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

Abstract

BackgroundWith 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.MethodsStructured 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.ResultsA 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.ConclusionsA 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.

Comparison of Supine and Prone Methods of Leg Length Inequality Assessment

“…This study did not include inter-examiner or intra-examiner modules, because prior studies had reported substantial reliability for both prone and supine leg checking procedures. 1,4 Although the leg checkers were very experienced in their respective prone and supine procedures, different leg checkers using somewhat different methods may have obtained different results. The lack of agreement between prone and supine leg checking results in this study may have been attributable either to variance between the methods per se or to different impacts of the patient's body position on LLIf; the design of the study did not allow discrimination between these alternative possibilities.…”

“…There are also leg checking protocols in which LLI is assessed as an evoked response, as when the head is turned or the knees flexed to 90°2 or when the examiner or patient makes contact with a part of the patient's body. 3 A review of the literature on the reliability and validity of measures used in manual therapy to localize the site of spinal manipulation 4 found varying levels of reliability for supine and prone LLI assessment procedures. [5][6][7][8][9][10][11][12][13][14][15][16][17][18] There was also some support for the validity of measures of supine and prone LLI.…”

Somatic dysfunction: An osteopathic conundrum

“…83 The diagnostic reliability of many of the indicators of somatic dysfunction is poor. [84][85][86] Palpation of tenderness has acceptable inter-examiner reliability, but reliability for palpation of segmental motion restriction or tissue texture changes is generally poor. [84][85][86] The reliability for assessment of asymmetrical bony landmarks is fair to poor, 87 unless substantial asymmetry exists.…”

“…[84][85][86] Palpation of tenderness has acceptable inter-examiner reliability, but reliability for palpation of segmental motion restriction or tissue texture changes is generally poor. [84][85][86] The reliability for assessment of asymmetrical bony landmarks is fair to poor, 87 unless substantial asymmetry exists. 88 Evidence suggests that consensus training can substantially improve the reliability of these findings between practitioners, 89,90 although the validity of these consensus findings still remains to be explored.…”

Training and certification of doctors of chiropractic in delivering manual cervical traction forces: Results of a longitudinal observational study

“…Students and clinicians typically master the delivery of manual therapies through a progression of lecture, laboratory sessions, and delivery to patients in clinical settings. [25][26][27][28][29][30][31][32][33][34][35] In educational settings, students often observe a teacher demonstrating a procedure, practice the technique on fellow student volunteers, and sometimes receive hands-on guidance and/or verbal feedback on their performance. [36][37][38] Researchers and educators have developed innovative bioengineering technologies, such as instrumented mannequins or treatment tables and other measurement devices, to provide objective feedback on forces, durations, and loading rates generated during SMT.…”