This is an excerpt from Clinical Guide to Surface Palpation 2nd Edition With HKPropel Online Video, A by Michael Masaracchio & Chana Frommer.
The body mechanics of the practicing clinician is an extremely important concept. It not only protects the clinician from potential injury but also aides in proper positioning between the patient and clinician to improve structure identification and treatment. Proper body mechanics will not only help the clinician work more efficiently but also aid the clinician in applying the appropriate force during examination and treatment. It is important to be constantly mindful of the stresses being put on your body. Always strive to be as efficient as possible (e.g., using gravity, using larger muscle groups, aligning the forearm when applying force) when performing techniques, and minimize trying to “muscle through it.” The following are techniques to consider for manual assessment and intervention.
- It is important to make sure the height of the table is correct. This allows for appropriate application of desired forces. For example, a downwardly directed force is one of the most frequently used, and one needs to make sure that force is perpendicular to the tissue. Often, students and novice clinicians place the table too high, which leads to inefficient application of forces in addition to poor movement patterns on the part of the clinician (e.g., hiking the shoulder, too much elbow flexion). This often results in excessive firing of muscles, which will cause fatigue during treatment. Conversely, if the table is too low, there is a tendency to adopt a position of lumbar spine flexion (as opposed to neutral), putting the clinician at increased risk of developing low back pain.
- It is important to understand the concept of a hip hinge and its role in a healthy back. Proper hip flexion rather than thoracolumbar flexion should be maintained (figure 1.4). The lumbar spine should be in a natural lordotic position. Excessive or insufficient lordosis can create excessive forces through the lumbar spine, which may increase the likelihood of injury.
- Be cognizant of foot position. A staggered stance is often optimal because it increases the clinician’s base of support and provides increased stability to the lower half of the body, optimizing alignment of the upper extremities for force application. Additionally, foot direction (neutral or externally rotated) is key to aligning the base of support with the force vector.
- Position the head, neck, and scapula in a neutral position. Often, clinicians work in a poor position, with the head forward, scapular elevation and protraction, and excessive neck flexion. This position not only makes it more difficult to appropriately apply force, but it can also cause excessive fatigue and pain to the treating clinician. Stacking the joints of the spine in a neutral column distributes forces to the sturdy vertebral column rather than to soft tissues.
- The most important tools are the hands. Clinicians must take care of them. During all palpation and manual therapy techniques, clinicians must avoid hyperextending their fingers during force application. This can lead to excessive compressive forces to the small joints of the hands (especially the first carpometacarpal joint) and may lead to early joint breakdown.
Palpation Clinical Pearls
- Most importantly, patients must first know how much you care.
- Remember to respect patient modesty and comfort and always obtain informed consent before beginning palpation.
- Touch is an extremely important aspect of the physical examination process. It helps foster the development of the patient–clinician relationship.
- Patient trust is imperative to their ability to avoid guarding the region being palpated.
- Firm but gentle hands enhance structure identification and also place the patient at ease.
- You must be aware of what your hands feel like from the perspective of the patient. Nails must be kept trimmed and smooth. The skin of the fingers and palms of the hands must also be kept soft and smooth.
- A thorough understanding of anatomy is essential for accurate palpation.
- Think about the structure you are trying to palpate and how that particular structure can be more easily identified.
- Always begin the palpation examination with superficial structures that can help orient you.