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. Brace yourself fella.

    Great piece. Can they also stop teaching bollocks about core stability, posture, stretching to correct posture(?) and movement imbalances?

    As always, thanks for your hard work and for the blog.

    Tom

      • Hey Adam,

        I love your blogs. I’ve spent a damn fortune on physio over the years. Every now and then I encounter a physio who seems to know what they are doing and I am very grateful for it, but most of the time I seem to get sent up the garden path. It is strangely comforting to learn from your blogs that the world of physio is as full of as much bullshit as the world of radiography, which I was dumb enough to have fallen into during a midlife crisis following a career in a more civilised field of work. Three years of utter shite and tripe I went through at Kingston Kindergarten, sorry, University, in order to get into this job, only to find that I had been taught very little that was accurate or of any use. At least I’m not alone…

        Nik

  2. Good post as usual, but maybe not enough swearing.

    Do you actually think it will ever change though? Most PTs/chiros/masseusi/osteos (?) will go on telling people all the stuff they are feeling with their hands and tools, the culture will continue to believe this.

    I think continuing to fight and educate is a worthy cause, but my inner nihilist/pessimist just doesn’t see it ultimately changing.

    Anyways, cheers, and hope you have a great day.

    Nick

    • Hi Nick, good question. I have no doubt that my little blog and my mumbles and rants are just a small drop in the ocean of bull shit and nonsense in our professions, but I am going to continue screaming into the hurricane, pissing into the wind, struggling up the hill… because it makes me feel a little better in some small way. Cheers Adam

  3. Allow me to agree and disagree with your words. Of course we can palpate and feel stifness, but very often it is totally impossible to say that we identify which vertebra we palpate. We can definitely feel tissue changes and differrent tissues resistance. This is easier in thin people and almost impossible in obesse ones.
    The problem with palpation is how do we interpretate our findings and we definitely need a shift in that, but as you say, physios need palpation skills additionally to other examination and treatments techniques. It is the interpretation of palpation findings that needs a huge shift in terminology and explanations.

    • I’m going to disagree that ‘of course we can palpate and feel stiffness’ stiffness is a sensation not a thing. For example, I very often feel stiff in my calf muscles the day after a long run, but the texture of my calf muscles feels exactly the same as it did before, they just feel stiffer and sore when I press them, but the structure is the same. We only feel stiff in others when they tell us where it is, they prime us to feel and find it. Do not under estimate your brains ability to find and feel things that arent actually their just because you expect it. Cheers Adam

  4. Adam, I am reminded of an old middle-eastern proverb, which I have updated: “The dogs bark, but the caravan of science moved on long ago.”

  5. This is why I like using McKenzie. No press and guess and just looking at the effects of repeated or sustained movements. Also keeps the patient as independent as possible due to the hands off nature. Any opinions on MDT? Keep up the good work Adam.

  6. This was a thoroughly enjoyable article to read. I love a bit of controversy! Palpation is essential for an informed treatment and going down the “bio-psycho- social” road is not the answer to keeping customers happy. Whilst I agree that there are many courses peddling palpation techniques that are too hard, I do think that some people are naturally gifted. The rest of us being not so gifted can improve with practice and thinking about what you are doing. As far as figuring out which level you are on, it seems to me that these palpatory legends have always had the discipline to count out the specific level from a set starting point. They also have the discipline to think carefully about what they are doing and reflect on what they have just done. I have tossed out cranio-sacral, those fiddly neck mobes from the headache courses, SIJ manips, PPIVMS etc, etc.

    • Hi Rebecca, I think some people are better therapists than others for sure, is this being gifted, I dont know. When it comes to palpation I dont think there is much difference in skill, just in belief about what can and can’t be felt in my opinion, I think some do a better job and convincing themselves and their patients, thats probably their ‘gift’. Cheers Adam

  7. Thank you for this read. I’m currently a fourth yr student doing placements and get increasing frustrated at not being able to palpate specific things the educators say they can. For example a transverse mobilisation on the Lumbar spine segment to show it’s stiff than the other joints. Felt very inadequate and somewhat embarrassed when the educator couldn’t believe I could feel it. Knocked my confidence around a bit. This article has helped restore some confidence in my abilities as a student. Thanks mate

    • You’re welcome Jeff, and please dont let your educators, or peers put you off from questioning and challenging their claims. Maybe show them some of the papers I posted here, but remember the kick back effect can be strong when you question someones long held ideas and beliefs so be careful… All the best for the future, Adam

  8. Loved your post! Doing my tDPT with Evidence in Motion Adrian Louw’s group, having such a hard time with the push for manual therapy and dry needling. They have 6 courses with almost 240 students getting trained in the “up to date pain knowledge” every term.”If we do not do manipulation we are harming our patients”  Wish I could write like you.  The registrations are picking up gradually for our course.Sharna 

    Sent from my Sprint Samsung Galaxy S9.

    • Thanks Sharna, and thats really disappointing to hear that a well respected and influential group like EiM and Adrian Louw are pushing for manips and dry needling so hard despite the evidence! Looking forward to seeing you in Portland soon. Cheers Adam

  9. May I just say— just priceless piece you write here! I have only about 10yrs experience of being a physio, but I have felt same feelings you wrote about…touch and didn’t felt… and I had courage to ASK WHY I don’t feel..and every time I got the same answer..that I was a rookie and have to practise more..and ever since I haven’t believe this s**t. Last 5 years of practicing different functional therapies..where patients actually DO things that make them better..have change 360 everything I’ve been thought in university and I’m soooo happy that I have this courage to not believe this old school stuff and learn new things every day ..also from my patients. I hope some day there will be more physios like you..like us👍Thank you!

    • Thanks Kadri, and glad to hear you have found the right path for you and your patients. Spead the word far and wide… theres a lot of misinformed people and therapists out there!

  10. Nice post Adam…I thought it was just me who struggled with what is ‘normal’ both as an undergrad and as a qualified clinician. Turns out patients are all unique individuals…how disappointing !

  11. Fun post to read! The issues you raise with palpation makes me think about the ongoing clash between proponents of the bio-psycho social model and the classic bio-mechanical model for pain. Some clinicians may base their reasoning solely on bio-mechanics while some may base their reasoning solely on the psychosocial/emotional factors of pain (throwing out all biomechanical/pathoanatomical reasoning for pain) and I feel like the truth is often somewhere between the two depending on the patient. Maybe that’s problem with palpation. Clinicians either draw way too many conclusion from it (I think that’s what you’re saying) or abandon it all together (Don’t touch their patients). On that note I do feel that it is possible with palpation to detect a muscle that is tight/hyper tonic and may be contributing to a patient’s pain when taking into account or combined with other findings such as changes in range of motion, strength, patient history etc… On the same note I do find that appreciating end feels when assessing range of motion is informative (“Is it muscle tightness/guarding/spasm limiting range of motion or is there something else?”) which I feel falls under the category of palpation.

  12. You are an absolute hero, sir. You should just start your own university, Meakins U, for the meek and mild-mannered physio.

    Many of my shoulder pain patients while insist that I feel the knots in their upper traps, ask how tight they are, and then remind me that they paid their $30 copay so don’t they deserve a massage? I love to then poke them in the lateral hip, usually anyone is tender right over that glute min/med, then say “knots there too huh? Maybe you need a hip eval too, I’ve got an opening next Tuesday”

    Keep spreading your message so I can stop being expected to wear my thumbs out “releasing fascia” and get back to the best rotator cuff exercise in the world…. the lateral raise.

  13. Excellent post as always Adam. I’d love to know how you deal with the conversation that will inevitably come up when a patient brings out a statement such as “the last guy I saw said my….. SIJ was too stiff/my shoulders were a mass of knots/my cerebrospinal fluid is out of kilter with my chi”. One the one hand I want to tell them how they’ve been told a crock of shit, but I don’t want to immediately come across as bitter and incompetent.

  14. Thanks Adam! Patients still crave the guru treatment. Redirecting / re-education of the patient/public, really reinforcement or redefining of our profession I suppose is a constant battle.

  15. Hi Adam, I graduated last year and definitely agree with the uni courses content pushing manual skills too much with reliance on ‘feeling’ but not on the bigger picture. I’m like you were in the start and what to progress but find it difficult with which courses are of benefit. I have a Bsc in Sport and Exercise Science and MSc in physio, and looking at CPD events in pain management, strength and conditioning, and your own course, do you have any personal recommendations for further CPD courses? Thanks

  16. Hi Adam,
    Thanks for your interesting and poignant blog and for alerting other clinicians via your tweets and blogs about the many myths that continue to be perpetuated about palpation and manual therapy etc etc.

    I thought that it might be helpful to mention that Louis Gifford and I co-authored a comprehensive review of the research and evidence base relating to manual therapy / palpation etc in the opening chapter of Topical Issues in Pain 5. The Chapter is titled ‘Manual Therapy in the 21st Century’. Before Louis died in 2014 we decided to make this chapter (and some of our other published work) available for free on his website. Anyone interested can download this chapter and more of our published work from giffordsachesandpains.com

    Although ‘Manual Therapy in the 21st Century’ was originally published 13-years ago in 2006 there has been little change to the evidence base. I re-read the chapter recently and was happy that I wouldn’t make any significant changes if I published it today. The chapter hopefully should be an interesting read for your blog followers in that it details and discusses many of the points that you have made in your tweets and blogs.

    Keep on challenging the myths, exploding the ridiculous and encouraging clinicians to enquire about the evidence and to keep asking questions.

    Kind regards,

    Steve Robson

    • Hi Steve, many thanks for your comments and directing people to the chapter you and Louis wrote. It is disappointing (although not surprising) that little has changed in 13 years. It seems this dogma is a stubborn one. I must also say the Louis was a huge inspiration for me when I went on one of his courses as a young disillusioned and disheartened physio. He gave me hope and direction on how to be a better physio that I still use today. Thanks again Adam

  17. I’ve been in the ‘manual therapy funk’ for some time and honestly depressed after having taken a bunch of courses trying to get ‘good’ and wondering why, after so much time and money spent, patient symptoms just don’t respond. Your posts have been super helpful, especially this one, in helping me realize I’m actually not crazy and that there has to be a better way that is more empowering to patients. A course I took recently has pushed me further back to what feels more like sanity, and more fun. Can’t wait to get my hands on more (no pun intended). I sincerely thank you for your thoughts and your willingness to engage others.

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