From a motion palpation point of view, the human body must be considered a totality of interdependent, interconnected functional components whose function/dysfunction has a profound effect on any of its parts, be they somato-somato, somato-visceral or viscero-somatic.
Motion palpation. Has it remained the same? Has anything been eliminated or altered? Has anything new been added? Has there been any new information or theories put forth that have direct impact on the methodology of motion palpation? The answers to these questions are in some cases simple and, in others, extremely complex; therefore, I shall attempt to answer them in a logical fashion so that the student or doctor may follow the logical sequence.
To begin with, it is reasonable, although time has shown that this is not so, to assume that the doctor and student have a comprehensive working knowledge of the anatomy of the area, including the interconnected functions of muscles, ligaments, viscera and joints, and the superior understanding of the normal physiological function of each.
Has motion palpation remained the same? In part one of this series, I stated that motion palpation has evolved significantly from its young days. It has done so based on current research and our understanding of various components: coupled motion; ligamentous restraints; fascial continuities; and the intricate interplay between these elements. Like most aspects of health care that are improving and upgrading, a commitment by the doctor to his or her patients should be made to update his or her database as new information is available.
Has anything been added? In 1992, 1995 and 1998 the world of manual therapies was treated to new and far-reaching concepts put forth by researchers and practitioners around the world. The concepts, results and theories of these three interdisciplinary conferences that have impacted on motion palpation analysis and interpretation. It is interesting to look back over the last 15 years and, based on the new research, see just how much of the old MPI let go and still more enlightening to see just how much new material has been added, not just to our methodology and technique but to our overall understanding of what it is we are doing. The result of all this new information is that each and everyone of us needs to go back to the books to study and practice if we are to maintain a leadership position in the field we have all chosen.
Misconceptions on the nature and methodology of motion palpation need to be addressed. If you start out on the wrong foot, you will surely fail in your attempt to accomplish your goal. The positioning of the patient is the first step to success or failure. This may seem like a small and perhaps insignificant part of the procedure, but it's not. Rather, it illustrates to the trained observer whether the examiner has any idea as to what he or she is doing.
Allow me to develop this concept. The patient must be seated in a position that allows for "unload" of:
- muscles that are hypertonic or asymmetrically contracted;
- ligaments that are pre-stressed by, for example, slump posture or anterior head carriage;
- the quadratus lumborum muscle and its impact on the rib cage and lumbar spine.
- The position of the femurs will have a deleterious effect on iliosacral joint position and therefore will somewhat predetermine the total excursion of sacral nutation/counternutation prior to the motion examination.
- The arms must be in a position of rest so that they do not cause a load to be applied to the thoracodorsal/lumbar fascia which, through its fascial plate connections, will impact on the available range of motion of spinal joints and ribs through the erector spinae aponeurosis, supraspinous ligament, interspinous ligament and the ligamentum flavum. The result is a decease of motion in all of the relevant areas.
- Osseous postural positions that increase stability of areas and thereby reduce the amount of available motion, i.e., the intimate relationships between sacral nutation/counternutation and the multifidus muscle, the psoas and the contralateral deep erector spinae group, the sacrotuberous ligament and the long dorsal sacroiliac joint ligament with the hamstrings;
One can see from these six items alone (there are others) that the proper positioning of the patient is of critical clinical examination importance. If any of the above areas are not given special attention prior to beginning the motion palpation exam, the results will be faulty or based on faulty predetermined postural abnormalities. Motion palpation has advanced considerably since the early days. It now requires much more understanding, preparation and practice to achieve exactness and reliability.
Understanding of the aforementioned and the repetitious practice of palpation of the "normals" is vital to the examiner, for unless one is aware of the "norms," it is impossible to pick out the "abnorms." A simple yet important example is atlas movement during the action of right lateral flexion. Does the atlas move towards the concavity or away from the concavity? Or does it actually do both of these actions based on the amount of lateral flexion? The answer to this question will be given in one of the following articles when the occiput-atlas-axis relationship is considered.
The next article in this sequence will deal with the fascial planes and their importance. The reader is encouraged to read Dr. Hammer's latest article on fascia (DC, January 12) to grasp an appreciation of its significance to treatment and examination procedures.