The accuracy of diagnostic palpation: the comparison of soft tissue findings with random blood sugar in diabetic patients

Kenneth E. Nelson, Department of Osteopathic Manipulative Medicine, Midwestern University, 555 31st Street; Downers Grove, IL 60515.

E-mail address: knelso@midwestern.edu.

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Introduction

In 1971, a recently graduated osteopathic physician was told by his then boss and mentor that “Harrison Fryette could estimate random blood sugar by touch.”1 This comment was met with shock and an incredulous response, something to the effect that it was such outlandish statements that gave the rest of the medical world the inclination to question the validity of osteopathic medicine. The disbelieving young- ster was taken to a hospital room containing two patients, one of whom was diabetic, and told to comparatively pal- pate the posterior cervical soft tissues in both patients. After a brief period, he was asked if he could discern a difference. There was, indeed, a palpable difference. The diabetic pa- tient’s soft tissues possessed a distinct tissue texture change not present in the tissues of the nondiabetic roommate. The tissues felt fuller; they felt “puffy.”

A year or so later, that same young physician had an encounter with a new patient who was complaining of cervico-thoracic pain. After obtaining a history of the chief complaint, he impetuously proceeded to the mus- culoskeletal examination and was surprised to feel that same subcutaneous fullness previously palpated in the diabetic patient’s tissues. A surreptitiously introduced inquiry into the patient’s current medications revealed that he was indeed an insulin-dependent diabetic.

So, if there was an observable subcutaneous finding in diabetic patients, from the clinical diagnostic perspective it was then necessary to demonstrate that this palpable differ- ence was consistently present. To this end, a simple protocol eventually was developed in which two groups of patients were blindly palpated to determine whether diabetic patients could be consistently differentiated from nondiabetic pa- tients. Of 17 individuals palpated blindly (7 diabetics and 10 nondiabetics), tissue texture change was identified in 100% of the diabetics and was absent in 80% of the nondiabetics. These “results suggest(ed) that palpatory findings may be useful in distinguishing chronically hyperglycemic individ- uals from normoglycemic individuals.”2

With the demonstration that there is indeed a discern- able palpatory difference that identifies the diabetic pa- tient, the question arises: How well may such a difference be quantified? If quantification proves to be possible, then the statement referring to Fryette’s diagnostic skills is not as outlandish as it initially appears to be upon cursory examination.

‌Subsequently, the following protocol was developed to determine whether a statistical correlation exists between subjectively quantified palpatory changes in tissue texture and the easily measurable independent variable of random blood sugar.

Materials and methods

‌Patients (n = 40) were recruited from the outpatient Family Medicine Clinic of the Chicago Osteopathic Medical Center and assigned sequential numeric identifiers to ensure ano- nymity of the patient-physician encounter. All were estab- lished diabetics. Patients meeting these criteria, with no exclusions, were enrolled and examined in the order that they presented to the clinic for routine follow-up visits. All patients who were asked to participate in the protocol did so without hesitation. This process was carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experimentation involving hu- mans (Midwestern University Institutional Review Board ap- proved).‌

‌Following standard-of-care procedures, patients’ random blood glucose levels (mg/dL) were assessed using the One- Touch (Life Scan, Inc., Milpitas, CA) blood glucose assess- ment system immediately before the physician-patient en- counter. After the blood glucose analysis, musculoskeletal examinations were performed in 2 X 3-M examination rooms as part of the routine osteopathic physician-patient encounter. This segment of the protocol was performed at the very beginning of the encounter and before the physi- cian’s review of the patient’s chart, blinding the examining physician to the blood glucose test results and before the acquisition of any verbal interim history, thereby reducing any other cues that might bias the examination. There were two examining physicians.

The palpatory examination

Patients were examined in the supine position on a stan- dard adjustable-height bench-type examination/manipulative-treatment table. The examining physician was seated at the head of the table. The patient’s posterior cervical soft tissues were palpated for tissue texture change by using a combination of skin rolling,3,4 Beal’s compression test,5,6 and layer palpation.3,4,7 Briefly, the examining physician grasped the skin and subcutaneous tissue of the patient’s posterior cervical region bilaterally between the thumbs and index fingers with sufficient digital pressure to focus atten- tion on subcutaneous tissue. Special attention was given to the posterior paraspinal tissues over the midcervical trans- verse processes. The degree of subcutaneous tissue texture turgidity (nonpitting or brawny edema) was quantified on a five-point scale (ordinal data) from 0, indicating no palpable tissue texture change, to 4, indicating severe tissue texture change (Table 1). This portion of the protocol required one to two minutes.

Statistical analysis

Ordinal data frequencies, descriptive statistics, and correla- tions (Pearson [zero-order] correlation, and Kendal and Spear- man rank-order nonparametric correlations) of blood sugar levels with palpatory assessment were computed using the SPSS 10.1 statistical package (SPSS, Inc., Chicago, IL).8

Results

Of the 40 patients enrolled, eight exhibited blood sugars ranging from 61 to 108 mg/dL, and 32 exhibited blood sugars >110 mg/dL (Table 2). Of these 32 patients, the blood sugars of 22 ranged from 110 to 199 mg/dL, six ranged from 200 to 299 mg/dL, two ranged from 300 to 399 mg/dL, and two were >400 mg/dL. Palpable tissue texture changes were exhibited by 27 of the 40 enrolled patients.

For each patient, the numeric quantification for the pal- pably assessed intensity of posterior cervical subcutaneous tissue texture change (Table 1) was recorded for comparison with the One-Touch blood glucose analysis (Table 3). No patient exhibited a tissue texture change value greater than 3 (moderate tissue texture change). Computation of three statistical correlation tests (Pearson, Kendal, and Spearman) resulted in the following findings: a Pearson correlation value of 0.210, with a probability of .097; a Kendal corre‌lation value of 0.215, with a probability of .042; and a Spearman correlation value of 0.269, with a probability of‌ .047 (Table 4).

Discussion

First, let it be said that the statistical strength of this study is limited by the relatively small cohort size, making it more appropriately considered a pilot study. The results also are limited by the weakness of the correlation. This having been said, the subject being addressed is quite relevant to the definition of osteopathic distinctiveness, and a statistical trend appears to be present, in that the p-values of two of the three statistical correlations used (Kendal and Spearman) are less than .05.

Considering the literature, the significance of tissue tex- ture changes in association with diabetes mellitus has been recognized in the osteopathic literature.2,9 Most of these reports look at diagnostic findings and the somatovisceral impact of osteopathic manipulative treatment.10,11

The continual improvement of refined palpatory skills is at the heart of the uniquely developed osteopathic approach to physical diagnosis.3-5,7 Although the knowledge of dia- betes as we currently understand it was unavailable to cli- nicians like H. H. Fryette, the physician’s sense of touch and the physiology of the diabetic patients they palpated were not different from today. The lack of technological diagnos- tics at the time, furthermore, required that they focus on physical diagnosis to correctly identify disease.

Although we typically refer to blood or serum glucose, the term “glycemia” is actually misleading. Glucose is ele- vated in diabetic patients throughout the extracellular com- partment. The elevated presence of the glucose exerts an osmotic effect upon the intracellular compartment causing water to be pulled from the cells. The fluid shift is directly proportionate to the elevation of glucose, resulting in pal- pable swelling of the soft tissues that is in turn also propor- tionate. This edema is most readily palpable in the subcu- taneous tissues and is, with a discerning sense of touch, quantifiable.

This exercise may seem to be nothing more than a clinically irrelevant “parlor trick.” What difference does it make if one can crudely quantify diabetic glycemia by palpation? Contemporary technology has produced pocket-‌sized devices, for little cost, that provide precise glycemic readings. Furthermore, the statistical power of this study is weak, but one must remember that H. H. Fryette practiced in the first half of the 20th century. Insulin was not discov- ered until the early 1920s, so for Fryette the descriptors “mild,” “moderate,” and “severe,” when applied to diabetic patients, probably applied more closely to glucose levels of 400, 800, and 1200 mg/dL.

It must be recognized that the data presented herein is internally biased by the fact that all patients examined were diabetic and, therefore, diabetic tissue texture change was to be anticipated in each individual examined. This bias is overcome by the ordinal nature of the data. It is further strengthened by the participation of two examiners using the same palpatory methods (Procedure Appendix) to evaluate patients with relatively controlled diabetes (range 61-487 mg/dL, Table 3) when compared with diabetic management in the early 20th century.

‌What this study does show, however, is (1) that palpatory discrimination exists for levels of tissue texture change that in turn mirror systemic physiology, and (2) that claims made about the early practices of osteopathic medicine should not be so quickly dismissed. The osteopathic profession has a rich tradition of distinctive palpatory physical diagnosis in an area where very few others have ventured—the quanti- fication of physical changes that constitute somatic dysfunc- tion. Physical diagnosis is by far the most cost-effective diagnostic method available. It does not replace technolog- ical diagnostics, but as has been said repeatedly in the past, technological diagnostics should be reserved for the purpose of confirming the conclusions drawn from a thorough his- tory and physical examination, not as a replacement for the history and physical. The acquisition of a thorough history, the performance of a careful osteopathic physical examina- tion, and the mental process of synthesizing a prioritized differential diagnosis list is, in fact, that which differentiates a physician from a technician.‌

Physical findings, identifiable by traditionally osteo- pathic diagnostic practices, are present that can alert the astute clinician to underlying systemic illness, in this case diabetes. But diabetes is not the only systemic condition mirrored by generalized tissue texture changes. The hypo- thyroid state is associated with myxedema. Systemic infec- tions result in a generalized soft tissue response. Renal failure results in osmotically induced fluid shifts that mirror the feel of diabetes to the extent that, in the previous dia- betes palpation study,2 the two nondiabetic individuals in- correctly identified as diabetics were actually renal failure patients.

Conclusion

The osteopathic profession needs to further delineate the extent of its palpatory diagnostics. The quantification of the palpatory experience helps to validate our distinctive osteo-

pathic approach and contribution to physical diagnosis. Our oral tradition is full of references to palpable findings asso- ciated with mechanical and reflex somatic dysfunction, as well as with systemic illness, which are worthy of further study.

Procedure Appendix

Note: The development of discerning touch, which al- lows the examiner to appreciate subcutaneous tissue texture, is of paramount importance in the diagnosis of somatic changes:

• found in association with systemic illness

• for the determination of the intensity of viscerosomatic reflexes

• for the differentiation between acute and chronic somatic dysfunction

The following diagnostic procedures are descriptions of the procedures as they were performed in the above proto- col. As such, they were performed to evaluate systemic changes in the posterior cervical subcutaneous tissue tex- ture, with the patient lying supine and the physician seated at the head of the examination table.

These procedures, however, may also be performed to assess for (mechanical or viscerosomatic reflex) segmental somatic dysfunction by comparing the soft tissues at each vertebral level with those of the segment above and below. Furthermore, they may be used to evaluate any spinal area by modifying the position of the patient, or that of the examining physician.

Palpation for tissue texture abnormality (layer palpation) Procedure

1. Slide both hands, palms up, beneath the patient’s cervi- cal spine.

2. Using the lightest touch, contact the skin on either side of the spine and palpate cutaneous temperature and texture.

3. Apply slightly more palpatory pressure, enough to pal- pate through the skin but not enough to appreciate the paravertebral muscles and their fascia. Evaluate the sub- cutaneous tissue by palpating for interstitial turgidity.

4. Assess the superficial fascial tension in the region with slightly greater pressure by introducing movement in different directions and identifying in which direction the movement is most free and in which it is the tightest.

5. Applying more pressure, sense the deep fascia. Palpate for areas of thickening involving the fascia that sur- rounds the paravertebral musculature.

6. Finally, palpate through the deep fascia to evaluate the underlying muscles. Identify individual muscle fibers and the direction in which they run. This will allow you to differentiate the superficial muscles that are oriented ‌cranio-caudally from the deeper muscles oriented more medio-laterally. Note areas of increased musculature tension.‌‌

‌Skin rolling Procedure

1. Slide both hands, palms up, beneath the patient’s cervi- cal spine.

2. On either side, with each hand, symmetrically grasp a fold of posterior-cervical skin between the pads of the thumbs and index fingers.

3. Gently pull the skin away from the underlying deep fascia and paravertebral musculature.

4. ‌Using the principles of layer palpation described before compress the grasped tissue to appreciate the turgidity of the skin and subcutaneous tissues.‌

Beal’s compression test Procedure

1. Slide both hands, palms up, beneath the patient’s cervi- cal spine.

2. The pads of the fingers should contact the paravertebral soft tissue on either side of the spine.

3. Using the principles of layer palpation described above, apply gradually increasing pressure directed anteriorly

   relative to the supine patient, compressing the paraver- tebral soft tissues to appreciate the turgidity of the skin and subcutaneous tissues.

   
   

   References

   1. Larson NJ: Personal communication, Chicago, IL 1971

   2. Tarr R, Nelson K, Vatt R, Richardson D: Palpatory findings associated with the diabetic state. J Am Osteopath Assoc 85:604-605, 1985

   3. DiGiovanna EL: Palpation. In DiGiovanna EL, Schiowitz S, eds.: An Osteopathic Approach to Diagnosis and Treatment, 3rd ed. Philadel- phia, PA: Lippincott Williams & Wilkins, 2005, pp 64-66

   4. Greenman P: Principles of structural diagnosis. In Greenman PE, ed.: Principles of Manual Medicine, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2003, pp 13-37

   5. Beal M: Palpatory testing for somatic dysfunction in patients with cardiovascular disease. J Am Osteopath Assoc 82:822-831, 1983

   6. Nelson KE: Viscerosomatic and somatovisceral reflexes. In Nelson KE, Glonek T, eds.: Somatic Dysfunction in Osteopathic Family Med- icine. Baltimore, MD: Lippincott Williams & Wilkins, 2007, pp 33-55

   7. Nelson KE: Diagnosing somatic dysfunction. In Nelson KE, Glonek T, eds.: Somatic Dysfunction in Osteopathic Family Medicine. Baltimore, MD: Lippincott Williams & Wilkins, 2007, 12-26

   8. SPSS, Inc.: Base 8.0 Applications Guide. Chicago, IL: Author, Copy- right © 1998, pp 32, 57-58

   9. Licciardone JC, Fulda KG, Stoll ST, Gamber RG, Cage AC: A case- control study of osteopathic palpatory findings in type 2 diabetes mellitus. Osteopath Med Primary Care. 2007, doi:10.1186/1750-4732- 1-6.

   10. Bandeen SG: Diabetes: report covering twenty-five years research on stimulation of pancreas, blood chemical changes. Osteopath Prof 17: 11-15, 38, 40, 42, 44, 46-47, 1949

   11. Licciardone JC: Rediscovering the classic osteopathic literature to advance contemporary patient-oriented research: a new look at diabe- tes mellitus. Osteopath Med Primary Care. 2008, doi:10.1186/1750- 4732-2-9