research and treatment bulletin

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International Journal of Osteopathic Medicine 12 (2009) 38e43

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RESEARCH AND TREATMENT BULLETINSection 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 researchNicholas Lucas, University of Western Sydney,Australia

While the focus is largely on diagnostic accuracy, there isan increasing awareness of the need to investigate thereliability of diagnostic tests. Poor reliability adverselyaffects the accuracy of diagnostic tests. If the accuracy ofthe test is not known, reliability is the only indicator wehave to designate if the test is useful. There are a numberof recent reliability studies of particular relevance toosteopaths; the first three report poor reliabilityoutcomes, and the last two report good outcomes.

Hickey et al.1 report on the reliability of observation forshoulder girdle dysfunction. In a well-designed study, 9subjects with shoulder girdle pain and 11 subjectswithout shoulder girdle pain were videotaped whilstperforming shoulder flexion, abduction, and scapularplane abduction. These video recordings were indepen-dently viewed by 11 manipulative (musculoskeletal)physiotherapists with graduate qualifications anda minimum of 5-years clinical experience.

The physiotherapists were asked to rate each subject atthree levels; (1) whether they thought the subject wassymptomatic; (2) if symptomatic, which shoulder was thesymptomatic shoulder; and (3) to identify the abnor-malities of movement that indicated that the shoulderwas symptomatic.

The results are surprising. Only 58% of 220 responsesregarding the symptom status of the subject werecorrect. While 71% of patients with left shouldercomplaints were correctly identified, only 30% ofpatients with right shoulder complaints were correctlyidentified. In terms of agreement between physiothera-pists, the kappa estimate for all subjects was only k 0.23.For the identication of abnormal movement, only vesubjects had two or more physiotherapists agree.

In another well-designed study, Sedaghat et al. report onthe reliability of a clinical grading system (Wisbey-Roth

rnal of Osteopathic Medicine

grading system) of motor control for patients with lowback pain based on the assessment of the activation andrecruitment of transversus abdominis and lumbar mul-tifidus.2 The assessment and rehabilitation of thesemuscles roared into popularity after it was demonstratedthat abnormal firing patterns and atrophy of groups ofmuscles occurs soon after the first onset of low backpain. Countless practitioners now use this model fortreatment and the phrase ‘core stability’ will be wellknown to many osteopaths.

Thirty-four subjects with chronic low back pain wererecruited for this study, and were assessed by four phys-iotherapists and one sports medicine physician. Theexperience of the assessors ranged from 3 years to 20 yearsand each reported that they frequently assessed the motorcontrol of the transversus abdominis and lumbar multi-fidus in private practice. Four of the five assessors had atleast 12 months experience in the assessment of motorcontrol. In addition, the assessors met twice and carriedout three pilot trials prior to the study in order to establishagreement 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. Theauthors conclude that the grading system they evaluatedshould not be used to exchange meaningful informationand make recommendations for improving the reliabilityof the assessment of motor control.

In the last of the three papers, Kim et al.3 report on thereliability and accuracy of landmarks of the pelvis toidentify spinal levels. It is commonly taught that thesuperior aspect of the iliac crest is in the same plane as theL4 spinous process. In my experience, students in the earlyyears of osteopathic education are frequently required tocarry out this procedure in practical examinations ofsurface palpation and lumbar spinal techniques. However,this procedure lacks both reliability and accuracy.

Sixty patients were assessed by four examiners with atleast three years clinical experience in musculoskeletalmedicine. A straight vertical line was drawn over themidline of the patient’s spine. For reliability, examiners

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were required to mark the most superior aspect of theiliac crest bilaterally. A straight transverse line was thendrawn between the two marks. The point at which thatline bisected the vertical midline was also marked as thereference point. Reliability was estimated as the amountof discrepancy between the reference points obtained byeach examiner, which ranged from 0.5 cm to 1.5 cm, withan average discrepancy of approximately 0.94 cm.

In order to assess the accuracy of this test, a further 72patients were examined. Radio-opaque markers wereapplied to the skin to indicate the superior aspect of theiliac crests bilaterally, and anteroposterior plain filmradiographs of the lumbar spine were then taken of eachpatient. Transverse lines were drawn between the tworadiopaque markers on each of the obtained radiographs,and the spinal level at which the line bisected the midlinewas identified. The data was reported in the form offrequency distribution of spinal levels at which thetransverse line bisected the midline.

The spinal levels estimated by the iliac crest method asconfirmed by plain film imaging ranged from the L2-3interspace to the L5 spinous process. In 10 out of 72patients, the L4 spinous process was correctly identified;nine were correctly identified as the L4-5 interspace; andseven as the L5 spinous process.

Collectively, these studies demonstrate that the reliabilityand accuracy of commonly used diagnostic and assessmentprocedures cannot be assumed. Experienced physiothera-pists were not able to reliably identify which subjects hadpainful shoulders, which shoulder was symptomatic, orwhich movements were abnormal. Clinicians experienced inassessment of the motor function of the transversusabdominis and lumbar multifidus did not reach acceptablelevels of agreement. Lastly, the method of using the iliaccrest to identify the L4 spinous process has poor accuracy.

Thankfully, it’s not all doom and gloom, as these last twoarticles demonstrate. The Stork test is a well-knownassessment procedure for the assessment of pelvicarthrokinematics and load transfer. Hungerford et al.investigated the reliability of the Stork test when used onthe support side.4 The procedure requires the patient tolift one leg into 90 degree of hip and knee flexion, whilstremaining standing on the contralateral leg (supportside). Typically, the motion between the sacrum andinnominate bone of the ‘lift’ leg is monitored; however, inthis study the movement between the sacrum andinnominate bone of the support leg was monitored. Thetest was considered abnormal if the PSIS on the supportside was observed to move cephalad.

Thirty-three subjects were examined by three physiother-apists. The subjects were either asymptomatic or had backor leg pain. When subjects were rated using a two-pointscale (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 wereasked to nominate if the PSIS moved cephalad, caudad orremained stationary, reliability was moderate (k 0.59).

Lastly, in a large and important study conducted across27 sites in the UK, McCarthy et al. investigated the reli-ability of the clinical tests and questions recommended ininternational guidelines for the assessment of low backpain.5 At each site (hospital), two physiotherapists inde-pendently assessed consecutive patients who presentedwith low back pain. Each assessment was conducted onthe same day using a proforma-guided examination, andconsisted of 50 clinical tests and questions. Each phys-iotherapist received only a one-hour explanation of theexamination guide but had no specific training on how toperform the clinical tests.

Two hundred and ninety five patients were examined by54 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 andthe multitude of sites at which the study was conducted,this is a surprising but welcome outcome. Of course, itwould have been more encouraging to see the majorityof tests obtaining reliability greater than k 0.6; howeverthis study provides evidence that the clinical assessmentof patients with low back pain as recommended byinternational guidelines is useful. It is likely that the reli-ability of each test can be improved with increasedtraining and standardisation between assessors.

Osteopaths are frequently reminded that when it comesto somatic dysfunction, we are to find it, fix it, and leave italone. Studies of diagnostic accuracy and reliability helpus to understand how useful physical examination testsare for the purpose of ‘finding it’. We also use diagnostictests to indicate if we have ‘fixed it’. Research into diag-nostic procedures is inherently osteopathic, and is, inmany ways, the new frontier. The challenge remains as tohow best to incorporate the evidence into osteopathicpractice and education.

References

1. Hickey BW, Milosavljevic S, Bell ML, Milburn PD. Accu-racy and reliability of observational motion analysisin identifying shoulder symptoms. Man Ther 2007;12:263e70.2. Sedaghat N, Latimer J, Maher C, Wisbey-Roth T. Thereproducibility of a clinical grading system of motorcontrol in patients with low back pain. J ManipulativePhysiol 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 supe-rior iliac spine and iliac crest palpation for spinal levelestimations. J Manipulative Physiol Ther 2007;30:386e9.

4. Hungerford BA, Gilleard W, Moran M, Emmerson C.Evaluation of the ability of physical therapists to palpateintrapelvic motion with the Stork test on the support side.Phys Ther 2007;87:879e87.


5. McCarthy CJ, Gittins M, Roberts C, Oldham JA. Thereliability of the clinical tests and questions recom-mended 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 insymptoms for which cervical spine manipulation is indicated.1 A large-scale, prospective cohort study was conducted toestablish and document the incidence and nature of outcomes following chiropractic neck manipulation. All registeredchiropractors who were members of the British and Scottish Chiropractic Associations were invited to participate and377 (31.9%) took part. Standardised forms recorded details on symptoms, treatments and outcomes in patients whoreceived 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 wererecorded; a) ‘‘immediate improvement’’ vs ‘‘no immediate improvement’’, b) ‘‘immediate worsening’’ vs ‘‘no immediateworsening’’, and c) ‘‘global improvement’’ vs ‘‘no global improvement’’. The immediate category consisted of change atthe end of the treatment consultation in which the manipulation took place. The global category was change by thereturn visit up to seven days later.

An immediate improvement in symptoms was noted in 70% of consultations. Stepwise multiple regression analysisidentified 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 symptomsafter treatment from 70% to 95%. However, if 5 of the predictors were present this probability fell to 60% ‘‘Stiffness’’ wasthe strongest single predictor for immediate improvement.

A worsening of symptoms was reported in 4.4% of treatment consultations. Again, stepwise multiple regression analysiswas 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 pre-senting 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 28,807treatments were followed up within seven days.

In discussing the results of their study the authors grapple with the complex nature of multiple predictors. As mentionedearlier, the number of predictors factored in to the predictive model could improve the predictive power of immediateresponse to treatment, but only up to a point. A 70% probability of immediate improvement occurred after manipu-lation for the whole sample, this rose to 85% if two of the identified predictors were present and to 95% if four werepresent. 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. Theseapparently paradoxical and somewhat contradictory findings are discussed by the authors in relation to the realities of

clinical practice where the presence of multiple symptoms is often considered a poor prognostic indicator. Similarly theysuggest that the same symptoms, but in varying combinations may be the reason for the same predictors beingresponsible for both worsening and improvement.

The authors suggest that their results can help clinicians to predict responses to treatment and so could aid in clinicaldecision making when selecting cervical manipulation for patients with clusters of identified symptoms. This is indeeduseful information. However the authors also state that this is a complex area, so using a simple tick-box approach todata 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 cervicalspine. J Manipulative Physiol Ther 2008:172e83.

The influence of musculo-skeletal function on respira-tory function variablesPaddy Searle Barnes, TheBritish School of Osteopathy,London, UK

Respiratory disease may causesecondary effects in the musculoskel-etal system, and in particular respira-tory muscles, which may lead toreduced efficiency of the ventilationsystem. There is good pathophysio-logical justification that stretching isbeneficial, but there has been littleprior evidence of its benefit in patients.

Putt et al. explored the effects ofa muscle stretching technique per-formed on patients with chronicobstructive pulmonary disease ina well-designed double blind crossovertrial (both the patient and the assessorwere blinded to the intervention per-formed).1 The study involved 14patients with stable COPD who hadrecently completed a pulmonary reha-bilitation programme, with 10 patientscompleting the study. A hold and relaxstretching technique was applied topectoralis major muscle. The subjectwas asked to move their arm in theagonist direction (glenohumeral hori-zontal extension, in 90 degrees ofgleno-humeral abduction and externalglenohumeral rotation with elbowbent). The subject was asked tocontract the pectoral muscles to movethe limb in the antagonistic direction


(glenohumeral horizontal flexion, in80e90 degrees of glenohumeralabduction and external glenohumeralrotation with elbow bent to meet theresistance applied by the researchassistant). This isometric contractionwas held for 6 s. The patient thenrelaxed and passive stretch in theopposite direction was applied.

The results of this intervention werecompared with a sham technique; atthe mid-range of glenohumeral flexionand extension, the subject’s arm wassupported and the subject was askedto try to bend the elbow to meet theresistance applied by the researchassistant. Each intervention wasrepeated 6 times on each arm with restsof 30 s in between. One interventionwas performed on 2 consecutive days,followed by a three-day rest period. Thealternative intervention was then per-formed on 2 consecutive days.

The primary outcome measure was vitalcapacity, and other measures assessedincluded perceived dyspnoea, axillaryand xiphisternal chest expansion, rightand left shoulder horizontal extensionand respiratory rate. The hold andrelaxed technique to the pectoralismajor muscle produced significanteffects on vital capacity (P< 0.01), andright (P< 0.01) and left (P< 0.05) upperlimb range of motion. There was nosignificant effect on the chest expan-sion, perceived dyspnoea, or respiratoryrate. The authors conclude that the holdand relax technique produces short-term benefits in patients with COPD, by

increasing range of movement in thechest and shoulder girdle, and anincrease in vital capacity, and should beinvestigated further.

It is notable that changes made on dayone with the hold and relax techniquewere maintained by the beginning ofday two, though these effects dis-appeared over the next 3 days beforeperforming the sham treatment. This isparticularly significant when consid-ering application to osteopathic prac-tice with regard to frequency oftreatment. However, as the authorspoint out, this study focused on onetechnique only, and it is possible thatthe combined effect of a series ofintervention techniques would havea greater and more lasting effect.

Another study by Ghanbari et al.explored whether ‘forward shoulderposture’ had any effect on pulmonarycapacities of women.2 The hypothesissuggested that people with forwardshoulder posture (FSP) or ‘‘roundedshoulders’’ might have reduced lungcapacities because of soft tissue short-ening as a result of the shoulder posture.The shoulder posture was analysedusing computer digitized photography.Spirometry was used to measure vitalcapacity, forced vital capacity and expi-ratory residual volume.

40 healthy female university studentswere analysed. Subject was excluded ifthey has a history of smoking, respira-tory, cardio-vascular, neuromuscular ororthopaedic disease. The results seem

to show a correlation between thedegree of FSP and respiratory values ofthe subjects. The observation is thatsuch a postural feature reduces respi-ratory function variables. However, thisstudy is published as a research letter,which by its nature is brief and thestatistical information is limited.Further studies would be of value, to


quantify the significance and the exactmechanism of the effects of FSP onpulmonary function.

References

1. Putt MT, Watson M, Seale H,Paratz JD. Muscle stretching techniqueincreases vital capacity and range of

motion in patients with chronicobstructive pulmonary disease. ArchPhys Med Rehabil 2008;89:1103e7.2. Ghanbari A, Ghaffarinejad F,Mohammadi F, Khorrami M, Sobhani S.Effect of forward shoulder posture onpulmonary capacities of women. Br JSports Med 2008;42:622e3.

Diagnosing myofascial trigger points: Acritical review of the evidence and clinicalimplicationsLuke Rickards, Private Practice, France

Myofascial trigger points (MTPs) are routinely diagnosed andtreated by clinicians in many musculoskeletal health disci-plines. MTPs have been associated with numerous clinicalconditions and prevalence studies claim that they mayaccount for 30e85% of patients complaining of regionalmuscular pain.1 Despite the widespread acceptance of MTPsas an important clinical entity the diagnosis of MTPs isa source of continuing controversy. There no acceptedbiochemical, electromyographic or diagnostic imagingcriteria recognised as a definitive diagnostic gold standard.2

Furthermore, there is currently no reliable list of physicaldiagnostic criteria for MTPs.1 The detection of MTPs is solelydependent on manual palpation and patient feedback.These circumstances have raised concerns regarding thenon-substantive manner in which MTPs are identified.

In the absence of an accepted gold standard, physicaldiagnostic tests should demonstrate inter-rater reliability inorder to be considered clinically useful. Myburgh et al.3 haverecently published the first systematic review of reliabilitystudies examining evidence for the use of manual palpationfor identifying MTPs. The reviewers used a comprehensivesearch strategy across relevant medical databases and thereference lists of related articles. The search revealed elevenrelevant studies; however five studies were subsequentlyexcluded because they did not use appropriate statisticalmeasures of agreement. The remaining six studies were thenassessed for internal validity and reproducibility accordingto predetermined quality criteria. Criteria for establishing thelevels of evidence (LOE) resulting from the analysis were alsodefined a priori.

The included studies examined the use of manual diag-nosis for MTPs in a variety of settings, populations, condi-tions and clinicians. This heterogeneity limited pooledanalysis of the results. In addition, none of the studies usedcompletely overlapping diagnostic criteria, and no singlemuscle was observed in more than two studies. The resultsof the quality analysis indicated two studies to be of high

quality, one of moderate quality, and three of low quality.None of the MTP criteria were found to have a high LOE. Atbest, the current literature suggests moderate evidence forthe reliability of local tenderness in the trapezius, and painreferral at gluteus medius and quadratus lumborum;however a single reliable criterion is insufficient to diag-nose a MTP according to commonly cited diagnosticcriteria. The authors concluded that the current evidencesupporting the reliability of diagnostic palpation for MTPsis weak and further high quality studies are required.

The clinical uncertainties surrounding MTP diagnosispresent challenges to the interpretation of all research onMTPs. In the absence of an accurate diagnosis, the resultsof any epidemiological, pathophysiologic, or clinicalinvestigation will be misleading.1 A potent example of thisis seen in the subsequent issue of the same journal, whereEttlin et al.4 report on the prevalence cervical MTPs in fourdifferent clinical populations and a group of healthycontrols. Having assumed that identification of each of theMTP characteristics is reliable, the researchers state thata clinically relevant MTP was present if three out four listedcriteria were met. However, using this methodology it ispossible that the diagnostic process would identifypresentations other than MTPs, such as non-specificmuscle pain, pain of peripheral nerve trunk origin, under-lying joint sensitivity, secondary hyperalgesia, or evennormal intramuscular physiology. It also explains theirreport of active MTPs in up to one third of the pain-freecontrols, which should be considered impossible consid-ering that active MTPs are symptomatic by definition. Untilboth consensus and reliability of diagnostic criteria foridentifying MTPs is achieved and implemented in researchstudies, data on the validity, prevalence, aetiology andtreatment of MTPs should be interpreted with prudence.

References

1. Tough EA, White AR, Richards S, Campbell J. Variabilityof criteria used to diagnose myofascial trigger point painsyndrome: evidence from a review of the literature. Clin JPain 2007;23:278e86.2. Rickards LD. The effectiveness of non-invasive treat-ments for active myofascial trigger point pain: a systematicreview 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 myo-fascial trigger points: evidence and clinical significance.Arch Phys Med Rehabil 2008;89:1169e76.


4. Ettlin T, Schuster C, Stoffel R, Bruderlin A, Kischka U.A distinct pattern of myofascial findings in patientsafter whiplash injury. Arch Phys Med Rehabil 2008;89:1290e3.

More data on the audible ‘click’ associated with joint manipulationDavid Evans, Warwick University, UK.

Well-designed studies that investigate the basic science of manipulation in any joint are few and far between. Even lesscommon are well-designed studies that investigate manipulation in spinal joints, which is why a study by Canadianchiropractor 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 fromthe same joint. It is generally well accepted that the audible click is caused by an event termed cavitation, whereby theincrease in volume in the enclosed joint capsule reduces the intra-articular pressure, which results in the formation ofa bubble from gases dissolved in the synovial fluid.2,3 The refractory period is therefore likely to represent the time takenafter 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 publishedinformation that does exist has been derived from metacarpophalangeal joints, typically describing the period to be inthe region of 20 min.2,4 Bereznick’s study differs as they used a systematic approach to investigate the duration of therefractory 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 potentiallyalter the phenomenon being investigated; similar to the ‘observer effect’ in physics. Hence, they could not justre-attempt a manipulation every 10 min as the change in pressure in the joint would probably extend the time takenfor gases to re-dissolve back into the synovial fluid. Therefore, the investigators decided to use a series of previouslydecided ‘time trials’ that they termed ‘potential refractory periods’, and did so over many days to avoid artefacts fromprevious manipulations (each test day occurred every third day for at least 34 days and two days were allowedbetween each test day for rest).

Each of the 3 healthy subjects that volunteered were exposed to ‘baseline’ side-lying lumbar manipulations, until nofurther 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 audibleclicks was recorded. The refractory period was declared when a minimum of 50% of the baseline audible clicks hadrecovered during the test manipulations. Hence, it is worth noting that, in this study, the refractory period representedthe 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 onfurther trials (even though there may have been some variation in individual joints). Furthermore, the duration of therefractory 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 was68.33 min, with a range of 55 min. Lastly, the number of audible clicks recorded during the many ‘exhaustive’ lumbarmanipulations never exceeded 6, which lends further support to the zygapophysial joints being the source of theaudible 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 metacarpophalangealjoint. Ann Rheum Dis 1971;30:348e58.3. Watson P, Kernohan WG, Mollan RA. A study of the cracking sounds from the metacarpophalangeal joint. Proc InstMech Eng [H] 1989;203:109e18.4. Roston JB, Wheeler-Haines R. Cracking in the metacarpophalangeal joint. J Anat 1947;81:165e73.

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