Palpation: some definitions

The Oxford Dictionary of English defines the verb to palpate as: ‘to examine (a part of the body) by touch, especially for medical purposes’. Its derivative noun is ‘palpation’ (from the Latin verb ‘palpare’: to ‘feel or touch gently’). According to The Chambers Dictionary, the term ‘palp’ means ‘to feel, examine or explore by touch’; ‘palpare’ is defined as ‘to touch softly, stroke, caress or flatter’. Churchill’s Medical Dictionary defines palpation as ‘to stroke, caress; to explore or examine by touching and probing with the hands and fingers’.

Whilst ‘stroking’, ‘caressing’ or (tactile) ‘flattering’ represent practices (through ‘gentle touch’) that are essentially designed to give physiological and psychological ‘healing’ to the recipient, palpation, for the purposes of this text, is primarily a purposeful activity requiring considerable skill. It is associated with methodical exploration and detailed manual examination, the aim of which is to acquire objective information that will eventually lead to a reasoned medical diagnosis upon which a subsequent treatment regimen can be based. Gould’s Medical Dictionary makes the direct link between the activity of palpation and diagnosis by gentle touch which involves the detection of the ‘characteristics and condition of local tissues of the underlying organs or tumors’.

In The Oxford Dictionary of English, to examine is defined as ‘to test; to inquire into; to question; to look closely at or into; to inspect’. According to The Chambers Dictionary, to examine is to ‘inspect (someone or something) thoroughly in order to determine the nature of a condition’. The activity involves critical, reflective thinking: the systematic weighing up of evidence in an attempt to arrive at a balanced conclusion.

General characteristics of palpation

Palpation is a highly complex and sophisticated manual skill. Citing Frymann, Chaitow (2003) draws attention to the potential which palpation offers members of the healing professions:

As Frymann emphasizes, the hand is particularly well equipped to play the key role in this activity. With reference to palpation of the human body, Chaitow reminds us that different parts of the hand possess the ability to discriminate between variations in tissue features: ‘… relative tension, texture, degree of moisture, temperature and so on’. He then makes the important point that ‘This highlights the fact that an individual’s overall palpatory sensitivity depends on a combination of different perceptive (and proprioceptive) qualities and abilities’ (Chaitow 2003).

Some general characteristics

Palpation involves the use of one of the primary senses, that of touch, in order to investigate and obtain information or to supplement that already gained by other means, such as by visual and auditory input. As Poon (1995) points out:

Montague (1978) reminds us that:

Not only is it the earliest system to become functional in the human being but also touch is thought to be the last of the senses to be lost immediately prior to death.

Touch plays a very significant part in our everyday experience:

Experience suggests, however, that there are instances when touch is often subjugated in favour of reliance upon other sensory modalities. Only when an awareness of an alteration in incoming stimuli occurs do we become conscious of the sense of touch. An example of this phenomenon might be when picking up a garment, we recognize its unfamiliarity through its texture or ‘feel’; another example might be an awareness of the material of trousers touching the legs immediately after a long period of wearing shorts.

Touch may be divided into two distinct categories: instrumental and expressive. Touch is described as instrumental when it is associated with a deliberate action: locating an anatomical structure for the purposes of examination during a clinical assessment, for example. Touch is identified as expressive when it is associated with spontaneous, affective actions: touching a distressed person’s arm in order to convey sympathy and offer comfort (MacWhannell 1992, Poon 1995).

Touch can be experienced as safe or unsafe; physically comfortable or uncomfortable. It can be used to establish rapport: hand-shaking as a formal greeting at the beginning of a clinical interview or as a means of ending a treatment session. Communication by touch is specifically permitted within particular interpersonal relationships (see later). In certain contexts, however, permission to touch may be required, for example, at the commencement, and during the various stages of a clinical examination and treatment session. Touch is associated with psychological reactions: it is difficult to touch or be touched by those who elicit negative responses. The anticipation of touching or being touched can increase stress levels and these reactions may be influenced by personality, cultural and social factors: some female patients may deliberately avoid consulting a male therapist; some patients may be reluctant to remove clothing. It is important to remember that professional personnel are placed in an extremely powerful and privileged position in relation to others: they are given a license to touch and this power and privilege should never be abused.

The physiology of touch

All areas of the skin supplied with appropriate receptors are normally able to perceive a variety of sensations (pain, degrees of pressure, temperature changes, etc.) to a greater or lesser degree. Some areas, however, are more sensitive to stimuli than others because:

Sensitivity to spatial discrimination is poor in the lumbar region, the legs and the back of the hands. In the back of the hands, for example, two points can only be perceived separately if they are more than 50–100 mm apart. The lips, tongue and fingertips, however, rate high (1–3 mm). Thus individuals with normal sensation in the fingertips should be able to distinguish between two points even when they are less than 6 mm apart. This is referred to as the ‘Two Point Discrimination Test’ (see Chaitow 2003, Evans 2000, Magee 1997). The significance of this is that only relatively large objects can be recognized by the receptors in the lumbar region, whereas fine point discrimination can be achieved when employing the fingertips.

Chaitow makes the further point that:

Additionally, Evans (2000) contends that:

Citing Meyers, Etherington and Ashcroft (1958), Evans suggests that:

While sighted Braille transcribers, relying solely on visual input, have been known to become proficient at reading Braille by the end of only three weeks, experience confirms that individuals attempting to conquer the system by touch are estimated to take an average of years to reach a speed suitable for serious study, even with regular practice. This is not due to lack of knowledge of the system; rather it is because the palpation and recognition of the signs using tactile input requires a considerable amount of dedicated time and practice in which to develop. As with all skills, the speed and quality of reading depends upon the frequency and amount of use. The ability to palpate with any finger or fingers can usually be developed, the use of the index finger being the most popular. Reading speed is further enhanced by using the fingers of both hands. In some cases, this skill never develops if the individual has not learnt to employ touch from an early age. In rare instances, people who have been unable to use their fingers have developed the same ability to read Braille by using their toes or even their lips! (see above). This means that regardless of the method by which this skill is acquired, the ability to increase the information received through sensory input can be improved, given time and serious dedication to regular practice. This can be of great benefit to the clinical practitioner who wishes to ‘read’ information that lies deep to the skin. The controlled use of pressure and movement, coupled with feedback and experience, unlocks a vast quantity of information that is often unavailable to the eye.

Obtaining information through touch is a skill, the practical significance of which is often not fully appreciated or valued until it is needed, perhaps to compensate for the impairment or loss of one of the other senses: sight or hearing, for example. Because of this, considerable practice is often required before the skill of palpation becomes developed to the point where it is of practical use to the individual concerned (see above). Initially, new techniques have to be devised and then undertaken slowly and carefully, with regular practice and evaluation, often involving feedback from other observers with consequent modification of behaviour. Efforts to recognize and accurately interpret tactile sensory input demand high levels of concentration which necessarily cause anxiety and additional stress to an individual who is unaccustomed to placing such reliance on this variety of incoming stimuli. These reactions are likely to be experienced by the novice clinical practitioner as well as by the recently disabled person and should be regarded as normal responses to the process of acquiring a new range of sophisticated psychomotor skills and personal strategies (Owen Hutchinson, Atkinson and Orpwood 1998).

In other non-medical contexts, touch-related skills are used to acquire general information about the environment such as establishing the temperature of water. A thermometer could be employed for this purpose, but it is often easier (and quicker) to test water temperature by utilizing the input from the sensory endings in the skin. While the results of this method of temperature testing are likely to be far less accurate than if a thermo- meter were to be used, they provide a range of potentially significant information upon which subsequent action could be based. The water temperature, for example, might be experienced as burning, scorching, boiling, extremely hot, very hot, fairly hot, hot, quite hot, very warm, blood heat, warm, fairly warm, slightly warm, cool, cold, quite cold, very cold, bitterly cold, freezing and icy cold. A temperature of 42°C read from a thermometer has little practical meaning as to whether something is too hot or too cold to touch.

The social significance of touch

The concept of the novice engaged in learning to interpret incoming stimuli received through touch extends, of course, into the realm of social interaction. As suggested above, touch can represent a powerful means of expressive communication (Nathan 1999). The way in which this communication is interpreted will be contingent upon such variables as personality, upbringing, culture and social situation and, in these contexts, it seems unhelpful to separate touch into mechanical and psychosocial categories. Referring to a medical intervention, Nathan contends that:

The degree to which people will engage in touching will be dictated by the nature of the interpersonal relationship in which they are involved at the time. Nathan continues:

Touch can be employed to communicate a variety of emotions. For example, affection may be conveyed by a gentle squeeze of the hand, whereas a loose handshake may imply indifference or even dislike. Touching and being touched can be extremely therapeutic. Montague summarizes the observations of many researchers who conclude that:

Montague quotes examples of cases that were studied by Lorna Marshall, a researcher who spent much time between 1950 and 1961 living among the Bushmen of the Kalahari Desert in Botswana, South West Africa. He observed that, within this society, the development of the newborn, infant, adolescent and adult appeared to be influenced by the way in which the child was handled in early life. Montague also refers to accounts by Margaret Mead, who studied the Arapesh and Mundugumor societies in New Guinea during the 1930s and documented the characteristics of their respective social practices. In the former tribe, the child was in contact with the mother for most of the day. The adults of this tribe were observed to be kind, happy and peace-loving people. In the latter tribe, the child had little human contact, being kept in a rough plaited basket which was usually suspended from the mother’s forehead. The adults of this tribe were observed to become unattractive, aggressive and cannibalistic.

The tendency to avoid close physical contact can be demonstrated in adults from certain cultures and within some social backgrounds of particular nationalities. Montague comments that ‘There exists not only cultural and national differences in tactile behaviour but also class differences.’ He cites the English upper class as a an example of a social group that is characterized by non-tactile social behaviour when compared with social groups of other nationalities: French and Italian people display more demonstrative behaviour when greeting one another and are observed to engage in more physical interpersonal contact.

When considering the practice of palpation skills, the significance of Montague’s observations cannot be underestimated. Not only is it crucial for us to recognize the relevance of culture, nationality and social class on the degree to which people communicate by touch, but also the impact of living in a multicultural society in which we are likely to encounter unfamiliar and potentially disconcerting practices. Additionally the effect of globalization on our patterns of non-verbal communication has been considerable.

In contrast to the somewhat reserved behaviour of English people in the 19th and early 20th centuries, we now regularly witness overt instances of emotion (love and friendship, happiness and sadness) through physical contact. Behaviour such as mutual embracing, hand-holding and kissing is frequently to be observed in public places. Sportspeople will leap in the air and hug each other following a winning achievement such as the scoring of a goal in football; equally, it is not uncommon for athletes to display tears of misery and frustration and to engage in mutually sympathetic embraces after a failure to attain high standards of performance.

Touch and clinical practice

Palpation, then, would seem to be a practice which involves a combination of many other skilled activities: the appropriate use of touch, the application of methodical investigatory techniques, accurate interpretation of sensory feedback (based upon sound general knowledge), the ability to draw on previous experience, to reflect, critically, upon findings and arrive at a reasoned conclusion.

A skill is attained and retained by its continual use, evaluation and modification of practice (Phillips 2004). The study and practice of manual contact techniques over a long period of time enables the practitioner to become highly skilled in the art of palpation. The development of this skill provides valuable supplementary information to that which can be obtained through observation and verbal questioning and is crucial to arriving at a meaningful clinical diagnosis. After many years experience of practising palpation skills, the moving, stretching and compression of tissues will be undertaken with precise control. This will enable the therapist to receive and interpret vital information from the patient and to apply and modify techniques as appropriate. Small changes in tension, temperature, dampness, movement and swelling will be identified by the sense of touch; these will then be noted and the appropriate course of action taken. Grieve states:

As has been noted above, however, learning to palpate is also associated with acquiring the skills to ‘read’, accurately, the patient’s problem. Citing Ford (1989) Chaitow reminds us that:

Personal experience confirms that patients can easily distinguish between a novice and an expert practitioner. During the initial examination, both the practitioner and the person being palpated progress through a learning process in which each is engaged in assessing the other by the giving and receiving of information. Relatively little significant information can be obtained if one of the participants in this relationship is reluctant to communicate. This learning process takes time and it is often the case that an accurate picture of the underlying issues does not appear until much later in the treatment session. The reason for this is partly due to the need for each participant to become comfortable with the other, so permitting mutual reduction in anxiety and the relaxation of tension. It is also due to the need for both parties to become familiar with the learning process itself, so that each can benefit from the knowledge gained as a result of their participation in this two-way event. The skill of palpation, therefore, should not be regarded merely as an arbitrary form of physical intervention; rather it must be respected as a highly skilled investigative process which elicits specialized information to both participants. In our experience, the skill of palpation is estimated to be only 10% innate: the other 90% is acquired through dedicated practice.

Patient and person

It is far beyond the scope of this book to enter into the complexities of the mind–body debate, but its significance in relation to clinical diagnosis and management cannot be ignored. Traditionally, medical practice has been characterized by the biomedical model of health. This model is underpinned by the philosophical principles of dualism: the mind and body are regarded as separate and distinct entities that do not interact and, essentially, the practitioner is engaged in treating one or the other. The manual therapist would, in this context therefore, be regarded as being concerned only with the treatment of the patient’s body. Indeed, it is not uncommon to hear therapists refer to a patient as ‘a neck’ or ‘a back’. The body is considered to resemble a sophisticated machine; if part of that machine is malfunctioning, physical intervention is required in order to rectify the fault (Chaitow in Nathan 1999, Christensen, Jones and Edwards 2004, Owen Hutchinson 2004).

The 1990s, however, have witnessed significant changes in the approach towards illness and disability with the consequent development of the biopsychosocial model of disability which ‘is a way of conceptualizing the multifactorial and complex system that shapes a person’s experiences of pain and disability’ (Christensen, Jones and Edwards 2004). Citing various sources, Christensen, Jones and Edwards explain the biopsychosocial theory:

(See also Ramsden 1999, Stevenson, Grieves and Stein-Parbury 2004.)

The last decade has also witnessed a growth in the popularity of complementary medicine, whose underlying holistic principles stand in direct contrast to those of orthodox medical practice. This trend would suggest that patients prefer to be treated as whole persons rather than as bodies requiring cures. When they seek consultation with a therapist, patients are asking for help with more than just a painful neck or back: they want far more than to be the passive recipient of skillfully performed physical techniques. Indeed, patients regard a satisfactory healing experience as one that acknowledges the inextricable links between mind and body and which therefore treats the whole person who is more than just the sum of a collection of constituent parts. Recognizing this, the therapist must adopt an empathic and sensitive approach to all input from the patient, both in terms of verbal and non-verbal communication. Social and cultural factors must also be taken into account.

The quality of all clinical interventions will improve dramatically if the person-centred approach to patient management is adopted. The therapist, however, should not underestimate the degree to which patients have learned the conventions associated with society in general and medicine in particular. During the session, patients will often choose to use language to conceal as well as to reveal emotional states: ‘That movement does not hurt any more’; ‘I feel much freer now’. It must always be remembered that the patient has this choice. It must also be borne in mind that some patients may not have recognized the link between physical and psychological states and may need to be encouraged to reflect upon their choice of language in order to gain insight into certain aspects of their emotional lives.

As has been suggested above, the act of touching and the feeling of being touched are very powerful experiences and the degree to which people engage in touching is largely contingent upon personality, cultural and social factors. Both patient and therapist may experience an increase in stress levels due to unfamiliarity within particular therapeutic contexts. The practitioner must demonstrate a respect for the patient as a person. Permission to touch should be obtained at the commencement, and during the various stages of a clinical intervention. Abuse of power and the privilege of being licensed to touch must be avoided.

The consultation process

For a variety of physical and psychosocial reasons, many patients remain reluctant to consult professional personnel on matters associated with their personal issues, especially those problems relating to their own bodies. Barriers may be erected by one or both participants in the therapist–patient relationship, although both must contribute to the dismantling of these barriers if effective communication and co-operation are to be achieved. Experience suggests that each patient usually presents with a combination of issues which are revealed by the identification of problems, the giving of information and the posing of a number of questions during the consultation process. Typically, no particular order of priority emerges except perhaps that associated with the overriding presence of pain. Some of the information provided by the patient may appear to be somewhat peripheral in relation to the practitioner’s objective of establishing a clinical diagnosis, but it nevertheless represents a vital component of the overall clinical picture and must be thoroughly evaluated before it can be discounted.

The practitioner must be sympathetically receptive to all forms of information offered by the patient. Standards governing all areas of professional practice demand that the clinician must objectively evaluate all clinical evidence and attempt to produce a comprehensive analysis of the presenting situation. On some occasions, a prescribed plan will be used to facilitate the compilation and evaluation of data; at other times, the practitioner will be expected to tailor the procedure according to the patient’s individual circumstances. The use of such strategies will enable the practitioner to arrive at a reasoned clinical diagnosis. Care must be taken, however, that any prescribed plan does not preclude the practitioner from obtaining relevant information from the patient; adherence to such standard pro forma can sometimes adversely affect the practitioner’s judgement and thus lead to an incorrect clinical assessment of the patient’s current problem.

It is crucial that the practitioner should manage the initial investigation with great care and sensitivity as this process is likely to have a significant influence on both parties during the subsequent clinical examination. The practitioner should exercise the same degree of tact and diplomacy when conducting the subsequent physical examination, which should be undertaken with equal care, precision and gentleness. Physical or verbal clumsiness at this stage of the proceedings could lead to a complete breakdown of the interpersonal relationship between the therapist and patient, who may become reluctant to communicate vital information. The therapist employs palpation techniques during the first contact with the patient and it is vital that efficient methods of obtaining information are employed at this time. Experience suggests that most patients have an expectation that a clinical examination involving the use of palpation techniques will take place; indeed, they would consider it to be unprofessional practice if such a procedure were not undertaken. Inevitably, each person will exhibit different reactions to being touched and it is important that the practitioner should establish and evaluate the patient’s unique reaction to such interventions at the earliest opportunity. An initial indication of the patient’s reaction to physical contact can be obtained by the act of hand-shaking at the commencement of the session. Additionally, information gained by the act of assisting the patient to and from a chair can provide the practitioner with valuable feedback relating to the patient’s degree of willingness or reluctance to accept help. Of course, such strategies represent only part of the range of techniques being employed during this initial session. The use of visual, auditory and olfactory input can also provide useful sources of relevant clinical information.

During the period of questioning, the practitioner is recommended to make sensitive and careful physical contact with the area of the patient’s pain. When these techniques are performed successfully, this encourages both parties to focus attention on the patient’s motivation in seeking the consultation. All movements should be tested carefully, palpation skills being employed simultaneously with continual observation of the ongoing situation, the therapist monitoring any reluctance on the part of the patient to perform movements due to tension, muscle spasm, joint anomalies and pain. Inadvertently eliciting symptoms of acute pain will inevitably destroy the patient’s confidence, resulting in an unwillingness to offer potentially significant information.

In most cases, the patient will gradually gain confidence and learn to trust the practitioner. Much of the apprehension of meeting will have passed during the initial contact. When the time comes for the therapist to undertake an objective physical examination of the patient’s movements, rapport should have been well established which overcomes that initial reluctance to seeking of medical advice.

Palpation continues throughout the examination and subsequent treatment. If it is carried out carefully and sympathetically, it reveals valuable information concerning the patient’s physical and psychological condition. Indeed, palpation has the potential to ‘unlock’ psychological issues which had hitherto been deliberately ignored or unrecognized by the patient as having any relevance to the presenting physical problem. Many practitioners will have experience of patients who seek medical consultation for a relatively minor physical ailment which, during the examination or treatment, will be found to be masking much deeper and more complex issues. All practitioners should be sensitive to this possibility and should note any incongruous sentiments that the patient may express during the session. Experience suggests that it is the physical contact with the patient which appears to facilitate the unveiling of these underlying issues, but the importance of recognizing this phenomenon is contingent upon the quality of the practitioner’s professional training.

That the patient must have confidence in the practitioner cannot be over-emphasized. This will promote the offering of information through both verbal and non-verbal communication methods. Throughout the consultation, the practitioner should be receptive to the patient; as the session progresses, continual evaluation of the patient’s verbal and non-verbal reactions to events should take place. Whether complex or simple, all treatment sessions should promote mutual trust and understanding. Experience indicates that the degree to which a patient contributes to the treatment session is directly proportional to the practitioner’s input; this reciprocal relationship is, however, contingent on the practitioner’s willingness to impart information and the patient’s genuine interest in receiving it.