International Journal of Osteopathic Medicine (2014) 17, 66e72

www.elsevier.com/ijos

The seven-step palpation method: A

proposal to improve palpation skills
Andrée Aubin a,*, Karine Gagnon a, Chantal Morin a,b

a
Centre ostéopathique du Québec, 2210 Boul. Henri-Bourassa E, Bureau 103, Montréal,
Québec, Canada H2B 1T3
b
School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de
Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, Québec J1H 5N4, Canada J1H 5NA

Received 19 December 2012; accepted 18 February 2013

KEYWORDS Abstract Palpation skills are fundamental in osteopathy because they affect clin-
Cognitive-load theory; ical results. However, palpation is a complex task that requires the right combina-
Motor learning theory; tion of knowledge, skills, and attitude thus making it a real challenge to teach. This
Osteopathy; article describes a seven-step palpation method that promotes the development of
Palpation; palpation skills by gradually mastering their complexity. This innovative teaching
Palpation skills; approach is based on well-known cognitive and motor learning theories and ad-
Perception; dresses technical as well as perceptual considerations. For the last three years,
Teaching practice; the Seven-Step Palpation Method has been used at the Centre Ostéopathique du
Visualization Québec. The advantages and challenges of its implementation are discussed along
with the main issues of osteopathic palpation.
ª 2013 Elsevier Ltd. All rights reserved.

Introduction correctly evaluate osteopathic dysfunctions and

Palpation skills are the central component of oste-
opathic clinical practice. They are essential to
Abbreviations: CLT, Case-load theory; WM, Working mem-
ory; LTM, Long-term memory.
* Corresponding author. Tel.: þ1 514 384 1271.
E-mail addresses: info@coq.org, andree.aubin@videotron.ca
(A. Aubin), kgagnon@videotron.ca (K. Gagnon), Chantal.Morin@
USherbrooke.ca (C. Morin).
master treatment techniques. Furthermore, they
ensure clinicians’ efficiency since palpatory findings
mainly determine the accuracy of clinical
reasoning.1 Palpation is a complex task that requires
many types of knowledge, motor skills, perceptual
skills, and a therapeutic attitude. Like other ap-
prenticeships, it is influenced by students’ personal
factors and the context in which it takes place.2
Palpation is also complex by nature since it is an
open-ended task seeking for an undefined solution.3

1746-0689/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijosm.2013.02.001
A proposal to improve palpation skills 67

Considering their importance and complexity, The construction, storage, and automation of
improving palpation skills should be part of the aim schemas can become essential teaching goals to
of every osteopathic curriculum.4 ensure their fluid use in problem solving.10
However, teaching, and assessing palpation skills Therefore, these preoccupations are addressed in
can be really challenging. Palpation processes are the suggested teaching method.
deeply connected to a person’s perception, and as
such, to a bystander. Moreover, observation of
Motor skill learning theory
skilled osteopaths has shown that very different
ways are valid.5 Teachers should also be preoccu-
Palpation tasks can be divided into two distinct
pied by the low reliability of diagnostic palpation
components: a motor component, in which the
established by many osteopathic studies. It remains
clinician acts on the patient’s tissues (the informa-
a serious problem for the credibility of osteopathy
tion travels from the clinician’s brain to the pa-
and directly concerns palpation skill teaching.6
tient’s tissues) and a perceptual component, where
This article suggests a teaching method to
the clinician feels the state of the tissues (the in-
optimize the development of palpation skills by
formation travels from the patient’s tissues to the
gradually mastering their complexity. The current
clinician’s brain).
approach is based on well-known cognitive and
Teaching the motor component of palpation
motor learning theories and addresses technical as
tasks is supported by the motor skill learning the-
well as perceptual considerations. For the last
ory. In the medical field, four factors have been
three years, this teaching method has been
shown to enhance motor skill learning11:
implemented with a promising start at the Centre
Ostéopathique du Québec.7
1. Observation of a mentor or peer (including
dyad practice) can improve learning;
Theoretical foundations 2. External focus (directed on the movement’s
effect) is more effective than internal focus
(directed at the performer’s body movements)
Case-load theory
to promote automaticity in motor control and
movement efficiency;
The Case-Load Theory (CLT) offers useful guide-
3. Feedback that positively influences learners’
lines to tackle the complexity of palpation tasks.
motivation is the most effective.
The CLT8e10 states that the learning process of
4. Self-controlled practice is more efficient than
complex tasks can be hampered if the quantity of
externally controlled practice conditions.
information outnumbers the integration capacity
of the human brain. It is now well known that the
Furthermore, the links between self-controlled
working memory (WM) is capable of holding a
practice, perceived self-efficacy, and the quality of
maximum of seven elements or items of informa-
learning have been well established in learning the-
tion at a time.8
ories12,13 and for motor skill learning in osteopathy.14
When a task is sufficiently repeated, different
Learning complex motor skills can be simplified
elements will be learned and treated as a single
by reducing the cognitive load. Dividing the task in
entity called a schema. A schema can be encoded
smaller parts helps novices because they are able
in the long-term memory (LTM) and can be treated
to handle each part separately.15,16 Since an
with varying degrees of automaticity as one
incorrect technique is difficult to change later on,
element of knowledge by the WM. The LTM can
ensuring the quality of motor skill learning at an
handle an almost infinite number of information
early stage is preferable.17
when they are organized in schemas. The number
The proposed teaching method insists on
of schemas and their complexity depend mainly on
external focus as well as self-controlled practice
the expertise level related to a specific field. The
and divides motor tasks in smaller parts. It also
completion of a task using schemas will require
provides opportunities for internal feedback.
fewer resources from the WM, so it will be possible
to add more elements and/or to solve a problem
with less effort and better results.8 Theoretical notions on the perceptual
Many factors influence the formation of these component
schemas: scaffolding, feedback, the simple-to-
complex sequencing of a task, and the presentation The perceptual component of palpation tasks is
sequence of information. All these factors must be harder to define than the motor component.
adapted to the expertise level of learners.9 Because of its subjective nature, the perceptual
68
component never expresses an “objective reality”
and remains, whatever we do, a personal, multi-
modal, and multidimensional experience. It varies
according to many factors like: emotional state,
cognitive factors, perceptual mechanisms and
their dimensions (bottom-up/top-down), as well as
the visualization process.18 Perceptual strategies
rely on the type of information to collect and prior
knowledge.19
Many specific difficulties of the palpation
perceptual component are addressed in the sug-
gested palpation method.
The seven-step palpation method:
P.A.L.P.A.T.E
This teaching approach is a systematic seven-step
method. Those steps are always presented to stu-
dents in the same order and can be remembered
by the P.A.L.P.A.T.E acronym (Table 1). At the
Centre Ostéopathique du Québec, a handbook
describing osteopathic palpation challenges and
the seven steps of the palpation method was spe-
cifically written for students and is available dur-
ing all technique classes.20
The first goal of this approach is to automate the
motor component of palpation tasks in order to free
sufficient cognitive space for perceptual explora-
tion. In technique classes, reasonable time should
always be granted for the sole purpose of percep-
tual exploration so that students can learn to sys-
tematically search for as much information as
possible to allow automation of perceptual explo-
ration processes. When students are familiar with
basic motor abilities and perceptual exploration, it
is easier for them to focus on learning a technical
move while applying osteopathic principles.
It is essential to introduce gradually the next
difficulty level corresponding to students’ zone of
proximal development.21 For each step, the type
Table 1 Seven-step palpation method.
Step
Step 1 to 5: Automation of motor component
1 P Position
2 A Anatomy
3 L Level
4 P Purpose
5 A Ascertain
Step 6: Addition of perceptual component
6 T Tweaking
Step 7: Application of motor and perceptual skills in osteopathic technique
7 E Evaluate or normalize
A. Aubin et al.
and quantity of directives as well as the precision
required must vary according to the learners’ level
of expertise. For example, for novices, the sixth step
could be lengthier and even be the core learning of a
practice session. However, for advanced students it
could remain a shorter exploratory phase and
quickly lead to tests and techniques planned for the
class.
By addressing each component of the palpation
task (motor component, perceptual component,
and technical learning), this method also enables
the use of free cognitive space to overcome the
simple technical aspect of palpation and attain
deeper readings of tissue response.22e24 Further-
more, the unused cognitive space could be
devoted to decipher palpatory findings, an essen-
tial process of osteopathic problem solving.1 From
experience, it could also be used to increase the
number of structures that are simultaneously
considered during a test or technique. Finally, it
could be dedicated to identify unfamiliar situa-
tions that should trigger further analytical
reasoning processes.25,26
The Seven-Step Palpation Method aims at
achieving greater autonomy for students training
to enhance their learning process.11 Students can
reproduce learning sequences, as often as they
need, in a self-regulated environment and with
useful internal feedback.2 These factors are
essential because complex learning must be
repeated many times and over a certain period to
stimulate the cerebral reorganization required for
long-term retention.27
Specific directives must stimulate students to
build explicit palpation reference frameworks for
test results and treatment responses. Those op-
portunities to encode schemas in their long-term
memory promotes the progressive development of
palpation expertise.28
It is crucial that the palpation method becomes
a learning tool and not a rigid protocol to follow or
Description
Confortable positioning of the clinician
3D anatomic visualization
Depth of tissue contact
Clear identification of intention
Initiate motion with a relative point of reference
Fine-tuning of the five previous steps and
perceptual exploration
Apply technique parameters
A proposal to improve palpation skills
additional data to learn. The project’s purpose
would be greatly impaired if it increased the
cognitive load of palpation skill learning instead of
reducing it.29
The seven steps
Each step will be shortly described.
1 Position/Confortable positioning of the clini-
cian: Practitioner’s discomfort must be avoided
to ensure quality palpation. Even though this
step seems obvious, students often impose
considerable postural constraints on
themselves.
2 Anatomy/3D anatomic visualization: Using an
external focus (towards the movement effect)
while executing the task can maximize motor
skill learning.11 Therefore, instructors should
urge students to study anatomy plates and
models, so they will use a valid anatomic
visualization as focus. Teachers should also
adapt the complexity of the suggested mental
image to learners’ level of expertise. For
novice learners, the mental representation can
be limited to the basic characteristics of the
structure or articulation being palpated, but,
for advanced students, it can be more complex
and include, for example, its relation with
adjacent structures and/or the movement
axis.
3 Level/Depth of tissue contact: To ensure the
technique’s efficacy, palpation should neither
be too deep nor too superficial. The right depth
is the one allowing the desirable movement
(see step 5).
4 Purpose/Clear identification of intention: Since
the cognitive load of the three first steps is
already substantial, this step is crucial for
novice learners. Students should explicitly ex-
press a precise intention and direct it towards
the expected outcome on the tissue. They will
then benefit from the learning experience by
positively modifying the motor control required
to achieve the desired action.30
The combination of step two, three, and four
uses visualization principles, which have been
proven successful to learn complex movement in
sport, musical, and surgical fields.31e33 Further-
more, visualization techniques are efficient enough
to result in cerebral reorganization.34 Therefore,
they can be helpful in palpation skill learning.
However, it is advisable to use them with caution
since visualization abilities do not seem to be
universal.35
69
5 Ascertain/Initiate motion with a relative point
of reference: This method’s novel element is
an essential step. Students should use an initial
contact point to mobilize the structure to be
tested or normalized while they monitor the
effect of that motion on a relative point of
reference. For instance, to evaluate the
possible motion of the sacroiliac joint, the
ilium is mobilized if, and only if, a proportional
repercussion is felt on the sacrum. This self-
validation process promotes self-controlled
and self-regulated learning as well as internal
feedback for each attempt. With simple ac-
commodations, this step can be equally valu-
able for motility movement.
The first five steps of the palpation method
involve motor learning characteristics.
6 Tweaking/Fine-tuning of the five previous steps
and perceptual exploration: The sixth step is a
turning point. This step eases the use of the
previous steps and is a great opportunity for
repetition. However, students should not use
their newly-acquired motor automatisms sim-
ply for repetition purposes but also for the
exploration of different perceptual paths by
successively and systematically directing their
focus on the quantitative components of mo-
tion (amplitude, asymmetry, and dysfunction
intensity) as well as the qualitative compo-
nents (tissue surface, sensibility, reaction to
touch (defense or happiness), tissue textural
changes, density, elasticity, heat, vitality,
etc.). According to learners’ level of expertise,
this step could be lengthier for novices than for
advanced students. At this point, the goal is
not to find right or wrong answers. In fact, it is
sometimes useful to enable wrong in-
terpretations.30,36 Allowing students to share
their different visions or representations at the
end of technique sessions can enhance their
experience. Since the perceptual component is
personal, multimodal, and multidimensional,
the words used to describe a palpation exper-
iment can be very different from one person to
another and therefore can be complementary
and not necessarily contradictory.37
7 Evaluate or normalize/Apply technique pa-
rameters: The seventh step exploits the abili-
ties acquired in the first six steps to facilitate
learning of the curriculum tests and tech-
niques. To increase internal feedback for
advanced students, this step could also include
the comparison of the tissue’s state before and
after normalization.
70
Discussion
The principal author of this article initially used
this seven-step palpation method in cranial tech-
nique classes. It was quickly concluded that the
number of repetitions required (many hundreds)
was too important to be assumed by only one
teacher. Moreover, to enhance their palpation
skills, students need to apply the same method
consistently. It then became essential to imple-
ment the Seven-Step Palpation Method for tech-
nique classes in all osteopathic fields (cranio-
sacral, parietal, soft tissue, and visceral).
In the last three years, the use of this teaching
method in more than half the technique classes of
the Centre Ostéopathique du Québec led to the
following observations.
The first advantage was to rally the teaching
staff towards a common project and stimulate
collaboration between teachers and clinical in-
structors. This kind of synergy promotes the
development of students’ general competence.38
However, this method presents some challenges
for teachers. They must drastically modify time
distribution of practice sessions. They also have to
adapt the way they teach techniques because they
need to factor in, attention focus, identification of
main and relative reference points, as well as
variable utilization of palpation method steps
(type/quantity of instructions and adaptation to
expertise level). To assist them, a handbook
describing the application and possible uses of the
palpation method was written.39 Workshops were
also organized during teacher meetings.
Additionally, multiple informal observations
were made since the implementation of the Seven-
Step Palpation Method showing sufficient positive
effects on students’ palpation skills to justify
maintaining the project at a larger scale. For
example, students seemed more confident and, as
predicted,16 demanded less external validation in
technique classes. They understood more clearly
the stakes of palpation and the importance of
repeating each technical movement. They stayed
focused for longer periods in practice sessions and
have shown more interest in the palpation process
itself rather than in its final result alone. Some of
the higher-level students, who were not systemat-
ically exposed to this palpation method and who had
major difficulties developing palpation skills,
showed interest for this new learning tool in indi-
vidual follow-ups and have, for the majority, greatly
improved their technical performance afterward.
Beyond these observations, it would be useful to
validate the effects of the Seven-Step Palpation
A. Aubin et al.
Method on the two main issues of osteopathic
palpation: reliability of palpatory diagnostic and
assessment of palpation processes.
Firstly, it has been shown that inter-observer
reliability rises following a period of consensus
training.6,40 In certain circumstances, the reli-
ability gain can be maintained and improved over
time.41 Since it is intrinsically personal, the
perceptual component of palpation might be the
one that needs to be specified the most. The
standardization of every dimension of palpation
tasks might not be necessary or even desirable.5
The precise, comprehensive, and systematic
identification of osteopathic dysfunction charac-
teristics (quantitative and qualitative) as well as
the constant incentive to build palpation refer-
ence frameworks might help to enhance reliability.
Secondly, the assessment of palpation pro-
cesses is a major pedagogical challenge. The
development of extensive palpation reference
frameworks might also contribute to alleviate this
issue. The imperceptible nature of palpation pro-
cesses could be compared to the hidden portion of
clinical reasoning. In medicine, it has been shown
that the outcomes of clinical reasoning can be
estimated according to practitioner’s capacity to
represent the clinical problem with semantic
qualifiers.42,43 By analogy, it would be interesting
to determine if the value of palpation processes
can be linked to the number of relevant qualifiers
that students select from their reference frame-
works in order to describe their palpatory findings.
Conclusion
The implementation of this systematic teaching
method, based on well established cognitive,
motor, and perceptual theories, seems a valid way
to help students gradually master the complexity
of palpation skills required in osteopathy. Howev-
er, future studies will be needed to objectively
confirm the impact of implementing the Seven-
Step Palpation Method. In future months, data will
be collected to evaluate the improvement of stu-
dents’ palpation skills and to assess more objec-
tively if the use of this approach in an osteopathic
curriculum can provide viable solutions for palpa-
tion teaching challenges.
Authors contribution statement
AA conceived the seven-step method and wrote
the first draft of the manuscript. KG wrote the final
version. All authors improved the palpation
A proposal to improve palpation skills
method as well as edited and approved the final
version of the manuscript.
Conflict of interest statement
The authors declare that they have no competing
interests.
Acknowledgments
We would like to thank our colleagues who read
the manuscript and Nicole Spino for her dedicated
work. Acknowledgments are also extended to all
the teaching staff of the Centre ostéopathique du
Québec for their collaboration and feedback.
References
1. Esteves JE. Diagnostic palpation in osteopathic medicine: a
putative neurocognitive model of expertise. In: Teaching
palpation. Potsdam: OsEAN; 2011.
2. Brydges R, Butler D. A reflective analysis of medical edu-
cation research on self-regulation in learning and practice.
Med Educ 2012;46:71e9.
3. Fossum C. Palpation: from past to present. In: Teaching
palpation. Potsdam: OsEAN; 2011.
4. Browning S. Teaching osteopathic students technique; using
research to identify good teaching practice. Int J Osteo-
pathic Med 2010;13:70e3.
5. Degenhardt BF. New horizons for research and education in
osteopathic manipulative medicine. JAOA 2009;109:76e8.
6. Degenhardt BF, Snider KT, Snider EJ, Johnson JC. Interob-
server reliability of osteopathic palpatory diagnostic tests
of the lumbar spine: improvements from consensus
training. JAOA 2005;105:465e73.
7. Aubin A. Palpation teaching methods: challenges and is-
sues. In: Teaching palpation. Potsdam: OsEAN; 2011.
8. Sweller J, van Merrienboer JGJ, Pass FGWC. Cognitive ar-
chitecture and instructional design. Educ Psychol Rev 1998;
10:251e96.
9. van Merrienboer JGJ, Kirschner PA, Kester L. Taking the
load off a learner’s mind: instructional design for complex
learning. Educ Psychol 2003;38:5e13.
10. Kalyuga S, Ayres P, Chandler P, Sweller J. The expertise
reversal effect. Educ Phychologist 2003;38:23e31.
11. Wulfs G, Shea C, Lewthwaite R. Motor skill learning and
performance: a review of influential factors. Med Educ
2010;44:75e84.
12. Bandura A. Self-efficacity mechanism in human agency. Am
Psychol 1982;37:122e47.
13. Zimmerman BJ. Self-efficacy: an essential motive to learn.
Contemp Educ Psychol 2000;25:82e91.
14. Mann DD, Eland DC. Self-efficacy in mastery learning to
apply a therapeutic psychomotor skill. Perceptual Mot
Skills 2005;100:77e84.
15. Wulf G, Shea C. Principles derived from the study of simple
skills do not generalize to complex skill learning. Psychon
Bull Rev 2002;9:185e211.
16. McNevin NH, Wulf G, Carlson C. Effets of attentional focus,
self-control, and dyad training on motor learning: implica-
tions for physical rehabilitation. Phys Ther 2000;80:373e85.
71
17. Vanvenckenray J, Martinus JB, Mendes RS, Helsen WF.
Relearning movements: modification of an incorrectly
timed reveral movement. Perceptual Mot Skills 1999;89:
195e203.
18. Dror I. Perception is far from perfection: the role of the brain
and mind in constructing realities. Behav Brain Sci 2005;28:
763.
19. Ernst E, Bülthoff HH. Merging the senses into a robust
percept. Trends Cogn Sci 2004;8:162e9.
20. Aubin A. Méthode d’apprentissage et de développement de
la palpation en 7 étapes e Guide pour l’étudiant. Montréal:
Centre ostéopathique du Québec; 2011.
21. Rogoff B, Wersch JV. Children’s learning in the "zone of
proximal development". In: New directions for child
development, vol. 23. San Franscisco: Jossey-Bass; 1984.
22. Comeaux Z. Zen awareness in the teaching of palpation: an
osteopathic perspective. J Bodywork Move Therapies 2005;9:
318e26.
23. Becker R. Life in motion. Portland: Rudra Press; 1997.
24. Liem T. Ostéopathie crânienne e Manuel pratique. Paris:
Maloine; 2010. p. 671.
25. Moulton C, Regher G, Myopoulos M, MacRae HM. Slowing
down when you should: a new model of expert judgment.
Acad Med 2007;82:S109e15.
26. Croskerry P. A universal model of diagnostic reasoning.
Acad Med 2009;84:1022e8.
27. Luft AR, Buitrago MM. Stages of motor skill learning. Mol
Neurobiol 2005;32:205e16.
28. Dreyfus SE. The five-stage model of adult skill acquisition.
Bull Sci Technol Soc 2004;24:177e81.
29. Lee TD, Swanson LR, Hall AL. What is repeated in a repe-
tition? Effects of practice conditions on motor skill acqui-
sition. Phys Ther 1991;71:150e6.
30. Elliot D, Grierson D, Hayes SJ, Lyons J. Action representa-
tions in perception, motor control and learning: implica-
tions for medical education. Med Educ 2010;45:119e31.
31. Hall JC. Imagery practice and the development of surgical
skills. Am J Surg 2002;184:465e70.
32. Sanders CW, Sadoski M, Bramson R, Wiprud R, Van
Walsum K. Comparing the effects of physical practice and
mental imagery rehearsal on learning basic surgical skills by
medical students. Am J Obstetrics Gynecol 2004;191:
1811e4.
33. Driskell JE, Cooper C, Moran A. Does mental practice
enhance performance? J Appl Psychol 1994;79:481e92.
34. Jackson PL, Lafleur MF, Malouin F, Richards CL, Doyon J.
Functional cerebral reorganization following motor
sequence learning through mental practice with motor
imagery. NeuroImage 2003;20:1171e80.
35. Sacks O. L’oeil de l’esprit. Paris: Seuil; 2011.
36. Dror I. A novel approach to minimize error in the medical
domain: cognitive neuroscientific insights into training. Med
Teach 2011;33:34e8.
37. Grace S. Enhancing students’ palpatory skills through lan-
guage. In: Teaching palpation. Potsdam: OsEAN; 2011.
38. Prégent R, Bernard H, Kozanitis A. Enseigner à l’université
dans une approche-programme-guide à l’intention des
nouveaux professeurs et chargés de cours. Montréal:
Presses Internationales Polytechnique; 2009.
39. Aubin A. Enseignement de la palpation en 7 étapes: diffi-
cultés et enjeux pour son apprentissage et le développe-
ment des habiletés de palpation e Guide d’utilisation pour
les enseignants. Montréal: Centre Ostéopathique du
Québec; 2011.
40. Rosen ME. Response to cranial palpation pressures used by
osteopathy students: effects of standardized protocol
training. JAOA 2009;109:381.
72 A. Aubin et al.

41. Degenhardt BF, Johnson JC, Snider KT, Snider EJ. Main- 42. Bordage G. Elaborated knowledge: a key to successful
tenance and improvement of interobserver reliability of diagnositc thinking. Acad Med 1994;69:883e5.
osteopathic palpatory tests over a 4-month period. JAOA 43. Bordage G. Prototypes and semantic qualifiiers: from past
2010;110:579e86. to present. Med Educ 2007;41:1117e21.

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