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This chapter will therefore focus on palpatory skill 126 Naturopathic Physical Medicine enhancement donepezil 10mg with mastercard medicine expiration, associated with the processes closure assessments of the sacroiliac joints involved in extracting information during palpation (DonTigny 1995 buy donepezil 10mg on line treatment variance, Lee 1999 purchase donepezil amex medicine bg, Norris 1998) and assessment – the means whereby data are derived • sacral assessment (Dalstra 1997) non-verbally 10 mg donepezil visa medicine 20th century. From the evidence gathered we make the therapeu- tic choices designed to reduce adaptive demands and Excavating for anatomic and enhance adaptive capacity, allowing self-regulation to physiological evidence operate more efﬁciently, while simultaneously pre- venting exacerbations and recurrences. Naturopathy sees dysfunction and disease as being parts of a process, rather than as entities, as discussed Accurate information gathering in Chapter 1. When we are palpating and assessing we are operat- The skill acquisition exercises are methods that even ing in present time. What is being revealed, however, experienced practitioners can use to improve proﬁ- relates to the accumulated effects of past mechanical, ciency, competence and dexterity. Apart from using chemical and emotional adaptations – stresses, strains, palpation in the sort of detective work described micro- and macrotraumas, toxicities, deﬁciencies, above, these skills are relevant to the safe, effective fears, anxieties, somatizations and more – all overlaid delivery of manual therapy. The examiner’s task is to identify ﬁrst identiﬁcation of resistance barriers, something essen- the present state of the body, and later the processes tial to the successful delivery of treatment (see notes that gave rise to the present state. What is being touched, tested, pressed, stretched Considering the evidence offered in Chapter 4, accu- and evaluated is as it is because of everything that has racy of information gathering is a foundational require- ever happened to it. These palpable and assess- the process of palpation is detection, the second step is able changes point us to the processes that have taken ampliﬁcation, and the third step must therefore be and are taking place, as the body adapts to age and interpretation. Kappler (1997) succinctly and accurately expressed This involves gathering evidence and then interpret- what is required: ing it in the context of the process of which the indi- vidual is currently a part. How tight, loose, weak, The art of palpation requires discipline, time, patience bunched, ﬂaccid, symmetrical, balanced, sensitive or and practice. To be most effective and productive, painful the tissues are, can tell a potent story without palpatory ﬁndings must be correlated with a words. From the accu- pathological states, a tumor for example, than to mulated evidence, we identify the stressors to which describe signs, symptoms, and palpatory ﬁndings the individual is adapting. Inappropriately focusing that lead to, or identify, pathological on symptoms such as restriction, sensitivity, loss of mechanisms. Palpation with ﬁngers and hands elasticity, reduced range of motion, rather than on provides sensory information that the brain interprets trying to understand the larger contextual picture, as: temperature, texture, surface humidity, elasticity, 128 Naturopathic Physical Medicine turgor, tissue tension, thickness, shape, irritability, pathological features associated with their back pain, motion. To accomplish this task, it is necessary to but: teach the ﬁngers to feel, think, see, and know. One • around 4% have compression fractures feels through the palpating ﬁngers on the patient; one (probably with osteoporosis as a background to sees the structures under the palpating ﬁngers through that) a visual image based on knowledge of anatomy; one thinks what is normal and abnormal, and one knows • 1% have tumors as the cause of the problem with conﬁdence acquired with practice that what is felt • between 1 and 3% of people with acute back is real and accurate. Giles (2003) has demonstrated how a number of very Beware imposter symptoms different conditions can produce back pain in pre- Grieve (1994) has described conditions that may ‘mas- cisely the same place: querade’ as others: • Carcinoma of the pancreas • Inﬂammatory arthropathy If we take patients off the street, we need. Suspicion or recognition of red ﬂags emerges from the person’s history and symptoms. If any of the signs listed below are present, further tumors) that closely mimic musculoskeletal symp- investigation should be suggested before treatment toms, and/or which may coexist alongside actual starts, particularly to exclude infection, inﬂammatory musculoskeletal dysfunction. Chapter 6 • Assessment/Palpation Section: Skills 129 • There is thoracic pain accompanying the back to be a reﬂective process in the practitioner to ensure pain. It is impor- • There is a history of prolonged use of tant for the health of the practitioner, and patients, to corticosteroids. Following on from the need to reﬂect on the inner • There are widespread neurological symptoms. With this continuously present, Note: It is probable that one form of physical medicine ﬂuctuations in the patient’s state are felt more clearly or another would be useful for back pain relating to as ‘outside’ events, and are not mixed together as in all or any of these signs and symptoms, but this should normal social interactions. Active and passive hands Yellow ﬂagssuggest psychosocial factors that ‘increase It is necessary to develop the ability to have one hand, the risk of developing, or perpetuating chronic pain or one part of the hand, being restful and ‘listening’ and long-term disability’ (Van Tulder et al 2004). The ﬁrst step of tactile evaluation • inappropriate attitudes about back pain – such (after verbal consent is given) is to be passive in as the belief that back pain is actually harmful general – a gently allowing of the hands to rest on the and potentially disabling, or that bed rest is all patient’s body, and a centering of the practitioner’s that is needed rather than performing speciﬁc body–mind to allow the ﬁrst meeting and dialogue to beneﬁcial exercises: one of the ﬁrst and most start. When the various activities of tactile evaluation important lessons people need to learn is that proceed, it helps to return frequently to the passive ‘hurt does not necessarily mean harm’ ‘palposcope’ to assess how the tissue is reacting and • inappropriate pain behavior (e. This will activity levels or ‘fear-avoidance’) increase the information gathered, and help to guide • compensation (the possibility of ﬁnancial gain towards ﬁnding the pressure and depth that are if back pain continues) and/or work-related appropriate and comfortable for that task. Principles of palpation (Chaitow 2003a, This varies with the tissues being evaluated: Frymann 1963, Kuchera & Kuchera 1994) • When skin is being palpated (see below), no more than touch (‘feather light’, ‘skin-on-skin’) Intention may be needed. The intention within the practitioner’s mind–body • When assessing tissues below the surface, drives the pressure and the rate of movement of the pressure is increased, and there are a number hand, the texture of their skin, the way it feels to the of ways of conceptualizing what is required at patient and, ultimately, the healing effect. Some clinicians advise discovering the degree of pressure required when pressing onto your own (closed) eyeball before discomfort starts, as a means of learning just how lightly to press. Others advise using the least necessary pressure to make contact with, and evaluate, the tissues in question. Early Surface level in the process of learning to palpate deep tissues, the amount of pressure needed to feel engaged with deep structures will be greater. When palpation Working level skills are reﬁned, the least necessary pressure is much less than a beginning student would consider Rejection level possible. Surface level involves The term ‘pressure threshold’ is used to describe the touch without any pressure at all. Rejection level is where pressure least amount of pressure required to produce a report meets a sense of the tissues ‘pushing back’ defensively. By of pain, and/or referred symptoms, when a trigger reducing pressure slightly from the rejection level, the contact point is compressed, and this will vary depending on arrives at the working level, where perception of tissue change should be keenest, as well as there being an ability to distinguish the depth of the trigger in different tissues, locations normal from abnormal tissues (hypertonic, ﬁbrotic, edematous, etc. Reproduced with permission from Chaitow (2005) Finding a ‘working level’ occur at different degrees of pressure, in How much palpation pressure different areas and in different circumstances. When you are at the rejection level there is a feeling • When working with or on the skin: surface of the tissues pushing back or resisting, and this has level to be overcome to achieve a sustained compression. Pick (1999b) has usefully described identiﬁcation of If a constant degree of stimulation of these receptors these levels of tissue that you should try to reach by is being sustained by the palpating hand, sensitivity application of pressure, when assessing and/or treat- tends to reduce as the ﬁring rate of the receptors ing the patient. Pick described the different levels of tissues to be The alteration in sensitivity resulting from rapid accessed as: adaptation to light touch is something that can be • Surface level: This is the ﬁrst contact, molding modiﬁed by practice. However, because mechanore- to the contours of the structure, involving ceptors serving joint and muscle are slow adapters, as no actual pressure. This is just touching, are pain receptors, some experts such as Upledger & without any pressure at all, and is used to Vredevoogd (1983) suggest that use of these proprio- start treatment via the skin – as described ceptive receptors should be incorporated into palpa- below. Most of you have been taught to palpate or touch with Within this level the practitioner can feel your ﬁngertips. Once melding and synchronization have Chapter 6 • Assessment/Palpation Section: Skills 131 At times during palpation too much information is Box 6. The brain cannot process everything • Touch the tissues and then slowly apply pressure at once. By concentrating only on the portion you (sink into the tissues) until you feel a sense of want, it becomes easy and fast to detect areas of ‘rejection’ – as though the tissues are pressing back signiﬁcant tissue texture abnormality. Kappler et al (1971) found that when student exam- • Then try to identify a point somewhere between iners were compared with experienced practitioner these two levels – between superﬁcial and deep. Physical therapy students have been taught to accurately produce speciﬁc degrees of pressure on request. They were tested applying posteroanterior pressure force to lumbar tissues, and after training, occurred, use your own proprioceptors to determine using bathroom scales to evaluate pressure levels, what the palpating part of your own body is doing. Meeting barriers Ford (1989) reminds us that we commonly ‘project’ Elasticity is a feature of all tissues – even bone.
The procedure is repeated making a low back pain repetitive horizontal line (side to side) buy cheapest donepezil medicine 2020, and A randomized between-groups design was used to then two diagonal lines buy genuine donepezil on-line symptoms 0f colon cancer, relaxing the eyes in evaluate massage therapy versus relaxation therapy their normal posture in between exercises purchase donepezil in united states online symptoms type 1 diabetes. By the time the latter reducing job absenteeism and increasing job produc- part of the exercise is being performed order 10mg donepezil with amex treatment plantar fasciitis, 90% of tivity. Thirty adults (mean age 41 years) with low back individuals report sleep to be rapidly pain with a duration of at least 6 months participated approaching. The groups did not differ in age, socio- • Yoga and melatonin production: The practice of economic status, ethnicity or gender. Sessions were 30 yoga meditation has been shown to effectively minutes long, twice a week, for 5 weeks. Sleep disturbance is common in patients with end- stage renal disease but no intervention studies have Low birth weight infant massage and addressed this problem. The purpose of a randomized control trial (Tsay et al 2003) was to test the effective- sleep behavior ness of acupoint massage for patients with end-stage A Russian study (Kelmanson & Adulas 2006) renal disease who were experiencing sleep distur- attempted to evaluate the impact of massage therapy bance and diminished quality of life. The measures included the Pittsburgh Sleep experimental group of babies and controlled for Quality Index, Sleep Log, and the Medical Outcome gender, gestational age, weight and date of birth. The assigned massage intervention therapy that included degree of ﬁnger pressure varied from 3. Interventions were limited formed by professionals until the infant was 8 months to 14 minutes, consisting of 5 minutes of massage to old. In addition, the tendency to study changes in small groups of good sleepers may also underestimate the Exercise and sleep (poor correlation) efﬁcacy of exercise for promoting sleep. Research studies (Youngstedt et al 2003) Although only moderate effect sizes have been examined associations between daily amounts noted, meta-analytical techniques have shown of physical activity and sleep. Strength training and sleep in No signiﬁcant associations between physical older adults activity and sleep were found in the main A review of the current research on strength training analyses of either study. These results fail and older adults evaluated exercise protocols in a to support epidemiological data on the variety of populations (Seguin & Nelson 2004). It value of exercise for sleep, but are demonstrated that a variety of strength-training consistent with experimental evidence prescriptions, ranging from highly controlled labora- showing only modest effects of exercise on tory-based to minimally supervised home-based pro- sleep. Research has demonstrated common with age, affect quality of life for that strength-training exercises have the ability to individuals and their families, and can increase combat weakness and frailty and their debilitating health care costs, and that older people are consequences. The primary outcome measure was the • premenstrual exacerbations number of incontinent episodes, as documented with • exacerbations after sexual intercourse. Forty-four percent of all enroll- ees had a ∼50% improvement in the number of incon- Structural and functional considerations tinent episodes per day. Six months after The functional integrity of the bladder, bladder neck, completing the course of exercises, approximately urethra and rectum are dependent on the intercon- one-third of all participants reported that they contin- necting structural support of the (1) arcus tendineus ued to note good or excellent improvement, and fasciae pelvic, (2) levator ani muscles, and (3) endo- needed no further treatment. Thiele massage and pelvic symptoms Voluntary bladder control requires intact structural support, functional neuromodulatory mechanisms deriving from hypertonia and urethral sphincter competency. The striated Some time before the Second World War a physician muscles of the pelvic ﬂoor play an integral role in named Thiele developed a technique in which coccy- closure of the urethral lumen and maintenance of geal prostate problems were treated by means of continence. The researchers point out that 95% of chronic cases of prostatitis are unrelated to bacterial infection, The effectiveness of transvaginal Thiele massage has and that myofascial trigger points, associated been shown (Holzberg et al 2001) on high-tone pelvic with abnormal muscular tension in key muscles, are ﬂoor musculature in 90% of patients with interstitial commonly responsible for the symptoms. Describing the technique, the researchers month study involved 138 men, and the results pro- note: duced marked improvement in 72% of the cases, with Subjects underwent a total of 6 intravaginal massage 69% showing signiﬁcant pain reduction and 80% sessions using the Theile ‘stripping technique’. The study noted technique encompasses a deep vaginal massage via a that: ‘back and forth’ motion over the levator ani, obturator TrPs in the anterior levator ani muscle often refer pain internus, and piriformis muscles as well as a to the tip of the penis. The levator endopelvic fascia myofascial release technique whereas a trigger point lateral to the prostate represents the most common was identiﬁed, pressure was held for 8 to 12 seconds location of TrPs in men with pelvic pain. Wise D, Anderson R 2003 A headache in the cystitis were evaluated for: (1) increased pelvic tone pelvis. National Center for Pelvic Pain and trigger point presence; and (2) sacroiliac dysfunc- Research, Occidental, California tion. Treatment comprised direct myofascial release, joint mobilization, muscle Physical therapy, the pelvic ﬂoor and energy techniques, strengthening, stretching, neuro- pelvic dysfunction muscular re-education, and instruction in an exten- • Low-tone pelvic ﬂoor muscles involved in sive home exercise program. There was a lesser problems (including dyspareunia) respond well to improvement in urinary urgency and nocturia. Apart from a placebo compared in one study is similar to, or entirely effect, only those receiving the appropriate symptom- different from, what is being considered in an relieving medication would demonstrate perceived other. The person with angina symptoms • Did it address abdominal or spinal or whole would not beneﬁt from the reﬂux medication, and body tissues? Activator) forms of chiropractic, or a soft-tissue massage, if anxiety had been evaluated as an etiologi- variation? In other words, what is being analyzed in such From a naturopathic perspective, manual (or any reviews is virtually guaranteed in advance to deliver other) methods of treatment need to match the needs an outcome that states precisely what Ernst pro- of the individual in order to achieve one or other of nounces, that ‘there is no fully convincing evidence two primary goals – to reduce the adaptive demands for effectiveness [of massage or chiropractic] in con- that are being responded to, and/or to enhance func- trolling musculoskeletal or other pain’. Rather, the It may be useful to consider an example from a key is to identify subgroups of patients with a high different setting. There were signiﬁcant changes in perceptions of physical and mental well-being, erector Manipulation, when this is not required, or massage spinae fatigue and ﬂexion relaxation measures when this is inappropriate, or exercise when this is (Fig. But when they are appropriate, out- • Beneﬁts of categorization of back pain patients: comes will reﬂect this, and will confound negative Categorizing low back pain patients into those reviews that are almost always going to produce ﬁnd- with pain of less than 16 days’ duration, and ings such as those suggested by Ernst, unless built-in those whose symptoms did not extend below bias is eliminated by avoiding unrealistic assump- the knee, has been shown to be a major tions, such as those outlined above. The authors conclude with a comment and rehabilitation methods in treatment of musculo- that could be designed to be read by skeletal and other sources of pain of various types. However, the risk of serious complication from manipulation of the lumbar If pain is involved as a presenting symptom, the infor- spine is extremely low, with estimates suggesting mation that can be gleaned by careful questioning is the risk of cauda equina syndrome is less than of considerable importance. Interpreting the real 1 per 100 million lumbar spine manipulations meaning of answers is a skill that needs to be (Assendelft et al 1996). In a naturopathic setting these randomized controlled trial, 120 patients with questions should help to identify some of the context chronic low back pain responded better to a out of which painful symptoms are emerging – so that combination of manipulation (rotational high a therapeutic plan can be developed. The structured exercise, using a Swiss ball, by authors further noted that: ‘A signiﬁcant patients with chronic non-speciﬁc low back difference was also found between the two pain, produced signiﬁcant improvements in groups in favor of the manipulation/exercise pain and disability that was maintained up to group at 6-month follow-up. The exercises were progressed based on pain: Low back pain with possible neural 482 Naturopathic Physical Medicine Figure 10. In an accident 2 years ago – my car was This is a common injury struck from the rear Where is your pain? Be numbness in both legs when I lie down suspicious that this chronic pain has a major psychological component On a scale of 0–10, how would 0/10 up to 8/10. I have episodes of no It is good that he reports episodes of no you rate your pain? All physical activity, mostly with my arms This pattern could lead to avoidance of all activity What makes your pain better? Heat, massage and physical therapy These may be passive-role therapies How often have you had I have had three separate therapists He is seeking complete relief physical therapy treatment? Every This is a very good sign time I exercised I felt better Are you exercising on your No, I am afraid I will hurt myself. He uses family and work as an excuse to avoid his responsibility for caring for himself What is your work?
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