RESEARCH NEWS
Static palpation is widely used by chiropractors and manual therapists, but is it reliable? By: Amber Beynon B.Sc. (Hons), B.Chiro Static palpation is commonly used by chiropractors and manual therapists, however, it is not really known if it is reliable or not, particularly within the thoracic spine. The authors set out to determine the agreement of thoracic spine static palpation to test for a manipulable lesion using stiffness or tenderness as diagnostic markers, and determine the effect of standardised training for examiners. They also wanted to explore if there was an expert consensus on the level of segmental tenderness required to locate a “manipulable lesion”. The authors used two experienced chiropractors to palpate the thoracic vertebrae on two occasions (pragmatic and standardised approaches), asking the participant about tenderness and judging segmental stiffness (N=36). Additionally, an expert panel of 10 chiropractors took part in a Delphi process to identify the level of meaningful segmental tenderness required to locate a “manipulable lesion”.
Overall, the reliability for stiffness when adjusted ranged from slight to substantial agreement, with moderate or substantial agreement demonstrated at the majority of spinal levels. Generally, there was fair to substantial agreement for segmental tenderness. Training did not significantly improve interrater agreement for stiffness or tenderness suggesting that the pragmatic approaches used by two experienced chiropractors were equivalent. The Delphi process indicated that a pain score of 2 out of 10 identified a potential “manipulable lesion” suggesting that tenderness should not just be a yes/no question. In a study of this nature, it seems preferable to use the NPRS and a potential manipulable lesion is scored as a pain score above 2 out of 10.
There was overall moderate reliability for static palpation for stiffness and tenderness, with tenderness showing a higher level of reliability. The findings lined up with many previous studies in that tenderness was more reliable than just testing for stiffness. The study did however actually find higher agreement for static palpation then many others as within the analysis they accounted for certain biases that can occur within reliability analysis. Nevertheless, segmental assessment for stiffness alone is not sufficiently reliable but improves when considering a region (multi-levels of vertebrae). Summing up clinically, the advice is to assess your patient for more than just stiffness and ask the patient about tenderness as well.
Interestingly there was a higher level of reliability of static palpation within the mid-thoracic spine when assessing for stiffness. The authors speculate that the anatomy of the thoracic spine in the mid-region may be easier to palpate given its flexibility to anterior forces in a prone position.
Beynon AM, Hebert JJ, Walker BF. The interrater reliability of static palpation of the thoracic spine for eliciting tenderness and stiffness to test for a manipulable lesion. Chiropractic & Manual Therapies. 2018 Dec;26(1):49.
Manipulation-induced hypoalgesia in musculoskeletal pain populations: a systematic critical review and meta-analysis By: Sasha Aspinall B.Sc. (Chiro), B.Sc. (Hons), B.Chiro Reduced pain sensitivity after spinal manipulation has been observed in both symptomatic and asymptomatic populations. But we don’t yet have any convincing evidence about whether changes in pain sensitivity after spinal manipulation are specific to the treatment and clinically relevant. So we decided to perform a systematic critical review with meta-analysis with the purpose of investigating changes in quantitative sensory testing measures following high-velocity lowamplitude spinal manipulation in musculoskeletal pain populations. Our objectives were to compare changes in quantitative sensory testing outcomes after spinal manipulation vs. sham, control and active interventions, to estimate how much pain sensitivity changed over time, and to determine whether changes were systemic or not. We were able to include fifteen randomised controlled trials, of which thirteen measured pressure pain threshold (PPT). Four of the PPT studies were sham-controlled. Our first metaanalysis found that there was no difference in the change in PPT after spinal manipulation compared to sham manipulation. In contrast,
our second meta-analysis found that PPT increased significantly over time after spinal manipulation by a mean of 0.32 kg/cm2, which occurred systemically. Unfortunately, there were not enough studies comparing to other interventions, or for other types of quantitative sensory tests, to make robust conclusions about these. So to summarise, we found that while PPT decreased throughout the whole body after SMT in people with musculoskeletal pain, our meta-analysis provided low quality evidence that this is not significant when compared to sham manipulation. We have some concerns with the sham manipulations that were used, and the studies were generally a bit disappointing in their quality, so we can’t be really confident with this result. We noticed though that changes in PPT didn’t seem to occur at all after lumbar manipulation, so there could also be a difference in how different spinal regions respond to manipulation.
tests like PPT is not clear. We have evidence that people with chronic pain problems tend to have increase pain sensitivity compared to people without ongoing pain, but we don’t know whether changes in pain sensitivity after particular treatments relate to symptomatic improvement in patients. So when you put that together with our result suggesting there might not be a difference compared to sham, we really can’t make any clinical recommendations off the back of this research. We believe that future research in this area should really focus on high-quality sham-controlled trials, on the clinical relevance of changes in quantitative sensory tests, and on other types of quantitative sensory tests like temporal summation. Aspinall SL, Leboeuf-Yde C, Etherington SJ, Walker BF. Manipulation-induced hypoalgesia in musculoskeletal pain populations: a systematic critical review and meta-analysis. Chiropractic & Manual Therapies. 2019 Dec;27(1):7.
From a clinical perspective, a big sticking point is that the clinical relevance of quantitative sensory W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U
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