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Chapter 8 / Treatment Plan
341
Figure 8-4. Progress report.
342 INTRODUCTION TO MASSAGE THERAPY
The process of developing treatment plans may seem
awkward at first, but with practice, you will become
very skilled at making recommendations for treatment.
In the beginning, you may find it easier to leave out the
treatment plan for initial appointments and only consider a treatment plan after subsequent massage sessions.
This gives you time to analyze the history and assessment findings and get a feeling for your client’s internal
healing environment and participation in healthcare.
Presenting the plan to clients is a way of educating them
about the information that guided your recommendations, essentially telling them why you are making the
recommendations. Clients are more likely to commit and
comply with your recommendations if they know why they
are doing so.
Treatment Recommendations
The first question clients typically ask is, “How long it
will take to (stop hurting, return to “normal” function,
or stay relaxed for longer than a day)?” There is no single
answer, much to their disappointment. You can explain
that health and healing times are affected by the physical,
emotional, mental, and nutritional stress that a person has
accumulated and that healing time can be reduced with
the help of massage and self-care. Once you educate your
clients about the “whys” of your recommendations, you
can discuss the treatment plan and use their input to make
adjustments to the plan. All of your recommendations for
future treatment are documented in the Plan section of
the SOAP note.
Referral Recommendations
If your assessment of the client reveals a health condition
or the possibility of a health condition that contraindicates
massage or is outside the scope of practice, it is in the client’s best interest to refer the client to the appropriate
healthcare professional. Anything in the client’s best interest is in your best interest. Sometimes clients are aware of
their conditions and sometimes not. If not, you may need
to have a delicate conversation to refer them to a medical
professional without making a diagnosis or alarming them.
Remember to be very careful not to suggest that clients
may have “XYZ” condition because they could misinterpret
your statement as a diagnosis; assume they have it; and tell
their friends, family, or healthcare practitioner. For example, if
you detect some inflammation at or around a musculotendinous juncture, do not say that it might be tendinitis or that you
think it could be tendinitis. Instead, you could say, “From my
assessment, I have determined that I can effectively treat your
soft tissue condition with massage.” Conversely, if you suspect
clients may need further examination, you could say, “From
my assessment, I have determined that massage might not
be helpful for you, and before I do any harm, I recommend
that you see your primary healthcare practitioner for further
examination. Once your doctor has determined that massage
is indicated, I would be happy to continue treatment.” There
are more complex situations, such as rotator cuff injuries, in
which clients have one condition that indicates massage and
another that presents a contraindication for massage. In this
situation, you could say, “After my assessment, I have determined that you have a soft tissue condition that I can treat,
and you also might have a condition that I do not treat. I recommend that you see your primary healthcare professional
for further evaluation, and when your doctor authorizes massage treatment, I can confidently continue treatment.”
Case Studies
The treatment plans for Rob Blackwell, Timothy Roberts,
and Kirsten Van Marter are based on the initial treatment
plan procedure.
Progressive Case Study 1:
Rob Blackwell
Considering Rob Blackwell’s health history, interview,
and assessment process, you determine that Rob’s
internal healing environment is good and that he is
very likely to participate in
his healing process. His
involvement with sports and
his self-employment as a
personal trainer suggest that
he is moderately likely to
repeat the motions that created his neck and shoulder
pain or reinjure the affected
tissues. Rob’s right shoulder
Chapter 8 / Treatment Plan 343
is elevated and rolled forward, and there are a number of associated hypertonic muscles. Despite his
good internal healing environment, the hypertonic
muscles, associated fascial restrictions, and his
likelihood to reinjure the tissues could increase the
healing time.
Since his musculature is so developed and
healthy, his body could withstand 90-minute
massages without suffering overtreatment, but his
financial situation cannot support them. Rob’s initial
treatment plan includes 60-minute massages once
a week for 6 weeks, at which point the goals will
be reevaluated. For the next session, you suggest
vibration over the right pectoralis muscles. You
mention that there are some self-care activities that
he could use to help maintain progress made during
the massage and reduce the length of the course
of treatment. He could apply ice to his right upper
trapezius for 20 minutes, at least once a day, every
day. You could demonstrate some specific stretches
for the pectoralis major and sternocleidomastoid
muscles, explaining that he could use these stretches
at least once a day, 5 days a week. He could also
increase water intake to 100 ounces per day. You
refer Rob to Dr. Christian for an evaluation and
current diagnosis of his knees to make sure massage
is not contraindicated. These recommendations are
highlighted in the Plan section of Rob’s SOAP chart
in Figure 8-5.
Progressive Case Study 2:
Timothy Roberts
Timothy is only seeking relaxation massage, and he reports
no pain, numbness, or
stiffness. From the client interview and general assessment, you
notice some restrictions in ROM of the
left ankle, but you also
detect his impatience
with the assessments.
To strike a balance
between gaining his
trust and remaining professional, your assessments
are brief, primarily looking for any contraindications.
For wellness clients like Timothy, you complete the
initial treatment plan procedure mostly for consistency in your documentation. Should he seek more
therapeutic treatment in the future, you would need
to perform a more thorough intake and assessment
as well as use the initial treatment plan procedure to
determine a more specific plan. His initial treatment
plan is simply to receive 60-minute relaxation massages at least once every 3 months, but you suggest
trying cross-fiber friction on the left ankle. You can
offer him a glass of water following the massage,
briefly mentioning that if he were to drink at least 80
ounces of water a day, it would help his body retain
the benefits of the massage. Timothy’s treatment
plan information is highlighted in his massage treatment record (see Fig. 8-6).
Progressive Case Study 3:
Kirsten Van Marter
Although she is a new
client to you, Kirsten’s
health information
form indicates that
she has received regular massage in the
past. The information
from the history and
assessment process
lets you know that her
internal healing environment is good, but
because of her hectic
lifestyle of taking care
of her child, being pregnant, and working two separate
jobs, she may not find time to participate in her healing process. She will probably repeat the motions that
created the soft tissue condition as she continues her
work and household activities. Both of her shoulders are
rolled forward, and her left hip is elevated. Even though
she is in her third trimester of pregnancy, the distribution of her weight will continue to change, and her hip
pain could get worse. Healing and restoring function
may be a challenge until after the baby is born.
Kirsten’s muscles and soft tissues are fairly healthy
because of her regular exercise and massage. The
initial treatment plan suggests 60-minute massages
once a week for 4 weeks. Since she is uncomfortable
with her pregnancy, it would be good to try more
bolsters during massage. You educate Kirsten about
the benefits of proper hydration and offer her a glass
of water following the massage, asking whether she
drinks at least 70 ounces of water a day. You also
demonstrate specific stretches for pectoralis major
and subscapularis muscles, explaining that if she
were to use those stretches at least once a day, every
day, it could help her retain the benefits of the current
massage. Kirsten’s SOAP note highlights the treatment
plan information (seeFig. 8-7).
344 INTRODUCTION TO MASSAGE THERAPY
Figure 8-5. Rob’s SOAP note, highlighting Plan information. (Modified with permission from Thompson DL. Hands
Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 2nd ed. Baltimore: Lippincott
Williams & Wilkins, 2002.)
Chapter 8 / Treatment Plan
345
Figure 8-6. Timothy’s HxTxC, highlighting Plan information. (Modified with permission from Thompson DL. Hands
Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 2nd ed. Baltimore: Lippincott
Williams & Wilkins, 2002.)
346 INTRODUCTION TO MASSAGE THERAPY
Figure 8-7. Kirsten’s SOAP note, highlighting Plan information. (Modified with permission from Thompson DL. Hands
Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 2nd ed. Baltimore: Lippincott
Williams & Wilkins, 2002.)
Chapter 8 / Treatment Plan 347
does not like to drink water. Your general
Massage therapists should always maintain a client-centered
focus for care. The treatment plan for client care is part of
that professional focus. With space and time constraints,
you can write only brief notes in your massage treatment
records, but you still need to document details accurately.
Another therapist should be able to read your SOAP note
and understand what the treatment plan includes, which
self-care activities were recommended between sessions, and
any referrals you may have made.
Self-care techniques give you a good topic of discussion
for the next session, asking about which self-care techniques
clients used or which ones were more effective. Soft tissue
health and healing should always be the objective of selfcare techniques recommended to clients. The effective and
efficient documentation of treatment and self-care are vital
aspects of a professional practice.
b. A 50-year-old man who appears in good
assessments discover bilateral symmetry with a
forward posture, rolled shoulders, and knockknees. He reports pain upon AROM and PROM
of his knees, suggesting that some passive
structures that are outside the massage scope of
practice are involved.
physical condition explains that his friend got
a massage from you and convinced him to try
one even though he has no areas of concern.
He swims for 30 minutes, at least five times a
week, and drinks at least 60 ounces of water
a day. He has a wife, three kids, and two dogs
and is self-employed in an established and
stable business. His posture is bilaterally symmetrical, but his head is forward, and he experiences occasional neck pain and tightness. You
found fascial restrictions all around the cervical
area, but did not have enough time to address
them. He reports that he was able to relax but
not until the massage was almost over and asks
1. Use abbreviations and symbols to rewrite the
following treatment plans:
a. Sixty-minute massages, twice a month, for 2
months. Try vibration over the left scapula,
and stay away from the client’s feet. Reevaluate
active range of motion of left shoulder extension to see if the triceps stretches that were
demonstrated and recommended once a day,
every day, were helpful.
b. Ninety-minute full body relaxation massages,
once a month, for 3 months. Avoid proprioceptive neuromuscular facilitation and active
range of motion evaluations, because the
client does not like to actively participate during the session. Referred to Dr. Park for pain
upon right elbow passive range of motion.
c. Thirty-minute massages, once a week, for 4
weeks. Only use supine, since client is claustrophobic and does not like to be prone.
Discussed use of a bolster under the knees
during sleep to relieve low back pain.
2. Develop and properly document treatment plans
for the following sample clients:
a. A 20-year-old man, at least 50 pounds overweight,
quietly complains of bilateral knee pain. His
physical activity is limited to his walk to and
from work, 5 days a week. At work, he sits at
a computer all day and drinks diet soft drinks
all day long. He eats fast food every day and
c. A 70-year-old woman has been coming to
3. Explain the difference between an initial treatment
4. List the six components included in the plan sec-
5. List at least five questions you can use to evaluate
6. Explain why it is not always better to recommend
7. Explain why it is not always better to recommend
if massages can be longer than 60 minutes.
you regularly, once a month, for over a year.
She is retired and enjoys her gardening club
activities and worldwide travel. Every day, she
drinks a glass of juice, a cup of tea, a glass
of water, and a cup of coffee. Every day, she
eats a lot of fruits and vegetables, very few
carbohydrates, and a small amount of protein.
In the past, she has always responded well to
a full-body relaxation massage that includes
some craniosacral work. She has not incorporated any self-care in the year you have been
treating her, but she always asks about what
she should do between sessions.
plan and a treatment plan for the subsequent massage sessions.
tion of the SOAP note.
clients’ internal healing environment to estimate
their healing time and length of treatment.
massage sessions that last longer and are more
frequent.
a lot of self-care activities.
348 INTRODUCTION TO MASSAGE THERAPY
George M. Learn to Relax: A Practical Guide to Easing Tension & Conquering
8. Explain why we encourage clients to participate in
self-care activities.
9. Name at least seven factors that can disrupt sleep.
10. Describe at least three different reasons why you
need effective communication skills to follow up
on your treatment plan.
SUGGESTED READINGS
Batmanghelidj F. You’re Not Sick, You’re Thirsty: Water for Health, for Healing,
for Life. New York: Warner Books, 2003.
Bicknell J, Benjamin BE. The importance of water. American Massage Therapy
Association’s Massage Therapy Journal 2003:28–36.
Chopra D. Restful Sleep: The Complete Mind/Body Program for Overcoming
Insomnia. New York: Three Rivers Press, 1994.
Stress. San Francisco: Chronicle Books, 1998.
Kneipp S. The Kneipp Cure: An Absolutely Verbal and Literal Translation for “Me-
ine Wasserkur” (My Water Cure). New York: Nature Cure Publishing, 1949.
Sapolsky RM. Why Zebras Don’t Get Ulcers: An Updated Guide to Stress, Stress-
Related Diseases, and Coping. New York: WH Freeman, 1998.
Thompson D. Hands Heal: Communication, Documentation, and Insurance
Billing for Manual Therapists. 2nd ed. Baltimore: Lippincott Williams &
Wilkins, 2002.
Tobias M, Sullivan JP. Complete Stretching: A New Exercise Program For Health
and Vitality. New York: Alfred A. Knopf, 1994.
Yee R, with Zolotow N. Yoga the Poetry of the Body. New York: Thomas
Dunne, 2002.
http://jointhealing.com/pages/productpages/cryotherapy.html, accessed 3.5.06.
http://www.21c-online.com/2001-pickering-sleep.htm, accessed 3.5.06.
http://www.boston.com/globe/search/stories/health/how_and
_why/011298.htm, accessed 3.5.06.
http://www.bottledwater.org/public/hydratio.htm, accessed 3.5.06.
http://www.healthyroads.com/mylibrary/data/ash_ref/htm/art
_waterrequirementshelpyourbodymaintainnormalfunction.asp?HP=&,
accessed 3.5.06.
Objectives
9
Upon completion of this chapter, the student will be
able to:
■
Name the three client positions on the massage
table
■
Demonstrate draping techniques to expose at
least three different areas of a partner’s body on
the massage table
■
Name the three stationary massage “strokes”
Key Terms
Centering: A technique that helps you focus your at-
tention on your clients.
Chair massage: A massage for persons who are fully
clothed that is delivered while the client is seated
in a specially designed chair, also called seated
massage, onsite massage, corporate massage, and
event massage.
Compression: A stroke that applies pressure to soft
tissues to squeeze them together without any slip.
Deep- ber friction: A stroke that is applied with deep, lo-
calized pressure without any slip on the skin to break
up fascial adhesions and separate the muscle fibers.
Ef eurage (EF-lur-ahzh): A slow, gliding stroke along
the client’s skin.
Flow: A routine-like sequence of steps that leads
the massage from one body part to the next in a
■
Identify and demonstrate the six basic massage
strokes
■
Explain at least two effects of each basic
massage stroke
■
Explain the effects of joint movement
■
Follow a basic relaxation massage flow
■
Demonstrate an abdominal massage
■
Identify at least three research-proven benefits
of massage in the workplace
systematic, fluid pattern that often specifies stroke
sequences.
Grounding: A technique you can use to establish an
emotional and energetic boundary between you and
your clients.
Petrissage (PET-rih-sahzh): A stroke that kneads soft
tissues with a grasping and lifting action.
Prone: Lying face down.
Resting stroke: A stroke that requires you to stop
moving and lightly rest your relaxed hands,
fingers, or arms on your client for several
seconds.
Side-lying ( laterally recumbent ): Lying on one’s
side.
Slip: The sliding of your skin over the surface of the
client’s skin.
349
350 INTRODUCTION TO MASSAGE THERAPY
Super cial friction: A brisk variation of light effleurage
that increases circulation in the superficial tissues
and dissipates body heat.
Supine: Lying face up, on back or spine.
he main considerations when performing massage are
comfort and safety for both you and your clients. To
T
relax, clients must feel safe, secure, and comfortable.
Before clients get on your massage table, you must be familiar with the different body positions clients can use, different
ways to drape their bodies to keep them warm and modestly
covered, and the different ways to position and support them
throughout the massage. Appropriate client positioning, proper bolstering, and secure draping, which must all be considered before and during the session, are the topics discussed in
this chapter.
Your own body should remain relaxed and comfortable to deliver massage techniques effectively and efficiently,
without injuring yourself. Remember to set up your workspace to allow you to move freely as you work and always
incorporate good body mechanics. As you learn, apply, and
practice your strokes and techniques, continually monitor
your body to make sure that you establish muscle memory
that includes good body movement habits.
Once you master how to position your client on the
table and how to use your own body during a massage session, you may realize that massage is both art and science.
There are individual nuances to every massage that make it
impossible to perform the exact same massage twice. This
artistic aspect of massage encompasses the personal and
unique characteristics of touch:
• The intent of the touch
• The delivery of the touch
• The attitude of the person delivering the touch
• The focus of the person delivering the touch
• The mental condition of the person receiving the touch
• The physical condition of the person receiving the touch
• All of the factors of the massage environment
Tapotement (tuh-POHT-ment): A fast rhythmic stroke
that uses both hands, like rapid drumming.
Vibration: A stroke that involves high-frequency shaky
hand movements and is capable of deep effects.
Touch can be obvious or subtle, significant or meaningless. For example, a very light caring touch is vastly
different from an accidental brush against a stranger in a
crowded store. As a massage therapist, you have the ability to use the power of touch to affect another human
being. The trick, therefore, is to know how to tailor
the massage session to the needs and wants of your clients. You must know how to perform the basic massage
strokes, but it is equally—if not more—important to
know where and when to use them. The scientific aspect
of massage includes all of the anatomy and physiology
involved in massage as well as the organized approach
to assessments and treatment plan. Along with effective
communication skills and your academic knowledge of
anatomy and physiology, the physiological effects of massage presented in this chapter will help you determine
which strokes are appropriate for each individual client.
Combining your scientific knowledge with an artistic and
individualized approach to touch creates a unique massage every time.
Even though each massage is different, there are
many similarities. The massage flow is like an outlined
sequence that leads the massage from one body part to
the next in a systematic, fluid pattern. Similar to a recipe, a flow can specify the parts of the body you treat, the
order in which you treat them, and the strokes you apply.
Some flows start with clients in the prone position (face
down), whereas others begin with clients in the supine
position. Some flows are designed for clients who remain
in a laterally recumbent (side-lying) position throughout
the entire massage, whereas others are designed for clients in a seated position. With practice, flow will become
second nature and you will be able to think about which
strokes and techniques to apply instead of which body
part to work on next.
Clients can lie on the massage table in three different
positions to receive massage: supine (face up), prone
(face down) , or laterally recumbent (side-lying) . Seated
massage, an alternative to table massage, is covered later
in this chapter as an alternative to table massage. Most
therapists develop a preference for starting clients in the