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) -Â 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)Â – 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
