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Chapter 7 / Assessment
321
Figure 7-12. Client health report for Timothy, highlighting Objective information. (Modified with permission from Thompson
DL. Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 2nd ed. Baltimore: Lippincott
Williams & Wilkins, 2002.)
322 INTRODUCTION TO MASSAGE THERAPY
Figure 7-13. General assessment form for Kirsten.
Chapter 7 / Assessment
323
Figure 7-14. SOAP note for Kirsten, highlighting Objective information. (Modified with permission from Thompson
DL. Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 2nd ed. Baltimore:
Lippincott Williams & Wilkins, 2002.)
324 INTRODUCTION TO MASSAGE THERAPY
The concepts of ethics and professionalism, effective
communication and documentation, and assessment skills
can be combined with your anatomy and physiology knowledge to develop a treatment plan with the objective of promoting overall health and well-being with a client-centered
focus.
1. Using the procedure outlined in this chapter, per-
form general assessments on at least five friends or
family members. (Try to use the same people who
filled out client histories and participated in the
intake interview exercises.)
2. Watch people (on television, in a shopping mall, in
the break room, at the beach, etc.) to make quick
postural assessments and write a list of at least 20
observations. For example, you might notice one
shoulder higher than the other, a hunched posture,
uneven arm swing, or a tilted head.
3. Demonstrate AROM for each of the movements
possible at the following joints, remembering to use a
slow, steady speed while keeping your body very still:
a. Glenohumeral joint
b. Knee
c. Elbow
d. Temporomandibular joint
e. Ankle
f. Neck
4. Using flexion of the elbow:
a. Ask someone to quickly and casually show
you the movement, without giving them any
specific directions.
b. Watch the movement and notice where the
ROM ends.
c. Then demonstrate slow and steady elbow flex-
ion, isolating the joint movement.
d. Ask your partner to perform the movement
again, this time using the technique you
demonstrated.
e. Compare the range that was performed quick-
ly to the range that was performed slowly and
write down any differences you notice.
5. Practice evaluating body rhythms on at least three
different people.
a. Ask the person to lie in a prone position, on the
stomach.
b. Gently place one hand over the person’s lum-
bar spine and the other over the thoracic spine.
c. Relax your hands and tune in to their breath-
ing—the rhythm, the amount of movement,
the location of the movement.
d. Try to notice other rhythms, such as the heart-
beat or the craniosacral rhythm.
e. Compare the different rhythms of different
people.
6. Perform AROM for elbow flexion. Perform PROM
for elbow flexion with your own arm. If they have
different end feels or different limits to the ROM,
list some reasons why they might differ.
7. Considering the guideline to treat where it hurts,
where it is compensated, and at the ends of the
fascial restriction, describe how fascia is involved in
muscle tissue and compensation patterns.
8. Position yourself in an abnormal standing posture
(hips forward, shoulders forward, shoulders shrugged
upward, head forward, shoulders backward, etc.).
a. Walk around with that posture for 2 to 3 minutes
and then return to your normal, relaxed posture.
b. Describe any areas that feel hypertonic or
uncomfortable.
c. Consider the long-term effects of that abnor-
mal posture and identify some of the muscles
that might become posturally shortened.
9. Use abbreviations and symbols to document the
following objective assessments:
a. The client’s right elbow flexion had a reduced
active range of motion.
b. The client’s skin was red and hot over the right
quadratus lumborum muscle.
c. The client’s left anterior superior iliac spine was
higher than the right anterior superior iliac spine.
d. Upon active range of motion of the neck
rotating to the left, the client shrugged the left
shoulder and dropped the chin.
e. Passive range of motion of neck rotation to
the left was greater than the active range of
motion of neck rotation to the left.
10. Take several deep breaths while doing the follow-
ing, and compare how the different postures affect
your breathing:
a. Tighten the muscles in your pelvic floor and
squeeze your abdominal muscles.
b. Hunch forward at the shoulders.
c. Slump in your chair, rolling your pelvis downward.
d. Raise your arms over your head.
e. Stand in your normal, relaxed position.
f. Sit in your normal, relaxed position.
Chapter 7 / Assessment 325
SUGGESTED READINGS
Biel A. Trail Guide to the Body. 2nd ed. Boulder, CO: Books of Discovery, 2001.
Clarkson HM. Musculoskeletal Assessment Joint Range of Motion and Manual Mus-
cle Strength. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2000.
Dickson FD. Posture Its Relation to Health. Philadelphia: JB Lippincott, 1930.
Kendall FP, McCreary EK, Provance PG. Muscles Testing and Function with
Posture and Pain. 4th ed. Baltimore: Williams & Wilkins, 1993.
Kendall HO, Kendall FP, Boynton DA. Posture and Pain. Baltimore: Williams
& Wilkins, 1952 (reprinted by Robert E. Krieger Publishing Company,
Malabar, FL, 1985).
Lowe W. Functional Assessment. Bend, OR: OMERI, 1997.
Rattray F, Ludwig L. Clinical Massage Therapy: Understanding, Assessing and
Treating over 70 Conditions. Toronto: Talus, 2000.
Souriau P. The Aesthetics of Movement. Souriau M, trans-ed. Amherst, MA:
The University of Massachusetts Press, 1983.
Thompson DL. Hands Heal: Communication, Documentation and Insurance
Billing for Manual Therapists. 2nd ed. Baltimore: Lippincott Williams &
Wilkins, 2002.
Trager M, Hamond C. Movement as a Way to Agelessness A Guide to Trager Men-
tastics. Barrytown, NY: Station Hill Press, 1995.
http://www.cofc.edu/~futrellm/mmtbasics.html, accessed 3.5.06.
http://www.k inesiologycentral.com/index.html, accessed 3.5.06.
http://www.k inesiology.net, accessed 3.5.06.
http://www.painreleaseclinic.com/muscletest.html, accessed 3.5.06.
http://www.uskinesiology.com/faq.htm, accessed 3.5.06.
8
Upon completion of this chapter, the student will be
able to:
■
Identify the three primary components of a
treatment plan
■
List the five aspects of future treatment to
address in a treatment plan
■
Describe why it is important for clients to
participate in the therapeutic process
Key Terms
Ergonomics: The science that designs and coordinates
people’s activities with the equipment they use and
the working conditions of their environment.
Hydrotherapy: The use of water as a treatment.
Refer: Recommend that someone see a specific
healthcare practitioner.
■
Name at least five topics that are commonly
used for self-care recommendations
■
Describe at least three different self-care
recommendations
■
Write at least five specific treatment plans,
using abbreviations and symbols
Self-care (self-help): Activities that clients can use be-
tween massage sessions to participate in their healing
process and help them achieve their treatment goals.
Treatment plan: Your recommendations for future
treatment, self-care activities, and referrals to other
healthcare professionals.
326
Chapter 8 / Treatment Plan 327
herapists who understand how to read and write all
components of the massage treatment record demon-
T
strate a professional image and, more importantly, can
make their treatments more effective. Your treatment plan
is the intended path you recommend for clients to reach
their goals, and the three primary components include your
suggestions for future treatment, your suggestions for selfcare, and referrals to other healthcare professionals. Future
treatment refers to the frequency, duration, expected length
of treatment, techniques, and reevaluation tips for future
massage sessions. Self-care (also called self-help ) refers
to activities that clients can use between massage sessions
to help maintain progress made during the massage session and encourage the healing process. Self-care activities
are excellent tools for getting clients involved in their own
healthcare. If you think clients should see another healthcare
professional for further evaluation and diagnosis, you can
refer them, or recommend that they see a specific health-
care practitioner. This component of the treatment plan is
not always included, as it is not always necessary.
Treatment plans can be used for both wellness and
therapeutic massage. Even in a spa, where the focus is typically wellness massage, clients occasionally ask for therapeutic massage because of a strained muscle or excessive
muscular tension. Writing treatment plans for all clients
keeps your documentation consistent, and consistency
helps you keep track of your clients’ progress toward their
goals. Additionally, if you work in a setting where other
therapists may be working on clients you have treated,
they must be able to use your massage treatment records
to design a massage that continues progress toward the
treatment goals.
Treatment planning is a process of examining a client’s
unique information and making an educated guess at the
best way to reach the treatment goals. The plan should
be flexible, allowing for alterations and changes of course
with each massage session because clients sometimes
reprioritize the original goals or develop new soft tissue
dysfunctions that change the priorities. The plan is a guide
and should be adapted to the client’s condition at the time
of treatment. Most importantly, the treatment plan should
always reflect how to continue progressing toward the prioritized goals.
include:
• Duration of sessions
• Frequency of sessions
• Length of treatment
• Techniques or specific areas to incorporate or avoid
• Self-care recommendations
• Referrals to other healthcare practitioners
Keeping all of these components in mind, you ask a
series of questions to develop the treatment plan. Ask leading
questions about repetitive motions, sustained positions, and
the likelihood of reinjuring the area and determine new compensation patterns. Use that information in conjunction with
your assessment of the client’s overall health to determine the
frequency, duration, and length of treatment as well as techniques, self-care activities, and necessary referrals to other
healthcare professionals. Before recording the treatment plan,
discuss it briefly with your client to ensure that it is feasible
The components of a plan for client care
and give the client an opportunity to ask any questions. Then
document the specifics in the Plan portion of the SOAP note.
Developing the initial treatment plan is a slightly different process from reevaluating the plan for subsequent
massage sessions, since you have more information to use
during subsequent sessions.
Initial Session
The first time clients come to you for massage, you have to
make an educated guess at your plan for reaching treatment
goals. Engage clients in a conversation during the initial session
to find out how they typically handle stress, how long it usually
takes to recover from illness or injury, or how physically active
they tend to be. Determining the goals and designing the treatment plan at an initial massage session is often a collaborative
effort in which you make suggestions for future treatment, and
the clients decide whether those parameters are reasonable for
them. To make initial suggestions and plan effective guidelines
for reaching treatment goals, you will need to consider your client’s health history, the client interview, general assessments,
lifestyle, and their willingness to participate in the process. These
are the factors that affect the internal healing environment, or
ability for the body to recover from illness and injury (Box 8-1).
For example, a new client comes to you who has a highpressure job, is going through a divorce, eats fast food, drinks
six cups of coffee daily, does not exercise or drink much
water, and has had multiple injuries. She has a relatively
328 INTRODUCTION TO MASSAGE THERAPY
Initial Treatment Plan
1. Evaluate the internal healing environment.
a. Health history
i. Injuries
ii. Length of time condition has been present
iii. What makes condition better or worse
b. Client interview
c. Accumulated stress factors
d. General assessments
e. Lifestyle
i. How do you typically handle stress?
ii. How long does it typically take to recover from illness
or injury?
iii. How physically active are you?
f. Participation
i. Generally, do you typically take medications or use
lifestyle changes as a remedy?
ii. Are you conscientious about leading a healthy lifestyle?
2. Make an educated guess about the client’s ability to heal or
recover from illness or injury (the following are just generalities).
a. Strong—minimal number of chronic conditions, few
injuries, few stress factors, actively manages stress,
usually heals within a week or two, daily exercise, uses
lifestyle changes instead of medications for treatments,
tries to eat balanced meals, drink sufficient water
b. Weak—several chronic conditions, several injuries, many
stress factors, does not dissipate stress, usually takes
months to heal, eats fast food, drinks a lot of coffee,
smokes cigarettes, no time or energy to lead a healthy
lifestyle
3. Consider the client’s treatment goals and ability to heal to
suggest a treatment plan.
a. Future treatment
b. Frequency
c. Duration
d. Length of treatment
e. Techniques or areas to include or avoid
f. Reevaluation suggestions
g. Self-care
h. Specific activities
i. Specific frequency, duration, and amounts
j. Referrals, if appropriate
k. Healthcare practitioner’s name
4. Discuss the plan with clients to make sure it is feasible for
them and to address any questions.
5. Document the treatment plan recommendations in the Plan
section of the SOAP note.
good internal healing environment, so you could set treatment goals that are easily attainable and recommend a fairly
aggressive treatment plan.
Long-term goal (LTG)—Within 2 months, be able to lift
her toddler in and out of the high chair twice a day, three
times a week, without pain.
Short-term goal (STG)—Within 2 weeks, be able to
put dishes into the above-counter cabinets once a day, three
times a week, without pain.
Given those goals, your treatment plan could recommend
60-minute massages, once a week, for 2 months. You might
want to try myofascial release work, proprioceptive neuromuscular facilitation work, and vibration for the muscles
involved in shoulder flexion. You could mention that if she
consumed at least 60 ounces of water each day and applied ice
to both shoulders for 20 minutes, at least three times a week,
she might be able to reach her goals faster. All of this information is recorded in the Plan section of the SOAP note.
Subsequent Sessions
In each subsequent massage session, ask questions to reevaluate the previous treatment plan and make necessary changes
(Box 8-2). Review the prior session’s treatment notes to know
how clients responded to the last treatment and follow up
on self-care activities and any referrals. Additionally, assess
their current stress level by asking them how they feel that
day, how they are doing, how life is treating them, and where
their body hurts. Record their answers in the Subjective section of the SOAP chart. If there are new areas of pain or
discomfort, perform the appropriate assessments to discover
new compensation patterns, which muscles might be affected, and any new contraindications. The new assessments are
recorded in the Objective portion of the SOAP note.
If clients seem to have continued progress between massage
sessions, you can use the treatment plan from the previous session as a springboard, incorporating similar techniques into the
current massage. If their condition seems worse or if they express
doubt, you can design a massage that is very different from the
previous session. Document techniques you use and the clients’
responses in the Activity and Analysis section of the SOAP note.
Consider the sample client used to illustrate the initial
treatment plan. A year later, she may have delegated some
of her work responsibilities, settled the divorce, received
massages once a month, and started to exercise and drink at
least 50 ounces of water every day. Her healing environment
is much better, and she would be able to reach more aggressive treatment goals with less treatment.
Chapter 8 / Treatment Plan 329
Session-to-Session Treatment Plan
1. Review the SOAP note from the previous massage session.
2. Ask clients about the self-care recommendations.
a. Were you able to incorporate the (insert specifics here)?
b. Did you have any trouble with any of the self-care?
c. Did any of the self-care make noticeable changes?
3. Ask clients about any referrals.
a. Were you able to talk with (insert practitioner’s name
here)?
b. If so, did the practitioner make any diagnoses, prescribe
any treatments, or make any recommendations?
4. Ask clients how they felt after the previous massage.
a. Better, worse, or no change?
b. How long did that last?
5. Ask about the client’s current condition.
a. How are you feeling today, in general, or, how is life
treating you?
b. Describe today’s pain level or discomfort and the areas of
discomfort.
LTG—Within 2 months, be able to lift her toddler in
and out of the crib twice a day, 5 days a week without pain.
STG—Within 2 weeks, be able to lift her toddler in and out
of the high chair three times a day, 3 days a week without pain.
The treatment plan could recommend 60- minute mas-
sages, twice a month, for 2 months. Your recommendations
c. Are there any new medications or other new treatments?
d. Are there any new areas of concern, cuts, or bruises?
• If so, perform the appropriate assessments and record
them as Objective information on today’s SOAP note.
6. Consider the client’s progress toward treatment goals and results
of the previous treatment to determine whether you will continue
with the original treatment plan or make adjustments to
a. Future treatment recommendations
b. Self-care activities
c. Referrals
7. Discuss the treatment plan with clients to make sure it is
feasible for them and to address any questions.
8. Properly document the current treatment plan in the Plan
section of your current SOAP note.
9. If the client had an appointment with the referred healthcare
practitioner, remember to obtain copies of the medical
records, either formally or informally.
for techniques could be primarily relaxation techniques
with a little extra attention to the muscles involved in
shoulder flexion. You could mention that warm baths
at least twice a week could help her relax and that consuming at least 60 ounces of water each day would help
maintain the soft tissue work that was accomplished.
The treatment plan includes your recommendations for future
massage treatments. You should refer to the duration and frequency of future sessions, length of treatment, techniques
to include or avoid, and specific suggestions for reevaluation.
The amount of time a client’s body requires to change the
condition of soft tissue strongly affects your determination of
future treatment. Document the future treatment information
in the Plan section of the SOAP chart. To recommend 60-minute massage sessions once a week for 8 weeks, incorporating
myofascial release at the left iliotibial band, you could write:
1-hr (M) 1X/wk for 8 wks, try MFR on (L) IT band
These notes help you determine progress and design
each massage session. Besides, it is often difficult to
remember details for each client, especially when seeing
many clients in your practice.
Healing Time
Approximated healing time, or the length of time that may
be required to restore normal function, influences the treatment plan. Healing time is affected by the client’s internal
healing environment, which you evaluate by learning about
their physical, emotional, mental, and nutritional stressors
in addition to their lifestyle, illness, injuries, and the general
length of their recovery or healing times. It takes longer for
330 INTRODUCTION TO MASSAGE THERAPY
clients to recover from illness or injury when they lead an
unhealthy lifestyle with a lot of stressors than when their
life is relatively uncomplicated and they are comfortable and
content. Healing time is unique to an individual and can
only be estimated as a relative amount of time for that person. You should not compare the healing time of one client
to that of another. In other words, your best estimations for
healing time are based on information that you accumulate
over a period of months or years. A strong healing environment allows a more aggressive treatment plan, with longer
or more frequent massages and more aggressive techniques.
A weak healing environment is best treated with a conservative plan, including shorter or less frequent massages and
less aggressive techniques.
Duration of Future Sessions
How long should the next massage last? The duration of
each future massage session is the first consideration when
developing a treatment plan. Massage sessions can be 15,
30, 60, or 90 minutes long. Most massage sessions are about
an hour, so most treatment plans imply future sessions of
60minutes. Occasionally, your clients might be better served
with a shorter or longer session. A shorter session may be
warranted if clients are uncomfortable during the massage,
for any reason. Discomfort can outweigh the benefits of the
massage, and clients who are uncomfortable throughout the
massage, either physically or mentally, can actually feel worse
after the massage. Your effective communication skills, especially with nonverbal cues, are critical for determining whether future sessions should be limited in duration.
If clients experience pain, uneasiness, or lack of trust in
you or your massage, those feelings can last for days. Thirtyminute sessions give those clients an opportunity to develop
trust with you as a professional therapist who understands
that everyone has different needs. Some clients, such as
elderly clients and chronic pain clients, are uncomfortable
lying on your massage table for extended periods of time.
Rather than subject them to hour-long sessions, you can
try 30-minute sessions to see if there is less discomfort and
more overall benefit. Clients who are focusing specifically
on healing a soft tissue injury may benefit from shorter sessions to avoid making their condition worse, or exacerbating
it. There is a delicate balance between beneficially treating
and overtreating an injury.
At the other end of the spectrum, some clients may
benefit from a 90-minute massage session. As long as their
internal healing environment is good, you might recommend
a 90-minute session for clients with multiple compensation patterns or those who need a longer period of time to feel relaxed.
Frequency of Future Sessions
Healing input influences healing output. This concept is a factor in determining the frequency of future sessions for both
wellness and therapeutic massage. Massage enhances the healing process by mechanically increasing the circulation of blood
and lymph to and around the area of concern. Nutrients and
oxygen are brought to the area by the arterial system, and
waste products are removed by the lymphatic and venous
systems. Massage is also beneficial by mechanically reducing
physical tension and reflexively inducing the parasympathetic
nervous response, both of which encourage relaxation.
Determining the frequency of massage sessions
depends on the condition of your clients’ soft tissues and
their lifestyle. For clients whose soft tissues are healthy,
treatments as frequent as twice a week can be beneficial
for maintaining relaxation, reducing muscular tension, and
relieving fascial adhesions that cause compensation patterns.
On the other hand, you can get too much of a good thing,
including massage. The problem with receiving massage too
frequently is that it can overwhelm the body and can easily
exacerbate the original condition.
There are a number of reasons to recommend at least
one massage every few months. Clients can benefit from a
regular investment in health maintenance. Occasional massage can help minimize the stressors and reduce the accumulation of stress to improve health and the internal healing
environment. Clients who regularly get an occasional massage benefit your practice. Seeing clients once every few
months allows you to develop relationships, which can lead
to more trust and stronger rapport. It also establishes a regular and dependable client base, which is what you depend on
for a financially stable practice.
The benefits of massage are cumulative, and your recommendations are based on how much healing input clients
need to restore function and reach their treatment goals.
You must balance the frequency of sessions such that you
can make steady progress but do not overtreat. Most likely,
the frequency of treatment is somewhere between once a
week and once every few months. Clients are ultimately
responsible for the frequency of their massage treatments,
taking into consideration their financial situation, transportation arrangements, schedules, and child care.
Length of Treatment
The length of treatment you recommend should not
exceed the time frame of the LTGs, which should be
attainable and recognizable within 1 to 2 months. It is