Johnston’s summary of the planning and criteria involved in a functional approach to assessment and treatment can be expressed as follows.
It is necessary to introduce motion in any one direction at a time which involves minimal force.
Motion direction is towards a sense of increasing ease, which is manifested by a lessening in the sense of resistance to pressure from the palpating fingers.
Different direction elements are combined, such as rotation and translation, producing variations in torsion.
Active respiration is also monitored for its influence on ease.
The examiner follows the continuous flow of information, signalling increasing ease/decreasing resistance during all procedures.
EXERCISE 8.4: FUNCTIONAL SPINAL PALPATION Time suggested: 10–15 minutes
Evaluate the spine of your seated palpation partner, assessing areas of flatness or fullness, as you observe the flexed spine from the side or from in front.
Palpate the area and seek out the central site of tissue dysfunction, greatest hypertonia or sensitivity, using one of the previous exercises such as 8.3A. Using the flexed fingertips of one hand, tap lightly and steadily on the tissues identified, as well as on those surrounding the area. (See Special topic Figure 10A).
Can you identify a different sound in the most affected tissues?
Once a suitably ‘different’ (from adjacent segments) sound has been identified, one hand (the listening hand) should be placed on these tissues. The other hand is used to introduce motion into the region, passively or with some active cooperation, but only if directed to do so by you.
A sequence of normal physiological motions should be introduced to the region and in each instance (in each direction) the palpating hand, on the tense dysfunctional tissues, should be feeling for greater ease or greater bind, trying to find a point where a combination of the greatest directions of ease (see below) are summated, in order to achieve maximal relaxation of the
tissues.
This, says Hartman, is a form of inhibition for the tense tissues, ‘in that areas of irritability are quieted, the practitioner constantly looking for the state of ease and release’.
The movements introduced (sequence is irrelevant) for assessment of ease and bind should include:
flexion and extension side-flexion, left and right
rotation, left and right
translation, anterior and posterior translation (shift), left and right
translation, cephalad and caudad (involving traction and compression) followed by:
respiration, involving both inhalation and exhalation.
Greenman describes the process of achieving the point of ease, involving the first six motions, as ‘stacking’ (the order in which these are applied is not significant; simply it is useful to apply them sequentially so that none is forgotten). This should be followed by the final respiratory screening, seeking the phase of the cycle which produces maximum ease.
Johnston (1997) has described this:
The final component step of the functional procedure involves a request for a specific direction of active respiration, whichever direction (inhalation or exhalation) contributes further to the increasing ease. For example, if inhalation, the request is for the subject to take a deep breath slowly, and to hold briefly.
After a position of greatest ease has been established using one of the planes of movement (say, flexion and extension), that position of ease is used as the starting point for the next direction (say, rotation left and right) or plane (say, side-flexion left and right) to be assessed for its position of greatest ease.
When this is discovered you will have found a combined position of ease for the first two directions of movement tested, say extension and side-flexion or rotation.
You will have ‘stacked’ the second onto the first and from that combined position of ease you would then introduce the next direction for assessment, say translation right and left ... and so on, until all directions have been evaluated and their positions of ease ‘stacked’, one onto the other (see Fig. 8.1).
Then the respiratory assessment is introduced and the final position of ease held for 60–90 seconds or so, before complete reevaluation of previously identified restrictions.
A sense of a wider range of normal (greater ease) should be felt by the practitioner as these releases occur.
Fig 8.1 Arrows show directions of movement, as ease and bind are assessed by the 'listening' hand on the spinal tissues during functional evaluation of spinal segments. Movements are: Flexion-extension, Rotation left and right, Side-bending left and right,
Translation to each side, Translation forward and back, Translation up and down (traction and compression).
EXERCISE 8.5: GREENMAN'S FUNCTIONAL LITERACY PALPATION Time suggested: 15–20 minutes for the three phases of the exercise
Greenman describes a sequence of exercises for achievement of ‘functional literacy’. The following is a modified summary of his sequence.
8.5A
Stand behind and to the side of your seated palpation partner, whose arms should be folded, so that the hands are holding the opposite shoulders. Place a ‘listening’ hand, or finger pads, onto the upper thoracic spine, where tissue tightness or fullness has been identified.
Allow the hand to be very still. Wait until it feels ‘nothing’ (no movement).
Your other hand (‘motor’ hand) should be placed on your partner’s head, in order to lead it through specific motions, such as flexion or extension (very slowly performed, without jerking).
The palpating hand tries to identify tissue changes, in terms of increased ease or increased bind.
Keep repeating a single movement of the head into slow flexion, back to neutral, into flexion, back to neutral ... noting where the point of maximum ease is located in this plane of movement.
Then introduce slow repetitive backward bending of the head as you palpate for ease. Extend slowly, return to neutral, extend, back to neutral.
Is the ease greater with the head in a flexed or extended direction?
8.5B
Return to neutral and introduce side bending right and rotation to the left of the head and neck on the trunk, several times (back to neutral after each excursion).
Then introduce side bending left and rotation to the right of the neck and head on the trunk, all the while palpating the area being assessed for alterations in their ease and bind characteristics.
In which parts of this compound series of movements do the tissues relax most or become most tense?
Is there a symmetrical range of ease and bind in both directions?
Find the point – somewhere between extreme side bending left, rotation right, and side bending right, rotation left – in which the palpated tissues feel at their most relaxed.
8.5C
Return the neck and head to neutral and introduce, and try to combine, the following movements, as you palpate for ease and bind:
small amount of forward bending, accompanied by right side bending and right rotation of the head and neck on the trunk follow this with slight flexion, left side bending and left rotation of the head and neck on the trunk.
Palpate constantly for ease in the thoracic segment under your listening hand. Evaluate the symmetry of the findings.
Was ease/bind found at the same place moving the head and neck to the left and to the right?
Comment
Greeman (1996) suggests that similar palpation exercises be performed in various regions of the spine. In each case what you are looking for in normal tissue, or where there is only minimal dysfunction, is a wide range of motion accompanied by minimal
signalling (i.e. most of the tissue being palpated is in relative ease).
Where a significant degree of dysfunction exists, there will be narrow ranges which produce signals of ease or decreased bind.
Experience is the only teacher as to what is and what is not significant clinically in this information.
EXERCISE 8.6: GREENMAN'S FUNCTIONAL SPINAL PALPATION Time suggested: 20 minutes
Note that this is more or less the same exercise as 8.5, with the difference that you should first practise it on a dysfunctional segment and then a normal one.
8.6A
Your palpation partner should be seated. You stand behind and to one side, palpating a previously identified area of dysfunction in the thoracic spine.
Adopt a contact where the patient has their arms folded and you embrace the shoulder furthest from you with one hand, drawing the opposite shoulder into your axilla, so that you can control the various directions of motion.
Sequentially introduce the elements of:
forward bending, followed by backward bending left side bending, right side bending
rotation left, rotation right
a combination of side bending in one direction, with rotation to the same side, during flexion and then extension.
Then introduce side bending in the other direction, with rotation to the opposite side during flexion and then extension.
Add to a combination of positions of ease discovered during these assessments elements such as translation anterior and posterior, translation from side to side and translation cephalad and caudad, in order to discover where the maximum point of ease occurs.
Can you sense ease positions in any of these motions?
Can you find a ‘most easy’ position, by combining elements of these motions?
Maintain the final position of ease and after a minute return the area to neutral.
Reevaluate the positions of ease. Have they changed?
8.6B
Perform exactly the same sequence on a segment lower down the spine which does not display evidence of dysfunction.
Compare your findings of range, and positions of ease and bind, with those discovered during the previous exercise.
EXERCISE 8.7: GREENMAN'S FUNCTIONAL SPINAL PALPATION, WITH BREATHING ASSISTANCE Time suggested: 20–30 minutes
8.7A
Repeat all the components of Exercise 8.6A but now introduce a long-held (as long as is comfortable to the person) breath, in both inhalation and exhalation, in each of those positions in which maximum ease was previously palpated.
Is there any additional release (or increase) of resistance during or after either phases of held breath?
The secret of this approach is learning to apply all suitable directions of motion which enhance ease, together with the respiratory component which produces maximal ease.
8.7B
Repeat the sequence of Exercise 8.6A but this time identify the most extreme positions of bind, so that you can eventually engage the restriction barrier.
In this position (whatever combination of movements has led to maximal bind), have the patient gently try to return to the starting
position (normal) against your resistance for a 10-second hold.
Repalpate the area of dysfunction after this isometric contraction and see whether you have increased the range, pushed back the barrier, increased ease? This is a muscle energy procedure, in which an isometric contraction of the tense soft tissues has encouraged a reduction in tone and an increase in elasticity, after the contraction.
Which approach appeals to you most, seeking ease or obliging the barrier to retreat after engaging it?