Manual palpation of

Most frequently, helical CT with a slice thickness ranging between 1 and 10 mm was used for preoperative imaging. The surgeons identified more nodules by meticulous palpation than helical CT.

It is noteworthy that up to Patients with smaller imaged nodules, multiple imaged nodules or primary mesenchymal tumour are more likely to have occult pulmonary nodules.

We conclude that not all palpable pulmonary nodules can be imaged preoperatively. Therefore, the objectives of the present study were 1 to assess the reliability of manual assessment during the ADIM, and 2 to investigate the concurrent validity of manual assessment by calculating cut-off values assessed with US imaging. Consecutive participants with LBP symptoms were recruited via local advertisement and screened for eligible criteria between December and December To be included, they had to have a history of nonspecific LBP without lower extremity referral for longer than 1 year.

Exclusion criteria included: 1 Current pregnancy; 2 LBP with a specific underlying pathology such as tumor, infection, inflammatory disorders, hernia disc, or prolapsed disc; 3 signs consistent with nerve root compression, e.

The medical history from each patient was solicited from their primary care physician to assess the presence of the exclusion criteria. In addition, a sample of comparative healthy participants were also recruited. To be eligible to participate, they had to be between 18 and 65 years old and with no history of recurrent LBP and no episode of pain in the previous year.

The same exclusion criteria as for the LBP group were applied. Participants provided written informed consent prior to their inclusion in the study. Participants were asked 1 to avoid eating or drinking at least 2 h prior to each data collection session, 2 to empty their bladder immediately before each assessment, and 3 to avoid any physical activity the day before the assessment, particularly exercising the abdominal muscles.

Demographic data, including age, gender, body mass kg , height cm , body mass index BMI , past medical history and location, and nature of symptoms, were collected. Pain intensity and pain-related disability were also assessed using questionnaires. The total score arises from summing all answers 0—50 , multiplied by 2 to obtain a final index ranging from 0 no disability to maximum disability.

The Spanish version of the ODI has shown good reliability and internal consistency [ 20 ]. Participants received a training session where they were taught how to properly perform an abdominal drawing-in maneuver ADIM. The ADIM involves the drawing-in of the abdominal wall eliciting a concentric contraction of the deep abdominal muscles. The training session was conducted in quadruped.

First, participants were manually assisted in finding their neutral spine position and instructed to perform the ADIM by drawing the umbilicus toward their lumbar spine. This contraction was performed 5 times, holding each contraction for the duration of 2 normal breaths 10 s. After the training session, participants performed the ADIM twice in the supine hook-lying position as real testing 1 for manual palpation and 2 for ultrasound assessment.

Each subject was given a rest period of 2 min between each trial by different assessors and a rest period of 10 min between the type of assessments manual palpation or ultrasound. Ultrasound images were obtained with participants in the supine hook-lying position using a real-time ultrasound scanner Shenzhen Mindray Co, M7 model, Guangdong Province, China , with a MHz curvilinear probe. For assessing muscle thickness, the probe was placed transversely just above the iliac crest in the midaxillary line Figure 1 A.

The focal depth was manually adjusted on each participant, focusing on the OI muscle to maximize optimal visualization of the 3 abdominal muscles EO, IO, TrA.

Three images were obtained bilaterally at rest and on muscle contraction during the ADIM at the end of exhalation [ 23 ], and the mean of the 3 measurements was used for analysis. Since all LBP patients exhibited bilateral symptoms, the mean value of both sides was considered in the statistical analysis. Ultrasound probe placed transversely just above the iliac crest in the midaxillary line A ; Manual palpation of the transversus abdominis by placing the index and middle fingers just 2 cm B ; medial to the anterior superior iliac spine C.

Once the image was captured, it was transferred to offline ImageJ 1. Muscle thickness was measured as the distance between the inside borders of hyperechoic fascial layers of each muscle separately, without including fascia thickness. To consistently measure over the same point along all the muscles, measurements were conducted in a vertical line located 3 cm lateral to the rectus sheath muscle-fascia junction semilunaris line as previously described Figure 2 [ 25 ].

Ultrasound image of the deep abdominal muscles A ; Color mark of the deep abdominal muscles B ; Ultrasound measurements conducted in a vertical line located 3 cm lateral to the rectus sheath muscle-fascia junction semilunaris line C. The change in muscle thickness from rest to contraction during the ADIM was reported as an absolute value in millimeters mm and as a percentage of change.

It has been described that the preferential activation ratio determines the relative coactivation of the TrA in relation to EO and IO muscles. Two assessors, who received 60 h of education on US imaging and manual palpation, participated. For manual palpation, the assessor placed the index and middle fingers just 2 cm medial to the anterior superior iliac spine, in the anatomical projection of the deep abdominal muscles as is commonly done in clinical practice Figure 1 B. The contraction was considered positive when the assessor perceived a slow, deep, and bilateral tension in the anatomical projection of the deep abdominal muscles, without any compensatory pattern as previously described.

Manual palpation was conducted by each assessor on 2 different days with 7 days between. Each day, manual palpation was repeated 3 times by each assessor. A positive contraction was considered when 2 of 3 trials were perceived as having involved contraction.

Intrarater reliability was calculated from the assessment of each assessor on both days test-retest , whereas interrater reliability was calculated from assessment of both assessors on each day. In addition, ultrasound assessment was conducted once by each assessor to assess interrater reliability of muscle thickness the first day of assessment. Participants were repositioned on each assessment and the order of assessment and raters was numerically randomized. Every image was coded to blind the assessors using alphanumerical codes.

We assessed interrater reliability of ultrasound imaging of muscle thickness with the mean data obtained the first day by each assessor. Data analysis was performed using SPSS version Demographics and clinical characteristics data were assessed for normality by the Shapiro—Wilk test and visual inspection of histograms. A 2-way mixed-model, consistency-type intraclass correlation coefficient ICC3,1 was used to evaluate the interrater reliability of muscle thickness TrA, IO, and EO measurements on the total sample as a group and by gender , as well as independently for each group patients or controls.

To better understand reliability, observed and expected agreements are also reported along with prevalence and bias indices. Additionally, given that the kappa value is sensitive to imbalances in prevalence and bias, the prevalence-adjusted and bias-adjusted kappa PABAK were also calculated [ 31 ]. The PABAK calculation is a more restrictive reliability analysis performed by adjusting for high or low prevalence and computing the average of cells a and d in a cross table, substituting this value for the actual values in those cells.

Similarly, an adjustment for bias is achieved by substituting the mean of cells b and c for the actual cell values [ 32 ].

Reliability was defined according to the classification system proposed by Landis and Koch: Excellent 0. Concurrent validity was analyzed by evaluating the correlation between the manual palpation with muscle thickness ratios. The correlation was evaluated using Spearman correlation coefficients: Very high correlation 0. Furthermore, the validity of the manual palpation during the ADIM to perceive the positive contraction of the deep abdominal muscles was evaluated by comparing the results obtained by palpation by the assessors during the ADIM with muscle thickness ratios.

For the analysis, the average of the original and modified preferential activation ratios provided by each assessor was used. The current gold standard to determine activation of the TrA during the test is fine wire electromyography, which is invasive and was not used. To calculate the optimal cut-off point for TrA preferential activation ratio, we therefore generated a new dichotomous variable based on the relative MDC obtained from the present study data repeated from different days for the total sample.

Accordingly, we considered a positive performance of the ADIM if the participant generated a contraction of deep abdominal muscle, i. Therefore, by means of a ROC curve operating characteristics curve the optimum point for the original and modified preferential activation ratio was established, which can be used as a criterion variable to qualitatively determine the correct performance, as identified by manual palpation, of the ADIM.

This cut-off point was determined by means of the Youden index, and the diagnostic precision was evaluated according to the area under the ROC curve, with values above 0. Finally, using the calculated criterion variable, sensitivity and specificity data of manual palpation of the ADIM applied by each assessor were established. In addition, 16 comparative healthy participants were also included.

Demographic and clinical features are shown in Table 1. The interrater reliability for muscle thickness ranged from good to excellent for the total sample ICC ranging from 0. In general, interrater reliability was slightly higher in the healthy group than in the LBP patient group. Again, no significant gender differences were found. The interrater reliability of the ADIM ranged from good to excellent regardless of the total sample, gender, or group k : 0.

Deeper structures require increased pressure and should be performed in a firm but gentle manner. Anatomic landmarks commonly palpated are listed in Table Midline projection of posterior aspect of skull at junction of head and neck. Used as a reference landmark.

Adjustive contact points lateral to EOP are commonly used with occipital C0-C1 dysfunctions subluxations. C2 spinous process Posterior. First bony point palpated in midline inferior to EOP. Commonly used as an adjustive contact point and reference land mark. Tender with spinal fractures, infections, sprain or strains, neoplasia, and dysfunctions subluxations. C6 spinous process Posterior.

Moves anteriorly away from palpating finger during cervical extension; easily palpated in cervical flexion. Commonly used as an adjustive contact point and reference landmark. C7 spinous process Posterior. Most prominent spinous process in this region T1 may be the most prominent in some individuals ; C7 moves on T1 during cervical flexion and extension; C7 palpated throughout cervical flexion and extension.

Cervical facet joints Posterior. Palpated 1. Commonly used as an adjustive contact point. Soft tissues over these areas are commonly tender to palpation with facet joint sprains or strains, and dysfunctions subluxations.

C1 transverse process Lateral. Palpated between mastoid process prominence of temporal bone posterior to ear and angles of the jaw. Used as an adjustive contact point. Tender with common conditions such as spinal dysfunctions subluxations , sprains or strains, and postural syndromes. May be most prominent spinous process in this region; C7 moves on T1 during cervical flexion and extension; also located at the level of acromioclavicular joint. T3 spinous process Posterior. Lies at the middle of a line drawn between medial aspects of spine of scapulae.

T7-T8 spinous process Posterior. Lies at the middle of a line drawn between inferior borders of scapulae. T1-T4 transverse process Posterior. Palpated one interspinous space above spinous process lateral to midline.

T5-T8 transverse process Posterior. Palpated two interspinous spaces above spinous process lateral to midline. T9-T12 transverse process Posterior. Second rib Posterior. Palpated at superior border of scapula. Serves as a reference landmark. Seventh rib Posterior. Palpated at inferior border of scapula. Lies at the middle of a line drawn between the highest points of iliac crests. L4-L5 intervertebral disk Posterior.

Soft tissues over this area are tender to palpation with intervertebral disk injury and syndromes. Lumbar facet joints Posterior. Soft tissues over these areas are commonly tender to palpation with facet joint sprains or strains, and dysfunctions.

S2 spinous process sacral tubercle Posterior. Lies at the middle of a line drawn between PSIS. Serves as a reference landmark and as a contact point for adjustments. PSIS Posterior. Skin dimples superior and lateral approximately 4 cm from midline to intergluteal cleft. Commonly used as a reference landmark and as a contact point for sacroiliac adjustments. Tender to palpation with sacroiliac dysfunctions subluxations and sprains.

Tip of coccyx Posterior. Lies at the middle of a line drawn between ischial tuberosities approximately 2. Tender with fractures, sprains, and dysfunctions subluxation of the coccyx. Ischial tuberosity Posterior. Palpated in the inferior part of buttock when hip is flexed. Commonly used as a contact point for sacroiliac adjustments. Tender to palpation with conditions such as apophyseal injuries, fractures, bursitis, and hamstring tendinopathies ASIS Anterior. Palpated by tracing iliac crest anterior and inferior; easier to palpate with the person seated when muscles attachments are relaxed.

Serves as the superior attachment site for the inguinal ligament. Iliac tubercle Anterior. A phase II study tested the validity of the multifidus lift test with and without hand weights to identify abnormal isometric multifidus muscle contraction when compared to measurement with real-time ultrasound imaging of lumbar multifidus muscle thickness [ 22 ] Table 4. The authors reported that the multifidus lift test correlates with ultrasound finding at the L4—5 level r biserial correlation coefficient: 0.

Another phase II study investigated the validity of sciatic nerve palpation between the ischial tuberosity and the greater trochanter for pain using the straight leg raise and slump test as reference standard to evaluate mechanosensitivity of the sciatic nerve [ 28 ]. Finally, one phase III study investigated the validity of static palpation of gluteal muscle for taut band, tenderness and pain recognition compared to an expert panel confirmation of radicular LBP informed by MRI and electro-diagnostic testing.

The authors reported that static palpation of the gluteal muscle had a sensitivity of We reviewed the reliability and validity of manual palpation used to assess patients with LBP. We retrieved eleven studies on the reliability of static and motion palpation of joint and soft tissue.

Overall, the evidence suggest that static joint palpation is not reliable in identifying pain and segmental mobility of the lumbar facet joints, lumbar spinous processes and SI joints, and location of spinal level contributing LBP symptoms. However, static soft tissue palpation may help reliably identify gluteal tender points, sciatic nerve pain, and multifidus contraction but not lumbar paraspinal muscle pain.

We identified six validity studies for the assessment of LBP using static joint, joint motion and soft tissue palpation. Gluteal muscle palpation for pain was able to help identify differentiate LBP patients with or without radiculopathy phase III study.

We found preliminary evidence for the validity of the piriformis and lumbar paraspinal muscle palpation for pain phase I study , spinous and sacroiliac joint palpation for pain phase I study , sciatic nerve palpation for pain to identify mechanosensitivity of the sciatic nerve as determined by the straight leg raise and slump test phase II study and the multifidus lift test to help identify abnormal isometric contraction phase II study ; and against posterior to anterior palpation used to identify stiffness from L1-L5 spine levels phase II study.

Sacroiliac joint motion tests were not associated with sacroiliac pain provocation tests phase II study. Overall, very little knowledge is available to support the usefulness of palpation of the lumbar and sacroiliac test when examining patient with low back pain. The results of our systematic review differ from previous systematic reviews [ 9 , 11 , 13 ].

Our finding that static joint palpation of the spinous processes, facet and sacroiliac joints is not reliable to identify pain disagrees with previous systematic reviews [ 9 , 11 , 13 ]. Our review disagrees with the previous finding by Stochkendahl et al. Our review found inconsistent reliability to identify soft tissue pain with the inclusion of three recent studies [ 22 , 24 , 28 ]. The different conclusions may be due to different search strategies, new evidence, inclusion of small sample studies, use of self-developed checklists, or use of predefined cut-off points to differentiate low and high quality studies in the four systematic reviews.

However, our results are consistent with a systematic review published in focusing only on segmental motion palpation [ 74 ]. Poor evidence regarding reliability and validity of segmental motion testing were reported and clinical use of stand-alone tests cannot be recommended [ 74 ]. Our systematic review has several strengths. First, our comprehensive search strategy of multiple databases was developed by a health sciences librarian in consultation with content experts and was then reviewed by an independent health sciences librarian using the PRESS Checklist [ 18 ].

Second, we used detailed, predefined inclusion and exclusion criteria to capture a diffuse range of possibly relevant citations. Third, we used paired independent reviewers to screen and critically appraise citations to minimize bias and error. Fourth, bias in reported results was minimized by performing a best-evidence synthesis that included only high-quality studies.

Finally, we only included studies that tested subjects with LBP. This makes our results more generalizable to the patients seen by practitioners in clinical practice. Our review also had limitations. First, our search was limited to studies published in English and French languages.

It is possible that relevant studies in other languages may have been excluded. Second, our search may not have retrieved all relevant studies, although our search strategy was comprehensive and the search was conducted in multiple major medical databases. Third, our search was limited to studies published after Fourth, it is possible that individual differences in scientific judgment could have resulted in varied critical appraisal outcomes among reviewers.

This bias was minimized using training with the standardized assessment tools and a consensus process for determining internal validity of studies. This may have limited the precision of the results and led to uncertainty in our assessment of motion palpation tests.

Our review found very little evidence for the use of manual palpation to assess low back pain patients. Manual palpation tests suffered from misclassification error in that they were unable to differentiate those with LBP to subjects without LBP. Soft tissue palpation of the sciatic nerve, gluteal muscles for pain and the multifidus muscle for isometric contraction were reliable but have not been tested sufficiently for their validity for use in clinical practice.

Although we did find that gluteal muscle palpation of trigger points and taut bands is valid to differentiate LBP patients with or without radiculopathy in a clinical setting. We found very limited evidence to support the use of joint palpation and clinician should reconsider its diagnostic value when assessing patients with low back pain.

We synthesize the evidence on the reliability and validity of manual palpation to assess adults with LBP. The evidence does not support reliability of joint palpation but static soft tissue palpation is reliable. There is little evidence on the motion joint palpation used in LBP patients. Gluteal muscle palpation for pain was able to differentiate LBP patients with or without radiculopathy phase III study. We found preliminary evidence from Phases I and II validity studies for some palpation tests.

High quality phase III and IV validity studies are required to understand the diagnostic value of manual palpation tests in the assessment of adults with LBP. Clinicians must reconsider the usefulness of these tests when examining patients. Global, regional, and national incidence, prevalence, and years lived with disability for diseases and injuries, — a systematic analysis for the global burden of disease study Article Google Scholar.

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