Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature.

STUDY DESIGN: A systematic review. OBJECTIVES: To determine the quality of the research and assess the interexaminer and intraexaminer reliability of spinal palpatory diagnostic procedures. SUMMARY OF BACKGROUND DATA: Conflicting data have been reported over the past 35 years regarding the reliability of spinal palpatory tests. METHODS: The authors used 13 electronic databases and manually searched the literature from January 1, 1966 to October 1, 2001. Forty-nine (6%) of 797 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus or a content expert reconciled discrepancies. RESULTS: The quality scores ranged from 25 to 79/100. Subject description, study design, and presentation of results were the weakest areas. The 12 highest quality articles found pain provocation, motion, and landmark location tests to have acceptable reliability (K = 0.40 or greater), but they were not always reproducible by other examiners under similar conditions. In those that used kappa statistics, a higher percentage of the pain provocation studies (64%) demonstrated acceptable reliability, followed by motion studies (58%), landmark (33%), and soft tissue studies (0%). Regional range of motion is more reliable than segmental range of motion, and intraexaminer reliability is better than interexaminer reliability. Overall, examiners' discipline, experience level, consensus on procedure used, training just before the study, or use of symptomatic subjects do not improve reliability. CONCLUSION: The quality of the research on interreliability and intrareliability of spinal palpatory diagnostic procedures needs to be improved. Pain provocation tests are most reliable. Soft tissue paraspinal palpatory diagnostic tests are not reliable.

S-adenosyl methionine (SAMe) versus celecoxib for the treatment of osteoarthritis symptoms: a double-blind cross-over trial. [ISRCTN36233495].

BACKGROUND: S-adenosylmethionine (SAMe) is a dietary supplement used in the management of osteoarthritis (OA) symptoms. Studies evaluating SAMe in the management of OA have been limited to Non Steroidal Anti-inflammatory Drugs (NSAIDs) for comparison. The present study compares the effectiveness of SAMe to a cyclooxygenase-2 (COX-2) inhibitor (celecoxib) for pain control, functional improvement and to decrease side effects in people with osteoarthritis of the knee. METHODS: A randomized double-blind cross-over study, comparing SAMe (1200 mg) with celecoxib (Celebrex 200 mg) for 16 weeks to reduce pain associated with OA of the knee. Sixty-one adults diagnosed with OA of the knee were enrolled and 56 completed the study. Subjects were tested for pain, functional health, mood status, isometric joint function tests, and side effects. RESULTS: On the first month of Phase 1, celecoxib showed significantly more reduction in pain than SAMe (p = 0.024). By the second month of Phase 1, there was no significant difference between both groups (p < 0.01). The duration of treatment and the interaction of duration with type of treatment were statistically significant (ps < or = 0.029). On most functional health measures both groups showed a notable improvement from baseline, however no significant difference between SAMe and celecoxib was observed. Isometric joint function tests appeared to be steadily improving over the entire study period regardless of treatment. CONCLUSION: SAMe has a slower onset of action but is as effective as celecoxib in the management of symptoms of knee osteoarthritis. Longer studies are needed to evaluate the long-term effectiveness of SAMe and the optimal dose to be used.

Spinal palpation: The challenges of information retrieval using available databases.

PURPOSE: This study addressed 2 questions: first, what is the yield of PubMed MEDLINE for complementary and alternative medicine (CAM) studies compared to other databases; second, what is an effective search strategy to answer a sample research question on spinal palpation? METHODS: We formulated the following research question: "What is the reliability of spinal palpation procedures?" We identified specific Medical Subject Headings (MeSH) and key terms as used in osteopathic medicine, allopathic medicine, chiropractic, and physical therapy. Using PubMed, we formulated an initial search template and applied it to 12 additional selected databases. Subsequently, we applied the inclusion criteria and evaluated the yield in terms of precision and sensitivity in identifying relevant studies. RESULTS: The online search result of the 13 databases identified 1189 citations potentially addressing the research question. After excluding overlapping and nonpertinent citations and those not meeting the inclusion criteria, 49 citations remained. PubMed yielded 19, while MANTIS (Manual Alternative and Natural Therapy Index System), a manual therapy database, yielded 35 citations. Twenty-six of the 49 online citations were repeatedly indexed in 3 or more databases. Content experts and selective manual searches identified 11 additional studies. In all, we identified 60 studies that addressed the research question. The cost of the databases used for conducting this search ranged from free-of-charge to $43,000 per year for a single network subscription. CONCLUSIONS: Commonly used databases often do not provide accurate indexing or coverage of CAM publications. Subject-specific specialized databases are recommended. Access, cost, and ease of using specialized databases are limiting factors.

Searching biomedical databases on complementary medicine: the use of controlled vocabulary among authors, indexers and investigators.

BACKGROUND: The optimal retrieval of a literature search in biomedicine depends on the appropriate use of Medical Subject Headings (MeSH), descriptors and keywords among authors and indexers. We hypothesized that authors, investigators and indexers in four biomedical databases are not consistent in their use of terminology in Complementary and Alternative Medicine (CAM). METHODS: Based on a research question addressing the validity of spinal palpation for the diagnosis of neuromuscular dysfunction, we developed four search concepts with their respective controlled vocabulary and key terms. We calculated the frequency of MeSH, descriptors, and keywords used by authors in titles and abstracts in comparison to standard practices in semantic and analytic indexing in MEDLINE, MANTIS, CINAHL, and Web of Science. RESULTS: Multiple searches resulted in the final selection of 38 relevant studies that were indexed at least in one of the four selected databases. Of the four search concepts, validity showed the greatest inconsistency in terminology among authors, indexers and investigators. The use of spinal terms showed the greatest consistency. Of the 22 neuromuscular dysfunction terms provided by the investigators, 11 were not contained in the controlled vocabulary and six were never used by authors or indexers. Most authors did not seem familiar with the controlled vocabulary for validity in the area of neuromuscular dysfunction. Recently, standard glossaries have been developed to assist in the research development of manual medicine. CONCLUSIONS: Searching biomedical databases for CAM is challenging due to inconsistent use of controlled vocabulary and indexing procedures in different databases. A standard terminology should be used by investigators in conducting their search strategies and authors when writing titles, abstracts and submitting keywords for publications.

Use of complementary and alternative medicine among the ethnic elderly.

OBJECTIVE: We sought to explore whether the elderly are high users of complementary and alternative medicine (CAM), and to determine which modalities they use. We also sought to describe patterns and positive predictors of CAM use among 3 ethnically diverse groups of community-residing elderly. DESIGN: A 7-page questionnaire was developed and translated into Spanish and Vietnamese. PARTICIPANTS: A population of 525 community-residing elderly completed personal interviews. RESULTS: Two hundred and fifty-one respondents (47.8%) reported using CAM over the past year. Dietary supplements (47.4%), chiropractic (16.3%), home remedies (15.9%), acupuncture (15.1%), and Oriental medicine (12.8%), were the most frequently cited therapies. The majority of CAM users (62.4%) did not inform their physicians that they were using it, but 58% consulted their physician for the same problem for which they used CAM. Family and friends were most relied upon for making the choice of therapy. Among the 3 ethnic groups studied, Asians were higher users of acupuncture (28%) and Oriental medicine (31%), Hispanics were higher users of dietary supplements (56%), home remedies (25%), and curanderos (8%), while white non-Hispanics were higher users of chiropractic (42%), massage (20%), vitamins (20%), diet (17%), and psychospiritual (15%) modalities. Pain was a higher indicator of CAM use among Asians, gastrointestinal problems and diabetes among Hispanics, and stress/fatigue and cardiovascular problems among white non-Hispanics. CONCLUSION: Findings indicated a high use of CAM among the elderly and emphasize the likelihood that elderly immigrants use those therapies with which they are familiar. Modalities and conditions varied with the ethnicity of respondents.

Content validity of manual spinal palpatory exams - A systematic review.

BACKGROUND: Many health care professionals use spinal palpatory exams as a primary and well-accepted part of the evaluation of spinal pathology. However, few studies have explored the validity of spinal palpatory exams. To evaluate the status of the current scientific evidence, we conducted a systematic review to assess the content validity of spinal palpatory tests used to identify spinal neuro-musculoskeletal dysfunction. METHODS: Review of eleven databases and a hand search of peer-reviewed literature, published between 1965-2002, was undertaken. Two blinded reviewers abstracted pertinent data from the retrieved papers, using a specially developed quality-scoring instrument. Five papers met the inclusion/exclusion criteria. RESULTS: Three of the five papers included in the review explored the content validity of motion tests. Two of these papers focused on identifying the level of fixation (decreased mobility) and one focused on range of motion. All three studies used a mechanical model as a reference standard. Two of the five papers included in the review explored the validity of pain assessment using the visual analogue scale or the subjects' own report as reference standards. Overall the sensitivity of studies looking at range of motion tests and pain varied greatly. Poor sensitivity was reported for range of motion studies regardless of the examiner's experience. A slightly better sensitivity (82%) was reported in one study that examined cervical pain. CONCLUSIONS: The lack of acceptable reference standards may have contributed to the weak sensitivity findings. Given the importance of spinal palpatory tests as part of the spinal evaluation and treatment plan, effort is required by all involved disciplines to create well-designed and implemented studies in this area.

Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial.

STUDY DESIGN: A randomized, assessor-blinded clinical trial was conducted. OBJECTIVE: To investigate the relative effectiveness of three manual treatments and back school for patients with subacute low back pain. SUMMARY OF BACKGROUND DATA: Literature comparing the relative effectiveness of specific therapies for low back pain is limited. METHODS: Among the 5925 inquiries, 206 patients met the specific admission criteria, and 200 patients randomly received one of four treatments for 3 weeks: back school, joint manipulation, myofascial therapy, and combined joint manipulation and myofascial therapy. These patients received assessments at baseline, after 3 weeks of therapy, and 6 months after the completion of therapy. The primary outcomes were evaluated using visual analog pain scales and Roland-Morris activity scales. RESULTS: All four groups showed significant improvement in pain and activity scores after 3 weeks of care, but did not show further significant improvement at the 6-month follow-up assessment. No statistically significant between-group differences were found either at the 3-week or 6-month reassessments. CONCLUSIONS: For subacute low back pain, combined joint manipulation and myofascial therapy was as effective as joint manipulation or myofascial therapy alone. Additionally, back school was as effective as three manual treatments.