Assessment is often poorly taught to massage therapists and as a result many of us end up terrified of treating pain conditions. Is the tingling down our client’s hand and arm a result of a nerve compressed by soft tissue (well within our scope of treatment) or something more serious? Is our client’s bad back a muscular problem or should they be referred back to their GP?
Precise and targeted clinical assessmentshould be a vital tool in any therapist’s toolbox and will not only gain you better outcomes but increase your professional standing with the medical profession, physios, chiropractors and osteopaths.
Knowing when to refer to these other professionals or when a condition is best treated by yourself is a key component to making our profession more professional
What is Orthopedic Assessment?
“ An assessment is an educated evaluation of a clients condition and physical basis for his/her symptoms in order to determine a course of treatment”(Clinical Massage Therapy: Rattray and Ludwig)
“ A judgement about something based on an understanding of the situation” (Encarta world English dictionary”)
Assessment, Diagnosis and working within your scope of practice
It is firstly important to understand the difference between assessment and diagnosis with respect to your role and scope of practice as a massage therapist. Massage therapists use the word assessment when evaluating the nature of a condition. This is not a diagnosis which is a term used by the medical profession. It is the difference between investigating the nature of a condition (assessment) and naming that a certain condition is present (diagnosis)
GPS have a much wider scope of knowledge and potential sources of pain – for example, tingling down the legs could be result of a tumour pressing on the spine. However if other causes of pain have been ruled out by the GP, your consultation and assessment can focus on whether the condition is being caused by soft tissue issues, emotional stress or other factors that lie within your scope of practice. For example if other causes have been ruled out the tingling down the legs could be result of the sciatic nerve being compressed by the piriformis which is easily treatable through massage therapy
Why do an assessment
Quite simply, a good assessment enables us to plan effective treatments that achieve the goals or outcomes that the client desires. From a business point of view, achieving good outcomes leads to satisfied customers, which leads to a thriving and interesting practice. Doing an assessment enables you to be the equivalent of a massage Sherlock Holmes, picking up clues from your client in various different ways to help you figure out what is going on and how you can best help. A good assessment enables you to see whether your treatment is working and gives you measurable benchmarks so both you and your client are able to assess progress.
Clinical assessment for massage therapists is usually divided into 5 components, which you can remember, by the acronym “HOPRS”:
• H -Health history questions (usually known as your case history or medical intake)
• O– Observations (i.e.: of posture)
• P– Palpation (of soft tissues including muscles and fascia)
• R– Range of motion testing (of movements at joints)
• S– Special Orthopaedic Tests (specific tests that help us to identify problems more precisely)
Your skill set may also mean that you carry out other forms of assessment to help determine the nature of the problem- for example the local or general listening techniques used in visceral manipulation; arcing used in cranial work or scanning the chakras for imbalances.
Depending on your skill, knowledge and scope of practice you may focus more on some areas of the above than others. However whether you are doing relaxation massage, sports massage, energy work or pregnancy massage, some form of assessment is vital. You always need to know why your client has come to you, what they are expecting from the treatment and a baseline for any changes you make.
“A good listener is not only popular everywhere, but after a while he knows something” (Wilson Mizner)
Taking a case history is often the first real contact you have with your client. This is the point where you can really start to hear your client’s story, make a connection with them as a human being, and start your detective journey gathering clues as to their physical, emotional and spiritual make up. It is also the point where your client will start to make judgements about you; your level of skills and professionalism, and ultimately whether they will come back to you. Taking time to do a thorough case history is an investment not only in your client’s welfare but your business.
Your job at this point is to draw out the information that you need to make an assessment of your clients needs and, most importantly, what outcome they would like to see from this treatment or series of treatments. It is your job as a professional to figure out how you can achieve this outcome and realistically how many sessions this may take.
A great simple question to ask is “How would you like to feel after the treatment”. This focuses the client onto their expectations- if they don’t know what they want from the treatment, it will be very difficult for you to meet their needs. Once you get an answer, try and narrow this down even further.
For example, your client may say they just wish to “relax”. This may seem like a simple goal but the more precise you can be, the better you will be able to achieve your outcome. Through careful questioning and listening, try to ascertain what relaxation feels like for the client- a useful question to ask is “How will that feel in your body that is different from now”. This more precise questioning will often get to the nub of what is needed – for example your client may then say, “ my shoulders will feel looser”. Great! Now you have something concrete you can do – any wonderful techniques you know to release shoulders (trigger point work, general Swedish techniques, hot stone work, stretching, range of motion). You also have a measurable outcome that you can refer back to at the end of the session; afterwards you can ask your client “how do your shoulders feel now”. If the answer is “looser” you both know you have done a good job!
If your client is presenting with some kind of pain problem you will need to focus in further with your questioning to give you the information you need to treat effectively. Use the mnemonic OPQRS to help:
O Origin of the pain. When did the pain begin? Was there a precipitating factor – accident, fall, emotional trauma?
P Provocation: Does anything make the pain worse? i.e.: cold, movement, getting stressed. Conversely does anything make the pain better? Ie: warm bath, moving around etc.
Q Quality of the pain. This can help you identify the source of the problem. Nerve pain tends to be tingling or electric. Chronic soft tissue pain can be dull and achy whereas more recent acute muscle pain can be sharp and stabbing. Pain of a muscular origin is often aggravated or relieved by movement. Beware of pain that is deep and unrelenting, even in sleep, and make sure that other causes have been ruled out. This type of pain can often be a sign of a more organic problem such as a tumour.
R Radiate: Does the pain stay in one place or does it radiate to different parts of the body?
S Site: Where is the pain exactly? Get your client to point to it. It can also be helpful to have a picture of a body on your case history form where the client can draw in the areas of pain.
This part of the assessment process begins the minute you see your client. How do they walk, take their coat off, are they easy in their body or are there areas of apparent restriction? How do they seem emotionally – do they have a good vital energy or do they seem tired and low? The more you use your powers of observation, the more you are able to develop this sense to your advantage. Ida Rolf, the founder of Rolfing, famously was able to assess the exact location of a lumbar herniation of an unknown client walking through the door in a heavy overcoat.
It is also useful to carry out a more structured process of body reading- the exact way you do this often depends on your training or particular bodywork discipline. Physios, osteopaths and other bodyworkers will often observe the body in a systematic fashion – noting for example, relative heights of the shoulders, tilts to the pelvis, rotations of the legs etc. This gives us clues as to what areas of soft tissue may be tight or restricted. For example a laterally rotated leg could indicate a tight piriformis muscle that may be the cause of a client’s sciatica by entrapping the sciatic nerve.
A quick way of assessing visually is simply to look at your client while they are standing and notice any gross, observable differences between the 2 sides of the body (left to right and front to back) Which areas seem tight or drawn together? These may well be areas you need to work to free up muscular or fascial adhesions.
“Palpation cannot be learned by reading or listening; it can only be learned by palpation” (Frymann 1962)
“There are no limits to sensitivity” Jean Pierre Barral
Palpation is truly one of the most wonderful tools in our repertoire and is a skill that we develop constantly in our work. There are no limits to palpation as an assessment tool – as we develop our sensitivity as bodyworkers, we find that we are able to feel more and more subtle differences in tissues and energy fields. Developing palpation skills relies on you touching the body with intent and focus; Neuman (1989) states “ The three most common errors made while palpating to assess tissue are:
• Lack of concentration on what is being touched
• Too much movement of the palpating fingers
• Using excessive pressure”
If you are focussing on soft tissue, the information gathered from palpation can be organised into 4 categories – the 4 “T’s” of palpation:
Temperature: Tissue may be hot, indicating inflammation, or cool, indicating ischemia.
Texture: Healthy tissue has an even texture throughout. Adhesions feel as if the muscle is stuck together. Trigger points can feel like a small pea or as big as an olive.
Tenderness: Pain can be indicated if the client winces with compression
Tone: Tissues can be hypertonic (increase in tone relative to nearby muscles) or hypotonic (decrease in tone)
Of course our palpation skills need not be limited to muscle and fascia- a skilled therapist will learn to appreciate subtle movements such as the cranial or visceral rhythm or subtle energies such as the chakras and the meridians. This is what makes massage so magical!
Range of motion and Special Orthopaedic Testing
These can be subdivided into:
• Active range of motion test: These focus on the contractile tissues i.e.: the muscle tendon unit.
• Passive Range of Motion test: These focus on the inert tissues i.e.: ligaments or the joint capsule
• Manual Resistive Tests: These assess contractile tissue for pain and weakness with muscle, tendon or peripheral nerve injury.
• Special Regional Orthopaedic Tests: These are used to isolate a specific condition.
Eastern Methods of Assessment
I have also found it useful to bring in ideas from other approaches to inform the assessment process. Traditional Chinese medicine (TCM) has an extremely thorough assessment process based on the following 4 traditional areas:
1. Looking: appearance; facial colour; tongue diagnosis
2. Listening and smelling: voice and respiration
3. Asking: The practitioner will do a thorough case history including preference for hot and cold (relates to TCM principles of Yin and Yang); headaches; pain; urine; thirst; sleep; family history
4. Touching: The practitioner will assess through taking the pulse (there are hundreds of different pulse qualities in TCM representing different states – for example a shallow and weak pulse indicates deficiency of qi (life force)
Bringing it all together
When you have gathered all your information from the various aspects of your assessment process you are in a position to make an informed judgement about a treatment plan. Make sure you have really listened to your client, not just with your ears but your informed touch and that your assessment is not based on snap judgements. Be prepared to modify your treatment plan as you go along depending on what you find with further exploration of the tissues and how your client responds.
Bringing assessment skills into your work will enhance your practice tremendously; try some ideas out bearing in mind the words of Socrates: “ Four things belong to a judge, to hear courteously, to answer wisely, to consider soberly and to decide impartially.”
Rachel Fairweather is co-founder and director of the Jing Institute of Advanced Massage. An acclaimed teacher and guest lecturer, she has been a massage therapist for 35 years and is author of a book on advanced massage approaches published by Handspring Publishing. Based In Brighton, the Jing Institute run a variety of courses in advanced techniques to help you build the career you desire including a a one year advanced clinical massage certificate
Our short CPD courses include excellent hands on learning in a variety of techniques including trigger point therapy, myofascial release, pregnancy, hot stone and stretching. For the first time you are now able to learn these techniques at your own time and pace with our revolutionary new online courses and webinars.
For the therapist who wants to be the best they can possibly be, we offer a BTEC level 6 (degree level) in advanced clinical and sports massage – the highest level of massage training in the UK.
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