The following exchange took place on an online Chiropractic forum.
It has been edited in order allow for the confidentiality of those who
participated in this exchange other than Dr. Nicholas Spano. Dr. Spano's
first message was in response to a post that discussed the lack of inter-examiner
reliability of Motion Palpation.
Thank you for this further exposure of Motion Palpation's shortcomings.
It comes as no surprise that even the best (presumably) Motion Palpators
can not document inter-examiner reliability with Motion Palpation as the
coupling patterns of a Functional Spinal Unit would be infinitely too complex
to discriminate accurately to begin with, but to then add the changing
tensions and reflexes of the overlying tissues as the spine is put through
even a seemingly simple range of motion would virtually eliminate any practical
value of this method for spinal analysis. Whereas I am finding extremely
promising inter-examiner reliability with muscle palpation among novices.
Before you ask; I have not yet done a study to demonstrate my claim and
so I expect that some will be skeptical and understandably so. I am planning
to do an inter-examiner reliability study this summer with Chiropractic
students who will be exposed to this method for the first time and as with
every other group that I have introduced to this work, we can expect a
high number will be in agreement with each other as to not only the spinal
level of their positive findings, but the very nature of the finding itself.
They will be totally blinded to the conclusions of the other examiners
and will not be allowed to have any communication with the examinee. Anyone
who is out there who has taken these seminars knows the reliability of
this method, but I realize that this is not science and so I hope to bring
this method to your attention again when I can finally prove these claims!
This of course will only be the beginning as this would not prove validity
of the finding; that is, the phenomenon that we are documenting and its
consistent relationship to the subluxation. This would prove to be a much
bigger hurdle as there is so little agreement on WHAT a subluxation is.
If we were to demonstrate that our findings occured concurrently with other
objectifiable findings this might satisfy those that regarded the comparitive
phenomenon as a legitimate measurement of the subluxation, but be dismissed
by others. This is so not only because we have not been able to find a
"gold standard" for subluxation measurement, but because we are not even
in agreement on "what" the subluxation is. And so we will begin this summer
with an inter-examiner reliability study and hope to turn some heads! If
we can demonstrate a respectable level of reliability using complete novices
this should create interest in this method of muscle palpation and possibly
attract the interest of one of you more well trained research Chiros.
Hi Nick,
I have over the years only kept up with some of the inter-examiner
reliability weaknesses of Motion Palpation, but to my knowledge they have
not been able to demonstrate reliability except in the S-I articulations.
Was every study done using students? This would pose a problem for such
a complex system of examination. I do not believe that this will be a problem
for our muscle palpation study and then if our results are favorable it
should be that much more apparent that a consistently identifiable phenomenon
occurs in close relation to the spine. My past experience in teaching this
method of analysis to students gives me the confidence to suggest that
a significant number of students in every seminar almost immediately demonstrate
a relatively high degree of inter-examiner reliability. As for asymptomatic
subjects, we have never correlated our findings with pain, tenderness or
symptoms, although I could make some anecdotal observations on this point
at another time. I do not forsee this posing any problem either though
as we discourage the discussion of symptoms in order to not bias our student's
findings while they are learning this method and we still observe very
strong inter-examiner agreement.
Here's something that I've always wondered
about with regards to muscle palpation and what it really means:
In the method that I teach we are looking for hypertonicity, but
not just any hypertonicity. To be a little more specific, we are palpating
the small muscles of the spine in order to find any segmental activity.
Is there a difference, and what does it mean?
Which is normal? Which is a clinical sign?
I suppose that either would be a clinical sign of something, but
I am not the one to ask concerning hypotonicity although I would think
that it has multiple origins. Some more valuable in their relationship
to any underlying articular dysfunction than others.
Normal is a relative term when we are discussing the theory in question;
I will get to that later.
The clinical sign that I am suggesting is paravertebral hypertonicity
occurring segmentally in the recumbent spine.
Have you considered the fact that the paraspinal
musculature that you palpate are not purely segmentally innervated? Unless
you can palpate the deep shunt stabilizers, the paraspinal muscles cross
multiple segments. How will you relate that back to joint/segmental dysfunction?
We are in fact palpating the deep muscles of the spine. As only one
muscle occupys its unique space between origin and insetion, we are confident
that as we palpate activity between these points of attachment we are palpating
the muscle that occupys that space or another similarly attached muscle
which would convey the same analytical conclusions to the doctor. We virtually
eliminate the question of polysynaptic innervation (except in the S-I region)
in that we are concerned with segmental activity that must by definition
be the result of monosynaptic pathways.
Now to "what it means": we suspect that this phenomenon, if you assume
that indeed we are actually on to something here, must be as a result of
some form of the stretch reflex as it is the only monosynaptic pathway
that innervates the paraspinal muscles. Again here you must assume that
we are palpating what we say we are palpating. If this is so then we must
be dealing with the stretch reflex and as we are palpating this activity
in the resting spine it would seem likely that we are more likely than
not observing the result of some form of the static stretch reflex. Also
keep in mind that the stretch reflex is under the governance of the gamma
efferent system to the muscle spindle whose fibers comprise 31 percent
of all motor nerve fibers to the muscle rather than type A alpha motor
neurons (Guytons). And so the reflex activity that we observe in the spine
is dominated by the stretch reflex, other reflex mechanisms notwithstanding.
We will also assume here that this phenomenon is consistently related to
segmental dysfunction. At this point we will make a further unsubstantiated,
but I think reasonable assumption (maybe for a later discussion), that
subluxation is by nature a disrelationship between two vertebrae that includes
a slight misalignment of the articular strutures among other possible manifestations.
If you have not seen it already then allow me to explain what all this
may mean. If this phenomenon of segmental activity is consistently associated
with the subluxation and it is representative of the static stretch reflex
and the vertebra that we are examining is in fact misaligned and hypomobile;
that is a slight mismatch of the articular structures blocked within the
normal parameters of physiologic motion, then the muscular activity is
likely responding to the vertebral misalignment in an effort to guard proper
joint positioning. We would be observing the body's inborn mechanism to
regain normal joint mechanics!
Is the muscular activity normal in such a scenario? You may want
to answer that for yourself.
Posted April 8, 1998
Good luck with your study. I believe that
that was one of the shortcomings of the motion palpation studies. Most
of the subjects were asymptomatic and the palpators were inexperienced
students.
When you palpate muscle function/tone, what
are you palpating for? HYPERtonicity or HYPOtonicity?
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