Assessments

As therapists know, one of the most important components of a session is the assessment. A good assessment should include a thorough interview. This helps guide the therapist toward the best approach for that individual. This interview should include questioning on the client’s employment and job duties, and whether the pain is work related. It is also important to know if there have been other accidents or injuries in the past that may contribute to this discomfort. This is also a good time to get more clarity on the type of pain the client is experiencing. Pain sensations are unique and can help guide the therapist to the type of injury causing the pain.

Documentation is a crucial part of the assessment process. Documenting all findings, subjective and objective, before and after the session will demonstrate whether the approach to care is working. When working with other parties such as other therapists, doctors, insurance companies, and so on, documenting what approach was taken and what changes have occurred is beneficial to all. The “subjective, objective, assessment, and plan,” or Soap note is a universal way of tracking progress over sessions. It is used by most medical facilities and it is suggested that therapists use this method for documentation. Other key forms to use are client histories, health histories, evaluations, body maps, and an initial consultation for first-time clients. Sample forms can be found in the appendix.

With all assessments, it is important to document the details of the tests performed. Be specific with the notes so the test can be repeated in the future. The position, type of test, joint, and action should be clearly noted. Identify and rate any deviations from normal as well as potential causes for any limitations. These details can be recorded during an initial body assessment and reassessments.

The interview and health intake process helps clarify the client’s medical history. Medical histories are important to determine whether massage is contraindicated for that client. It is also important to learn about any medications the client might be taking. Many medications can interfere with the session or at least alter the responses the therapist receives. General pain killers, for example, if taken before the session, may numb the client’s pain sensations, which could result in inaccurate feedback. This could cause the therapist to use more pressure, which may do more damage than good. This is a big concern when using deep tissue massage.

Being thorough with your interview helps create an ideal treatment plan for the future. If the process of designing a treatment plan is seen as solving a puzzle, the interview process builds the border of the puzzle. Having an understanding of what has been going on with the client and what he or she is currently feeling will be helpful in focusing the attention of the therapist during the physical part of the assessment.

Experts suggest using a separate page specifically for the initial body assessment. This allows the therapist to complete a thorough assessment that can be referred to and compared with during future sessions. Forms should document all assessment methods such as postural assessment, gait assessment, and functional assessment.

Postural assessment

The postural assessment is a starting place for most massage therapists. Be cautious when performing a postural assessment. People automatically alter their normal standing position when the topic of posture is approached. During a postural assessment, the client needs to be in a natural, relaxed standing position. If it is necessary, have your client march in place for 30 seconds to 1 minute. Pay attention to the motion of the knees and hips. Be sure to have the client “pump” his or her arms during this motion; this can also be used as one of the functional assessments. Stop the motion and have the client stand in place without making any compensation.

Now the therapist can document head position, shoulder level, hips, knees, and ankles. Take a superficial glance at first, noting things like an asymmetrical stance, contours of the body, and body type. From the anterior view, look for the head position: are the mastoid processes even and balanced? Draw a mental line from acromion process to acromion process: are the shoulders level with each other? Look at the iliac crests and the anterior superior iliac spines: do they appear even? Also look at the head of the fibulas and the malleoli: are they even with each other? If necessary, palpate the structures to confirm your assessment (Figure 2-1).

Figure 2-1 Anterior postural assessment.

From the lateral view the therapist should look for alignment of the body. Imagine a line perpendicular to the ground, or use a plumb line to assess the posture. This line should go through the external auditory meatus, acromioclavicular joint, greater trochanter, fibular head, and just anterior to the lateral malleolus (Figure 2-2). It is common to see upper crossed syndromes and lower crossed syndromes from this view. Understanding these crossed patterns and applying them throughout the body will help the therapist identify possible areas of weak muscles or hypertonic muscles.

Figure 2-2 Lateral postural assessment.

Recognizing upper and lower crossed syndromes can help guide the therapist to an appropriate technique or approach. The upper crossed syndrome presents itself with a protracted shoulder girdle often caused by tightness in the pectorals and the posterior neck muscles. Hypertonicity in these muscles is compensated by weak anterior neck and lower trapezius muscles. The lower crossed syndrome is also prominent from a lateral view. This shows tight hip flexors and low back muscles, and weak abdominals and gluteals. The pelvis appears to tilt forward, often referred to as an anterior tilt (Figure 2-3).

Figure 2-3 Upper and lower crossed syndromes.

As with the other postural assessments, the therapist should look for symmetry of the contours of the back and alignment of the spine. This can be completed using a plumb line or an imaginary line perpendicular to the ground. Starting from the top down, look for the symmetry of the mastoid processes, acromion processes, inferior angle of the scapula, iliac crest, posterior superior iliac spine, head of the fibula, and the lateral malleoli. This view helps the therapist confirm what he or she noticed from the anterior and lateral assessments. Although in the anterior view a deviation in the hips may look like a hip hike, or elevation, it may not be seen from the posterior. This inaccuracy between assessments may be due to a rotation versus an elevation or depression in the hip. This is important to document so the therapist can follow up with palpation and other functional assessments throughout the session (Figure 2-4, p. 15).

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