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Pressure Variances in the Diagnosis of Lumbar Somatic Dysfunctions
George, E. [3]
Angelo, N. [8]
Voleti, N. [2]
Gaspari, M. [2]
Cheriyan, G. [6]
Yao, S. C. [54]

Journal: Journal of Osteopathic Medicine Date: 2017/11, 117(11):Pages: e116-e118. doi: Subito , type of study: observational study

Full text    (https://www.degruyter.com/document/doi/10.7556/jaoa.2017.141/html)

Keywords:

diagnosis [263]
lumbar spine [43]
observational study [126]
palpation [170]
pressure [109]

Abstract:

Research Questions: In the clinical practice of osteopathic medicine, palpatory skills are an essential diagnostic tool, often implemented in the physical examination to assess for somatic dysfunctions. During the first 2 years of osteopathic medical education programs, students are taught from experienced osteopathic physicians how to develop their palpatory skills and apply them for diagnostic and treatment purposes. Students further refine their skills during 2 years of clinical rotations and with their own patients as they continue to practice medicine. The use of pressure measurements has been used in similar fields of research to evaluate the pressure needed to reach pain at a trigger point and pain in various muscles. However, amount of pressure used during osteopathic palpation has not been well defined. Specifically, the authors wish to quantify the pressure applied in diagnosing somatic dysfunction. Identifying this pressure can contribute to osteopathic medical education and help identify potential differences between skill ranges of osteopathic examiners. The palpatory pressure used by examiners was measured objectively with the TekScan tool. The TekScan system has been used to gauge pressure in various areas of medical research but not to assess palpation forces. We hypothesized that the time taken to reach a diagnosis and the magnitude of pressure used during palpation while diagnosing will decrease as participants progress through clinical training. Methods: This study was approved by the NYITCOM institutional review board BHS-1120. The inclusion criteria required that participants be currently attending or have successfully graduated from an osteopathic medical school. All participants read and signed the consent form before participation. One person was recruited to be a “model” for the study and consented to serving as the model for the duration of the study. For data collection, the model laid prone on the examination table, and an investigator confirmed the location of the L5 lumbar segment with ultrasonography. TekScan pressure sensors were placed in the lumbar region and secured with velcro. Two physicians board certified in neuromusculoskeletal medicine/osteopathic manipulative medicine (NMM/OMM) confirmed an L5 somatic dysfunction diagnosis. Each participant was asked to approach the patient on their dominant side and diagnose L5 documenting the flexion/extension, side bending, and rotation. The TekScan sensors were used to record the pressure used by participants on the L5 transverse processes from the moment they began to palpate the patient.Data Analysis: Twenty-one participants were included in the analysis: 11 participants were students (OMS I, OMS II, and OMS III), and 10 participants were attending physicians in the OMM and family medicine department. Fischer exact tests were used to analyze differences in L5 diagnoses based on experience levels. Point biserial correlation tests were performed to analyze differences in peak and average pressure used during diagnosis. An independent samples t test was performed to analyze differences in time taken to reach a diagnosis based on experience levels. Results: Participants with an L5 diagnosis corresponding to the diagnosis made by the 2 attending physicians had less of a difference in peak force, mean difference 62.50 g/cm2, between their contact points (right vs left hands) vs those participants with a differing L5 diagnosis from the 2 physicians (mean difference, 319.38 g/cm2). The difference between the average force used between contact points resulted with the same finding. Participants with the corresponding L5 diagnosis had a smaller average difference (16.81 g/cm2) between the average pressure in their right and left contacts vs those who did not, an average difference of 123.92 g/cm2. There was no significant differences between attending physicians and students in the accuracy of the diagnosis of L5 (P=.387) or time taken to reach a diagnosis (P=.199). However, these values were trending toward significance as participant numbers increased. Conclusion: Our findings demonstrated no statistical significance in accuracy and pressure use and time to diagnosis with experience level. However, diagnosis accuracy corresponded with participants who used a more equal force in both contact points. These results suggest that accuracy of diagnosis can potentially be improved with the use of pressure sensors so students and physicians can learn to use a more equal pressure when palpating. Future studies should be conducted to further evaluate time to diagnosis, level of training, diagnostic accuracy, peak pressure used, and variance in pressure between hands with a greater sample size.

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