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Chapter 17 – Therapeutic Procedure Notes

INTRODUCTION

  • Therapeutic procedure serves as a basis to understand a client’s condition and to choose techniques for addressing concerns during a massage.
  • Provides guidelines for creating a treatment plan and helps clients understand goals of each session.
  • Evaluation of outcomes helps to improve treatment strategy for current and future clients.
  • Chapter overview: describe the four parts of the therapeutic procedure and how therapeutic modalities and classical massage techniques can be combined to fit client needs.
  • Clients with pain, injury, or recovery needs may require more focused, body-area-specific treatment; whole-body vs. targeted approaches are both possible depending on client goals.

FOUR PARTS OF THE THERAPEUTIC PROCEDURE

  • Therapeutic modalities and classical massage techniques can be combined in various ways to fit client needs.
  • The procedure encompasses a full process that moves from history to plan to intervention and evaluation.
  • The aim is to design a treatment plan that provides guidelines and clarifies goals for each session.

THERAPEUTIC PROCEDURE: FOUR BASIC STEPS

  • Step 1: Assessment
  • Step 2: Planning
  • Step 3: Performance
  • Step 4: Evaluation
  • The procedure is a continuous, feedback-rich process during a massage session; therapists continually gather information and adjust techniques.
  • Documentation is essential; SOAP charts (Subjective, Objective, Assessment, Plan) are recommended for recording each segment of the therapeutic procedure.
  • The procedure can be implemented long-range (six to ten sessions) or short-range (a single session), with evaluation guiding future care.
  • Long-range planning can encompass several sessions; planning considers goals, strategies, and chosen techniques.
  • Short-range planning focuses on a specific complaint and a single session, with outcome evaluation informing future sessions.
  • Throughout the massage, the therapist continually gathers feedback from palpation and client communication to adjust the plan.

DOCUMENTATION OF THE THERAPEUTIC PROCEDURE

  • All information must be carefully documented in the client’s files.
  • SOAP charts are well-suited for recording subjective data, objective findings, assessment, and plan.
  • Chapter 9 provides information about SOAP charts.

THERAPEUTIC PROCESS: LONG-RANGE VS. SHORT-RANGE PLANNING

  • Long-range goals may require extensive assessment and planning; six to ten sessions are typical for long-range planning.
  • Short-range planning may be adequate for addressing a specific complaint within a single session.
  • After the strategy is formulated and treatments are delivered, an evaluation determines progress and whether further therapy is needed.
  • The therapist continuously evaluates during the session, making adjustments as tissue responses are sensed.

THERAPEUTIC PROCESS: CONTINUOUS FEEDBACK DURING TREATMENT

  • The therapist observes tissue responses during treatment and uses palpation and client feedback to guide next moves.
  • The hands continuously sense changes in muscle structures and tissue; the therapist adjusts movements accordingly.
  • The evaluation process is continuous, as feedback from the client and tissue response informs ongoing strategy.

CHAPTER 17: CLIENT INTAKE PROCEDURE FOR THERAPEUTIC MASSAGE

  • Intake procedures build on preliminary intake from Chapter 9 but are more extensive for therapeutic massage.
  • Intake includes assessment techniques and planning strategies to determine services addressing client concerns.
  • The extent of intake depends on visit purpose and massage intent; intake begins when the client calls or makes an appointment and continues until consent to proceed.
  • Segments of intake may include:
    • Setting the appointment: initial screening to determine match between services and client needs.
    • Initial greeting and consultation: extra time to fill intake forms and exchange information (reasons for visit, policies, procedures).
    • Assessment: client interview, health history, observation, palpation, and special tests (e.g., range of motion).
    • Treatment plan: collaboratively determine a plan for one or multiple sessions.
    • Informed consent: client signs consent as the session commences.

ASSESSMENT TECHNIQUES: COMMON PROTOCOLS

  • Effective practice hinges on accurate assessment; therapists must understand client and condition to decide massage procedures or referrals.
  • The extent of examination depends on intended therapy.
  • If the visit is mainly a relaxation massage, only enough information is exchanged to rule out contraindications; informed consent is obtained and the session proceeds.
  • For specific concerns or soft tissue dysfunction, a more extensive assessment helps identify pathology and guide treatment.
  • Common assessment protocols include:
    • Client medical history
    • Close observation
    • Posture assessment
    • Gait assessment
    • Pain assessment
    • Palpation of suspected structures

ASSESSMENT TOOLS AND GOALS

  • The goal of assessment is to identify dysfunctional tissues and, if possible, the conditioning cause.
  • Assessment tools vary by modality; a common protocol includes:
    • Client medical history
    • Close observation
    • Posture assessment
    • Gait assessment
    • Pain assessment
    • Palpation of suspected structures

CHAPTER 17: CLIENT HEALTH HISTORY FORMS (EXCERPTED CONTENT)

  • Client information forms collect age, occupation, hobbies, and visit reasons; medical history includes major illnesses, medications, surgeries, traumas, allergies.
  • The back of the health history form collects infectious diseases, congenital or acquired disabilities, surgeries, injuries, current conditions, medications, substances use, stress-relief activities, and other concerns.
  • A separate Release of Medical Information form authorizes sharing records with involved physicians or healthcare practitioners.
  • The intake process includes a client-therapist consultation to clarify information and set intentions for the session.

POST-INTERVIEW: GATHERING INFORMATION DURING THE INTERVIEW

  • Information from forms plus client interview clarifies concerns, needs, and expectations.
  • Review of forms and questioning helps determine whether to proceed, refer, or contact a doctor before proceeding.
  • The therapist should consider challenging or questionable conditions and refer to appropriate healthcare professionals when in doubt.
  • Data from forms and interview provide information about the nature of the complaint, affected tissues, whether chronic or acute, and what worsens or improves the condition.
  • Questions explore onset, progression, prior treatments, and triggers; determine pain location, intensity, quality, and impact on function.
  • If pain medication is used, consider how meds influence feedback and massage technique choices.

SUBJECTIVE VS. OBJECTIVE FINDINGS; PAIN SCALE

  • Findings are twofold:
    • Subjective: client describes feelings, location, timing, and modifiers of pain.
    • Objective: therapist notes observable and measurable data (pain ratings, ROM, strength, etc.).
  • Pain scales: a tool to assess discomfort levels and guide treatment intensity.
  • The 0-10 Numeric Pain Rating Scale is commonly used; a Wong-Baker Faces Pain Rating Scale provides a visual alternative.
  • Pain scales help determine appropriate pressure during modalities like trigger-point release or positional release, aiming for a target discomfort level (e.g., rating 5–7 on a 0–10 scale).

MASSAGE CORNER 17.2: ARNDt–Schultz LAW

  • Arndt-Schultz law: weak stimuli activate physiologic processes; strong stimuli inhibit them.
  • If the intervention is too strong, the nervous system may not respond; if too weak, response is minimal.
  • Aiming for a moderate level (roughly around 6–7 on a 10-point scale) helps the nervous system respond and shift signals to the muscle via the reflex arc.
  • Educate clients that forceful or “grin and bear it” approaches are not ideal for shifting pain patterns.

USE OBSERVATION AS AN ASSESSMENT TOOL

  • Observation begins at entry and continues until exit; body language reveals pain and tension patterns and emotional state.
  • Visual observation focuses on structural alignment, symmetry, and skin color/condition; compare sides to identify deviations.
  • Posture assessment involves observing alignment relative to gravity; ideal posture distributes mass around the center of gravity with balanced postural muscles.
  • Postural distortion may arise from trauma, work habits, pathology, or age; compensation can shift stress to other areas and increase pain.
  • Guidelines for posture observation:
    • Observe from four sides (anterior, posterior, left lateral, right lateral) with the client standing.
    • Assess from bottom to top, noting symmetry of bony landmarks (ankles, fibular heads, greater trochanter, iliac crests, scapulae, AC joints, ears).
    • For women, PSIS-ASIS angle should be within ~$10$ degrees from horizontal; for men, within ~$5$ degrees.
    • A perfectly plumb line bisects the body from front/back; from the side, line passes through ear, shoulder, elbow, acetabulum, knee, and slightly anterior to the ankle.
  • Gait assessment: observe walking posture and rhythm from multiple angles; look for smooth heel-to-toe transition, symmetrical stride, and alignment of trunk, pelvis, arms, and head.

ROM AND END FEEL ASSESSMENT

  • ROM assessment includes active, passive, and resisted movements to gauge joint mobility and tissue status.
  • Definitions:
    • Active Range of Motion (AROM): client moves body part through normal joint range; assesses willingness and ability to move.
    • Passive Range of Motion (PROM): therapist moves the joint with the client relaxed; assesses laxity, end feel, and smoothness.
    • Resisted Range of Motion (RROM): isometric testing to assess contractile tissue strength.
  • Cyriax concepts include contractile tissue, inert tissue, end feel, and capsular patterns:
    • Contractile tissues: muscles, tendons, attachments.
    • Inert tissues: bone, ligaments, bursa, blood vessels, nerves, cartilage.
    • End feel: quality of joint movement at end range.
    • Capsular pattern: proportional limitation due to muscular control.
  • Testing sequence: test the good side first; perform active, then passive, then resisted movements; record objective and subjective findings.
  • Interpretation:
    • Strong, pain-free: healthy tissue.
    • Strong, painful: lesion in contractile tissue (e.g., minor strain).
    • Weak, painless: nerve or circulation issue; possible severe tissue damage if no strength.
    • Weak and painful: severe lesion (possible tear or fracture) requiring referral.
  • Other orthopedic tests exist but are beyond scope; pursue advanced study for orthopedic assessment if desired.

END FEEL, ABNORMAL PATTERNS, AND MUSCLE TESTING

  • End feel types (normal):
    • Hard: bone-on-bone contact; abrupt, painless stop (e.g., knee/ elbow extension).
    • Soft: cushioned, painless stop due to soft tissue limitation.
    • Springy/firm: most common; tissue stretch with slight resistance as ROM approaches end.
  • Abnormal end feel patterns:
    1. Bone-to-bone: hard, abrupt stop earlier than normal; may indicate degenerative joint disease, dislocation, or fracture.
    2. Firm: earlier-than-usual limitation indicating increased muscle tone or soft tissue shortening.
    3. Muscle spasm: sudden stop with pain, seen in acute/subacute arthritis, severe lesion, or fracture.
    4. Empty end feel: pain before end range, indicating pathology or injury.
    5. Springy block: rebound sensation, suggesting internal meniscal tear or similar issue.
  • PROM assessment indicates inert tissue status; full, painless ROM suggests healthy joint and tissues; pain with movement or end-feel abnormalities suggest tissue dysfunction.
  • Indications of capsulitis or arthritis when pain and limitation are present in multiple directions.

RESISTED RANGE OF MOTION (RROM) AND MUSCLE TESTING

  • RROM assesses the relative strength of muscles and the contractile tissue (muscle, tendons, attachments).
  • Procedure: stabilize near midrange, instruct client to move limb against resistance; observe pain, weakness, and quality of movement.
  • Interpretations:
    • Strong and pain-free: healthy contractile tissue.
    • Strong and painful: minor lesion in contractile tissue (1st- or 2nd-degree strain).
    • Weak and painless: nerve supply or circulation impairment.
    • Very weak and painful: severe lesion (torn ligament or fracture) requiring medical referral.
  • Compare sides for normence; higher severity correlates with more significant tissue dysfunction.
  • Note: RROM findings complement ROM findings and help localize tissue involvement.

OTHER ORTHOPEDIC TESTS

  • Numerous tests isolate specific structures; names often reflect area tested or the tester's name (e.g., Adson’s test, Phalen’s test, Ober’s test).
  • Many tests exist for various body regions; comprehensive coverage is beyond this text; pursue additional study for orthopedic assessment skills.

SOFT TISSUE BARRIERS (TISSUE BARRIERS)

  • Soft tissue barriers represent limits within which tissues can be effectively manipulated.
  • Barriers arise when compressing, stretching, or mobilizing tissues and joints; barriers vary with tissue condition.
  • Three barriers:
    1. Resistive barrier (pathologic barrier): first sign of resistance to movement.
    2. Physiologic barrier: end range where movement remains easy but approaching discomfort; lies within the anatomic barrier.
    3. Anatomical barrier: the actual anatomical limit; moving beyond risks tissue damage.
  • In healthy tissue, movement passes through and beyond barriers with ease until end range is reached; in damaged tissue, barriers can be encountered early (contractile tissue restrictions, scar tissue, trigger points).
  • Ischemic compression around a trigger point: the resistive barrier is felt at first, followed by physiologic barrier as discomfort increases; avoid reaching the anatomical barrier to prevent tissue damage.
  • Therapeutic approach targets forces between the resistive and physiologic barriers to maximize therapeutic response without causing tissue injury.

PALPATON: PALPATION SKILLS AND LAYER PALPATION

  • Palpation is a skill and art used to locate tissue layers, assess texture, and monitor changes during treatment.
  • Palpation can be learned and refined through practice; it is enhanced when used with ROM and orthopedic assessments.
  • Layer palpation sequence (from superficial to deep):
    • Skin and subcutaneous fascia (skin rolling helps assess extensibility and fascia health).
    • Superficial lymph nodes and blood vessels (palpation along common sites; enlarged nodes require medical referral).
    • Skeletal muscles and fasciae (tactile assessment of muscle tone, tenderness, adhesions, and taut bands).
    • Tendons and musculotendinous junctions (palpate end of muscle where tendon attaches; watch for hypersensitive trigger points).
    • Joints and ligaments (palpate joint spaces and ligaments for instability or tenderness).
    • Visceral structures (abdominal viscera palpation when appropriate).
  • Common palpable findings include taut bands, trigger points, adhesions, scar tissue, and hypersensitive nodules.
  • Palpation is essential for identifying tissue quality, abnormalities, and the presence of lesions; always perform bilateral comparisons.
  • Tools of palpation include the therapist’s hands and thumbs for deeper structures.
  • Layer palpation can help differentiate between muscle belly, tendon, fascia, and bone attachments; develop tactile differentiation between normal and abnormal tissue.

TART: DESCRIPTIVE TERMS FOR LAYER PALPATORY EXAMINATION

  • TART stands for Texture, Asymmetry, Range of motion, Tenderness.
  • Descriptive continuums used for assessment:
    • Texture: Superficial – Deep
    • Tenderness: Nonpainful – Painful
    • Temperature: Cold – Hot
    • Mobility: Hypomobile – Hypermobile
    • Surface quality: Smooth – Rough
    • Tissue state: Thin – Thick; Dry – Moist
    • Consistency: Soft – Hard
    • Compliance: Compressible – Rigid
    • Elasticity: Flexible – Stiff
    • Duration: Acute – Chronic
    • Distribution: Circumscribed – Diffuse
  • The TART framework helps document structural and tissue-level variations that influence treatment decisions.

TART IN PRACTICE: ACUTE vs CHRONIC CONDITIONS

  • Acute vs chronic distinctions describe onset and duration:
    • Acute: sudden onset, relatively short duration; sharp pain; identifiable incident; inflammation is often present.
    • Chronic: lingering or ongoing condition; dull or diffuse pain; may lack a clear cause; may persist for weeks to years.
  • Acute soft tissue injury pathway involves inflammatory response with phases: acute, subacute, regenerative, remodeling.
  • Inflammation signs: heat, redness, pain, swelling; histamines cause vasodilation and vascular permeability, leading to swelling and tenderness.
  • PRICE protocol during acute injury: Protection, Rest, Ice, Compression, Elevation.
  • Early management focuses on protecting tissue and reducing swelling; lymph massage proximal to the injury can aid drainage.
  • Subacute phase: gentle cross-fiber techniques; light ROM help align collagen and restore mobility; avoid aggressive loading.
  • Remodeling phase: collagen cross-linking continues; large tissue lengthening and cross-fiber work can help restore function; ice massage can be used; progressive loading and stretching encouraged.
  • Chronic conditions often require longer-term, gradual interventions and may include frequent sessions to manage pain and restore function.
  • In general, most acute injuries are contraindications to massage until stabilization; subacute injuries allow gentler, carefully directed work; chronic conditions may tolerate more frequent sessions depending on tolerance and medical clearance.

USING ASSESSMENT INFORMATION TO PLAN SESSIONS

  • After completing assessments, therapists develop session strategies that align with client goals.
  • Movement assessments reveal restrictions in pain and tissue constriction; palpation confirms affected tissues.
  • A well-constructed treatment plan includes modalities, techniques, and regime details tailored to the client’s needs.
  • Goals should be realistic and attainable, guiding session planning and interventions.
  • Components of treatment plans may include:
    • Referral to another health professional for assessment or treatment
    • Initial number and frequency of sessions (full body vs. targeted)
    • Estimated treatment length and modalities (heat, ice, hydrotherapy, etc.)
    • Specific techniques to be used or avoided
    • Areas to address or avoid
    • Home self-care recommendations
    • Expected results and timeframes

GOAL SETTING AND TREATMENT PLANS

  • Goals for the massage session or series should address:
    • Improved body function and efficiency
    • Increased client self-awareness, balance, and fluidity
    • Pain relief and improved local fluid movement
    • Reduced ischemia and improved lymph uptake
    • Normalization of soft tissue and reduction of hypertonic muscle tissue
    • Lengthening of constricted fascia
    • Increased flexibility and ROM
    • Reintegration of function into the whole body
    • Relaxation and stress relief
  • The treatment plan should reflect the client’s values and needs, and should be revisited and adjusted based on outcomes.

CONTINUING EDUCATION AND COMMUNICATION WITH CLIENTS

  • The massage field includes many techniques and systems with different perspectives on assessment and treatment.
  • Continuing education supports advanced learning, deeper understanding, and broader skill sets.
  • When communicating assessment findings and treatment plans, use terminology the client understands; use diagrams or charts when helpful.
  • Explain interventions, expected benefits, and possible risks; obtain informed consent and remind clients of their right to modify or withdraw consent during the session.

PERFORMANCE STRATEGIES AND BEGINNING THE TREATMENT

  • Determine performance strategies tailored to each client’s needs.
  • In the performance portion, apply techniques and modalities to meet session goals and client concerns.
  • Begin treatment once intake, assessment, and planning are complete; various modalities (e.g., hot packs, ice packs, ice massage, hydrotherapy) may be used in combination with stretching and exercise.
  • Follow the treatment plan but remain flexible; ongoing assessment during the session informs adjustments as tissues respond.
  • Throughout the session, maintain a continuous visual assessment of body position, symmetry, and tissue responses; modify techniques as needed.

NOTES ON RESOURCES AND ACCESS

  • Bonus resources may be available at specified websites; refer to the Preface for access instructions.
  • Figures and examples provided in the course material illustrate forms, diagrams, and assessment tools (e.g., client health history forms, release forms, and visual posture charts).

SUMMARY OF KEY TERMINOLOGIES AND CONCEPTS

  • Therapeutic procedure: four steps (Assessment, Planning, Performance, Evaluation) with continuous feedback and documentation via SOAP.
  • Intake and assessment: comprehensive client interview, health history, and observation; establish treatment plan and informed consent.
  • Assessment tools: history, observation, posture, gait, pain assessment, palpation.
  • Pain assessment: 0–10 Numeric Pain Rating Scale; Wong-Baker Faces scale; use to calibrate treatment intensity and monitor progress.
  • Arndt-Schultz Law: balance stimulus intensity to activate physiological responses without inhibition.
  • Observation: posture, gait, symmetry, and movement quality inform tissue dysfunction.
  • ROM assessment: AROM, PROM, and RROM; end feel types (hard, soft, springy) and five abnormal end-feel patterns.
  • Soft tissue barriers: resistive, physiologic, and anatomic barriers; approach between resistive and physiologic barriers for safe, effective therapy.
  • Palpation: layer-by-layer assessment from skin to deeper structures; bilateral comparison; detect taut bands, trigger points, adhesions, and tissue quality.
  • TART framework: Texture, Asymmetry, Range of motion, Tenderness; used to describe soft tissue dysfunction.
  • Acute vs chronic injury management: PRICE; staged inflammation; subacute gentle work; chronic conditions may tolerate longer-term plans.
  • Treatment planning: goals, modalities, frequency, home care, referrals, and client education; ensure informed consent throughout the process.
  • Continuing education: important for expanding skills and maintaining ethical, effective practice.

6\text{ to }10\text{ sessions}
0-10 Numeric Pain Rating Scale; 0-10 scale for pain intensity