Palpatory skills are a huge part of our practice that we start within first semester of physical therapy school. We learn to identify surface structures and through further experience, can identify faults through a “reflection” of the skin. The faults can be in the soft tissue structures through changes in tissue texture & tone or determine the position of the joint underneath the muscles. The latter will be the grounds of this post.
How detailed do we and should we be when educating patients about our assessment of their dysfunction, especially based on possible anatomical malalignment?
During an evaluation, I sometimes think in the back of my head…”am I really that confident of my examination outcomes and what I just told my patient about their condition?”. Is this evidenced-based and more importantly, safe clinical practice?
Let me explain further…I’ll start with a rare, but possible scenario…
You have been treating a neck or back pain patient for a few weeks and one day, he or she goes into further details about how a lawyer has been hired due to litigation from a MVA. Since you, the physical therapist has been main healthcare provider due to only seeing medical doctor once since the accident, the patient wants to use you as witness to validate his or her injuries. The patient reminds you that on first visit, you mentioned to him or her that “the sacroiliac joint and lumbar spine was rotated this way, and side-bent that way, etc.” He or she wants to use what you said in a video-taped deposition with both prosecuting and defense lawyers present. A “oh-no!” or other expletive words come to mind and you think, what did I really say!?
You think, this will never happen but it can. Reality = Our profession is growing. We are moving away from burning patients with hot packs as the only legal action in physical therapy.
What does the evidence say? Well…not too good for us.
Reliability of identifying spinous process of C7 and L5.
–Inter-rater reliability is poor for C7 and moderate for L5. And we thought this was an easy one!!
Measurement of Sacroiliac Joint Dysfunction
–Reliability of measures from pelvic symmetry or movement tests are too low for clinical use (agreement between 60-69%)
–All symmetry and motion tests show poor inter-tester reliability, low sensitivity (0.46-0.49) and low specificity (0.38-0.64)
Reliability and assessment of alignment is still questionable in static and dynamic conditions. Most of the data shows poor to fair reliability, sensitivity and specificity. Nevertheless, combination of multiple tests show more substantial numbers but not up to par.
This is not enough to make me feel comfortable to back what I say based solely on asymmetry. I hope we don’t continue to educate patients about asymmetry based on poor tests. This is a disservice to them…and a disservice to us as if we were placed as a witness, how will we fare?
-Robinson R., Robinson HS, Bjorke G. et al. Reliability and validity of a palpation technique for identifying the spinous processes of C7 and L5. Manual Therapy. Volume 14, Issue 4. August 2009. Pages 409-414.
-Riddle DL, Freburger JK. Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study. Physical Therapy. 2002, August 82(8). 772-81.
-Tong HC, Heyman OG, Lado DA, et al. Interexaminer Reliability of Three Methods of Combining Test Results to Determine Side of Sacral Restriction, Sacral Base Position, and Innominate Bone Position. JAOA. 2006, 106: 8. 464-468.