REHA2171 Osteopathy Theory and Practice 1

Lecture 1 Study Guide

These notes are a guide to the information you should be familiar with. It is your
responsibility to do further reading to ensure you have a thorough understanding of the
topics covered. References have been provided as a start for your further reading and you
are welcome to read other texts (books, journal articles, etc) that are not on this list.
Professional Behaviour
As osteopathic students, you are studying to be a registered osteopath. Osteopaths are
governed by the Osteopathy Board of Australia (OBA), who works in partnership with the
Australian Health Practitioner Regulation Agency (AHPRA), to provide guidance to our
profession and protect the public. These organisations have a code of conduct1 which
osteopaths are expected to follow.
Professional behaviour is associated with what the general population would expect from
someone of a particular profession. Osteopaths are expected, according to the Code of
Conduct of the OBA, to display a standard of behaviour that warrants the trust and respect
of the community. This includes observing and practising the principles of ethical conduct.1, p
11
The Code also provides details of professional values and qualities that are expected of an
osteopath. These include qualities such as: integrity, truthfulness, dependability and
compassion.1, p 2 Osteopaths must display respect for different cultures and beliefs, gender,
sexuality, religious and age differences. They are expected to put the needs of their patients
first.
Within this program you will learn to further develop these qualities within the practical
classes and in the Teaching Clinic. Taking note of how you are reacting to those around you
and different situations is a good way to begin understanding how your beliefs will influence
your professional behaviour. An article by T Brennan2 on current thoughts on professional
behaviour provides a concise and easy to read discussion.
A study noted in Chila,3, p 356 by M Papadakis et al,4 found that medical students who were
noted to be irresponsible, had a lowered ability for self-improvement and demonstrated poor
initiative were more likely to face disciplinary action after they completed their qualifications.
This article and the chapter on professionalism in Chila may help you to further understand
the qualities that you need to adopt when entering the osteopathic profession and it
discusses potential consequences of failing to behaviour in a professional manner.
Informed Consent
When a person consults an osteopath, or other health care professional, they are entitled to
understand the diagnosis, or what is causing the symptoms they are presenting with. They
are also entitled to be advised of what risks or benefits are associated with any tests,
examinations, treatment or management they will be undertaking. Only then can they agree
to the management of their condition as recommended by a practitioner. This is known as
informed consent. The Code of Conduct guidelines of the OBA give this definition :
Informed consent is a persons voluntary decision about health care that is made with
knowledge and understanding of the benefits and risks involved.1, p 5

The National Health and Medical Research Council provide further information about the
type of information and different situations that are required or associated with obtaining
informed consent. This information can be found in their publication General Guidelines for
Medical Practitioners on Providing Information to Patients.5
Within the practical classes for this course, you will begin to practice informing the patient of
what you are about to do and ask for permission to do the activity. By practising in the
practical class setting you learn to confidently and clearly explain what you are about to do
and gain consent. By the time you are practicing in the Teaching Clinic, and later as a
registered osteopath, gaining informed consent will be second nature to you.

Palpation and Touch

Palpation is an extremely important skill to learn within osteopathy. Osteopaths gain
significant amounts of information about their patients health and well-being from their ability
to palpate and interpret their palpation findings. Palpation also forms a dialogue between you
and your patient. It has the potential to create trust and respect within the practitioner-patient
relationship. The opposite can also occur.
The Educational Council of Osteopathic Principles (ECOP), in the Glossary of Osteopathic
Terminology, 3, p 401 define palpation as the application of variable manual pressure to the
surface of the body for the purpose of determining the shape, size, consistency, position,
inherent motility, and health of the tissues beneath. By continually repeating the practice of
palpation it is possible to distinguish between the tissue layers of the body and forming more
reliable inferences from the tissues about their state of health. It is possible to develop a
tactile memory of what a specific type of tissue dysfunction feels like across multiple
patients, and remember what it feels like in a specific individual from one treatment to the
next.
Palpation also forms one of the important aspects of developing your skill in technique
application. Each osteopathic technique requires an ability to understand what is happening
to the tissues at the site of contact and distal to it.
Lack of concentration, too much pressure and excessive movement are common errors that
distract or block the ability to palpate.

Anatomy and physiology of touch3, p 221-227

Palpation begins with a stimulus to receptors within the dermis and epidermis. The signal
generated will travel to the spinal cord, with a significant amount ascending to the brain stem
and then further into the cortex of the brain.
There are two main groups of receptors that enable this stimulus to be perceived. There are:
a. Free endings: usually associated with unmyelinated or lightly myelinated axons and
they provide information about general contact with an object.
b. Encapsulated endings: provide information in relation to being able to discriminate
between one object and another, and also provide information regarding light touch.
Due to the large number of receptors in the hand and fingers there is an increased sensitivity
and sensory discrimination compared to most other parts of the body (the mouth being the
exception). It is therefore the most suitable part of the body to palpate with.

Stages of Palpation
Palpation may be considered to have three stages:
1. Reception
2. Transmission
3. Interpretation
The reception stage is associated with the stimulation of receptors of the palpating structure,
ie the pads of your fingers, or the palm of your hand. This is followed by the transmission of
impulses from the receptors in the periphery to the central nervous system (spinal cord and
brain); the transmission stage. The third stage is interpretation of the impulses received by
the central nervous system.
Factors that Facilitate Palpation
Factors that facilitate palpation include:
1. Keeping your applicator, or body part that is palpating, relaxed
2. Keeping your wrist in neutral as much as possible. Increased extension may hamper
palpation by sending to many proprioceptive signals that prevent the signals
associated with palpation to be received
3. Being centred and balanced, ie steady posture, whether seated or standing, so you
dont have to pay attention to supporting yourself
4. Keeping your neck in neutral so your head is not bent forward
5. Being willing to receive the input without having to label what you are feeling
immediately
6. Keeping the depth of palpation appropriate to the structure being palpated
The following describes different types of palpation, or touch:
Light touch: this type of palpation requires only a slight pressure. It enables the quality of the
tissues to be observed and assessed. It also allows you to differentiate between normal and
abnormal textures.
Deep touch: this type of palpation requires more pressure. This does not mean hard or
strong pressure. Often with deep touch you need to let your fingers sink into the tissues at a
steady pace. If you press too hard or too fast you will encounter resistance from the tissues
you are attempting to palpate and either get false information about the tissues state or will
be unable to palpate the structure you are interested in. Deep touch allows you to palpate
through multiple layers of tissues. You can use a shearing motion to palpate the interaction
between the layers.
Movement: you can use a still hand to assess the inherent movement of the tissues you are
palpating. You can move you hand to assess the tissues at rest; for example changes in
texture, temperature and pressure. Depending on the aim of palpation you can vary the
speed at which you palpate structures. In early stages of palpation, it is recommended that
you use a slower approach to avoid missing and small differences that may be present. As
you skill and confidence grows you may wish to speed up your palpation.

Palpatory Language
Words that are commonly used to describe tissues of the body being palpated may include:

Superficial/deep
Boggy
Hypertonic/hypotonic
Strong/weak
Flaccid
Clammy
Hot/warm/cold
Moist/damp/dry
Tender
Tight/slack
Ropey
Tense/relaxed
Responsive/unresponsive
Irritable
Local/diffuse

Building a vocabulary in regard to the different findings associated with palpation of the body
helps to increase the sensitivity and awareness of what is occurring within the tissues being
palpated. It can also be used to describe to another practitioner the palpatory findings and
reason for the working diagnosis.
Dominant Eye
There is a theory that if you use your dominant eye when assessing what you are palpating
that you will get more accurate information. To find which eye is your dominant eye:
1. Pick an object on a wall opposite you that is a reasonable distance away
2. With one of your hands, either:
a. Circle the object with the thumb and index finger of the hand
b. Use your index finger to line up with the object, ie if looking at a clock on the
wall, place your index finger so that the tip of the finger lines up with the
centre of the clock
3. Close your left eye and notice whether the object stays within the circle of your finger
or is still aligned with your index finger
4. Open you left eye and close your right eye and observe for any movement of the
object you are looking at in relation to your monitoring hand.
5. Your dominant eye is the one where the object does not move from the monitoring
hand.

See Chila3 p 404 for further information on finding your dominant eye.

Assessment of a Patient
As a general rule there is a process that is undertaken to ascertain what is the most likely
cause for the patients symptoms. An example of this would be:
1. Observe the patient as they move from the waiting room and walk into your
consulting room
2. Take a case history from the patient to gain an insight as to why they have consulted
you, their general health and any other factors that may be
3. Examine the patient. This entails observing the patient, performing active and
passive range of motion tests, orthopaedic, neurological, physical examinations and
ordering other tests or procedures as deemed necessary
In this course we will concentrate mainly on observation and active and passive range of
motion.
With observation some of the things you are looking for include:

1. areas of redness and unusual skin markings. For example, a patchy reddened area
may indicate infection or inflammation.
2. skin lumps such as lipomata (fatty masses) appearing as lumps in the area of the low
back may be a sign of underlying neurological disorders.
3. an unusual hairy patch on the low back may also be evidence of underlying bony or
neurological abnormality.
4. birth marks should be carefully investigated, as they may also suggest underlying
pathology.
5. symmetry of structures. For example: are the shoulders the same height; is the
muscle tone and size the same for a paired muscle (pectoralis major, etc); is the
spine in a vertical line or does it deviate to one side
For active and passive range of motion you are assessing for:
1. The ability of the person to perform the action themselves and how well they do the
action
2. What the joint feels like while you are passively moving the joint?
3. Can the joint go through its complete range of motion?
As you progress through the program your understanding and ability of observation and
assessment will increase.

References
1. Osteopathy Board of Australia. Code of Conduct for Registered Health Practitioners.
Melbourne:AHPRA. 2010-2012
2. Brennan T, et al. Medical professionalism in the new millennium: A physician charter. Ann
Intern Med. 2002. 136(2):243-246

3. Chila AG. Editor. Foundations of Osteopathic Medicine. 3rd Ed. Philadelphia: Lippincott
Williams & Wilkins. 2011. Ch 1-4, 26 (Professionalism), p 404
4. Papadakis MA, Teherani A, Banach MA, Knettler TR. Disciplinary Action by Medical
Boards and Prior Behaviour in Medical School. The New England Journal of Medicine. 2005.
353(25):2673-82
5. NHMRC. General Guidelines for Medical Practitioners on Providing Information to
Patients. Ref: E57. 2004. Canberra:Australian Government. Available:
http://www.nhmrc.gov.au/guidelines/publications/e57 Viewed:26.2.2102