Manual physical assessment of spinal segmental motion: intent and validity

Validity of a clinical test can be defined as the extent to which the test actually assesses what it is intended to assess. In order to investigate the validity of manual physical assessment of the spine, it is therefore essential to establish what physical therapists intend to assess when they are applying these tests. The aims of this study were to (1) establish what manual physical therapists are intending to assess while applying passive intervertebral motion tests; and (2) examine the face validity and content validity for manual physical assessment of the spine. We surveyed 1502 members of the national manual physical therapist organisations of New Zealand and the United States of America using a web-based survey instrument. Sixty-six percent of 466 respondents believed passive accessory intervertebral motion (PAIVM) tests were valid for assessing quantity of segmental motion, and 76% believed passive physiologic intervertebral motion (PPIVM) tests were valid for assessing quantity of segmental motion. Ninety-eight percent of manual physical therapists base treatment decisions at least in part on the results of segmental motion tests. Quality of resistance to passive segmental motion was considered of greater importance than quantity of kinematic motion during PAIVM tests, while the quality of complex kinematic motion was considered of greater importance than quantity of displacement kinematics during PPIVM tests. Manual physical therapists accept the face validity of manual physical assessment of spinal segmental motion to a great extent, however a minority voice scepticism. Content validity is dominated by concepts of segmental kinematics and the force-displacement relationship. Intent of assessment does, however, vary widely between therapists. These data will inform the design of concurrent validity studies. Further work is recommended to increase consistency of intent, methodology and terminology in manual physical assessment of the spine.     

Reliability of accessory motion testing at the carpal joints

The testing of accessory motion has become a very important part of manual therapy practice. Its value is in assessing whether joint mobility is ideal or impaired. Despite its use, there is little evidence in the literature to support the reliability of such testing. Most of the research carried out on accessory motion testing has focused on the spine. In view of this we decided to evaluate the intra- and interrater reliability of accessory motion testing of carpal joints. Two skilled therapists tested the available motion and the end-feel response of carpal joints in 30 students and 15 patients on two separate occasions. Pain scores were also obtained. In students a moderate to good percentage of agreement [67-97%] was obtained for motion testing. In patients the percentage of agreement ranged from 60% to 100% and weighted kappa values were between 0.33 and 1.0. Intrarater reliability was better than interrater reliability in both groups. Intra- and interrater agreement on end-feel was very good. Overall, the reliability of accessory motion testing of carpal joints was acceptable. The results suggest that this form of testing can be valuable in the training of manual therapists and in clinical practice.     

Manual and manipulation techniques for rheumatic disease.

Table 1 summarizes many of the studies cited in this article. Can we specifically answer the question, "Does manipulation effectively treat musculoskeletal disorders and arthritis?" It is apparent that many individuals make decisions to see therapists who use manual techniques for pain relief and improved function even though few third-party payers cover such treatments. If this question could unequivocally be answered in the affirmative, these treatments would likely be reimbursed by the payers. The studies noted in Table 1 show mixed results for several conditions. Each study has its strengths and weaknesses, but the most powerful ones indicate that manual techniques are beneficial for back and neck pain when compared with no treatment or "placebo." Comparative studies against other techniques such as physical therapy, education, or exercise do not show a clear superiority for manual therapy, however. Thus, one would have to conclude that these techniques have usefulness, primarily as adjuncts to a comprehensive treatment program. Particularly, manual techniques are useful for painful conditions as a means to break the pain cycle and increase tolerance of exercise and other educational approaches. Although clinical trials do provide important information, they do not provide information on the mechanism by which the therapy assists in the healing process. Further work is needed to understand the mechanism by which manipulation affects pain and motion. Such research should clarify the discrepancies reported in the clinical trials and provide better designs for future studies.     

Perceptions and use of passive intervertebral motion assessment of the spine: a survey among physiotherapists specializing in manual therapy

Manual therapists commonly use passive intervertebral motion (PIVM) assessment within physical examination. Data describing the use and interpretation of this manual diagnostic procedure, as well as therapists' perception of related importance and confidence, are lacking. A survey was conducted among Dutch physiotherapists specializing in manual therapy (MT) using a 13-item, self-administered, structured questionnaire. Three hundred and sixty-seven questionnaires were analysed. Response rate from the postal part of the survey was 56%. Dutch manual therapists most frequently apply passive segmental motion assessment to the cervical region and they prefer three-dimensionally coupled motions. They consider end-feel or, to a lesser extent, provocation of patient's pain as decisive for diagnostic conclusions. Respondents believe that these spinal motion tests are important for treatment decisions and are confident in their conclusions drawn from it. These perceptions were largely stable across subgroups of therapists with different gender, age, experience, and educational background. Weekly amount of work related to spinal disorders was positively associated with perceived importance and confidence. Reported use and interpretation of PIVM assessment and related perceptions could only partly be substantiated by evidence. Results from this survey will help researchers design studies better reflecting daily practice in MT.     

Intrarater reliability of manual muscle testing and hand-held dynametric muscle testing

Physical therapists require an accurate, reliable method for measuring muscle strength. They often use manual muscle testing or hand-held dynametric muscle testing (DMT), but few studies document the reliability of MMT or compare the reliability of the two types of testing. We designed this study to determine the intrarater reliability of MMT and DMT. A physical therapist performed manual and dynametric strength tests of the same five muscle groups on 11 patients and then repeated the tests two days later. The correlation coefficients were high and significantly different from zero for four muscle groups tested dynametrically and for two muscle groups tested manually. The test-retest reliability coefficients for two muscle groups tested manually could not be calculated because the values between subjects were identical. We concluded that both MMT and DMT are reliable testing methods, given the conditions described in this study. Both testing methods have specific applications and limitations, which we discuss.     

Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice

Central sensitization plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how manual therapists can recognize this condition. Therefore, mechanism based clinical guidelines for the recognition of central sensitization in patients with musculoskeletal pain are provided. By using our current understanding of central sensitization during the clinical assessment of patients with musculoskeletal pain, manual therapists can apply the science of nociceptive and pain processing neurophysiology to the practice of manual therapy. The diagnosis/assessment of central sensitization in individual patients with musculoskeletal pain is not straightforward, however manual therapists can use information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize central sensitization. The clinical examination used to recognize central sensitization entails the distinction between primary and secondary hyperalgesia.     

Clinical reliability of manual muscle testing. Middle trapezius and gluteus medius muscles

The purposes of this study were to develop a protocol to examine the reliability of manual muscle testing in a clinical setting and to use that protocol to assess the interrater reliability of manually testing the strength of the middle trapezius and gluteus medius muscles. One hundred ten patients with various diagnoses participated as subjects, and 11 physical therapists participated as examiners in this study. The results showed that interrater reliability for right and left middle trapezius and gluteus medius muscles was low. The percentage of therapists obtaining a rating of the same grade or within one third of a grade ranged from 50% to 60% for the four muscles. This study indicates that using manual muscle testing to make accurate clinical assessments of patient status is of questionable value.     

Peak pressures during manual ventilation

INTRODUCTION: Manual (bag) ventilation sometimes achieves better oxygenation than does a mechanical ventilator. We speculated that clinicians might generate very high airway pressure during manual ventilation (much higher than the pressure delivered by a mechanical ventilator), and that the high airway pressure causes alveolar recruitment and thus improves oxygenation. Such high pressure might injure alveoli in some patients. METHODS: We tested the hypothesis that manual ventilation may involve substantially higher pressure than is delivered by a mechanical ventilator. We asked experienced respiratory therapists to manually ventilate a lung model that was set to represent several typical clinical scenarios. RESULTS: We found that the peak airway pressure generated by the therapists was sometimes in excess of 100 cm H(2)O. CONCLUSIONS: The high airway pressure during manual ventilation would be considered extreme in the context of conventional mechanical ventilation, which raises questions about whether manual ventilation causes barotrauma.     

The role and position of passive intervertebral motion assessment within clinical reasoning and decision-making in manual physical therapy: a qualitative interview study

Passive intervertebral motion (PIVM) assessment is a characterizing skill of manual physical therapists (MPTs) and is important for judgments about impairments in spinal joint function. It is unknown as to why and how MPTs use this mobility testing of spinal motion segments within their clinical reasoning and decision-making. This qualitative study aimed to explore and understand the role and position of PIVM assessment within the manual diagnostic process. Eight semistructured individual interviews with expert MPTs and three subsequent group interviews using manual physical therapy consultation platforms were conducted. Line-by-line coding was performed on the transcribed data, and final main themes were identified from subcategories. Three researchers were involved in the analysis process. Four themes emerged from the data: contextuality, consistency, impairment orientedness, and subjectivity. These themes were interrelated and linked to concepts of professionalism and clinical reasoning. MPTs used PIVM assessment within a multidimensional, biopsychosocial framework incorporating clinical data relating to mechanical dysfunction as well as to personal factors while applying various clinical reasoning strategies. Interpretation of PIVM assessment and subsequent decisions on manipulative treatment were strongly rooted within practitioners’ practical knowledge. This study has identified the specific role and position of PIVM assessment as related to other clinical findings within clinical reasoning and decision-making in manual physical therapy in The Netherlands. We recommend future research in manual diagnostics to account for the multivariable character of physical examination of the spine.     

Interexaminer reliability of observations in physical examinations of the neck

The purpose of this study was to collect data on interexaminer reliability of a set of tests representative of the clinical examination of a patient with neck and radicular pain. A conventional neurological examination, palpations, and tests for the provocation or relief of radicular symptoms were performed on 52 patients by two independent raters. Good reliability was obtained in the atrophy inspection of the small muscles of the hand, in the sensitivity tests for touch and pain, and in the neck compression and axial manual traction tests. Fair reliability was obtained in muscle strength testing and in the estimation of the range of motion, and poor reliability was obtained for many palpations. Poor standardization of examination procedures and changes in the patients' attention were considered the main factors affecting reliability. Better operational definitions and procedures, such as the standardization of palpation pressure and traction force, are suggested for future studies.     

Interpreting validity indexes for diagnostic tests: an illustration using the Berg balance test.

Physical therapists routinely make diagnostic and prognostic decisions in the course of patient care. The purpose of this clinical perspective is to illustrate what we believe is the optimal method for interpreting the results of studies that describe the diagnostic or prognostic accuracy of examination procedures. To illustrate our points, we chose the Berg Balance Test as an exemplar measure. We combined the data from 2 previously published research reports designed to determine the validity of the Berg Balance Test for predicting risk of falls among elderly people. We calculated the most common validity indexes, including sensitivity, specificity, predictive values, and likelihood ratios for the combined data. Clinical scenarios were used to demonstrate how we believe these validity indexes should be used to guide clinical decisions. We believe therapists should use validity indexes to decrease the uncertainty associated with diagnostic and prognostic decisions. More studies of the accuracy of diagnostic and prognostic tests used by physical therapists are urgently needed.     

Identifiers suggestive of clinical cervical spine instability: a Delphi study of physical therapists

BACKGROUND AND PURPOSE: Clinical cervical spine instability (CCSI) is controversial and difficult to diagnose. Within the literature, no clinical or diagnostic tests that yield valid and reliable results have been described to differentially diagnose this condition. The purpose of this study was to attempt to obtain consensus on symptoms and physical examination findings that are associated with CCSI. SUBJECTS: One hundred seventy-two physical therapists who were Orthopaedic Certified Specialists (OCS) or Fellows of the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT) participated in the survey. METHODS: This study was a 3-round Delphi survey designed to obtain consensual symptoms and physical examination findings for CCSI. RESULTS: The symptoms that reached the highest consensus among respondents were "intolerance to prolonged static postures," "fatigue and inability to hold head up," "better with external support, including hands or collar," "frequent need for self-manipulation," "feeling of instability, shaking, or lack of control," "frequent episodes of acute attacks," and "sharp pain, possibly with sudden movements." The physical examination findings related to cervical instability that reached the highest consensus among respondents included "poor coordination/neuromuscular control, including poor recruitment and dissociation of cervical segments with movement," "abnormal joint play," "motion that is not smooth throughout range (of motion), including segmental hinging, pivoting, or fulcruming," and "aberrant movement." DISCUSSION AND CONCLUSION: The Delphi method is useful in situations where clinical judgments are encountered but empirical evidence to provide evidence-based decision making does not exist. Findings of this study may provide beneficial clinical information, specifically when the identifiers are clustered together, because no set of clinical examination and symptom standards for CCSI currently exists. Diagnosis of CCSI is challenging; therefore, appropriate clinical reasoning is required for distinctive physical therapy assessment using pertinent symptoms and physical examination findings.     

Evaluation of the Usefulness of 2 Prediction Models of Clinical Prediction Models in Physical Therapy: A Qualitative Process Evaluation

Objective

The purposes of this study were to (1) evaluate the usefulness of 2 prediction models by assessing the actual use and advantages/disadvantages of application in daily clinical practice and (2) propose recommendations to enhance their implementation.

Methods

Physical therapists working in 283 practices in the area of Breda (the Netherlands) were invited to participate in this study. Two prediction models were presented: (1) to predict persistent shoulder pain and (2) to predict the preferable treatment in nonspecific neck pain. Participants were asked to apply both models in practice. After 2 months, their opinions about the usefulness of both models were gathered during a focus group meeting or by using an online questionnaire in order to identify the most important advantages/disadvantages of each prediction model.

Results

In total, 46 physical therapists (13.8%) of 39 practices participated. Evaluative data were available from 32 participants who used the shoulder model 102 times and the neck model 126 times. For the shoulder model, the most frequent advantage (mentioned 14 times) was that it enabled physical therapists to estimate a motivated prognosis, that is, a prognosis based on the score of the model. The most frequent mentioned disadvantage was that participants expressed their doubts about the validity of the model because the model initially was developed for usage in a general practice setting. For the neck model, the most frequently mentioned advantage (29 times) was that the model was easy to interpret. The most important disadvantage (mentioned 14 times) was that the model only takes a few treatment options into account.

Conclusions

The physical therapists participating in this study reported that both models evaluated in this study were not easy to use in daily practice. Based on the findings of this study, we recommend that these models are modified to meet the practical needs of the therapist, before assessing their impact on daily clinical care and patient outcomes.     

Reliability of testing measures in Duchenne or Becker muscular dystrophy

In a multiinstitutional collaborative study, we ascertained the interevaluator and intraevaluator reliability of six physical therapists who performed assessment measures on 36 boys (11.7 +/- 3.9 years) with Duchenne or Becker muscular dystrophy. Upper and lower extremities were evaluated by manual muscle testing for function, range of motion, and strength. The data were analyzed using intraclass correlation coefficients (ICCs). For the interevaluator phase, ICCs were as follows: average muscle strength, .90; range of motion, .76; and upper extremity functional performance, .58. For the intraevaluator phase, corresponding ICCs were .80 to .96; .33 to .97; .34 to 1.00. Our results confirm and extend observations by others that these assessment measures are sufficiently reliable for use in a multiinstitutional collaborative effort. Such results can be used to design clinical trials that have sufficient statistical power to detect changes in the rate of disease progression. Investigators planning clinical trials in a multiinstitutional collaborative setting should first standardize the assessment methods, provide evaluator training, and document reliability.     

Reliabilität der manualmedizinischen Tests bei Low Back Pain (LBP) Patienten

Numerous manual examinations are widely used in clinical practice. However, to gain widespread acceptance in clinical trials these tests need to meet certain psychometric standards. So far, evidence supporting the reliability of manual examination tests has been weak. The purpose of the present study was to evaluate interexaminer reliability in the assessment of manual tests commonly used in the physical examination of patients with low back pain (LBP). Two therapy centres were selected for each of three schools providing certified training in manual medicine for physicians in Germany. Experts agreed unanimously on the selection of 11 commonly used manual examination tests for this study, and criteria for interpretation of their results were defined. In each study centre, 40 LBP patients volunteered to undergo a physical examination performed by an experienced teacher of manual medicine. The sequence of the investigators was randomised for each patient. Cohen's kappa was calculated to evaluate the agreement between the raters' findings within and between schools. The results show good to moderate reliability of the tests between all raters. Agreement was better for pairs of examiners within any one school, and especially in the case of tests specific to a particular school. The reliability was higher for pain provocation tests than that for functional tests in all schools. Contradictory results, including both exceptionally good and very poor reliability, were nonetheless also reported. Both the level of education and training and the application of school-specific skills could be crucial to interpersonal agreement on manual diagnostic findings. Even experienced examiners could be trained intensively in the planning and performance of reliability studies. International standardisation in the definition of normal and pathologic results is essential before a core set of tests that meet psychometric criteria for use in research and clinical practice can be devised.     

Techniken der klinisch-manualmedizinischen Untersuchungen

Background

For structural disorders a differentiation must be made between impaired structures (reversible alterations) and destroyed structures (irreversible alterations). The latter can be objectified by means of x-ray imaging and laboratory investigations. The causes of reversible alterations are mostly functional disorders which are very difficult to diagnose but clinical manual medicine examinations can be useful.

Methods

The examination includes the patient history, inspection, palpation, provocation and function tests, sample treatment and various procedures for verification or exclusion of the clinically suspected diagnosis.

Results

Using a combination of diagnostic examinations the location and type of disrupted structure and the resulting manifestation of complaints can be determined.     

Practitioners' reading patterns, attitudes, and use of research reported in occupational therapy journals.

Occupational therapists are encouraged to use research-based evidence to guide practice. In this study, we investigated whether members of the American Occupational Therapy Association read their flagship journal, the American Journal of Occupational Therapy (AJOT, or other scholarly journals. Therapists' attitudes about research, their reading patterns, and their use of research in clinical practice were also explored. A proportional, random sample of 626 therapists from five states was mailed a questionnaire; 52% were returned. Of the 328 respondents, 85% reported reading AJOT: For those who did not read AJOT, barriers cited included time constraints, difficulty interpreting results, lack of clinical information, and too much scientific information. Attitudes about research generally were positive, although ratings regarding the usefulness of research to inform clinical practices were less favorable. Attitudes about and use of research ratings were not strongly related to practice settings, educational degree level, years of experience, or state of residence. Results suggest education and clinical practice changes may be necessary to support therapists' use of empirical evidence in practice contexts.     

The Application of a Token Reinforcement System to the Treatment of Stuttering in Children

The frequency of use and utility of aphasia tests was determined in the Brisbane metropolitan area by an audit and questionnaire. Fourteen speech pathologists who had assessed and treated at least five aphasic patients during a six month period participated in this survey. Of the 128 assessments coded in the audit stage, the most frequently used were the Aphasia Screening Test (Whurr, 1974), the Boston Diagnostic Aphasia Examination (Goodglass &; Kaplan, 1972), informal assessments, and the Boston Naming Test (Kaplan, Goodglass &; Weintraub, 1983). Therapists' comments about the clinical usefulness of these assessments are provided and in general reflect some dissatisfaction with this aspect of aphasia assessments. It is suggested that test developers need to place a higher priority on aspects of a test's utility, for example ensuring that the manual is clearly written and comprehensive, and that the pictures are of high quality.     

Articular dysfunction patterns in patients with mechanical neck pain: A clinical algorithm to guide specific mobilization and manipulation techniques

In view of a didactical approach for teaching cervical mobilization and manipulation techniques to students as well as their use in daily practice, it is mandatory to acquire sound clinical reasoning to optimally apply advanced technical skills. The aim of this Masterclass is to present a clinical algorithm to guide (novice) therapists in their clinical reasoning to identify patients who are likely to respond to mobilization and/or manipulation. The presented clinical reasoning process is situated within the context of pain mechanisms and is narrowed to and applicable in patients with a dominant input pain mechanism. Based on key features in subjective and clinical examination, patients with mechanical nociceptive pain probably arising from articular structures can be categorized into specific articular dysfunction patterns. Pending on these patterns, specific mobilization and manipulation techniques are warranted. The proposed patterns are illustrated in 3 case studies. This clinical algorithm is the corollary of empirical expertise and is complemented by in-depth discussions and knowledge exchange with international colleagues. Consequently, it is intended that a carefully targeted approach contributes to an increase in specificity and safety in the use of cervical mobilizations and manipulation techniques as valuable adjuncts to other manual therapy modalities.     

Who is treated using restrictive behavioral procedures?

Controversy about the use of restrictive behavioral procedures persists within the field of developmental disabilities. Many advocates and proponents of the use of exclusively nonrestrictive behavioral procedures have argued that restrictive procedures pose unacceptably high risks of adverse side effects and harm to the people who are treated with them. Yet, little is known about the extent to which procedures like timeout, manual restraint, and overcorrection are actually used in the treatment of people with developmental disabilities who manifest severe behavior disorders. In this article, data gathered on a national sample of people with developmental disabilities age 45 years and older are reviewed to ascertain the extent to which several restrictive procedures are being used in treatment. Findings indicate that these procedures are not being used in an indiscriminate manner.