Palpation Skills and Improving Body Mechanics
Consider Manual Therapy and Complementary and Alternative Medicine for Optimal Health
Develop Palpation Skills and Avoid Arm, Wrist and Hand Pain Related Burnout
Seventy-five percent of people taking massage courses for medical students reported that “their main motivation was to improve palpation skills”. The study took place in the 1990’s at the Frankfurt University Medical School.
―Falkenbach, A., E. Blumenthal, et al. (1998). “Course in massage therapy for medical students.” Med Educ 32(5): 514–6.
The excellence of palpation skills often predicts the success a hands-on therapist will have with their clients. As a result, those who excel in manual therapy are always looking for ways to increase their ability to perceive variations in tissue quality, signs of inflammation, rhythmic impulses throughout the body and the story held within the tissue of the client on their table.
One key way to develop palpation skills is to practice perceiving information with your hands. Using this avenue brings greater skill with experience.
Reading and studying are additional ways to gain skill in knowing what tissue is under your hand. Touching the skin and being able to visualize and sense the deeper structures is important to our palpation skills. There are many anatomy, physiology and pathology books available for students of the body. One book that can be helpful in visualizing and knowing what is below the surface is Anatomy : palpation and surface markings. Consider what Sir William Osler said, “To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”
Taking classes that focus on an area of the body or address using the hands as diagnostic tool is another way palpation skills can be developed.
Getting yourself treated is an excellent way to improve palpation skills. With treatment you can experience from the inside what different kinds of touch feel like. Notice what information you gain about your body when a therapist palpates your back or arm or abdomen. How do the different areas respond? What information can you gain about your own body? Another benefit of getting treatment is that your arms and hands and nervous system improve and with those improvements comes a greater palpation skill and healing in your body. Hands that are cold or stiff due to a lack of blood flow will not be able to perceive the subtle differences in tissue quality. There are several techniques listed at the end of the article from two book that help to decrease muscles tension and encourage blood flow in the arms. The books are Integrative manual therapy, for the upper and lower extremities. volume II (Rev. ed.) and Integrative manual therapy for the autonomic nervous system and related disorders : utilizing advanced strain and counterstrain technique. These techniques can be used by two therapists on each other or can with enough pillows be used as self-treatment.
Another way to treat hands and arms, increasing blood flow, decreasing muscle tension and improving nervous system function are with techniques from a Connecticut School of Integrative Manual Therapy class called Ball Biomechanics (see below). These techniques make a remarkable difference in the health of the therapist’s arms and hands, improving not only the ability to palpate and understand the information coming from the tissue but also enables them to be more skilled in treating their clients and avoid the burn out that comes from hand, wrist and arm pain.
Neurofascial process (NFP) is an excellent way to improve palpation skills. The book Body Wisdom clearly explains NFP, which is a self-care exercise where one hand touches one area of the body and the other hand contacts another area bringing the two areas in communication with each other for improved health. The term Neurofascial process tells you that this communication is facilitated by the nervous system and the connective tissue pathways through out the body. The process component is the release of emotional and other process energies from the tissues as a result of the hand contact. One way to use NFP to facilitate improved palpation is by putting one hand on the ureters (low back), which is considered an area of drainage and the other hand on the arm and hand. This can be challenging to do by yourself so working with a friend, having the friend put a hand on the ureters while you contact both your hands and forearms can be very beneficial. This contact should continue for 15 or 20 minutes at a time and can be repeated as many times as desired.
A fun exercise that improve palpation skills and stimulates the nervous system is taking two boxes and putting the same things in each box. Use things that have different kinds of sensation — a piece of sand paper, an apple, a piece of silk or carpet or a magic marker. Cut a hole in one box so you can see the contents. In the other box cut a small hole on the side that allows you to reach in but not to see the contents. Then look in one box and choose the item you will pick up — such as the piece of silk. Pick up the silk. Then with the other hand, reach into the other box and feel around for the piece of silk and pull it out. More information of how, looking, contracting muscles, touching, feeling, contracting muscles on the opposite side and picking up something is found in the book, Smart Moves, why learning isn’t all in your brain. Remember to mix things up by looking and reaching with the right hand then switching and using the left hand first. You can also reach into the box, feel for the first thing you touch then look in the other box and locate that thing visually, then engage your muscles to pick it up.
Interrater Reliability
In a study to examine the interrater reliability of a passive physiological intervertebral motion (PPIM) test of a mid-thoracic spine motion segment, researchers noted, “Percent agreement ranges were 63.4% to 82.5%, with kappa scores ranging from 0.27 to 0.65. The PPIM testing demonstrated fair to substantial interrater reliability. A majority of females (91%) demonstrated greatest segmental PPIM motion in contralateral rotation with lateral flexion, whereas a majority of males (90%) demonstrated greatest segmental PPIM motion in ipsilateral rotation with lateral flexion. These findings are applicable to asymptomatic subjects of the same age category. Interrater reliability of 3-dimensional PPIM testing is fair to substantial for assessing passive segmental mobility of the mid-thoracic spine.”
―Brismee, J. M., D. Gipson, et al. (2006). “Interrater reliability of a passive physiological intervertebral motion test in the mid-thoracic spine.” J Manipulative Physiol Ther 29(5): 368–73.
Applied Kinesiology Palpation
“A case series of thirty patients between the ages of 18 to 75 who had spinal fixations and decreased rib expansion were chosen for this study.
All patients were measured for 1) spinal flexion, 2) passive arm abduction, 3) lateral bending of the neck and head, 4) rib expansion at the xiphoid process, 5) motion palpation of the spine, and 6) muscle testing for AK correlations with spinal fixations by testing for bilateral inhibition of the deltoid, popliteus, teres major, lower trapezius, psoas, gluteus maximus, and neck extensor muscles.
Treatment consisted of testing and correcting one or more of the following: 1) anterior talus, 2) dropped navicular, 3) lateral cuboid, 4) posterior calcaneus, 5) treatment to strengthen inhibited tibialis posterior, posterior longus, and gastrocnemius muscles. Proprioceptive neuromuscular facilitation (PNF) was applied to the ankle and foot muscles, and proper instructions on walking were given. The patients were then asked to walk for 100 steps on a treadmill and the above tests and measurements were repeated. All but 5 patients showed all spinal fixations corrected, and rib expansion increased an average of 1.3 inches. Spinal flexion increased an average of 3.75 inches. The patients were then asked to walk 30 steps with their previous improper gait pattern, and all but two were found to have their original restrictions return.
Normal walking creates patterns of muscle action that normalizes spinal mechanics and rib expansion.”
―Leaf, D. (2005). “Effects of proper walking on spinal fixations.” Collected Papers International College of Applied Kinesiology, 2005–2006;1:95–96
A case series of 200 patients were examined to determine the correlation between spinous process tenderness and a subluxated vertebra as found with Applied Kinesiology methods found, “118 males and 82 females were evaluated, ranging from 5 to 75 years of age. Each patient was examined by manual palpation for spinous process sensitivity, and the patient gave a numerical value from 1 to 10 for the pain level. Care was used in assuring that the amount of pressure used would not cause pain in normal subjects. An electronic scale was used and found that 8 to 10 pounds of force was sufficient to elicit the tenderness response. After this examination method, each section of the spine that elicited tenderness to spinous process pressure was evaluated by standard AK MMT procedures to see if these sections would also therapy localize and be positive to challenge.”
The study showed an 83.3% correlation between the presence of spinous process pain and subluxation findings using AK methods.
Chiropractic Palpation
There are a number of criteria that chiropractors use to determine which vertebrae to adjust. Demonstrating a correlation between these findings is desirable. This paper demonstrates a statistically significant correlation between the signs and symptoms AK physicians use to determine the presence of vertebral subluxation and spinous process tenderness.”
―Sprieser, P. T. (2001). “Spinous process sensitivity as an indicator of subluxation.” Collected Papers International College of Applied Kinesiology, 2001–2002;1:37–39.
Palpating and Improving Circulation with Manual Therapy
Good palpation skills can be used to find the source of the pain or dysfunction. Here are a series of references on what is palpable about the circulation system.
Trauma, compression, atherosclerosis can all contribute to decreased abdominal blood flow, which can contribute to back pain, radiating shoulder pain, dysmenorrhea [menstrual dysfunction], cysts, hematomas [pooled blood] and cancers of the abdominal organs. Circulation problems related to trauma are especially common among athletes. (Holt, J. 2004)
Hypovascularized sites or areas of compromised blood flow are particularly common in the celiac artery. Stenosis of the celiac artery, a branch off of the aorta (the main artery leaving the heart), is found in up to 24 percent of the general population. Many of these people have no symptoms. (Park, 2001)
The most common cause of celiac axis stenosis or a narrowing of the celiac artery is external compression on the artery, according to Park, 2001 in “Celiac axis stenosis: incidence and etiologies in asymptomatic individuals.” Atherosclerosis is the second most common cause. Often the compression is caused by the median arcuate ligament, a ligament that comes off of the respiratory abdominal diaphragm. Because the ligament is attached to the diaphragm, the tension on the celiac artery can be release on inhalation or breath in. The arcuate ligament starts as a thickening of the connective tissue of the psoas muscle at the lumbar spine and hip. The medial arcuate ligament goes from either side of the first lumbar vertebrae to the respiratory abdominal diaphragm. A compression in this area can lead to decreased blood flow and back pain.
Massage and manual therapy is often used to decrease pain and tension in the area of the low back, spine, hip muscles, including psoas and the respiratory abdominal diaphragm. Breathing exercises can also help decrease tensions in this area. The most common symptoms of decreased blood flow in the abdomen is back pain and abdominal pain right after eating. Vomiting is another common symptom.
Caution is wise when treating the abdomen as the most common reason for find an asymptomatic stenosis or narrowing of the celiac artery is a scan or diagnostic procedure for some kind of abdominal cancer, liver, stomach, gallbladder, or pancreas. The literature is not clear about whether the lack of blood flow proceeded or in any way influenced the development of the cancer.
Manual therapists use palpation to feel for areas of tissue density, temperature changes and rhythms reflective of circulation. They can use this diagnostic information to treat the soft tissue area of dysfunction. Advanced Strain and Counterstrain (Wheeler, L. 2004 in Massage Therapy Journal) and Myofascial Release (Weiselfish-Giammatteo, S., J. B. Kain, et al. 2005. Integrative manual therapy for the connective tissue system : myofascial release) are two ways to decrease tensions and normalize circulation through the tissue.
In 2000, Arutiunian in “Effects of manual therapy on pain reflex syndromes and various hemocoagulation parameters in patients with ischemic heart disease after surgical treatment”, recommended manual therapy after coronary artery bypass surgery (CABS). The researchers concluded, “the addition of manual therapy to the complex of rehabilitation measures in coronary patients early after CABS eliminates postoperative anginal attacks in 70% cases.” A year earlier, researchers noted, “pressure on acupoints can significantly influence the cardiovascular system” (Sudmeirer, 1999). A placebo controlled study using a color doppler sonograph, found that reflexology, positively influenced blood flow in the kidneys. Researchers found a “significant decrease of the resistive index during foot reflexology in the verum group indicates a decrease of flow resistance in renal vessels and an increase of renal blood flow.”
A 2006 study on vascular surgery concluded, “low back pain was improved by merely performing treatment for the vascular system and might provide support for the presence of vascular backache.” (Takeyachi and Yabuki, 2006). Another study recommended manual therapy as part of an intensive rehabilitation program. They concluded, “intensive rehabilitation in combined treatment is shown to improve external respiration function, central hemodynamics, tissue blood flow, sleep, appetite, healing of bedsores, and to enhance cough reflex.” (Kachesov, Kartavenko, et al. 2004).
This literature review indicates that palpation skills among Integrative Manual Therapists can find and change the trajectory of pain and dysfunction.
