Palpatory Diagnosis Research Articles

Ultrasonography to Assess the Efficacy of Osteopathic Manipulative Treatment for Lumbar Spine Asymmetry.

The effectiveness of osteopathic manipulative treatment (OMT) on the lumbar spine has been studied qualitatively, but quantitative measurement of the effects of OMT has not been thoroughly investigated. To quantitatively measure the palpated improvements of OMT on the lumbar spine using ultrasonography (US) and correlate palpatory diagnosis with US measurements of lumbar asymmetry. From September to November 2018, we recruited 20 adult participants 18 years of age or older. Lumbar somatic dysfunction (SD) was identified via osteopathic palpation. US was then performed on all participants with standard machine settings (frequency, 7 MHz; depth, 7 cm; dynamic range, 60; tissue harmonic imaging; and single-image focus). Longitudinal images of each lumbar transverse process were recorded and saved bilaterally by an experienced radiologist and a medical student. The participant's SD was then managed using OMT, including Still technique, myofascial release, muscle energy technique, high-velocity low-amplitude technique, functional positional release, balanced ligamentous tension, and counterstrain. Following OMT, US was performed again in the same method. Measurements of the saved US images were reviewed using a Digital Imaging and Communications in Medicine viewer. These measurements were obtained by 3 separate observers (J.W., A.K., S.M.), using the same computer software. Statistical analysis included a 2-tailed paired t-test to analyze rotational asymmetry pre- and posttreatment, an intraclass correlation coefficient (ICC) to test intra- and interobserver reliability, and a Pearson correlation coefficient (PCC) to analyze the correlation between US findings and OMT. The difference in soft tissue thickness before and after OMT was significant (P=.014), indicating improvements in rotational asymmetry. Side-bending asymmetry did not demonstrate statistically significant improvement. US findings correlated with the physician's palpatory rotational diagnosis (PCC=0.62, P=.004). ICC was greater than 0.9 for intra- and interobserver reliability tests of both US operation and offline image processing. The results of this study demonstrate that US is a feasible method of evaluating the efficacy of OMT. These results show good intra- and interobserver reliability of US acquisition and landmark measurement. Our study suggests that US assessment correlated closely with palpatory diagnosis. Our results also suggest that OMT can significantly improve lumbar rotational asymmetry, but did not improve side-bending asymmetry.

Isometric osteopathic manipulation influences on cervical ranges of motion and correlation with osteopathic palpatory diagnosis: A randomized trial

IntroductionIsometric manipulation is a current practice in osteopathy and treatment benefits have been reported in the literature. Such benefits could be assessed using experimental non-invasive cervical mobility measurements. The main objective was to quantitatively measure the effects of isometric manipulation on principal and compensatory cervical motions. Methods101 healthy volunteers were included in this study. 51 healthy volunteers selected randomly underwent the experimental protocol before and after isometric treatment and were compared to 50 healthy volunteers who underwent a placebo treatment. Osteopathic diagnosis was performed on each healthy volunteer before and after the treatment. The experimental protocol included measurements by a motion capture system focusing on principal range of motion and compensatory motions. ResultsIn both the isometric and the placebo sample, respectively including 51 (age: 29.2 ± 8.1, BMI: 22.2 ± 3.5) and 50 healthy volunteers (age: 27.4 ± 6.8, BMI: 22.9 ± 2.8), a pre-treatment diagnosis revealed a light cervical dysfunction in all subjects, mainly in levels C3 and C4. Altered ranges of motion thresholds (C3/C4 alterations) were identified: 113.2° for flexion, 130.0° for rotation and 90.2° for lateral flexion.After manipulations, the volunteers who underwent the isometric treatment presented a slight increase in amplitude for lateral flexion (p < 0.04), which was not found in the volunteers who underwent the placebo treatment. Compensatory motions showed differences pre and post isometric treatment without reaching significant values. ConclusionPrincipal ranges of motion were found significantly higher after osteopathic treatment when compared to the placebo treatment. Osteopathic palpatory diagnosis showed significant correlation with range of motions before treatment.

Haptic modules for palpatory diagnosis training of medical students

We have developed and evaluated a novel tool based on haptics and virtual reality technology for augmenting the teaching of palpatory diagnosis. This novel tool can act as an automated expert and an animated textbook to illuminate palpatory diagnosis concepts by touch on a laptop PC and by using affordable haptic interfaces that can be housed in a medical student resource library. It can be used for unlimited student practice for improving skills from Osteopathic Manipulative Medicine laboratory and also as a repeatable and objective measure of palpatory skill to track student progress. The system was evaluated by 22 osteopathic medical students (16 first- and 6 second-year). The majority of the participating students (>90.9 %) thought that future practice with the system may help them develop their palpatory skills. The majority (>77.3 %) of the students also thought that the instructions on the module screens were clear. When the students were asked about the user interface, most of the students (>86.4 %) responded that it was clear and easy to interpret. Evaluation results also showed that when the students were asked whether they would like to use the modules in the future for training at least 90.9 % of them answered “Yes” or “Maybe.” The achievement of purpose ratings for individual modules changed between 6.27 and 8.82 on a 10-point scale. This project has the potential to be extended from osteopathic medicine to allopathic medicine, veterinary medicine, physical therapy, massage therapy, and chiropractic schools.

The Robotic Lumbar Spine: Dynamics and Feedback Linearization Control

The robotic lumbar spine (RLS) is a 15 degree-of-freedom, fully cable-actuated robotic lumbar spine which can mimic in vivo human lumbar spine movements to provide better hands-on training for medical students. The design incorporates five active lumbar vertebrae and the sacrum, with dimensions of an average adult human spine. It is actuated by 20 cables connected to electric motors. Every vertebra is connected to the neighboring vertebrae by spherical joints. Medical schools can benefit from a tool, system, or method that will help instructors train students and assess their tactile proficiency throughout their education. The robotic lumbar spine has the potential to satisfy these needs in palpatory diagnosis. Medical students will be given the opportunity to examine their own patient that can be programmed with many dysfunctions related to the lumbar spine before they start their professional lives as doctors. The robotic lumbar spine can be used to teach and test medical students in their capacity to be able to recognize normal and abnormal movement patterns of the human lumbar spine under flexion-extension, lateral bending, and axial torsion. This paper presents the dynamics and nonlinear control of the RLS. A new approach to solve for positive and nonzero cable tensions that are also continuous in time is introduced.

Trainer-to-student ratios for teaching psychomotor skills in health care fields, as applied to osteopathic manipulative medicine.

The hallmark of osteopathic medical education is the inclusion of hands-on instruction in osteopathic manipulative medicine (OMM), which includes palpatory diagnosis and osteopathic manipulative treatment (OMT). This OMM training typically involves a primary instructor presenting theory and techniques with step-by-step demonstrations to a large group of first- and second-year osteopathic medical students. Additional instructors, referred to as table trainers, assist the primary instructor by supervising the students as they practice the presented techniques. To the authors' knowledge, there is no currently accepted standard for a table trainer-to-student ratio in OMM skills laboratories within osteopathic medical schools in the United States. However, through a Google Web search and PubMed literature review, the authors identified published trainer-to-student ratios used in other health care skills training curricula. Psychomotor skills training courses in health care fields typically have a table trainer-to-student ratio of 1 trainer to 8 or fewer students. On the basis of these findings and psychomotor skills learning theory, the authors conclude that this ratio is likely sufficient for OMM skills training.

A Stiffness Discrimination Experiment Including Analysis of Palpation Forces and Velocities

The incorporation of haptics, the sense of touch, into medical simulations increases their capabilities by enabling the users to "feel" the virtual environment. We are involved with haptics-augmented virtual reality training for palpatory diagnosis. We have developed a stiffness discrimination program to train and test users in finding subtle differences in human tissue stiffness for medical diagnoses. In this article, we studied the effect of surface stiffness on the stiffness discrimination task and analyzed the palpation force and speed during haptic exploration. The ability to discriminate stiffness differences was studied by means of a psychophysical experiment with 13 second-year medical students (eight women and five men). Subjects were asked to identify the stiffer of two virtual computer-generated surfaces (top surfaces of two cylinders) by means of a PHANToM Omni (SensAble Inc.) haptic device with a modified stylus to accommodate their fingers. The modification of the stylus provided the mechanical advantage to simulate surface stiffness values that are beyond the original capability of the haptic device. An adaptive two-alternative forced-choice procedure was used on each trial. Palpation velocity and force vectors were recorded directly from the haptic device for further analyses. Weber fraction was determined by using an automated mastery algorithm. Four standard stiffness values (0.25, 0.50, 1.00, and 1.25 N/mm), typical of the stiffness range of human soft tissues, were used as references. The average experimental Weber fractions observed were 0.20, 0.27, 0.26, and 0.30, respectively, with higher Weber fractions corresponding to lower stiffness discrimination ability. At 1.00 and 1.25 N/mm standard stiffness, the correlation analysis for Weber fraction and the palpation speed revealed significant differences (P < 0.05). These differences suggested that the subjects with a higher palpation velocity tended to have a higher Weber fraction. There was no significant difference between male and female subjects. There was no significant difference between subjects new to the haptic device and those who had used it previously. The average amount of force that was applied by the subjects to the standard stiffness side and the comparison stiffness side within the sessions was not significantly different. However, the subjects increased the average force they applied with increasing standard stiffness value across the sessions (P < 0.05). For the four standard stiffness values investigated, 0.25, 0.50, 1.00, and 1.25 N/mm, the resulting average stiffness-discrimination Weber fractions were 0.20, 0.27, 0.26, and 0.30, respectively. The average of the forces applied by the subjects was constant within a single session (with a single standard stiffness value). This average force monotonically increased as the standard stiffness value increased across the sessions. We also found positive correlation between the Weber fraction and the palpation speed in the sessions tested with 1.00 and 1.25 N/mm standard stiffness. This correlation suggested that higher speed is related to lower sensitivity in discrimination of stiffness differences for these two standard stiffness values. Our results are applicable to tasks involving stiffness discrimination between multiple objects.

Inclusion of Surface Anatomy in an Integrated Medical Curriculum: A Hands‐on Experience.

The importance of including learning experiences designed to facilitate the acquisition of surface anatomy skills has become a pillar of the modern medical and health professional curricula promoting the integration of basic sciences knowledge with clinical sciences. Acquiring surface anatomy palpatory skills however is a time consuming and challenging endeavor in educational centers teaching large classes. Educators have developed a variety of strategies to achieve their goals, including the coordination of clinical activities with cadaver dissection and the use of virtual reality simulation to train students in palpatory diagnosis as shown in the other presentations in this refresher course. Over the last ten years, educators involved in the teaching of surface anatomy at the Medical University of South Carolina have developed a database of digital resources in the form of still pictures and mini‐videos clips to promote the teaching of surface anatomy. During this session, a selection of mini‐clips will be shown to the audience and time will be dedicated to the self‐palpation of clinically relevant anatomical structures of the upper limb by the participants themselves, illustrating how students can use these digital resources to strengthen their clinical skills.

Haptic Simulation of the Feel of the Body Surface for Training in Palpatory Diagnosis

Surface anatomy plays a special role in osteopathic medicine because palpatory diagnosis of musculoskeletal problems is prerequisite to manipulative treatment. As part of the physical exam, students learn to palpate the back for signs of dysfunction, which may be somatic or visceral in origin, and may be mediated by altered excitability of spinal neurons. The Virtual Haptic Back (VHB), a virtual reality simulation of the contours and textures of the human back, is used to help students learn palpatory diagnosis. Two haptic interfaces permit students to practice locating by touch regions within the paravertebral musculature of the simulated back having abnormal tissue texture (stiffness). The location of the abnormality varies randomly between trials, and the degree of compliance alteration also varies, allowing differences in task difficulty. In each trial students get immediate feedback as to the correctness of their diagnosis. Data from over 300 students demonstrate: 1) improvement in palpatory precision and speed over six, 15‐minute practice sessions, and 2) positive evaluations of the experience in terms of contributing to the development of student palpatory skills.

The virtual haptic back: A simulation for training in palpatory diagnosis

BackgroundModels and simulations are finding increased roles in medical education. The Virtual Haptic Back (VHB) is a virtual reality simulation of the mechanical properties of the human back designed as an aid to teaching clinical palpatory diagnosis.MethodsEighty-nine first year medical students of the Ohio University College of Osteopathic Medicine carried out six, 15-minute practice sessions with the VHB, plus tests before and after the sessions in order to monitor progress in identifying regions of simulated abnormal tissue compliance. Students palpated with two digits, fingers or thumbs, by placing them in gimbaled thimbles at the ends of PHANToM 3.0® haptic interface arms. The interface simulated the contours and compliance of the back surface by the action of electric motors. The motors limited the compression of the virtual tissues induced by the palpating fingers, by generating counterforces. Users could see the position of their fingers with respect to the back on a video monitor just behind the plane of the haptic back. The abnormal region varied randomly among 12 locations between trials. During the practice sessions student users received immediate feedback following each trial, indicating either a correct choice or the actual location of the abnormality if an incorrect choice had been made. This allowed the user to feel the actual abnormality before going on to the next trial. Changes in accuracy, speed and Weber fraction across practice sessions were analyzed using a repeated measures analysis of variance.ResultsStudents improved in accuracy and speed of diagnosis with practice. The smallest difference in simulated tissue compliance users were able to detect improved from 28% (SD = 9.5%) to 14% (SD = 4.4%) during the practice sessions while average detection time decreased from 39 (SD = 19.8) to 17 (SD = 11.7) seconds. When asked in anonymous evaluation questionnaires if they judged the VHB practice to be helpful to them in the clinical palpation and manual medicine laboratory, 41% said yes, 51% said maybe, and 8% said no.ConclusionThe VHB has potential value as a teaching aid for students in the initial phases of learning palpatory diagnosis.

Kinematic measures to objectify head and neck motions in palpatory diagnosis: a pilot study.

Physicians typically combine the use of palpation and objective measures, as evidence-based medicine dictates, to improve patient diagnosis and care. Practitioners also use palpatory examination in manual medicine to diagnose musculoskeletal impairment; however, there are no commonly accepted objective measures to complement palpatory findings. To evaluate coupled vertebral motion as a parameter to complement palpatory findings from a standard clinical diagnostic test of cervical function. Two examiners performed a blind screening of volunteer subjects for the presence of palpable symmetry or asymmetry in motions of the head and neck. In cases of interexaminer agreement, subjects then participated in kinematic assessment of cervical motion patterns. Neck angles were recorded, plotted, and evaluated for amounts of vertebral coupling. Interexaminer agreement was reached with 18 of the 34 subjects screened. Seven subjects with symmetric responses constituted the control group. Experimental subjects consisted of an asymmetric-asymptomatic (pain-free) group (n=6) and an asymmetric-symptomatic (pain) group (n=5). Control subjects exhibited the smallest average linear slope (-0.32) for the least amount of coupled motion. The average linear slopes for asymmetric subjects was -0.42 (asymptomatic) and -0.50 (symptomatic). Data analysis revealed that statistically significant differences among groups will be detected with a larger sample size. Objective, kinematic parameters can be generated, measured, and evaluated relative to palpatory findings of musculoskeletal impairment by identifying trends in ratios of cervical lateral flexion and axial rotation.

Palpatory diagnosis training on the virtual haptic back: performance improvement and user evaluations.

Learning palpatory diagnosis is a challenge for many osteopathic medical students. The Virtual Haptic Back (VHB) is an aid in teaching and learning these skills. The device simulates the contours and surface compliances of the human back and allows these to be felt through haptic interfaces. Regions of abnormal tissue texture are simulated by altered surface compliance. To examine the effectiveness of the VHB in training osteopathic medical students in palpatory diagnosis and to determine students' subjective impressions of the potential value of the VHB in learning palpatory diagnosis. Twenty-one first-year osteopathic medical students at the Ohio University College of Osteopathic Medicine in Athens took performance tests on the VHB before and after a series of eight 15-minute practice sessions, which occurred during multiple 2-week sessions between September 2005 and January 2006. The tests and practice sessions measured student accuracy and speed in locating regions of abnormal compliance in the haptic back, which varied randomly among 12 sites in the thoracic region. After completing the practice sessions and performance tests, students filled out a questionnaire regarding their impressions of the potential value of the VHB as a learning aid. Students collectively improved in accuracy and speed following the practice sessions compared with the initial performance test. Subjects improved from being able to detect only a 40% difference in compliance to being able to detect an 11% difference (P<.05). The greatest improvements occurred at the difficulty levels near the apparent detection limit of compliance differences. Survey responses indicated that students thought the VHB experience was helpful in developing their palpatory skills. The VHB has potential as an effective aid to osteopathic medical students in learning palpatory diagnosis.

The Virtual Haptic Back: a teaching aid for palpatory diagnosis

The virtual haptic back (VHB) is a virtual reality simulation of the feel of a real human back, designed as a teaching/learning aid in palpatory diagnosis. The simulation is based on compliance measurements made on living subjects with PHANToM 3.0 haptic interfaces from SensAble Technologies and uses these interfaces in the simulation. First year osteopathic medical students (N=89), required to participate as part of the manipulative medicine course, were tested as to their ability to find sites of abnormal tissue compliance in the VHB before and after six practice sessions. On the pre-test subjects as a group failed to show mastery in detecting compliance differences of 39%; following practice they were able to detect differences as little as 14%. Improvement in performance during the practice sessions were seen with compliance differences as low as 7%. Following the practice sessions students were asked, “Do you think that the practice with the Virtual Haptic Back will be of help to you in the development of your palpatory skills in the manipulative medicine laboratory?” 39% said “yes;” 51% said maybe;” 10% said “no;” The VHB offers an objective measure of palpatory skill and appears to have promise for teaching palpatory diagnosis of the human back. This technology may prove to be useful in developing teaching aids for other palpatory examinations used in making clinical diagnoses. Supported by the Osteopathic Heritage Foundation.

High-stakes Assessment of Clinical skills in A simulated Environment.

BACKGROUND: Consistent with its mission to protect the public, the National Board of Osteopathic Medical Examiners (NBOME) implemented a clinical skills examination into its COMLEX-USA licensure examination series in 2004. The COMLEX-USA Level 2-Performance Evaluation (Level 2-PE) assesses the clinical skills of osteopathic candidates in a simulated clinical environment with standardized patients. These skills include physical examination, medical history-taking, palpatory diagnosis and osteopathic manipulative treatment (OMT), doctor-patient communication, professionalism, and written communication skills. Physician raters score the written notes and OMT. METHOD: Candidates completed a twelve station examination, where they are asked to evaluate and treat the standardized patient as appropriate. Candidates are allotted 23 minutes to complete the interview and patient evaluation and to document and synthesize their clinical findings, impressions, and plan in a written note. All testing was completed at NBOME’s National center for Clinical Skills Testing, a state-of-the-art simulation facility designed to ensure the necessary safety, security, and standardization required for high-stakes testing. RESULTS: From September, 2004 through June, 2006, NBOME tested 5748 candidates. First-time takers had a 95.7% pass rate. Generalizability coefficients for the data-gathering and doctor-patient communication components of the examination ranged from 0.78–0.84, respectively. There were modest correlations between scored Level 2-PE components (data-gathering-written note, r= .50). Correlation between clinical skills components and knowledge-based clinical science scores were moderate. CONCLUSIONS: The addition of Level 2-PE to the COMLEX-USA examination series allows for the valid and reliable measurement of clinical skills in a simulated medical environment. While standardized patients offer the opportunity to assess “hands-on” skills, many patient conditions are difficult, or impossible, to simulate. Other relevant competencies (e.g., technical procedures sure as phlebotomy and sensitive examinations such as digital rectal examinations) are difficult to test using standardized patients. Here, to improve the content validity of the assessment, the addition of other simulation modalities may be helpful.

Palpatory diagnosis of plagiocephaly

The term plagiocephaly, from the Greek plagios (oblique) and kephalê (head), means distortion of the head, and refers clinically to cranial asymmetry. Cranial Osteopathy, since it was first proposed, has focussed upon the diagnosis and treatment of birth trauma and cranial asymmetries, and consequently specific therapy for plagiocephalic deformities has been described. Osteopathic manipulation also has been proposed as a treatment for torticollis, a condition associated with plagiocephaly. For these reasons, we decided to look at the mechanics of the occipital bone and the adjacent atlas and bones of the cranial base, in relation to functional plagiocephaly. The records of 649 children seen in an osteopathic practice in Lyon, France, were reviewed retrospectively, in compliance with the legal requirements of the Commission Nationale de l'Informatique et des Libertés (CRIL) and the Helsinki accord, for gender, age at presentation, birth history, obstetrical data (breech presentation, vacuum extraction, forceps delivery or Caesarean section), presenting complaint, side of posterior plagiocephaly, side of frontal plagiocephaly, torticollis, motion pattern of the occipital bone upon the atlas, and motion pattern of the spheno-occipital synchondrosis. We found significant correlations between plagiocephaly (right/left) and primipara (P=0.024), use of forceps (P=0.055) and extractor suction (P=0.055). Correlations were also found between flattening of the occiput (right/left) and lateral strain of the spheno-occipital synchondrosis (P=0.002) and between plagiocephaly (right/left) and occipito-atlantal motion (P=0.000). We found a significant correlation between the lateral strain pattern of the spheno-occipital synchondrosis and plagiocephaly and between rotational dysfunction of the occiput upon the atlas and the side of posterior plagiocephaly. We suggest that thorough neonatal osteopathic examination can identify individuals predisposed to develop posterior plagiocephaly.

Community-based osteopathic manipulative medicine student clinic: changes in curriculum and student confidence levels.

The West Virginia School of Osteopathic Medicine in Lewisburg instituted a free, community-based medical clinic in spring 1995 as part of an institution-wide Osteopathic Principles and Practices Integration Project. Under this initiative, osteopathic medical students are provided with 26 hours of supervised experience in osteopathic palpatory diagnosis and osteopathic manipulative treatment. The educational goal of the clinic is to increase the confidence of osteopathic medical students in their technical abilities in using osteopathic manipulative medicine to diagnose and treat community patients. Based on a variety of results from student-completed surveys, the authors conclude that the osteopathic manipulative medicine student clinic at West Virginia School of Osteopathic Medicine has met its goal of increasing student confidence in the application of these skills.

Dissection of the thoracic paraspinal region – implications for osteopathic palpatory diagnosis: A case study

Background Authors in the field of osteopathy have claimed that tissue texture abnormalities in the paravertebral gutter (PVG), the region between the erector spinae mass and the spinous processes, are indicators of intervertebral somatic dysfunction, but the cause of texture abnormality is unknown. Methods The PVG was identified using manual palpation and marked with marker pins before dissection. A progressive dissection of the medial paraspinal thoracic region was performed and the anatomy of this region was reviewed. Results Progressive dissection revealed the trapezius, spinalis, semispinalis, multifidus and rotatores muscles to be immediately deep to the marked location, and deep to these muscles, directly below the marker, was the zygapophysial joint. Discussion The possible relevance of these medial paraspinal structures to tissue texture abnormality detected with palpation was discussed. Authors in the field of osteopathy have suggested that dysfunction of either the rotatores muscles or the underlying zygapophysial joint may be responsible for tissue texture change in the PVG, and these structures were located directly under the palpated site. Conclusion Further research to examine the tissues associated with textural abnormalities in the PVG is warranted.

An overview of osteopathic medicine.

Despite an initial lack of acceptance by mainstream medicine, and amidst projections of a serious oversupply of physicians, the osteopathic profession continues to grow, successfully competing for shrinking health care resources and attracting the attention of insurers and those in managed care. However, a recent telephone survey of 800 health maintenance organization beneficiaries suggested that the public is not yet familiar with osteopathic medicine. The history, philosophy, and current status of the osteopathic profession are presented, along with theories of the physiologic basis of and supporting evidence for palpatory diagnosis and manipulative therapy.

Palpatory diagnosis and manipulative management of carpal tunnel syndrome: Part 2. 'Double crush' and thoracic outlet syndrome

The physician treating carpal tunnel syndrome needs to be aware of the possible concomitant occurrence of thoracic outlet syndrome, the so-called double crush syndrome. Palpation is used to differentiate carpal tunnel syndrome from thoracic outlet syndrome. Such palpatory examination assists the physician in planning the initial treatment, including osteopathic manipulation and self-stretching maneuvers, targeted specifically at the most clinically significant pathologic region. Supplemental physical medicine modalities such as ultrasound may enhance the treatment response. Some illustrative cases are reported.

Interexaminer agreement on palpatory diagnosis and patient self-assessment of disability: A pilot study

To evaluate interexaminer agreement on palpatory diagnostic findings, we compared interexaminer results, patient disability self-evaluations, and assessment of patients' progress by referring physicians. Three examiners (two clinicians and a third-year osteopathic medical student fellow) monitored patients' progress using negotiated examination procedures. The patients were examined independently by each examiner at each of eight weekly visits. Patients completed a disability assessment form at each visit, and the referring physicians recorded changes in their patients' condition. The patients' disability self-rating and examiner test results did not show clear correlation. There was a 62.2% agreement between the two physician examiners when the general descriptors "improvement," "no change," or "aggravation" were used. The student examiner's agreement with the clinician examiners was 60.2% and 51.8%. Interexaminer agreement of findings from osteopathic testing procedures appears to depend on general clinical experience and specific experience with the testing procedures.

Palpatory diagnosis and manipulative management of carpal tunnel syndrome

Carpal tunnel syndrome was studied by use of supplemental palpatory diagnosis in 20 abnormal wrists. Restriction in motion at the carpal tunnel was quantified with a rating system. All wrists with carpal tunnel syndrome revealed at least moderate restriction to motion, as compared with only mild or no restriction in 20 wrists in normal, symptom-free subjects. Several participants (16 abnormal wrists) underwent osteopathic manipulative treatment, including a new "opponens roll" maneuver, and self-stretching, or a similar treatment accomplished by use of a self-treatment accomplished by use of a self-treatment appliance. In those treated, palpatory restriction decreased into the normal range, often before symptoms decreased. Improvement in nerve conduction studies usually followed within 1 to 3 months. Palpatory diagnosis is a useful adjunctive method of assessing patient status in carpal tunnel syndrome and helpful in prognosticating outcome. The modified manipulative technique described for the treatment of mild to moderate carpal tunnel syndrome may be effective in more severe cases.