Skin and muscles represent independent sensory input organs for treatment methods based on reflexes (connective-tissue massage) and energy flow (acupuncture) as well as locally applied treatment methods (e.g., Swedish massage).
Systematic palpation of these tissues has long been a topic of discussion. In connective-tissue massage, changes in skin consistency, for example, are attributed to specific disorders of the inner organs or the vertebral column. Classical massage treatment targets pathological muscle tension in particular. In these treatment methods, palpation is used for the purpose of assessment and also for monitoring progress. Massage is rarely used without previously palpating local or general hardening in the muscles.
Therapists must manually palpate through skin and muscles if they wish to reach deeper-lying structures. As an example, certain segmental tests and treatment procedures cannot be successfully conducted without moderate pressure being applied to deeper tissues. It would be easy to incorrectly interpret the patient’s pain solely as a result of the applied pressure, if you were unable to assess the sensitivity of the different layers of tissue. Therapists should not only gain information about superficial tissue if, for example, they wish/intend to treat these tissue later (Swedish massage, connective-tissue massage), the sensitivity of superficial tissue should also be assessed in cases where the therapy involves applying sufficient pressure to penetrate deeper layers of tissue (manual therapy).
In particular, patients with chronic back symptoms are the least able to provide exact information about their symptoms. These patients are frequently affected by hyperalgesia (hypersensitivity to pain stimuli) or hyperesthesia (hypersensitivity to touch) as a result of central sensitization. They have difficulty describing the exact location of their symptoms, and the corresponding interpretation of tests that use direct pressure is unsuccessful.
Regional or locally applied techniques: Swedish massage, heat therapy, soft-tissue techniques in manual therapy (▶ Fig. 8.1), and more.
Even beginners only need a short amount of time to gain the relevant prerequisite knowledge. Being able to initially orient yourself using general bony (▶ Fig. 8.2 ) and muscular structures (▶ Fig. 8.3 ) in the neck, back, and pelvis is sufficient. The techniques used to locate these structures will be described in the coming sections. Two prerequisites are the following:
The entire surface of the skin and the underlying muscles from the gluteal area to the occiput will be palpated. This includes the following muscles in particular: the glutei, erector spinae, latissimus dorsi, trapezius, rhomboids, infraspinatus, supraspinatus, and the deltoid.
The following characteristics are assessed: smooth/rough, dry/moist, warm/cold, hair growth, protrusions. Also check whether the changes are general or only found locally (compare with the other side of the body!).
The term consistency has many different meanings. It is used here as a standard to measure the compliancy of tissues when displaced or when pressure is placed on them. It is along these lines that the viscoelastic properties of tissue are assessed.
Skin sensation is checked in passing when the surface of the skin and its consistency are being examined. It does not need to be assessed separately in clinical practice. The therapist will be made aware that the sensation needs to be assessed during the subjective assessment or when the patient informs them of sensory changes during palpation.
Sensory deficits are rare in the trunk. They are more likely to occur in the joints of the limbs as a result of nerve-root compression or peripheral-nerve lesion. A hypoesthesia or an anesthesia in the region of the back is to be classified as dangerous! If one of these symptoms is encountered, it is necessary to clarify whether this is a familiar symptom or whether it should be investigated further.
Sensory deficits interfere with massages or other interventions (e.g., electrotherapy) as the patient cannot provide the therapist with important feedback regarding the appropriate dosage. Such treatment must be performed with appropriate caution.
When considering whether, and in what dosage, treatment should be administered, it is also important to identify possible hypersensitivity to touch (hyperesthesia) or pain stimuli (hyperalgesia). It is normal for tissue to be hypersensitive to pressure during wound healing in the acute, exudative stage. This is the result of peripheral sensitization. Pathological hyperesthesias or hyperalgesias develop secondary to chronic pain. This is the result of central sensitization in the dorsal horn of the spinal cord. Hypersensitive parts of the body transmit pain signals when touched roughly and can only be treated using techniques where minimal pressure is applied or large surface contact is made (e.g., stroking as part of classical massage). At times it may be appropriate not to treat manually at all (refer to van den Berg, 2003 to gain further knowledge of the physiology of chronic pain).
The size of the area being treated and the selection, speed, and intensity of treatment techniques are chosen according to the pain sensitivity of the tissue, among other factors. It is also possible to estimate the expected results of muscle treatment by assessing whether the muscles are the source of pain. Ideally, the techniques described later in the book provoke pain in the patient’s muscle tissue. If the techniques do not provoke pain in the muscles or if the skin or skeleton are the source of symptoms, the treatment of soft tissue will not result in any kind of pain relief.
▶ Fig. 8.4 illustrates the procedure used to assess the consistency of the skin (left-hand side) and the muscles (right-hand side).
The techniques are conducted using different areas of the hand. These areas are suitable for the palpation of certain sensations due to their differing degrees of special receptor dispersion. For example, the most successful method for the palpation of skin temperature is to use the back of the hand or the posterior surface of the fingers. A large number of thermoreceptors are found here. The finger pads are used to detect fine differences in contour and consistency in tissue. The high density of mechanoreceptors makes the finger pads ideal for this purpose.
Neutral and relaxed pronation is appropriate when assessing the soft tissue of the posterior trunk. This should be standard for comparable assessment techniques. Of course, it is possible to alter this neutral starting position (SP) if necessary for certain treatment techniques or if it ensures that the patient is free of symptoms when lying. For example, padding is placed under the hip joint, pelvis, and abdomen in cases of arthritis. The following description depicts an ideal case scenario and applies to most of the SPs in Chapters 9–12.
During general inspection of the prone patient (▶ Fig. 8.5), the therapist determines whether the head, thoracic spine, thorax, lumbar spine, and pelvis are situated in a straight line without lateral shift or rotation:
The arms are positioned next to the body; the fingers can be placed slightly under the pelvis. Alternatively, the arms may also be placed over the side of the table. The arms should never be positioned at head level. This tenses the thoracolumbar fascia, making palpation of structures more difficult at the transitional area between the lumbar spine and the sacrum. In addition, it causes rotation of the scapula, which in turn alters the length of various muscles in the shoulder girdle.
The distal lower leg rests on a foot roll, ensuring that the muscles of the lower leg and thigh are relaxed. The foot roll may be dispensed with if the rotation of the legs does not change the tension in the gluteal muscles.
Some frequently asked questions are: Should padding always be placed underneath the pelvis and abdomen and the head-end of the treatment table lowered? How much lordosis or kyphosis should be allowed or supported? What can therapists decisively orient themselves on in addition to what the patient feels? The answers can be found when you look at the patient’s posture in standing. The general rule is: the curvature of the patient’s spine in standing is also permitted in the prone position. This is achieved by altering the position of the treatment table or providing support with padding.
The therapist stands to the side of the treatment table opposite the side to be palpated. Naturally, the therapist pays attention to the height of the treatment table. The table should be sufficiently high to ensure an ergonomical standing position.
Observation and palpation findings in the prone position differ significantly from the vertical (e.g., sitting) and side-lying position. One reason for this is that gravity causes the skin to sag. The skin is therefore subject to some degree of preliminary tension. The back and neck muscles are more tense in unsupported sitting as they maintain the body’s upright position. It is therefore difficult to feel changes in muscle consistency (e.g., increased muscle tension).
If you want to reduce the anti-gravity effect in the trunk and neck muscles, ensure that the weight of the head, arms, and, when necessary, the upper body rests on a supportive surface. This can be achieved by sitting on the side of a treatment table and using appropriate padding. When the active muscle tension in the back and neck muscles is reduced, the body bends forward and hip flexion surpasses 90° (caution with recent total hip replacements [THRs]). This results in a flexed lumbar spine, with flexion continuing more or less up into the thoracic spine. This in turn increases the passive tension in all posterior fasciae and the trunk muscles and increases the resistance that the palpating finger has to work against.
The neutral sitting position roughly imitates the curvature of the spine when the patient is standing upright. The best position to obtain this is unsupported sitting on the corner of a treatment table. This SP is generally not very stable. Description of a more stable SP in sitting follows below.
The patient sits on the treatment table with the thighs resting fully on the table. It is recommended that only patients with circulatory disorders and those with poor stability have the soles of the feet in contact with the floor. The knees are separated further than the width of the hips, facilitating pelvic tilt movements. This enables positioning of the lumbar lordosis. The thoracic and cervical curvatures are positioned to correspond with the curvatures in standing or are corrected when necessary. The patient’s arms hang down loosely beside the body. The forearms or the hands rest on the thighs.
The therapist stands to the side of the patient and opposite the side to be palpated. The therapist should pay attention to the height of the treatment table, ensuring that the standing position is ergonomical.
This SP also attempts to reproduce the patient’s natural spinal curvature (▶ Fig. 8.6). If the patient cannot adopt this position without pain, the position is naturally adapted to make it possible for the patient to remain in the side-lying position for a certain amount of time.
This is achieved by placing the patient in an easily accessible side-lying position and placing padding underneath the lumbar and cervical spines so that these sections of the vertebral column are no longer laterally flexed. This accommodation requires individual effort.
Both legs should rest on top of each other. The hip joints are not flexed more than 70° so that the lumbar spine is not forced out of its lordotic position. The knee joints are clearly flexed. Check the head position again.
The procedure for palpating the skin incorporates all posteriorly accessible parts of the skin. The palpation starts in the pelvic region, in particular over the sacrum and the iliac crests, and continues upward to the occiput. Attention is paid to the skin’s quality and varying temperature (see also Chapter 1).
The qualities of the skin, its roughness, etc. are assessed by slowly stroking the skin systematically with flattened hands (▶ Fig. 8.7).