The present study received approval from the local institutional review board and the American Academy of Osteopathy (AAO). In May 2010, physician members of the AAO were e-mailed a description of the study and a link to an electronic survey regarding the physical examination and diagnosis of 15 anatomically incongruent tender points and tender point groups. Members of the AAO were targeted for this survey because the AAO oversees board certification in neuromusculoskeletal medicine/osteopathic manipulative medicine (NMM/OMM) and provides continuing medical education programs that focus on OMM. Nonphysician members, students, resident physicians, and foreign AAO members were not e-mailed to participate in the study. The electronic survey was open for 4 weeks, and a reminder e-mail was sent 2 weeks after the first e-mail. To ensure that the respondents were familiar with the use of counterstrain in clinical practice, they were asked whether they used counterstrain diagnosis and treatment in their practices. Only respondents who reported that they used counterstrain diagnosis and treatment in their clinical practices were eligible to complete the entire survey. Before completing the main part of the survey (
1), respondents were asked demographic questions regarding sex, specialty, and years in practice.
To develop the survey, we assessed tender points commonly taught at US osteopathic medical schools and identified 15 tender points and tender point groups that were incongruent with their named location or were questionable with regard to the somatic dysfunction body region to which they belonged. We listed these 15 incongruent tender points in the survey (created using Zoomerang software [Zoomerang, San Francisco, California]) and asked participants to identify the body area that would be physically evaluated during the assessment of each tender point or tender point group and the body region in which somatic dysfunction would be diagnosed if a tender point were present (
1). The survey also contained space for participants to leave open-ended comments.
Because different counterstrain references may cite slightly different locations for the same tender points, we noted the general location of some of the tender points in the survey for clarity. For example, the anterior C1 (AC1) tender point is cited as occurring on the posterior angle of the mandible by Jones
6(p51) and on the C1 transverse process by Essig-Beatty et al.
8 Further, the survey was designed so the respondent could choose only 1 physical examination body area or somatic dysfunction body region for each question. The survey included the following 10 physical examination body areas identified in the 1995 CMS E/M coding guide
7: head, neck, spine, chest/ribs/breasts, abdomen, pelvis/groin/buttocks, right upper extremity, left upper extremity, right lower extremity, and left lower extremity. In addition, the survey included the following 10 somatic dysfunction body regions identified in
International Classification of Disease, Ninth Revision (ICD-9),
9 followed by their ICD-9 code: head (739.0), cervical (739.1), thoracic (739.2), lumbar (739.3), sacral (739.4), pelvic (739.5), lower extremity (739.6), upper extremity (739.7), rib cage (739.8), and abdomen (739.9).
10
To categorize the physicians' responses as indicating either a structural or functional approach, multiple counterstrain reference textbooks
1-3,5,6 were reviewed for descriptions of the physical locations of each tender point included in the survey. If respondents chose the physical location of the tender point for either the location of the physical examination or the somatic dysfunction diagnosis, then their response was categorized as indicating a structural approach. In some instances, separate counterstrain reference textbooks cited different physical locations for the same tender point. The responses for questions regarding these tender points were categorized as indicating a structural approach for both locations. For example, Jones
6(pp60,72,73) describes the upper pole L5 (UPL5) tender point as physically located on the superior medial surface of the posterior superior iliac spine (PSIS), whereas Rennie and Glover
3 describe this tender point as physically located on the L5 spinous process or between the L5 spinous process and the PSIS. Therefore, if respondents chose the spine or pelvic/groin/buttocks area as the physical examination location for this tender point or if they chose the lumbar or pelvis region for the somatic dysfunction diagnosis, their responses were categorized as indicating a structural approach to that aspect of billing and coding. If respondents chose a distal region or the region moved by the muscular structure (muscular insertion site) for the physical examination location or somatic dysfunction diagnosis of a tender point, then their responses were categorized as indicating a functional approach.
The percentage of responses indicating a structural approach vs a functional approach and the 95% confidence interval for each percentage were calculated for physical examination location and somatic dysfunction diagnosis for each tender point. McNemar tests were used to test for inconsistencies in approach to physical examination location and somatic dysfunction diagnosis within individuals (eg, if an individual chose a response indicating a structural approach for the physical examination location of a tender point and a response indicating a functional approach for the somatic dysfunction diagnosis of the same tender point). In order to test for differences in approach to physical examination location and somatic dysfunction diagnosis according to respondents' reported sex, specialty, and years in practice, Fisher exact tests were used. Statistical analyses were conducted using SAS software (version 9.2; SAS Institute Inc, Cary, North Carolina). P≤.05 was considered statistically significant.