Osteopathic Treatment: Palpation

by Tyler Cymet, DO, FACOFP

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    00:01 I wanted to talk to you about how to touch people.

    00:04 In osteopathic medicine, you are going to be doing manipulation.

    00:07 You are going to be doing diagnostic assessments by touching a person, and when most people go to medical school, we know how we touch our family. We know how to touch our friends.

    00:17 We don’t know how to touch strangers.

    00:19 We don’t know how to touch people who are sick so it is a privilege we have to be invited into peoples’ lives to help make their lives easier and more comfortable.

    00:30 It is a privilege to be able to examine somebody and to touch them, but there are things about touch that we do have to be aware of, we do have to guard against, and do have to use to the maximum benefit.

    00:43 So palpation or touch is the application of the fingers to the surface of the skin.

    00:49 It’s touching somebody in order to get information about that person’s body, their functioning, the makeup of their tissues, and there are a lot of things that go into palpation.

    01:01 It allows you to spend time with your patient’s body to get more information about their functioning.

    01:10 So where does palpation fit in? Just about every patient who comes to the physician expects to be touched.

    01:18 They expect to be touched to be assessed, to be evaluated, and sometimes for treatment as well.

    01:24 So it is part of the look, listen, feel, and move your patient to figure out what’s going on with them.

    01:30 In osteopathic medicine, we’re assessing whether or not a patient has somatic dysfunction.

    01:36 And again, there’s an ART to it.

    01:37 You look for asymmetry, you look for range of motion changes, and you look for temperature, tenderness, or tissue texture changes.

    01:46 That’s the ART of diagnosis somatic dysfunction.

    01:50 For the tenderness, touch helps.

    01:53 For tissue texture changes, touch is essential.

    01:56 For temperature changes, touch is incredibly sensitive.

    02:00 Even asymmetry is better diagnosed with touching a patient to see if they move the same amount on both sides and both ways.

    02:09 And range of motion changes, restrictions to motion, can often be felt better when you’re trying to move somebody than by just observing them.

    02:18 So you have to use the passive and active motion to see how people move.

    02:22 Things to know when palpating.

    02:25 First of all, there’s a mindfulness that goes into palpation.

    02:28 Being there with the patient, focusing on what you’re feeling, focusing on what’s deeper and what’s underneath the tissue that is where your hands are.

    02:38 So you need to get some background as to what’s going on with the person, while they’re there, and know how they’re going to respond to your palpation, know how they’re going to respond to being touched, and watch the patient to see how they respond when they’re touched because you’re going to start with diseased tissue, with the area of pain, with the area of discomfort, because that’s where the patient expects to be touched and that’s where you’re going to start— typically, trying to find out how much tenderness, is there tenderness all the time, is it worse with touching.

    03:14 So with tissue finding, you want to go through the mind, body, spirit thinking and say, “Is this just the tissue underneath it? Could this be referred?” In osteopathic medicine, we talk a lot about somato-somatic, somatovisceral, and viscerosomatic reflexes where the body may exhibit an organ being ill or the body may exhibit dysfunction in one place, in another place, which is somato-somatic or it could be somatovisceral where musculoskeletal changes affect the functioning of some of the organs.

    03:46 And palpation will help you with all of those.

    03:50 Just general observations, palpation is a simple logical process.

    03:55 It has cognitive and physical pieces to it.

    03:58 Touching is one thing, picturing what should be under there and what it should feel like, should the muscle fell boggy, should the skin feel milky, should you have flaking when you’re touching somebody— all go beyond just the touch.

    04:11 It’s adding a cognitive process to the touch process, and it gives you the opportunity to make observations about abnormalities and function.

    04:20 Is it boggy like the patient’s potassium is too high? Is it edematous as if they’re third spacing or leaking fluid from somewhere? Those are all things you’ll be able to tell from touch.

    04:32 It informs us about the tissue structure, the function, and the overall health of the patient.

    04:39 So the body is a physical structure, touching it is going to help us understand what’s going on and the external manifestation of a person and the internal body functioning are integrated, so touching people will help give you some assemblance of what’s going on.

    04:58 And again, the structure of the body reflects the physiology.

    05:02 What can you tell from palpation? Obviously temperature and tissue texture.

    05:07 You can learn about the shape of a muscle, the size of a muscle. How big is it compared to how big it should be? Is there anything underlying the tissue? Is there tension to the tissue that’s not moving or does it move better in certain ways and not others? We know that a scar can limit mobility.

    05:26 t can limit tissue tensegrity or tissue motion and ability to flow and be used.

    05:34 One scar can limit activity, so you need to be aware of those things.

    05:39 It can also share the body’s motion possibilities, and again, edema.

    05:46 The benefits of palpation, it is part of clinical practice.

    05:50 It helps you bond to a patient because the patient is being touched in a way that they’re not touched by anybody else.

    05:59 It is a clinical way of bonding and linking with a patient, showing them that you’re not afraid to touch the areas that other people might not want to touch and that’s why it is generally the unhealthy areas, the areas that do have abnormalities or do have pain, where we usually start touching.

    06:16 And again, the patients feel a bond and they feel a connection and they do expect it.

    06:23 The key rules to palpation—be present, be concise— this is not a time to do something other than get information.

    06:30 So when you touch someone, touch someone with purpose, be there, focus on what you’re feeling, and focus on what’s underneath what you’re feeling.

    06:39 Communicate with your patient. Tell them what you’re touching and what you’re finding, sharing results shares that this is medical and gives the patient an understanding of why you’re touching, where you’re touching, and what you’re trying to get out of that.

    06:52 Receive permission from the patient.

    06:54 Some patients may have had experiences in their past or feelings about medical care that differ.

    07:01 They may not want to be touched.

    07:03 They may not want to be touched extensively.

    07:05 And we have to communicate about why we need certain things exposed, why we might need a hat taken off or clothes taken off.

    07:14 You need to share that with your patient and then you can negotiate, discuss and figure out what they’re comfortable with versus what you feel is the best way for you to get information.

    07:25 Pay attention to the patient’s body language, see when they’re uncomfortable.

    07:28 Make sure that this is concise, medical, and with purpose.

    07:34 Start slowly and gently, visualize the relevant anatomy both with what you’re touching and under what you’re touching, and adjust your approach based on the patient’s response, and to continue to communicate what you’re feeling, what you’re learning, and why you continue to palpate the patient.

    07:54 In OMM Lab, it is important that we do get access to tissues that are being treated, that people not wear tight fitting clothes that would limit palpation and limit our ability to comfortably move them, comfortably assess extremes of motion, and know when someone is hitting a physiologic barrier versus an anatomic barrier.

    08:13 Can you take them past an anatomic barrier or are the clothes going to limit your activity? These are things that are going to matter.

    08:20 Visualize the anatomy that you’re touching— that’s the idea behind it.

    08:24 Locate the correct tissue levels—if you’re going for the cervical or thoracic spine, you can start a level above or a level below before you get to the level where you think the problem is— just so you don’t jump to where the pain is but the area is the area of interest and the area of the complaint.

    08:41 Note to the tissue texture, put that in the chart, and get feedback from the patient during the process if there’s anything uncomfortable or anything that might need explanation.

    08:52 In preparing for palpation, you’re a professional— they’re going to look at your fingers, they’re going to look at your hands, and they expect them to be clean, well groomed, fingernails kept short, and make sure that you focus on what information you want and you get it directly.

    09:07 Keep the atmosphere professional and keep it goal oriented to what you’re doing, what you’re doing for a reason, and as a physician, you’re touching them for more information that will help you make a diagnosis or if you’re manipulating them, you’re treating them to enhance motion, ease pain, or make life more comfortable for them.

    About the Lecture

    The lecture Osteopathic Treatment: Palpation by Tyler Cymet, DO, FACOFP is from the course Osteopathic Principles and Tenets.

    Included Quiz Questions

    1. Viscero-somatic dysfunction
    2. Phantom Pain
    3. Somato-visceral dysfunction
    4. Somato-somatic dysfunction
    1. All of the answers are correct
    2. It is a logical cognitive and physical process
    3. Provides information on structure and function
    4. Provides information on the overall health of the patient
    5. Provides information used in decision making in regards to the patient
    1. Scar tissue
    2. Over hydration of tissue
    3. Systemic alkalosis
    4. Diabetes

    Author of lecture Osteopathic Treatment: Palpation

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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