Only cervical vertebrae C0-C2, not C3 are relevant for subgrouping migraine patients according to manual palpation and pain provocation: secondary analysis of a cohort study

BACKGROUND

Subgrouping of migraine patients according to the pain response to manual palpation of the upper cervical spine has been recently described. Based on the neuroanatomy and the convergence of spinal and trigeminal nerves in the trigeminocervical complex, the cervical segments C1 to C3 are potentially relevant. To date it has not been investigated whether palpation results of all upper cervical segments are based on one underlying construct which allows combining the results of several tests. Therefore, the aim of this secondary analysis of a cohort study was to determine whether results from all three segments form one construct.

METHODS

Seventy-one migraine patients with chronic or frequent episodic migraine diagnosed according to the international headache society classification version 3 were examined by one physiotherapist. Manual palpation using a posterior to anterior pressure was performed on the upper three cervical vertebrae unilaterally left and right. The results of the palpation according to the patients' responses were combined using factor analysis. In addition, item response theory (IRT) was used to investigate the structure of the response pattern as well as item difficulty and discrimination.

FINDINGS

Factor analysis (principal component) showed that the palpation of C3 loads less onto the underlying construct than the palpation of C1 and C2. Considering a cut-off value > 1.0, the eigenvalues of all three segments do not represent one underlying construct. When excluding the results from C3, remaining items form one construct. The internal consistency of the pain response to palpation of C1 and C2 is acceptable with a Cronbach's alpha of 0.69. IRT analysis showed that the rating scale model fits best to the pain response pattern. The discrimination value (1.24) was equal for all items. Item difficulty showed a clear hierarchical structure between the palpation of C1 and C2, indicating that people with a higher impairment are more likely to respond with referred pain during palpation of C2.

CONCLUSION

Statistical analysis confirms that results from the palpation of the cervical segments C1 and C2 in migraine patients can be combined. IRT analysis confirmed the ordinal pattern of the pain response and showed the higher probability of a pain response during palpation of C2. The pain response to C3 palpation is not relevant for unidimensional IRT analysis.

TRIAL REGISTRATION

German registry of clinical trials (DRKS00015995), Registered 20. December 2018, https://www.drks.de/drks_web/setLocale_EN.do.

Reliability and validity of manual palpation for the assessment of patients with low back pain: a systematic and critical review

BACKGROUND

Static or motion manual palpation of the low back is commonly used to assess pain location and reproduction in low back pain (LBP) patients. The purpose of this study is to review the reliability and validity of manual palpation used for the assessment of LBP in adults.

METHOD

We systematically searched five databases from 2000 to 2019. We critically appraised internal validity of studies using QAREL and QUADAS-2 instruments. We stratified results using best-evidence synthesis. Validity studies were classified according to Sackett and Haynes.

RESULTS

We identified 2023 eligible articles, of which 14 were low risk of bias. Evidence suggests that reliability of soft tissue structures palpation is inconsistent, and reliability of bony structures and joint mobility palpation is poor. We found preliminary evidence that gluteal muscle palpation for tenderness may be valid in differentiating LBP patients with and without radiculopathy.

CONCLUSION

Reliability of manual palpation tests in the assessment of LBP patients varies greatly. This is problematic because these tests are commonly used by manual therapists and clinicians. Little is known about the validity of these tests; therefore, their clinical utility is uncertain. High quality validity studies are needed to inform the clinical use of manual palpation tests.

Inter- and Intra-Rater Reliability of Soft Tissue Palpation Scoring in the Equine Thoracic Epaxial Region

Back pain is a significant factor for horses and is challenging for professionals to diagnose, with assessment frequently using subjective tools such as manual palpation. Reliable and valid objective measures are required and use of a pressure algometer (PA) has been investigated as an assessment tool; however, it has limitations, and other more realistic methods may be better suited for the task. The aim of the study was to establish inter- and intra-rater reliability for PA, FlexiForce Sensor (FFS), and manual palpation for equine epaxial soft tissue, measuring mechanical nociception threshold responses. In group 1, 10 horses underwent three repeated tests with PA and FFS, and once for manual palpation, with three Association of Chartered Physiotherapists in Animal Therapy (ACPAT) Chartered Physiotherapists in the right thoracic epaxial region. Group 2 followed the same protocol using one ACPAT Chartered Physiotherapist and 22 horses. The order of palpation was randomly applied for each test and each experimenter. Manual palpation showed excellent interrater reliability with no significant differences between scores (P = .64; intraclass correlation coefficient [ICC] 90.0%). PA (P = .002) and FFS (P = .025) scores significantly differed between experimenters. Intrarater testing showed significant differences (P = .014) with horses increasing sensitivity over repeated PA measures. The FFS showed no significant differences (P = .347; ICC 94.7%) in repeated measures with excellent reliability and consistency. The PA showed a lack of consistency in intrarater reliability conflicting with previous research findings, whereas the FFS showed greater reliability in comparison; however, it proved difficult to use in clinical practice. Manual palpation by physiotherapists was shown to have excellent interrater reliability when using a categorical scoring system.

The impact on anatomical landmark identification after an ultrasound-guided palpation intervention: a pilot study

Background

To determine whether a discrepancy exists in identifying three musculoskeletal landmarks (medial meniscus, lateral malleolus and lateral epicondyle of the humerus) and whether ultrasound-guided (US-guided) palpation intervention can reduce that discrepancy and improve localization for chiropractic interns.

Methods

Sixteen chiropractic interns were asked to identify three subcutaneous anatomical landmarks before/ after the intervention and at a 3-day follow-up. The intervention was a three-minute US-guided demonstration of the landmarks after the intern’s initial localization. The primary outcome measure was the change in distance between the intern’s landmark identification. Non-normal data were analyzed with the Friedman’s and Wilcoxon signed rank tests. Discrepancy between examiner-determined landmarks and intern-identified landmarks at the initial time point was assessed with a 1-sample Wilcoxon signed rank test.

Results

All locations demonstrated an initial discrepancy between examiner-determined landmarks and intern-identified landmarks at the initial time point. Overall, a statistically significant difference was noted in the identification of the medial meniscus (p = 0.012) and lateral malleolus (p = 0.001), but not at the lateral epicondyle (p = 0.086). For the before and immediately after comparison, a significant improvement was found with the medial meniscus (p = 0.005) and lateral malleolus (p = 0.002). The 3-day post-intervention comparison found an improvement only for the lateral malleolus (p = 0.008).

Conclusion

This pilot study demonstrated palpatory discrepancy at identifying all three landmarks. Our data suggests that US-guided palpation intervention seems to improve an intern’s ability to palpate two landmarks (medial meniscus and lateral malleolus) post-intervention.

Variables Affecting Fusion Rates in the Rat Posterolateral Spinal Fusion Model with Autogenic/Allogenic Bone Grafts: A Meta-analysis

The rat posterolateral spinal fusion model with autogenic/allogenic bone graft (rat PFABG) has been increasingly utilized as an experimental model to assess the efficacy of novel fusion treatments. The objective of this study was to investigate the reliability of the rat PFABG model and examine the effects of different variables on spinal fusion. A web-based literature search from January, 1970 to September, 2015, yielded 26 studies, which included 40 rat PFABG control groups and 449 rats. Data regarding age, weight, sex, and strain of rats, graft volume, graft type, decorticated levels, surgical approach, institution, the number of control rats, fusion rate, methods of fusion assessment, and timing of fusion assessment were collected and analyzed. The primary outcome variable of interest was fusion rate, as evaluated by manual palpation. Fusion rates varied widely, from 0 to 96%. The calculated overall fusion rate was 46.1% with an I ² value of 62.4, which indicated moderate heterogeneity. Weight >300 g, age >14 weeks, male rat, Sprague-Dawley strain, and autogenic coccyx grafts increased fusion rates with statistical significance. Additionally, an assessment time-point ≥8 weeks had a trend towards statistical significance (p = 0.070). Multi-regression analysis demonstrated that timing of assessment and age as continuous variables, as well as sex as a categorical variable, can predict the fusion rate with R ² = 0.82. In an inter-institution reliability analysis, the pooled overall fusion rate was 50.0% [44.8, 55.3%], with statistically significant differences among fusion outcomes at different institutions (p < 0.001 and I ² of 72.2). Due to the heterogeneity of fusion outcomes, the reliability of the rat PFABG model was relatively limited. However, selection of adequate variables can optimize its use as a control group in studies evaluating the efficacy of novel fusion therapies.

Is manual palpation of the lung necessary in patients undergoing pulmonary metastasectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether manual palpation of the lung is necessary in patients undergoing pulmonary metastasectomy. In total, 56 articles were found using the described search strategy. After screening these articles and their references, 18 publications represented the best evidence to answer the clinical question. No randomized controlled trial addressing the three-part question was available. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers were tabulated. The studies reported on 1472 patients with different primary cancers. The patients underwent more than 1630 pulmonary metastasectomies between 1990 and 2014 after the treatment of primary cancer. Almost three quarters of patients underwent open procedures like thoracotomy or sternotomy. Most frequently, helical CT with a slice thickness ranging between 1 and 10 mm was used for preoperative imaging. The sensitivity in detecting pulmonary nodules ranged from 34 to 97%. The corresponding sensitivity rates for PET-CT were 66-67.5 and 75% for high-resolution CT. The positive predictive value for lesions detected by helical CT varied from 47 to 96%. Helical CT reached a specificity between 54 and 93% in detecting pulmonary nodules. The surgeons identified more nodules by meticulous palpation than helical CT. It is noteworthy that up to 48.5% of these palpated nodules were benign lesions (false-positive). 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. Thoracotomy allows the manual palpation of the ipsilateral hemithorax and might be superior to video-assisted thoracic surgery regarding radical resection. However, not all palpable nodules are malignant, and the impact of non-resected pulmonary metastases on patient survival is not clearly evaluated.