Four Reasons To Reject Palpation-Based Models Of Care

In 1997, I presented the results of a study on spinal evaluation techniques at the 5th McKenzie Institute International Conference in Philadelphia. The purpose of the study was to survey entry-level physical therapy educational programs regarding the spinal evaluation techniques that were taught to their students. The survey went out to all of the physical therapy educational programs in the United States, Canada, UK, Australia, and New Zealand.

To briefly summarize the results, it was found that most physical therapy programs worldwide place a very heavy emphasis on teaching palpation skills and palpation-based assessment and treatment models. These would include massage, manual mobilization, active release therapies, trigger points, and the like. Not much has changed from my own PT education in the ‘80s all the way to current 2011 educational programs. The same focus on palpation skills holds true for the educational programs of chiropractors, massage therapists, and many other alternative therapies.

But there are some major reasons to debate and reject palpation-based assessment and treatment approaches. The scientific literature on palpation has been very well-documented over the years – and the results will probably surprise you.

There are four key issues at stake: reliability, validity as an assessment technique, treatment models (and physiological premises), and patient independence.

First and foremost, we must examine the scientific literature regarding the reliability of palpation skills. If two therapists are palpating the same person, can they agree on what they feel?

The answer? A resounding NO. Palpation is highly unreliable. This has been shown repeatedly in the literature. The conventional wisdom is that this is a factor of training. But many studies have shown that students actually have better rates of agreement than those “highly trained” individuals!

The next question becomes quite elemental – if two therapists are unreliable in their assessment method (i.e. they cannot agree on what they feel via their palpation skills), then how can a consistent and repeatable diagnosis be made? With that in mind, how can the assessment have any validity? This then puts palpation-based models of assessment in significant doubt from a purely scientific perspective. 

These issues of reliability and validity are hotly debated by many gurus from many different assessment and treatment “camps”. They want us to believe that we can only aspire to having good enough manual skills, and that science certainly doesn’t always explain the results of their ability to”find” or “diagnose” problems with their magical hands. They profess that only those that have refined their manual palpation skills will have the ability to diagnose problems effectively; those that don’t have that wisdom in their hands will not be able to offer the same degree of care.

Sadly, the scientific literature doesn’t support this premise.

What happens when a treatment approach is now built upon those same low levels of inter-rater reliability and questionable validity? You are building your house on a foundation of quick sand. The inaccuracy of assessment snowballs with the treatment intervention, and somewhere along the line we’re faced with a treatment that may have little to no effect, or a treatment effect that is virtually random or highly susceptible to the placebo effect. It also assumes a quantum leap in clinical reasoning - that palpating a painful structure means that it is the cause of the problem and not just an associated effect.

But check out the marketplace and you will find that there are a plethora of assessment and treatment approaches that utilize manual palpation skills -

Manual therapy, massage therapy, active release therapy, strain-counterstrain, myofascial release, fascial stretch therapy, chiropractic care … the list goes on and on and on.

Finally, and perhaps most importantly -  all of the aforementioned approaches are passive in nature. They foster patient dependence upon the clinician, as opposed to true empowerment and competent self care. The long-term solutions for health care reform will need to focus less on passive approaches and more on patient-centered active approaches.

The scientific literature is resoundingly against the use of palpation-based models of assessment and treatment, time and time again, for all of the reasons I have listed. So what do we do, given that this is the currently accepted community standard of care – for clinicians and for patients?

Part II on health gurus and health mentors will focus on the solutions.

Photo credits: Wikipedia