Regardless of what some continuing education instructors claim, no one modality aids everyone. This is why the ability for massage therapists to create treatment plans for clientele is fundamental to success.
In my private practice in Tempe, Arizona, clients routinely thank me for my ability to assess, deduce data and apply a proper modality to their body. At my practice, we combine knowledge of anatomy, kinesiology and pathology to determine how the client’s condition is affecting their body. From this point, we determine massage treatment planning to help the client ease their present state of signs and symptoms and achieve goals.
All therapists can better improve their massage treatment planning skills with thoughtful introspection and critical thinking applied to client cases. Critical thinking applied to devising a proper treatment plan involves many components. This article is intended to aid the reader in the critical thought process needed to best determine clients’ massage treatment plans.
I will first introduce the essential elements of creating treatment plans. I will also use a case study example from my personal practice to show how an effective massage therapy treatment plan is formulated.
The essential elements of creating treatment plans include several key steps: the initial intake, assessment, goal creation, progress evaluation and new goals. These steps ultimately nurture the therapeutic relationship and lead to rapport and trust with clients.
1. Perform the initial intake. There are three components of doing a thorough initial interview: written, verbal and nonverbal.
First, we provide time for clients to answer questions in written form. This documentation will be key, as the therapist can review this information in subsequent days to recall the client case and thoughtfully examine the case upon session completion.
Second, we allow clients to verbally elaborate upon their written responses. This clarification may add key insight to their written answers. This allows the client to better understand the questions asked while also allowing the therapist to best interpret client responses.
Third, nonverbal communication can be interpreted to help provide a complete picture of the client before the session begins. It is well understood that the majority of communication is nonverbal. Being able to read this within our clients allows the therapist to better understand our client responses in an accurate context.
For example, if a client expresses they feel completely comfortable verbally yet their body language indicates being closed to the therapist, then the therapist may need to change their approach to allow the client to open up to their environment. Clients often omit feelings of angst to not offend a therapist or create friction in the room. This same client will likely not be as open on the table to receive bodywork, leaving the therapist to wonder why their work was not effective.
2. Assess. There are four types of assessment methods massage therapists use: visual, postural, palpation and testing.
A visual assessment allows one to examine the skin for areas of bruising, lesions, swelling and cautionary areas.
A postural assessment takes the visual component to an elevated level, specifically viewing for areas of short, compressed tissue indicating areas of contracted muscle tissue that is locked short.
Palpation assessment involves feeling certain bony landmarks and muscles for areas of tenderness and pain.
Finally, testing range of motion, muscle efficiency or joint efficiency can provide useful information to pinpoint the source of dysfunction.
Together, subjective and objective data is obtained, giving the therapist a clear clinical view of the client. Subjective data is based on client perceptions, such as, “It hurts like this.” Objective data is based on specific, measurable findings such as, “The right shoulder is elevated more so than the left by one-quarter inch.”
3. Create goals. Types of goals include functional (related to an activity) and objective (measurable, specific).
Functional goals relate to activities and tasks clients routinely perform. Running without pain, cleaning one’s home without discomfort, and using tools with ease are examples of functional goals clients will recognize. Speaking to these goals between sessions in follow-up efforts helps us track progress of a session’s effectiveness.
Objective goals are measurable and specific to a body region. Range-of-motion measurements, blood marker indicators and gait observations are examples of objective goals clients will notice. As clients witness these changes and visible results are beheld, they realize how effective massage is for their bodies.
At this point, therapists consider which modalities will best accomplish these goals and how many sessions are reasonable to expect progress witnessed and goals achieved.
4. Evaluate progress in relation to intended goals. Matching treatment outcomes to intended goals is a key step toward massage treatment planning. Here are questions therapists may ask themselves while keeping track of progress in relation to intended goals:
• Is there progress in both functional goals and objective goals witnessed? If the functional and objective goals coincide, we should see both of them manifest in a fairly equal time frame.
• Do we see a lack of progress necessitating the need to alter the original treatment plan? The original treatment plan may indicate deadlines for goals.
• Are there other factors confounding the clinical picture? Chronic disease, sedentary lifestyle, heightened stress and injury are all factors that impact healing.
5. Create new goals. Upon revelation that either a client has achieved their functional or objective goals or a client will not achieve these goals in the foreseeable future, a wise move by the therapist will be to create new goals.
For clients who achieve their intended goals, a schedule of maintenance massage may be appropriate to maintain client progress. For clients who have yet to achieve their intended goals, a therapist may need to ask these questions:
• What other modalities may facilitate the intended client goals? Many modalities produce similar effects upon soft tissues.
• Do I have sufficient training in these modalities? Sufficient implies attending a formal training, more so than merely watching a video or attending a weekend workshop.
• Must I refer to more experienced massage therapist? Will another massage therapist have a better grasp of how to aid this clinical patient?
• Must I refer to another type of health professional? The challenges witnessed within the client may be beyond the normal scope of practice of massage.
• Do I need to work in combination with another health professional? A signed medical release form is advised to ensure you can speak to other professionals about client case.
• Where can I attain more information about a specific pathology or condition? A pathology textbook within your personal library will come in handy.
Here is a case study highlighting how I formulated an effective treatment plan with a client.
I first began working on this client, Margie (name has been change to protect confidentiality), two years ago. This moderately active 54-year-old female presented with a physician’s diagnosis of degenerative cervical osteoarthritis coupled with degenerative intervertebral discs.
Step 1: Initial intake. On paper and verbally, the client shared with me: a) the original mechanism and extent of injury; b) her physician’s formal diagnosis; and c) exercises the physical therapist employed. Nonverbally the client shared a trust in me with inviting body language, indicating she was comfortable sharing information with me.
Step 2: Assessment. Upon visual assessment, the client presented with remarkably red-toned and thinner skin at neck and shoulder girdle than elsewhere.
Upon postural assessment, the client presented with her head and neck tilted to the left, left shoulder elevated more so than the right, lack of definition amongst both scapula bones and anterior pelvic tilt of more than 25 degrees.
Upon palpation, her anterior neck musculature felt tender and spongy, and ridden with inflammation and sensitivity. Touch of more than five grams of pressure at the neck and shoulder girdle elicited a pain response and extreme discomfort. Same findings for posterior neck musculature and C7 aponeurosis.
Upon testing, cervical range of motion was more limited to the right than left. Also, flexion of the neck past 60 degrees created a pain response at C5–C7 bone levels.
Step 3: Creating goals. Initial functional goals are to reduce pain upon palpation and reduce daily pain felt as her day progresses. Initial objective goals: Increase range of motion—flexion of neck. Equalize range of motion—lateral flexion and rotation of neck. Realign head and neck posture in relation to the torso. Equalize shoulder height bilaterally.
Goal to achieve these goals: Within four weekly sessions.
Modalities chosen: myofascial release, craniosacral therapy and hydrotherapy.
Step 4: Evaluating progress in relation to intended goals. All three modalities chosen proved effective of accomplishing functional goals within four sessions. Objective goals took longer to achieve. When the client participated in yoga and related exercise, objective goals were more easily achieved. When the client missed these activities during the week, objective goals dissipated.
Step 5: Create new goals. As the weeks progressed, goals were adjusted depending on client’s new exercise activities chosen and new jobs acquired. At this point, pain is no longer a factor as weekly massages are now maintenance sessions consisting of Swedish massage primarily.
A therapist with a vast array of modalities to utilize will have an easier time with creating massage treatment plans. I use the analogy of a carpenter’s tool belt: The more tools one possesses in the tool belt, the more effective the carpenter becomes. Similarly, a massage therapist with a multitude of modalities to utilize will be a more effective therapist.
More healing options equates to varied approaches to the healing process. I encourage all therapists to continue their education in modalities and techniques to best aid their clientele. As your tool belt grows, so will your confidence in providing best care within your massage practice.
Jimmy Gialelis, LMT, BCTMB, is owner of Advanced Massage Arts & Education in Tempe, Arizona. He is a National Certification Board for Therapeutic Massage & Bodywork-approved provider of continuing education, and teaches “Professional Ethics for LMTs” and many other CE classes. He is a regular contributor to MASSAGE Magazine, and his articles include “For HIV/AIDS Patients, Massage Provides a Touch of Humanity” and
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