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Integrated Bodywork

By Leon Chaitow, ND, DO

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Palpation Skills in Clinical Practice?

Have you ever thought about the process involved in the way experts make instant decisions as they work? Experts can be shown to have the ability to observe, recognize, interpret, judge, decide and to act appropriately, in a split second – not based on planned decision-making, but more on a foundation of sound knowledge and practiced skills. Consider these examples:

  • A tightrope walker's instant balance adjustment on the high-wire to retain balance
  • A baseball pitcher's ability to take advantage of something he almost intuitively observes about a batter's possible weakness
  • A neurosurgeon's instant, life-saving modifications to the scalpel's planned direction while operating, based on an unanticipated deviation from what is expected
  • A jazz musician's ability to seamlessly improvise, based on sounds he hears while simultaneously playing
  • And of course, we all do something very similar, every day, in conversation with others: As the form and content of conversations take unpredictable directions, we improvise our responses.

Not Intuition Alone

It would be a mistake to label such improvisation as merely intuitive. Intuition, in expert settings, needs to be based on solid foundations, otherwise we would all be brain surgeons or gifted musicians. This is just as true in manual therapy as in any other field, since skilled manual therapists are also experts.

palpation - Copyright – Stock Photo / Register Mark Consider the words of Donald Schon as he discusses reflection in action: "Often when a competent practitioner recognizes, in a maze of symptoms, a particular pattern, and constructs the basis for a coherent design in dealing with it ... something is being done, which cannot easily be described. Practitioners/therapists make judgments of quality for which they cannot [always] state adequate criteria. It is not difficult to understand why practitioners [therapists] should [sometimes] be puzzled by their own performance in the indeterminate zones of practice."1

I am sure that we can all relate to describing something as deviating from normal when palpating – far more easily than we can describe what that difference is; for example, when tissues just do not feel right. During palpation our hands recognize normality, as well as deviations from it. However, trying to put the perceived differences into words, or to analyze those differences, is not always easy. It seems that many skilled people – in all areas of life – demonstrate know-how as they learn to perform complex actions, without necessarily being able to describe them.

Palpation: Skill PLUS Art

It has been suggested that four basic characteristic signs should be evaluated when seeking evidence of localized musculoskeletal dysfunction.2 The acronym STAR can usefully be applied to describe these features:

  • Sensitivity: Is pain or tenderness noted in response to pressure or movement?
  • Textural changes: Can abnormalities in the tissues be palpated or observed – stiff, tense, flaccid, etc.?
  • Asymmetry: Is only one side of the body affected?
  • Restriction: Is there evidence of altered range of motion?

Where a combination of these characteristics are located and identified by observation, palpation and assessment, is also where evidence of a dysfunctional musculoskeletal area exists (described as somatic dysfunction in osteopathic medicine).

  • How tense, flaccid, indurated, hyper- or hypotonic are the soft tissues, which are being evaluated?
  • How mobile, restricted, functional/dysfunctional are the joints that are being tested, compared to normal joints?
  • Are the associated fascial structures functioning normally? And so on...

Of course, this sort of palpated evidence doesn't tell us why dysfunction has occurred, only that it may be present.

Tests, palpation and observation assessments may offer answers to the question what. For example, that the tissues being evaluated are sensitive, asymmetrical, restricted, short, tight, weak, etc., but such findings do not actually offer indications as to what to do clinically.

When we ask why, we can narrow down treatment choices:

  • Why is this sensitive to pressure?
  • Why are these tissues restricted?
  • What is preventing a free range of movement?
  • Above all – what is helping to cause/maintain these findings? Is it the result of overuse, repetitive strain, postural factors? If so, what can the person do to ease and/or prevent recurrence?
  • Can/should this be beneficially modified by manual therapy or exercise ?
  • Is the area of dysfunction secondary to some other, unidentified problem? For example, part of a compensation pattern?
  • Or is it the result of reflex activity or local trigger-point activity?

What we feel, what we sense, and most importantly, how we interpret the information we gather from palpation and assessment, determines how we treat the problems that we're asked to manage.

References

  1. Schon D. "Teaching by the Case Method." Boston: Harvard Business School, 1984.
  2. Fryer G, et al. The relationship between palpation of thoracic paraspinal tissues and pressure sensitivity measured by digital algometer. Journal of Osteopathic Medicine, 2004;7(2):64-69.
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