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Archived Comments for: Review of methods used by chiropractors to determine the site for applying manipulation

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  1. Paraspinal skin temperature assessment rating incongruent with the data from studies.

    Mark Lopes, Gonstead Clinical Studies Society

    27 November 2013

    We found the article, "Review of methods used by chiropractors to determine the site for applying manipulation" by Triano et. al. to be, in many ways, very applicable and clinically important and we commend the authors on this accomplishment. However, there is a subjective nature to parts of the process involved in this review, which has led in our opinion to at least one inaccurate determination. We found the rating of ‘unfavorable’ applied by the authors to skin temperature assessment to be inappropriate, primarily based on the studies accepted for review by the authors.

    The P.A.R.T.S. concept, described as a widely utilized method to justify treatment, was used as an integral part of this review and was the format for the sections in the article. The ‘T’ in P.A.R.T.S. stands for tissue temperature, texture, and tone.

    In regards to the tissue temperature portion of this ‘T’ section, the authors stated: “The evidence from high quality studies is unfavorable toward the use of paraspinal skin temperature measures to locate the site of care, due to limited reliability.” We found this statement particularly interesting given that our study (1) was the top rated study by the authors in this category. We note that the authors generally refer to a range of findings of Kappa statistical values from our study, but do not mention the ICC values or the regional concordance differences or the differences between the first and second set of scans.

    Instrumentation for paraspinal thermography is also one of the oldest methods of chiropractic assessment. Such instrumentation, including relatively new technology as with some of the instruments used in studies accepted for this review, has in most cases showed acceptable to excellent reliability as noted in the following articles reviewed by the authors:

    Owens: “Intraexaminer and interexaminer reliability of paraspinal thermal scans using the TyTron C-3000 were found to be very high, with ICC values between 0.91 and 0.98. Changes seen in thermal scans when properly done are most likely due to actual physiological changes rather than equipment error (2).”

    Hart:  Reliability testing with 10 minute intervals between samples showed good ICC values of > 0.75 (3).

    Roy: “…the infrared cameras showed that they were valid tools in a controlled environment (4).”

    Plaugher, Lopes, et. al.: Following agreement for a positive finding in a given area, the interexaminer reliability of the first set of observations showed fair agreement with ICC values of 0.28. Intraexaminer agreement was moderate (ICC: 0.51) for one examiner and excellent (ICC: 0.86) for the other examiner.  For the second set of observations between examiners the ICC values showed substantial agreement (0.64) and intraexaminer agreement was moderate for one examiner (0.51) and excellent for the other (0.86). Concordance measured with Kappa statistics were slight to moderate in the C4-T2 region and substantial in the T4-8 region. There was excessive overlap of the observations in the lumbar region, which contraindicated the use of Kappa statistics for that region (given a pre-requisite of some variation needed for Kappa), but this overlap more likely indicated high levels of interexaminer agreement in skin temperature differential findings frequently occurring at the same spinal levels (1).

    Noting the range of possible determinations that could be applied to each procedure being reviewed, it appears that ‘unfavorable’ was not consistent with the evidence the authors accepted for their review. Here is the range of choices given by the authors:

    “Favorable:                  For general use by clinicians to determine site of care

    Favorable with limitations:     Favorable for determining site of care although limits exist such as number and quality of studies, limited generalizability, etc.

    Unclear:                       Based on the evidence available, it is unclear whether or not this procedure should be recommended for use

    Unfavorable with exceptions: Procedure is not recommended for general use but may be used in limited circumstances

    (e.g. other techniques unavailable.)

    Unfavorable:               Procedure is not recommended for use (limited number of studies, significant flaws in methods, not generalizable, high quality evidence against validity and/or reliability”

    Triano et. al. mention that the unfavorable paraspinal skin temperature rating was based on “high quality studies” and since our study (1) was rated the highest and other studies on this subject showed favorable findings for reliability, it appears that the authors may have utilized our study as their primary source to opine that skin temperature assessment is unfavorable. Considering the findings of our study mentioned above in totality, the results were more positive than negative for reliability in our study, which leaves us with some confusion as to what Triano et. al. based a completely “unfavorable” rating on in regards to their conclusion.

    The authors also seem to overlook the fact that various methods of skin temperature assessment exist. Contact thermocouple instrumentation is not the same as infrared thermography, which has shown very favorable reliability. The contact thermocouple instrument from our study in 1991, commonly known as a Nervoscope, was the original, non amplified version. There are now electronically amplified versions of that unit that need testing and it should not be assumed that one instrument study, no matter the quality, answers all questions about paraspinal thermography. Given the favorable results of the other paraspinal skin temperature studies utilizing different instruments and technology than ours, it seems those studies met the inclusion criteria and then were completely ignored in determining this rating.

    We understand that there are some questions about the use of paraspinal skin temperature assessment: environmental controls, skin contact possibly affecting a reading or pattern, validity inadequately tested, etc. But many or most of the other assessment procedures deemed favorable in this study have similar questions about them.

    There is enough data from the studies accepted for this review that show moderate to excellent reliability, however, that at least a conditional designation such as ‘favorable with limitations’ or ‘unclear’ should have been given for the paraspinal skin temperature assessment, although a ‘favorable’ rating appears more appropriate. The noninvasive nature of the assessment, lack of an expense burden to a patient, and a reasonable number of studies showing decent reliability should be enough to suggest this as a favorable assessment or at least unclear or favorable with limitations. Instrumentation thermography is close to a gold standard for this aspect of the P.A.R.T.S. concept.

    Further, when comparing the designation of unfavorable for skin temperature assessment to tissue texture assessment (another part of the ‘T’ section), which was given a ‘favorable’ designation, we felt that tissue texture assessment proved to be no more or possibly less supported by the evidence presented in this review article than that presented for paraspinal skin temperature assessment. Tissue texture was listed as favorable based on only five studies, with three showing reliability of slight, fair and moderate respectively. It appears, therefore, that a more rigorous standard was applied to the paraspinal thermography than to tissue texture assessment.


    Mark A. Lopes, D.C.

    Roger R. Coleman, D.C.

    1. Plaugher G, Lopes MA, Melch PE, Cremata, EE. The inter- and intraexaminer reliability of a paraspinal skin temperature differential instrument. J Manipulative Physiol Ther 1991,14:361-367.

    2. Owens EF Jr, Hart JF, Donofrio JJ, Haralambous J, Mierzejewski E: Paraspinal skin temperature patterns: an interexaminer and intraexaminer reliability study. J

    Manipulative Physiol Ther 2004, 27:155–159.

    3. Hart JH, Omolo B, Boone WR, Brown C, Ashton A: Reliability of three methods of computer-aided thermal pattern analysis. J Can Chiropract Assoc 2007, 51:175–185.

    4.. Roy R, Boucher JP, Comtois AS: Validity of infrared thermal measurements of

    segmental paraspinal skin surface temperature. J Manipulative Physiol Ther 2006,


    Competing interests

  2. RE: Response to Dr. Lopez commentary to the Editor on “Review of methods used by
    chiropractors to determine the site for applying manipulation”

    John Triano, CMCC

    30 November 2013

    Dear Editor,

    The authors thank Dr. Lopez for his comments on our paper and our treatment of his
    work with Plaugher and colleagues on inter-rater and intra-rater reliability of
    paraspinal skin temperature measures. While their work was the highest rated by
    the investigative team of our study (using the QAREL scoring system), it would
    be in error to conclude that this one paper is the foundation of the
    recommendation on suitability of paraspinal skin temperature for use in general
    practice. The most compelling reason for this is that the recommendations are
    based upon the substance of the evidence for both validity and reliability. The
    quality of the evidence was rated by QUADAS and by QAREL instruments,
    respectively. High quality evidence does not presume that the substance of the
    evidence is either favorable or unfavorable.

     The reader will understand that summary recommendations attempt to be brief and, no
    matter how carefully crafted, may be interpreted differently by some. In the
    case of paraspinal skin temperature, only the work of Zaproudina et al (2006)
    examined the question of validity using both healthy and unhealthy subjects per
    our a priori entrance requirements for the study. In their work involving both healthy and chronic low back patients, the difference in temperature from side to side could not differentiate between
    the groups. “In 90.77% of LBP patients, at least one regional interside
    temperature difference was more than 0.3o C with maximal ΔT being
    2.84o C. In reference subjects, the figures were 90% and 1.79oC,
    respectively; in 10% of them, ΔT was more than 0.3o C only in the
    heel area.” As suggested by the last phrase in the quote, the differences seen
    were not in the back but rather in the lower extremity, especially for patients
    with pain extending into the leg (See Zaproudina et al, Table 2, p 222). Even
    those changes were complex with some (50.8%) showing warming and others (49.2%)
    showing cooling of the skin surface.

    In the work by Plaugher et al (1991), using only a small
    sample of asymptomatic student volunteers, the substantive information shows a
    wide range of Kappa values (0.03 < K < 0.66). By Kappa alone, clinically
    acceptable levels ( K > 0.60) were found between two examiners only for T4 –
    T8.  Indeed, the authors acknowledge that one subject (Plaugher et al p
    363) “was examined twice by the same doctor in succession. In this particular
    case, the examiner noted different findings.” Further, there are some concerns
    about which data were included in the final publication. Plaugher et al stated
    that  “A break [positive finding] was considered only if it was present for at least three out of four successive glides.” In other words, it appears as if data were only reported and analysed
    after they had been tested informally for reliability. The authors also stated
    that “If a break gradually diminished after successive glides it was considered
    less significant than if the break remained stable or was accentuated by
    repeated scans.” This again raises some concern about pre-filtering of data for
    reporting and analysis. It also appears as if the authors had used an
    intervention which they described as ‘prescans’ to accentuate positive
    findings. These methods raise the question as to their generalizability to
    standard practice. Consequently, based upon the substance of the literature
    rated as high quality, we conclude that there is no foundation to change the
    recommendation of paraspinal skin temperature measures as “unfavourable”.

    None of these concerns negate the value of the contributions
    by Plaugher et al to the literature. Rather, we raise these issues to
    demonstrate the depth of our analysis beyond the simple computation of quality
    summary scores.

    Dr. Lopez goes on to note that certain other papers were
    not included in our analysis, even commenting on some of lower quality that
    were, and that the technology continues to evolve. These are valid criticisms
    as were noted in our manuscript’s section on limitations. Differences in the
    inclusion criteria might have led to differences in the strength of evidence
    for one modality or another, as is true of all systematic reviews.
    Additionally, there are likely to be technical improvements in the actual
    instrumentation and, based on work such as that by Roy et al (2006),
    improvements in how that machinery is used clinically. Our review, like all
    systematic reviews, was a snapshot in time based upon our evaluation of the
    literature which met our inclusion criteria to address the scientific question.


    John Triano DC, PhD

    Brian Budgell DC, PhD


    Zaproudina N, Ming Z, Hannienen OO: Plantar infrared
    thermography measurements and low back pain intensity. J Manipulative Physiol
    Ther 2006, 29:219-223.

    Plaugher G, Lopes MA, Melch PE, Cremata, EE. The inter- and intraexaminer reliability of a paraspinal skin
    temperature differential instrument. J Manipulative Physiol Ther

    Roy R, Boucher JP, Comtois AS: Validity of infrared thermal measurements ofsegmental paraspinal skin surface temperature. J Manipulative Physiol Ther 2006,29:150–155.

    Competing interests

    There are no competing interests.
  3. Comment on: Review of methods used by chiropractors to determine the site for applying manipulation

    Username: TeddKoren, Disqus ID: TeddKoren

    28 July 2017

    This paper sells the chiropractic profession short. A far better paper would be using outcomes study methodologies similar to those done to test NSA. In addition brain coherence analysis would have also been a better measurement of inter-technique research. This is not valuable in helping the practitioner in day to day practice. It ignores the potential of chiropractic by focusing mostly on musculoskeletal issues rather than health issues which is what chiropractic was discovered to help.

    Competing interests