Palpation: Definition, application and practice

1 Palpation


Definition, application and practice



Contents



Some definitions and concepts


Palpation: some definitions

General characteristics of palpation

Touch


Some general characteristics

The physiology of touch

The social significance of touch

Touch and clinical practice

Effects of palpation on the patient


Patient and person

The consultation process

Techniques of palpation


Improving the art of palpation


Care of the hands


Palpation of different tissues


Summary



Some definitions and concepts



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:




The human hand is equipped with instruments to perceive changes in texture, surface texture, surface humidity, to penetrate and detect successively deeper tissue textures, turgescence, elasticity and irritability. The human hand, furthermore, is designed to detect minute motion, motion which can only be detected by the most sensitive electronic pick-up devices available. This carries the art of palpation beyond the various modalities of touch into the realm of proprioception, of changes in position and tension within our own muscular system.


(Chaitow 2003)


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).



Touch



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:




The act of touching and the feeling of being touched are very powerful experiences … (and touch) is the earliest and most primitive form of communication.


(Poon 1995)


Montague (1978) reminds us that:




Touch is the first of the senses to develop in the embryo and it plays a very important role in the birth process itself and in the early life of the individual.


(Montague 1978)


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:




When the other senses are not wholly effective, we return to the sense of touch to rediscover reality. Clothing is felt to determine its quality, fruit is squeezed to determine its ripeness and paint is touched to test for dryness.


(Mason 1985)


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:




The degree of tactile sensitivity in any area is in direct proportion to the number of sensory units present and active in that area, as well as to the degree of overlap of their receptive fields, which vary in size. Small receptive fields with many sensory units therefore have the highest degree of discriminatory sensitivity.


(Chaitow 2003)


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:




Not only is there a difference of perception relating to spatial accuracy, but also one relating to intensity. An indentation of 6 micrometers is capable of being registered on the finger pads, while 24 micrometers is needed before the sensors in the palm of the hand reach their threshold and perceive the stimulus.


(Chaitow 2003)


Additionally, Evans (2000) contends that:




Under normal conditions, touch is an exploratory sense rather than purely receptive, and it is becoming increasingly evident that tactile acuity is enhanced in active exploration when compared with passive reception.


(Evans 2000)


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




An early indication of the phenomenon may be seen in an examination of the parameters of perception required to read Braille. The dots are separated by 2.3 mm, which is close to the threshold value for two-point discrimination at the pad of the index finger. Reduction of the inter-dot space to 1.9 mm only moderately reduces the legibility of the Braille text.


(Evans 2000)


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 image 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:




Touching a person’s body in a non-therapeutic context is not normally considered an act of merely mechanical significance. Nor is it a procedure of a technique – rather it is an act of self-expression, or occasionally self-assertion, or preservation.


(Nathan 1999)


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:




In the main, frequent touching is reserved for parent–child relationships, lovers and close friends. In these contexts it both signifies emotional intimacy and is emotionally significant.


(Nathan 1999)


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:




Cutaneous stimulation in the various forms in which the newborn and young receive it is of prime importance for their healthy physical and behavioural development …. It appears probable that for human beings, tactile stimulation is of fundamental significance for development of healthy, emotional and affectional relationships.


(Montague 1978)


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.

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Jun 11, 2016 | Posted by in ANATOMY | Comments Off on Palpation: Definition, application and practice

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