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PTA Blog Talk

Palpating Musculature

Published December 15, 2010 5:31 PM by Jason Marketti

I swear my body responds quickly if people lose their balance during gait. Maybe my hands are prone to pick up the smallest change in their gait pattern from the smallest quiver of their musculature to the slightest hesitation to advance their assistive device.

In school, the first day, our instructor asked us to palpate a hair follicle that was folded in a piece of paper. Impossible, I thought at the time. Now I am not so sure. I know from experience that in an outpatient setting, one has to excel at palpation to accurately assess the patient and any deficits that may exist. However, that is not the only setting where small tremors in musculature tell a greater story.

While standing in the parallel bars doing LE exercises with one gentleman, I felt a tensing of his upper body before I saw him waver and collapse in the wheelchair thoroughly exhausted. I can also feel the resistance someone displays during a pivot transfer and determine how much assistance he will require. This may seem simple enough, until you begin to palpate a person tensing up for a transition from sit to stand, then stand to pivot on the mat table. The changes are often subtle and can result in a patient falling if you are not aware of what the person's body is doing during the transfer.

I have seen therapists grab a gait belt that is around someone and hold on for dear life throughout the session for fear of the patient falling. The gait belt then slides up around the patient's chest along with his shirt as he begins to stand and move around. To stand patients, I typically use their scapulae to bring them forward and up, standing in front of them. If I am next to them, I assist patients to stand either at the hips or with one hand on their upper back as they push up out of the chair. I can then palpate and get a better sense of what their overall body is doing and how they respond to the transfer. For example, how is their rotation at the trunk, does the pelvis move "freely" during the transitional activity or are the patients tight and unable to effectively flex, extend and rotate their upper body?

Do my super-sensitive hands find all the subtle cues? Absolutely not. Patients have fallen during gait with me and it was completely unexpected. But I do find that my ability to anticipate a patient having difficulties does have a direct correlation to palpating musculature that tenses up just prior to a loss of balance or difficult movement.

2 comments

Couldn't agree more with the two of you.  Gait belts should not be tools of our trade.

The worst - only- injury I ever sustained during patient care, and the only time I had a patient hit the floor came at the hands of a gait belt.  I honed my palpation/manual skills during one of my clinicals with an amazing CI who never used a gait belt treating patients with SCI and TBI!  Somewhere along the way, I began to doubt myself and picked up the gait belt.  Eventually, I found my self confidence again and while I continued to don the mandated gait belts, I quit actually using them.  I used hand placement, cueing, and my skills as a therapist instead of relying on a prop to do the job for me.  I never "lost" a patient to the floor after that.

A complimentary skill is knowing when a patient is ready to transfer, stand, and walk.  Another therapy trick I learned from that same CI.  You never stand a patient before he is ready.  That's one reason she didn't have to use a gait belt.  She didn't cave to pressure to get the patient "up and moving".  She refused to participate in drag therapy.  

Good discussion topic.

Janey Goude December 18, 2010 4:14 PM

Jason, you have hit upon one of my biggest arguments with management. They want to prevent a fall at all costs and a bean counter somewhere said "Gait belts are the way to do it". Now they are mandated in some institutions.

I agree with you. I think one's hands upon a patient give cues and messages long before the visual kicks in. Once one has become experienced in this, they are safer with a hands on/belt off approach.

Now, how do we get the less experienced to develop that skill without anyone hitting the floor?

Cheers, Dean

Dean Metz December 15, 2010 3:14 PM

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    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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