Introduction to Palpation
The term “palpation” has usage recorded as early as 1483, from the French, palpitation, derived from the Latin, palpitare "to throb, to flutter", which in frequent usage meant "touch gently” or “stroke"(1).
Based on this etymology, the term appears to resemble a comforting and gentle caress, instead of the mechanistic probing that characterizes medical palpation, orthopedic tests, and even the palpation styles of bodywork paradigms.
As early as 1303 there is usage of the term examiner, from the French, meaning "to test” or “to try" (derived from the Latin, examen "a means of weighing or testing"(2)), indicating there was a clinical practice of manual examination.
Today usage of the term “palpation” encompasses a variety of techniques, approaches, and styles – each a required and respectable clinical tool that enables the physician, therapist, or bodyworker to determine how to proceed.
In brief, palpation includes the use of one’s hands to explore, examine, and test the client’s body; retrieving information to be interpreted according to one’s skill, which can be useful to guide the treatment.
The Role of Palpation in Treatment
In the clinical setting, a therapist is challenged to discover relevant contextual and practical information about the client’s general and specific conditions; adapting their palpatory approach and techniques to explore and gather information from the body, and possibly performing diagnostic tests for specific patterns and relationships.
The simple question; “Where does it hurt?” can lead one’s hands to the general area indicated by the client. The therapist must discover not only the specifics of the tissue involved, such as whether the pain is structural or neurological, but how acute the condition is, and if there are involved areas which the client may not be consciously aware of.
Palpatory techniques reveal quantitative information, such as location, tonus, shape, proportion, development, and anatomical symmetry. Touch also discovers qualitative information such as dryness, hydration, lubrication; heat, cold, clamminess; vibrancy, morbidity; sensitivity, dullness; hardness or softness.
One may also palpate vitality, strength or weakness, mobility, and flexibility of tissue, apply orthopedic tests and look for specific signs, locate scars from accidents and surgeries, or determine contraindicated areas one must work around.
Generally(3), palpation is performed with a moving, feeling hand; using finger pressure for specificity. Brushing and friction with the finger tips is also helpful. To palpate mobility of tissue or flexibility of a joint, assisted movement is utilized, and that can involve grasping and some upper body movement. To palpate using specially designed orthopedic tests, the therapist can use motions that push and pull, along with using their weight and strength to anchor or assist parts of the client’s body.
Palpation can be superficial or deep, and involve gathering information from several layers of tissue to assess various body systems. Deep, complex palpation requires greater knowledge and experience, including a thorough understanding of anatomy and physiology and their condition in health and dysfunction. Body-listening skills, a free and lucid mind, and real-time analysis of sensations and somatic information combine with the effective use of verbal questioning to confirm the therapist’s intention to use specific techniques.
Important Additional Aspects of Palpation
Aside from perhaps shaking the hand of a client in greeting, palpation is the first touch-contact. It is this initiatory experience which informs and expands the underlying expectations about the roles played by therapist and client in the clinical environment.
This first physical “communication” addresses the boundaries of the client’s body, not only for the therapist seeking palpatory information, but also for the client, who may immediately gain a wider experience of their condition. Depending on the relaxed or traumatized state of the client’s tissue, the therapist may not be able to palpate certain regions. Additionally, the therapist’s senses and reactions, as well as mood and manner, provide feedback to the client information about their body and condition.
This establishment of this multi-level communication loop can have a profound affect on the level of trust between client and therapist, and potentially affects the therapeutic outcomes of the session. However, the degree that palpatory communication affects the healing process ultimately depends on the specific circumstances.
Nevertheless, palpation at the beginning of a therapeutic session warms up the client’s tissue, brining circulation and fluid exchange to the cells, nervous stimulation, and the elongation of muscle fibers. This preparatory clinical phase may have some therapeutic effect, especially if followed by a supportive and well performed treatment.
Palpation in the Therapeutic Community(4) Today
The therapeutic community includes a spectrum of complimentary modalities that, for the purposes of this essay, I will divide into three families: Virtuoso Touch, Western-aligned Manual Therapy, and World Medical Traditions.
While this grouping is not a complete model, in the context of this paper it serves as a logical premise. In fact, the true landscape consists of a long list of modalities which exist in complimentary relationships. In many cases, these approaches influence one another, and sometimes complimentary modalities are integrated within a single therapeutic session.
Several sophisticated systems of touch therapy practiced today have been developed by extraordinarily gifted individuals, who, following a natural gift throughout their lives developed insightful modalities that have contributed to the growing landscape of healing praxis in the therapeutic community.
In my opinion, such individuals include Ida Rolf, Milton Trager, Moshe Feldenkrais, Randolph Stone D.C., M.D., and John Barnes. Of course, this list includes Dr. John Upledger, D.O., O.M.M., whose contribution is elaborated on below.
It could be said that what is primary about Rolfing, Trager, Feldenrkrais, Polarity Therapy, Myofascial Release, (and CranioSacral Therapy), is the palpatory virtuosity of each of its founders. That virtuosity, ideal in its source, is a core attribute each of these schools reflect in their adherents.
Rather than being founded in the conventional attitude toward palpation and perceptions about anatomy, these systems are founded in the premise of listening to the body with an awareness that generates integrating, balancing, releasing, unwinding, movement, gentleness, intuition, and a consciously affirmed individualistic and holistic spiritual connection.
This framework requires a deep commitment to pure perception, and the courage to work without the support of external validation from accepted models.
Western Aligned Manual Therapy
Moving more into the mainstream, we find schools that are anchored in the mechanistic, linear cause-and-effect model of modern collective thinking. Rather than being based in unique, virtuoso touch and courageous perception, Swedish Massage, Sports Massage, Neuromuscular Therapy (NMT), and Physical Therapy (PT) practice a reduced scope of palpation in which sensory and therapeutic expectations are entirely systematized.(5)
In the case of the popular Swedish Massage modality, which originated in the physical culture movement called European Physik and was practiced for its healing properties, it has been mainstreamed as a spa treatment. Due to this discursion from its clinically therapeutic nature, palpation is no longer as critical.
With regard to Sports Massage, NMT, and PT, while their therapeutic nature is still central, the purpose of palpatory discovery is in the techniques which test and measure symptomatic conditions. In these systems, the practitioner has many book-learned expectations about the body, and fundamentally requires the patient to “fit” into preconceived notions of acceptable disease and health states. Here the awareness is more “looking for,” than “listening to.”
World Medical Traditions
The healing arts developed prior to the age of industrial medicine do not depend on machine-based testing to diagnose conditions. Instead, they employ rich sets of palpation and observation techniques founded in the ability of the practitioner to draw information about the client using the physical and spiritual senses. Extending these techniques of palpation and observation, additional clinical skills include working directly with the Vital Force at a subtle level (presently considered Energy Work), using intuitional guidance, astrological charts, and forms of spiritual and ancestral divination.
Indian, Chinese, Tibetan, and Thai medicine (which currently enjoy growing influence in the West) are founded in a holistic understanding of the body in which biological existence is viewed as partaking of a cosmic existence, where multiple causes and effects occur in a web of interrelated phenomena.
The therapeutic context and intent is one of balancing bio-energy, its organ-system relationships, elemental relationships, past personal and ancestral karmas, and fundamental spiritual destiny. In addition to medical branches such as therapeutics, herbalism, and surgery, these traditions all have a major branch of therapeutic touch. In contrast, Western Medicine has stripped itself of its ancient practices, which once included palpatory and therapeutic touch, and replaced formerly holistic and unitary paradigms with an ultra-mechanistic and separative awareness.
In World Medical Traditions, the clinical techniques of palpation and therapeutic touch are grounded in a view of human anatomy and physiology that includes bio-energetic mappings such as marma points, meridian points, sen lines, and the chakra system. These maps redefine the human body of both practitioner and patient to allow for a greater participation in the healing process.
Palpation in Energy Work
Taking Energy Work as a separate category of “body work,” it is possible to enlarge the definition of palpation to include sensations obtained from expanded awareness.
In pure Energy Work modalities, such as Reiki or spiritual healing, the practitioner does not assess the condition of the patient through manual palpation, even when the hands are laid on. In this case, the practitioner “palpates” an energetic current which flows from its Source in the Divine.
Palpation of “divine” energy fields and currents can be extended to include the influence of a variety of conscious and non-conscious vibrations. Because all vibrations are forms of intelligent consciousness, it takes focus of the mind and attunement of the heart and a fully integrated sensory apparatus (the subtle body) to honestly and effectively navigate and utilize the spectrum of available intelligent energy.
The resonances of the Five Elements, helpers and guides, vibrations of other planets, crystal and gems, and herbal Deva presences all require one to “reach out and touch” across the subtle planes, in a way similar to our methods of gross physical palpation previously discussed.
Palpation in CranioSacral Therapy
Several preconditions ideally must be met for palpation skills to develop and mature in CranioSacral Therapy, where emphasis on mechanical techniques decreases over time, and focused therapeutic intent and “gestalt”(6) or “mandala”(7) awareness takes its predominant role over technical skill. Therefore, palpation initially understood in relation to expected conditions, becomes palpation in relation to an ever-expanding field of therapeutic awareness.
The first precondition is the willingness to suspend control, cynicism, judgment, and disbelief — and to tacitly allow and observe all perceptions — even if they are deemed unscientific, unreal, and even hallucinatory, by common standard.
In addition to reducing dependency on rigid analytical thought, one must reduce visual dependency, letting the hands alone become the source of perception. From this position, one can extend one’s physical boundaries to “meld” with the client. In this melding, one allows the sensations of one’s own physical limits to “go to the background,” so that the minute details of sensation are allowed to flow unobstructed by mental rigidity and even ego (self-idea) so that one can accept what one experiences as valid.
Palpating the Craniosacral Rhythm
The craniosacral system originates in the ventricular system of the brain where cerebrospinal fluid is produced by the capillary-dense choroid plexii inside of the ventricles. This system is continuous with the central canal of the spinal cord down to the sacrococcygeal complex, and is sheathed in the dural membrane. The dural membrane provides connective tissue support, and contains the cerebrospinal fluid, providing a dynamic hydraulic environment. The cyclic nature of the system is due to the dynamic production and reabsorption of cerebrospinal fluid, which provides the fluid pressure and a concomitant transmission of motion throughout the body.
Taking the “pulse” of the craniosacral system is the initial clinical palpatory skill that students of CranioSacral Therapy must acquire, as this pulse is the gateway to the entire therapeutic system, which treats the craniosacral rhythm (CSR) with the same depth and respect Traditional Chinese Medicine and Ayurveda afford the cardiac pulse. These traditional physicians keenly observe multiple layers of physiologic, energetic, and elemental information through the cardiac pulse, palpated in as many as 12 different physical locations.
While Trauma specialists and Emergency Medical Technicians utilize more pulses than most other medical professionals (because the patient can be on the verge of death or dismembered, pulse location and pulse quality are critical), most nurses and doctors perfunctorily palpate the cardiac and respiratory rhythms and routinely note down their rates as if the only data gained from their sacred resonance is of an important, yet limited nature.
However, CranioSacral Therapy approaches pulse and rhythm as a dialog with consciousness itself; the quantum and symbolic dimension that underlies all physiologic appearances. The rhythm of the craniosacral system is palpable on most areas of the body, and for more advanced sensibilities, at times, off the body.
Palpating Flexion and Extension
In the physiologic dimension the cycling of the craniosacral system is perceptible as a range of motion, expressed as a wave, flowing between states of flexion and extension.
The flexion motion of the body, in response to the craniosacral system, is an external rotation of the feet, knees, pelvis, and shoulders along their coronal axes. The parietals turn subtly outward along their sagittal axes and the head may appear wider along with a general widening of the entire body.
In extension the reverse is true, where the craniosacral system promotes the inward turning of these landmarks and the body may appear thinner and longer. In addition there is caudal motion of the occiput which coincides with posterior and cephalad motion of the sacrum during flexion. In extension they reverse.
To the beginner, the flexion and extension movements are most easily palpated with the hands evaluating the plantar and dorsal surfaces of the feet, upper thighs, hips, ribs, shoulders and parietals, all with the client in the supine position. However, with experience, craniosacral rhythm can be palpated anywhere on the body.
Primarily, it is this range of motion which communicates to the therapist the state of the craniosacral system and its somatic relationships. Due to its subtle nature, an extremely light touch is required to palpate and follow the craniosacral rhythm and the motion it instills. Therefore, palpatory (and therapeutic) touch must be so unobtrusive it neither interferes with the system’s subtle wavelike motion, nor elicits any “guarding” contractions from the client’s tissue.
In CranioSacral Therapy, light touch is defined as the amount of force it takes to “raise a nickel with one finger” (approximately 5 grams), or comfortably press with a finger on one’s closed eyelid. From this non-invasive form of palpation expands the wealth of touch-types and attitudes variously described as “melding,” “listening,” “following,” “neutral,” and “sending energy.” Within these modes of touch (and therapeutic interaction) the therapist can dance; seamlessly moving from palpation of the craniosacral rhythm to palpation of tissue, its movement, and to therapeutic release.
Palpating Tissue Release
Along the elastic web of fascia, in which all structures, organs, vessels and nerves float, connected; movement travels in what could be called, a sacred geometry. This geometry is a constant motion of push and pull, waves and ripples, points and referrals.
A constant process of fascial accommodation allows the body to rebalance itself through various holding-patterns in which energy is redistributed and stored in contractions. While fascial accommodation is essential to redistribute stress within the system, accommodative restrictions affect tissue tonus, fluid circulation, and the ability of life force to flow.
While a plethora of known pathologies contribute to fascial restriction, an infinitely greater number of unknown causes make their imprint on the soma, either as the residue of daily life or the influence of acute and sustained traumas.
When the flow of life force has been compromised and tissue looses its integrity, it must often be coaxed into a release, so that it may readjust and be realigned by the inner wisdom of the body. CranioSacral Therapy provides both palpation and therapeutic touch(8) skills which encourage this to occur.
The skill of palpating tissue release is developed upon the foundation of light touch described above. The CranioSacral Therapist palpates the tissue as it releases, and applies therapeutic touch at the same time, staying focused on the tissue and following its movement until it reaches its final released state.
Just as a hand placed upon the ribcage moves up and down with the flow of the breath, a therapist’s hand that holds no agenda will be moved by the client’s tissue. Tissue movement may proceed longitudinally, transversely, or diagonally, or in whorls and eddies. With the central nervous system enshrined in fascia, consciousness itself thus presents its unlimited healing power to release restrictions which invest the tissue that surround it.
Virtuoso Touch Revisited
To further this discussion of palpation in CranioSacral Therapy, I leave my brief mention of anatomy and technique and return to the concept of virtuoso touch, the category into which I placed Dr. John Upledger and the school of CranioSacral Therapy which he founded.
When a therapist’s primary concern is technique their ability to repeat strategic manipulations upon the map-board of medical anatomy is critical. But I believe the heart of CranioSacral Therapy is founded in virtuosity, which I define as accomplishment that transcends skill, expressed within a personality that transcends reality.
For me the Zen koan “finger pointing to the moon” illustrates how skills and expectations must be left behind; the teacher’s finger pointing to the moon is only an illustration, in our case, of therapeutic intent. It’s not the realization of therapeutic intent itself.
Philosopher Alfred Korzybski’s said, “the map is not the territory,” which is a contemporary expression of the same point. Furthermore, through the mathematics of infinite regression, it has been demonstrated that, “the map is a map of a map of a map (ad infinitum).”(9)
So for a CranioSacral Therapist, the central question becomes, “how do I get out of the map of the map of the map, and have the complete realization (siddhi(10)) of therapeutic intent?” I believe the answer pointed to by Dr. John Upledger is to enlarge the map until the mind has to let go, and the siddhi can freely flow.
Kinematics and Development of Palpation Skills
Tissue states perceived through the norm of three-dimensional awareness appear in superior/inferior, posterior/anterior and superficial/deep planes. If one adds a small measure of pressure and heat sensitivity to the range of perception, we arrive at the general level-limit of palpation practice in most modalities.
Consider this passage:
The introduction of the techniques of percussion and auscultation into medical practice immediately altered the relationship between physician and patient in a very significant way, specifically because these techniques relied almost entirely upon the physician listening. Not only did this greatly reduce the patient's capacity to observe and contribute to the process of diagnosis, it also meant that the patient was often instructed to stop talking, and remain silent.(13)
Therefore, we are called by the above observation to deeply question the impact even the simplest therapeutic techniques have on the entire process continuum. With this developmental perspective in mind, I suggest it is the depth of kinematics(14) experienced during the CST training process, which provides the greater awareness of tissue state, and results in expanded, multidimensional palpation skill.
The Impact of “Following the Tissue”
The accurate perception of tissue movement is fundamental to the understanding of CranioSacral Therapy. During training, by “following the tissue,” the student of CranioSacral Therapy is immediately placed beyond the limited three-dimensional awareness noted above by adding the element of time. Indeed, it is “craniosacral time” which so unitively strings together more points of perception, recognition, trust, allowing, presence, and listening, than are available through the practice of other therapeutic modalities.
As the student learns to follow the tissue they stretch their wings and fly into the melding of kinematic mystery and kinesthetic(15) wisdom, in a healing yoga of subtle beauty.
The Impact of “Following the Rhythm”
Detection of the craniosacral rhythm (CSR) is fundamental to the practice of CranioSacral Therapy and during training, in carefully sequenced stages, students learn to tune into the CSR and monitor it at both predefined anatomical landmarks and therapeutically determined locations on the body by “following the rhythm.”
Rhythm(16) is another larger dimension through which CranioSacral Therapy redefines palpation. Rhythm represents the regular coming into being of points of focus. Pulse, or vibration, is the essence of a wave(17) or field(18), which according to mystical traditions including Hinduism (Shakta and Shaiva) is the form of consciousness itself(19).
The Impact of “Not Following”
Ceasing to follow the movement of tissue, and “being a barrier,” is a gentle and purposed technique of non-involvement. It consists of introducing the stillness in order to, allowing deeper strata of tissue to release. Motionlessness is the counterpoint, or pivot, upon which all motion rests. Perhaps learning “not following” during the training phase of CranioSacral Therapy allows the student to access the hidden dimension to all motion and rhythm.
My Personal Exploration of CST Palpation Concepts
Through CranioSacral Therapy I have come to know the unlimited inner healer; a “presence” and an energy source hidden in the heart of every medical tradition and therapeutic modality. In the natural world of our ancestors, thisprimal being was always visible, and therefore communion with it predates all human systems of healing.
Primal Healing – Laying on of Hands
While popular spirituality conjures up visions of indigenous healing by tribal shamans with magical herbal lore; sweat lodges and vision quests; and animal spirits and natural energies linked to the phases of the moon, these are only superficial cultural accoutrements.
I believe human touch is the actual basis for all healing, because long before healing materials or rituals appeared, the initial response to another person in pain, sickness, injury, or on their deathbed, was to gather as many compassionate people as could be found and encircle the sufferer with human touch. In desperate moments, if even water is unavailable, human touch alone can easily transmit profound Life Force power through the conscious focused intention for healing.
CranioSacral Therapy is a pure and open modality with which to explore the primal, unlimited healer, which responds fully to human touch and needs no external element, skill, or understood reality, for its efficaciousness.
Extending Palpation – “Laying Hands” on the Universe
CranioSacral Therapy utilizes extended palpation techniques that comprehend the non-physiognomic energetic structures of consciousness. One such technique is arcing, in which a therapist may use their hands to perceive the concentric arcs of energy signaling the presence of an energy cyst(20) pathogen in the patient. Another extended palpation technique is used in the resetting of vectors(21) and realignment of chakras(22).
During the segment of my training on arcing, I experimentally palpated numerous intersecting arcs from all the individual bodies in the room simultaneously, exploring their vertexes and arcs. I later spent the evening sitting in the sand on the beach, expanding my perception by using my hands to palpate arcs of energy radiating from life forms in the depths of the ocean. Taking this experience farther by removing all notions of limitation to the technique, I palpated planets in space. This experience confirmed for me what was stated by Patanjali(23), that spiritual concentration on the universe brings knowledge of objects hidden to the five senses. Today, it is from this perspective that I palpate my clients.
Advanced palpation skills are central to CranioSacral Therapy, which among the many modalities of the healing arts, provides an expanded conceptual framework and training system, in which palpation becomes an art, and through dissolving all preconceived barriers to awareness, perhaps becomes even a “yoga” in itself.
1 Online Etymological Dictionary, http://www.etymonline.com
3 It is not within the scope of this essay to give a detailed explanation of the palpation techniques used in a medical examination or in special orthopedic testing.
4 For this essay, the scope of the term “therapeutic community” does not include the “medical community” who practice Western Medicine. Also, CranioSacral Therapy is omitted here because it is discussed below.
5 In these schools, palpating bioenergy, chakras, or cosmic energy for example, is not in scope.
6 “A physical, biological, psychological, or symbolic configuration or pattern of elements so unified as a whole that its properties cannot be derived from a simple summation of its parts. A physical, biological, psychological, or symbolic configuration or pattern of elements so unified as a whole that its properties cannot be derived from a simple summation of its parts.” http://dictionary.reference.com/browse/gestalt
7 “(in Jungian psychology) a symbol representing the effort to reunify the self.” http://dictionary.reference.com/search?r=2&q=mandala
8 The term “therapeutic touch,” has many meanings outside of the study of CranioSacral Therapy. I use it herein to indicate touch that is focused with therapeutic intent, and may include offering energy, or use any therapeutic touch techniques taught in CST.
20 Upledger, John E., CranioSacral Therapy II, Eastland Press, 1987. 212-213.
21 Upledger, John E., SomatoEmotional Release and Beyond, 1996. Chapter 3.
22 Upledger, John E., 1987. 229-230.
23 Patanjali. Yoga Sutras. 3.24