Palpation: A Lost Art or an Overlooked Skill?

A growing wave of negative discourse surrounds manual therapy (MT). Much of this criticism stems from studies highlighting the perceived deficiencies or limitations. However, perhaps this negative literature casts doubt not only on MT itself but on the skill level of contemporary clinicians. At its core, MT relies on specialised palpation skills, yet these skills are no longer universally regarded as fundamental to practice.[1]

For those familiar with the Watson Headache® Approach, asymptomatic asymmetries are common, and palpation findings must always be interpreted within the broader context of the clinical presentation. The Approach places significant emphasis on skilled palpation, particularly detecting abrupt, early resistance when assessing intervertebral movements, the spinous process, and the articular pillars of C2. Despite this, contemporary perspectives often dismiss palpation findings as overly subjective or even imaginative.

A Radiologist’s Thumbs-Up: Proof of Palpation Accuracy

This recalls my experience while teaching in Europe about 15 years ago. On the first day of a Level 1 Foundation course, the host gently questioned my ability to palpate the articular pillar of C2. While initially taken aback, I confidently affirmed my ability. At the end of the day, the host invited me downstairs to a radiological imaging facility he had explicitly arranged for this purpose. A radiologist placed a small, solid MRI-friendly marker on the distal part of my thumbnail, and I indicated when I was palpating the host’s C2 articular pillar. When I confidently announced my position, the radiologist extended his arm from behind the screen, gave a ‘thumbs-up’, and verbally confirmed my accuracy. I requested a copy of the image (which I still have) and later reflected on the moment with gratitude for Geoff Maitland’s teachings and perseverance.

This experience underscores that specialised palpation skills can be taught and mastered, provided commitment and reflective practice exist. Clinicians treating headache and migraine conditions with MT will recognise that a lack of specificity in technique or a ‘blind’ approach often leads to patient aggravation.

Empiricism vs. Expertise: Are We Oversimplifying Manual Therapy?

Modern MT perspectives, as reflected in the attached case studies,[1] suggest a departure from specific palpation findings, joint force or direction rules, and pathoanatomical considerations. While aiming to simplify MT, these perspectives risk reducing it to a superficial practice. For instance, the assertion that MT performed, and I quote from one of the case studies ‘without reference to specific palpation findings, joint force or direction rules, or reinforcement of pathoanatomical beliefs. Three minutes of safe, comfortable, and efficient passive movement may have influenced neurological phenomena and produced some cortical changes (a huge assumption). Communication has been direct and person-centred, and contextual healing has been established’ (the latter describing the multifaceted Geoff Maitland – a recognised mechanistic/nociceptive/MT devotee – to a tee).

Such perspectives may hinder recognising cervical afferents’ critical role in primary headache conditions and contribute to the declining emphasis on palpation-based MT training. The authors of these perspectives acknowledge that their views are ‘rooted in empiricism and deliberately based on available research data from within the health science disciplines’ [1] p.8. However, it is only fair that the empirical data supporting palpation in MT be given equal consideration. The quality of the two attached case studies does little to substantiate the authors’ argument for the future direction of MT training, which, as noted, is primarily based on empiricism.

Reviving Palpation: The Future of Manual Therapy Training

In conclusion, the diminishing profile of palpation in MT training risks undermining the depth and specificity that skilled palpation brings to clinical practice. Those of us committed to advancing the field must advocate for the continued recognition and teaching of these specialised skills, ensuring that MT remains a precise and effective tool for addressing complex conditions like headache and migraine.

Reference:

1. Kerry, R., et al., A modern way to teach and practice manual therapy. Chiropr Man Therap, 2024. 32(1): p. 17.