INFLAMMATION

Prévia do material em texto

As
n
musculoskeletal medicine, the
inflammatory response.
Most of the features of
. More precise ‘tissue diagnosis’
. A much wider range of tissue
prognosis
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Journal of Bodywork and Movement Therapies (2001
5(2),124^131
# Philip Latey
doi:10.1054/jbmt.2000.0209, available online at
http://www.idealibrary.com on
Philip Latey
1 Toongarah Road, North Sydney,
NSW 2060, Australia
Correspondence to: P. Latey
Tel: +61 (02) 9929 6603; Fax: +61 (02)
Received August 2000
Revised September 2000
Accepted October 2000
T h e m e s f o r t h e r a p i s t s : p a p e r 1 0
JOUR
inflammation are really ‘common
knowledge’ in this field; but it is
always worth returning to the
fundamentals. Even a small shift
in the starting conditions and
cornerstones of our understanding
can make surprising differences to
the outcome.
I will be looking at localized
biomechanical aspects of
inflammation: and, except in the
short sections on withdrawal and
sensory optimism, I have mostly
avoided social and psycho-physical
complications.
It seems to me that, apart from
complex systemic illnesses and
. Better management
. Easier ‘cure’, or resolution of the
underlying condition (where
possible).
Starting with a look at the
five basic characteristics of
inflammation, I will show how they
may appear in different orders, and
within radically different time
frames at different sites and tissues.
This should help to shed light on
some common problems. I will
explore some aspects of
inflammation as it appears in typical
low back pain, shoulder, knee, foot
and forearm ‘syndromes’ later in the
. . . . . . . . .
)
9929 8785
124
NAL OF BODYWORK AND MOVEMENT THERAPIES APRIL 2001
pects of infl
A study of injury, heali
. . . . . . . . . . . .
Philip Latey
Introduction
In previous ‘Themes for therapists’
I have emphasized the need for a
particular sort of bio-psychological
awareness in physical therapies. For
me to make a secure prognosis of
around twenty sessions for
intractable crippling migraines
(Latey 2000b, 2000c) would not be
possible without some such
approach to my work. In contrast
this paper returns to one of the most
basic physical phenomenons of
ammation
g and repetitive strain
conditions, inflammation is often
viewed too simply. We take it for
granted that any injured or strained
part will be inflamed. And, apart
from perhaps cooling the area to
reduce heat and swelling, or
suggesting anti-inflammatory
medication, it is tempting to think
no further than this. I suggest that
some revision of the fundamental
features of inflammation may help
us achieve:
Aspects of in£ammation
paper: emphasizing the restoration
of sensory optimism.
The palpatory findings and
various time frames that I use to
compare tissue patterns are
generalizations, and come more
from personal experience in my own
private practice rather than from
research-based studies.
Overall patterns
The common acute synovial joint
‘sprain’ with minimal tissue damage
shows how the patterns of
inflammatory response are part and
parcel of the healing process, and
quite predictable. For 2 days the
joint is much too sore and swollen to
use — it cannot function normally.
The body adopts typical antalgic
gaits and postures. For the next
4–14 days it is stiff, with pain only
on particular movements —
decreasing as function is regained.
After this the joint appears to
function normally, but is weak, a
little unstable and vulnerable to re-
strain for 8–28 days.
This sort of rule of thumb
timeframe, with modifications,
needs to be in the back of our minds
with acute patients. All of the
synovial joints, including the
vertebral facet joints of the back and
neck tend to follow these three
phases.
We see these sorts of sequences
repeat themselves so often that it
should be possible to note small
differences from case to case, and so
make precise predictions for the
patient. But this is only one
particular inflammatory pattern. A
broader look at some other common
musculo-skeletal problems will show
a much wider spectrum of aspects to
inflammation.
The five basics:
1. Heat
2. Redness
3. Swelling
4. Pain
JOURNAL OF BO
5. Loss of function
are the basic signs of inflammation.
Without detailing the physiological
cascade and histamine response
patterns, these are quite simply
explained (Box 1).
The heat and redness arise from
increased blood flow and
vasodilatation. After any initial
shock response to impact, contusion
and direct trauma, that may include
vasoconstriction, it is an advantage
to have a much increased flow into
an area in need of repair and
antisepsis.
Unless there is a direct bleeding
into perivascular tissues
(haematoma), swelling arises from
localized increase in the permeability
of the vascular bed. This allows for
rapid perfusion of fresh plasma and
repair cells throughout an injured
area. Swelling will persist and
increase as long as the slow rate of
lymphatic reabsorption is exceeded.
When overall cardiovascular
function is chronically poor, or
lymphatic drainage from the
interstitial spaces is restricted,
swelling may become permanent —
as in pitting oedema or
lymphoedema.
Pain and altered sensations may
be much more variable and
complex. Light touch to the skin
over an injury can vary between very
painful and completely numb; often
with neighbouring areas showing
either extreme. Obviously local
nerve endings directly traumatized
in the tissues will signal pain
Box1 In£ammation
Heat (calor): Circulatory hyperaemia.
Redness (Rubor): Peripheral
vasodilatation.
Swelling (Turgor): Local tissue
perfusion.
Pain (Dolor): Physiological/
mechanical signals.
Loss of function: Central and
peripheral responses.
125
DYWORK AND MOVEMENT THERAPIES
immediately. Others will respond to
the build up of altered biochemistry
much more broadly throughout the
traumatized region.
Less locally there may be
temporary disruption of locomotor
coordination and muscle sensation
at the spinal level; extending perhaps
as high as the reticular activating
system or even to cerebellar centres.
Pain may also arise from protective
muscular spasm. Other sensations of
disconnection and ‘uselessness’
commonly originate from areas that
refuse to function normally. This
aspect of loss of function, a sensory
loss that may be associated with
either spastic muscular bracing of
parts or limp flaccidity, may be
crucial to the outcome in some of
our more chronic cases. The
cognitive, emotional and social
effects of even a small functional
‘loss’ may be substantial.
The three ‘Ds’
The patterns of inflammation that
we see in the body differ enormously
from one area to another, and from
one tissue to the next. From the
neuro-muscular and musculoskeletal
point of view inflammation is always
an attempt at a healing response,
whatever its nuisance value in other
respects. The time frame over which
it can operate is hugely variable.
Consider the difference between
the common acute calf muscle strain
that is gone in a couple of days with
no sequelae, and an equivalent
medial coronary ligament sprain
that may continue to be troublesome
for decades — until properly
treated. The forces and proportion
of tissue damage may have been
much the same.
The differences here lie mainly in
the density of the tissues suffering
some insult, their distance from their
vascular supply and drainage, and
the ease of dispersal of heat from the
area.
APRIL 2001
Latey
Density
Will vary from the hardness of
bone, tightly bound elasticity of
fibrocartilage, and firmly
compressed collagen packed into
ligament and tendon — to the soft
jelly-like fluidity of fast-twitch
muscle belly.
Distance
Might be representedby the number
of tight corners and compressed
areas traversed by the arteries and
veins. Compare the biceps and
gastrocnemius with the tortuosity of
the geniculate arteries, the supply
for the interior of the forearm
tendons, the scaphoid, the Achilles
tendon and the annulus fibrosis.
Dispersal
Is more a measure of the local fluid
flow and perfusion, combined with
the body’s overall ability to disperse
heat. Local hyperphysiology due to
overactivity, inflammation and
mechanical friction can become
highly destructive where dispersal is
poor or habitually restricted.
The combination of these three
linked factors gives us a good
measure of high eciency or low
eciency in the inflammatory
response.
Emergence and resolution
The three ‘D’s’ are not just helpful
prognosticators; they are also key
factors in the emergence of the
symptoms. This is of absolutely
crucial importance to our
understanding of the repetitive
strain syndromes, and much
traumatology.
To see the difference between
tissues of high and low eciency,
study the sequences that emerge in a
typical whiplash injury — say from
a quite severe ‘rear-shunt’ impact
during a road trac accident.
JOURNAL OF BO
Initially the person and tissues are in
shock. Neck movements are free, if a
little slow — but they feel numb and
quite disconnected to the victim in
the hours following the accident.
Next morning the patient’s
sternomastoid muscles have become
acutely painful: often being unable
to raise their head from the supine
position. Over the next 3–10 days
the sternomastoids return to
normal, but in the more serious
cases their neck slowly becomes
markedly stiffer in all ranges of
movement; with radicular
symptoms, referred pain, mid-upper
thoracic and lumbar problems (if
any) beginning to emerge. Posterior
and deeper structures have clearly
taken much longer to come ‘out of
shock’ and start their normal
inflammatory sequence.
In whiplash we will often see full-
blown brachial neuritis, low back,
sacral and hip problems emerging
weeks or even months after the
initial injury. For complex reasons
the full ‘impacted’ image and
shock-wave pattern may even wait
for years to resolve — perhaps until
we talk over the cognitive, social and
emotional repercussions with them;
and as tissues begin to revitalise and
move freely with good manual and
movement work.
Low back strain
Whiplash may be very complex and
dicult to help — especially as
medicolegal issues will often
complicate the picture and colour
our involvement. Low back strains,
on the other hand are often much
simpler. Nevertheless the speed of
onset can be deceptive.
In my first year of practice I did
3 days per week locum in a busy
suburban practice. A builder
telephoned for an emergency
appointment. He had just slipped
while removing scaffolding poles
from a lorry. On examining him 2 h
later he localized the pain to deep
126
DYWORK AND MOVEMENT THERAPIE
behind his hip: with no radiation.
His lumbar spine seemed fully
mobile, and muscles evenly
balanced; but his right ileum seemed
to be pulled upwards and
backwards. I carried out a ‘lumbar
roll’ technique that was in those
days supposed to be corrective for
‘posterior innominate’ lesions. He
walked out with the hip feeling a
little easier.
That night he phoned in to the
practice, completely immobilized,
and with the beginnings of cauda
equina symptoms. His care was
taken over by the senior osteopath.
With more experience I would
have known to recognize signs of
shock in the person and tissues.
I should have been more alert to the
deep ‘rubbery’ spasm of the hip
external rotators, that does not
respond at all to soft-tissue
techniques, guarding more severe
injury. I would also nowadays be
able to predict a worsening
prognosis with some reliability;
and advise the patient about
conservative care and management.
I am unsure whether my
manipulation was responsible for
worsening the problem, but have not
used the same technique since.
There are many tissues around the
low back that have an extremely low
eciency in their inflammatory
response. The annulus fibrosus,
posterior longitudinal ligament,
sacroiliac and ilio-lumbar ligaments
may all take 2 days or more for
inflammation and swelling to reach
a full peak. It is quite usual for
patients to have had slight ‘warning
signs’ for a week following unusual
strain: and then suffer severe acute
symptoms precipitated by some
trivial ordinary movement.
The two day rule
When we use manual therapies to
release tensions, restore movement
and enable the body to rebalance its
stresses, the response is often quite
S APRIL 2001
Aspects of in£ammation
unpredictable. In my own practice I
am careful to tell patients that:
‘these changes my take a couple of
days to begin working their way
through. So, if you feel a bit odd,
and there’s pain in a day or two, just
blame it on that dreadful osteopath,
and take care to look after the
body... etc.’
This is not just a characteristic
response to strong treatment. On the
contrary, very slow and non-
invasive ‘functional’ types of
technique that I make much use of,
seem to be able to reach deeper
tissues than the linear pressures and
‘thrusts’ that are applied to the
body, rather than with the body.
Revascularisation and
reinnervation, then, may include
inflammatory responses that can
happen very slowly in deeper tissues.
A 24–48 h onset of response to our
work is quite usual when the
momentum towards change is
reaching tissues that have a low
inflammatory eciency.
Repetitive strain
There are many pernicious aspects
to the repetitive strain syndromes
that make them very dicult to
resolve. The repeating actions that
have caused the problem are often
necessary for the person’s
employment, and may also be
incorporating frustrations and
resentments that have accumulated
in the workplace or elsewhere. Or, in
the course of sports and hobbies,
these strenuous repeating actions
may have provided an excitement,
distraction, relaxation and release of
tension to which they are powerfully
habituated. The social embedding of
their activity usually provides the
‘glue’ that makes the habituation so
intense.
Tissues prone to repetitive strain
problems are typically very low in
the eciency of their inflammatory
response. In an acute strain the pain
JOURNAL OF BO
is usually immediate; and precedes
the heat, swelling and redness. Loss
of function may also be immediate.
By contrast pain signals from these
dense and circulatorally distant
tissues are usually very faint, and
seem to arise long after the
hyperaemia, heat and swelling have
begun. So the signals that would tell
us to ‘stop and revive’ arrive far too
late to prevent the area from
becoming compromised.
If inflammation is building up
over several days of, say, heavy
typing to meet deadlines, each bout
of activity is compounding the
effects of the previous days’s efforts.
With only a dull pain to cope with,
that increases very slowly, the
person is able on carry to regardless
for longer than one might expect. As
they gradually become more aware
of their forearms, and feel vague
aches increasing, they will notice
that the spells of activity before the
aches increase become shorter. The
time for the aches to diminish after
they stop will also be increasing. The
‘weakness’ of loss of function may
also have preceded any pain from
the area.
Even these obvious signs are
not enough to stop a determined
over-activist. If forced to do so the
body will attempt to recruit other
muscle groups to accomplish the
tasks. In typing this might amount
to inappropriate use of upper arm,
shoulder, chest and torso muscles.
Our pain thresholds are also highly
labile. So, in a state of excitement,
arousal or ‘adrenaline rush’ we are
unable to notice rising levels ofmoderate pain — and may be able
to sustain arousal over extended
periods of determined effort:
although this may be more typical of
sport than of typing.
When all these delaying effects are
exhausted, they may still not bring
on a complete loss of function.
There is an even more global way of
continuing to use the parts—after a
fashion.
127
DYWORK AND MOVEMENT THERAPIES
Withdrawal
Under some circumstances we can
substantially reduce the vitality of
whole areas, parts and functions of
the body. This is equivalent to
turning the volume control right
down to a barely intelligible
whisper. Here the blood circulation
is much reduced, and muscle power
becomes greatly enfeebled. Sensory
awareness of the area is also
markedly reduced to a dim and
distant ghostliness.
The person has had to retreat
inwardly from their normal healthy
‘outwardly directed’ contact with
the world. To hold back and
attempt to avoid painful stimuli is,
of course completely normal. But
here at least one whole aspect or
part of themselves is in permanent
recoil and profound withdrawal
from rich responsive sensorial
engagement with their human
environment. This is sometimes
visible in their postural stance, and
in the way that their limbs are held:
as if they had just grabbed hold of a
hot stove; or stamped on a nail.
In the longer terms this can only
be achieved if a substantial chunk
of their beingness is disowned
(psychologically and
physiologically) and cut off from
the mainstream of their self-fullness.
An important part of this will be a
disconnection from the combination
of muscular senses studied in my
earlier work (Latey 1979) and in the
first issue of this journal (Latey
1996).
This means that we cannot make
any lively contact with the person
when we handle the parts that are
‘in withdrawal’. Be it perhaps a hand
or a foot, it feels lifeless, pale, dull,
flacid and feeble to us — and
without the feeling of warmth,
motility and sensitivity to pressure
usual for the meeting of our flexor
surfaces. Compared to the physical
‘presence’ of the more normal
bodies that we handle daily, there is
APRIL 2001
Latey
hardly any feeling of connectedness
between us and the patient.
Proximal to the limb affected we
might look for rings of deep
contraction in the muscles of the
pelvic or shoulder girdles. These
may be very numb and unresponsive
in chronic states; but can be very
sensorially alive and painful to
pressure in more recent and
acute states of withdrawal.
Metaphorically we could imagine
these muscles ‘choking off’ and
occluding vitality. By a further
analogy the muscles are forming a
‘clenched fist’ (Latey 1979) that only
offers the coarse, numb extensor
surfaces of the hand for contact with
the world.
In the more extreme states of
withdrawal there is such lifelessness
that the tissues may resemble the
atrophic states seen in ‘reflex
sympathetic dystrophy’ or similar
pathologies. Autonomic and
neuro-humeral processes may seem
to be widely disrupted or stuck. In
any case the effect of lowered vitality
may be enough to stay below the
threshold of an inflammatory
response. So we would probably see
the typist’s hands flopping loosely
over the keyboard, working slowly
and lackadaisically: with an
error-prone and distracted manner.
Brittleness and
compression
Tissues with low eciency in their
inflammatory response are also
those that warm up for physical
activity most slowly. We are all
aware of stiffness after sitting for too
long in a cramped position. If we
stand up after an hour or so spent in
lotus position, or start to walk after
sitting through a long movie, our
knees will take a while to get
moving; and can even be quite sore
for a minute or two. This pain is
commonly localized at either edge of
the infra-patellar tendon, or right in
the middle of it above the insertion.
JOURNAL OF BO
Many tissues are unusually brittle
and fragile after periods of sustained
compression. The joints between the
carpal bones and the tendons around
the wrist are often surprisingly sore
after a relatively short time leaning
our weight through the hand.
Similarly the acromio-clavicular
ligaments and rotator cuff tendons
complain after leaning on the elbow
for longer periods.
Some tissues are prone to
crowding, and easily become
crimped and pinched; their natural
pliability and elasticity are
anatomically vulnerable to
compression. Deep structures that
lie just anterior to the hip joint are a
common source of trouble.
Mechanical or ergonomic habits of
sitting with the hips flexed beyond
90 degrees with little abduction, and
failure to use fuller extension
movements in the gait will
predispose to trouble here.
One commonly overlooked tissue
anterior to the hip is the origin of
the reflected head of rectus femoris
— that I often find involved in
‘groin strain’ and general hip
problems. The hip may seem
relatively free until we flex the hip
fully with adduction and slight
internal rotation: the pain and
restriction from compression
become obvious straight away.
Postural habits of the head
and neck will often over-compress
and pinch structures lying deep to
the occipital triangle muscles.
A sustained ‘myopic’ posture while
sitting at the computer is a typical
source of chronic trouble here.
The extensor tendons at the wrist
are crowded and compressed against
the distal end of the ulna when the
hand is used in full pronation (as in
reaching sideways to the computer
mouse).
Ageing
All of the ‘low eciency’ tissues
seem to be prone to early
128
DYWORK AND MOVEMENT THERAPIE
degenerative changes. This is not
just the ‘normal wear and tear’ of
ageing that we associate with
osteoarthritis; particular sites seem
to be more vulnerable. The common
‘rotator cuff syndrome’ is a good
example. Occurring most often in
the fifth and sixth decades of life,
the large tendon shared by the
supraspinatus, infraspinatus and
teres minor becomes so ‘inecient’
that it is no longer able to repair any
local microtrauma — and becomes
necrotic.
Here the combined effects of poor
posture, thoracic kyphosis, upper
chest tightness, inwardly rotated
shoulders and diminishing
cardiovascular eciency form a
highly resistent set of predisposing
factors, that are also factors that
maintain the problem. Very
challenging to the therapist!
The hip joints often wear fastest
— not just because they dissipate
heat poorly, and become crimped in
the anterior soft tissues. The
sufferer, often overweight, has
usually earlier in life adopted a
stomping ‘saddle sore’ forceful type
of gait: sometimes in response to
injury. There is no easy flow to their
walking movements; no graceful
rotation and extension movement
that makes good use of the foot and
spine. Here impact and wear are not
well distributed: they are confined to
the central weightbearing area of the
hip. Attrition is confined to the
uppermost part of the hip joint
before spreading more widely.
Patterns of habitual gait may
be responsible for another
inflammatory condition that a‚icts
the same age group. Plantar fascitis
is quite common in late middle-aged
men. These are the senior workers
whose uniform includes very rigidly
heeled leather shoes — with which
they have inflicted the stamp of
authority on pavements, floors,
themselves and their view of the
world. It may be hard for them to
get over the feeling of ‘degenerating
S APRIL 2001
Aspects of in£ammation
into a slob’ when they finally accept
really comfortable ergonomic foot
gear!
Chronic in£ammation
Palpation
Sites of chronic inflammation are
often very interesting to palpate.
Very long-term overuse of tendons,
for example, leads to failure of
lubrication and a very distinctive
‘ribbing’ of the tendon sleeves. De
Quervain’s disease, the late-stage
degeneration of the extensor/
abductorthumb tendons, is
a good example.
We lay our finger pads along the
length of the tendons and ask them
to move the thumb slowly up and
down and in and out. Straight away
the lubrication feels patchy and
sticky, with small crepitations and
jerkiness, as the tendon tries to slide
through its sleeve. This doesn’t
completely jam up — as in ‘trigger
finger’ — but the bind and
restriction stand out very clearly.
Here the continuity of fluid flow in
the tendon sleeve seems to have
broken up into small islands of
consolidated desiccated jelly that
can no longer fulfil its function.
Chronic Achilles tendinitis has a
similar feel. The tissues are very easy
to palpate here. The sleeve doesn’t
cover the whole of the tendon — but
can often be felt to have formed
tight circular rings and corrugations:
along with any puness when the
inflammation is active. While this is
usually more evident in later life, it is
not uncommon to find in athletes
and ballet dancers who have early
on developed Achilles problems.
The glueyness and stickiness felt
in the lubrication of chronically
inflamed tendons is also palpable in
some disturbed joint movements. It
is extremely common, for example
for the carpal bones to feel adhesive
and give noticeable crepitations as
we test their antero-posterior glide
JOURNAL OF BO
and translation movements.
Compromised shoulder joints and
ankles can have a similar feel when
we test their ancillary movements.
Over-manipulated spinal joints
may become hypermobile and fail to
‘couple’ smoothly with their
neighbours. They have a typical feel
to them that is floppy, roughened
and discoordinated through the
middle of their range, and with a
highly distinctive ‘sticky end’ to the
movement. This is often present in
necks and low backs that have been
over treated; and may be felt in
hypermobile joints elsewhere in the
body.
Chronic swelling around badly
strained ankles that has been present
for many weeks and months comes
to have a sort of doughy mashed
potato feel to it. Short of the pitting
oedema of cardiovascular failure,
this will often take a great deal of
slow squeezing, e‚eurage and
drainage before it begins to
dissipate: another case of
‘consolidation’ in the inflammatory
exudate.
Another quite characteristic feel is
the ‘squelchiness’ of the chronically
overloaded temporo-mandibular
joint (TMJ) on gentle lateral
springing. Most ‘grippers and
grinders’ eventually build up a
consolidated inflammatory exudate
that is clearly palpable on
masticatory movement. They can
often hear this themselves, the TMJ
being just millimetres from the
auditory tube, and are sometimes
quite revolted by the sound.
Palpating origins and bellies
There may not be much puness
around chronically inflamed
epicondyles. Whether it is a golfers
(medial) or tennis (lateral) elbow, it
is occasionally possible to palpate
little ‘gaps’ in the myo-periosteal
junctions, and a few millimetres
down towards the belly of the
muscle is sometimes very painful.
129
DYWORK AND MOVEMENT THERAPIE
Much more common is a
pronounced ‘gritty’ feel to the
forearm muscles starting about half-
way down to the wrist. It is as if the
repeated failure to heal at a small
part of a muscle origin has
compromised the whole synergistic
group. Plantar fascitis may also feel
like this when we palpate along the
middle of the fascia.
When muscles have been
chronically inflamed over very long
periods, the belly seems to retreat
from the ends of its functional
envelope. We can palpate the sacral
origins of gluteus maximus very
clearly when a good healthy dancer,
skater or athlete extends (lifts) the
straight leg in a prone position. The
belly of the muscle curves right
across the joint, to attach straight
down into its origin.
When there have been chronic low
back and sacroiliac problems, a
healthy gluteal muscle belly may not
be present, even two or three
centimetres lateral to the line of the
sacroiliac joint. This gap is now
bridged by stringy fibrotic strands
that feel inert and partially
avascular. They are themselves a
common source of soreness and
ache — and may need a lot of our
‘deep frictional’ work and good
exercise before they can reconvert to
healthy muscular tissue.
It is often dicult to choose
whether to start work on the belly of
the muscle or at the ends and edges.
We will usually have to do both!
Visceral in£ammation
The smooth muscles of the viscera
all have wave-like patterns of
contraction. While we cannot
observe these as directly as we can in
the musculoskeletal system, most
people are aware of some aspects of
peristalsis. Diarrhoea, constipation
and the involuntary effort of
defecation all have familiar features:
and vomiting shows the forceful
reversal of normal peristalsis.
S APRIL 2001
Latey
Inflammatory phenomena here
have more to do with irritation,
engorgement, stretch with fullness,
spastic tightness, congestion and
turgidity. Gynaecological cramps
and fluid balances will be linked to
hormonal and prostaglandin
functions that we may be unable
to help. Nevertheless gentle
per-abdominal palpation and
treatment can be very revealing and
helpful; especially when combined
with abdominal breathing patterns.
These are naturally disturbed and
reduced in most conditions where
there is abdominal discomfort or
poor function. Palpation here, when
feeling through the abdominal wall,
is more a question of comparing the
normal multi-directional slithery
fluid jellyness with any noticeable
tense fullness, rubbery resistance, or
adhesive ‘tetheredness’.
Sensory optimism
A patient suffering from an acute
lumbar disc herniation reported that
he felt ‘a huge emptiness in my side,
like a vacuum between my stomach
and hip. It’s like something large is
missing; there’s only emptiness
there’.
After 3 days of careful rest this
feeling had vanished — but the rest
of the pain and discomfort from the
injury had not yet started to
diminish.
Such ‘gaps’ and holes in peoples’
bodily perceptions are actually quite
common in acute injury; but may
not be mentioned or noticed much
unless we ask carefully. Oliver Sacks
gives a very clear account of this in
his book ‘A leg to stand on’ (Sacks
1994). Damage, inflammation and
repair to the nervous systems may be
far more complex than with our
study of other tissues. This is the
most dicult aspect of loss of
function for the patient and
practitioner to overcome.
If the person is in retreat from
repeated painful stimuli there may
JOURNAL OF BO
not be any gross damage to the
nervous systems. Nevertheless it is
as if the ‘corporeality’ of the patient
is an internal amoeba that has
permanently withdrawn one of its
major pseudopods. Encouraging the
body to extend a lively presence
back into the abandoned limb or
part is one of the major components
of manual therapy.
The body can be encouraged to
restore much fuller bodily beingness
and sensory optimism through the
use of good manual therapy:
. Sensitivity to light touch and
deep touch.
. Sensitivity to temperature.
. Sensitivity to light pressure and
deep pressure.
. Specially sensitivity to movement.
All of these are gradually restored
and enhanced in well-attuned
bodywork. The imprinted images
of fear, weakness, uncertainty and
hesitation, sometimes even with
shame, rejection and
embarrassment, can gradually melt
away and be overcome. This may
happen even in the presence of
minor discomfort and reminders if
their recovery is not being rushed at
too fast a pace.
Confidence in movement,
lengthening and opening the body,
feeling the full extension in space,
attuning the breathing and
functioning ergonomically; all of
these will help enormously. The
good movement teacher, in a hand
clinic perhaps, will encourage the
maintenance of dexterity. With the
hand I will aim to devisea sequence
with the patient, say from jigsaw
puzzles to squash balls and clay
modelling and perhaps on to rock
and roll, table tennis and mime
class. I may, for instance, ask them
to massage the good limb with the
bad one — using whatever parts will
still function.
The patient may be battling
feelings of weakness and
ineffectuality. With chronic
130
DYWORK AND MOVEMENT THERAPIE
disability they may be much reduced
in their confidence and sense of
agency — their ability to engage
socially and act effectively in the
world. To me it seems that the
interpersonal rapport with the
practitioner, both physically and
conversationally, can do a great deal
to restore feelings of humanity, and
reverse the inevitable attrition that
goes with severe and chronic
disability.
Conclusion
Aspects of inflammation are always
present in the background for
manual therapists, and for much
movement work — and will be
relevant to most of the problems we
are asked to help solve with our
patients. While most inflammatory
phenomena that we meet are
relatively straightforward, the
time-frames, and occurrence of
different sequences are very
interesting — specially when we
realise the participation of
inflammation in most healing
responses.
It seems to me extraordinary that
we have only recently begun to look
at the significance of touch (Nathan
1999), rhythmical movement
(Lederman 1999) and the
interpersonal rapport in manual
therapy (Latey 2000a) in useful
ways. In conditions where there has
been a long term battle with
inflammation, it seems to me
essential that we also tackle the loss
of function by whatever means we
can use that will help to restore
sensory optimism.
REFERENCES
Latey P 1979 The Muscular Manifesto
(2nd edn 1982). Osteopathic Publishing,
London
Latey P 1996 Feelings, muscles and
Movement. Journal of Bodywork and
Movement Therapies 1: 44–52
S APRIL 2001
Latey P 2000a. Placebo: a study of persuasion
and rapport. Journal of Bodywork and
Movement Therapies 4: 123–135
Latey P 2000b Curable Migraines: part 1.
Journal of Bodywork and Movement
Therapies 4: 202–215
Latey P 2000c Curable Migraines: part 2.
Upper body technique. Journal of
Bodywork and Movement Therapies
4: 251–260
Lederman E 1999 Harmonic technique.
Churchill Livingstone, Edinburgh
Nathan B 1999 Touch and emotion in manual
therapy. Churchill Livingstone,
Edinburgh
Sacks O 1994 A leg to stand on. Picador,
London
Aspects of in£ammation
JOURNAL OF BO
131
DYWORK AND MOVEMENT THERAPIES
 APRIL 2001
	Introduction
	Overall patterns
	The three `Ds'
	Density
	Distance
	Dispersal
	Emergence and resolution
	Low back strain
	The two day rule
	Repetitive strain
	Withdrawal
	Brittleness and Compression
	Ageing
	Chronic inflammation 
	Palpation
	Palpating origins and bellies
	Visceral in£ammation
	Sensory optimism
	Conclusion
	REFERENCES