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OBJECTIVE: This is a report of the results of 4 facilitated workshops aimed at developing a standardized chiropractic technique curriculum. METHODS: Workshops were held at research conferences during 2014, 2016, 2018, and 2019. Participants were tasked with developing recommendations for diagnostic and therapeutic procedures appropriate for chiropractic technique programs. RESULTS: For diagnostic procedures, there was general agreement among participants that chiropractic programs should include diagnostic imaging, postural assessment, gait analysis, palpation (static, motion, and joint play/springing), global range of motion, and evidence-based orthopedic/neurological tests. No consensus could be reached with respect to chiropractic x-ray line marking (spinography) nor heat sensing instruments, and there was only partial consensus on leg length assessment. For therapeutic procedures, all participants agreed that the following should be included: high-velocity, low amplitude spinal and extremity manipulation, adjustments assisted by hand-held instruments, drop tables, flexion-distraction tables, and pelvic blocks. There was unanimous support for teaching mobilization of the spine and peripheral joints, as well as for manual and instrument-assisted soft tissue therapies. There were some overarching issues: participants strongly preferred assessment methods known to be reliable and valid and therapeutic procedures known to be safe and effective. Where evidence was lacking, they insisted that diagnostic and therapeutic methods at minimum have face validity and biological plausibility. However, they cautioned against applying aspects of evidence-based care too rigidly. CONCLUSIONS: Despite differing views on chiropractic terminology, philosophy, and scope of practice, participants' opinions were similar regarding diagnostic and therapeutic procedures that ought to be included in chiropractic technique programs.

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This is a secondary analysis of two previous systematic reviews demonstrating cephalad bias in using palpation to enumerate lumbopelvic levels, based on the conventional landmark rule that the spinal level of the palpated iliac crests=L4. Our study included 7 articles which enumerated lumbopelvic levels based on this rule, and furthermore reported data such that the direction and magnitude of errors could be abstracted from the article. The primary goal was to determine if enumeration accuracy would have improved had examiners known that the spinal level of palpated crests was closer to the L3-4 or L3 spinal level, as shown in our previous review. For the articles included, the mean error in spinal level enumeration diminished from 0.79 to -0.21 spinal levels, while accuracy increased from 26.3% to 46.9%. Since accuracy remained <50%, further refinements in iliac crest palpation are unlikely to improve enumeration accuracy, suggesting another method might best be sought.

Il s'agit d'une analyse secondaire de deux études méthodiques antérieures démontrant un biais céphalique dans l'utilisation de la palpation pour dénombrer les niveaux lombopelviens, basée sur la règle repère conventionnelle selon laquelle le niveau spinal des crêtes iliaques palpées est de L4. Notre étude comprenait sept articles qui énuméraient les niveaux lombopelviens basés sur cette règle, et qui, de plus, rapportaient des données telles que la direction et l'ampleur des erreurs. Ces éléments peuvent être extraits des articles. L'objectif principal était de déterminer si l'exactitude du dénombrement se serait améliorée si les examinateurs avaient su que le niveau spinal des crêtes palpées était plus près du niveau spinal L3­4 ou L3, comme nous l'avons démontré dans notre étude précédente. Pour les articles en question, l'erreur moyenne dans le dénombrement du niveau spinal a diminué de 0,79 à −0,21, tandis que la précision a augmenté de 26,3 % à 46,9 %. Étant donné que la précision est restée inférieure à 50 %, il est peu probable que d'autres améliorations dans la palpation de la crête iliaque augmentent la précision du dénombrement, ce qui suggère la recherche d'une autre méthode.

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OBJECTIVES: The purpose of this study was to assess the interexaminer reliability of palpation for stiffness in the cervical, thoracic, and lumbar spinal regions. METHODS: In this secondary data analysis, data from 70 patients from a chiropractic college outpatient clinic were analyzed. Two doctors of chiropractic palpated for the stiffest site within each spinal region. Each were asked to select the stiffest segment and to rate their confidence in their palpation findings. Reliability between examiners was calculated as Median Absolute Examiner Differences (MedianAED) and data dispersion as Median Absolute Deviation (MAD). Interquartile analysis of the paired examiner differences was performed. RESULTS: In total, 210 paired observations were analyzed. Nonparametric data precluded reliability determination using intraclass correlation. Findings included lumbar MedianAED = 0.5 vertebral equivalents (VE), thoracic = 1.7 VE, and cervical = 1.4 VE. For the combined dataset, the findings were MedianAED = 1.1 VE; MAD was lowest in the lumbar spine (0.3 VE) and highest in thoracic spine (1.4 VE), and for the combined dataset, MAD = 1.1 VE. Examiners agreed on the segment or the motion segment containing the stiffest site in 54% of the observations. CONCLUSIONS: Interexaminer reliability for palpation was good between 2 clinicians for the stiffest site in each region of the spine and in the combined dataset. This is consistent with previous studies of motion palpation using continuous analysis.

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OBJECTIVE: The purpose of this study was to quantify the extent to which apparent movements of the posterior superior iliac spine and sacral base areas Gillet sacroiliac motion testing were related to (a) degree of hip flexion and (b) the examiner's palpatory pressure. METHODS: A preliminary exploratory study quantified relative PSIS/S2 displacements in 10 sacroiliac joints among 5 asymptomatic subjects at 10° increments of hip flexion from 0-90°. A comprehensive follow-up asymptomatic study quantified PSIS/S2 displacements at 0° vs. 30° vs. 90° hip flexion, and for light vs. firm pressure at 30° hip flexion. Displacements measured in pixels on digital photographs were transformed to mm. Mean differences for the various test conditions were evaluated for statistical significance using paired t-testing and Wilcoxon signed rank test. RESULTS: With light pressure, the left PSIS moved caudal for hip flexion ≤30° during right-legged stance, whereas the right PSIS moved cephalad relative to the sacral base. For hip flexion =90°, both PSISs moved cephalad. The use of firm palpatory pressure abolished the initial caudal movement of the left PSIS, as well as differences in the amount of cephalad PSIS movement at 30° vs. 90° hip flexion. CONCLUSIONS: The results are consistent with there being left-right differences in gluteus medius and biceps femoris activation among asymptomatic individuals that result in different balancing strategies during one-legged stance. This may create the appearance of relative PSIS/SB displacement, even though the results of Gillet testing can be wholly or partially explained by pelvic obliquity owing to muscle function asymmetry. This study questions the validity of the upright Gillet test for sacroiliac motion.

OBJECTIF: Cette étude visait à déterminer dans quelle mesure les déplacements de l'épine iliaque postéro-supérieure (EIPS) par rapport à la base sacrée durant le test de la mobilité sacro-iliaque de Gillet étaient reliés a) au degré de flexion de hanche et b) à la pression palpatoire exercée par l'examinateur. MÉTHODOLOGIE: Une étude exploratoire préliminaire avait consisté à mesurer les déplacements relatifs de l'EIPS par rapport à S2 dans 10 articulations sacroiliaques chez 5 sujets asymptomatiques, en augmentant progressivement par palier de 10 degrés la flexion de hanche, à partir de 0° jusqu'à 90°. Une étude de suivi chez des patients asymptomatiques a consisté à mesurer les déplacements de l'EIPS par rapport à S2 lorsque la flexion de hanche était de 0°, de 30° et de 90°, quand l'examinateur exerçait une pression légère et une pression forte et que la flexion de hanche était de 30°. Les déplacements exprimés en pixels sur des photographies numériques ont été convertis en millimètres. Les différences moyennes entre les diverses conditions du test ont été évaluées par tests t pour échantillons appariés et par test des rangs signés de Wilcoxon. RÉSULTATS: Quand l'examinateur exerçait une pression légère, l'EIPS gauche se déplaçait en direction caudale lorsque le patient se tenait sur la jambe droite et que la flexion de hanche était de ≤ 30°, alors que l'EIPS droite se déplaçait en direction céphalique par rapport à la base sacrée. Lorsque la flexion de hanche était de 90°, les deux EIPS se déplaçaient en direction céphalique. En exerçant une forte pression palpatoire, l'examinateur abolissait le déplacement initial en direction caudale de l'EIPS gauche de même que les différences de déplacement des EIPS en direction céphalique observées entre une flexion de hanche de 30° et une flexion de hanche de 90°. CONCLUSIONS: Les résultats sont compatibles avec les différences d'activation du muscle moyen fessier et du biceps fémoral gauche et droit observées chez des patients asymptomatiques et qui expliquent les différentes stratégies d'adaptation pour le maintien de l'équilibre en position debout sur une jambe. Il pourrait en résulter un semblant de déplacement relatif de l'EIPS par rapport à S2, même si les résultats du test de Gillet pourraient s'expliquer en tout ou en partie par l'inclinaison du bassin causée par l'asymétrie musculaire. La présente étude remet en question la validité du test de Gillet en position debout pour évaluer la mobilité sacro-iliaque.

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OBJECTIVE: The purpose of this study was to undertake a systematic review of the literature to determine and compare, for patient sub-groups, the spinal level of the iliac crests as commonly measured through manual palpation and radiographic imaging procedures. METHODS: Relevant citations were retrieved by searching the PubMed, ICL, CINAHL, AMED, Osteopathic Research Web, OstMed, and MANTIS biomedical databases, and included articles were rated for quality. Search terms included Tuffier*, intercristal line, intercrestal line, Jacoby's line, lumbar spine, lumbar landmark, pelvic landmark, palpation, and TL (Tuffier's Line). Meta-analyses were performed on the full datasets as well as subsets based on various patient demographics. RESULTS: Original search strategies retrieved 1301 citations; 47 articles were used for qualitative synthesis and 31 for meta-analyses. Across these studies imaged crests were found to be most consistent with and closest to the L4-5 interspace in females and L4 spinous process in males. In comparison, the spinal level for the palpated crests was nearest to the L3-4 interspace in males and females. The palpated crest line was 0.7 levels cephalad to the imaged crest line in males, and 1.0 levels cephalad to the imaged line in females. DISCUSSION AND CONCLUSIONS: During manual palpation, the examiner's fingers contact soft tissue overlying the iliac crests, thereby usually identifying the L3-4 spinal level rather than the assumed L4-5 level. Palpating iliac crests to guide anesthetic injections or manual therapy without appreciating these findings can be hazardous or lead to suboptimal patient care.

OBJECTIF: Cette étude visait à entreprendre un examen systématique de la littérature dans le but de déterminer et de comparer, pour les sous-groupes de patients, le niveau rachidien des crêtes iliaques comme on le mesure souvent par palpation manuelle et imagerie radiographique. MÉTHODOLOGIE: On a tiré des citations pertinentes par le biais d'une recherche dans les bases de données médicales PubMed, ICL, CINAHL, AMED, Osteopathic Research Web, OstMed, et MANTIS, et les articles compris étaient cotés aux fins de qualité. Les termes de recherche comprenaient Tuffier*, ligne intercrête, ligne de Jacoby, colonne lombaire, repère lombaire, repère pelvien, palpation et LT (ligne de Tuffier). On a effectué des méta-analyses des ensembles de données complètes, ainsi que des sous-ensembles, fondées sur les diverses données démographiques sur les patients. RÉSULTATS: Les premières stratégies de recherche ont permis de tirer 1 301 citations; on a utilisé 47 articles aux fins de synthèse qualitative et 31 pour des méta-analyses. À l'échelle de ces études, les crêtes imagées étaient les plus conformes et proches de l'espace intercostal L4­5 des femmes et de l'apophyse épineuse L4 des hommes. Comparativement, le niveau rachidien des crêtes palpées était plus près de l'espace intercostal L3­4 des hommes et des femmes. La ligne de crête palpée était de niveau 0,7 vers la tête par rapport à la ligne de crête imagée des hommes et de niveau 1,0 vers la tête par rapport à la ligne imagée des femmes. DISCUSSION ET CONCLUSIONS: Lors de la palpation manuelle, les doigts de l'examinateur touchent aux tissus mous qui recouvrent les crêtes iliaques, ce qui, en général, détermine de ce fait le niveau rachidien L3­4 plutôt que le niveau L4­5 présumé. La palpation des crêtes iliaques visant à guider les injections anesthésiques ou la thérapie manuelle sans souscrire à ces constatations peut s'avérer dangereuse ou mener à des soins sous-optimaux aux patients.

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OBJECTIVE: The primary objective of the current study was to determine the reliability between methods of supine and prone leg length inequality (LLI) assessment. The secondary objective was to determine if the degree of examiner confidence affected the degree of intermethod agreement. METHODS: Two experienced doctors of chiropractic assessed 43 participants for LLI, one using a prone and the other a supine method. They stated whether they were confident or not confident in their findings. RESULTS: Kappa values for intermethod agreement were 0.16 for the full data set; 0.00 for the n = 20 subgroup with both examiners confident; 0.24 for the n = 18 subgroup with 1 examiner confident; and 0.55 for the n = 5 subgroup with neither examiner confident. Supine and prone measures exhibited slight agreement for the full data set, but no agreement when both examiners were confident. The moderate agreement with both examiners not confident may be an artifact of small sample size. CONCLUSIONS: This study found that supine and prone assessments for leg length inequality were not in agreement. Positioning the patient in the prone position may increase, decrease, reverse, or offset the observed LLI that is seen in the supine position.

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BACKGROUND: This is a secondary analysis of three previous studies on the cervical, thoracic, and lumbar spines. It uses continuous analysis of the stiffest spinal site rather than more typical level-by-level analysis to assess interexaminer reliability, and the impacts of examiner confidence and spinal region. The primary goal was secondary analysis of the combined data; secondary goal was de novo analysis of combined data emphasizing absolute indices of examiner agreement; and tertiary goal was analysis of actual vs. simulated data to determine to what degree the information provided by motion palpation impacted interexaminer reliability. METHODS: This study emphasized Median Absolute Examiner Differences and Bland-Altman Limits of Agreement to calculate examiner differences, which are immune to subject homogeneity, and de-emphasized intraclass correlation, which is not. It calculated Median Absolute Deviation to determine data dispersion. The study analyzed the entire n = 113 combined dataset, as well as subgroups stratified by examiner confidence and spinal region. Simulations were run using a random number generator to provide chance data for examiners' findings of the stiffest spinal site, the analysis of which was compared with that of the actual data. RESULTS: Median Absolute Examiner Differences for the combined dataset were 0.7 of one vertebral level, suggesting examiners usually agreed on the stiffest spinal site or the motion segment including it. When both examiners were confident in their findings (53.4%), the median examiner difference decreased to 0.6 levels, increasing to 1.0 levels when one lacked confidence and to 1.8 levels when both lacked confidence. Reliability was greater in the cervical and lumbar spines (each 0.6 vertebral levels examiner differences) than in the thoracic spine (1.1 levels examiner differences). The actual information provided by motion palpation compared to simulated data improved interexaminer reliability by a factor ranging from 1.8 times to 4.7 times, depending on the regional subset analyzed. CONCLUSIONS: Examiner decisions regarding the location of the stiffest spinal site were deemed adequately reliable, especially when the examiners were confident. Researchers and clinicians alike might best design their study protocols and practice methods using the stiffest segment protocol as an alternative to level-by-level spinal analysis.

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INTRODUCTION: Most studies show motion palpation unreliable. This study's primary objective was assessing its reliability using a continuous measure methods, most-fixated level paradigm, stratified by examiners' confidence; and the secondary objective was comparing various indices of examiner agreement. METHODS: Thirty-four minimally symptomatic participants were palpated in side posture by two experienced examiners. Interexaminer differences in identifying the most-fixated level and degree of examiner confidence were recorded. Indices of agreement were: Intraclass correlation coefficient, Mean and Median Examiner Absolute Examiner Differences, Root-Mean-Square Error and Bland-Altman Limits of Agreement. RESULTS: Three of four reliability indices (excluding intraclass correlation) suggested on average examiners agreed on the most fixated motion segment, and agreement increased with confidence. Statistical measures of data dispersion were low. The analyses of subgroups were "fragile" due to small sample size. DISCUSSION: Although subject homogeneity lowered ICC levels, the other reliability measures were not similarly impacted. Continuous measures statistical analysis demonstrates examiner agreement in situations where discrete analysis with kappa may not. CONCLUSION: Continuous analysis for the lumbar most-fixated level is reliable. Future studies will need a larger sample size to properly analyze subgroups based on examiner confidence.

INTRODUCTION: La plupart des études montrent que la palpation dynamique n'est pas fiable. L'objectif principal de cette étude était d'évaluer sa fiabilité en utilisant des méthodes de mesure continue, le paradigme du niveau intervertébral le plus fixé, empreint du degré d'incertitude des examinateurs; et l>objectif secondaire était de comparer divers indices de concordance des examinateurs. MÉTHODOLOGIE: Trente-quatre participants minimalement symptomatiques ont été palpés en position couchée par deux examinateurs expérimentés. Les différences, dans la capacité de désigner le niveau intervertébral le plus fixé, entre les examinateurs et le degré d'incertitude de ces derniers ont été enregistrés. La liste suivante constitue les indices de concordance : le coefficient de corrélation intraclasse, la moyenne et la médiane des examinateurs, les différences absolues entre les examinateurs, et les limites de concordance selon Bland-Altman. RÉSULTATS: Trois des quatre indices de fiabilité (à l'exception de la corrélation intraclasse) ont suggéré qu'en moyenne les examinateurs concordent sur le niveau intervertébral le plus fixé en palpation dynamique; la concordance augmente avec le niveau de certitude. Les mesures statistiques de dispersion étaient faibles. Les analyses des sous-groupes n'étaient pas fiables en raison de la petite taille des échantillons. DISCUSSION: Bien que l'homogénéité des sujets réduise les niveaux du CCI, cela n'affecte pas pour autant les autres mesures de fiabilité. Les analyses statistiques des mesures continues révèlent une concordance entre les examinateurs dans des circonstances où une analyse discrète avec l'indice de concordance kappa en serait incapable. CONCLUSION: L'analyse continue du niveau intervertébral le plus fixé est fiable. Les études futures auront besoin d'un plus grand échantillon afin d'analyser correctement les sous-groupes en fonction du niveau de certitude des examinateurs.

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INTRODUCTION: Among pelvic landmarks routinely palpated by manual therapists, the posterior superior iliac spines (PSISs) are particularly important. In addition to serving as landmarks for identifying possible pelvic torsion, contacting the PSISs is integral to many other static and dynamic pelvic palpatory procedures. The primary study goal was to systematically review the literature on the intra- and interexaminer reliability of PSIS palpation. METHODS: Electronic databases and secondary searches led to the retrieval of articles that satisfied inclusion criteria. Two investigators rated the quality of included articles using the QAREL instrument. RESULTS: The search identified 13 articles, one judged high quality, satisfying the inclusion criteria. Intraexaminer exceeded interexaminer reliability. Among 8 studies that reported interexaminer agreement using kappa, mean Ï°=0.27 (adjusted for sample size). DISCUSSION AND CONCLUSION: Current methods of palpating for PSIS asymmetry do not result in levels of interexaminer reliability supporting clinical utility. Improved methods should be sought.

INTRODUCTION: En ce qui concerne la région pelvienne régulièrement palpée par des thérapeutes manuels, les épines iliaques postéro-supérieures (EIPS) sont particulièrement importantes. En plus de servir de points de repère pour l'identification d'une possible torsion pelvienne, la palpation de l'EIPS fait partie intégrante de nombreuses autres procédures palpatoires pelviennes statiques et dynamiques. L'objectif principal de l'étude était d'examiner systématiquement les documents scientifiques concernant la fiabilité intra- et inter-examinateurs de la palpation de l'EIPS. MÉTHODOLOGIE: Les bases de données électroniques et les recherches secondaires ont abouti à la découverte d'articles qui répondaient aux critères d'inclusion. À l'aide de l'instrument QAREL, deux enquêteurs ont évalué la qualité des articles inclus. RÉSULTATS: La recherche a révélé 13 articles, dont un de haute qualité, répondant aux critères d'inclusion. Le nombre d'articles traitant de la fiabilité intraexaminateurs était supérieur à ceux traitant de la fiabilité interexaminateurs. Pour les 8 études qui ont mentionné un accord d'interexaminateurs utilisant l'indice kappa, la moyenne Ï° = 0,27 (ajusté à la taille de l'échantillon). DISCUSSION ET CONCLUSION: Les méthodes actuelles de palpation pour l'asymétrie de l'EIPS ne mènent pas à des niveaux de fiabilité interexaminateurs pour soutenir l'utilité clinique. Il faut rechercher des méthodes améliorées.

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OBJECTIVE: The purpose of this pilot study was to test methods needed to conduct a study with adequate power to investigate consistency between the arm-fossa test (AFT) and the Gillet test. METHODS: A convenience sample of chiropractic college students enrolled in a weekend Sacro-Occipital Technique seminar participated. Each was tested with AFT and sacroiliac orthopedic tests, including the Gillet test. Statistical testing included calculation of κ for consistency of the AFT and Gillet test and their diagnostic efficiency. RESULTS: This study recruited 14 participants. Important issues arose in gathering and recording data, the standardization of examiner methods, and the flow of participants to examination stations. κ for AFT and Gillet test consistency = 0.55, corresponding to "moderate." CONCLUSION: This pilot suggests that the future study should include a mix of symptomatic and asymptomatic participants; record trichotomous data, where appropriate; use washout periods between diagnostic tests; and refine the selection of orthopedic tests deployed besides the AFT. The preliminary data are consistent with but do not establish due to the very small sample size and experimental design issues, that a positive AFT may be consistent with a negative Gillet test.

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OBJECTIVES: Primary goal: to determine the validity of C1 transverse process (TVP) palpation compared to an imaging reference standard. METHODS: Radiopaque markers were affixed to the skin at the putative location of the C1 TVPs in 21 participants receiving APOM radiographs. The radiographic vertical distances from the marker to the C1 TVP, mastoid process, and C2 TVP were evaluated to determine palpatory accuracy. RESULTS: Interexaminer agreement for radiometric analysis was "excellent." Stringent accuracy (marker placed ±4mm from the most lateral projection of the C1 TVP) = 57.1%; expansive accuracy (marker placed closer to contiguous structures) = 90.5%. Mean Absolute Deviation (MAD) = 4.34 (3.65, 5.03) mm; root-mean-squared error = 5.40mm. CONCLUSIONS: Manual palpation of the C1 TVP can be very accurate and likely to direct a manual therapist or other health professional to the intended diagnostic or therapeutic target. This work is relevant to manual therapists, anesthetists, surgeons, and other health professionals.

OBJECTIFS: But principal : Déterminer la validité de la palpation de l'apophyse transverse C1 par rapport à une référence d'imagerie normale. MÉTHODOLOGIE: On a posé des marqueurs radioopaques sur la peau à l'emplacement supposé de l'apophyse transverse C1 chez 21 participants recevant une radiographie APOM (bouche ouverte en incidence antéro-postérieure). Les distances verticales radiographiques entre le marqueur de l'apophyse transverse C1, l'apophyse mastoïde et l'apophyse transverse C2 ont été évaluées afin de déterminer la précision de la palpation. RÉSULTATS: Les examinateurs se sont accordés pour dire que l'analyse radiométrique était « excellente ¼. Précision rigoureuse (marqueur placé à ± 4 mm de la projection la plus latérale de l'apophyse transverse C1) = 57,1 %; précision expansive (marqueur placé plus près des structures contiguës) = 90,5 %. Écart absolu moyen (EAM) = 4,34 (3,65, 5,03) mm; valeur quadratique moyenne d'erreur = 5,40 mm. CONCLUSIONS: La palpation manuelle de l'apophyse transverse C1 peut être très précise et présente de fortes chances de guider un thérapeute manuel ou un autre professionnel de la santé vers le diagnostic ou la cible thérapeutique souhaités. Ce travail concerne les thérapeutes manuels, anesthésistes, chirurgiens et autres professionnels de la santé.

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Practitioners in several of the health care professions use anatomical landmarks to identify spinal levels, both in order to enhance diagnostic accuracy and to specifically target the site of intervention. Authoritative sources usually state the upright inferior scapular angle (IAS) aligns with the spinous process (SP) of T7, but some specify the T7-8 interspace or the T8 SP. The primary goals of this study were to systematically review the relevant literature; and conduct a meta-analysis of the pooled data from retrieved studies to increase their statistical power. Electronic searching retrieved primary studies relating the IAS to a spinal level, as determined by an imaging reference standard, using combinations of these search terms: scapula, location, landmark, spinous process, thoracic vertebrae, vertebral level, palpation, and spine. Only primary studies were included; review articles and reliability studies related to scapular position but lacking spinal correlations were excluded. Eight-hundred and eighty (880) articles of interest were identified, 43 abstracts were read, 22 full text articles were inspected, and 5 survived the final cut. Each article (with one exception) was rated for quality using the QUADAS instrument. Pooling data from 5 studies resulted in normal distribution in which the upright IAS on average aligns closely with the T8 SP, range T4-T11. Since on average the IAS most closely identifies the T8 SP in the upright position, it is very likely that health professionals, both manual therapists and others, who have been diagnosing and treating patients based on the IAS = T7 SP rule (the conventional wisdom), have not been as segmentally accurate as they may have supposed. They either addressed non-intended levels, or made numeration errors in their charting. There is evidence that using the IAS is less preferred than using the vertebra prominens, and may be less preferred than using the iliac crest for identifying spinal levels Manual therapists, acupuncturists, anesthesiologists, nurses, and surgeons should reconsider their procedures for identifying spinal sites in light of this modified information. Inaccurate landmark benchmark rules will add to patient variation and examiner errors in producing spine care targeting errors, and confound research on the importance of specificity in treating spinal levels.

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BACKGROUND: Upright examination procedures like radiology, thermography, manual muscle testing, and spinal motion palpation may lead to spinal interventions with the patient prone. The reliability and accuracy of mapping upright examination findings to the prone position is unknown. This study had 2 primary goals: (1) investigate how erroneous spine-scapular landmark associations may lead to errors in treating and charting spine levels; and (2) study the interexaminer reliability of a novel method for mapping upright spinal sites to the prone position. METHODS: Experiment 1 was a thought experiment exploring the consequences of depending on the erroneous landmark association of the inferior scapular tip with the T7 spinous process upright and T6 spinous process prone (relatively recent studies suggest these levels are T8 and T9, respectively). This allowed deduction of targeting and charting errors. In experiment 2, 10 examiners (2 experienced, 8 novice) used an index finger to maintain contact with a mid-thoracic spinous process as each of 2 participants slowly moved from the upright to the prone position. Interexaminer reliability was assessed by computing Intraclass Correlation Coefficient, standard error of the mean, root mean squared error, and the absolute value of the mean difference for each examiner from the 10 examiner mean for each of the 2 participants. RESULTS: The thought experiment suggesting that using the (inaccurate) scapular tip landmark rule would result in a 3 level targeting and charting error when radiological findings are mapped to the prone position. Physical upright exam procedures like motion palpation would result in a 2 level targeting error for intervention, and a 3 level error for charting. The reliability experiment showed examiners accurately maintained contact with the same thoracic spinous process as the participant went from upright to prone, ICC (2,1) = 0.83. CONCLUSIONS: As manual therapists, the authors have emphasized how targeting errors may impact upon manual care of the spine. Practitioners in other fields that need to accurately locate spinal levels, such as acupuncture and anesthesiology, would also be expected to draw important conclusions from these findings.

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OBJECTIVE: The purpose of this case report is to describe chiropractic management of a patient with overactive bladder (OAB) and to describe an hypothetical anatomical basis for a somato-vesical reflex and possible clinical link between pelvic and symphysis pubis dysfunction to OAB. CLINICAL FEATURES: A 24-year-old nulliparous female with idiopathic OAB, with a primary complaint of nocturia presented for chiropractic care. Her sleep was limited to 2 consecutive hours due to bladder urgency. Pubic symphysis shear dysfunction was observed on physical examination. INTERVENTION AND OUTCOMES: The primary treatment modality used was chiropractic side-posture drop-table manipulation designed to reduce pubic shear dysfunction. After 8 treatments in 1 month, the pubic shear gradually reduced while nocturia diminished and consecutive sleep hours increased from 2 to 7. At 1-year follow-up, the nocturia remained resolved. CONCLUSION: The patient reported in this case responded favorably to chiropractic care, which resulted in reduced nocturia and increased sleep continuity.

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INTRODUCTION: Motion palpators usually rate the movement of each spinal level palpated, and their reliability is assessed based upon discrete paired observations. We hypothesized that asking motion palpators to identify the most fixated cervical spinal level to allow calculating reliability at the group level might be a useful alternative approach. METHODS: Three examiners palpated 29 asymptomatic supine participants for cervical joint hypomobility. The location of identified hypomobile sites was based on their distance from the T1 spinous process. Interexaminer concordance was estimated by calculating Intraclass Correlation Coefficient (ICC) and mean absolute differences (MAD) values, stratified by degree of examiner confidence. RESULTS: For the entire participant pool, ICC [2,1] = 0.61, judged "good." MAD=1.35 cm, corresponding to mean interexaminer differences of about 75% of one cervical vertebral level. Stratification by examiner confidence levels resulted in small subgroups with equivocal results. DISCUSSION AND CONCLUSION: A continuous measures study methodology for assessing cervical motion palpation reliability showed more examiner concordance than was usually the case in previous studies using discrete methodology.

INTRODUCTION: Généralement, la palpation évalue le mouvement de chaque niveau de la moelle épinière palpé, et sa fiabilité est évaluée sur des observations jumelées et séparées. Nous avons émis l'hypothèse que l'utilisation de la palpation afin d'identifier le niveau de la moelle épinière cervicale le moins mobile, dans le but de permettre le calcul de sa fiabilité à l'échelle du groupe pourrait être une approche alternative utile. MÉTHODOLOGIE: Trois examinateurs ont palpé 29 participants asymptomatiques allongés atteints d'hypomobilité de l'articulation cervicale. L'emplacement de ces segments hypomobiles s'est fondé sur leurs distances par rapport à l'apophyse épineuse T1. La concordance entre les examinateurs a été estimée en calculant le coefficient de corrélation interne (ICC) et les valeurs de la différence absolue moyenne (MAD), stratifiés selon le degré de confiance de l'examinateur. RÉSULTATS: Pour tout le bassin de participants, ICC [2,1] = 0,61, jugé « bon ¼. MAD = 1,35 cm, ce qui correspond à la différence moyenne entre les examinateurs d'environ 75 % d'un segment de la colonne vertébrale. La stratification par le niveau de confiance de l'examinateur a entraîné des petits sousgroupes avec des résultats équivoques. DISCUSSION ET CONCLUSION: Une méthodologie ayant recours à des mesures continues pour l'évaluation de la fiabilité de la palpation de la colonne vertébrale a indiqué une plus grande concordance entre les examinateurs qu'à l'accoutumée lors des précédentes études, qui utilisaient la méthodologie séparée.

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BACKGROUND: With 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. METHODS: Structured 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. RESULTS: A 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. CONCLUSIONS: A 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.

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OBJECTIVE: The purpose of this study is to perform a secondary analysis using modified methods of previously reported data to analyze the amount of examiner concordance in the Johnston and Friedman percussion scan of the most fixated spinal level. METHOD: A 2001 study evaluated interexaminer reliability of the percussive method of Johnston and Friedman for detecting altered segmental mobility (somatic dysfunction, spinal/segmental dysfunction, or chiropractic subluxation) in the thoracic spine. The original reported level of agreement using the κ statistic for discrete measures was only 0.07, judged "slight." The data were reformatted to permit recalculating the degree of interexaminer agreement using the intraclass correlation coefficient statistic, which uses continuous analysis, unlike κ that performs discrete analysis. Following an initial calculation, the data were modified to reflect the caudally increasing vertebral height of the thoracic vertebrae. RESULTS: The reformatted and modified data, intraclass correlation coefficient (2,1) = 0.253 (0.100,0.482), showed the findings as "poor," which is better interexaminer agreement for percussion motion palpation than the original reported κ value judged as "slight." CONCLUSIONS: Reanalyzing the data using an alternative statistical method showed greater interexaminer reliability than was originally reported. This secondary analysis demonstrates how study results may vary depending on the experimental design and statistical methods chosen for analysis.

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OBJECTIVE: Motion palpation is integral to most chiropractic techniques and can be found in curricula of most every chiropractic college. Paradoxically, most studies do not show strong reliability for motion palpation. The purpose of this study was to determine if allowing motion palpators to rate their confidence in their findings, as well using a continuous data analytic method, would influence the level of concordance. METHODS: Subjects were 52 asymptomatic chiropractic student volunteers. Two palpators assessed posterior to anterior glide of T3-10 in the prone position, alternating in their order and blinded as to each other's results. Each examiner identified the location of maximal restriction in this range and also whether they were "very confident" or "not confident" in their finding. RESULTS: For all subjects combined, the examiners' calls were "poor": intraclass correlation coefficient [2,1] = .3110 (95% CI, .0458-.5358). In contrast, interexaminer agreement was "good" when both examiners were very confident: intraclass correlation coefficient [2,1] = .8266 (95% CI, 0.6257-0.9253). CONCLUSION: When each examiner was "very confident" as to the most fixated thoracic segment, the levels they identified were very close. This corresponds to "good" agreement, an uncommon result in most interexaminer motion palpation studies. Thus, the confidence level of examiners had an effect on the interexaminer reliability of thoracic spine. Our novel continuous measures, statistical methodology, and subtyping the subjects according to the confidence of the palpators seem more capable than level-by-level discrete analysis of detecting interexaminer agreement.

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Several primary studies have shown that an anatomical short leg predicts anterior rotation of the ipsilateral ilium, whereas anatomical long leg predicts posterior rotation of the ilium on the long leg side. At the same time, in chiropractic and other manual therapy professions, it is widely believed that the leg check finding of a short leg is associated with posterior ilium rotation, and a long leg with anterior ilium rotation. The purpose of this commentary is to explore the consequences of this paradox for the manual therapy professions, insofar as leg checking procedures are commonly used to derive appropriate vectors for chiropractic manipulation/adjustive procedures.