There are many ways of using palpation skills to enhance our awareness of just what is happening in our patients.
Take the simple action of a firm dragging action of a digit or the thumb across an area of skin, in which hyperaemia is produced – a ‘red reaction’.
It is fascinating to go back through the history of bodywork and to find how many ways this simple method has been utilised.
Many researchers and clinicians have described an assortment of responses in the form of such ‘lines’, variously coloured from red to white and even blue-black, after application of local skin dragging friction, with a finger or probe.
In the early days of osteopathy in the 19th Century the phenomenon was already in use.
Carl McConnell D.O.stated the following in 1899:
‘I begin at the first dorsal and examine the spinal column down to the sacrum by placing my middle fingers over the spinous processes and standing directly back of the patient draw the flat surfaces of these two fingers over the spinous processes from the upper dorsal to the sacrum in such a manner that the spines of the vertebrae pass tightly between the two fingers; thus leaving a red streak where the cutaneous vessels press upon the spines of the vertebrae. In this manner slight deviations of the vertebrae laterally can be told with the greatest accuracy by observing the red line. When a vertebra or section of vertebrae are too posterior a heavy red streak is noticed and when a vertebra or section of vertebrae are too anterior the streak is not so noticeable’.
Much more recently, Marshall Hoag D.O. writes as follows regarding examination of the spinal area using skin friction:
‘With firm but moderate pressure the pads of the fingers are repeatedly rubbed over the surface of the skin, preferably with extensive longitudinal strokes along the paraspinal area. The blunt end of an instrument or of a pen may be used to apply friction, since the purpose is simply to detect colour change, but care must be taken to avoid abrading the skin. The appearance of less intense and rapidly fading colour in certain areas as compared with the general reaction is ascribed to increased vasoconstriction in that area, indicating a disturbance in autonomic reflex activity. The significance of this red reaction and other evidence of altered reflex activity in relation to (osteopathic) lesions has been examined in research. Others give significance to an increased degree of erythema or a prolonged lingering of the red line response’.
John Upledger D.O. writes of this phenomenon:
‘Skin texture changes produced by a facilitated segment [localised areas of hyper-irritability in the soft tissues involving neural sensitisation to long term stress] are palpable as you lightly drag your fingers over the nearby paravertebral area of the back. I usually do skin drag evaluation moving from the top of the neck to the sacral area in one motion. Where your fingertips drag on the skin you will probably find a facilitated segment. After several repetitions, with increased force, the affected area will appear redder than nearby areas. This is the ‘red reflex’. Muscles and connective tissues at this level will:
- have a ‘shotty’ feel (like BBs under the skin);
- be more tender to palpation;
- be tight, and tend to restrict vertebral motion; and
- exhibit tenderness of the spinous processes when tapped by fingers or a rubber hammer’.
Roger Newman Turner N.D., D.O. describes the research of another osteopath/naturopath, Keith Lamont N.D., D.O., who first described the ‘black line’ phenomenon:
‘It is a common observation of osteopaths who use a spinal meter, to detect the most active lesions, that pressure on either side of the spine with a hemispherical probe of approximately 0.5 cm diameter, will, in some patients, illicit a dark blue or black line. The pressure of the probe is usually very light since it is intended to register variations in skin resistance, but it has a pinching-off effect on the arterioles and venules of the capillary network beneath the skin. Local engorgement of the capillary bed with deoxygenated venous blood causes the appearance of the line which slowly fades as the circulation returns.’
This is considered to relate to a nutrient deficit in those patients in whom this sign is seen:
Keith Lamont, who first drew attention to the Black Line Phenomenon, has found that administration of vitamin E, bioflavonoid complex and homoeopathic ferum phosphate will correct this deficiency.
Bertrand DeJarnette D.C. the developer of sacrocranial technique, writes extensively on the subject of the ‘red reaction’-
He describes how he initially makes assessments of patients (partly based on blood pressure readings) into various categories, during which process he has them treated in order to alter the relative oxygenation levels which are assumed on the basis of these categories. None of these methods are pertinent to this survey of skin reactions, but are a necessary preamble to his descriptions, which would be confusing otherwise. In a ‘type 1’ patient, who has received the appropriate preliminary attention as outlined (‘carbon dioxide elimination technic’):
‘Sit or stand immediately behind the patient facing the patient’s back. Have the patient bend slightly forward. Be sure the light is even on the patient’s back to avoid shadows. Place the index and middle fingers of your right hand upon the 7th cervical vertebra, having the two fingers about an inch lateral from the spine of the 7th cervical vertebra. Keep the fingers evenly spaced as you go down the spine, so each line is as straight as possible. For the ‘Type 1’ patient (normal BP after appropriate techniques) use a light touch. To produce an even pressure of both fingers on the back they may be fortified by placing the fingers of the left hand over them. As you go down the spine, your pressure will be just hard enough to cause the fingers to dent the skin.
Now draw your fingers down the spine very quickly ending at the coccyx. Step back and watch the reaction. A red line will usually appear all the way down the spine. This soon starts to fade and the fading is what you must watch. The area that appears Reddest as this fading starts, is the major [lesion] for this patient and should be marked with a skin pencil. You will often notice on this type of patient that the major area is much wider than any other area of your lines down the back. This is caused by tissue infiltration’.
The ‘Type 2’ category patient will have slightly high blood pressure after DeJarnette’s preliminary treatment. After adopting the same starting position:
‘Making a firm pressure, draw fingers down the spine, with a fairly slow motion. You should be able to count to 15 while drawing the fingers from the 7th cervical to the coccyx, by counting steadily. With a good light on the back, the results should show a line which becomes red, some portions brighter and some very faintly coloured. Now watch the lines fade. The area which shows the Whitest is marked as the major [lesions] for this is the most anaemic spinal muscle area. It will be paler than any portion of skin on the patient’s body.’
Moving next to the final category which interests us in this survey, (patients with high blood pressure) DeJarnette asks that you adopt the same start position and then:
‘Making heavy pressure, come down the spine slowly, counting 20 as you go from 7th cervical to coccyx. Now watch the reaction. The line that shows the Whitest is the major [lesion]. In this type the blood pressure is over 180 (systolic) the whitest area shows a waxy, pale colour and may persist for several minutes.’
Professor Irvin Korr, writing of his years of osteopathic research described how this red reflex phenomenon was shown to correspond well with areas of lowered electrical resistance, which themselves correspond accurately to regions of lowered pain threshold and areas of cutaneous and deep tenderness.
‘You must not look for perfect correspondence between the skin resistance (or the red reflex) and the distribution of deeper pathologic disturbance, because an area of skin which is segmentally related to a particular muscle does not necessarily overlie that muscle. With the latissimus dorsi, for example, the myofascial disturbance might be over the hip but the reflex manifestations would be in much higher dermatomes because this muscle has its innervation from the cervical part of the cord.’
By use of a mechanical instrument which quantified the pressure applied at a constant speed, followed by measurement of the duration of the redness resulting from the action of the frictional stimulator on the skin, Korr could detect areas of intense vasoconstriction which corresponded well with dysfunction elicited by manual clinical examination.
It could be said that the opportunity to ‘feel’ the tissues was being ignored during all these ‘strokes’, and ‘drawing’ of the fingers down the spinal musculature.
This thought was not lost on Marsh Morrison D.C. who describes his views as follows:
‘Run your fingers longitudinally down alongside the dorsal and lumbar vertebrae (anywhere from the spinous processes extending laterally up to two inches) and stop at any spot of tissue which seems ‘harder’ or different from normal tissue. These thickened areas, stringy ligaments, bunched muscle bounds, all represent indurated tissue; they are usually protective and indicate irritation and dysfunction. Once these indurated areas are palpated press down and almost always they will be sensitive, indicating a need for treatment.’
Morrison used a technique for easing such contractions similar to that later described by Lawrence Jones D.O. in his Strain/ counterstrain system.
Osteopathic researchers, Doctors, Cox, Gorbis, Dick and Rogers, writing in 1983 (regarding their work on identification of palpable musculoskeletal findings in coronary artery disease describe their use of the ‘red reflex’ as part of their examination procedures (other methods included range of motion testing of spinal segments and ribs, assessment of local pain on palpation, and altered soft tissue texture). In this study the most sensitive parameters, which were found to be significant predictors for coronary stenosis, were limitation in range of motion and altered soft tissue texture.
‘Red reflex’ cutaneous stimulation was applied digitally in both paraspinal areas [T4 and T9-11] simultaneously briskly stroking the skin in a caudad direction. Patients were divided arbitrarily into three groups.
- a/ Grade 1 – erythema of the spinal tissues lasting less than 15 seconds after cutaneous stimulation.
- b/ Grade 2 – erythema persisting for 15 to 30 seconds after stimulation
- c/ Grade 3 – erythema persisting longer than 30 seconds after stimulation.
In this context the Grade 3 – maintained erythema – is seen to represent the most dysfunctional response.
Making Sense of the Red Reaction
Clearly there is a good deal to learn from and about the simple procedure of stroking the paraspinal muscles. Whether or not DeJarnette’s preliminary methods are validated does not alter the possible wisdom of his subsequent observations, employing as it does variable pressures and looking as it does at the fading of redness, rather than the initial red reaction itself, for evidence of altered function.
Similarly, Lamont’s nutritional observations would need verification, something which does not alter the fact that some patients demonstrate this unusual ‘black streak’. As with so much in palpation there is little question of ‘something’ being ‘felt’ or observed. It is the interpretation of what it means that excites debate.
The simpler observations of Upledger, Hoag, Morrison and McConnell are readily applicable, and should be tested against known dysfunction to assess the usefulness of these methods during assessment.
The research of Cox et al indicates that one musculoskeletal assessment method alone is probably not sufficiently reliable to be diagnostic, however when for example tissue texture, changes in range of motion, pain and the ‘red reaction’ are all used, a finding of the presence of several of these is a good indication of underlying dysfunction which may involve the process of facilitation.
A Simpler Use for the Reaction
A less complex use of the red reaction is to go back a century to McConnell’s method, described earlier in this special topic note, in order to highlight spinal deviations. By creating erythema paraspinally you can stand back and visualise the general contours of the spine as well as any local deviations in the pattern created by application of your firm digital strokes.
How do you know whether your palpating fingers or thumbs are applying equal pressure bilaterally during such assessments, or when palpating elsewhere, bilaterally?
A useful guide to the uniformity of pressure can be obtained by comparing the relative blanching of your nail beds; are they equally white, pink, red?
1. McConnell C The Practice of Osteopathy 1899
2. Hoag M Osteopathic Medicine McGraw Hill, 1969.
3 Upledger J. Vredevoogd W. Craniosacral Therapy, Eastland Press, Seattle 1983
4. Newman Turner R Naturopathic Medicine Thorsons, Wellingborough UK, 1984
5. DeJarnette B Reflex Pain (Nebraska,1934)
6. Korr I The Physiological Basis of Osteopathic Medicine, Postgraduate Institute of Osteopathic Medicine and Surgery, N.Y. 1970
7. Morrison M Lecture Notes, London 1969
8. Cox, Gorbis, Dick and Rogers Journal American Osteopathic Association vol.82 No.11 1983