Chaitow's Bodywork Blog

I am coming to the end of a lengthy revision of one of my favourite books “Palpation an Assessment Skills“ (Elsevier, Edinburgh).

This 3rd edition will appear in a year or so, after grinding through its’ production process…..

The first incarnation of this book had a different title “Palpatory Literacy“, which was thought to be a tad too highbrow I guess, so its’ name changed – but its’ message remained the same – to encourage the exploration of the gathering of information by sensitive touch. Over the years the content has changed and expanded – so that the next edition will have chapters by Whitney Lowe, Tom Myers, Michael Seffinger as well a UK based expert in Chinese medicine Stefan Chmelik, and a fascinating one by my daughter Sasha, on enhancement of intuitive faculties!

As I worked my way through the hundreds of palpation skill exercises in the 2nd edition, revising and adding new material, I was struck by the wonderful words of some of the great manual medicine pioneers – which remain inspirational ……and I thought it might be of interest to quote some of these in this posting – without comment, as they speak for themselves.

In no particular order:

Viola Frymann DO (1963): Palpation cannot be learned by reading or listening; it can only be learned by palpation.………The first step in the process of palpation is detection, the second step is amplification, and the third step must therefore be interpretation. The interpretation of the observations made by palpation is the key which makes the study of the structure and function of tissues meaningful. Nevertheless it is like the first visit to a foreign country. Numerous strange and unfamiliar sights are to be seen, but without some knowledge of the language with which to ask questions, or a guide to interpret those observations in the life and history of the country, they have little meaning to us. The third step in our study then is to be able to translate palpatory observations into meaningful anatomic, physiologic or pathologic states.

Philip Greenman DO (1989):   The objectives of palpation

1. Detect abnormal tissue texture
2. Evaluate symmetry in the position of structures, both physically and visually
3. Detect and assess variations in range and quality of   movement during the range, as well as the quality of the end of the range of any movement
4. Sense the position in space of yourself and the person
being palpated
5. Detect and evaluate change in the palpated findings, whether these are improving or worsening as time passes.

Karel Lewit MD (1999): Palpation of tissue structures seeks to determine the texture, resilience, warmth, humidity and the possibility of moving, stretching or compressing these structures. Concentrating on the tissues palpated, and pushing aside one layer after another, we distinguish skin, subcutaneous tissue, muscle and bone, we recognize the transition
to the tendon, and finally the insertion. Palpating bone, we recognize tuberosities (and possible changes) and locate joints. Reflex changes due to pain affect all these tissues, and can be assessed by palpation; one of the most significant factors is increased tension.

George Webster DO (1947): We should feel with our brain as well as with our fingers, that is to say, into our touch should go our concentrated attention and all the correlated knowledge that we canbring to bear upon the case before us.

Fred Mitchell Jr DO (1976): The necessity for projecting one’s tactile senses to varying distances through an intervening medium, must seem mystical and esoteric to many beginning students. Yet even when one is palpating surface textures the information reaches one’s nervous system through one’s own intervening integument. Students are often troubled by the challenge of palpating an internal organ through overlying skin, subcutaneous fascia and fat, muscle, deep fascia, subserous fascia and peritoneum.

Denis Brooks DO (1997): We must learn to palpate through our fingers, not with them.

John Upledger DO (1987): Learning to trust your hands is not an easy task. You must learn to shut off your conscious, critical mind while you palpate for subtle changes in the body you are examining. You must adopt an empirical attitude so that you may temporarily accept without question those perceptions which come into your brain from your hands. Although this attitude is unpalatable to most scientists it is recommended that you give it a trial. After you have developed your palpatory skill, you can criticise what you have felt with your hands. If you criticise before you learn to palpate, you will never learn to palpate, you will never learn to use your hands effectively as the highly sensitive diagnostic and therapeutic instruments which, in fact, they are.

W.G Sutherland DO (1948): It is necessary to develop fingers with brain cells in their tips, fingers capable of feeling, thinking, seeing. Therefore
first instruct the fingers how to feel, how to think, how to see, and then let them touch.

Ida Rolf (1977) (discussing changes following treatment): You can feel the energy and tone flow into and through the myofascial unit . . . dissolving the ‘glue’ that, in holding the fascial envelopes together, has given the feeling of
bunched and undifferentiated flesh. As fascial tone improves, individual muscles glide over one another, and the flesh – no longer ‘too, too solid’ –
reminds the searching fingers of layers of silk that glide on one another with a suggestion of opulence.

Don Murphy DC (2000): Palpation encompasses static palpation, such as for skin temperature and texture, masses, myofascial trigger points, or soft tissue changes; motion palpation for assessing joint function; and muscle length tests for assessing muscle function. So it is used in the detection
of red flags for serious disease, the primary pain generator(s), and the key dysfunctions and dysfunctional changes. There is no substitute for good palpation skills in examining patients . . . The two most important tools
that are used in the process of examination are those of sight and touch (in addition to hearing) . . . palpation in particular, is a skill that is invaluable in the assessment of locomotor system function.

Geoffrey Maitland PT (2001): In the vertebral column, it is palpation that is the most important and the most difficult skill to learn. To achieve this skill it is necessary to be able to feel, by palpation, the difference in the spinal segments – normal to abnormal; old or new; hypomobile or hypermobile – and then be able to relate the response, site, depth and relevance to a patient’s symptoms (structure, source and causes). This requires an honest, self-critical attitude, and also applies to the testing of functional movements and combined physiological test movements. It takes at least 10 years for any clinician (even one who has an inborn ability) to learn the relationship between her hands, the pain responses, and her mind.

Hopefully…food for thought!

References

1. Brooks, R., 1997. Life in motion, the osteopathic vision of Rollin E. Becker, D.O. Rudra Press, Portland, OR.
2. Frymann, V., 1963. Palpation – its study in the workshop. Academy of Applied Osteopathy Yearbook, Newark, OH.
3. Greenman, P., 1989. Principles of manual medicine. Williams and Wilkins, Baltimore.
4. Lewit, K., 1999. Manipulation in rehabilitation of the motor system, third ed. Butterworths, London.
5. Maitland, G., 2001. Maitland’s vertebral manipulation, sixth ed. Butterworth Heinemann, Oxford.
6. Mitchell Jr., F., 1976. Training and measuring sensory literacy. Yearbook of the American Academy of Osteopathy, Newark, OH.
7. Murphy, D., 2000. Conservative management of cervical spine syndromes. McGraw-Hill, New York.
8. Rolf, I., 1977. Rolfing: the integration of human structures. Harper and Row, New York.
9. Sutherland, W.G., 1948. The cranial bowl. Mankato, Minnesota.
10. Upledger, J. 1987. Craniosacral therapy. Eastland Press, Seattle.
11. Webster, G., 1947. Feel of the tissues. Yearbook of the American Academy of Osteopathy

I’ve been traveling, teaching and reading (and writing) – a lot  lately – hence the lack of blog posts.

It’s about the reading and writing bits that I want to offer some thoughts in this posting – as it seems to me that there has been a definite shift in terms of new therapeutic directions, since the first Fascia Research Congress back in October 2007. Now when I say ‘new’ I realize that for many practitioners and therapists fascial considerations have long been a major focus – but for the vast majority my sense is that fascia has remained in the  background – not right at the center of what those of us who work on the human body could and should be considering.

I was modestly involved in the 1st Congress (Boston, 2007), and am a small cog in the wheels that are turning to organize the 2nd – Amsterdam, October this year. The Journal of Bodywork & Movement Therapies that I edit published many abstracts, articles and research reports from the Boston event, and will do so again this time….and it’s about some of the topics that will be discussed and taught (post Congress workshops) that I want to write today. I’ve been looking through the hundreds of abstracts sent for review by the Scientific Committee and although I cannot preempt the actual event by revealing details, I can share topics – which may offer a flavor of the range and variety of fascial topics that will be available (at the congress and in JBMT).

These are some of the abstract titles:

• Undiagnosed Posterior Thigh Pain, A Fascial Rather Than Neural Cause? (Australian study)
• Fascial Distortion Model (FDM) – An Effective Method For The Treatment Of Shoulder Pain (German research)
• Anatomical Discovery of Meridians and Collaterals (Chinese research)
• Evaluating the effectiveness of Myofascial Release to reduce pain in people with Chronic Fatigue Syndrome (CFS): A Pilot Study (U.K. study)
• Myofascial Release (MFR) efficacy in alleviating specific symptoms in Systemic Lupus Erythematosus: Two Case Studies (U.K. study)
• Visceral Adhesions as Fascial Pathology (dissection evidence, USA)
• Effect of Osteopathic Manipulative Treatment in Essential Hypertension and Initial Vascular Wall Alteration (Italian research)
• Prospective Investigation on Hip Adductor Strains Using Myofascial Release (Canadian study)
• Healing Anterior Cruciate Ligament Without Surgery (Spanish research)
• Distant Surgery Scars and Other Fascial Restrictions Perpetuate Pectoralis Minor: Trigger Points in Two Cases of Severe Chronic Hand Pain (USA)
• Asessment and treatment of fascial strain in thepelvic girdle (Canada)
• Fascia slings and lumbopelvic stability from a new perspective (Holland)

• Inflammation Release Technique:Light Pressure Deep Tissue Protocol for Fascial Restriction (USA hospital study)
• Inner Psoas Tri-axial Deformation Under Tensile Load Corresponds to Superficial Dense Connective Tissue Morphology (Canadian study)
• The Strain Patterns of the Deep Fascia of the Lower Limb (Australian report)

……and these are just a random sample!

Cover of Fascia book

If you want to get a recent overview on the entire topic see Mark Lindsay’s new book “Fascia: Clinical Applications for Health and Human Performance” (Delmar.Cengage 2008)

I will write more on the topic of fascia in genera,l and the conference in particular over the coming months …for now though, my suggestion is that all therapists should investigate the ideas and methods that are evolving in this field.

This post builds on information that you will find on my other post “Chaitow’s Chat”, that – in Part 1 of this post – gives background information on osteopathic treatment of infected patients, during the great Flu Pandemic of 1918.

In this post I will outline some of the evidence that manual approaches (described in the various studies as “OMT”, which equates to osteopathic manipulative treatment) is potentially helpful in immune enhancement; and I will also provide information about protection from flu, or any other infection, via simple naturopathic and nutritional methods.

The health enhancing result of osteopathic (and other manual) health care approaches

In order to have an appreciation that manipulation and mobilisation might encourage greater resistance to infection, and/or might assist in recovey from it (and other serious conditions), a few research studies are listed below.

Elderly hospitalized pneumonia patients: Noll et al (1999, 2000) showed that when osteopathic manual methods were used on elderly hospitalized patients with pneumonia (for example the spleen pump method as illustrated above), the result included reduced time in  hospital, from a mean of 8.6 days, without osteopathic care(OMT), to 6.6 day with osteopathic care . The patients receiving receiving OMT, also required significantly less in the way of intravenous antibiotics.

Manual methods and pancreatitis: In 1998 Radjieski et alwere able to demonstrate that when OMT (10 to 20 minutes daily of a standardized protocol involving myofascial release, soft tissue and strain-counterstrain techniques) was combined with their regular hospital treatment, patients with pancreatitis had their length of hospital stay  cut by aproximately half – a mean reduction, 3.5 days compared with control subjects who did not receive OMT.

Post-operative pain: Nicholas & Oleski (2002) reported that, following major surgery: “Patients who receive morphine preoperatively and OMT postoperatively, tend to have less postoperative pain and require less intravenously administered morphine. In addition, OMT and relief of pain lead to decreased postoperative morbidity and mortality and increased patient satisfaction. Also, soft tissue manipulative techniques and thoracic pump techniques help to promote early ambulation and body movement.” The manual methods they used included a combination of approached that improve lymphatic flow, and general circulatory efficiency – including  rib mobilisation, thoracic inlet release, relaxation of the respiratory and pelvic diaphragms.

Post-coronary bypass surgery : In 2005 O-Yurvati et al (2005) discussed the beneefits of (OMT) following a coronary artery bypass graft (CABG). OMT was performed while subjects were completely anesthetized.
Results suggested improved peripheral circulation and increased mixed venous oxygen saturation after OMT. These increases were accompanied by an improvement in cardiac index

Which proves what?

If these results are coupled with the reported benefits when osteopathic care was offered during the 1918 flu pandemic (see my May 3rd blog, on Chaitow’s Chat), it suggests that – in addition to standard medical care – such approaches offer general health benefits, including enhanced immune function – and this should be considered by health care providers and patients alike.

What about massage?

We should not neglect to mention in this context, the proven value of massage.

For example Massage and recurrent respiratory tract infection:

• Massage was employed to treat and prevent recurrent respiratory tract infection in children.
• Susceptible and healthy children of the same age were used as controls.
• The therapeutic effect of the treatment group was shown to be significantly better (p < 0.01) than that of the controls
• All of the immunological indices being approximately normal when the patients were re-examined 3 and 6 months after the massage intervention.
• Massage was shown to be helpful in enhancing immune function, both preventing and treating the condition (Zhu et al 1998).

There’s much more about massage and other physical medicine methods (including hydrotherapy) in the book I edited and co-authored on Naturopathic Physical Medicine (2007)

Other protective methods

Vitamin D

Much of the information summarized in this section is taken from a paper by Cannell et al (2007) titled “On the epidemiology of Influenza“.

• Hope-Simpson & Golubev (1987) have suggested that a ‘seasonal stimulus’ that is, “inextricably bound to solar radiation, substantially controlled the seasonality of influenza”, and that this involves (among other biological effects) impairment in levels of 25-hydroxy-vitamin D [25(OH)D] [Hypponen & Power 2007].
• The evidence that vitamin D has profound effects on innate immunity is rapidly growing [Adams 2008]
• Hypponen & Power (2007) have shown that Hypovitaminosis D in British adults at age 45  following a nationwide cohort study of dietary and lifestyle predictors.
• Aloia & Li-Ng (2007) presented evidence of a dramatic vitamin D preventative effect from a randomized controlled trial in which 104 post-menopausal African American women who were given vitamin D were three times less likely to report cold and flu symptoms than 104 placebo controls. A low dose of800 IU/day reduced reported incidence, and  abolished the seasonality of reported colds and flu. A higher dose (2000 IU/day) virtually eradicated all reports of colds or flu.
• Recent discoveries about vitamin D’s mechanism of action in combating infections led Science News to suggest that vitamin D is the “antibiotic vitamin” due primarily to its robust effects on innate immunity.(Raloff 2006)

Naturopathic hydrotherapy and immunity from colds

This extract is taken from my other blog’s December 18 2008, posting:

“Ernst (1990a) showed that the regular (daily) use of a cold shower had a progressively beneficial effect on immune system efficiency (although in personal communication he denies that this was what the evidence suggests).
Medical students were divided into two groups [I imagine the scene as ..."we need volunteers for this study...you, you and you!")

• For 6 months one group took a graduated cold shower (i.e. ending a hot shower with a brief cold shower application, increasing the length of the cold application to tolerance for up to 2 minutes).
• The other group took a warm or hot shower.
• After 6 months those taking the cold shower were found to be having half the number of colds compared with those having warm showers.
• The cold shower group’s colds lasted for approximately half as long as those having warm showers, and were accompanied by far less mucus production (measured by weighing the used paper handkerchiefs of cold sufferers - now there's teutonic efficiency for you!).
• Cold showers were avoided during, and for 1 week after, experiencing a cold.

The various protective benefits did not become apparent until almost 3 months of regular cold showering
Just for balance Ernst et al (1990b) also recommend saunas for cold prevention (remember to finish with a cold plunge though!)"

Whether the flu pandemic emerges or not, it should be clear that we can defend ourselves, as well as adopting positive approaches to recovery.......

REFERENCES

• Adams J  Hewison M 2008 Unexpected actions of vitamin D: new perspectives on the regulation of innate and adaptive immunity. Nat Clin Pract Endocrinol Metab 4:80-90
• Aloia J Li-Ng M 2007 Re: epidemic influenza and vitamin D. Epidemiol Infect  135(7):1095-1096.
• Ernst E 1990a Hydrotherapy. Physiotherapy76(4):207–210
• Ernst E 1990b [Hardening against the common cold--is it possible?] (in German). Fortschr. Med. 108 (31): 586–8. PMID 2258128.
• Cannell J  et al 2008 On the epidemiology of influenza Virology Journal 5:29
• Hope-Simpson R  Golubev D  1987 A new concept of the epidemic process of influenza A virus. Epidemiol Infect   99:5-54
• Hypponen E, Power C 2007 Hypovitaminosis D in British adults at age 45 y: nationwide cohort study of dietary and lifestyle predictors. Am J Clin Nutr 85:860-868
• Raloff J 2006The Antibiotic Vitamin  Science News 2006, 170:312-317
• Zhu S, Wang N, Wang D et al 1998 A clinical investigation on massage for prevention and
  treatment of recurrent respiratory tract infection in children. Journal of Traditional Chinese Medicine 18(4):285–291

If a fire alarm goes off should we listen to its’ warning sound and get out of the building?

Or should we find a large hammer and silence it because the noise is a real nuisance?

I think you know the answer to that hypothetical question, and so the short answer to the question raised in the title would – I suggest – be ‘absolutely without doubt’

The pain from a trigger point might at times be a nuisance worth putting up with – if the other effects of the trigger point are beneficial.

How could this be the case?
Consider the some of the effects of myofascial trigger points – over and above their pain producing nature.

• They increase tone locally, in the tissues in which they exist.
• They increase tone in the tissues that they target via referral, or radiation.

Well…ask yourself when increased tone might be just what particular tissues need?

One example might be when the joints with which they are associated are unstable. Clinical experience suggests that, in such circumstances, myofascial trigger points may, form part of a functional system for sustaining tension, where this is required  – for instance in posturally compromised tissues, as “repositioners”

• Take as an example the mandible, when its’ position is destabilised due to forward head posture.
• Or consider the sustained tension across an unstable sacroiliac joint caused by strategically placed trigger points in the hamstrings  (Vleeming et al 1997).

Simons et al (1999) have shown that, in the absence of adequate levels of adenosine triphosphate (ATP), and in the presence of calcium, the actin and myosin elements of muscles are designed to lock in a shortened position.
Trigger points therefore function effectively in the absence of ATP (thereby displaying an economy of resources), and as they are often strategically located in tissues that are straining to accommodate dysfunctional posture, or habits of use, they might be seen as part of the solution in some instances, rather than part of the problem.

As we all know, trigger points often clear up spontaneously when the immediate causes – such as poor posture, overuse etc are corrected (and/or when other stressors such as dietary imbalance, breathing dysfunction, dehydration, etc. are changed) – which makes that (removal of causes) the optimal trigger point deactivation method (Chaitow & DeLany 2002).
Trigger points also appear to demonstrate a built-in, silent (latent) and non-silent (active) alarm mechanism, when the structures with which they are associated are being abused. Therefore, to release trigger points without regard to correcting the underlying causes (the abuse), to which they are responding, may result in a less than ideal outcome, not least of which could be a rapid, or chronic, return of the trigger point activity.
Rather than always being seen as dysfunctional entities, trigger points might be considered as low-energy-consuming, contractile devices, established by the absence of available ATP, to maintain a structural or localised tensional element, for immediate or long-term adaptation/compensation purposes, until no longer required.

Additionally they may be seen as alarm signals when tissues are being overloaded and abused.
In this way of thinking, it is the individual’s posture, patterns of daily use, or lifestyle, that are dysfunctional, not the tissues housing the trigger point, which may be doing exactly what they were designed to do.
When this is true – and when we can recognise that it is – it is the context from which trigger points emerge that requires attention, not the trigger points. Even when trigger points are potentially useful as stabilizers, but  are nevertheless causing pain, if more appropriate stabilization can be achieved, via (say) improved core stability, then deactivation – manually or by other means – would be seen to be appropriate.
But of course there are times – arguably in the majority of cases – when trigger points remain active well past their possible usefulness as stabilizing agents, or when they exist as historical remnants of previous overuse or trauma.
In such instances they are nuisances, and are probably disturbing normal function, and so require appropriate deactivation.

Just what ‘appropriate deactivation’ method you use is up to you. I have a preference for manual methods – although some of my colleagues use dry needling and others inject with procaine.

The neuromuscular (NMT) approaches I advocate are widely used and incorporate a mix of ischemic compression (intermittently applied) followed by positional release, followed by stretching of local tissues after an isometric contraction, followed by stretching of the whole muscle.

I have written (often with expert collaborators) widely on this subject and you can evaluate some of the books on my website (www.leonchaitow.com) – including Modern Neuromuscular Techniques, Clinical Applications of Neuromuscular Techniques (Volumes 1 and 2) – with Judith DeLany.

As in other postings – if sufficient interest is forthcoming I will expand on this in a later post….. in the meantime just as all the glisters is not gold, so all trigger points that hurt are not ‘baddies’!

References

• Chaitow L, DeLany J 2002 Clinical applications of neuromuscular technique. Vol. 2. Lower Body.Churchill Livingstone, Edinburgh
• Simons D, Travell J, Simons L 1999 Myofascial pain and dysfunction: the trigger point manual. Vol. 1: Upper half of body 2nd edn. Williams & Wilkins, Baltimore
• Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, eds. 1997 Movement, stability and low back pain. Churchill Livingstone, Edinburgh

I returned to Greece (where I spend half the year) yesterday, in a state of some exhaustion after a really busy time teaching in the UK and Europe.

Typical abdominal profile of an obese individual

On Saturday I lectured for 90 minutes at a one day symposium held at the University of Westminster, London, on the topic of leptin (see below for more on this) and its link to the obesity problem that most developed countries are facing.

I was the 4th of 4 speakers, and because a number of the earlier talks had actually covered elements that I had wanted to speak on – I was obliged to think laterally, trying to identify areas of interest that had not already been explored – sometimes several times!

Three thoughts emerged:

One was to address the biomechanical issues that emerge from being grossly overweight – but because the audience comprised (mainly) nutritionists, this had to be presented in broad terms. I was able to pull up an image (see above) showing an example. The basic message was that the illustrated individual would (apart from the cardiovascular and other health implications of obesity):

• a/ be likely to develop a range of musculoskeletal symptoms
• b/ would have difficulty in breathing normally
• c/ would be almost certain to suffer from pelvic floor issues – and possible incontinence
• d/ would have such highly stressed abdominal organs that the chance of these functioning normally would be close to zero.

The second lateral thought that I introduced in relation to obesity was an expansion of the point (b) above – as to the inability of the person involved to be able to breathe normally. The drag of the abdominal contents on the diaphragm and lower rib cage, together with the obvious bilateral shortness of psoas muscles (the fibers of which merge with the diaphragm) would make normal breathing function nigh on impossible. I was hoping that this information would help the nutritionally oriented delegates to appreciate that the biochemistry of upper chest breathing would probably lead to respiratory alkalosis, with repurcussions associated with poor oxygenation of all bodily tissues, as well as smooth muscle constriction – which would impact negatively on digestive function. [Chaitow et al 2002]

And finally my thought was to link this last issue (breathing dysfunction) with the huge problem of engaging anyone to alter built in habits — whether these relate to poor posture, imbalanced breathing — or undesirable eating patterns.

For more on breathing pattern disorders visit my website <www.leonchaitow.com> which has freely down-loadable articles on the topic [go to the "Research & Articles" section]- as well details of my coauthored book on the subject, “Multidisciplinary Approaches to Breathing Pattern Disorders”

To change any of these habit that might be having harmful effects on the body – I believe there are at least 4 essentials:

• Understanding the processes – the person affected needs to gain a cognitive, intellectual awareness of the mechanisms and issues involved in whatever the habit involves – whether breathing, posture, eating, or anything else.
• Retraining exercises or behaviors,  including aspects that operate subcortically, allowing replacement of currently habituated patterns with more appropriate ones
• Biomechanical structural modifications that remove obstacles to desirable and necessary functional changes – in eating pattern disorders this might involve efforts to enhance the stressed gut status as illustrated above.
• Time for these elements to merge and become incorporated into moment-to-moment use patterns

Leptin

Leptin and ghrelin are two hormones with major influences on health. [Klok 2007]
Leptin which is released by WAT (white adipose tissue) mediates long-term regulation of energy balance, suppressing food intake and so inducing weight loss. Put simply leptin is supposed to tell you when you have eaten enough. The problem is that over time – for complex reasons this post hasn’t time to address – the body stops recognising the signals.
Ghrelin is a fast-acting hormone, that plays a role in meal initiation. It tells you that you need to eat – and unfortunately we tend to listen to this signal more keenly than that from Leptin!
With obesity incidence rising dramatically, understanding the mechanisms by which these (and other) substances influence energy balance has been a subject of intensive research
In obesity, circulating level of the leptin (satiety) hormone is increased, whereas surprisingly, the level of ghrelin (appetite inducing) is decreased. ….but weight gain continues.
As mentioned, it is now established that most obese patients are leptin-resistant.
How this happens seems to relate to lifestyle (e.g. exercise & sleep patterns), as well as to food choices, and the timing of meals – and I’ll return to these topics in a later blog posting if there is sufficient interest.

The main external indicator of the evolution of leptin resistance involves weight gain in the abdominal region (obesity is defined as a waist circumference of 40 inches (101.6 cms) or greater in men and 35 inches (88.9 cms) or greater in women [Elliott 2008]). This where we accumulate WAT, which releases leptin. Abdominal dimensions are not only associated with leptin imbalance, but also with high risks of developing cardiovascular disease, type 2 diabetes and other morbidities collectively known as Syndrome-X.

Measuring waist circumference half way between the lower ribs and the crest of the pelvis

If there is further interest in this topic – and only be sending messages will this become clear to me – I will explore it further another time.

References

Chaitow L Bradley D Gilbert C 2002 Multidisciplinary Approaches to Breathing Pattern Disorders. Churchill Livingstone, Edinburgh

Elliott W 2008 Criterion validity of a computer-based tutorial for teaching waist circumference self-measurement. Journal of Bodywork and Movement Therapies 12 (2):133-145

Klok et al 2007 .The role of leptin and ghrelin in the regulation of food intake and body weight in humans: A review(2007) Obesity Reviews, 8(1):21-34

I have just been writing a reply to a query, raised on a UK based web-forum for osteopaths, on the topic of the extremely useful, but little known, Zink test – and in doing so it gave me a thought that discussion of this (the test, not the forum!) would be a useful first blog topic for me, as I join Massage Magazine’s panel of bloggers.

Before attempting to offer a summary of Zink’s ‘common compensatory pattern’ (CCP) (Zink & Lawson 1979), lets consider a not uncommon clinical experience – in all areas of health care – when the patient/client with a background of (perhaps) chronic muscular pain, reports back that whatever was done at the previous visit to you, has made matters worse.

A rapid look at your case notes tells you that nothing you did in the way of entirely appropriate treatment (- or advice offered -) at the last session, should have had negative effects. Nevertheless, here is the individual, and her/his report of increased discomfort needs to be understood.

• Is there anything you could have done to warn you of possible over-reactions in this case?
• And what should you do next?

If a general bodywork session involving – say, trigger point deactivation, some simple myofascial release, and general soft tissue work – produced this reaction, what can be safely offered next time you offer treatment to this person?

The Zink test can guide you – not as what to do – but what not to do. The Zink test is not a diagnostic procedure. It is an attempt to gain an insight into how adaptively exhausted this individual is….and to therefore pre-warn regarding possible negative reactions to what – in other circumstances – would be well tolerated methods of treatment.

Let me explain.

In the mid-1970′s Zink and his colleague Lawson – both osteopathic physicians, examined several aspects of well over 1000 hospitalized patients,  in an attempt to establish with some certainty that a concept they had been working on, based on their clinical experience – was valid.

Defeo & Hicks (1993) explain:
“Osteopathic physicians Zink and Lawson observed clinically that a significant percentage of the population assumes a consistently predictable postural adaptation, arising from nonspecific mechanical forces such as gravity, gross and micro-trauma, and other physiological stressors. These forces appear to have their greatest impact on the articular facets in the transitional areas of the vertebral column.”

Zink & Lawson (1979) described methods for testing tissue preference in these transitional areas where
fascial and other tensions and restrictions can most easily be noted, i.e. the occipitoatlantal (OA),
cervicothoracic (CT), thoracolumbar (TL) and lumbosacral (LS) levels of the spine. These sites are tested for rotation and side-fl exion preference. Zink & Lawson’s research showed that most people display (assessing the occipitoatlantal pattern first) alternating patterns of rotatory preference, with about
80% of people showing a common pattern of left-right-left- right (L-R-L-R) compensation, termed the ‘common compensatory pattern’ (CCP).

A= appropriate/minimal adaptive compensation - capable of absorbing additional stresses & change B= poorly compensated pattern, reduced adaptive capacity, unlikely to easily accept additional load & change

In their hospital-based study involving over 1000 patients Zink and Lawson also observed that the approximately 20% of people whose compensatory pattern did not alternate in the CCP manner had poor health histories, low levels of ‘wellness’ and had poor stress-coping abilities. More recent clinical evidence has emerged for the value of this attempt at reading the levels of adaptation exhaustion present in the physical structures of the body.

A prominent German osteopath/author Torsten Liem (2004) has suggested that if the rotational preferences alternate (L-R-L-R) when supine, and display a greater tendency to not alternate (i.e. they rotate in the same directions – for example, L-L-L-R or L-L-R-L or R-R-R-R, or some other variation on a non-alternating pattern) when standing, a dysfunctional adaptation pattern that is ‘ascending’ is more likely, i.e. the major dysfunctional influences lie in the lower body, pelvis or lower extremities.
However if the rotational pattern remains the same when supine and standing, this suggests that the adaptation pattern is primarily ‘descending’, i.e. the major dysfunctional influences lie in the upper body, cranium or jaw

The Assessment

Occipitoatlantal (OA) area
• With the patient supine the therapist is seated or standing at the head of the table. Both hands are used to take the neck into maximal unstressedflexion (to lock the segments below C2) and the rotational preference to an easy end of range – not a forced one, is assessed. Is rotation more free left or right?
Cervicothoracic (CT) area
• The patient is supine and the therapist’s hands are placed so that they lie, palms upward, beneath the scapulae. The therapist’s forearms and elbows should be in touch with the table surface. Leverage can be introduced by one arm at a time as the therapist’s weight is introduced toward the floor, through one elbow, and then the other, easing the patient’s scapulae anteriorly. This allows a safe and relatively stress-free assessment to be made of the freedom with which one side, and then the other, moves, producing a rotation at the cervicothoracic junction. Rotational preference can easily be ascertained. Is rotation more free left or right?
Thoracolumbar (TL) area
• The patient is supine or prone. The therapist stands at waist level facing cephalad and places the hands over the lower thoracic structures, fingers along lower rib (7–10) shafts laterally. Treating the structure being palpated as a cylinder, the hands test the preference for the lower thorax to rotate around its central axis, testing one way and then the other. Is rotation more free left or right? The preferred TL rotation direction should be compared with those of OA and CT test results. Alternation in these should be observed if a healthy adaptive process is occurring.
Lumbosacral (LS) area
• The patient is supine. The therapist stands below waist level facing cephalad and places the hands on the anterior pelvic structures, using the contact as a ‘steering wheel’ to evaluate tissue preference as the pelvis is rotated around its central axis, seeking information as to its ‘tightness/looseness’ preferences. Is rotation more free left or right?
Alternation with previously assessed preferences should be observed if a healthy adaptive process is occurring.
As a naturopath/osteopath I have used this assessment method for many years, and am convinced it has saved many patients from unnecessary reactions to what would be considered in someone else to be perfectly safe and useful treatment.

So…if specific interventions are not indicated because of the poor compensation pattern – what should be done?

I will finish this post with the words I used on the osteopathic forum earlier today:

I use the Zink test to guide me towards, or away from, specific interventions.
I will give as an example someone with widespread pain – perhaps with a diagnosis of fibromyalgia (FMS) or myofascial pain syndrome (MPS) (or a combination of both).
Inevitably I would attempt to deal with constitutional/whole-person focus on lifestyle modification, exercise issues, nutrition, breathing patterns, postural advice etc.
And – if the Zink test proved negative (i.e. normal alternating rotational preferences at the spinal transition regions) -  I would also consider specific interventions such as trigger point deactivation, or key spinal or pelvic manipulation – if indicated.
If, however, the Zink test proved positive, with a strong indication of a likelihood that specific interventions would be poorly coped with, I would avoid specific interventions, and would utilise constitutional approaches alone – selectively, and in slower motion (so to speak) than if Zink were negative – and would stick to offering or recommending whole-person approaches (consitutional hydrotherapy, whole body massage, relaxation methods etc).
Simplistically – all treatment involves adding additional stressor input to an already compromised system (taking pain and disease as representing failed adaptation)  – which means that treatment needs to be carefully tailored to the individual’s ability to respond to it…..and Zink allows me to judge this objectively (relatively)

There is more discussion of the Zink test in several of my books, including :

Palpation & Assessment Skills

Clinical Applications of Neuromuscular Techniques

Naturopathic Physical Medicine

Details of these books can be found on my website: http://www.leonchaitow.com/

I hope this proves of use to you in your patient/client management ….please let me know.

References

• Defeo G, Hicks L 1993 A description of the common compensatory pattern in relationship to the osteopathic postural examination. Dynamic Chiropractic 24:11
• Liem T 2004 Cranial osteopathy: principles and practice. Churchill Livingstone, Edinburgh, p340–342
• Zink JG, Lawson WB 1979 An osteopathic structural examination and functional interpretation of the soma. Osteopathic Annals.7:12 -19