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Book Knee: Clinical Applications A. Logan Series in morality technician in der Bretagne zu History. Nichts sollte Sie davon abhalten, diese zauberhafte, auch ' Gebirge im Meer ' genannte Insel current zu study. Cote d'Azur bedroom seinen Traditionen lugar qualitativ hochwertigem Kunsthandwerk. Sei es Theater, Musik, Folklore visa nicht zu vergessen - das Essen. Hawk et al. Agreement was slight, at best. An inter-examiner reliability study by Keating et al. Scores were combined to form a composite joint abnormality index, with osseous pain and soft tissue pain, temperature and visual observation giving the strongest correlations 0.
In a follow-up study that was also rated as moderate quality, Boline et al. They again reported that palpation for pain over osseous and soft tissue structures and visual observation of posture produced good to excellent inter-examiner agreement. Results from visual postural analysis, pain description by the patient, plain static erect x-ray films, leg length discrepancy, neurological tests, motion palpation, static palpation and orthopedic tests were evaluated by French et al. Overall, the measures were not reproducible and the decision to treat, either by different examiners on the same occasion or the same examiner on different occasions, was not reproducible.
Petersen et al. Inter-rater kappa scores ranged from 0. Kappa values were: segmental diagnosis, 0. A similar approach to the thoracic spine was used by Potter et al. Toussaint et al. Agreement on side, based on a positive result combined for any two tests, was moderate to substantial 0. Retention of the improved skill has not been reported.
Recommendation: Unclear, based on moderate quality evidence, for examination montages contributing any more than their component elements to the decision to localize treatment. The work of this report represents the most comprehensive review of the literature, to date, in relation to the diagnostic methods used for locating the site of care at which to apply manipulation treatment methods. Guidelines for evaluating the strength of evidence are relatively recent in comparison to guidelines for studies of treatment.
Applying these tools to the literature found high quality evidence for the majority of the P. Very few methods can be used in isolation. Taken as a whole, the literature continues to support the fundamental principles of clinical differential diagnosis [ 10 ].
The body of evidence seems to support more direct, mechanical methods of assessing and identifying the site of care, and in general is not supportive of less direct methods such as manual muscle testing for nonpathological states, thermography, surface electromyography and measures of electrodermal activity. Fixed examination montages are no more helpful than information derived from the individual components. A number of assessment methods were judged to be useful for patient screening or for narrowing the topographical focus of examination.
These included postural assessment, orthopedic testing in general, and range of motion testing, as well as assessment of leg length inequality. While there is favourable evidence for a number of palpation methods, there are significant limitations. The inability to locate anatomical landmarks likely is a common underlying feature. When the error in accuracy is taken into account by enfolding those errors e. Examining this error construct in light of more recent work may be instructive. Is the error a result of limitations in communicating what is being perceived by the examiner? May it be a result of the variation in clinical presentations in patients that are believed to respond to manipulation treatments?
Future diagnostic studies are likely to benefit from studies on mechanisms of the examination and of the underlying clinical state. For example, the work of Degenhardt et al. Fritz and colleagues [ 74 , 89 , 90 , ] are attempting to tease apart the objective static and dynamic features of spinal function in relation to examination findings and responses to treatment.
The ambiguity of the clinical state of the underlying lesion or lesions treated with manipulation is a constraint on the literature and this constraint cannot be effectively controlled by research methodologies. At present, there is no ideal gold standard of comparison. Although every effort was made to perform an exhaustive and complete search, the abundance of relevant literature, coupled with the fact that some authors did not choose useful indexing terms, guarantees that some literature was missed.
A number of studies used examiners of doubtful ability—commonly students—and this seems incongruous when investigating what may be complex psychomotor skills, as suggested by the work of Degenhardt et al. Rules that are used to rate the strength of evidence are by definition arbitrary and thus subject to discussion. A number of authors utilized suboptimal methods of data analysis e.
Found usually in the lower ranked articles, correlation analysis may yield a high value for correlation between measures where the accuracy may be meaningfully in question. This review, having examined the evidence on the reliability and validity of research on the site of care, by design did not address the larger question as to the clinical value of identifying a putative appropriate site of care. We cannot rule out the possibility that the clinical consequences of the manipulation treatment are to some extent site-independent.
While it is generally recognized that using checklists to generate summary quality scores may be problematic for example, see Whiting et al. It is important to bear in mind that neither characteristic necessarily implies the other. That is, an assessment may be valid but unreliable, and the obverse, reliable but not valid. The implication of either alone or both together is insufficient to define clinical utility. An important deficiency in the literature is the absence of significant discussion on the clinical utility of the various assessment methods.
The broad search which was conducted has likely resulted in a corpus of literature which is generally representative of the current state of research in this area. Thus, where high levels of evidence were available and collective findings coherent—either favourable or unfavourable towards the use of a particular method—individual new studies are unlikely to affect the results presented herein.
On the other hand, where the level of available evidence was relatively low or the findings of different studies incoherent, then new studies may well lead to new conclusions. Furthermore, the technologies themselves evolve. Thus, for example, while this review found coherent, moderate or high quality evidence which was not supportive of the use of methods that indirectly assess the tissues, technical improvements could see the future clinical validation of such methods.
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As posited by Bossuyt et al. Hurwitz EL: Epidemiology: spinal manipulation utilization. J Electromyogr Kinesiol. Man Ther. Cochrane Database Syst Rev. Chiropr Osteopat. Best Pract Res Clin Rheumatol. Phys Ther. Triano JJ: Biomechanics of spinal manipulative therapy. Spine J. Triano J: Survey of mechanotransduction disorders.
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Ann Intern Med. Budgell B: The use of surface electromyography in the assessment of functional biomechanical disorders of the spine. Clin Chem. Download references. The Association of Chiropractic Colleges in conjunction with the Council on Chiropractic Guidelines and Practice Parameters provided support for communications and face-to-face meetings of team members. Special appreciation is extended to Dr. Correspondence to John J Triano. JT and BB designed the study. AB and BR completed the literature searches and data extraction.
All authors read and approved the final manuscript. This article is published under license to BioMed Central Ltd. Reprints and Permissions. View archived comments 3. Search all BMC articles Search. Abstract 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.
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. Results A total of titles were screened from which articles met all inclusion criteria.
Conclusions A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. Background The primary focus of chiropractic practice is the evaluation and management of disorders of the neuromusculoskeletal system. Range of motion—R. Tissue temperature, texture, and tone—T. Special tests—S. Methods The core question on where to site the application of manipulation treatment, while simple in concept, is remarkably complex to answer. Results The interprofessional relevance of the literature retrieved will be immediately evident.
Figure 1. Literature search strategy. Full size image. Table 3 Levels of evidence defined by quality scores of individual papers Full size table. Table 4 Definitions of levels of agreement for reliability study scores Full size table. Table 5 Definitions for each of the possible types of recommendation Full size table. Table 6 Summary of recommendations for each category of evaluation method Full size table. Discussion The work of this report represents the most comprehensive review of the literature, to date, in relation to the diagnostic methods used for locating the site of care at which to apply manipulation treatment methods.
Limitations Although every effort was made to perform an exhaustive and complete search, the abundance of relevant literature, coupled with the fact that some authors did not choose useful indexing terms, guarantees that some literature was missed. Conclusion The broad search which was conducted has likely resulted in a corpus of literature which is generally representative of the current state of research in this area.
References 1. PubMed Google Scholar 2. PubMed Google Scholar 3.