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The eighth movement involves lymphatic drainage of cumulative scope of the movements thus far discount 400mg levitra plus. The ninth movement is a general mobilization of the • It can be seen that all of the spinal segments have upper limbs purchase levitra plus 400 mg otc. The tenth movement incorporates a series of • The twisting motions of the passive stretches levitra plus 400mg cheap, along a movements to manipulate the contents of the transverse plane, in some way address the segments abdomen. The practitioner is been mobilized in a superior, inferior and rotational instructed to break up adhesions in each of the fashion. Finally, the kidneys are manipulated • These segments will also have been treated for in a rotational fashion with varying pressure. Comment on visceral approaches • The musculature of the posterior shoulder girdle and The instruction to manipulate the internal organs cervicothoracic region will have been stretched and illustrates the evolution of professional lexicon over the kneaded. Manipulation can have a as individually in an inferior-oblique and superior- variety of meanings and, in this case, manipulation is to oblique fashion. The breaking up of adhesions is another manipulative technique pioneered in the first half of the 20th century as ‘bloodless surgery’. Chiropractic influences Fielder & Pyott (1955) compiled a rigorous academic The tremendous role that the chiropractic profession work in 1952, renaming the approach manipulative affords spinal mobility should be reflected upon surgery. Particular restrictions of the movement, over the kidneys, is said to affect all of should have been identified, with the option for the abdominal viscera. The movement certainly subjects these to be treated more specifically at a later a large area of the abdomen to a rotational traction and point in the treatment. The effect can be seen as a logical experienced practitioner would have begun to evaluate result of the pumping action induced by rotation and a larger pattern of tissue dynamics, due to the stretching of the vascular and lymphatic tissues, and the important region that will have been surveyed. The amount of time required for an stretching of the abdomen that included kneading experienced practitioner to reach this point of the along the length of the sartorius. This takes approximately 6–8 minutes, during which time movement involves a passive stretching of the almost every portion of the body will have received cervical muscles and prepares the lymphatic attention. These physiologic reactions rate and excursion constitute the response of the organism to some 2. Dysponesis relates to human health as a functional whole, rather than a sum of independent parts. Disturbed tone was considered the most ing homeostasis, via focused manipulative methods, readily observable manifestation of dis-ease. The other critical aspect is the can/must: concept of abnormal articular nociception and mechanoreception leading to hypertonic or hypotonic • improve circulation and drainage autonomic function. Instead, much mainstream chiropractic usually The naturopathic context operates on the assumption that spinal dysfunctions (vertebral subluxation complexes) have widespread In the context of a naturopathic therapeutic encounter, influences on health, correctable by manipulation. American Institute of The next chapter takes these themes forward, as Manipulative Surgery Inc. Fitz-Ritson D 1990 The chiropractic management and rehabilitation of cervical trauma. Journal of Manipulative and Physiological Therapeutics 13:17–25 References Foldi M, Strossenreuther R 2003 Foundations of manual Alcantara J 2002 Chiropractic care of a patient with lymph drainage, 3rd edn. Eastland Press, Livingstone, Edinburgh, p 131–141 Seattle Hovind H, Nielsen S 1974 Effect of massage on blood Biomerth P 1994 Functional nocturnal enuresis. American Academy 14(6):558–568 of Osteopathy Journal 7(4):25–29 Kent C, Gentempo P 1994 Dysponesis: chiropractic in a Chaitow B 1980 Personal communication to the author. Thorsons, Wellingborough htm Chaitow L 1980 Neuromuscular technique: a Kuchera M, Kuchera A 1990 Osteopathic practitioner’s guide to soft tissue manipulation. Churchill Livingstone, Edinburgh Larsson S, Bodegard L, Henrikssn K et al 1990 Chronic trapezius myalgia. Acta Clark R, McCombs T 2006 Postoperative osteopathic Orthopaedica Scandinavica 61(5):394–398 manipulative protocol for delivery by students in an allopathic environment. Churchill Livingstone, Edinburgh, Technique 10(2):75–78 p 31–66 Cordingley A 1925 Principles and practice of Lederman E 2005b Science and practice of manual naturopathy: a compendium of natural healing. Butterworth- Chiropractic Association: Proceedings of National Heinemann, Oxford 312 Naturopathic Physical Medicine Lief P 1963 Neuromuscular technique. British Rozmaryn L, Dovelle S, Rothman E et al 1998 Nerve Naturopathic Journal and Osteopathic Review Autumn, and tendon gliding exercises and the conservative p 304 management of carpal tunnel syndrome. Journal of Hand Therapy 11(3):171–179 Lindlahr H 1981 Natural therapeutics, vol 2: practice. Journal of the American Masarsky C, Todres-Masarsky M 2001a Osteopathic Association 93(8):834–838 Somaticovisceral considerations in the science of tone. In: Masarsky C, Todres-Masarsky M (eds) Stiles E 1977 Osteopathic manipulation in a hospital Somatovisceral aspects of chiropractic. Osteopathic Annals 7(1):35–38 In: Masarsky C, Todres-Masarsky M (eds) Tamir L, Hendel D, Neyman C et al 1999 Sequential Somatovisceral aspects of chiropractic. Churchill foot compression reduces lower limb swelling and pain Livingstone, New York, p 4 after total knee arthroplasty. Journal of Arthroplasty Mootz R, Dhami M 1994 Chiropractic treatment of 14(3):333–338 chronic episodic tension type headaches. Journal of the Walsh M, Polus B 1998 A randomized placebo Canadian Chiropractic Association 38(3):152–159 controlled clinical trial on the efficacy of chiropractic Nicholas A, Oleski S 2002 Osteopathic manipulative therapy on premenstrual syndrome. Journal of Vertebral of the American Osteopathic Association Subluxation Research 1(2):33–38 99(3):143–152 Wendel P c. Hemodynamic effects of osteopathic manipulative Behavioral Science 13:102–124 treatment immediately after coronary artery bypass graft surgery. American Association 105(10):475–481 Academy of Osteopathy Convocation presentation Perrin R, Edwards J, Hartley P 1998 Evaluation of the Williams P 1988 Effect of intermittent stretch on effectiveness of osteopathic treatment on symptoms immobilised muscle. Journal of Medical Engineering Williams P, Catanese T, Lucey E et al 1988 The and Technology 22(1):1–13 importance of stretch and contractile activity in the Radjieski J, Lumley M, Cantieri M 1998 Effect of prevention of accumulation in muscle. Journal of osteopathic manipulative treatment on length of Anatomy 158:109–114 stay for pancreatitis: a randomized pilot study. Wittlinger H, Wittlinger G 1982 Textbook of Dr Journal of the American Osteopathic Association Vodder’s manual lymph drainage, vol 1: basic course, 98:(5):264–272 3rd edn. Swiss ball training 396 Various models are presented – some established, Neural drive/survival reflex 397 some adapted and some new. In the production and presentation of new concepts, there is always poten- Parasympathetic enhancement exercises 398 tial for controversy. The logical progression of the Classical movement and rehabilitation discussion presented here is designed to allow you to approaches 399 feel at ease with these concepts, and to fit them into Nutritional considerations in rehabilitation 403 your current understanding of the functional human Viscerosomatic reflexes 403 organism. Hydration 405 As stated above, the primary objective of this chapter Model of dimensional mastery 406 is to provide a broader contextual framework within which you may fit current and future knowledge in The unified model of rehabilitation 407 the field of rehabilitation and movement re-education approaches. A secondary objective of this chapter is to provide useful applicable information to allow Before starting to read this chapter, it should be rec- naturopaths and other health care providers to coach ognized that the style is one of a story – a story of patients back to optimal function using foundational evolution and of how the human locomotor apparatus corrective exercise principles. This, it is proposed, as broad as the combined knowledge base and imagi- allows for a better understanding of how human bio- nations of all those involved in rehabilitation – and mechanics are supposed to function based on the therefore is an ever-expanding task – impossible to fit stresses to which they have been exposed and to into any textbook, let alone chapter. This approach also contextualizes the should be emphasized that these are simply useful many different rehabilitation approaches available – clinical models – and do not purport to be an ultimate each with its own merits and shortcomings. In this context then, it is hoped that you can Consequently, if you wish to use this chapter in develop your own truth, utilizing what fits with your more of a textbook, reference style, the contents list own model and leaving what does not. However, if you wish to Most importantly, the naturopathic triad – which is understand a bigger picture, and still want to use the the cornerstone of naturopathic medicine – is referred chapter as a reference source, the mindmap (Fig.

Changes at the tissue and cell level include improvement in oxidative metabolism in mitochondria and hypoxia-induced factor-1 sig- Diseases Related to High Altitude naling of vascular endothelial growth factor cheap levitra plus 400 mg with visa. The barometric pressure at sea level is 760 mm Hg order discount levitra plus on-line, The term high-altitude illness encompasses three whereas on the summit of Mount Everest (altitude conditions that occur as a result of acute exposure 8 cheap levitra plus 400 mg visa,848 m or 29,029 feet) it is approximately 250 mm to hypobaric hypoxia during rapid ascent in alti- Hg. Long-term exposure to high altitude may high altitude and low inspired oxygen that allows result in the development of chronic mountain minimizing effects of hypoxia. It is manifested by the physical examination may include tachycar- neurologic symptoms and signs such as headache, dia, mild crackles in the chest with auscultation, loss of coordination, ataxia, confusion, halluci- and peripheral edema. It has been reported to occur at altitudes Chest radiograph may show enlarged pulmonary 730 Diseases Related to High Altitude and Diving (Aksenov and Strauss) arteries and patchy or homogenous infiltrates that cabin pressures be maintained at pressures equiv- commonly involve the right middle lobe and both alent to altitudes less than 2,438 m (8,000 feet), lower lobes of the lungs. Medications that this, patients with underlying lung disease may can be used for prophylaxis include nifedipine, become hypoxic, and patients who are already dexamethasone, phosphodiesterase inhibitors, and receiving oxygen may require increased oxygen salmeterol. Symptoms can be patients who have a resting sea level Spo2 of 92 to reduced by oxygen administration, phlebotomy, 95% with additional risk factors, hypoxic challenge and acetazolamide. In general, an altitude diver should be screened with the use of stan- of 1,520 m (5,000 feet) is equivalent to Fio2 of dards similar to those for a sedentary person who 17%; 2,438 m (8,000 feet) to Fio2 of 15%; and decides to start a conditioning/aerobic exercise 3,048 m (10,000 feet) to Fio2 of 14%. If the States, according to the Professional Association predicted in-flight Pao2 decreased 50 mm Hg, of Dive Instructors, no mandatory medical exam- then supplemental oxygen is recommended. However, Professional Asso- Federal Aviation Administration rules do not ciation of Dive Instructors as well as other diving allow passengers to carry their own oxygen tanks certification organizations require candidates who or liquid oxygen on commercial flights. Patients should have a letter history questions are checked as being present, from a physician with an explanation of their then an evaluation and clearance by a physician medical condition(s) and their oxygen require- is usually required before the diving candidate is ments for commercial air travel. Deep diseases that would contribute to heart problems technical diving, surface supply diving, and satu- caused by the physical demands of diving and ration diving are not considered recreational types pulmonary overpressure syndromes with depth of diving and are not included in Table 1. For example, if the patient with anxiety ers also seem so be prone to plaque-like lesions in receives sedative medications, then he or she their brains and spinal cords that resemble those should not dive because (1) anxiety during diving seen in multiple sclerosis. Consequently, careful may cause rapid ascent and result in serious prob- neurologic screening of the commercial diver is lems (see next section) and (2) effects of sedative essential, and if there is any question of neurologic medications may be increased under pressure. These conditions significantly increase the risk are provided by the Association of Diving Contrac- of extraalveolar air (pulmonary overpressure) tor Standards (1994), the United States Navy, the syndromes. Epilepsy is also an absolute contrain- Occupational Safety and Health Administration, dication for all types of compressed gas diving the National Oceanographic and Atmospheric because of the risk of seizures from alterations in Administration, and the American Academy of the partial pressure of the breathing gases. Fluid vides a passage to the middle ear space from the may need to be drained from the middle-ear space back of the nasopharynx, whereas the ostia of the (tympanotomy). If a perforation occurs, the diver sinuses provide connections to the sinus cavities must not re-enter the water until the ear drum has and make it possible to equilibrate pressures in healed (ie, approximately 2 to 3 weeks) because of these structures. They may be caused by The ear and sinus cavities are lined with well- round or oval window ruptures or injury to the vascularized respiratory epithelium. The next stage (stage 2) in the are of three types: subcutaneous/mediastinal progression is leakage of fluid from the vessels into emphysema, pneumothorax, and arterial gas the middle ear space. It has been reported after breathing a resolve because the middle-ear space becomes a compressed gas from depths as shallow as eight fluid-filled cavity and the pressure differential is feet and then breath-holding while coming to the obliterated. Extraalveolar air syndromes are caused middle-ear space can cause vertigo, lead to disori- by air retention in the lungs either as the result entation, and generate uncontrollable panic. The air bubbles become pseudoephedrine) both orally and via nasal instal- emboli, are carried to the brain, and occlude its lation can reduce congestion and may allow circulation. First, medical screenings before starting during transport of the nitrogen released from the diving should be performed to detect asthma and tissues to the lungs and block circulation, bends other chronic lung conditions that may trap air shock or symptoms caused by the occlusion of the during ascent. Second, dive training to teach buoy- blood supply to critical organs such as the heart, ancy control and avoiding panic are essential to brain, and spinal cord occur. If the patient is alert, fluid administra- changes of pressure with descent and ascent alter tion and ingestion of a single dose of an antiplate- the partial pressures of the gases in the breathing let agent such as aspirin are recommended. For example, with a dive to a depth of 33 breathing helps to “wash out” the nitrogen, feet (10 m; equivalent to 2 absolute atmospheres whereas fluids and aspirin help to maintain the [atm abs]) the partial pressures of the oxygen and circulation of blood. In remote areas, returning to the water and ily, this has little effect on oxygenation of tissues, breathing pure oxygen at a depth of 33 feet and but if the pressure is increased 10-fold, the then gradually ascending, although controversial, increased Po2 could lead to a seizure as the result is recommended by some authorities in diving of oxygen toxicity. The rate of on-gassing (process of gas recompression treatment, repetitive treatments entering the tissue due to the increased pressure) should be administered until the symptoms resolve depends on depth (pressure gradient), duration, completely or plateau over a 3- to 7-day period. Factors such as fitness, adequate hydration, ability of the tissue to off-gas (process of gas and following dive computer (or dive tables) pro- leaving the tissue due to the decreased pressure) files are fundamental to safe diving. Aspiration often is associated beverages during the dive activities; and (7) and with drowning because the breathing reflexes are using common sense to avoid interfering with the usually the last to remain after a hypoxic injury orderly off-loading of nitrogen; for example, not to the brain. Whereas aspiration and the resulting lung injury Other Indirect Effects of Pressure: Nitrogen Nar- can be managed effectively with appropriate cosis, Oxygen Toxicity, Carbon Dioxide Toxicity, Car- interventions, the consequences of hypoxic brain bon Monoxide Poisoning, and High-Pressure Nervous injury are usually irreversible and can range from System Syndrome: These problems occur infre- imperceptible to a persistent vegetative state. Additional Problems Associated With Indirect Effects of Pressure Condition Etiology Symptoms Management Prevention Nitrogen narcosis, Narcotic effects from Confusion, irrational Ascent; the dive buddy Adhere to safe depth ie, “rapture of the breathing this gas actions, stupor, synco- needs to control the limits ( 130 feet). Carbon dioxide Increased carbon diox- Headache, increased Ventilate by breathing Strict adherence to toxicity ide from problems respiratory rate, feel- fresh air. Carbon monoxide Contamination of air Headache, confusion, Surface; breathe pure Ensure gas supply poisoning supply with exhaust collapse, syncope, oxygen; hyperbaric is free of fumes from internal coma, and death oxygen; contamination. The secondary effects serving effects of the diving reflex and hypothermia include, but are not limited, to the following: (1) from immersion in cold water. Remarkable recov- vasoconstriction to reduce posttraumatic edema; (2) eries have been reported from near-drowning, even enhancement of host factor functions such as fibro- after the victim has been immersed for 30 min. Once the primary cause is augmentation of certain antibiotics; (4) mitigation identified, appropriate management becomes logi- of the reperfusion injury by perturbing the neutro- cal. In addition, concurrent optimal management of the pulmonary and brain injuries The following 13 indications are approved uses from near-drowning must be administered. Treatments may be performed in a single-per- • Enhancement of healing in selected problem son chamber (monoplace) or multiplace chamber wounds; (ie, may hold two or more people). The book is divided into parts by the stages of pregnancy, within which the authors cover four main areas: ∑ the balance of power in the doctor–patient relationship and the justiWable limits of paternalism and autonomy; ∑ the impact of new technologies and new diseases; ∑ disability and enhancement (the ‘designer baby’); and ∑ diVerence – to what extent the clinician should respect the tenets of other faiths in a multicultural society, even when the doctor believes requested interventions or non-interventions to be morally wrong. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. The chapter by Cynthia Daniels is adapted and enlarged from her article ‘Between fathers and fetuses: the social construction of male reproduction and the politics of fetal harm’ (1997), in Signs: Journal of Women in Culture and Society, vol. Cynthia Daniels would like to thank Sam Frost, Robert Higgins, Suzanne Marilley and Linda Zerilli for their helpful comments and assistance on her chapter. In the second chapter, Carson Strong comple- ments this introduction by suggesting a normative framework for use in debating issues in reproductive ethics generally, and maternal–fetal ethics in particular. Another less familiar way of phrasing this tension, as Jean McHale puts it in her chapter (6), is in terms of two dominant but conXicting rhetorics – ‘choice’ versus ‘responsible parent- ing’. If there is no such thing as disability per se, in the extreme version of this view, then we must question the basis for interventions aimed at reducing disability in populations or preventing the birth of a ‘handicapped’ child to a particular couple. Similarly, at the other end of the scale, if ‘normality’ is not a clinical but a normative concept, what do we do about the desire to have children who are in some way ‘better’ than ‘normal’? To what extent must the clinician respect the tenets of other faiths in a multicultural society, even when patients or their families request inter- ventions which the doctor believes to be morally wrong?

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They have also difficulties understanding questions so questions should be asked in simple language order levitra plus online from canada, using short sentences cheap levitra plus 400mg overnight delivery, appropriate to the adult’s developmental level buy levitra plus 400 mg free shipping. The assessment may need to be repeated, and longer periods of time may be needed for answers to be given and understood. While minimizing the tendency to acquiescence is a skill that has general applicability to any psychiatric interview, it is particularly important in this population. The attitude of anyone being interviewed is likely to be influenced by expectations of the interaction. It is therefore important for the interviewer to maximise the patient’s confidence and sense of security by extensive explanation of the purpose of the interview as well as constant reassurance. Therefore it is important to recapitulate and summarize previously stated material. This has the benefit of re-engaging and focusing the patient’s attention as well as giving an opportunity to collect more detail, in addition to allowing the patient to agree or disagree with the interviewer’s interpretation of what has been said. If doubt exists about the meaning of responses, it is very important to clarify with the help of a carer or family member who knows the patient well. Obsessional symptoms: it is very difficult to obtain a clear description of obsessions being the product of a person’s own mind, for example. Resistance is often found to be minimal, especially if the obsessions are long-standing. It is also significant to remember that the content of the delusional beliefs is usually developmentally appropriate for the person’s overall ability. Sometimes, beliefs that, on the surface, appear to be delusional, may simply be a reflection of overall cognitive development of the patient. In general, complex psychotic symptoms such as delusional perceptions are infrequently found, due to the difficulty in eliciting such phenomena in people with limited verbal and intellectual skills. A careful assessment, with collateral information, will help distinguish these presentations. A functional analysis of behaviour is frequently needed to ensure accurate diagnosis. Diagnosis and Diagnostic Classification Assessment aims not only to detect the presence of psychiatric illness and make a diagnosis, but also to identify the features that make a person vulnerable to them. Any therapeutic interventions must take into account a number of factors, including the patient’s wishes, the diagnosis and vulnerability factors including psychological (for instance characteristic ways of thinking), biological (such as genetic predisposition or medication) and social (including environmental factors). Some of these vulnerability factors (such as brain damage) cannot be changed, but others (such as an optimal control of Epilepsy) can and should form part of the care plan. Many of the factors are the same as in the general population and it is their interaction that is important in creating the particular vulnerability to developing mental illness. It is also essential that the development and delivery of clinical services hold what is known as prevention and minimization of those disturbances. Bizarre velocardiofacial syndrome behaviours and adaptive regression can occur Bipolar Affective More common than general It can be diagnosed whatever the degree of Disorder population disability. Recording behavioural correlates of mood can help to establish the cyclical nature of the disorder, and be used to monitor treatment. Dementia More prevalent than in general Psychotic symptoms and epilepsy may be a population (14% v. Strong association with Down’s those over 65) syndrome, where it presents earlier. Tuberous Sclerosis and echolalia, pronoun reversal), stereotyped patterns phenylketonuria. Point prevalence rates of psychotic disorder (including schizoaffective disorder) have been found to be 5. The symptoms/signs are not a direct consequence of any other psychiatric or physical disorder or a result of prescribed or illegal drugs or alcohol. Impossible/fantastic delusions (delusions that are culturally inappropriate and completely impossible). Thought insertion or withdrawal or broadcasting, or thought echo or delusions of control, influence or passivity, or delusional perception or hallucinatory voices giving a running commentary. One of following present for most of the time during one month, or some time every day for at least a month: a. Negative symptoms, where there is definite evidence that this is a change from the individual’s premorbid state. Disordered form of thought, where is definite evidence that this is a change from the individual’s premorbid state. An adequate mental health assessment should always take into account the individual’s developmental level and it should include a history from the patient and a mental state examination, a detailed collateral history and a risk assessment. These are useful tools as general indicators but less useful at determining the nature of the illness (http://www. Regression to increased dependency, psychomotor agitation, increased irritability, worsening of existing behavioural and self-injurious behaviours, reduced communication and social isolation, catatonic features and visual hallucinations are more common in this group. Changes in affect and activity levels can be observed and reported by people with mania and mild to even very severe intellectual disabilities and their carers. In Down’s syndrome, mania is very uncommon among women, whereas in the general population the male: female ratio is equal. Interestingly, those with Down’s syndrome less frequently have a positive family history. Similarly, cyclothymia (persistent mood swings not meeting severity criteria for affective disorders) has as yet received little attention in this population. High levels of anxiety are thought to be part of the behavioural psychiatric phenotype in William’s syndrome. Obsessive Compulsive Disorder Compulsive behaviours have reported frequencies of 3. Compulsions are significantly associated with stereotypies and self-injurious behaviour. Obsessions and compulsions can arise in a number of disorders other than obsessive–compulsive disorder, such as depression and pervasive developmental disorder. Some specific stereotyped movements have been associated with disorders such as Rett syndrome (hand-wringing movements in front of the body) and Smith–Magenis syndrome (body self-hugging, self-biting). Although obsessions and compulsions may need pharmacological treatment in individuals with Prader–Willi syndrome, the effectiveness of serotonin reuptake inhibitors in the treatment of stereotyped movements in Rett syndrome and Smith–Magenis syndrome is less established. The risk of posttraumatic stress disorder and adjustment disorder is therefore likely to be significantly increased. In the acute phase, management usually focuses in accessing services, ensuring safety of the patient and others and initiation of medication. After resolution of the acute phase, management is more likely to focus on maintaining good mental health, insight-related work and relapse prevention planning. Treatments should be tailored to the individual, and so take into account any co-existing medical conditions such as epilepsy, other drugs being taken and any other particular requirements.

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This search for information purchase 400 mg levitra plus with amex, conducted before suggesting or applying • What is the appropriate initial treatment for this corrective measures generic 400 mg levitra plus fast delivery, would seem to offer a more situation? The transmission of these responses to the • How do these findings equate with the evidence brain order levitra plus 400mg with visa, and gathered from the Zink and Lawson (common 3. The interpretation or analysis or perception of compensatory pattern) assessment (see pages 138/139) the information. Clearly, if any aspect of these operations is distorted • What whole body, constitutional methods might be or inaccurate, the conclusions drawn from them are most suitable for this individual, rather than likely to be suspect. Numerous examples exist of poor inter-examiner reliability in use of palpation and motion assessment The following paradigm may be found to be con- detection of spinal (cervical or elsewhere) dysfunc- structive when making clinical decisions: tion. There are, however, also examples of excellent • Identifying the physiological status of the tissues assessment outcomes (Christensen et al 2002, Downey and the context in which these exist + et al 2003, Gibbons et al 2002, Mior et al 1985). Whether interpreting symptoms • Rational, effective, evidence-based treatment and signs, radiographic evidence (Aprill & Bogduk choices. Questions 1 and 2 relate to the type, location and condition of the tissues involved, and palpation is central to answering these questions. Posing questions to the body Question 3 is about identifying the process that may have led (or contributed) to, or that is maintaining, All motion testing represents the posing by the exam- this state. For example, the of tissue texture cues at rest, as well as during gentle answer to ‘Why is this knee restricted? This is detective work, physiological disturbance, or adaptation, in the tissues seeking information from witnesses that can only being palpated. This recognition will assist in making offer information in a minimalist manner – Yes? In this way skilled palpation whether appropriate answers will emerge, for clearly, and observation can contribute to improved clinical assessment of flexion potential in the wrist will tell choices, and therefore of results. Chapter 5 • Assessment and Palpation: Accuracy and Reliability Issues 105 The way the question is phrased, i. Palpation and observation is a process of Authors in the field of manual therapy claim that mining for data, not a process of proving one’s suspi- intervertebral dysfunction – known as somatic dys- cions correct. We need to use the unconscious, non- (DiGiovanna & Schiowitz 1997, Gatterman 1995, judgmental mind (more right-brain function) to gain Greenman 1996, Grieve 1981, Kappler 1997, Kuchera unbiased information, and then switch to the con- et al 1997, Leach 1994) – can be detected by skilled scious, decision-making mind (more left-brain func- manual palpation (DiGiovanna & Schiowitz 1997, tion) to interpret the data. Jull et al suggest that one reason for the often reported Given the traditional time frame for assessment ‘fair to poor’ reliability of motion palpation in the (30–60 minutes maximum), arriving at accurate neck region (DeBoer et al 1985, Mior et al 1985) is that answers to these questions may be extremely difficult repeated, consecutive palpatory procedures might to achieve – particularly if the clinician has a holistic alter joint play within the cervical spine, and therefore understanding of biomechanics. This underlines the need for minimal contact when For example, watching someone do a full squat means palpating and as few repetitions of active or passive that you have multiple joints and body segments cou- movements as possible. This means that a pattern of restriction or asymmetry, sometimes employing radiographic dysfunction becomes magnified by the attempted analysis to determine positional asymmetry (Leach coupling of multiple joints (this is the premise in prep- 1994). Hence there are referred to in manual therapy literature to define rafts of sports people and members of the general ‘somatic dysfunction’, biomechanical dysfunction public who manifest ‘dysfunction’, and unless cor- or ‘chiropractic subluxation’ (DeBoer et al 1985, rected it is just a matter of time before that dysfunc- Greenman 1989, Kappler 1997). Pain thresholds differ from person to person, and in the same person, depending on, among other things, How valid are these components of how worried the person is about the pain, and what dysfunction, and how accurately they meaning they ascribe to the pain (Jensen & Karoly can be assessed by palpation? A study by Jull et al (1988) concluded that manual A stomach-ache after overeating will be less worry- diagnosis, performed by an experienced manual thera- ing than a stomach-ache that has no obvious cause, pist, was as accurate at identifying symptomatic cervi- especially if someone you know has recently been cal zygapophyseal joints as diagnostic nerve blocks, diagnosed with abdominal cancer! While one person may report a muscle or joint as Whilst results for determining the inter-examiner being ‘painful’, another might report the very same reliability in detection of cervical spine dysfunction joint as ‘uncomfortable’. There are cultural as well are promising, there remains a continuing need for physiological, ethnic and gender reasons for this studies that investigate the reliability and validity of (Hong et al 1996, Melzack & Katz 1999). When Since only one of these factors needs to be present for other findings are made, a pain report by the a diagnosis of dysfunction to be made (Jones 1997), patient can positively complement the practitioner’s dysfunction can be present before the advent of pain. This, then, is of greater application in preventive medi- cine, rather than just reactive work – which, of course, is where most of our time as therapists is spent. Tissue texture Most studies of athletic/sporting injury rates only Fryer et al (2004a) report that little direct evidence reflect the ‘tenderness’ or pain component of dysfunc- exists for the actual nature of abnormal paraspinal tion, as subjects are generally only considered ‘injured’ tissue texture detected by palpation, and note that if they miss a competitive match, miss a training palpation for tenderness is more reliable than palpa- session or report to a clinic with pain. In 1993, Cassisi et al disagreed, stating that there was The relevance of abnormally increased muscle activ- little direct evidence to support the existence, or ity to paraspinal regions that are tender, and that feel nature, of paraspinal tissue texture change that was abnormal to palpation, remains untested, but it is fea- claimed to be detected with palpation. The concept of sible – indeed probable – that increased muscle activ- segmental reflex paraspinal muscle contraction had ity would be detectable with palpation, and possibly not at that time been supported, they said, at least in that the act of palpation itself might provoke further association with low back pain. Ten years later the evidence has changed, and it safe Actual structural modifications may be present, as to say that their supposition was incorrect. They observed It seems that tissue texture changes and tenderness marked wasting on the symptomatic side, located at can indeed be located by palpation, if they are present, just one vertebral level. And there is clearly asym- range and quality of motion of a joint, as it is moved metry involved, and, as Fryer et al have shown, the both actively and passively. Subsequent palpation of the shortened or descriptors you give them), perceived during palpa- lengthened structures associated with such an imbal- tion of active or passive movement, is clearly at ance might reveal altered tone and/or abnormal least as important as being aware of the variables texture and/or tenderness. Does the ‘restricted, hesitant’ movement page 184) creates a level of inevitability of tissue indicate pathology? Is the end-feel: compensatory postural changes to accommodate the • normal but soft? Or is there a pathological end-feel such as help they have compensated several times from the reduced elasticity – relating perhaps to scar original ‘dysfunction’ until, eventually, their body is tissue? Like that famous end-feel because the movement has been analogy of ‘peeling an onion’, the skilled practitioner stopped by the patient, perhaps to avoid pain must now trace back through the patient’s history or because of psychological reasons (their biography) and through their biomechanics (Kaltenborn 1985, Mennell 1964)? As Myss (1997) states, ‘your biography suggest structural, neural, psychological, becomes your biology’. This suggestion, however, has no ground- achieve literacy in this subjective, interpretive skill. Physiological principles dictate that relative symmetry is not only a require- Malalignment implications – ment for functional biomechanics (see discussion of including visceral ‘Laterality’ in Chapter 9) but also for attractiveness and reproduction (Enquist & Arak 1994), something Schamberger (2002) has condensed much of the dis- noted by Darwin (1882) in the 19th century. If, due to overuse or misuse (or process that needs to be evaluated and understood, if disuse), specific muscle groups shorten or lengthen the patient is to be helped towards recovery and over time they will reciprocally influence their antago- prevention. Sahrmann (2002) describes the malalignment concept Whether the palpating hands, or observation, deduce of Schamberger using standard biomechanical descrip- changes in tissue texture, increased sensitivity, asym- tors. She explains the importance of maintaining the metry (malalignment) or altered range of motion is optimal instantaneous axis of rotation of any given less relevant than an understanding, not only of the joint. The end result is that the cumulative micro- More examples of palpation stress evolves into macro-strain. Palpation may have issues with accuracy, and to a lesser extent Did the chicken cause the egg or with precision, but it is real-world. Other more ‘high-tech’ Since 85% of patients attending for orthopedic con- methods of assessment bring with them their own sultation describe having no specific onset of symp- flaws; as Gracovetsky (2003) delights in pointing out, toms (Vleeming 2003), experience suggests that these x-ray and other imaging techniques cannot, for emerge from a process of functional imbalance that, example, distinguish between the spine of a living perpetuated over time, emerges as symptoms as patient and a cadaver! For example, the upper crossed syn- information about structure and only loose assump- drome (see page 183 for description and Fig. Since individual tests are frequently unreliable as a The criteria used to decide relative dysfunction, basis for a decision regarding manipulation, the use during anteroposterior pressure on the spinous of a cluster of indicators clearly offers more reliable process, were: evidence than any single piece of evidence on which to base any clinical decision regarding high velocity • abnormal end-feel thrust manipulation or other specific attention to the • abnormal quality of resistance to motion implicated segment.