Miami, Florida, United States (Fall 2014)
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
(Definition of Pain, The International Association for the Study of Pain, 2010)1
|Andrew Taylor Still, 1914|
Pain is a complex sensation that incorporates the mental and the physical. Physicians are trained to ask specific questions to better understand the patient’s symptoms. These questions invite the patient to share his narrative, his story that reflects the lived experience of pain. Listening to the patient’s narrative allows the physician to grasp the extent of the pain, to better understand the patient as a person, and to establish a more connected relationship. But this is only one part of the pain experience. How does the doctor come to understand the “actual or potential tissue damage,” in other words, the physical part of pain?
As a reader and interpreter, it is the doctor’s role to listen and use that information in the diagnostic process. But a different form of communication is also needed, and that occurs through palpation. Through touch the doctor is able to feel the affected tissue, and that sensation gives a better understanding of what is occurring in the body and how this translates into the patient’s experience of pain.
Palpation is at the core of osteopathic medicine, founded by Dr. Andrew Taylor Still in 1874. Doctors of Osteopathic Medicine (DOs) are skilled in providing the benefits of modern-day medicine, but are also trained to use osteopathic manipulative treatments (OMT), hands-on therapeutic techniques to help alleviate pain and restore functioning.2 DOs learn to diagnose somatic dysfunctions, defined as “impaired or altered function of related components of the somatic (body framework) system: skeletal, athrodial, and myofascial structures, and their related vascular, lymphatic, and neural elements.”3 By treating with their hands, osteopathic physicians become sensitive to minute changes in the musculoskeletal system. They assess patients by four criteria: tissue texture change, asymmetry, restriction of motion, and tenderness (commonly known as TART).4 Touch, a critical component of osteopathic medicine and a fundamental attribute of the healing process, allows the DO to read the body’s expression of pain and translate it into medical treatment.
Skill at palpation requires an understanding and appreciation of each layer of the body and its corresponding feel. The first layer is the skin, where light palpation can detect changes in temperature, how the skin drags (meaning if the skin is dry or oily), and if some areas of the body are rougher than others. Deeper into the skin is the subcutaneous tissue, which may feel soft since this is a layer that cushions. Deeper palpation reaches the muscle layer, where by feeling the doctor can detect the tone, tension, and contraction.
As these layers of the body cannot be seen by the naked eye, the physician must hone in on what he is feeling.5 Osteopaths use their hands as perceptive tools that can discriminate the different layers of the body and detect how a group of muscles react when pulled in a certain direction. Some DOs even close their eyes while palpating in an effort to tune out the surrounding environment and concentrate on the singular sensation of touch, thus sensing slight changes that can have an immense impact and help diagnose the dysfunction.
Osteopathic medicine has developed its own language, incorporating descriptive metaphors to help differentiate chronic versus acute pain. It classifies acute somatic dysfunction as feeling warm, tender, and boggy.6 For the most part these terms seem medically related and applicable, but “boggy” is one that would not commonly be found in the medical vernacular. DOs define boggy as, “A tissue texture abnormality characterized by a palpable sense of sponginess in the tissue, interpreted as resulting from congestion caused by increased fluid content.”7 The term “boggy” is meant to describe the swampy atmosphere of a bog, to portray the stifling humidity and uncomfortable mugginess. Utilizing such a metaphorical term creates a vivid image and a sensory-filled reference source for the physician to understand the muscle and the surrounding area within the body. Likewise, the description of chronic pain uses subjective terminology to capture the essence of the somatic dysfunction.
Chronic somatic dysfunction is described as feeling cool, dry, tightened tissue.8 Again, osteopathic medicine utilizes terms that are full of imagery. Ropiness is defined as “a tissue texture change characterized by a cord- or rope-like feeling.”9 While this particular phrasing might seem unusual to describe muscle tissue, it does in fact depict what is felt during palpation. Ropey illustrates how the muscle fibers have wound up on each other, and imagining the muscles transformed into a tight cord enhances the physician’s understanding of the patient’s pain experience. Such language allows both the physician and the patient to picture how this muscle has been distorted over time, and reflects the intensity of chronic, long-lived pain. Furthermore when these findings are shared with the patient, the diagnosis becomes more accessible because it is based on everyday language, helping to establish a better patient/doctor relationship.
The concept of tenderness is an opportunity for both patient narrative and body narrative to merge into one cohesive story. An area of somatic dysfunction is likely to have a surrounding area of sensitivity, and if the physician applies too much pressure while palpating, the patient will respond. As author Caroline Stone explains in Science in the Art of Osteopathy, “The person will react with inappropriate emotions if that part is moved, so they avoid engaging it…If someone moves that part of the body for the person, the emotional response may well be retriggered.”10 Pain is as much a physical experience as it is a psychological one, and the osteopathic belief that the patient is a unit of body and mind respects the multilayered experience of pain.
A patient who has lived with chronic pain may have learned to live with the discomfort, and by not engaging the affected part of the body, the patient is able to suppress the pain into a latent form. The osteopath palpates the body and locates tenderpoints, which are “small areas … of oedematous and tense muscle or fascia that is tender to palpation.”11 While reading these tender areas, that dormant sensation could be triggered and the patient might respond, either as a verbal exclamation or an emotional release. There is a fine line between applying just enough pressure on the body to feel these small, swollen nodes and applying too much pressure that inflicts pain and set off an emotional response. It is an interpretation that requires sensitivity, and one that blends with the osteopathic philosophy.
Palpation is an insightful diagnostic method, but more importantly it is a way to connect with the patient and to fully comprehend the physical changes that cause pain. Pain affects all areas of life, and by interpreting both the body narrative and the patient narrative the osteopathic physician can understand pain’s immense impact on life. But the effect of palpation transcends the scope of medicine. The humanistic quality of one person comforting another through touch is the beginning of the healing process. From day one, osteopathic physicians learn how to use their hands to diagnose and treat patients, but also to appreciate the uniqueness of every body. The osteopathic medical touch reaches both the physical and the emotional facets of pain, and offers patients a holistic treatment of pain.
- Merskey, H. Pain Terms: A List with Definitions and Notes on Usage Recommended by the IASP Subcommittee on Taxonomy. Pain 1979; 6: 249-252.
- American Association of Colleges of Osteopathic Medicine. The History of Osteopathic Medicine. 2008-2013. Web. Accessed 1 March 2014.
- Educational Council on Osteopathic Principles of the American Association of College of Osteopathic Medicine. Glossary of Osteopathic Terminology. Revised November 2011. http://www.aacom.org/resources/bookstore/Documents/GOT2011ed.pdf. Accessed 1 March 2014. P. 53.
- Nicholas, Alexander S., and Evan A. Nicholas. Atlas of Osteopathic Techniques. Philadelphia: Lippincott Williams & Wilkins, 2008. P. 6.
- Becker, Rollin E. Life in Motion. Portland: Stillness Press, 1997. P. 160-161.
- DiGiovanna, Eileen L., et al. An Osteopathic Approach to Diagnosis and Treatment 3rd Edition. Philadelphia: Lippincott Williams & Wilkins, 2005. P. 17.
- Educational Council on Osteopathic Principles of the American Association of College of Osteopathic Medicine. Glossary of Osteopathic Terminology. Revised November 2011. http://www.aacom.org/resources/bookstore/Documents/GOT2011ed.pdf. Accessed March 1, 2014. P. 9.
- Ibid. P. 53.
- Ibid. P. 43.
- Stone, Caroline. Science in the Art of Osteopathy. Cheltenham: Nelson Thornes Ltd., 2002. P. 60.
- Parsons, Jon, and Nicholas Marcer. Osteopathy: Models for Diagnosis, Treatment and Practice. Philadelphia: Elsevier Ltd., 2006. P. 246.
ANEESA SATAUR, MA, DO, is a first year resident in the Family Medicine program at Westchester General Hospital in Miami, FL. She received her BA in Biology and English with honors from Bryn Mawr College in 2004, and her MA in Medicine & Literature with honors from King’s College London in 2007. She received her doctorate in Osteopathic Medicine in 2014.