ther 2007;87:879e87.
5. McCarthy CJ, Gittins M, Roberts C, Oldham JA. The reliability of the clinical tests and questions recommended in international guidelines for low back pain. Spine 2007;32:921e6.
Is the response to chiropractic manipulation of the neck predictable? Clarissa Parry, The British School of Osteopathy, UK This study by Haymo Thiel et al. set out to identify the predictors of either immediate improvement or worsening in symptoms for which cervical spine manipulation is indicated.1 A large-scale, prospective cohort study was conducted to establish and document the incidence and nature of outcomes following chiropractic neck manipulation. All registered chiropractors who were members of the British and Scottish Chiropractic Associations were invited to participate and 377 (31.9%) took part. Standardised forms recorded details on symptoms, treatments and outcomes in patients who received at least one cervical spine manipulation (high velocity, low amplitude or mechanically assisted thrust). In all, data on 28,807 treatment consultations including cervical manipulation was collected. Three response categories were recorded; a) ‘‘immediate improvement’’ vs ‘‘no immediate improvement’’, b) ‘‘immediate worsening’’ vs ‘‘no immediate worsening’’, and c) ‘‘global improvement’’ vs ‘‘no global improvement’’. The immediate category consisted of change at the end of the treatment consultation in which the manipulation took place. The global category was change by the return visit up to seven days later. An immediate improvement in symptoms was noted in 70% of consultations. Stepwise multiple regression analysis identified the following predictors of immediate improvement:
Neck pain Shoulder/arm pain Reduced neck/shoulder/arm movement (stiffness) Headache Upper/mid back pain One or less presenting symptom
The presence of any 4 of these predictors raised the probability for an immediate improvement in presenting symptoms after treatment from 70% to 95%. However, if 5 of the predictors were present this probability fell to 60% ‘‘Stiffness’’ was the strongest single predictor for immediate improvement. A worsening of symptoms was reported in 4.4% of treatment consultations. Again, stepwise multiple regression analysis was employed to identify the most likely predictors of immediate worsening, these were:
Neck pain Shoulder/arm pain Headache Numbness/tingling of the upper limbs Upper/mid back pain Fainting/dizziness/light-headedness
The presence of any 4 of these predictors raised the post-treatment probability for an immediate worsening in presenting symptoms from 4.4% to 12%. The strongest predictors of immediate worsening were found to be fainting/ dizziness/light-headedness and numbness/tingling of the upper limbs. The data presented on global improvement is difficult to interpret purely because only 48% of the original 28,807 treatments were followed up within seven days. In discussing the results of their study the authors grapple with the complex nature of multiple predictors. As mentioned earlier, the number of predictors factored in to the predictive model could improve the predictive power of immediate response to treatment, but only up to a point. A 70% probability of immediate improvement occurred after manipulation for the whole sample, this rose to 85% if two of the identified predictors were present and to 95% if four were present. If all five predictor variables were entered into the model the probability of immediate improvement fell to 60%. They also note that, as can be seen, some of the same predictors can predict either improvement or worsening. These apparently paradoxical and somewhat contradictory findings are discussed by the authors in relation to the realities of International Journal of Osteopathic Medicine
clinical practice where the presence of multiple symptoms is often considered a poor prognostic indicator. Similarly they suggest that the same symptoms, but in varying combinations may be the reason for the same predictors being responsible for both worsening and improvement. The authors suggest that their results can help clinicians to predict responses to treatment and so could aid in clinical decision making when selecting cervical manipulation for patients with clusters of identified symptoms. This is indeed useful information. However the authors also state that this is a complex area, so using a simple tick-box approach to data collection may be premature. Finally, the authors of this large-scale study (involving 19,722 patients, and 377 chiropractors) should be congratulated, this was no small task! Reference 1. Thiel HWB, Jennifer E. Predictors for immediate and global responses to chiropractic manipulation of the cervical spine. J Manipulative Physiol Ther 2008:172e83.
The influence of musculoskeletal function on respiratory function variables Paddy Searle Barnes, The British School of Osteopathy, London, UK
(glenohumeral horizontal flexion, in 80e90 degrees of glenohumeral abduction and external glenohumeral rotation with elbow bent to meet the resistance applied by the research assistant). This isometric contraction was held for 6 s. The patient then relaxed and passive stretch in the Respiratory disease may cause opposite direction was applied. secondary effects in the musculoskel- The results of this intervention were etal system, and in particular respira- compared with a sham technique; at tory muscles, which may lead to the mid-range of glenohumeral flexion reduced efficiency of the ventilation and extension, the subject’s arm was system. There is good pathophysio- supported and the subject was asked logical justification that stretching is to try to bend the elbow to meet the beneficial, but there has been little resistance applied by the research prior evidence of its benefit in patients. assistant. Each intervention was Putt et al. explored the effects of a muscle stretching technique performed on patients with chronic obstructive pulmonary disease in a well-designed double blind crossover trial (both the patient and the assessor were blinded to the intervention performed).1 The study involved 14 patients with stable COPD who had recently completed a pulmonary rehabilitation programme, with 10 patients completing the study. A hold and relax stretching technique was applied to pectoralis major muscle. The subject was asked to move their arm in the agonist direction (glenohumeral horizontal extension, in 90 degrees of gleno-humeral abduction and external glenohumeral rotation with elbow bent). The subject was asked to contract the pectoral muscles to move the limb in the antagonistic direction
International Journal of Osteopathic Medicine
increasing range of movement in the chest and shoulder girdle, and an increase in vital capacity, and should be investigated further.
It is notable that changes made on day one with the hold and relax technique were maintained by the beginning of day two, though these effects disappeared over the next 3 days before performing the sham treatment. This is particularly significant when considering application to osteopathic practice with regard to frequency of treatment. However, as the authors point out, this study focused on one technique only, and it is possible that the combined effect of a series of repeated 6 times on each arm with rests intervention techniques would have of 30 s in between. One intervention a greater and more lasting effect. was performed on 2 consecutive days, Another study by Ghanbari et al. followed by a three-day rest period. The explored whether ‘forward shoulder alternative intervention was then per- posture’ had any effect on pulmonary formed on 2 consecutive days. capacities of women.2 The hypothesis
The primary outcome measure was vital capacity, and other measures assessed included perceived dyspnoea, axillary and xiphisternal chest expansion, right and left shoulder horizontal extension and respiratory rate. The hold and relaxed technique to the pectoralis major muscle produced significant effects on vital capacity (P < 0.01), and right (P < 0.01) and left (P < 0.05) upper limb range of motion. There was no significant effect on the chest expansion, perceived dyspnoea, or respiratory rate. The authors conclude that the hold and relax technique produces shortterm benefits in patients with COPD, by
suggested that people with forward shoulder posture (FSP) or ‘‘rounded shoulders’’ might have reduced lung capacities because of soft tissue shortening as a result of the shoulder posture. The shoulder posture was analysed using computer digitized photography. Spirometry was used to measure vital capacity, forced vital capacity and expiratory residual volume. 40 healthy female university students were analysed. Subject was excluded if they has a history of smoking, respiratory, cardio-vascular, neuromuscular or orthopaedic disease. The results seem
to show a correlation between the degree of FSP and respiratory values of the subjects. The observation is that such a postural feature reduces respiratory function variables. However, this study is published as a research letter, which by its nature is brief and the statistical information is limited. Further studies would be of value, to
quantify the significance and the exact motion in patients with chronic mechanism of the effects of FSP on obstructive pulmonary disease. Arch pulmonary function. Phys Med Rehabil 2008;89:1103e7. 2. Ghanbari A, Ghaffarinejad F, Mohammadi F, Khorrami M, Sobhani S. References Effect of forward shoulder posture on 1. Putt MT, Watson M, Seale H, pulmonary capacities of women. Br J Paratz JD. Muscle stretching technique Sports Med 2008;42:622e3. increases vital capacity and range of
Diagnosing myofascial trigger points: A critical review of the evidence and clinical implications Luke Rickards, Private Practice, France Myofascial trigger points (MTPs) are routinely diagnosed and treated by clinicians in many musculoskeletal health disciplines. MTPs have been associated with numerous clinical conditions and prevalence studies claim that they may account for 30e85% of patients complaining of regional muscular pain.1 Despite the widespread acceptance of MTPs as an important clinical entity the diagnosis of MTPs is a source of continuing controversy. There no accepted biochemical, electromyographic or diagnostic imaging criteria recognised as a definitive diagnostic gold standard.2 Furthermore, there is currently no reliable list of physical diagnostic criteria for MTPs.1 The detection of MTPs is solely dependent on manual palpation and patient feedback. These circumstances have raised concerns regarding the non-substantive manner in which MTPs are identified. In the absence of an accepted gold standard, physical diagnostic tests should demonstrate inter-rater reliability in order to be considered clinically useful. Myburgh et al.3 have recently published the first systematic review of reliability studies examining evidence for the use of manual palpation for identifying MTPs. The reviewers used a comprehensive search strategy across relevant medical databases and the reference lists of related articles. The search revealed eleven relevant studies; however five studies were subsequently excluded because they did not use appropriate statistical measures of agreement. The remaining six studies were then assessed for internal validity and reproducibility according to predetermined quality criteria. Criteria for establishing the levels of evidence (LOE) resulting from the analysis were also defined a priori. The included studies examined the use of manual diagnosis for MTPs in a variety of settings, populations, conditions and clinicians. This heterogeneity limited pooled analysis of the results. In addition, none of the studies used completely overlapping diagnostic criteria, and no single muscle was observed in more than two studies. The results of the quality analysis indicated two studies to be of high International Journal of Osteopathic Medicine
quality, one of moderate quality, and three of low quality. None of the MTP criteria were found to have a high LOE. At best, the current literature suggests moderate evidence for the reliability of local tenderness in the trapezius, and pain referral at gluteus medius and quadratus lumborum; however a single reliable criterion is insufficient to diagnose a MTP according to commonly cited diagnostic criteria. The authors concluded that the current evidence supporting the reliability of diagnostic palpation for MTPs is weak and further high quality studies are required. The clinical uncertainties surrounding MTP diagnosis present challenges to the interpretation of all research on MTPs. In the absence of an accurate diagnosis, the results of any epidemiological, pathophysiologic, or clinical investigation will be misleading.1 A potent example of this is seen in the subsequent issue of the same journal, where Ettlin et al.4 report on the prevalence cervical MTPs in four different clinical populations and a group of healthy controls. Having assumed that identification of each of the MTP characteristics is reliable, the researchers state that a clinically relevant MTP was present if three out four listed criteria were met. However, using this methodology it is possible that the diagnostic process would identify presentations other than MTPs, such as non-specific muscle pain, pain of peripheral nerve trunk origin, underlying joint sensitivity, secondary hyperalgesia, or even normal intramuscular physiology. It also explains their report of active MTPs in up to one third of the pain-free controls, which should be considered impossible considering that active MTPs are symptomatic by definition. Until both consensus and reliability of diagnostic criteria for identifying MTPs is achieved and implemented in research studies, data on the validity, prevalence, aetiology and treatment of MTPs should be interpreted with prudence. References 1. Tough EA, White AR, Richards S, Campbell J. Variability of criteria used to diagnose myofascial trigger point pain syndrome: evidence from a review of the literature. Clin J Pain 2007;23:278e86. 2. Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: a systematic review of the literature. Int J Osteopath Med 2006;9:120e36.
3. Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Arch Phys Med Rehabil 2008;89:1169e76.
4. Ettlin T, Schuster C, Stoffel R, Bru¨derlin A, Kischka U. A distinct pattern of myofascial findings in patients after whiplash injury. Arch Phys Med Rehabil 2008;89: 1290e3.
More data on the audible ‘click’ associated with joint manipulation David Evans, Warwick University, UK. Well-designed studies that investigate the basic science of manipulation in any joint are few and far between. Even less common are well-designed studies that investigate manipulation in spinal joints, which is why a study by Canadian chiropractor David Bereznick et al. is noteworthy.1 The study investigated a phenomenon known as the ‘refractory period’, which is a period of time that follows the audible ‘click’ sound associated with joint manipulation, during which it is not possible to elicit a second or subsequent click from the same joint. It is generally well accepted that the audible click is caused by an event termed cavitation, whereby the increase in volume in the enclosed joint capsule reduces the intra-articular pressure, which results in the formation of a bubble from gases dissolved in the synovial fluid.2,3 The refractory period is therefore likely to represent the time taken after cavitation, for the gases to dissolve back into the synovial fluid solution. Previous research has not studied this phenomenon at great depth or in a systematic manner, and the limited published information that does exist has been derived from metacarpophalangeal joints, typically describing the period to be in the region of 20 min.2,4 Bereznick’s study differs as they used a systematic approach to investigate the duration of the refractory period, and they used lumbar spine manipulation. To measure the refractory period, the researchers potentially could have designed their study in a number of ways. However, the difficulty of measuring the duration of this phenomenon is that taking a measurement will potentially alter the phenomenon being investigated; similar to the ‘observer effect’ in physics. Hence, they could not just re-attempt a manipulation every 10 min as the change in pressure in the joint would probably extend the time taken for gases to re-dissolve back into the synovial fluid. Therefore, the investigators decided to use a series of previously decided ‘time trials’ that they termed ‘potential refractory periods’, and did so over many days to avoid artefacts from previous manipulations (each test day occurred every third day for at least 34 days and two days were allowed between each test day for rest). Each of the 3 healthy subjects that volunteered were exposed to ‘baseline’ side-lying lumbar manipulations, until no further audible cracks were recorded (a minimum of 3 audible clicks had to be recorded). Further lumbar manipulations (on the same side) were then attempted after each potential refractory period, at which point the number of audible clicks was recorded. The refractory period was declared when a minimum of 50% of the baseline audible clicks had recovered during the test manipulations. Hence, it is worth noting that, in this study, the refractory period represented the entire side of the spine, rather than one single joint. The refractory period was different for each subject and, once identified for the entire lumbar spine, was fairly stable on further trials (even though there may have been some variation in individual joints). Furthermore, the duration of the refractory period in the lumbar spine was much longer than previous estimates based on metacarpophalangeal joints: 40 min for subject A; 70 min for subject B; and, 95 min for subject C. The average refractory period across subjects was 68.33 min, with a range of 55 min. Lastly, the number of audible clicks recorded during the many ‘exhaustive’ lumbar manipulations never exceeded 6, which lends further support to the zygapophysial joints being the source of the audible click. References 1. Bereznick DE, Pecora CG, Ross JK, McGill SM. The refractory period of the audible ‘‘crack’’ after lumbar manipulation: a preliminary study. J Manipulative Physiol Ther 2008;31:199e203. 2. Unsworth A, Dowson D, Wright V. ‘Cracking joints’. A bioengineering study of cavitation in the metacarpophalangeal joint. Ann Rheum Dis 1971;30:348e58. 3. Watson P, Kernohan WG, Mollan RA. A study of the cracking sounds from the metacarpophalangeal joint. Proc Inst Mech Eng [H] 1989;203:109e18. 4. Roston JB, Wheeler-Haines R. Cracking in the metacarpophalangeal joint. J Anat 1947;81:165e73.
International Journal of Osteopathic Medicine
International Journal of Osteopathic Medicine 12 (2009) 38e43 www.elsevier.com/locate/ijosm
RESEARCH AND TREATMENT BULLETIN Section Co-ordinator: Paul Blanchard The British School of Osteopathy, Research Centre, 275 Borough High Street, London SE1 1JE, UK
The problems of diagnosis e recent research Nicholas Lucas, University of Western Sydney, Australia While the focus is largely on diagnostic accuracy, there is an increasing awareness of the need to investigate the reliability of diagnostic tests. Poor reliability adversely affects the accuracy of diagnostic tests. If the accuracy of the test is not known, reliability is the only indicator we have to designate if the test is useful. There are a number of recent reliability studies of particular relevance to osteopaths; the first three report poor reliability outcomes, and the last two report good outcomes. Hickey et al.1 report on the reliability of observation for shoulder girdle dysfunction. In a well-designed study, 9 subjects with shoulder girdle pain and 11 subjects without shoulder girdle pain were videotaped whilst performing shoulder flexion, abduction, and scapular plane abduction. These video recordings were independently viewed by 11 manipulative (musculoskeletal) physiotherapists with graduate qualifications and a minimum of 5-years clinical experience. The physiotherapists were asked to rate each subject at three levels; (1) whether they thought the subject was symptomatic; (2) if symptomatic, which shoulder was the symptomatic shoulder; and (3) to identify the abnormalities of movement that indicated that the shoulder was symptomatic. The results are surprising. Only 58% of 220 responses regarding the symptom status of the subject were correct. While 71% of patients with left shoulder complaints were correctly identified, only 30% of patients with right shoulder complaints were correctly identified. In terms of agreement between physiotherapists, the kappa estimate for all subjects was only k 0.23. For the identication of abnormal movement, only ve subjects had two or more physiotherapists agree. In another well-designed study, Sedaghat et al. report on the reliability of a clinical grading system (Wisbey-Roth
International Journal of Osteopathic Medicine
grading system) of motor control for patients with low back pain based on the assessment of the activation and recruitment of transversus abdominis and lumbar multifidus.2 The assessment and rehabilitation of these muscles roared into popularity after it was demonstrated that abnormal firing patterns and atrophy of groups of muscles occurs soon after the first onset of low back pain. Countless practitioners now use this model for treatment and the phrase ‘core stability’ will be well known to many osteopaths. Thirty-four subjects with chronic low back pain were recruited for this study, and were assessed by four physiotherapists and one sports medicine physician. The experience of the assessors ranged from 3 years to 20 years and each reported that they frequently assessed the motor control of the transversus abdominis and lumbar multifidus in private practice. Four of the five assessors had at least 12 months experience in the assessment of motor control. In addition, the assessors met twice and carried out three pilot trials prior to the study in order to establish agreement about the assessment protocol. The estimated reliability of the assessors ranged from k 0.01 to k 0.56 with an average weighted k of 0.26. The authors conclude that the grading system they evaluated should not be used to exchange meaningful information and make recommendations for improving the reliability of the assessment of motor control. In the last of the three papers, Kim et al.3 report on the reliability and accuracy of landmarks of the pelvis to identify spinal levels. It is commonly taught that the superior aspect of the iliac crest is in the same plane as the L4 spinous process. In my experience, students in the early years of osteopathic education are frequently required to carry out this procedure in practical examinations of surface palpation and lumbar spinal techniques. However, this procedure lacks both reliability and accuracy. Sixty patients were assessed by four examiners with at least three years clinical experience in musculoskeletal medicine. A straight vertical line was drawn over the midline of the patient’s spine. For reliability, examiners
were required to mark the most superior aspect of the iliac crest bilaterally. A straight transverse line was then drawn between the two marks. The point at which that line bisected the vertical midline was also marked as the reference point. Reliability was estimated as the amount of discrepancy between the reference points obtained by each examiner, which ranged from 0.5 cm to 1.5 cm, with an average discrepancy of approximately 0.94 cm. In order to assess the accuracy of this test, a further 72 patients were examined. Radio-opaque markers were applied to the skin to indicate the superior aspect of the iliac crests bilaterally, and anteroposterior plain film radiographs of the lumbar spine were then taken of each patient. Transverse lines were drawn between the two radiopaque markers on each of the obtained radiographs, and the spinal level at which the line bisected the midline was identified. The data was reported in the form of frequency distribution of spinal levels at which the transverse line bisected the midline. The spinal levels estimated by the iliac crest method as confirmed by plain film imaging ranged from the L2-3 interspace to the L5 spinous process. In 10 out of 72 patients, the L4 spinous process was correctly identified; nine were correctly identified as the L4-5 interspace; and seven as the L5 spinous process. Collectively, these studies demonstrate that the reliability and accuracy of commonly used diagnostic and assessment procedures cannot be assumed. Experienced physiotherapists were not able to reliably identify which subjects had painful shoulders, which shoulder was symptomatic, or which movements were abnormal. Clinicians experienced in assessment of the motor function of the transversus abdominis and lumbar multifidus did not reach acceptable levels of agreement. Lastly, the method of using the iliac crest to identify the L4 spinous process has poor accuracy. Thankfully, it’s not all doom and gloom, as these last two articles demonstrate. The Stork test is a well-known assessment procedure for the assessment of pelvic arthrokinematics and load transfer. Hungerford et al. investigated the reliability of the Stork test when used on the support side.4 The procedure requires the patient to lift one leg into 90 degree of hip and knee flexion, whilst remaining standing on the contralateral leg (support side). Typically, the motion between the sacrum and innominate bone of the ‘lift’ leg is monitored; however, in this study the movement between the sacrum and innominate bone of the support leg was monitored. The test was considered abnormal if the PSIS on the support side was observed to move cephalad. Thirty-three subjects were examined by three physiotherapists. The subjects were either asymptomatic or had back or leg pain. When subjects were rated using a two-point scale (positive or negative) the reliability was good, with
International Journal of Osteopathic Medicine
kappa ranging from k 0.67 to k 0.77. When raters were asked to nominate if the PSIS moved cephalad, caudad or remained stationary, reliability was moderate (k 0.59). Lastly, in a large and important study conducted across 27 sites in the UK, McCarthy et al. investigated the reliability of the clinical tests and questions recommended in international guidelines for the assessment of low back pain.5 At each site (hospital), two physiotherapists independently assessed consecutive patients who presented with low back pain. Each assessment was conducted on the same day using a proforma-guided examination, and consisted of 50 clinical tests and questions. Each physiotherapist received only a one-hour explanation of the examination guide but had no specific training on how to perform the clinical tests. Two hundred and ninety five patients were examined by 54 physiotherapists. Of the 50 clinical tests and questions, only 14% obtained kappa estimates of less than k 0.40, with the remaining 86% achieving ‘fair’ reliability (k > 0.4). Given the modest training of each physiotherapist and the multitude of sites at which the study was conducted, this is a surprising but welcome outcome. Of course, it would have been more encouraging to see the majority of tests obtaining reliability greater than k 0.6; however this study provides evidence that the clinical assessment of patients with low back pain as recommended by international guidelines is useful. It is likely that the reliability of each test can be improved with increased training and standardisation between assessors. Osteopaths are frequently reminded that when it comes to somatic dysfunction, we are to find it, fix it, and leave it alone. Studies of diagnostic accuracy and reliability help us to understand how useful physical examination tests are for the purpose of ‘finding it’. We also use diagnostic tests to indicate if we have ‘fixed it’. Research into diagnostic procedures is inherently osteopathic, and is, in many ways, the new frontier. The challenge remains as to how best to incorporate the evidence into osteopathic practice and education. References 1. Hickey BW, Milosavljevic S, Bell ML, Milburn PD. Accuracy and reliability of observational motion analysis in identifying shoulder symptoms. Man Ther 2007;12: 263e70. 2. Sedaghat N, Latimer J, Maher C, Wisbey-Roth T. The reproducibility of a clinical grading system of motor control in patients with low back pain. J Manipulative Physiol Ther 2007;30:501e8. 3. Kim HW, Ko YJ, Rhee WI, Lee JS, Lim JE, Lee SJ, et-al. Interexaminer reliability and accuracy of posterior superior iliac spine and iliac crest palpation for spinal level estimations. J Manipulative Physiol Ther 2007;30:386e9.
4. Hungerford BA, Gilleard W, Moran M, Emmerson C. Evaluation of the ability of physical therapists to palpate intrapelvic motion with the Stork test on the support side. Phys Ther 2007;87:879e87.
5. McCarthy CJ, Gittins M, Roberts C, Oldham JA. The reliability of the clinical tests and questions recommended in international guidelines for low back pain. Spine 2007;32:921e6.
Is the response to chiropractic manipulation of the neck predictable? Clarissa Parry, The British School of Osteopathy, UK This study by Haymo Thiel et al. set out to identify the predictors of either immediate improvement or worsening in symptoms for which cervical spine manipulation is indicated.1 A large-scale, prospective cohort study was conducted to establish and document the incidence and nature of outcomes following chiropractic neck manipulation. All registered chiropractors who were members of the British and Scottish Chiropractic Associations were invited to participate and 377 (31.9%) took part. Standardised forms recorded details on symptoms, treatments and outcomes in patients who received at least one cervical spine manipulation (high velocity, low amplitude or mechanically assisted thrust). In all, data on 28,807 treatment consultations including cervical manipulation was collected. Three response categories were recorded; a) ‘‘immediate improvement’’ vs ‘‘no immediate improvement’’, b) ‘‘immediate worsening’’ vs ‘‘no immediate worsening’’, and c) ‘‘global improvement’’ vs ‘‘no global improvement’’. The immediate category consisted of change at the end of the treatment consultation in which the manipulation took place. The global category was change by the return visit up to seven days later. An immediate improvement in symptoms was noted in 70% of consultations. Stepwise multiple regression analysis identified the following predictors of immediate improvement:
Neck pain Shoulder/arm pain Reduced neck/shoulder/arm movement (stiffness) Headache Upper/mid back pain One or less presenting symptom
The presence of any 4 of these predictors raised the probability for an immediate improvement in presenting symptoms after treatment from 70% to 95%. However, if 5 of the predictors were present this probability fell to 60% ‘‘Stiffness’’ was the strongest single predictor for immediate improvement. A worsening of symptoms was reported in 4.4% of treatment consultations. Again, stepwise multiple regression analysis was employed to identify the most likely predictors of immediate worsening, these were:
Neck pain Shoulder/arm pain Headache Numbness/tingling of the upper limbs Upper/mid back pain Fainting/dizziness/light-headedness
The presence of any 4 of these predictors raised the post-treatment probability for an immediate worsening in presenting symptoms from 4.4% to 12%. The strongest predictors of immediate worsening were found to be fainting/ dizziness/light-headedness and numbness/tingling of the upper limbs. The data presented on global improvement is difficult to interpret purely because only 48% of the original 28,807 treatments were followed up within seven days. In discussing the results of their study the authors grapple with the complex nature of multiple predictors. As mentioned earlier, the number of predictors factored in to the predictive model could improve the predictive power of immediate response to treatment, but only up to a point. A 70% probability of immediate improvement occurred after manipulation for the whole sample, this rose to 85% if two of the identified predictors were present and to 95% if four were present. If all five predictor variables were entered into the model the probability of immediate improvement fell to 60%. They also note that, as can be seen, some of the same predictors can predict either improvement or worsening. These apparently paradoxical and somewhat contradictory findings are discussed by the authors in relation to the realities of International Journal of Osteopathic Medicine
clinical practice where the presence of multiple symptoms is often considered a poor prognostic indicator. Similarly they suggest that the same symptoms, but in varying combinations may be the reason for the same predictors being responsible for both worsening and improvement. The authors suggest that their results can help clinicians to predict responses to treatment and so could aid in clinical decision making when selecting cervical manipulation for patients with clusters of identified symptoms. This is indeed useful information. However the authors also state that this is a complex area, so using a simple tick-box approach to data collection may be premature. Finally, the authors of this large-scale study (involving 19,722 patients, and 377 chiropractors) should be congratulated, this was no small task! Reference 1. Thiel HWB, Jennifer E. Predictors for immediate and global responses to chiropractic manipulation of the cervical spine. J Manipulative Physiol Ther 2008:172e83.
The influence of musculoskeletal function on respiratory function variables Paddy Searle Barnes, The British School of Osteopathy, London, UK
(glenohumeral horizontal flexion, in 80e90 degrees of glenohumeral abduction and external glenohumeral rotation with elbow bent to meet the resistance applied by the research assistant). This isometric contraction was held for 6 s. The patient then relaxed and passive stretch in the Respiratory disease may cause opposite direction was applied. secondary effects in the musculoskel- The results of this intervention were etal system, and in particular respira- compared with a sham technique; at tory muscles, which may lead to the mid-range of glenohumeral flexion reduced efficiency of the ventilation and extension, the subject’s arm was system. There is good pathophysio- supported and the subject was asked logical justification that stretching is to try to bend the elbow to meet the beneficial, but there has been little resistance applied by the research prior evidence of its benefit in patients. assistant. Each intervention was Putt et al. explored the effects of a muscle stretching technique performed on patients with chronic obstructive pulmonary disease in a well-designed double blind crossover trial (both the patient and the assessor were blinded to the intervention performed).1 The study involved 14 patients with stable COPD who had recently completed a pulmonary rehabilitation programme, with 10 patients completing the study. A hold and relax stretching technique was applied to pectoralis major muscle. The subject was asked to move their arm in the agonist direction (glenohumeral horizontal extension, in 90 degrees of gleno-humeral abduction and external glenohumeral rotation with elbow bent). The subject was asked to contract the pectoral muscles to move the limb in the antagonistic direction
International Journal of Osteopathic Medicine
increasing range of movement in the chest and shoulder girdle, and an increase in vital capacity, and should be investigated further.
It is notable that changes made on day one with the hold and relax technique were maintained by the beginning of day two, though these effects disappeared over the next 3 days before performing the sham treatment. This is particularly significant when considering application to osteopathic practice with regard to frequency of treatment. However, as the authors point out, this study focused on one technique only, and it is possible that the combined effect of a series of repeated 6 times on each arm with rests intervention techniques would have of 30 s in between. One intervention a greater and more lasting effect. was performed on 2 consecutive days, Another study by Ghanbari et al. followed by a three-day rest period. The explored whether ‘forward shoulder alternative intervention was then per- posture’ had any effect on pulmonary formed on 2 consecutive days. capacities of women.2 The hypothesis
The primary outcome measure was vital capacity, and other measures assessed included perceived dyspnoea, axillary and xiphisternal chest expansion, right and left shoulder horizontal extension and respiratory rate. The hold and relaxed technique to the pectoralis major muscle produced significant effects on vital capacity (P < 0.01), and right (P < 0.01) and left (P < 0.05) upper limb range of motion. There was no significant effect on the chest expansion, perceived dyspnoea, or respiratory rate. The authors conclude that the hold and relax technique produces shortterm benefits in patients with COPD, by
suggested that people with forward shoulder posture (FSP) or ‘‘rounded shoulders’’ might have reduced lung capacities because of soft tissue shortening as a result of the shoulder posture. The shoulder posture was analysed using computer digitized photography. Spirometry was used to measure vital capacity, forced vital capacity and expiratory residual volume. 40 healthy female university students were analysed. Subject was excluded if they has a history of smoking, respiratory, cardio-vascular, neuromuscular or orthopaedic disease. The results seem
to show a correlation between the degree of FSP and respiratory values of the subjects. The observation is that such a postural feature reduces respiratory function variables. However, this study is published as a research letter, which by its nature is brief and the statistical information is limited. Further studies would be of value, to
quantify the significance and the exact motion in patients with chronic mechanism of the effects of FSP on obstructive pulmonary disease. Arch pulmonary function. Phys Med Rehabil 2008;89:1103e7. 2. Ghanbari A, Ghaffarinejad F, Mohammadi F, Khorrami M, Sobhani S. References Effect of forward shoulder posture on 1. Putt MT, Watson M, Seale H, pulmonary capacities of women. Br J Paratz JD. Muscle stretching technique Sports Med 2008;42:622e3. increases vital capacity and range of
Diagnosing myofascial trigger points: A critical review of the evidence and clinical implications Luke Rickards, Private Practice, France Myofascial trigger points (MTPs) are routinely diagnosed and treated by clinicians in many musculoskeletal health disciplines. MTPs have been associated with numerous clinical conditions and prevalence studies claim that they may account for 30e85% of patients complaining of regional muscular pain.1 Despite the widespread acceptance of MTPs as an important clinical entity the diagnosis of MTPs is a source of continuing controversy. There no accepted biochemical, electromyographic or diagnostic imaging criteria recognised as a definitive diagnostic gold standard.2 Furthermore, there is currently no reliable list of physical diagnostic criteria for MTPs.1 The detection of MTPs is solely dependent on manual palpation and patient feedback. These circumstances have raised concerns regarding the non-substantive manner in which MTPs are identified. In the absence of an accepted gold standard, physical diagnostic tests should demonstrate inter-rater reliability in order to be considered clinically useful. Myburgh et al.3 have recently published the first systematic review of reliability studies examining evidence for the use of manual palpation for identifying MTPs. The reviewers used a comprehensive search strategy across relevant medical databases and the reference lists of related articles. The search revealed eleven relevant studies; however five studies were subsequently excluded because they did not use appropriate statistical measures of agreement. The remaining six studies were then assessed for internal validity and reproducibility according to predetermined quality criteria. Criteria for establishing the levels of evidence (LOE) resulting from the analysis were also defined a priori. The included studies examined the use of manual diagnosis for MTPs in a variety of settings, populations, conditions and clinicians. This heterogeneity limited pooled analysis of the results. In addition, none of the studies used completely overlapping diagnostic criteria, and no single muscle was observed in more than two studies. The results of the quality analysis indicated two studies to be of high International Journal of Osteopathic Medicine
quality, one of moderate quality, and three of low quality. None of the MTP criteria were found to have a high LOE. At best, the current literature suggests moderate evidence for the reliability of local tenderness in the trapezius, and pain referral at gluteus medius and quadratus lumborum; however a single reliable criterion is insufficient to diagnose a MTP according to commonly cited diagnostic criteria. The authors concluded that the current evidence supporting the reliability of diagnostic palpation for MTPs is weak and further high quality studies are required. The clinical uncertainties surrounding MTP diagnosis present challenges to the interpretation of all research on MTPs. In the absence of an accurate diagnosis, the results of any epidemiological, pathophysiologic, or clinical investigation will be misleading.1 A potent example of this is seen in the subsequent issue of the same journal, where Ettlin et al.4 report on the prevalence cervical MTPs in four different clinical populations and a group of healthy controls. Having assumed that identification of each of the MTP characteristics is reliable, the researchers state that a clinically relevant MTP was present if three out four listed criteria were met. However, using this methodology it is possible that the diagnostic process would identify presentations other than MTPs, such as non-specific muscle pain, pain of peripheral nerve trunk origin, underlying joint sensitivity, secondary hyperalgesia, or even normal intramuscular physiology. It also explains their report of active MTPs in up to one third of the pain-free controls, which should be considered impossible considering that active MTPs are symptomatic by definition. Until both consensus and reliability of diagnostic criteria for identifying MTPs is achieved and implemented in research studies, data on the validity, prevalence, aetiology and treatment of MTPs should be interpreted with prudence. References 1. Tough EA, White AR, Richards S, Campbell J. Variability of criteria used to diagnose myofascial trigger point pain syndrome: evidence from a review of the literature. Clin J Pain 2007;23:278e86. 2. Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: a systematic review of the literature. Int J Osteopath Med 2006;9:120e36.
3. Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Arch Phys Med Rehabil 2008;89:1169e76.
4. Ettlin T, Schuster C, Stoffel R, Bru¨derlin A, Kischka U. A distinct pattern of myofascial findings in patients after whiplash injury. Arch Phys Med Rehabil 2008;89: 1290e3.
More data on the audible ‘click’ associated with joint manipulation David Evans, Warwick University, UK. Well-designed studies that investigate the basic science of manipulation in any joint are few and far between. Even less common are well-designed studies that investigate manipulation in spinal joints, which is why a study by Canadian chiropractor David Bereznick et al. is noteworthy.1 The study investigated a phenomenon known as the ‘refractory period’, which is a period of time that follows the audible ‘click’ sound associated with joint manipulation, during which it is not possible to elicit a second or subsequent click from the same joint. It is generally well accepted that the audible click is caused by an event termed cavitation, whereby the increase in volume in the enclosed joint capsule reduces the intra-articular pressure, which results in the formation of a bubble from gases dissolved in the synovial fluid.2,3 The refractory period is therefore likely to represent the time taken after cavitation, for the gases to dissolve back into the synovial fluid solution. Previous research has not studied this phenomenon at great depth or in a systematic manner, and the limited published information that does exist has been derived from metacarpophalangeal joints, typically describing the period to be in the region of 20 min.2,4 Bereznick’s study differs as they used a systematic approach to investigate the duration of the refractory period, and they used lumbar spine manipulation. To measure the refractory period, the researchers potentially could have designed their study in a number of ways. However, the difficulty of measuring the duration of this phenomenon is that taking a measurement will potentially alter the phenomenon being investigated; similar to the ‘observer effect’ in physics. Hence, they could not just re-attempt a manipulation every 10 min as the change in pressure in the joint would probably extend the time taken for gases to re-dissolve back into the synovial fluid. Therefore, the investigators decided to use a series of previously decided ‘time trials’ that they termed ‘potential refractory periods’, and did so over many days to avoid artefacts from previous manipulations (each test day occurred every third day for at least 34 days and two days were allowed between each test day for rest). Each of the 3 healthy subjects that volunteered were exposed to ‘baseline’ side-lying lumbar manipulations, until no further audible cracks were recorded (a minimum of 3 audible clicks had to be recorded). Further lumbar manipulations (on the same side) were then attempted after each potential refractory period, at which point the number of audible clicks was recorded. The refractory period was declared when a minimum of 50% of the baseline audible clicks had recovered during the test manipulations. Hence, it is worth noting that, in this study, the refractory period represented the entire side of the spine, rather than one single joint. The refractory period was different for each subject and, once identified for the entire lumbar spine, was fairly stable on further trials (even though there may have been some variation in individual joints). Furthermore, the duration of the refractory period in the lumbar spine was much longer than previous estimates based on metacarpophalangeal joints: 40 min for subject A; 70 min for subject B; and, 95 min for subject C. The average refractory period across subjects was 68.33 min, with a range of 55 min. Lastly, the number of audible clicks recorded during the many ‘exhaustive’ lumbar manipulations never exceeded 6, which lends further support to the zygapophysial joints being the source of the audible click. References 1. Bereznick DE, Pecora CG, Ross JK, McGill SM. The refractory period of the audible ‘‘crack’’ after lumbar manipulation: a preliminary study. J Manipulative Physiol Ther 2008;31:199e203. 2. Unsworth A, Dowson D, Wright V. ‘Cracking joints’. A bioengineering study of cavitation in the metacarpophalangeal joint. Ann Rheum Dis 1971;30:348e58. 3. Watson P, Kernohan WG, Mollan RA. A study of the cracking sounds from the metacarpophalangeal joint. Proc Inst Mech Eng [H] 1989;203:109e18. 4. Roston JB, Wheeler-Haines R. Cracking in the metacarpophalangeal joint. J Anat 1947;81:165e73.
International Journal of Osteopathic Medicine