The Somatic Connection  |   October 2011
Improving Interexaminer Reliability of Palpation of Vertebral Landmarks
Article Information
The Somatic Connection   |   October 2011
Improving Interexaminer Reliability of Palpation of Vertebral Landmarks
The Journal of the American Osteopathic Association, October 2011, Vol. 111, 573. doi:
The Journal of the American Osteopathic Association, October 2011, Vol. 111, 573. doi:
Snider KT, Snider EJ, Degenhardt BF, Johnson JC, Kribs JW. Palpatory accuracy of lumbar spinous processes using multiple bony landmarks. J Manipulative Physiol Ther. 2011;34(5):306-313. 
Physicians depend on reliable and accurate tests to make correct diagnoses and administer appropriate treatments. Osteopathic physicians who use osteopathic manipulative treatment depend on palpatory cues to identify somatic dysfunctions that are amenable to manipulation. More than 30 years ago, William L. Johnston, DO, who was associate editor of JAOA—The Journal of the American Osteopathic Association—pioneered interexaminer reliability studies of palpatory diagnostic tests used to detect somatic dysfunction. A review and update of his landmark studies from the 1970s were summarized in his Louisa Burns Memorial Lecture, which was published in the JAOA in August 1982 (1982;81[12]:819-829). Most reliability studies concur that palpatory evaluation of anatomic landmarks, especially spinal vertebral landmarks, demonstrate poor interexaminer reliability (Seffinger et al. Spine. 2004;29:E413-E425). 
As the field of research in accuracy and reliability of palpatory diagnostic tests enters its fifth decade, osteopathic physicians at A.T. Still University of Health Sciences-Kirksville College of Osteopathic Medicine have demonstrated that improvement in both accuracy and reliability of these tests is possible by having examiners assess multiple landmarks, instead of only 1 landmark, in the surrounding lumbar region. In a study by Snider et al, accuracy of the palpatory diagnostic tests was assessed using radiography. 
Four osteopathic physician examiners (3 faculty and 1 resident) specializing in neuromusculoskeletal medicine/osteopathic manipulative medicine (NMM/OMM) independently identified the spinous processes of L1 to L4 on 60 prone volunteers (27 men, 33 women) aged 20 to 60 years. Five distinguishing characteristics were used in identification, including spinous process sizes and segmental relation to the 12th ribs, sacral base, and iliac crests. Each examiner marked the selected spinous processes with radiopaque skin markers. These locations were then assessed for accuracy by an independent radiologist via posteroanterior lumbar radiographs. Interexaminer reliability was determined using weighted κ values. Generalized linear mixed models assessed the relationship of palpation accuracy to examiner training level. Cochran Mantei-Haenszel tests assessed the effects of volunteers' sex, obesity, and anatomic anomalies on palpation accuracy. 
Examiners identified a spinous process in 91% of vertebral assessments. Examiners correctly identified vertebral level in 69% of assessments (κ=0.81; 95% confidence interval [CI], 0.79-0.83). Accuracy of faculty examiners in correctly identifying a lumbar spinous process using various regional landmarks averaged 74%, which, according to the authors, was higher than in any other study evaluating palpation accuracy using radiologic or magnetic resonance imaging. Faculty examiners were significantly more accurate in identifying the correct vertebral level than was the resident examiner (P≤.03). There was good interexaminer reliability (73% agreement) among faculty examiners (κ=0.66; 95% CI, 0.61-0.71) and moderate interexaminer reliability (62% agreement) among all examiners (κ=0.53; 95% CI, 0.49-0.56). 
The presence of 12th-rib anomalies decreased palpatory accuracy for all examiners from 74% to 55% (P≤.05). Accuracy was significantly higher when examining male volunteers than female volunteers (P=.01). Palpatory accuracy was significantly lower when examining obese volunteers than nonobese volunteers (P <.001) at L3 (50% vs 73%, respectively) and L4 (44% vs 72%, respectively). 
The authors conclude that identification of lumbar spinal levels using the spinous processes in conjunction with multiple landmarks was more accurate than previously reported identification results obtained from using a single landmark. However, palpatory accuracy was dependent on the presence or absence of anatomic anomalies, volunteer characteristics (eg, sex, obesity) and examiner experience. The authors also note that having 1 examiner who was less experienced than the others limited the conclusions that they could make. 
Finally, bearing in mind that even faculty examiners specializing in NMM/OMM and trained to teach palpatory skills failed to achieve 100% accuracy, the authors suggest that objective radiologic evaluations be used in cases demanding anatomic accuracy, such as cases involving anesthesiology procedures or patient referrals between physicians.—M.A.S. 
   “The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of JAOA—The Journal of the American Osteopathic Association strives to chronicle the significant increase in published research on manipulative methods and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.   To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact JAOA Associate Editor Michael A. Seffinger, DO (, or Editorial Board Member Hollis H. King, DO, PhD (