Objectifying SOT Palpatory Indicators

Ano: 2015 | Volume: 6 | Número: 1

Autores: John Crescione, D.C. D.I.C.S.

Resumo Inglês:

Introduction

Many practitioners of chiropractic have no longer developed the skill and desire to actually palpate to the level of what would be considered necessary and basic, let alone to a high degree of skill.
With the advent of muscle testing and therapy localization, there becomes less of a need for palpation skills. However, the objectivity of certain indicators becomes even more subjective and the ability to palpate the body becomes a lost art.
Highly skilled palpators within the SOT world have developed their skills so that they can tell if a dime is heads or tails through a blanket. SOT doctors, especially Craniopaths, have spent a huge amount of time being able to feel the slightest motion. This can range from an organ’s restriction of movement, to a cranial fluid flow within the skull, microwave radiation, heat or energy coming off the body.

Manual muscle testing of the kinesiological type of Goodheart, Walther and others has become a valuable diagnostic tool for the average clinician. It is both visual and reproducible for the Dr. and patient. The built in objections of Voodoo, party tricks and being too subjective demeans many that have used and relied on the skill.
Manual muscle testing has a number of different models as to why there is a weakening or delay in muscle reactivity. None have been accepted by mainstream medicine as well as some circles of chiropractic. Unfortunately in the medical model-even within chiropractic-palpation skills can be just as non-objective as muscle testing based on inters examiner reliability. Palpation as an objective indicator can only be compared using time and experience. Someone with 10 years of training, or for our example, a certified Craniopath may have superior skills
at palpation then someone with 10 years in muscle testing.
Until the Dr. can develop these higher level skills, or by trying to eliminate muscle testing as an indicator, an alternate approach in training needs to be obtained. The attempt of using palpatory indicators is a challenge, forcing doctors to feel the changes within the indicator muscle.
The Challenge
Webster's dictionary defines a challenge as a calling into question, or a demand for identification. For the chiropractor it is done through touch from the Dr. or the patient, subjectively or objectively. Any place on the body can be challenged. Usually vertebral segments but also cranial bones, extremity joints and the viscera as well. It may be as simple as "Does this hurt when I press here?"
Or it can be more involved.
The patient or Dr. may touch an area of the body while the Dr. looks for any changes within the chosen indicator.
This indicator can be anything that will respond to the touch of the “challenged” area. Muscle strength change or leg length change is the most commonly used for the measure of outcome result. In order to understand the SOT challenge, we need to look at how muscles work.
Muscles
Muscles move bones. Upon contraction, muscles move from their origin and insertion and meet in the middle. Stabilize the origin, and the muscle will contract towards the origin from the insertion, for example a standing biceps curl. Stabilize the insertion, and the origin moves toward the insertion, as in a chin up. Muscles have both elastic and contractile ability. The Golgi Tendon Organ, Muscle Spindle cells and specific nerve tracts firing from excitation of the muscle by the anterior motor neuron are responsible for some of the muscles' attributes.
Muscle spindles are found within the belly of the muscle and report back to the nervous system about the length of the muscle, or its rate of change of length.
Golgi Tendon Organs send information about the rate of tension or amount of tension in the muscle and are found where the muscle tendon attaches to the muscle fiber
.Again, the muscle spindle monitors length, and has an excitatory function- the Golgi Tendon Organ, tension and inhibitory. Both have a dynamic and static response that we need to look at within the stretch reflex and tendon guard reflex.
The stretch reflex simply stated is that whenever a muscle is stretched, it causes an excitation of the spindle cell, which causes it to contract reflexively. The dynamic stretch reflex of the muscle spindle occurs when a muscle suddenly becomes stretched, causing an instantaneous, strong muscular contraction. Once the stimulus has ceased, the contraction relaxes and the muscle adjusts to its new length. However, a secondary reflex, the static stretch reflex initiates or continues afterward for a prolonged period of time.
It causes continuous muscle contraction as long as the muscle is under excessive stretch.
This becomes important in both palpating and determining the direction of challenge.
The Golgi Tendon Organs dynamic stretch response occurs when the muscle’s tension is suddenly increased in a small period of time. There is also a static response, which occurs to a normal degree of steady state firing when under normal tension.
This reflex is inhibitory, which means that it prevents too much tension in the muscle by lengthening or relaxing the muscle. This is called the lengthening reaction and is a protective mechanism to prevent the muscle/tendon being avulsed from the bone. If the tension is too great, the muscle will relax due to inhibition from the tendon organ. If there is too little tension, impulses from the tendon organ ceases and then loss of tension or inhibition allows the alpha motor neurons to become active, firing muscle tension to a higher level.
To illustrate an example of clinical function, when we palpate for Cat. 2 (Sacroiliac hypermobility) indicators, the medial knees, lateral legs and upper and lower inguinal (fossa) areas are checked for fibrositis, swelling and edema, muscle "spasm" and reactivity.
Using a right short leg model, upon examination the right upper inguinal area was taut, fibrous and reactive to palpation, and the medial knee on the same side was also found to be taut, fibrous, swollen and reactive to palpation.
Conventional mainstream Medical and Chiropractic wisdom concludes that the sartorius and pes anserine muscles would be in a state of spasm-pulling the Illium to the anterior.
In S.O.T. however we see it as the opposite-because the weight bearing integrity of the Sacroiliac joint has been lost, the Illium on that side has gone towards the posterior (generally) and/or Sacrum slipping to the anterior. The separation of the Sacrum to Illium causes a reactivity and contraction of the anterior thigh muscles to pull the Illium toward the anterior and over time cause the gluteals and hamstrings to shorten due to length approximations between the Illium and knee.
The above is common knowledge and thought process to most in S.O.T.. Why is this conventional S.O.T. wisdom not carried over to the spine, joints, cranium and visceral system?
With an understanding of the reactivity of muscles and the compensatory effects, the practitioner can solve most patient problems quite easily.
Simply stated, the SOT Challenge is to test direction and vector against the best or most appropriate indicator until the indicator is cleared.
The "best" or appropriate indicator is usually found within the respective Category. Or, use a Cat. 2 indicator to correct against the challenge if the patient is a Cat. 2.
What follows are a few examples...
Categorization
One of S.O.T.'s hidden strengths is in determining just when and what to do first to the patient. Even here, traditional S.O.T. procedures can be challenged without the use of Mind Language, Therapy Localization or Muscle Testing.
Posture Analysis
Most think of this as looking for sway. But DeJarnette's written works up until the 70's placed a huge emphasis on posture, or distortion analysis to find subluxations and subluxation patterns. Chiropractors today really do not rely on a standing visual analysis to determine levels of subluxation, as do experienced SOT'ers. With the advent of the S.A.M. units now in vogue, which combines a scale with a Posture Analyzer, the Chiropractor of today uses this as a patient education tool, more then as a diagnostic one.
For the purposes of this paper, we will confine this huge subject to the Category system.
DeJarnette emphasizes checking many of our indicators against gravity, since man has to fight it constantly.
1) We stand and look at the patient. After sway is noted-absent, present and to which direction, we check rib head motion-standing.
2) If the patient seems to indicate a Cat. 2 as the primary subluxation pattern, the Dr. must ask the next question, which is "Is the Cat. 2 coming from an extremity, or pelvic lesion?"
Dr. Nelson Decamp of Florida uses a wonderful story of a patient complaining of recurrent foot pain, and upon posture analysis found the patient was weight bearing on the same side as foot pain!
This indicates a greater stress and problem on the other side of the body, with the patient’s foot complaint becoming a symptom of the weight bearing lesion on the other side.
3) Next have the patient seated and recheck the rib head motion. If the ribhead's motion stays the same, on the same side this would indicate that the weight bearing lesion is in the pelvis as the primary, since the other weight bearing extremities, such as knees and feet, have been eliminated.
4) Had the ribhead switched sides, for example, standing-right rib head-seated, left ribhead; at this point, a conclusion of an extremity problem causing the weight bearing shift including the TMJ could be the cause. To eliminate the TMJ, have the patient open, close, swallow, bite and translate to both sides while checking for ribhead pain and motion. If any one motion increases or decreases pain you have a positive indicator for the TMJ involvement and probable direction of correction.
Arm Fossa Test (AFT)
The best or worst test in S.O.T., according to who you speak to.
Based on the above results, we have noted a lateral sway (or shift) with unilateral ribhead motion and pain. When placed supine to do the AFT, no clear change in any of the fossa is present. There may in fact be upper fossa pain and swelling on one side, and lower fossa pain and swelling on the other. The medial knee and lateral leg indicators all agree, as do the long and short leg. Why then, is there no positive arm fossa? If we factor out the Dr.'s skill at the test, it may be that the patient is in a state of adaptation and guard. In order to challenge the AFT, we must exacerbate the suspected lesion. This will cause both the muscle spindle and Golgi Tendon Organs to fire. The Arm Fossa Test is a neurologic timing test that compares the anterior ligament (inguinal) proprioception of the pelvis, with the posterior ligament proprioception of the pelvis. A very basic explanation of the neurology is as follows.
The attempt of the AFT is barrage the CNS with 3 commands, testing both upper and lower motor neurons.
Pulling on the arm (lower motor neuron stimulation/response) involves the Spinothalamic tract and Fasiculus Cuneatus up into the Medial Lemniscus and Ventral Posterior Lateral Lemniscus.
Touching the inguinal ligament stimulates the Spinothalamic tract and Fasiculus Gracilis into the spinal cord at L1/L2. Traction on the inguinal ligament stimulates posterior ligament proprioception in at S1/S2. Both touch and traction pull meet in the lumbar spine and travel up in a parallel pathway to the Medial Lemniscus. Both enter and meet in the Ventral Posterior Lemniscus.
The command “Hold” (which is upper motor neuron stimulation) activates the collateral tracts and connects to the inferior colliculus, a branch of the medial lemniscus, which goes to the Ventral Posterior Lemniscus. All three meet and create an overload if there is a problem.
The Arm Fossa Test tries to elicit a defense reaction by a barrage into the Ventral Posterior Lemniscus. It must now handle multiple impulses, the result of which is neural fatigue.
The fatigued system must now have time to repolarize, which takes time and causes a delay. This results in the apparent “weakening” of the arm and a “positive” Arm Fossa Test.
Here is an example.
The patient complains of low back pain. Exam revealed a left lower Fossa swelling with lateral leg pain on the long leg side and unilateral rib head-yet no present AFT. The patient's right foot is placed on the table, knee bent. The fossa is then rechecked. If there is no change, the left foot is dropped off the side of the table and then rechecked.
If still negative, the right leg is placed on the table while the left remains off and then rechecked. One of the positions should reveal a positive arm fossa that will correlate with the other findings.
Another variation of this is for the patient to plantar flex the foot as far as possible on the suspected long leg side, or dorsiflex the foot on the suspected short leg side. This variation may expose an extremity subluxation within the Cat. 2 complex as well, while still presenting a positive AFT.
In difficult cases the legs may need to be placed in a long leg/short leg position to bring out the positive arm fossa.
Rib Head
Sometimes the ribhead as an indicator can be, well, a pain in the neck! In Cat. 1, Cat. 2 and Cat. 3 work, monitoring of the rib heads is of major importance. Whether for completion of our procedures for that office visit or as a monitor of degree of improvement, the ribhead is usually given great importance.
In the case the above Cat. 2 patient, anything can be challenged against the ribhead.
If the patient has been blocked Cat. 2, the standard blocking procedure may have improved but not eliminated the rib head. Subsequent visits still have not been able to eliminate the rib head, in spite of all auxiliary Cat. 2 pelvic/spinal procedures. At this point other pelvic investigation may be warranted, or extremity (or both).
For example, with a left ribhead present, a vector can be challenged to negate the rib head the same as in the AFT previously described. Using the left leg, place it into the bent, long leg position of long leg/short leg correction test. This is the orthopedic test, the Fabere (Flexion, Abduction, External Rotation, and Extension) Test. This is also an exacerbation of an IN Illium, using the familiar Gonstead listing. Should that fail to improve the rib head, then go into then other direction and challenge again? The leg is placed in the short leg position, or an EX Illium position, Gonstead listing, which is also the orthopedic POSH (POsterior SHearing) test. If one of the pelvic positions corrects the rib head, the pelvis is then adjusted into that vector.
Occasionally, the Illium on the side opposite the ribhead will be the cause. Therefore, challenge that Illium against the active rib head for the correct pelvic correction.
In some instances, it will not be the pelvis at cause. In which case the extremity system should be investigated first.
Continuing on the same vein, with the left ribhead present and pelvic involvement ruled out, we use the knee as an example.
Besides the normal SOT protocol for determining what type of knee subluxation is present, one component often overlooked is anterior/posterior translation between the distal femur and proximal tibia. This will involve both upper and lower leg and the anterior and posterior cruciate ligaments as well.
Using the above left ribhead, once palpated, the distal femur and proximal tibia are translated in opposite directions. The ribhead is checked again. If no change, then the joint is challenged in the other direction; if a translation subluxation is present, the ribhead will clear, or improve.
Correction can be done by impulse in opposite vectors, drop table or single block according to the vector that negates the ribhead.
Translation may also occur in a lateral/medial direction as well. The patella itself may also become subluxated and will respond accordingly to the ribhead. All directions must be checked. The easiest fashion is to start at relative 12 o'clock, then proceed to 6, 3 and 9, or any combination thereof. It is important to note that a straight ceilingward direction also can be challenged.
SOTO
This procedure is commonly used in Cat. 3 and sometimes Cat. 1 for Sciatica. It is also used to attempt to diagnose the reason for the patient's leg pain-whether muscular, structural or disc related.
In all of DeJarnette's early work with postural distortion, one method he used quite frequently was to have the patient do a standing SOTO test and then see if the muscular postural distortion had changed. In fact, as told to most in SOT, the "invention" of SOTO was DeJarnette's observation of patient's with sciatica entering into his office in the SOTO position to alleviate the leg pain.
When discussing SOTO, we first must look at the piriformis muscle. Mainstream consciousness says that a spasm in the piriformis will pinch the sciatic nerve. From a SOT standpoint, we propose that is a stretched or lax piriformis is crowding the sacro-sciatic notch, and putting pressure on the sciatic nerve.
What is important to the above article is that the piriformis muscle and the SOTO test can be challenged against the ribhead whether in Cat. 1, 3 and 2.
In a Cat. 1 with bilateral rib tenderness and motion - with or without sciatica - the piriformis muscle may be involved with the sacrum and/or the sacral boot mechanism not functioning properly.
Since there are bilateral rib heads, either side can be used, but generally we start with the short leg side first. As in most things SOT, off the blocks is the test, on the blocks the correction. So with a right short leg and bilateral rib head pain before blocking, SOTO is performed to the right leg. The rib head can be palpated while in SOTO or immediately upon returning the leg to the table. If the ribhead remains painful, COTI is attempted and the ribhead rechecked.
If the ribhead still remains painful, the piriformis muscle is not involved on that side of the Cat. 1. Repeat procedure on the other side.
There have been occasions with Sciatica, where it will be necessary to move the piriformis muscle on the opposite side of the sciatic leg, instead of the sciatic leg side. This usually occurs with a lumbar disc involvement or a structural pelvis problem within the sacrum or illium that is causing the leg pain.
Conclusion
These have been a few examples of how to challenge a problem and look for a reasonably objective and reproducible answer to the patient’s complaints by utilizing SOT indicators.
Our mainstream indicators such as Trapezius and Gluteal fibers can be vectored to determine the side and angle of correction against their respective fibers. In the Lovett Brother R + C Technique, the lumbar related cervical indicator is always checked by vector of correction in its associated lumbar spinal segment.
So the next time the patient presents with a tight Erector Spine on one side of the body, you must now ask, ”Is the muscle in spasm, or in defensive physiology in the other direction?”
Now you have the basis for investigation. Challenge the indicators to get your answer.
If we may borrow a line from the Bogart movie, “Treasure of Sierra Madre”.
As far as SOT’ers is concerned,” We don’t need any stinking muscle tests

REFERENCES:

Carpenter, Malcolm B., M.D. Core Text of Neuroanatomy. 3rd ed. Williams & Wilkins, Baltimore, Maryland, 1985
DeJarnette, MB.DC. Sacro Occipital Technic of Spinal Therapy, Privately Published, Nebraska City, Nebraska, 1940.
DeJarnette, MB. DC. Sacro Occipital Technique. Privately Published, Nebraska City, Nebraska ,1984.
Guyton A. MD. Textbook of Medical Physiology. W.B. Saunders Co., Philadelphia, PA., 1981.
Neufeldt, V., Ed. in Chief. Webster’s New World Dictionary. Simon & Shuster, New York, N.Y., 1988.