Massage Therapist: The Basics of Therapeutic Massage and Bodywork Assessment

Key Topics:
- Client consultation and intake procedures
- Assessment techniques and treatment plans
- Client recordkeeping
- Tips for answering questions on therapeutic massage and bodywork assessment
 

Therapeutic massage and bodywork assessment is the process by which you gather relevant information about the client and plan an effective course of treatment based on your findings. During the assessment process, you will collect information in a number of ways. You will get some information directly from the client via intake forms or answers to your questions. You will gather other data from your observations of the client’s physical condition and the physical assessments you conduct.
Implementing a systematic assessment process is essential for therapists for a number of reasons. First and foremost, a methodical approach allows you to thoroughly evaluate each client to ensure that the course of treatment is advisable and not contraindicated by some underlying condition. The assessment should clearly indicate if massage is a good treatment choice or if you should refer the client to a different type of health-care provider. Second, an organized approach enables you to efficiently determine the root causes of the client’s symptoms so that you can quickly plan an appropriate treatment. Finally, the care you take will reinforce for the client that you are a serious health-care professional. It will also confirm that both you and the client are operating from the same set of expectations for treatment.
 

For examination study, at a minimum, you should be able to do the following five things:

(1) explain how to appropriately conduct a client consultation; (2) describe the assessment methods used during client evaluation, including observational, palpatory, and other techniques; (3) identify postural alignment and physical holding patterns in the body; (4) integrate your findings and formulate an appropriate course of treatment; and (5) describe techniques for orderly and professional client recordkeeping.

Although this guide does not review every detail of these subjects, it highlights important information and gives you some practice questions in these areas.

The number of questions you will need to answer on therapeutic massage and bodywork assessment varies by exam. If you are taking the MBLEx, you will be required to answer a total of 125 questions; of these, about 17 percent, or around 21 questions, are on this topic. If you are taking the NCETMB, you will be required to answer a total of 160 questions; of these, about 18 percent, or around 28 questions, touch on this topic.

History of Massage in the West
Although it is widely known that therapeutic massage originated in the Eastern cultures of Asia, it is not always recognized that massage has also had a long history in the Western parts of the world as well. The first Western peoples known to have practiced some form of therapeutic massage were the ancient Greeks. By 300 B.C.E., the practice of massage was widely accepted across Greece, thanks in large part to a priest-physician named Aesculapius, who developed the practice of gymnastics as a combination of exercise and massage. Via the Greeks and later the Romans, the practice of massage gained popularity throughout Europe. Although practice declined sharply in the Middle Ages, massage reemerged during the Renaissance due to a renewed interest in science and medicine.
As interest in massage continued to grow over the centuries, many medical practitioners incorporated it into their treatment regimens. In some places, massage came to be the preferred method for maintaining personal health and treating diseases.

In the seventeenth and eighteenth centuries, Swedish physiologist Per Henrik Ling pioneered a system of movements called Medical Gymnastics and founded the Royal Swedish Central Institute of Gymnastics. In time, Ling’s system, later known as Swedish Movements or the Swedish Movement Cure, spread through Europe. In the mid-1800s, brothers Charles Fayette and George Henry Taylor introduced Ling’s system in the United States and further increased the visibility of massage with the general public and among medical professionals.

As the nineteenth century progressed, the practice of massage continued to be refined and further established as a medicinal approach. Some notable achievements included those of Dr. Johann Mezger, who introduced the concept of scientific massage, and Dr. Douglas O. Graham, who pioneered Swedish massage in the United States. By the end of that century, massage practice had accelerated into a popular, serious business.
However, at the beginning of the twentieth century, the British Medical Association uncovered widespread abuses in the education and practice of massage therapy. These discoveries undermined the credibility of the massage industry and caused a significant decline in practice.

Over time, the practice of massage slowly regained some of its footing as new techniques like Connective Tissue Massage and Deep Transverse Friction massage were developed. In the 1960s, the United States saw a notable upsurge of interest in massage treatment as many people turned to massage and other therapies as alternatives to traditional medicine.
Today, with the emergence of new practices, such as chiropractic medicine, as well as the accreditation of massage schools and the proliferation of professional affiliations, the practice of therapeutic massage has slowly but surely regained its standing as a viable treatment field.

Client Consultation and Intake Procedures
During your initial meeting with the client, you should plan to spend a few minutes gathering data to evaluate the client’s physical condition and determine if massage treatment is appropriate. Standard intake forms allow the client to easily provide you with relevant information such as full name, address, emergency contact, and insurance provider (if applicable). In addition, intake forms encourage clients to provide a complete health history by requiring them to answer questions about current or past medical conditions; previous surgeries or procedures; current or past medications; allergies that might impact treatment; and any relevant symptoms, signs, or concerns.
Once the client has completed the intake forms, you can conduct an interview to clarify the information and delve further into the reasons for treatment. It is critical to follow up on any issue that may contraindicate treatment, or to get clarifying information about any conditions, procedures, or medications that are unfamiliar to you.

An effective way to learn more is to ask the client appropriate follow-up questions during the interview, for example: “I see you are taking such-and-such medication; can you tell me more about the condition being treated with this medication? How long have you been taking this substance? How does it make you feel?”

Tips:
Clients may not always be entirely forthcoming about their health history or they may refuse to answer relevant questions about their current physical condition. In such situations, even if the client appears healthy, you should refuse to conduct treatment, as you have no way of knowing what underlying conditions may be present.

The intake interview is also an opportunity to ask the client questions about his or her current lifestyle, as day-to-day activities or recent events or traumas may provide some indication as to what may be causing or aggravating the condition for which the client is seeking treatment.
As part of the intake process, you can also use a simple anatomical diagram to allow clients to indicate exactly where on the body they are experiencing pain or other symptoms. You can follow up by asking appropriate questions about the issue, such as, “How long have you had this condition? Is there anything that gives you relief from the pain?” You should assess the patient’s level of pain or discomfort by having the client rate his or her pain level on a scale of 1 to 10. Later you can use this as a marker to gauge the effectiveness of the treatment.

Exercises: Client Consultation and Intake Procedures
Choose the option that best answers the question.

1. An intake form can be used to gather complete information about all of the following EXCEPT (A) the client’s insurance provider. (B) the client’s medical history. (C) a list of the client’s allergies. (D) the effects of the client’s medications.
Although the intake form can be used to gather a wide variety of details about the client, the effects of his or her medication are generally too broad and complicated to be listed on a form. In this case, you should ask the client follow-up questions about his or her medications or consult with the client’s primary physician. The correct answer is (D).

2. A new client you are interviewing for the first time refuses to divulge certain sensitive details about his medical history, but is quite insistent upon getting a massage. How should you proceed? (A) Give him a massage with whatever information you have. (B) Decline to work on the client if he will not cooperate. (C) Demand that he tell you what you need to know. (D) Seek further information from others who know the client.
If the client refuses to provide pertinent information about his medical history or condition, you should decline to perform any work. Working on a patient without his or her full medical history may be dangerous, as he or she may have an underlying condition that may contraindicate massage. The correct answer is (B).

Assessment Techniques and Treatment Plans
Massage therapists use a variety of assessment techniques when evaluating clients.
- Observation/visual input: What do you observe when you look at the client? Does the client appear healthy? What do the client’s posture, gait (manner of walking), and movements tell you about the client’s body structure and potential functional issues?
- Palpatory input: What observations can you make as you physically manipulate the client’s body? Do you notice any trigger or tender points in the muscle tissues or joints? If the client is complaining of pain or discomfort, can you pinpoint the source? Does the client’s temperature seem high? What is the client’s pulse rate? Do you detect any abnormalities in sensation level? Assess the client’s soft tissues and bony landmarks and look for trigger points, endangerment sites, or adhesions.
- Auditory and olfactory input: What kind of input are you getting from your other senses? Do you hear any clicking noises or other sounds that might indicate a potential problem? Any sounds heard during assessment may help you to identify the source of the problem and localize treatment. Do you smell anything odd or out of the ordinary? Though smell is not itself a diagnostic tool, many practitioners learn to recognize the presence of distinct odors.
- Energetic input: What kind of energy are you sensing in the client? For energy practitioners, this is often a literal, objective assessment tool. For other, more traditional practitioners, the energy input is not diagnostic but rather refers to the “vibe” you get from the client.
- Intuitive input: What is your intuition telling you about the client? Are you getting the sense the client is not being fully honest with you? Do you intuitively sense the client’s root issue?

Range-of-Motion Assessment
Assessing the client’s range of motion (ROM) is an essential part of the initial evaluation. Range-of-motion assessment allows you to identify potential problems with joints and surrounding tissues. ROM assessment includes the following:
- Active movement: What happens when the client moves each of his or her limbs through a particular range of motion? Can this be accomplished easily and without pain?
- Passive movement: What happens when you move the client’s limbs through their full range of motion? Do you encounter any resistance or catches? Does the client seem to hesitate or feel pain?
- Resisted movement: What happens when you apply resistance against the client’s movements? Does the client experience weakness or pain?

Note:
Can you locate and name the body’s bony landmarks? You will need to be able to identify these for the examination.

Postural Analysis and Physical Holding Patterns
As part of the client assessment, you will analyze the client’s posture and physical holding patterns. Postural analysis allows you to identify the possibility of muscular imbalances or other symmetry deviations that can cause or contribute to pain or discomfort. Postural difficulties can result in compensatory patterns or muscular adaptations that eventually cause the client pain, dysfunction, and/or restricted motion by putting undue stress on the skeleton, joints, or muscles.
You can conduct a postural analysis informally with a visual inspection or you might conduct the analysis more formally using a plumb line and a postural analysis grid chart. Make sure you view the client from the front, both sides, and the back.
You will also look for physical (also called somatic) holding patterns. These are less-than-optimal movement patterns that can develop over time due to muscular or skeletal imbalances, lack of symmetry, or injury. For example, if a client suffered a knee injury at some point and the injury never healed properly, you might notice issues with the client’s gait. Eventually, maladaptive holding patterns can cause musculoskeletal or other types of pain.
One example of a physical holding pattern is muscle guarding. This is the practice of unconsciously holding a muscle in a partially contracted state. This condition can occur for any number of reasons (such as a skeletal imbalance or fear of reinjuring a damaged muscle) and can result in tenderness, soreness, and pain.
All of the information you gather during the assessment will be used to determine if massage is appropriate treatment for the client. If it is indicated, you can use the information you have collected to formulate the client’s treatment plan.

Formulating the Treatment Plan
Treatment plans should be individualized to the client; they should be appropriate for the client’s overall condition and designed to address the specific issues or problems the client is experiencing. The treatment plan is essentially a blueprint of the expected end result and how you intend to get there. Your treatment plan should cover:
- Recommended number and frequency of massage sessions
- Massage techniques to be utilized
- Particulars of treatment: length of sessions, specificity to body part, and so on
- Additional modalities, such as hot stones or hydrotherapy
- Treatment goals and anticipated timeline
- Referrals or recommendations for other care providers, either instead of or in conjunction with massage treatment

Exercises: Assessment Techniques and Treatment Plans
Choose the option that best answers the question.

1. Information regarding a client’s temperature or pulse rate would be considered (A) intuitive input. (B) observational input. (C) palpatory input. (D) energetic input.
A client’s temperature or pulse rate would be considered palpatory input, which refers to information ascertained from physically manipulating a patient’s body. The correct answer is (C).

2. When you physically move a client’s limb, what range of motion are you using? (A) Passive (B) Active (C) Resisted (D) Precipitated
When you physically move a client’s limb, you are performing a passive range of motion movement. The correct answer is (A).

3. Pain and discomfort associated with postural difficulties is most often related to (A) muscular adaptations. (B) skeletal defects. (C) vitamin deficiencies. (D) genetic dispositions.
The pain and discomfort commonly associated with postural difficulties is most often related to muscular adaptations. It is also frequently related to compensatory patterns. Pain and discomfort results from the undue strain muscular adaptations and compensatory patterns place on the client’s skeleton, muscles, or joints. The correct answer is (A).

4. The primary influencing factor of a treatment plan is the client’s (A) ability to afford treatment. (B) goals and desires. (C) understanding of treatment. (D) physical issues/needs.
Physical issues/needs are the most important factor in the development of a treatment plan. Your blueprint for treatment should be based primarily on the client’s physical condition and address the needs created by this condition. Although the client’s goals and desires are important, they would generally be a secondary consideration. The correct answer is (D).

Note:
Recent research suggests that you can enhance your ability to retain the information you are studying simply by varying the places in which you study. For example, if you typically study at the kitchen table, you may find that you can remember more about a topic if you study in another room in your house (your living room, for example) or at the local library.
Researchers believe the change in surroundings enhances retention because the brain creates associations between the material being studied and the location/conditions under which it is reviewed. If you study in unique circumstances, the brain can more easily access the content later due to these associations.

Client Recordkeeping
In some states, massage therapists are required to create and update records for their clients. In other states, recordkeeping is not required but is still highly recommended. Diligent recordkeeping ensures that you always have access to complete information about the client, including notes you make before, during, and after treatment. Keeping records also prevents situations in which the client has to answer the same questions over and over again.
If you work with other health-care providers or if you or your clients will be reimbursed by a health insurance company, you may be required to share your records with others. This is one of the key reasons your client records should be professional, thorough, and follow all recordkeeping protocols.
- Intake forms: Client intake forms allow you to quickly gain a substantive amount of information about the client. You can buy preprinted intake forms from a medical supply store or you can create your own. Regardless, any intake form you use should be professional, concise, and ask the client to provide only information that is relevant to treatment.
- SOAP note: The acronym SOAP stands for Subjective, Objective, Assessment, and Planning. SOAP is a four-part documentation format used by many different kinds of health-care providers to document and track client/patient progress.

Each part of a SOAP note has a distinct purpose.
Subjective: The subjective section is a summary of the client’s commentary regarding his or her condition. This includes statements made at the initial interview and during and after treatment. It provides a summary of symptoms, potential origins of problems, and the client’s perception of pain, impact of other activities, and so on. This section might also include comments shared by the client’s other health-care providers.
Objective: The objective section is a summary of your observations of the client. This includes findings from the different assessments you have completed as well as the results of any tests or evaluations.
Assessment: The assessment section is a record of your findings, the treatment conducted, and the client’s response to the treatment. This section compares the client’s response to the treatment against the goals and also indicates progress (or lack thereof).
Planning: The planning section is a summary of suggestions for future treatment, follow-up care, and instructions for the client.

Exercises: Client Recordkeeping
Choose the option that best answers the question.
 1. Which part of the SOAP system is based solely on information you receive directly from the client or other health-care providers the client has seen? (A) Subjective (B) Objective (C) Assessment (D) Planning
The subjective portion of the SOAP system is based entirely on information you receive directly from the patient or other health-care providers he or she has seen. This includes client commentary and any relevant information you receive from other medical professionals who have treated the client. The correct answer is (A).
 2. The assessment portion of the SOAP system would include all of the following EXCEPT (A) the treatment conducted. (B) the client’s response to treatment. (C) post-treatment instructions. (D) a record of findings.
The assessment portion of the SOAP system would NOT contain the client’s post-treatment instructions. This information would be included in the planning portion. The correct answer is (C).

Tips for Answering Questions on Therapeutic Massage and Bodywork Assessment
- When you are assessing clients for treatment, you are pulling together everything you have learned about massage therapy so far. You are reviewing the client’s anatomy and body structures, checking for pathologies and contraindications, and identifying physical conditions that can benefit from the application of therapeutic massage. Based on this assessment, you will formulate an individualized treatment plan. As you study this topic, you will have the most success if you draw from and integrate your knowledge of related subject matter. For example, consider the integumentary system. You know what it is, what it is made of, and how it works. You can recognize common pathologies that impact the skin. Now, you can also determine how those pathologies might impact the treatment plan for the client. It is much easier to remember information if you can make it follow a logical path.
- The acronym SOAP is an excellent way to remember the four different aspects that must be considered in any client record. An acronym can act as a mnemonic, which is a technique for improving memory. Some other mnemonic strategies you might apply to this material involve creating a pattern out of rhyming words (similar to a poem or song), creating a visual of the information, or writing a story based on a list related to the content. What are some mnemonics you can use for the information in this section?