Measurement challenges in physical diagnosis: refining inter-rater palpation, perception and communication

Abstract

Many approaches to bodywork depend on the validity of palpatory findings in preparation for manipulative treatment. And yet the literature is replete with challenge to validity and inter-rater, as well as intra-rater reliability, in physical diagnostic tests that support the theoretical constructs of the musculoskeletal therapist. Osteopathy uses the term somatic dysfunction to reflect the variations from the normal symmetrical, state of the body, citing the parameters of restriction of motion, tissue texture changes and sensitivity. These are usually associated with pain or immobility and attributed to the results of trauma or stress. Spinal segmental assessment in the patient with back pain is the classic example of application. Within this subset of body workers, the question of inter-rater reliability is often the focus in this quest to validate the approach to diagnosis and manipulative treatment. This article reports on a pilot study to assess the inter-rater reproducibility of diagnosis in a well defined protocol. Three similarly trained practitioners evaluated the lower cervical and upper thoracic spine (C2–T8) in 54 volunteers at Ohio University College of Osteopathic Medicine. The results show Kappa coefficients of 0.12 and 0.56 (chance agreement of 0.0051) between various tests and examiners. The pilot study sheds light on some of the issues that may change future research design in this field.