Touch it…

I spend a great deal of my time with patients trying to correct lots of misinformation or misunderstandings they get from many other sources, such as the media, the internet, or from other clinicians. One subject I challenge a lot is when patients have been told that their pain is due to a part of their body being too stiff, too tight, or too lumpy, as discovered by a clinician touching it.

I’m still astounded at the number of myths and misconceptions that exists around diagnostic palpation within musculoskeletal therapy. I have discussed this before over the years here and here, but I feel I need to again as many therapists are still peddling some utter bull shit about what they can diagnose with touching things.

Crystal clear

However, before I begin let me make this crystal clear for all my haters and those who like to sling ad homs, false dichotomies, and straw men at me, I am not questioning the THERAPEUTIC benefits of touch here, although I do think this is an over-egged and over-exaggerated point as most therapeutic touch is given to pander and please patients rather than genuinely help them.

I am also NOT saying nor have I ever said, that we should NOT touch or palpate our patients. I actually advocate that all therapists take the time to thoroughly examine their patients, which includes palpation, as this is both a critical and essential part of all assessments. There is nothing worse than hearing a patient tell me that they last clinician they saw didn’t even bother to look at the area that concerns them let alone touch it.

This lazy, sloppy, and downright dangerous approach to palpation is just as bad as those who make ridiculous, nonsensical, and far fetched claims about it. Taking the time to examine a patient’s painful area with palpation feeling for any swelling, heat, or gross deformity is a simple basic fundamental part of a good assessment.

Ridiculous!

However, many other therapists take palpation to the realms of ridiculousness claiming that they can feel some downright crazy and stupid things. For example, some therapists think they can feel specific vertebra in spines that are too stiff, or not moving correctly when performing passive accessory movement tests, despite evidence showing little reliability or utility of these tests (ref, ref, ref, ref, ref, ref).

Some therapists still think they can feel the teeny tiny movements of the sacroiliac joint under many layers of thick muscle and dense ligaments despite this being refuted many, many times (ref, ref, ref, ref).

Some therapists think they can feel knots and taut bands in muscles despite evidence demonstrating, again and again, no reliability (ref, ref, ref, ref, ref). Some even think they can feel blockages in lymphatic and cerebrospinal fluids under skin, muscles, and even skull bones, which defies any scientific rationale or common sense (ref, ref). And finally, there are the crackpots who think they can feel blocked energy, distorted auras, and other mystical claptrap.

Student days!

I remember as a physio student some 19 years ago being taught to feel for stiff spines and muscles using these palpation tests. I was taught to push joints in the spine, pelvis, and periphery to feel if they moved too little, or too much. I was taught to press into soft tissues and feel for overactivity, tightness, spasm, and knots. Yet despite hours and hours of practice and seeing others all around me saying they could feel this stuff, I couldn’t feel jack shit.

I was told that I was just too inexperienced and that I had to keep practising then I would be able to feel the things my peers and tutors could, and I would become a better physio. So I did, for years and years, but I still couldn’t feel shit, and I still can’t feel shit 19 years later.

The first problem I found was trying to decide what is too stiff or too loose. To be able to identify whats abnormal I first need to establish what’s normal. However, during my training when I was pressing, poking, prodding normal pain-free fully functional people I found them to all be variable in feelings of stiffness, tightness, and lumpiness. With this wide variation in texture and feel in normal people (if you can class physio students as ‘normal’), how the hell am I supposed to decide if someone in pain is too stiff or too lumpy?

Another problem I found was any feelings of stiffness were highly dependant on the force I applied to an individual. When I pressed lighter they felt stiffer, when I pressed heavier they felt looser. This variability in force meant I could change the feel of something being too stiff or not. Lots of research has demonstrated huge variation in the forces that therapists apply with these tests meaning any interpretations of stiffness will also be hugely variable (ref, ref, ref, ref).

The final issue I had with diagnostic palpation tests was trying to feel what I was supposed to feel. For example, I had difficulty in determining if a lump felt in a muscle was an abnormality or a normal anatomical structure. I also had issues with trying to interpret what I was feeling was actually the structure I was supposed to be palpating and not the other tissues above it.

I even had difficulty finding something as simple as a specific spinal level, and I still do. For example, I could be thinking I am palpating a C6 or L4 vertebra when in fact I could be 1 or 2 levels out. And it’s not just me that can’t reliably find them, many other experienced and skilled clinicians have been shown to be very poor at identifying specific vertebral levels (ref, ref, ref).

Ignorance, ego, and fear

So why is it that despite these issues and decades of research demonstrating poor reliability of diagnostic palpation tests do so many therapists continue to use them, and are adamant that they can feel things that evidence says they cant?

Well, I think its a combination of ignorance, ego, and fear. Most therapists who continue to use these palpation tests simply haven’t kept up with the research, and are unaware of these reliability issues, and more importantly that these tests are not correlated with patients pain or problems.

Those therapists that are aware, or have read this research yet still continue to use and teach these diagnostic palpation tests usually do so due to cognitive dissonance. Usually, their ego refuses to let them abandon something that they have spent so long working on to perfect, and which has involved investing a lot of time, energy, and money to learn.

And believe it or not I do empathise a lot with these therapists, as someone who has spent many years of my life and thousands of my hard earned pounds on further training in palpation and manual therapy seeking to become a better physio, I also feel annoyed, frustrated, and cheated, but I got over it and moved on.

The final reason I think many therapists refuse to abandon these unreliable and unevidenced diagnostic palpation tests is fear. A fear of inadequacy. Many therapists are just not comfortable or confident with themselves or their position within healthcare, often feeling inferior and subservient to our medical and surgical colleagues. So to inflate their position and give them more confidence they often claim to be able to do highly specialised and skilled things which others can not. This is both sad and embarrassing.

Therapists don’t need superhuman powers of palpation to be respected. Therapists don’t need Jedi manual therapy skills or belief in mysterious, mystical forces to be confident in what they do. If more therapists just had more confidence in the simple basic things such as getting people in pain and disability back to the things they want to do, with advice, reassurance, encouragement, activity, and of course exercise, then I think we would be respected even more by our colleagues.

Universities need to change!

I want to finish by asking why in 2019 are physio students still being taught these diagnostic palpation tests. Why are many universities still teaching students spinal PIVMs, PAMs, SIJ palpation, and trigger points assessments? Why are students still being asked to feel for things they will never be able to feel. Why are students being made to feel inadequate or unskilled just like I was 19 years ago?

I know very well why there are so many postgraduate courses out there teaching this kind of bull shit… the very strong financial incentives. These palpation/manual therapy courses cost a lot and reward those teaching them very well. These postgrad manual therapy courses feed off new grads leaving university who feel inadequate and unskilled in palpation and who desperately want to be better physios just like I did.

But here’s the thing, these postgrad courses would soon be redundant and obsolete if undergrad students were taught in university about the issues with these tests, and shown the research about diagnostic palpation, and not made to feel inadequate or unskilled so that they keep searching and practising on courses in an attempt to feel like good therapists.

So I will sign off by once again reiterating that these diagnostic joint motion palpation and muscle trigger point tests are unreliable and not needed to help patients or to be a good therapist. But, please do take the time to fully examine and palpate your patients, just remember to use your common sense, and the evidence, to help inform you what you can and can not feel in a patient.

As always thanks for reading

Adam

37 thoughts on “Touch it…

  1. If the profession took what you say to heart and wanted to change, it would have done so long ago. Unfortunately, the PT profession lacks the self awareness necessary to even know it lacks self awareness. It has circled the wagons long ago and isn’t interested in accepting its truth. Instead, the PT profession focusses on self-promoting only positive stories that it uses as it flits from one fad to the next, never achieving depth, or self-confidence in its assumed identity. Physios on the whole seem more concerned about being seen as a “hero” than improving its effectiveness in successfully helping people.

    Simply put, the profession suffers from an inferiority complex that it has never reconciled. The PT profession is shallow and driven by a need to be seen as special, but doesn’t deliver the goods. Adam, your articles are entertaining, the comments often revealing, but the PT profession is going nowhere.

  2. I have read this blog off and on for a while and have always been impressed. I will say above being interesting and entertaining, it is important. I have been amazed at what continues to grow in popularity while existing in the era of “evidence-informed practice.” I think the greatest dissonance I have is working shoulder-to-shoulder with therapists who practice various forms of manual diagnosing/treatment and I do see their dedication and earnest effort. I have become convinced there are two reasons for the questionable, ongoing diagnostic manual paradigm: 1) the patient has come to expect it as the extortion-style pricing of health care here in the U.S. demands a “valuable” finding that justifies the expenditure; and 2) the vast insecurity of therapists who are trying to procure a seat at the table of health care. How better to distinguish yourself than to use your magic mitts to find things that others can’t. Now, if nobody else and nothing else (imaging) can find it …. ?

  3. So sad to see dissenting voices disappear from your comments section. Yes, as always Adam, it’s your blog, your sandbox. It’s a wasted opportunity if you cannot attract those who disagree or voice opinions that you don’t want to hear. This is how PT has burrowed itself into a silo, unable to embrace critical self reflection in order to evolve.

    • What are you on about? I have removed any dissenting voices! If there are not as many as you expect, perhaps its because they are either not engaging (which suits me) or there are not as many as you think!

    • Oh and another thing I dont always respond to comments immediately or even quickly as I have many other things to do and honestly much better things to be doing with my time than arguing with manual therapists online.

  4. Adam, you do such good work for us, students. I was very frustrated with so MUCH that I didn’t understand about all the manual therapies, and all the courses that cost so much, and my empty toolbox at the end of my college degree.
    I was suspecting something was wrong with me, but after reading this, I have realised its the system, not me. THANK YOU for letting us know, I didn’t know how bad the situation was.
    THANK YOU for saving me a lot of my money, that I won’t spend on these courses, for the time I was gonna spend studying this nonsense and the relieving news about the REALITY of our profession.

    I have no idea how MUCH your blog helps us all.

    THANK YOU again.

    Alex from Spain.

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