Observation and Palpation.

Observation is conducted on numerous levels, ranging from the gross to the subtle. Gross observation may reveal relative asymmetry of the body in general (e.g., left versus right), as well as of specific regions or structures relative one to the other (e.g., scapulae, levels of the iliac crests, levels of the mastoid processes).

Palpation may also be conducted on numerous levels, ranging from the gross to the subtle. Certain osteopathic practitioners have reputations for their skills in palpation on very subtle levels. Major factors that greatly influence palpation results include personal intention when undertaking the task as well as where or on what level the physician's attention or focus is placed.

The practitioner must learn to distinguish normally functioning tissue from any variation from the anatomico-physiological norm. Because most medical curricula focus on disease, recognition of normal function requires additional study on the part of the physician.

Basic palpatory skills may help confirm the acuteness or chronicity of a complaint. Much of this is related to the action of the sympathetic nervous system over time on the musculoskeletal realm. Another vital component noted during palpation is skin drag. Skin drag represents relative resiliency of the superficial tissues and fascia. For example, with the patient in the supine position, the physician places the palm of his or her hand on the sternum and with slight posterior pressure makes contact and then slowly rotates the hand to the right and then to the left. In a dysfunctional state, the hand rotates better in one direction compared with the other. Variations of this maneuver may be performed all over the body and can provide valuable information regarding the functional state of the fascias.

Tissue findings during palpation, including tone, temperature, relative resistance to pressure, texture, and moisture, also provide information regarding the sympathetic nervous function in the region. In addition, segmental muscle and visceral function may be evaluated both directly and indirectly using palpation.

Informed muscular palpation may yield extremely valuable information. For example, one of the most commonly found causes of sciatica is secondary to contraction of the piriformis muscle. Evaluation takes approximately 5 to 10 seconds and, besides providing instant feedback, may save much needless and costly traditional workup. Other important muscles commonly implicated in major symptomatic complaints include the scalenes (so-called thoracic outlet syndrome); various intraoral muscles, especially the masseter (temporomandibular joint pain); and the psoas (incapacitating low back pain). The writings of Janet Travell, MD, are most helpful for students of such palpation.

Evaluation of fascial function is key to the osteopathic evaluation. The main dysfunctions found in the fascia, which is ubiquitous, being continuous from the most macroscopic to the microscopic levels (it actually ensheathes individual muscle fibers), involve sprains and various strain patterns. These are secondary to a variety of sources, including postural, emotional, traumatic, and others. Some of these patterns may be recent, whereas others may be traced back to early traumas.

One aspect of such palpation actually allows the clinician to approximately date the onset of the dysfunction. Regardless of the origin, these fascial dysfunctions all inevitably contribute to functional impairment, resulting in disease and pathology on many levels. Dr. Still said, “I know of no part of the body that equals the fascia as a hunting ground”.