Quality touch is an old care idea made new

Expert discusses ways to bring touch into rehab

Physiatrists might improve their patient care by learning skills for quality touch, which is a holistic way of dealing with patients that incorporates some age-old methods and philosophies into the new era of rehabilitation treatment.

"The ability to palpate and touch is essential," says Mark A. Tomski, MD, a clinical assistant professor at the University of Washington, Department of Rehabilitation Medicine, in Seattle. Tomski has a private practice in Puyallup, WA, and he gave a workshop about quality touch at the 63rd Annual Assembly and Technical Exhibition of the American Academy of Physical Medicine and Rehabilitation, held Nov. 21-23
in Orlando.

Tomski instructs physiatrists about the importance of using manual techniques in order to enhance function from the inpatient to outpatient rehab setting, and he also discusses acupuncture and other cutting-edge approaches to rehab care.

The goal is to increase physiatrists’ ability to diagnose and treat, and the emphasis is on increasing their ability to have more sensitive palpation during hands-on procedures and treatments, Tomski says.

For example, if an inpatient has total joint rehab, and the patient’s mechanics are such that the patient is not able to bring the legs forward, there is a major problem that needs to be addressed, Tomski says.

"Sometimes by increasing the extension of palpatory skills, the physician might find that the problem really is at the knee, and this can be treated with counterstrain, a manual technique or muscle energy technique," Tomski says.

Through quality touch, the physician was able to sense where the problem was qualitatively, he adds.

Often, Tomski starts a workshop on quality touch by asking participants to learn relaxation skills. He’ll have them center themselves through relaxation by closing their eyes and stilling their thoughts.

It’s in this relaxed state that physicians will be able to use touch as an instrument of diagnosis, Tomski says.

Historically, physiatrists have always done manual care, but this philosophy hasn’t had a deep penetration in the rehab field, Tomski notes.

However, once physiatrists try the touching techniques, they discover that it changes the ways in which they interact with patients.

For instance, a physiatrist trained in quality touch might teach patients a little of the relaxation techniques, using terminology that is amenable to the patient’s personal philosophy. "One thing I teach residents and colleagues is that a patient may not be centered, and this affects the patient’s ability to receive information," Tomski says.

Since patients often are suffering from pain, their thoughts and energy are off-balance. As a result, the patient may make a movement that stiffens the neck and causes pain.

So the idea is for the physiatrist to first work at bringing the patient into a more centered state of being in which the patient’s muscles begin to relax and their agitation decreases. As these changes occur, the patient may begin to experience some improvement in neck stiffness.

A physician can help accomplish this by modeling a calm demeanor for the patient, Tomski says.

"I’ll enter the room and sit and be centered, and then say, How can I help you?’" Tomski says. "And this will change the dynamic for a chronic pain patient who is used to being cut
off and treated with an Oh, no, here they are again!’"

That simple technique of entering the patient care room calmly and without a sense of rush or impatience is enough to shift the patient’s mood — and the entire patient encounter — for the better, Tomski says.

"The typical clinical medicine doctor cuts off the patient in 17 seconds," he says, adding that by spending more time with the patient and letting the patient speak first, the physician can learn more and change the way the patient perceives the entire encounter.

"Most patients will speak truthfully about their pain for seven to 10 minutes, and if the physician can be in that room for 10 minutes to listen and sit there, you can build a rapport," Tomski says.

Of course, one of the keys for this to succeed is for the physician to be relaxed and centered. "I do centering prayer twice a day for 20 to 40 minutes as a practice," Tomski says.

Once the patient has finished talking about his or her concerns, it’s important for the physiatrist to address those concerns, deviating a little from the normal routine of bringing up whatever was noted by the referring doctor, Tomski says.

The next step is to examine the patient by using quality touch skills and observing how the patient is holding him- or herself. Through observation, the physician will note such things as poor posture that makes it difficult for the patient to gain any benefit from physical therapy, since the patient probably is doing the exercises with the incorrect posture and isn’t aware of this, Tomski says.

The chief difference between quality touch and the typical type of touching used in a physical exam is that the physiatrist is open to his or her own intuition and will be able to perceive problems in the patient’s body that aren’t readily apparent, Tomski says.

"Those of us who have been on this road for more than a decade can feel some very subtle things," Tomski says. "For example, in advanced courses I’ve taken, people can feel a thread of hair through multiple pages of a telephone book."

Think of quality touch more as a way to focus one’s attention than as a physical action. "We’re able to actually feel different joints and whether the joints are working properly or not and if they are in joint alignment or joint dysfunction," Tomski says. "All of this has been around forever and is part of the physical medicine literature."

The last step is to develop a treatment plan that takes into consideration the concerns of all parties involved, including the patient, referring physician, insurer, and therapist. This might entail teaching patients about their own unrealistic expectations or at least shifting the patient away from goals that will not be feasible, Tomski notes.

"If someone is sitting there and is psychotic and wants to jump off the building and fly, your job is to get the patient off the roof," Tomski says.

Or, with rehab patients, it often is the case that patients were injured at a job in which the patients already didn’t like the supervisor, and so patients will say they ought to be retrained for a new position. The physiatrist, who knows the expectations of the employer and worker’s compensation insurer, realizes that the patient’s goal is unrealistic and won’t happen. So it’s up to the doctor to educate patients about their work history, the worker’s compensation laws, and how these mean that the patient must be treated with the goal of returning to the same position as before, Tomski says.

"Ultimately, physicians have to have a good sense of themselves," Tomski says. "If you know what your limits are and set clear limits with patients, you won’t have problems."

Also, it’s important to be practical and realize that there are good days and good patients as well as bad days and troublesome patients, and that the practice of medicine won’t run smoothly all of the time, Tomski says.

"Our job as physicians is to help those who are willing to accept our help to heal and to let those go down the tube who want to go down the tube," Tomski says. "But we still treat everyone with compassion."

Need More Information?

  • Mark A. Tomski, MD, Clinical Assistant Professor at the University of Washington, Department of Rehabilitation Medicine, Seattle. Private practice: 205 15th Ave. SW, Suite B, Puyallup, WA 98371-7487. Telephone: (253) 770-5675. E-mail: mark@dr-tomski.com.