International Journal of Osteopathic Medicine 12 (2009) 9296

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International Journal of Osteopathic Medicine

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Research report

Inter-examiner reliability of palpation for tissue texture abnormality in the

thoracic paraspinal region
Tania Paulet a, Gary Fryer a, b, c, *
a
School of Biomedical and Clinical Sciences, Victoria University, Melbourne, Australia
b
Centre for Ageing, Rehabilitation & Exercise Science, Victoria University, Melbourne, Australia
c
A.T. Still Research Institute, A.T. Still University of Health Sciences, Kirksville, MO, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Palpation of soft tissue changes is claimed to be important for osteopathic diagnosis and
Received 2 May 2008
treatment. Few studies, however, have examined the inter-examiner reliability for the detection of
Received in revised form
altered segmental paraspinal tissue texture.
9 July 2008
Accepted 11 July 2008 Objective: To determine the inter-examiner reliability of the identication of abnormal tissue texture in
the thoracic paraspinal region using palpation.
Keywords: Method: Ten nal-year osteopathic students examined the thoracic paravertebral gutter regions of ten
Reliability subjects presenting with a recent history of thoracic symptoms. Each examiner palpated each subject to
Palpation determine which of four predetermined areas exhibited the most obvious alteration or abnormality in
Muscle tissue texture. One week prior to the study, all examiners received consensus training to standardise the
Osteopathic medicine
method of palpation.
Manual therapy
Results: The inter-examiner agreement for the site with the most marked tissue texture change was fair
(k 0.26; Po 0.46; Pe 0.28; 95% CI 0.190.33). When only the rst ve assessments from each
examiner were analysed, the agreement improved slightly, but remained fair (k 0.32; Po 0.52;
Pe 0.30; 95% CI 0.160.47).
Conclusions: Inter-examiner reliability of palpation for abnormal tissue texture in the deep thoracic
paraspinal region was only fair. The inuence of either examiner fatigue or tissue change due to repeated
palpation appeared to be small. Although the practice of palpating for segmental tissue texture abnor-
malities without concurrent reports of tenderness from the patient is not typical of clinical practice, this
study suggests that assessment of texture change is complex and not highly reproducible between
examiners.
2008 Elsevier Ltd. All rights reserved.

1. Introduction diagnostic characteristics of somatic dysfunction have been sum-

Palpation is used by manual therapists from various disciplines
in the assessment, diagnosis and manipulative treatment of
patients with musculoskeletal pain and dysfunction. Somatic
dysfunction, also termed segmental dysfunction or intervertebral
dysfunction, and comparable to the chiropractic professions
subluxation, chiropractic subluxation or manipulable subluxa-
tion,1,2 is considered to be a musculoskeletal condition involving
impaired or altered function of tissues of the musculoskeletal
system, and is amenable to manipulative treatment.3 The clinical
* Corresponding author. 800 W. Jefferson St, Kirksville, MO 63501, USA. Tel.: 1
660 626 2530; fax: 1 660 626 2099.
E-mail address: gfryer@atsu.edu (G. Fryer).
marised using the mnemonic TART: Tissue texture change (typi-
cally involving palpation of the paraspinal tissues), Asymmetry of
the bony (or other) landmarks, Range of motion abnormality of the
joint, and Tenderness on palpation of the area.4,5 Authors in the
eld of manual therapy claim that skilled practitioners are able to
detect somatic dysfunction,48 however the validity and reliability
of detecting the proposed clinical signs of somatic dysfunction have
been questioned.911
The cutaneous mechanoreceptor system of the hand is
extremely sensitive to stimuli. Studies have determined that
detectible pressure thresholds are as low as 10 mm of indentation of
the skin, and that individuals can detect groove widths of less than
1 mm and differences in thickness of 0.08 mm.1216 This suggests
that palpation has the potential to be a highly sensitive tool for the
detection of musculoskeletal abnormalities that are accessible to

1746-0689/$ see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijosm.2008.07.001
 T. Paulet, G. Fryer / International Journal of Osteopathic Medicine 12 (2009) 9296
palpation. Of the TART criteria, however, only palpation for
tenderness and pain provocation tests (reproduction of the
patients familiar pain) have been demonstrated to have acceptable
reliability between different examiners.10,17,18 Poor inter-examiner
agreement has been reported for motion palpation10,17,18 and static
spinal asymmetry.19,20
Despite reports of poor reliability for motion palpation, some
studies suggest that it may potentially be reliable in some
circumstances. Humphreys et al.21 reported that examiners could
detect the presence or absence of xation in the cervical spine
using motion palpation techniques in lateral exion and rotation in
patients with a congenitally fused vertebral segment. Landel et al.22
demonstrated good inter-examiner reliability for identifying the
least mobile lumbar segment using posterioranterior springing,
however, the validity of these ndings were questionable because
they did not concord with intervertebral motion measured during
the test using MRI.
In contrast to motion palpation, several studies investigating the
reliability of palpating spinal tenderness have shown good to
excellent reliability.10,17,18 Although tenderness and pain provoca-
tion have been claimed to be a useful tool for identifying symp-
tomatic joints in the cervical spine,23 the validity of motion
palpation and pain provocation to accurately distinguish symp-
tomatic from non-symptomatic joints has been disputed.24 Wide-
spread pain and referred tenderness are common clinical ndings
and localised tenderness does not always reect the site of
pathology.25,26 However, reproduction of pain may not be the only
clue for joint dysfunction. For example, Jull et al.27 have demon-
strated that direct verbal reports of pain were not required for
examiners to identify symptomatic joints in the cervical spine.
Osteopaths commonly palpate for tissue texture changes in
three paraspinal regions: the medial paravertebral groove (PVG) or
gutter, which is located between the spinous processes of the
vertebrae and the erector spinae muscles, the bulk of the erector
spinae, and the iliocostalis muscle bres overlying the angles of the
ribs.4,28 Some authors claim that palpation of hypertonicity of the
deep fourth layer of paraspinal muscles (semispinalis, rotatores and
multidus) in the medial paravertebral groove is a cardinal sign of
somatic dysfunction.4,5 Segmental tissue texture changes are
reported to include abnormal hardness, bogginess, or ropiness of
the underlying paraspinal muscles.4,5
Considering the proposed importance of palpation for para-
spinal tissue texture abnormalities for the identication of somatic
dysfunction, this criterion should be established as a reliable and
valid nding. However, few researchers have investigated the
reliability of palpating tissue texture abnormalities, and those
studies available have reported only fair to poor reliability.10,17,29
Regions in the thoracic PVG identied as abnormal using palpation
have been veried as having a lower mean pressure pain threshold
than surrounding normal tissues,30 and have been reported to
display abnormally increased electromyographic activity,31 which
suggests that palpation may be useful in identifying tissue abnor-
mality in the paraspinal region.
Natural variability in the texture of paraspinal muscles may act
as a confounding factor in reliability studies,30 and careful pre-test
training may minimise the effects of individual examiner inter-
pretations of different tissue texture changes. Studies that have
used pre-test consensus training or training in a standardised
examination procedure suggest that training improves the agree-
ment of ndings between examiners palpating tissue texture
changes related to spinal dysfunction or the presence of myofascial
trigger points.32,33 Additionally, inter-examiner reliability of pal-
patory examinations has been reported to be slightly higher using
symptomatic subjects,17 and so the use of subjects with a degree of
symptoms may assist with establishing diagnostic reliability.
93
The reliability of palpation to detect the clinical features of
somatic dysfunction is fundamental in establishing the concept of
somatic dysfunction as a valid diagnosis. The inter-examiner reli-
ability of palpation for abnormal tissue texture of the thoracic
paraspinal muscles has not yet been established, thus the aim of
this study was to investigate the inter-examiner reliability of
palpation for abnormal tissue texture at pre-determined areas in
the thoracic spine between a group of nal year osteopathic
students.
2. Methods
2.1. Participants
Ten subjects (5 male and 5 female, age range 1923) were
recruited from the student population at Victoria University (VU),
Melbourne, Australia, in response to posted notices. In order to be
included in this study, subjects were required to be over 18 years of
age and have had an episode of mild thoracic spinal pain (less than
4 on a 10 point visual analogue scale) or stiffness within the two
weeks prior to testing. None of the participants were symptomatic
on the day of testing. Limiting inclusion to subjects with a recent
history of thoracic symptoms was thought to increase the possi-
bility of the subjects having regions of tissue texture abnormality
and somatic dysfunction. Participants were excluded from the
study if they suffered from severe thoracic pain, had any gross
spinal deformities, had a diagnosed pain syndrome such as bro-
myalgia, if palpation of thoracic tissues produced more than minor
discomfort, or if they were unable to lay prone on a treatment
couch for 20 min. Subject weight, height and prior thoracic pain
history was not recorded, although no subject was visibly obese. In
addition to the ten subjects, ten examiners (3 male and 7 female,
age range 2224) were recruited from the nal year osteopathy
student population at Victoria University. All participants signed
informed consent forms and the procedures for this study were
approved by the VU Human Research Ethics Committee.
2.2. Examiner training
In order to minimise individual variation in the application of
examination techniques, pre-test training in a standardised
examination procedure has been recommended.32,34 One week
prior to the study, all examiners spent one hour with an experi-
enced osteopath (Researcher 1) in an attempt to standardise the
palpation techniques and arrive at agreement as to the state of the
tissue under palpation. Examiners agreed to palpate the thoracic
PVG with the index and middle ngers using moderately deep
pressure and a short longitudinal sliding motion (Fig. 2). Sites were
determined as having abnormal texture if the alteration was
palpated in the oor of the PVG. Texture abnormality at the lateral
border of the PVG (erector spinae bulk) was not considered.
2.3. Experimental procedure
The ten subjects were positioned prone on treatment couches
arranged in a large room, and were assigned a letter from A to J. In
each subject, Researcher 1 identied four areas within the thoracic
PVG region and marked each with a line just lateral to the PVG (so
that repeated palpation in the PVG would not remove the mark)
with a skin pencil (Fig. 1). There was an attempt to include at least
one area of increased tissue texture tone, judged by Researcher 1 as
relatively hard, lumpy or boggy. The remaining areas were
marked at random, with two marked areas on each side of the
spine. The four areas were labelled from superior to inferior as
numbers 14. The subjects were instructed not to talk to the
94 T. Paulet, G. Fryer / International Journal of Osteopathic Medicine 12 (2009) 9296
Fig. 1. Areas marked in the PVG region.
Fig. 2. Palpating the muscles of the PVG.
examiners throughout the test, except to inform the examiner if the
pressure of palpation became too uncomfortable.
The ten examining students then entered the room and were
assigned to a subject. Examiners had no information concerning
the clinical status of the subjects. The examiners were instructed
not to talk to or observe each other, or to ask the subject questions
regarding the ndings of other examiners. The examiners had
approximately one minute to palpate the four areas marked on
each subject to determine which of the four areas exhibited the
most obvious alteration in tissue texture and note this on their
record sheet. In cases where an examiner could not decide between
two regions of equal abnormality, it was permissible to list two
regions. The examiners then were instructed to move to the subject
to their left. The procedure was then repeated until all examiners
had assessed all ten subjects.
2.4. Statistical analysis
Inter-examiner reliability was analyzed with SAS version 9.1
(SAS Institute, Inc., Cary, NC) using Fleiss Kappa for multiple raters.
k (Po  Pe)/(1  Pe), where Po is the proportion of observed
agreement between examiners, and Pe is the proportion of agree-
ment achieved by chance alone. Kappa is therefore the proportion
of observed agreement above chance divided by the maximum
possible agreement above chance. Kappa can be used when cate-
gorical data is collected for analysis. For perfect agreement, k 1,
for chance agreement, k 0, and when chance agreement is greater
than observed agreement, k is negative. The guidelines proposed by
Landis and Koch35 were used to interpret the Kappa values (Table
1). In order to exclude possible effects from examiner fatigue or
changes in tissue texture due to repeated palpation, a sub-analysis
of only the rst ve assessments of each subject was also
performed.
3. Results
The inter-examiner agreement for the site with the most
marked tissue texture abnormality was fair (k 0.26; Po 0.46;
Pe 0.28; 95% CI 0.190.33) (Table 2). In two of the subjects, one
examiner could not decide between two sites for the site of most
marked texture, and these were included in the analysis. In order to
exclude possible effects from examiner fatigue or changes in tissue
texture due repeated palpation, analysis of only the rst ve
assessments of each subject was also performed. On analysis of the
rst ve assessments a small increase in reliability was noted
(k 0.32; Po 0.52; Pe 0.30; 95% CI 0.160.47), however,
agreement remained only fair.
4. Discussion
Previous studies investigating the inter-examiner reliability of
palpation for tissue texture changes have largely shown poor
agreement between examiners.10 The present study demonstrated
fair (k 0.26) inter-examiner reliability for the examination and
ranking of thoracic paraspinal tissue texture abnormality in
subjects with a recent history of thoracic symptoms. This result
compares favourably to previous studies involving asymptomatic
subjects,17,19,36 but may be considered unsatisfactory for clinical
purposes. When analysis included only the rst ve assessments of
each subject, inter-examiner reliability was slightly improved
(k 0.32). It is possible that the tissue texture of the subjects was
affected by repeated palpation, however, the kappa coefcient
calculated from analysis of the rst ve assessments was not
substantially different to the coefcient based on all assessments,
therefore indicating that repeated palpation was not a substantial
factor.
It should be noted that the study procedure required examiners
to palpate four pre-determined sites, thus the examination process
was not reective of clinical practice. It is possible that if examiners
were instructed to select a site that demonstrated the most obvious
change independently of pre-dened areas the agreement level
would have been different. This should be examined using symp-
tomatic subjects in future studies.
Additionally, the identication of somatic dysfunction is
generally recommended to be based on a group of ndings, such as
the TART criterion,4,5 rather than a single nding of altered tissue
texture as examined in this study. The use of combined tests, or
parallel testing, has been reported to improve reliability.29 Given
the poor agreement for the determination of most marked tissue
Table 1
Guidelines for interpreting kappa values36
Kappa value (k) Agreement
0.811.0 Almost perfect
0.610.80 Substantial
0.410.60 Moderate
0.210.40 Fair
0.000.20 Slight
 T. Paulet, G. Fryer / International Journal of Osteopathic Medicine 12 (2009) 9296
Table 2
Agreement between examiners (n 10) for the site with most marked tissue texture
abnormality in all subjects (AJ)
Subject Area 1 Area 2 Area 3 Area 4 Total
A 0 1 5 4 10
B 9 0 1 0 10
C 6 0 3 1 10
D 0 1 1 8 10
E 5 0 3 3 11
F 1 0 7 2 10
G 5 0 0 6 11
H 7 2 1 0 10
I 2 7 1 0 10
J 3 4 0 3 10
abnormality, it is recommended that such clinical ndings be
interpreted in conjunction with other more reliable physical nd-
ings, such as palpation for tenderness and provocation of familiar
pain. This recommendation is likely to be consistent with clinical
practice.37
The reliability of diagnostic palpation has been demonstrated to
improve when examiners receive pre-test consensus or stand-
ardisation training.32,33 Consensus training sessions of various
durations have been used, ranging from short sessions immediately
prior to testing33,38 to 12 hours a week over a 4-month period.32
Extensive consensus training has been reported to substantially
improve examiner concordance.32 Degenhardt et al.32 found that
inter-examiner reliability of palpation for tissue texture changes
prior to training was only slight (k 0.12), but after 4 months of
consensus training between the three examiners the reliability
improved to a moderate level (k 0.45). In the present study, the
examiners all had a similar level of training and experience with
palpation, and it was believed that only a single one-hour training
session would therefore be required to ensure standardisation of
palpation technique. Despite this, it was evident that differences
existed in the methods used by students during the training
session, such as the pressure and depth of palpation, the movement
of the probing nger and the restriction of palpation to the
precisely dened region. It is possible that more extensive
consensus training may have resulted in increased agreement
between examiners and a kappa reliability coefcient >0.40, which
is considered clinically acceptable by some authors.32 The relative
inexperience of the student examiners may offer a further possible
explanation for the low agreement recorded in this study, however,
despite their student status, all examiners had 4 years of palpatory
experience. Furthermore, previous studies have not found that less
experienced palpators demonstrate poorer agreement than expe-
rienced practitioners.39
The subjects included in this study reported a history of thoracic
spinal pain within the two weeks prior to the testing procedure,
however no subjects reported having pain at the time of the test.
Boline et al.17 conducted a study using both symptomatic and
asymptomatic subjects and reported a small increase in examiner
agreement for two of six lumbar segments palpated for muscle
spasm in symptomatic subjects compared to symptomatic and
asymptomatic subjects combined, however the change in the
kappa scores were negligible. This suggests that the use of symp-
tomatic subjects in inter-examiner reliability studies of palpation
for paraspinal tissue changes may not produce a substantial
increase in agreement. Despite the belief that somatic dysfunction
frequently occurs in asymptomatic people,1 and reports that other
tissue abnormalities (such as myofascial trigger points) can be
detected in asymptomatic populations,40,41 it is possible that
subjects with acute symptoms may have more marked tissue
changes due to the inammatory change in the tissues. Further
95
study of symptomatic subjects is warranted. The use of asymp-
tomatic subjects in reliability studies also affects the applicability of
the data by limiting the ndings to populations unrepresentative of
patients who normally present to clinicians. Additionally, the kappa
statistic becomes unstable when there is a very limited spread of
ndings,35 but this appeared not to be the case in the present study.
Natural variability in the location and quality of tissue texture
alterations in the paraspinal region may have been a confounding
factor in the study. During the training session, it was noted that
there were different types of abnormal tissue texture, such as
whether the altered tissues appeared to be located deep in the oor
of the paraspinal groove, more supercially, or at the lateral border
of the PVG. Variation in tissue texture abnormalities in the PVG may
depend on the specic tissues involved and the extent to which
they are affected. This variability has been noted in previous
studies30 and may confound the interpretation of examination
ndings unless carefully controlled. As well as being a potential
confounding factor for reliability studies, tissue variability will
equally be a confounding factor for palpation in clinical practice,
and the ndings of this study are still relevant to osteopathic
practice. Furthermore, the clinical relevance of segmental tissue
abnormalities should be investigated, since these sites are
commonly detected in asymptomatic individuals.30,31 The
frequency and severity of these abnormal sites in individuals with
and without symptoms, as well as the effect of treatment on these
sites, would help establish their clinical relevance, although the
poor reliability for detecting these sites presents substantial dif-
culty for this type of investigation.
5. Conclusion
Inter-examiner reliability of palpation for tissue texture abnor-
mality in the medial and deep thoracic paraspinal region of subjects
who reported an episode of thoracic pain in the two weeks prior to
testing was only fair. Although the practice of palpating for tissue
texture change without concurrent reports of tenderness is not
typical of clinical practice, this study suggests that assessment of
texture change is complex and not highly reproducible between
examiners. In view of the ndings of this study, it is recommended
that the presence of abnormal paraspinal tissue texture should be
interpreted with caution and in conjunction with other tests with
more established reliability, such as pain provocation and motion
palpation.
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