Health Outcomes of Deprescribing Interventions Among Older Residents in Nursing Homes: A Systematic Review and Meta-analysis.

Manipulative Therapy for Lower Extremity Conditions: Expansion of Literature Review

With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation. Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation. A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement. A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.

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Review of methods used by chiropractors to determine the site for applying manipulation

Manipulative therapy for lower extremity conditions: update of a literature review.

Study design. Cross-sectional baseline dataset on the sagittal standing posture of 1196 adolescents.
Objective. To describe and quantify common variations in the sagittal standing alignment in boys and girls who are in the same phase of growth, and to explore the association between habitual standing posture and measures for spinal pain.
Summary of Background Data. Data on postural characteristics and spinal pain measures in adolescence is sparse, especially when somatic and biological maturity status is to be considered. Furthermore, our understanding of the relation between standing posture in the sagittal plane and spinal pain is deficient.
Methods. Six hundred thirty-nine boys (mean ± SD age, 12.6±0.54 years) and 557 girls (10.6±0.47 years) with predicted years from peak height velocity (PHV) being 1.2±0.71 years and 1.2±0.59 years pre-PHV, respectively, were studied. Postural examination included the assessment of global alignment and local spinopelvic characteristics, using post-hoc analyses of digital images and direct body measurements (palpation, digital inclinometry, and wheeled accelerometry). Spinal pain experience was assessed by questionnaire.
Results. A wide interindividual variation in sagittal posture characteristics was observed. Logistic regression analyses yielded global alignment parameters to be associated with low back pain (lifetime prevalence), neck pain (lifetime prevalence, 1-month prevalence, and doctor visit), and thoracic spine pain (doctor visit) outcome measures. None of the included local spinopelvic parameters could be identified as an associated factor with measures of spinal pain.
Conclusions. The orientation of gross body segments with respect to the gravity line appear superior to local spinopelvic features in terms of clinical importance, at least in the current pre-PHV cohort. Opportunities may exist for postural subgrouping strategies to begin with global alignment parameters in order to gain further insight in the relationship between sagittal alignment and the relative risk of developing spinal pain/seeking medical consultation for this pain.

Sagittal Standing Posture and Its Association With Spinal Pain: A School-Based Epidemiological Study of 1196 Flemish Adolescents Before Age at Peak Height Velocity

Context: Establishing reliable palpatory tests continues to be a critical, yet elusive, step in osteopathic medical research and evidence-based clinical practice. Objective: The authors investigated the interobserver reliability of common osteopathic palpatory tests used to evaluate the lumbar spine. Design and Methods: Subjects (N=119) were recruited from the faculty, staff, and students of Kirksville (Mo) College of Osteopathic Medicine (KCOM) of A.T. Still University of Health Sciences. Three osteopathic medical examiners residency trained in neuromusculoskeletal medicine initially evaluated lumbar segments on subjects from one subgroup (n=42) in a blinded assessment. The examiners performed palpatory tests of tenderness and tissue texture changes, as well as—in three planes—vertebral positional asymmetry and motion asymmetry. Kappa statistics (! ) were used to evaluate interobserver reliability. Following a period of consensus training, subjects from another subgroup (n=77) were evaluated in a blinded assessment for those palpatory tests that seemed most likely to produce reliable findings. The interobserver reliability was then re-evaluated. Results: During the initial evaluation of interobserver reliability, ! ranged from " 0.02 to 0.34, within the poor-to-fair reliability range. Following consensus training, reliability improved, rising into the moderate range for tissue texture changes (! =0.45) and into the substantial range for tenderness assessments (! =0.68). Reliability for positional asymmetry in the transverse plane (! =0.34) and rotational motion asymmetry (! =0.20) were improved but remained in the fair range. Conclusion: The authors concluded that consensus training improved the interobserver reliability of common osteopathic palpatory tests of the lumbar spine. In two of the four tests that were studied—tissue texture and tenderness—acceptable ! values for clinical tests were achieved after consensus training.

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Interobserver reliability of osteopathic palpatory diagnostic tests of the lumbar spine: improvements from consensus training.

Palpatory Accuracy of Lumbar Spinous Processes Using Multiple Bony Landmarks

Study design The level of Tuffier's line was assessed on 200 standing and 60 prone lumbar radiographs. Sex, height, weight, and body mass index (BMI) were correlated with the radiograph findings. Objective To determine whether the level of Tuffier's line is associated with sex, height, weight, or BMI. Summary of background data Tuffier's line (intercristal line) is a commonly used landmark for identification of the L4-L5 interspace; however, multiple studies have identified that this landmark is unreliable. Methods The level of Tuffier's line was assessed retrospectively on 200 standing anteroposterior lumbar radiographs and correlated with sex. Prospectively, the level of Tuffier's line was assessed on 60 prone posteroanterior lumbar radiographs and correlated with sex, height, weight, and BMI. Results In men, the intercristal line most often intersected the L4 body or inferior endplate. In women, the intercristal line most often intersected the L5 body or superior endplate. Weight and BMI had no correlation with Tuffier's line. Subjects with a Tuffier's line through L4 were taller than those with a Tuffier's line through L5. Conclusion Tuffier's line demonstrated predictable sex-related differences: men had an intercristal line that most often intersected the L4 body or inferior endplate whereas the women's intercristal line most often intersected the L5 body or superior endplate. However, because the actual level of Tuffier's line may vary from the L4 body to the L5 body, the intercristal line is insufficient to use as the sole landmark for assessing spinal segmental level.

Reliability of Tuffier's line as an anatomic landmark.

Context Few studies have shown that diagnostic palpation is reliable. No studies have shown that the reliability of diagnostic palpatory skills can be maintained and improved over time. Objective To investigate whether the reliability of selected palpatory tests used to identify lumbar somatic dysfunction was maintained during a 4-month period as part of a clinical observational study. Methods Participants with low back pain and participants without low back pain, recruited from a rural Midwestern community, were examined during 6 separate sessions over a 4-month period. During each data collection session, two blinded examiners, who had previously completed comprehensive consensus training, evaluated the lumbar region with four tests: static segmental positional asymmetry of the transverse processes in the horizontal plane, tissue texture abnormalities, resistance to anterior springing on the spinous processes, and tenderness induced by pressure on the spinous processes. Detailed protocols for each test were defined during a previous comprehensive consensus training period and were not revised during the current study. To verify that established interobserver reliability was maintained throughout the clinical study, quality control sampling was performed on all data. When findings were inconsistent between the two examiners, focused consensus training was performed as a means of recalibration to understand why assessments were inconsistent. Interobserver reliability for determining the presence or absence of somatic dysfunction was assessed using kappa coefficients. Results The study enrolled 64 participants, and 14 to 33 participants were examined per session. All four tests had acceptable interobserver reliability by the final data collection session. The test for static segmental positional asymmetry of the transverse processes in the horizontal plane had moderate to substantial reliability in all 6 sessions. The test for tissue texture abnormalities had moderate reliability in 5 of the 6 sessions. The test for resistance to anterior springing on the spinous processes had moderate reliability for 3 of the 6 sessions. The test for tenderness had substantial to almost perfect reliability for all 6 sessions. In general, interobserver reliability improved over time. Conclusions Examiners were able to maintain and improve interobserver reliability of four lumbar diagnostic palpatory tests over a 4-month period.

Maintenance and improvement of interobserver reliability of osteopathic palpatory tests over a 4-month period.

Background: The use of manipulation has long been advocated in the treatment of chronic obstructive pulmonary disease (COPD), but few randomized controlled clinical trials have measured the effect of manipulation on pulmonary function. In addition, the effects of individual manipulative techniques on the pulmonary system are poorly understood. Therefore, the purpose of this study was to determine the immediate effects of four osteopathic techniques on pulmonary function measures in persons with COPD relative to a minimal-touch control protocol. Methods: Persons with COPD aged 50 and over were recruited for the study. Subjects received five, single-technique treatment sessions: minimal-touch control, thoracic lymphatic pump (TLP) with activation, TLP without activation, rib raising, and myofascial release. There was a 4-week washout period between sessions. Protocols were given in random order until all five techniques had been administered. Pulmonary function measures were obtained at baseline and 30-minutes posttreatment. For the actual pulmonary function measures and percent predicted values, Wilcoxon signed rank tests were used to test within-technique changes from baseline. For the percent change from baseline, Friedman tests were used to test for between-technique differences. Results: Twenty-five subjects were enrolled in the study. All four tested osteopathic techniques were associated with adverse posttreatment changes in pulmonary function measures; however, different techniques changed different measures. TLP with activation increased posttreatment residual volume compared to baseline, while TLP without activation did not. Side effects were mild, mostly posttreatment chest wall soreness. Surprisingly, the majority of subjects believed they could breathe better after receiving osteopathic manipulation. Conclusion: In persons with COPD, TLP with activation, TLP without activation, rib raising, and myofascial release mildly worsened pulmonary function measures immediately posttreatment relative to baseline measurements. The activation component of the TLP technique appears to increase posttreatment residual volume. Despite adverse changes in pulmonary function measures, persons with COPD subjectively reported they benefited from osteopathic manipulation.

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Eric J. Snider

Papers

Interobserver reliability of osteopathic palpatory diagnostic tests of the lumbar spine: improvements from consensus training.

Palpatory Accuracy of Lumbar Spinous Processes Using Multiple Bony Landmarks

Reliability of Tuffier's line as an anatomic landmark.

Maintenance and improvement of interobserver reliability of osteopathic palpatory tests over a 4-month period.

The immediate effect of individual manipulation techniques on pulmonary function measures in persons with chronic obstructive pulmonary disease