J Manipulative Physiol Ther. 2008 (Oct); 31 (8): 616626 ~ FULL TEXT
Michael T. Haneline, DC, MPH, Robert Cooperstein, MA, DC, Morgan Young, DC, Kristopher Birkeland, BA
Palmer College of Chiropractic West,
San Jose, California 95134, USA.
OBJECTIVE: Spinal motion palpation (MP) is a procedure used to detect intersegmental hypomobility/hypermobility. Different means of assessing intersegmental mobility are described, assessing either excursion of the segments (quantity of movement) or end feel (quality of motion when stressed against the paraphysiological space). The objective of this review was to classify and compare studies based on method of MP used, considering that some studies may have used both methods.
METHODS: Four databases were searched: MEDLINE-PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature databases for the years 1965 through January 2007. Retrieved citations were independently screened for inclusion by 2 of the authors consistent with the inclusion and exclusion criteria. Included studies were appraised for quality, and data were extracted and recorded in tables.
RESULTS: The search strategy generated 415 citations, and 29 were harvested from reference lists. After removing articles that did not meet the inclusion criteria, 44 were considered relevant and appraised for quality. Fifteen studies focused on MP excursion, 24 focused on end feel, and 5 used both. Eight studies reported high levels of reproducibility (kappa = >or=0.4), although 4 were not of acceptable quality, and 2 were only marginally acceptable. When only high-quality studies were considered, 3 of 24 end-feel studies reported good reliability compared with 1 of 15 excursion studies. There was no statistical support for a difference between the 2 groupings.
CONCLUSIONS: A difference in reported reliability was observed when the method of MP varied, although it was not statistically significant. There was no support in the literature for the advantage of one MP method over the other.
Key Indexing Terms:
Palpation, Chiropractic, Spine, Vertebra, Sacroiliac Joint
From the FULL TEXT Article:
Motion palpation (MP) of the spine and sacroiliac joints is a diagnostic procedure used by chiropractors and manual therapists to detect intersegmental hypomobility/hypermobility. It is used in determining where to apply a manipulative thrust or mobilization. However, the validity of MP of the spine and sacroiliac joints has not been established [1, 2] and studies of its reliability have generally reported low indices of agreement.  Previous literature reviews on the reliability of MP have reported κ values suggesting only slight interexaminer reliability and moderate intraexaminer reliability. [4-8]
Different means of assessing intersegmental motion have been described that assess either the excursion of the segments or their end feel.  Some, in addition, look at pain provocation. Motion palpation of excursion is also known as quantitative or active palpation, whereas MP of end feel is also known as qualitative or passive palpation. Excursion depicts the quantity of movement of the examined segments within the normal range of motion (ROM), whereas end feel refers to the quality of motion when the segments are taken to their extremes of ROM and then stressed by the examiner against the paraphysiological space. The objective for the MP examiner is to detect gross movement of the segments during excursion and/or their relative stiffness when the segments are stressed at the extremes of normal ROM. Authors in MP studies that used qualitative assessment have not consistently described their methods clearly enough to determine whether they used the end-feel method as we describe it or rather evaluated joint play within an ROM short of the end range. In our study, we had no choice but to lump such studies together, as more similar in method to each other than to the excursion method.
To our knowledge, no reviews have assessed whether there were differences in reliability according to whether the end-feel or excursion methods were used. The objective of this literature review was to classify the studies as to which method of MP was used, allowing for the possibility that a study may have used both methods at the same or at different segments.
Previous literature reviews on spinal MP have, in general, pointed to a lack of support for the procedure. Troyanovich et al  called for abandoning the procedure on this basis. Dishman  reported on only a few MP interexaminer reliability studies, concluding that the procedure was supported by the literature. However, it was not a systematic review and all of the cited studies merely reported percentage of agreement between examiners. Another review by Haas  concluded that the chiropractic literature at that time could not substantiate claims about the reliability of any of the diagnostic instrumentation or palpatory procedures commonly used by chiropractors, including MP. Breen  reviewed the literature on physical examination techniques used by chiropractors, finding their reliability to be lacking. He suggested that, in addition to establishing observer reliability, studies should be designed that pay attention to issues of validity by incorporating the use of gold standards. A review by Panzer  concluded that most previous MP studies had reported marginal to poor interexaminer and good to moderate intraexaminer reliability. Stochkendahl et al  reviewed studies that investigated the reliability of manual examination methods, including a number of MP reliability studies. The authors concluded that the procedure was not clinically acceptable.
In agreement with other reviews on the reproducibility of spinal MP, [2, 3, 8, 44, 92, 93] the overall results of this review point to a low degree of reproducibility among the included studies, with intraexaminer reliability generally faring better than interexaminer reliability. Thus, in a clinical context, one method would not be preferred over the other. Furthermore, if MP is used in clinical practice, the procedure should be accompanied by complementary tests that have established reliability and validity.
It is noteworthy that so many articles were located while searching the reference sections of the included studies and reviews on MP. We were able to uncover an additional 29 articles using this process, which, when combined with those found in the database searches, is more than any other MP review to date. This experience was similar to that of Murphy et al,  who were still able to locate an additional 11 citations via manual searches and content experts, after searching 13 databases on the reliability of spinal palpation procedures.
We searched 4 biomedical databases using diverse search terms and also gleaned a number of references from the included articles. Nonetheless, it is possible that some relevant citations may have been missed.
We have attempted in this review to compare the reported reliability of studies that used MP excursion vs end feel. However, when combining the results of reliability studies, one must consider that this exercise is fraught with a number of difficulties.  Some examples include the following: studies commonly used dissimilar interpretations of what the calculated κ values meant (eg, 0.4 is judged satisfactory in one study, whereas another study requires ≥0.5), studies used examiners with different experience levels, and some studies used symptomatic and others asymptomatic subjects. Furthermore, the included studies often used somewhat different methods of MP, used dissimilar study designs, included diverse populations, and reported different reliability indices. These difficulties have resulted in an overall study heterogeneity that makes direct comparison difficult.
Studies of MP are inherently prone to error because, even if the examiners agree on the level of hypomobility, there is a significant chance they will unknowingly differ in their identification of the level of palpated segments, even when they agree on the location of fixation. For instance, Billis et al  reported on the interexaminer reliability of simply locating the C5, T6, and L5 spinous processes by palpation, which was low at all spinal levels. Some researchers have attempted to ameliorate this problem by collapsing segmental data into regions, although Haas  criticized this practice because it inflates reliability. An example of a study that attempted to control for disagreement about the level being palpated was Maher et al,  who had the examiners locate and mark the spinous process of the target vertebra by consensus. They thought that the marking procedure may have contributed to the reported relatively high interexaminer reliability, artificially increasing reliability estimates, because the target level must be located independently in clinical practice. Huijbregts  suggested that the reason intraexaminer MP studies have on average reported higher indices of agreement than interexaminer studies may be related to the difficulty of identifying spinal levels between examiners.
Some of the operational definitions of the palpation procedures that were given in the various articles were vague, which sometimes made it difficult to ascertain the actual method of palpation that was used. In our classification of studies as having used the end-feel method, we reluctantly lumped together procedures that assessed joint movement at the end ROM and those that assessed joint play (ie, posteroanterior stiffness springing short of end range). The 2 methods are in some respects discrete, as they assess somewhat different aspects of joint integrity, although they both involve applying pressure and judging the tissue's response.
A major limitation in attempting to determine the preference of one type of MP over the other is the lack of evidence concerning the validity of the 2 types. It should also be noted that, to actually determine whether one type of MP is more reliable than another, it will be necessary to conduct a study that involves a head-to-head comparison of independent tests.
The reliability of both the excursion and end-feel MP methods was, for the most part, found to be meager in this review, given that the reported κ values of most studies were below 0.4. When only considering high-quality studies, there did not appear to be any advantage of one method of MP over the other. In light of the findings of Marcotte et al, [78, 79] future MP reproducibility studies, at least those involving the cervical spine, may benefit by controlling the kinematics of palpation between examiners. Studies should also be more careful to describe their methods, for ease of classification as excursion, end feel, or joint play palpation.
Two forms of spinal MP may be described, one assessing joint end feel and the other excursion of the intervertebral joints.
The reported reliability for both methods of spinal MP is generally low.
The proportion of studies that reported good reliability favored the end-feel method over excursion, although differences were not statistically significant.
Leboeuf-Yde, C, van Dijk, J, Franz, C et al.
Motion palpation findings and self-reported low back pain in a population-based study sample.
J Manipulative Physiol Ther. 2002; 25: 8087
Hestbaek, L and Leboeuf-Yde, C.
Are chiropractic tests for the lumbo-pelvic spine reliable and valid?
A systematic critical literature review.
J Manipulative Physiol Ther. 2000; 23: 258275
Spinal motion palpation: a review of reliability studies.
J Man Manip Ther. 2002; 10: 2439
Static and dynamic components of the chiropractic subluxation complex: a literature review
J Manipulative Physiol Ther. 1988 (Apr); 11 (2): 98-107
The reliability of reliability.
J Manipulative Physiol Ther. 1991; 14: 199208
The reliability of palpation and other diagnostic methods.
J Manipulative Physiol Ther. 1992; 15: 5456
The reliability of lumbar motion palpation.
J Manipulative Physiol Ther. 1992; 15: 518524
Stochkendahl MJ, Christensen HW, Hartvigsen J, et al.
Manual examination of the spine: a systematic critical literature review of reproducibility.
J Manipulative Physiol Ther 2006;29:475-85, 85 e1-10.
Cassidy, J and Potter, G.
Motion examination of the lumbar spine.
J Man Manip Ther. 1979; 2: 151158
Maclure, M and Willett, WC.
Misinterpretation and misuse of the kappa statistic.
Am J Epidemiol. 1987; 126: 161169
in: Fundamentals of biostatistics. 4th ed.
Duxbury Press, Belmont, Calif; 1995: 518
Portney, LG and Watkins, MP.
in: Foundations of clinical research: applications to practice. 2nd ed.
Prentice Hall, Upper Saddle River, NJ; 2000: xiv, 768
Statistical methodology for reliability studies.
J Manipulative Physiol Ther. 1991; 14: 119132
Inscoe, E, Witt, P, Gross, M et al.
Reliability in evaluating passive intervertebral motion of the lumbar spine.
J Man Manip Ther. 1995; 3: 135143
in: Precision Journalism: A Reporter's Introduction to Social Science Methods. 4 ed.
Rowman & Littlefield Publishers, Inc., New York; 2002: 194
Chiropractic biomechanical evaluations: validity in myofascial low back pain.
J Manipulative Physiol Ther. 1982; 5: 155161
Deboer, KF, Harmon, R, Tuttle, CD et al.
Reliability study of detection of somatic dysfunctions in the cervical spine.
J Manipulative Physiol Ther. 1985; 8: 916
French, SD, Green, S, and Forbes, A.
Reliability of chiropractic methods commonly used to detect manipulable lesions in patients
with chronic low-back pain.
J Manipulative Physiol Ther. 2000; 23: 231238
Johnston, WL, Allan, BR, Hendra, JL et al.
Interexaminer study of palpation in detecting location of spinal segmental dysfunction.
J Am Osteopath Assoc. 1983; 82: 839845
Johnston, WL, Beal, MC, Blum, GA et al.
Passive gross motion testing: Part III. Examiner agreement on selected subjects.
J Am Osteopath Assoc. 1982; 81: 309313
Johnston, WL, Elkiss, ML, Marino, RV et al.
Passive gross motion testing: Part II. A study of interexaminer agreement.
J Am Osteopath Assoc. 1982; 81: 304308
Johnston, WL and Hill, JL.
Spinal segmental dysfunction: incidence in cervicothoracic region.
J Am Osteopath Assoc. 1981; 81: 2228
Johnston, WL, Hill, JL, Elkiss, ML et al.
Identification of stable somatic findings in hypertensive subjects by trained examiners using
J Am Osteopath Assoc. 1982; 81: 830836
Johnston WL, Kelso AF, Babcock HB.
Changes in presence of a segmental dysfunction pattern associated with hypertension:
Part 1. A short-term longitudinal study.
J Am Osteopath Assoc 1995;95:243-8, 53-5.
Johnston, WL, Hill, JL, Sealey, JW et al.
Palpatory findings in the cervicothoracic region: variations in normotensive and hypertensive subjects.
A preliminary report.
J Am Osteopath Assoc. 1980; 79: 300308
Jull, G, Zito, G, Trott, P et al.
Inter-examiner reliability to detect painful upper cervical joint dysfunction.
Aust J Physiother. 1997; 43: 125129
McConnell, DG, Beal, MC, Dinnar, U et al.
Low agreement of findings in neuromusculoskeletal examinations by a group of osteopathic physicians
using their own procedures.
J Am Osteopath Assoc. 1980; 79: 441450
Moran, RW and Gibbons, P.
Intraexaminer and interexaminer reliability for palpation of the cranial rhythmic impulse at the head and sacrum.
J Manipulative Physiol Ther. 2001; 24: 183190
Rhudy, T, Sandefur, M, and Burk, J.
Interexaminer/intertechnique reliability in spinal subluxation assessment: a multifactorial approach.
Am J Chiropr Med. 1988; 1: 111114
Pool, JJ, Hoving, JL, de Vet, HC et al.
The interexaminer reproducibility of physical examination of the cervical spine.
J Manipulative Physiol Ther. 2004; 27: 8490
Beal, MC, Goodridge, JP, Johnston, WL et al.
Interexaminer agreement on patient improvement after negotiated selection of tests.
J Am Osteopath Assoc. 1980; 79: 432440
Ghoukassian, M, Nicholls, B, and Mclaughlin, P.
Inter-examiner reliability of the Johnson and Friedman percussion scan of the thoracic spine.
J Osteopath Med. 2001; 4: 1520
Palpation and X-ray of the upper cervical spine: a reliability study.
J Vertebr Subluxat Res. 2006; 25: 114
Horneij, E, Hemborg, B, Johnsson, B et al.
Clinical tests on impairment level related to low back pain: a study of test reliability.
J Rehabil Med. 2002; 34: 176182
Kappler, RE, Larson, NJ, and Kelso, AF.
A comparison of structural examination findings obtained by experienced physician examiners and
student examiners on hospital patients.
J Am Osteopath Assoc. 1976; 75: 528529
Toussaint, R, Gawlik, CS, Rehder, U et al.
Sacroiliac joint diagnostics in the Hamburg Construction Workers Study.
J Manipulative Physiol Ther. 1999; 22: 139143
Van Suijlekom, HA, De Vet, HC, Van Den Berg, SG et al.
Interobserver reliability in physical examination of the cervical spine in patients with headache.
Headache. 2000; 40: 581586
Interexaminer reliability of observations in physical examinations of the neck.
Phys Ther. 1987; 67: 15261532
Gonella, C, Paris, SV, and Kutner, M.
Reliability in evaluating passive intervertebral motion.
Phys Ther. 1982; 62: 436444
Leboeuf, C, Gardner, V, Carter, A et al.
Chiropractic examination procedures: a reliability and consistency study.
J Aust Chiropr Assoc. 1989; 19: 101104
de Wijer, A, Steenks, MH, Bosman, F et al.
Symptoms of the stomatognathic system in temporomandibular and cervical spine disorders.
J Oral Rehabil. 1996; 23: 733741
Lower cervical spine motion palpation (C2-7).
J Can Chiropr Assoc. 1984; 28: 219221
Haas, M, Panzer, D, Peterson, D et al. S
hort-term responsiveness of manual thoracic end-play assessment to spinal manipulation:
a randomized controlled trial of construct validity.
J Manipulative Physiol Ther. 1995; 18: 582589
van der Wurff, P, Hagmeijer, RH, and Meyne, W.
Clinical tests of the sacroiliac joint. A systemic methodological review: Part 1.
Reliability. Man Ther. 2000; 5: 3036
van Schalkwyk, R and Parkin-Smith, GF.
A clinical trial investigating the possible effect of the supine cervical rotatory manipulation and
the supine lateral break manipulation in the treatment of mechanical neck pain: a pilot study.
J Manipulative Physiol Ther. 2000; 23: 324331
Hawk, C, Phongphua, C, Bleecker, J et al.
Preliminary study of the reliability of assessment procedures for indications for chiropractic
adjustments of the lumbar spine.
J Manipulative Physiol Ther. 1999; 22: 382389
Potter, L, McCarthy, C, and Oldham, J.
Intraexaminer reliability of identifying a dysfunctional segment in the thoracic and lumbar spine.
J Manipulative Physiol Ther. 2006; 29: 203207
Inter- and intra-examiner reliability of palpation for sacroiliac joint dysfunction.
J Manipulative Physiol Ther. 1987; 10: 164171
Flynn, T, Fritz, J, Whitman, J et al.
A clinical prediction rule for classifying patients with low back pain who demonstrate
short-term improvement with spinal manipulation.
Spine. 2002; 27: 28352843
Herzog, W, Read, LJ, Conway, PJ et al.
Reliability of motion palpation procedures to detect sacroiliac joint fixations.
J Manipulative Physiol Ther. 1989; 12: 8692
Lundberg, G and Gerdle, B.
The relationships between spinal sagittal configuration, joint mobility, general low back mobility
and segmental mobility in female homecare personnel.
Scand J Rehabil Med. 1999; 31: 197206
Meijne, W, van Neerbos, K, Aufdemkampe, G et al.
Intraexaminer and interexaminer reliability of the Gillet test.
J Manipulative Physiol Ther. 1999; 22: 49
Mior, SA, McGregor, M, and Schut, B.
The role of experience in clinical accuracy.
J Manipulative Physiol Ther. 1990; 13: 6871
Paydar, D, Thiel, H, and Gemmell, H.
Intra- and interexaminer reliability of certain pelvic palpatory procedures and the sitting flexion test
for sacroiliac joint mobility and dysfunction.
J Neuromusculoskel Syst. 1994; 2: 6569
Potter, NA and Rothstein, JM.
Intertester reliability for selected clinical tests of the sacroiliac joint.
Phys Ther. 1985; 65: 16711675
Robinson, HS, Brox, JI, Robinson, R et al.
The reliability of selected motion- and pain provocation tests for the sacroiliac joint.
Man Ther. 2007; 12: 7279
Strender, LE, Lundin, M, and Nell, K.
Interexaminer reliability in physical examination of the neck.
J Manipulative Physiol Ther. 1997; 20: 516520
Strender, LE, Sjoblom, A, Sundell, K et al.
Interexaminer reliability in physical examination of patients with low back pain
Spine. 1997; 22: 814820
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.
J Am Osteopath Assoc. 2006; 106: 464468
Vincent-Smith, B and Gibbons, P.
Inter-examiner and intra-examiner reliability of the standing flexion test.
Man Ther. 1999; 4: 8793
Reproducibility and interexaminer correlation of motion palpation findings of the sacroiliac joints.
J Can Chiropr Assoc. 1980; 24: 5669
Bergstrom, E and Courtis, G.
An inter- and intra-examiner reliability study of motion palpation of the lumbar spine in
lateral flexion in the seated position.
Eur J Chiropr. 1986; 34: 121141
Binkley, J, Stratford, PW, and Gill, C.
Interrater reliability of lumbar accessory motion mobility testing.
Phys Ther. 1995; 75: 786792
Boline, P, Keating, J, Brist, J et al.
Interexaminer reliability of palpatory evaluations of the lumbar spine.
Am J Chiropr Med. 1988; 1: 511
Brismιe, JM, Gipson, D, Ivie, D et al.
Interrater reliability of a passive physiological intervertebral motion test in the mid-thoracic spine.
J Manipulative Physiol Ther. 2006; 29: 368373
Christensen, HW, Vach, W, Vach, K et al.
Palpation of the upper thoracic spine: an observer reliability study.
J Manipulative Physiol Ther. 2002; 25: 285292
Comeaux, Z, Eland, D, Chila, A et al.
Measurement challenges in physical diagnosis: refining inter-rater palpation, perception and communication.
J Bodyw Mov Ther. 2001; 5: 245253
Degenhardt, BF, Snider, KT, Snider, EJ et al.
Interobserver reliability of osteopathic palpatory diagnostic tests of the lumbar spine:
improvements from consensus training.
J Am Osteopath Assoc. 2005; 105: 465473
Downey, B, Taylor, N, and Niere, K.
Can manipulative physiotherapists agree on which lumbar level to treat based on palpation?
Physiotherapy. 2003; 89: 7481
Haas, M, Panzer, D, and Raphael, R.
Reliability of manual end-play palpation of the thoracic spine.
Chiropr Tech. 1995; 7: 120124
Hanten, WP, Olson, SL, and Ludwig, GM.
Reliability of manual mobility testing of the upper cervical spine in subjects with cervicogenic headache.
J Man Manip Ther. 2002; 10: 7682
Hicks, GE, Fritz, JM, Delitto, A et al.
Interrater reliability of clinical examination measures for identification of lumbar segmental instability.
Arch Phys Med Rehabil. 2003; 84: 18581864
Humphreys BK, Delahaye M, Peterson CK:
An Investigation into the Validity of Cervical Spine Motion Palpation Using Subjects
with Congenital Block Vertebrae as a 'Gold Standard'
BMC Musculoskelet Disord 2004 (Jun 15); 5 (1): 19
Jull, G and Bullock, M.
A motion profile of the lumbar spine in an aging population assessed by manual examination.
Physiother Pract. 1987; 3: 7081
Love, RM and Brodeur, RR.
Inter- and intra-examiner reliability of motion palpation for the thoracolumbar spine.
J Manipulative Physiol Ther. 1987; 10: 14
Maher, C and Adams, R.
Reliability of pain and stiffness assessments in clinical manual lumbar spine examination. (discussion 09-11)
Phys Ther. 1994; 74: 801809
Maher, C, Latimer, J, and Adams, R.
An investigation of the reliability and validity of posteroanterior spinal stiffness judgments made
using a reference-based protocol.
Phys Ther. 1998; 78: 829837
Marcotte, J, Normand, MC, and Black, P.
The kinematics of motion palpation and its effect on the reliability for cervical spine rotation.
J Manipulative Physiol Ther. 2002; 25: E7
Marcotte, J, Normand, MC, and Black, P.
Measurement of the pressure applied during motion palpation and reliability for cervical spine rotation.
J Manipulative Physiol Ther. 2005; 28: 591596
McPartland, JM and Goodridge, JP.
Counterstrain and traditional osteopathic examination of the cervical spine compared.
J Body Mov Ther. 1997; 1: 173178
Mior, S, King, R, McGregor, M et al.
Intra and interexaminer reliability of motion palpation in the cervical spine.
J Can Chiropr Assoc. 1985; 29: 195199
Mootz, RD, Keating, JC, Kontz, HP et al.
Intra- and interobserver reliability of passive motion palpation of the lumbar spine.
J Manipulative Physiol Ther. 1989; 12: 440445
Nansel, DD, Peneff, AL, Jansen, RD et al.
Interexaminer concordance in detecting joint-play asymmetries in the cervical spines of otherwise asymptomatic subjects.
J Manipulative Physiol Ther. 1989; 12: 428433
Smedmark, V, Wallin, M, and Arvidsson, I.
Inter-examiner reliability in assessing passive intervertebral motion of the cervical spine.
Man Ther. 2000; 5: 97101
Zito, G, Jull, G, and Story, I.
Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache.
Man Ther. 2006; 11: 118129
Fjellner, A, Bexander, C, Faleij, R et al.
Interexaminer reliability in physical examination of the cervical spine.
J Manipulative Physiol Ther. 1999; 22: 511516
Keating, JC, Bergmann, TF, Jacobs, GE et al.
Interexaminer reliability of eight evaluative dimensions of lumbar segmental abnormality.
J Manipulative Physiol Ther. 1990; 13: 463470
Lindsay, D, Meeuwisse, W, Mooney, M et al.
Interrater reliability of manual therapy assessment techniques.
Phys Ther Can. 1995; 47: 173180
Olson, KA, Paris, SV, Spohr, C et al.
Radiographic assessment and reliability study of the craniovertebral sidebending.
J Man Manip Ther. 1998; 6: 8796
Phillips, DR and Twomey, LT.
A comparison of manual diagnosis with a diagnosis established by a uni-level lumbar spinal block procedure.
Man Ther. 1996; 1: 8287
Troyanovich, SJ, Harrison, DD, and Harrison, DE.
Motion palpation: it's time to accept the evidence.
J Manipulative Physiol Ther. 1998; 21: 568571
Seffinger, MA, Najm, WI, Mishra, SI et al.
Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature.
Spine. 2004; 29: E413E425
Diagnostic palpation of the spine: a review of procedures and assessment of their reliability.
J Manipulative Physiol Ther. 1983; 6: 181183
Murphy, LS, Reinsch, S, Najm, WI et al.
Spinal palpation: the challenges of information retrieval using available databases.
J Manipulative Physiol Ther. 2003; 26: 374382
Billis, EV, Foster, NE, and Wright, CC.
Reproducibility and repeatability: errors of three groups of physiotherapists in
locating spinal levels by palpation.
Man Ther. 2003; 8: 223232
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