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Chapter 6 / Communication and Documentation
291
Figure 6-9. (continued )
292 INTRODUCTION TO MASSAGE THERAPY
Figure 6-10. SOAP chart for Kirsten Van Marter, subjective information highlighted. (Reprinted with permission from
Thompson DL. Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 3rd ed.
Baltimore: Lippincott Williams & Wilkins, 2006.)
Chapter 6 / Communication and Documentation 293
• -pathy
1. Name the three word elements and explain how
they are used in a medical term.
2. Define each of the following prefixes:
• ab-
• ad-
• bi-
• circum-
• contra-
• dys-
• hyper-
• hypo-
• infra-
• inter-
• -stasis
• -al
• -ar
5. Break down the following words into separate
elements and define:
• osteoarthritis
• fibromyalgia
• neuropathy
• tendinitis
• intervertebral
• unilateral
• hypertonic
• contralateral
• atrophy
• poly-
• post-
• pre-
• supra-
3. Define the following roots:
• arthr(o)-
• brachi(o)-
• cervic(o)-
• cost(o)-
• crani(o)-
• dermat(o)-
• fibr(o)-
• my(o)-
• neur(o)-
• oste(o)-
• stern(o)-
• thorac(o)-
• vertebr(o)-
4. Define the following suffixes:
• -algia
• -asis
• -iasis
• -ism
• -itis
• -oma
• -osis
6. Using the procedure outlined in this chapter,
perform at least five different client intake interviews with friends or family members.
7. Using the procedure outlined in this chapter, take
at least five different client histories from friends or
family members.
8. Identify the stress factors for yourself and five
other people.
9. Identify the appropriate section of the SOAP note
(Subjective, Objective, Activity and analysis, Plan)
for documenting the following information:
• Within the next week, the client should be able
to lift 10 pounds at a time, three times a day, for
5days with no shoulder pain.
• Applied a full-body relaxation massage using therapeutic techniques on the left quadriceps femoris
muscles.
• Client complains of low back pain.
• Client was referred to Dr. Bob Smith for skin
abnormality.
• Upon posttreatment assessment, the client’s lateral neck flexion and neck rotation to the right
increased.
• Next session, try to address the right biceps femoris muscle with therapeutic techniques.
• The client’s skin was red and hot around the left
scapula.
• The client barely swings her left arm when
walking.
294 INTRODUCTION TO MASSAGE THERAPY
• After the massage, the client says he has to be able
to lift 50 pounds at a time, repeatedly throughout
the day, for his job.
• The client responded well to vibration over the
levator scapula muscles.
10. List the signs and symptoms of the following
categories that you should ask about during a client
interview: General, Circulatory, Musculoskeletal,
Neurological, Psychosocial.
11. Identify at least five of the steps required for
HIPAA compliance.
12. Identify four of the client’s rights that can be
included on your Notification of Privacy Policies
(NOPP) form.
13. Identify the five components of an effective goal.
14. Use abbreviations and symbols from Table 6-6 to
shorten the following sentences:
• The client complains of pain in the right levator
scapula muscle.
• Lateral flexion of the neck increased with
massage.
• I applied a full-body relaxation massage with a lot
of effleurage bilaterally over the quadratus lumborum muscles.
• The client has decreased ROM at the left ankle,
and no dorsiflexion is possible.
• The client came in with a headache and a fever,
which is a contraindication, so I explained that he
could return for a safe massage treatment when his
fever has subsided.
15. Design your own client intake form by following
the steps below:
• What client contact information do you want to
record?
• Do you want clients’ insurance information?
• What questions do you want to include regarding
the current condition of the clients’ soft tissues?
• What health history information do you want to
know about?
• Do you want to know about daily activities?
• Do you want to include a body diagram for the
client to use?
• Do you want to include the informed consent for
care on your intake form?
REFERENCES
1. Thompson DL. Hands Heal: Communication, Documentation, and Insurance
Billing for Manual Therapists . 3rd ed. Baltimore: Lippincott Williams &
Wilkins, 2006.
SUGGESTED READING
Austrin MG, Austrin HR. Learning Medical Terminology: A Worktext . 7th ed. St.
Louis, MO: Mosby Year Book, 1991.
Chabner DE. Medical Terminology: A Short Course . Philadelphia: WB Saun-
ders, 1999.
Cohen BJ. Medical Terminology: An Illustrated Guide . 3rd ed. Philadelphia:
Lippincott-Raven, 1998.
Fisher JP. Basic Medical Terminology . 5th ed. Westerville, OH: Glencoe-Mc-
Graw Hill, 1999.
Ford RD, ed. Health Assessment Handbook . Springhouse, PA: Springhouse
Corporation, 1985.
Loeb S (executive editorial director). Mastering Documentation . Springhouse,
PA: Springhouse Corporation, 1995.
McCann JAS. Medical Terminology Made Incredibly Easy . Springhouse, PA:
Springhouse Corporation, 2001.
Moisio MA, Moisio EW. Medical Terminology A Student-Centered Approach .
Albany, NY: Delmar Thomson Learning, 2002.
Newell R. Interviewing Skills for Nurses and Other Health Care Professionals: A
Structured Approach . New York: Routledge, 1994.
Random House Webster’s College Dictionary . New York: Random House, 1997.
Salvo S. Massage Therapy, Principles and Practice . 2nd ed. St. Louis, MO: WB
Saunders, 2003.
Shea er BP (project coord). Mary’s Story: A Curriculum for Teaching Medi-
cal Terminology, Institute for the Study of Adult Literacy. University
Park, PA: Penn State University, 1991–1992.
Stedman’s Concise Medical Dictionary for the Health Professions . 4th ed. Balti-
more: Lippincott Williams & Wilkins, 2001.
Rattray F, Ludwig L. Clinical Massage Therapy: Understanding, Assessing and
Treating over 70 Conditions . Toronto: Talus Incorporated, 2000.
Thompson DL. Hands Heal: Documentation for Massage Therapy, A Guide to
SOAP Charting . Seattle, WA: Diana L. Thompson, 1993.
Thompson DL. Hands Heal: Communication, Documentation, and Insurance
Billing for Manual Therapists . 2nd ed. Baltimore: Lippincott Williams &
Wilkins, 2002.
Thompson DL. Hands Heal: Communication, Documentation, and Insurance
Billing for Manual Therapists . 3rd ed. Baltimore: Lippincott Williams &
Wilkins, 2006.
Thompson DL. Hands Heal Essentials: Documentation for Massage Therapists .
Baltimore: Lippincott Williams & Wilkins, 2006.
Werner R. A Massage Therapist’s Guide to Pathology . Philadelphia: Lippincott
Williams & Wilkins, 1998.
Willis MC. Medical Terminology The Language of Healthcare . Philadelphia: Lip-
pincott Williams & Wilkins, 1996.
http://www.acupuncturetoday.com, accessed 6.12.05.
http://www.cms.hhs.gov/hipaa/, accessed 2.23.05.
http://www.ctconline.net/hipaa_sense.htm, accessed 6.12.05.
http://www.hhs.gov/ocr/hipaa/consumer_summary.pdf, accessed 2.23.05.
http://www.hhs.gov/ocr/hipaa/ nalreg.html, accessed 4.4.05.
http://www.hhs.gov/ocr/hipaa/privruletxt.txt, accessed 2.23.05.
http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index
.html, accessed 12.28.11.
http://www.hipaacomplianceguide.com, accessed 6.12.05.
http://www.massagetoday.com/archives/2003/01/05.html, accessed 6.05.05.
http://www.ncvhs.hhs.gov/020911p2.htm, accessed 6.05.05.
http://www.sohnen-moe.com/articles/abmp-1-2003.php, accessed 6.12.05.
Objectives
7
Upon completion of this chapter, the student will be
able to:
■
List the five kinds of observations included in
general assessments
■
Describe why massage therapists should
understand fascial adhesions
■
Define compensation pattern
■
Identify at least three characteristics to evaluate
during postural assessment
Key Terms
Active range of motion (AROM) : Joint move-
ment that requires clients to actively use their
own energy to demonstrate how much of the full
range can be completed comfortably and without
restriction.
Assessment: The process of evaluating a client’s
condition.
Compensation pattern: A postural offset that is the
body’s attempt to correct an imbalance or protect a
primary dysfunction or injury.
Direction of ease: The direction in which tissues
move with least resistance.
End feel: A unique feel when a joint reaches the end of
its passive range of motion (PROM) determined by
specific structures that stop the movement.
■
Name the six aspects of gait assessment
■
Name the two different kinds of range-ofmotion evaluations
■
Define end feel
■
Name the three characteristics to assess with
palpation
■
Describe the purpose of functional
assessments
Fascial adhesion (fascial restriction): An area where
the fascia has adhered to nearby tissues or has
been crumpled or kinked.
Gait: A walking pattern.
Palpation: The skillful art of client evaluation that uses
touch to locate and assess the quality of different
structures.
Passive range of motion (PROM): Joint movement
that requires the therapist to move the relaxed
client through a range of motion to determine
how much of the full range can be completed
comfortably and without restriction.
Range of motion (ROM): The end-to-end distance
of a specific joint movement that is structurally
possible.
295
296 INTRODUCTION TO MASSAGE THERAPY
ell-trained massage therapists are soft tissue experts
with a solid understanding of muscular system anat-
W
omy and physiology. Assessment is the process of
evaluating a client’s condition to determine which muscles and soft tissues of the client’s body to work on and
which massage techniques to use. Good assessment skills
go hand in hand with skilled and effective treatments.
They help you evaluate the condition of the client’s soft
tissues to:
• Determine which techniques to use to reach the
client’s treatment goals
• Identify compensation patterns
• Determine whether massage therapy is indicated or
the client needs to be referred to a healthcare professional for further evaluation
The physical condition of clients, in addition to their
treatment goals, will guide your approach to treatment.
Using techniques that are too aggressive or too subtle can
be inappropriate or ineffective, as can massage sessions that
are too short or too long and techniques that are too slow
or too fast.
Although assessment skills help you determine the condition of the client’s tissues for massage and discover contraindications, you do not use them to diagnose any specific
medical conditions or prescribe treatments. Medical diagno-
sis and prescription are out of the massage therapy scope of
practice and should not be performed by massage therapists
under any circumstance.
Many assessment tools can be used to evaluate the
condition of soft tissues. The massage therapist’s first
assessment tool is the client’s health history. The initial
interview process gives you a general idea of the condition of the soft tissues and the past and present stress
factors that influence the healing process. Clients often
come to you with specific areas of concern and functional limitations that serve as a starting point for your assessment. Some common areas of concern are neck tension,
low back pain, and shoulder stiffness. The accompanying
functional limitations can include the inability to turn the
neck to check blind spots while driving, the inability to
sit for long periods of time, and difficulty brushing and
washing hair.
Along with the health history that provides information about the client’s condition, there are general
assessments and functional assessments (FAs). General
assessments include postural, gait, range-of-motion
(ROM), visual, and palpation (tactile) observations. More
advanced, FAs can help you determine whether a specific
pain or injury condition warrants massage or whether
massage may be contraindicated. FAs include manual
muscle testing, manual resistive testing, and orthopedic
tests. They require additional training because to elicit
accurate and useful information, you need careful technique and supervised practice. Referring clients for further evaluation to rule out contraindications conveys the
message that you know your limits and that the client’s
health and well-being is at the center of care. Understand
that massage is not necessarily the appropriate treatment
for all soft tissue conditions.
conditions that present contraindications have been ruled
out, massage is one of the best treatments for soft tissue
conditions.
Often, though, when medical
The general assessments you perform prior to all wellness
and therapeutic massage sessions include postural, gait,
ROM, visual, and palpation (tactile) observations. For clients seeking nonspecific relaxation massage for wellness, the
general assessment process does not need to be extensive or
time consuming, but it still needs to be done. Without an
initial assessment, it is more difficult for you and your client
to recognize the results of the massage treatment, and it is
also more difficult to write an effective treatment plan. The
assessments pertinent to the areas of concern are documented on your massage treatment records. When clients have
concerns about health conditions beyond the massage scope
of practice (soft connective tissues), you should refer them
to the appropriate healthcare professionals who can perform
the necessary examinations to determine whether there are
any contraindications for massage.
Wellness versus Therapeutic Massage Assessments
The general assessment process for wellness and relaxation
massage is usually completed in less than 2 to 3 minutes.
You can use the following guidelines for a short but complete assessment:
1. Ask a series of two or three questions to elicit the
client’s goal(s) for the treatment session.
2. Ask a couple of questions to determine if there are any
functional limitations, areas to concentrate on, or areas
to avoid.
Chapter 7 / Assessment 297
3. Look for obvious visible differences in the evenness or
levelness of the body, especially in the client’s area of
concern or area of functional limitation.
4. Before or during the massage, evaluate one or two
movements that relate to the functional limitation or
area of previous injury.
5. During the massage session, pay attention to the general texture and movement of soft tissues.
Many clients who initially come to you for relaxation
massage on a regular basis can benefit from therapeutic
massage if their pain pattern becomes worse or if they
sustain an injury. When these clients look for more than
a relaxation massage, your general assessments can last
5 minutes or longer because you need more information
to determine safe and effective treatment. The assessment process for therapeutic massage can include the
following:
1. Determine the client’s goal(s) for the session.
2. Ask a series of leading questions to understand the condition of the client’s soft tissues.
3. Ask a series of leading questions to determine the client’s functional limitations and how they affect the
client’s lifestyle.
4. Before the massage, perform the general assessments
shown in Procedure Box 7-1 to evaluate posture, gait,
and ROMs.
5. Evaluate each movement of the joint(s) involved in the
functional limitations.
6. During the massage session, pay attention to the textures
and movement of soft tissues throughout the body.
The general assessments give you a better idea of
whether or not a client presents any contraindications for
massage, which soft tissues you should address, and how
you should address them.
There are also occasions when therapeutic massage clients reach a point at which relaxation massage is indicated
and a brief assessment is sufficient. Either way, you need to
have a thorough understanding of the assessment process to
determine how much assessment is necessary to ensure the
most appropriate massage treatment.
protection and forms a sort of spider web throughout the
body. The protein fibers in fascia can get crumpled, kinked,
or stuck together, making it difficult for muscle fibers to
slide back and forth for smooth contraction and movement.
These fascial adhesions , also called fascial restrictions , are
disruptions in the smooth fascia that can result from:
• Insufficient hydration
• Injury
• Accumulated scar tissue
• Tissue dehydration
• Repetitive motions
• Sustained positions
• Postural deviations
In addition to the local restrictions and tightness, fascial adhesions have far-reaching effects on other soft tissues
because of the intertwined, three-dimensionality of fascia.
For massage, fascial adhesions are particularly important to understand because fascia’s involvement with muscle
tissues can cause the location of your clients’ pain to differ
from where the pain originates. Fascia is much like a sheet
of plastic wrap. When a sheet of plastic wrap is pulled on
at one corner, the tension creates deformities that extend
across the plastic in lines. When a section in the middle of
a sheet of plastic is crumpled, it creates several lines of tension that radiate out from the crumpled area. If there is a
local restriction in the muscle and soft tissues, there will be
similar lines of tension called fascial lines that extend out to
other areas of the body. Figure 7-1 illustrates lines of tension
that reach out from a restriction to other areas, similar to
the way a fascial adhesion can pull on structures far away.
Restricted movement, compensation patterns, reduced circulation, muscular tension, and pain in seemingly unrelated
areas can all result from fascial tension. Generally, the longer
the restriction exists, the more the fascia will be deformed
and the longer it will take for the client’s tissues to return
to normal. For example, right shoulder pain can be caused
not only by structures in and immediately around the glenohumeral joint but also by fascial tension that originates in
the abdomen or near the spine. The length of time the pain
and restriction have existed, in addition to stress factors and
client participation, will determine the best treatment techniques and the amount of time it could take to “unwind”
the restriction.
Fascia
When assessing the soft tissue, keep in mind the widespread nature of fascia. As described in the body systems
chapter, fascia is very pervasive, wrapping around and running between all the organs, muscles, and layers of tissue.
Its tough, pliable, plastic structure provides support and
Compensation Patterns
The body’s objective is to have all the muscles in balance to
remain upright, in ideal posture and moving efficiently.
the body deviates from this balanced state, muscles become
shortened or overstretched to compensate for the imbalance.
When
298 INTRODUCTION TO MASSAGE THERAPY
BOX 7-1
Therapeutic Massage
Standing Postural Assessment
(You can use the body diagram on the general assessment form)
1. With the client fully clothed, shoes off, ask the client to stand comfortably with heels about 3 inches apart, arms
hanging in a relaxed position.
You can use a door frame as a vertical reference line by asking the client to stand in front of it so that the
vertical part of the frame can be seen centered between the client’s feet.
2. View the client’s anterior aspect to look for obvious differences in the height of bilateral surface or bony landmarks
or obvious deviations off the midsagittal plane (off to one side).
a. Head (nose, chin, ears)
b. Shoulders (acromion process)
c. Sternum
d. Navel
e. Pelvis (ASIS and iliac crest)
f. Hands (fingertips, wrists)
g. Knees (patella)
h. Feet—flat, normal, or high arches, lateral deviation (toes point out) or medial deviation (toes point in), how
client wears out soles of shoes
3. Ask the client to turn around and face the door frame in the same relaxed position.
4. View the client’s posterior aspect to look for obvious differences in height of bilateral surface or bony structures, or
obvious deviations off the midsagittal plane.
a. Head (ears)
b. Shoulders (acromion process)
c. Spine
d. Pelvis (iliac crest or PSIS)
e. Hands (fingertips, wrists)
5. Ask the client to turn so the door frame is behind the ankle and stand in the same relaxed position.
6. View the client’s lateral aspect to look for obvious deviations toward the anterior or posterior.
a. Head (ear just anterior to midsagittal line)
b. Shoulders (center of glenohumeral joint on midsagittal line)
c. Hands (palms directed medially)
d. Pelvis (greater trochanters on midsagittal line)
e. Knees (center of joint on midsagittal line)
7. Ask the client to turn and face the other direction, in the same relaxed position, with the door frame behind the ankle.
8. View the second side to confirm the anterior or posterior deviations observed on the first side or to show
differences from right to left, suggesting rotation.
a. Head (left ear is anterior to the right ear, or vice versa)
b. Shoulder girdle (left acromion process is anterior to right, or vice versa)
c. Pelvis (right ASIS is anterior to the left, or vice versa)
9. Document any obvious differences or deviations on the general assessment form and in the objective portion of
the SOAP chart.
Chapter 7 / Assessment 299
BOX 7-1
Therapeutic Massage (continued)
Gait Assessment
1. Ask the client to walk across the floor.
2. Observe how the client walks, paying attention to the quantity, quality, and fluidity of steps (bilateral symmetry,
evenness of steps, smoothness).
3. Observe the alignment of the head over the spine and the position of the shoulders.
4. Observe the arm swing for bilateral symmetry and smooth movement.
5. Observe the medial or lateral deviation of the feet (indicating rotation of the hip).
6. Observe the knee flexion upon a step and the bounce in the step or lack thereof.
7. Document any deviation from the normal gait pattern on the general assessment form and in the SOAP note’s
Objective section.
Active Range-of-Motion Assessment
1. Determine the possible movements of the joint.
2. Starting and ending in the anatomical position, demonstrate the ROM to clients, moving slowly and steadily,
keeping the body very still to isolate the joint movement.
3. Explain that there are no successful results or failures possible because it is not a test. Ask clients to tell you if
there is any sensation of discomfort or pain.
4. Ask clients to demonstrate the ROM slowly and steadily, starting with the joint on the side that is unaffected or
least affected, and ending when there is any sensation of restriction, tightness, or discomfort.
5. Evaluate clients’ movement.
a. Glitches or hesitations
b. Facial expressions
c. Changes in breathing patterns
d. Variations in speed or fluidity
e. Recruitment of other muscles to complete the range
f. Completeness or limitations to the ROM
6. Ask clients to repeat the ROM using the affected joint, with a slow, steady movement while holding the body still.
7. Evaluate clients’ movement of the affected side as in step 5.
8. Document any findings from your evaluations of AROM on the general assessment form and in the SOAP note’s
Objective section.
300 INTRODUCTION TO MASSAGE THERAPY
BOX 7-1
Therapeutic Massage (continued)
Passive Range-of-Motion Assessment
1. Identify the movements possible at the particular joint and the muscles and passive structures involved with the
joint movement.
2. Explain that clients relax their bodies while you slowly and gently move them through an ROM and to let you do the
work. Reassure clients with your confidence and sufficient stabilization, holding them securely and using a gentle
but knowledgeable tone of voice.
3. Explain that there are no successful results or failures possible because it is not a test. Ask clients to tell you if
there is any sensation of discomfort or pain.
4. Ask clients to sit or lie comfortably while you start with the joint on the uninvolved or less involved side.
5. Holding the client’s body securely, slowly, steadily, and gently move through the ROM of the joint.
6. Evaluate the movement.
a. Glitches or hesitations
b. Resistance
c. Changes in breathing patterns
d. Variations in fluidity of movement
7. Move to the affected side, telling the client to remain relaxed while you repeat the process on the other side.
8. Holding the client’s body securely, slowly, steadily, and gently move the affected joint through the ROM.
9. Evaluate the movement for the same factors as in step 6.
10. Document any findings from your evaluations of PROM on the general assessment form and in the SOAP note’s
Objective section.
Appearance of Tissues
1. Before and during the massage, visually evaluate clients.
a. Differences in color (areas of redness or paleness)
b. Differences in fullness or thickness of soft tissues
c. Bilateral symmetry of soft tissues
d. Marks, bruises, moles, wounds, scars
2. Document any visual findings on the general assessment form and Objective portion of the SOAP note.
Palpation Assessments
1. During the massage, take note of what you feel.
a. Differences in temperatures (cold areas or hot areas)
b. Textural differences in skin and soft tissues
c. Movement of skin and soft tissues
d. Areas of fullness or swelling
e. Body rhythms
2. Document any palpation findings on the general assessment form and the Objective portion of the SOAP note.