PALPATION

Palpation is an art that can only be taught to oneself.”
Rollin Becker DO

Palpatory ability is one of the foundations of osteopathic clinical practice. For us osteopaths, it is an essential method to evaluate dysfunctions and select the most suitable treatment techniques.
Also according to classical medicine, palpation is important, being defined as a method of clinical investigation and a manual semeiological maneuver, which is based on the proprioceptive sensitivity of the doctor and constitutes one of the classic cornerstones of the patient’s physical examination, thus obtaining tactile information useful for clinical purposes such as temperature, consistency, degree of resistance, presence of pulsations, vibrations, pain, etc…
It is one of the oldest forms of diagnosis and has always been considered one of the most effective methods of examination.

Palpation is therefore an essential tool for the osteopath. Our great masters insist on the importance of acquiring good palpatory skills. Sutherland said: “Osteopathic technique consists in an intelligent application of tactile sensibility… A well-trained touch is an essential principle of osteopathy; and is essential for both diagnosis and treatment… This is not learned by observing other colleagues manipulating, but it is learned and acquired only by positioning the hands correctly and following them as if they were an intelligent palpation monitor, as if they were seeing, if they were listening, if they were thinking…” (from The Cranial Bowl).
Palpation for the osteopath is not limited to being a “data collection”: the concept of intelligent palpation leads to feeling, listening, perceiving and detecting changes in the texture of tissues through the hands.
Rollin Becker said, “Only textiles know.” The problem is to enter into a relationship with the tissues and make them tell them what they know, to put them in communication with each other, which can only happen through palpation.

The subjective parameters of palpation.

Presence, intention, attention, visualization are the subjective parameters of palpation, characterize its quality and are essential for communicating with the patient.

Presence: it means to occupy the present space, to occupy the present moment. It is being “here and now” (here and now). The term presence derives from the Latin “praesentia” which means “to be ahead”, “in the presence of”.
Being present requires the awareness of listening to both the patient’s speech and body. Often we are so caught up in ourselves that we don’t even grasp the verbal messages that the patient communicates to us. Therefore, presence is the primary necessity to start a relationship with the patient, both verbal and physical.

Intention: This is what you intend to do to achieve a given end. It is the starting point of all events, if there is no intention there is no action. Communication follows this rule: if we communicate with someone, it means that we have the intention of telling them something and that they understand. The same thing happens in palpation: what do I want to do when I place my hands on the patient? What do we want to hear? The information we obtain will be contingent on our intentions.
Intention is the source of the kind of sensations, of movements that I want to perceive: if our intention is to perceive the cranial pulse we will perceive it, if we want to feel the “unraveling” of a tissue that is freed from tension we will feel it. Therefore, when we place our hands on the patient, it is necessary to be clear about what we want to do. It is important to channel our intention accurately because what we perceive will be directly related to the precision of the intention.

Attention is closely linked to intention if we want perception not to be polluted by other parasites.
Attention: it is another very important element for communication and therefore for palpation. From the Latin attenzio-onis, that is, to turn the soul; it is the act by which the mind turns to an object; It is the process by which the organism focuses its nervous and psychic activity on a stimulus or set of stimuli that reach the perceptual field. In structuralist psychology, attention was seen as a characteristic of consciousness, while for other authors, attention was already placed outside consciousness as a process that precedes it and selects and prepares its activity. We could therefore define it as the ability to select all the influences that prevent, the interesting ones and the less interesting ones, and also to select them with regard to their quality (sight, hearing, taste, touch, etc.) and their possible location in space. For example: we are at a social meeting and the place is full of people and the buzz is more or less loud, at some point we recognize a friend and start talking to him. We did several things that involved attention in a relevant way. Noticing the friend, our attention, which previously encompassed a large, defined space, has been localized to a narrow space, encompassing the friend, ourselves and the space that separates us. It is obvious that it is not the space that has shrunk but our space of perception. Initially, we received all the stimuli without discriminating, but then we selected the type of stimuli we perceived. In the same way, we may receive from a living body a multitude of information that coexists, and which we neither discern nor isolate.
Thus, when we relate to the patient by listening to the sensations that reach us with palpation, we receive a myriad of information, messages given by movements such as heart rate, chest breathing, movements related to cellular life, the functioning of the MRP, fascia, etc. It is our attention that allows us to isolate and perceive distinctly what we want, neglecting the other elements that coexist during palpation. For example, when we “listen” to the skull it is our attention that makes us discriminate the movement of the blood pulse from the MRP, or when we listen to the ribcage bands it is always our attention that makes us discriminate the movement of chest breathing from the intrinsic movement of the fascia.

Thus intention creates action, while attention determines what it is located on. Intention therefore modulates attention. It is important, however, not to induce anything: intention guides attention, but we must be careful not to incite the tissues that we are palpating or they will do exactly what we are inducing with our hands. We must limit ourselves to listening.

Visualization: it means to make something visible, to represent it through images. In order to correctly perceive the information that comes to us from a part of the body, we have said, it is important that our attention is directed towards that part of the body that we are listening to. It is precisely from this that we perceive exactly what comes to us from the tissues. If our attention is not focused, we will no longer be able to connect the sensations we perceive with the tissue itself, and therefore in order to discern well, it is important that our attention is on the tissues and not on our hand. And it is precisely in these circumstances that our anatomical knowledge comes to our aid; In order to be fixed, attention needs a reality, which in our work is the anatomical reality, the anatomical visualization. Our anatomical knowledge allows us to represent, to mentally visualize the region we are palping. One of the philosophical principles of osteopathy is: anatomy, anatomy and more anatomy. One of the aims of our anatomical study is to obtain a correct anatomical image: not all areas of the body that we want to perceive are directly visible; many are deep and not accessible to the eye. But if you have a good mental visualization, what we will perceive will come from that particular area that we are imagining. Visualizing anatomy correctly is important to give anatomical meaning to what is perceived. How would it be possible to interpret the movement of the skull bones felt under the hands without having a clear image of the skull bones? Or rather, how can we interpret the tactile sensations that come to us from the cranial contents without having a precise anatomical image of the various structures within the skull?
Our anatomical knowledge therefore allows us to really understand what we will feel under our hands and visualization is what allows us to have perception even from the very deep tissues contained within the cranial, thoracic and abdomino-pelvic cavities.

Objective parameters of palpation

In the previous paragraph, the question we asked ourselves was how palpation should be carried out in relation to communication; Now, to understand what the objective parameters of palpation are, we need to ask ourselves another question: “What should I palpate?”
These parameters are linked to the physical qualities of the biological tissue and therefore linked to the living organism and to the organization of living matter itself.
The body, belonging to the physical universe, is made up of matter, and as such is organized in space and time, and what makes matter move is the intrinsic energy of matter itself.
If we relate these elements, energy, mass, space, and time, we obtain various ratios that express certain qualities of matter.
What interests us as osteopaths are in particular density, tension, speed. They characterize a fabric in motion.

Density: it is the ratio between mass and volume of a substance, so it is the amount of matter in relation to space; It therefore indicates the impregnation of energy of that part of matter and therefore also the relationship between energy and space. When I go to feel the density of a fabric, I look for the compactness and body of a fabric.
The structures of the body do not all have the same density, the density of a muscle is different from that of a bone or that of an organ, a bowel or a fascia. Therefore, it is important during palpation to pay “attention” to which tissue we want to feel, and the density of the tissue we want to mobilize is an important element: the denser a tissue is, the longer it will take to change its initial state consistency.
The concept of density is therefore strongly linked to the fact that matter is concentrated, ordered energy, stabilized in space and time, consequently it is advisable to adjust the palpation to the density of the tissues to be treated.

Tension: a term that, in scientific use, has passed from mechanics understood as elasticity to other fields. A practical example is represented by the comparison between two balloons, one more inflated than the other: the two objects will have a different tension (surface tension) and elasticity from each other. It is these tactile sensations that indicate the tension of a fabric.
The rhythm of the fabric: refers to the movement of a fabric. From a physical point of view, it is the relationship between space and time: a body that moves in space and time. It is therefore the propensity of a body to move. The movement of a fabric can be slow or rapid, and the denser a fabric is, the slower it is. It is therefore the ability of a fabric to circulate energy, understood in this sense as an expression of movement.
According to modern physics, everything is energy. The energy of a body or system is defined as its aptitude, ability, to perform work; But it is not easy to give a definition of energy as this is closely related to the very definition of what life is.
In fact, every biological organism, in order to live, must continuously perform operations of various kinds: synthesis, demolition, transfer of substances, osmotic work, electrical work, etc. And all of these processes require energy. This implies the fact that the movement of a body takes place thanks to the energy of the body and is at the same time an expression of energy. A biological system, in order to maintain a good state of health, must therefore continuously give rise to energy exchanges (communicate) both with the environment inside and outside the cell itself. When, for various reasons, this does not happen, the state of health is altered: a state of non-communication and a retraction resulting from non-communication is determined, which modifies the very organization of the cell. The consequences are an increase in density, loss of elasticity, it will become a point of non-movement and therefore the very function of that tissue will be disturbed.
After identifying the various parameters of palpation, we move on to the palpatory agreement with the tissue with which we intend to communicate: we need to be in tune with the tissue (tune in) and this is possible only if I relate to the density, tension and speed of the tissue itself. This is the access key that opens communication and that will allow me to enter the tissues and thus help the process of self-regulation. Our job then is to look for the restriction zones with greater density, go to their level of density, and through our intention and attention rebalance the energy until something moves and communication resumes. When this agreement is made, the tissues release their accumulated energy by moving and releasing the accumulated energy in turn also in the form of heat.

Therapeutic silence.

“Silence does not belong to us, silence belongs to music, to nature, to things. Man would claim to possess everything, but silence can be sought or, paradoxically, listened to.
Listening will not be able to possess silence, but to verify its impossibility of existing.” M. Brunello (2014)

The breath, the pause, the suspension, that is, the silence, become a fundamental part of the therapeutic thought, creating new perceptions on the tissue. These perceptions are essential to make the patient understand the new bodily adaptations, after the technique.
These pauses allow to increase the parasympathetic effect on the body and in the most sensitive subjects, to understand the change in the treated tissue.
On the contrary, if we stimulate with many techniques without any pause, we will obtain a sympathetic neurovegetative response. This is definitely the wrong stimulation for the majority of our patients.
The common mistake for us osteopaths, and not only in our profession, that we have all made for decades in thinking, that technique is the primary consideration of treatment and the more I do the perhaps better, to satisfy our ego or calm our insecurity.
The rhythm of communications, i.e. the techniques, is essential for a better synergy with the patient, but all this is learned after decades of profession.

In tissue listening we have to understand what type of tissue we are going to palpate, each tissue communicates differently and requires different correction times, due to the time that the dysfunction is present, in this case we should also wait for the effects of several treatments for a rebalancing of the area, of the emotion, or of the tissue characteristics of that area.
A fundamental piece of advice: if you want to learn to feel, you have to be very patient and curious, in order to discover new sensations and new results.
A difference between bone tissue and fascial tissue is well evident, bone will take us some time for an intra-osseous dysfunction of 20 years earlier, a fascial tissue, much less, but if it is emotionally charged, let’s take a small example I have a small knee sprain. The ligamentous and fascial strain no longer allows me to run, the patient has a moment of great stress and running was his therapy, in these cases the times become longer because an emotional component is associated.
Endocrine tissue takes time and lightness. Its sensation is vibrant, you have to understand if it is hypo or hyper, easier to feel and also to correct is hyper. We can have dysfunctions of a metabolic nature, such as hormonal imbalances in pre-menopause, as well as others associated with stress, as well described by H. Selye (1958) defined as “General Adaptation Syndrome”.
When the body is subjected to the prolonged effects of multiple stressors, such as physical, mental, social or environmental stimuli, when it can no longer adapt, there is a
The evolution of the syndrome occurs in three phases: Alarm, the body responds to stressors by implementing coping mechanisms, which are made up of increased heart rate, blood pressure, muscle tone, spasm, and arousal (psychophysiological activation). Endurance, the body attempts to fight and counteract the negative effects of prolonged fatigue by producing specific hormonal responses from various glands, the adrenal glands for example.
Exhaustion, if the stressors continue to act, the subject can be overwhelmed and permanent adverse effects can be produced on the psychic and/or somatic structure.
So depending on the stage of the process of activation of the problem, the treatment time will change on hormonal dysfunctions coupled with stress, it will need more attention and time.
A tumor tissue is dense and does not want to communicate, but then it gives way and then the density quickly returns, if we have similar sensations it is recommended to have medical checks, also because improving fluid circulation is a contraindication in this case, but in cases of terminal patients the treatments improve the patient’s final quality of life.