Thursday, December 20, 2012


This is a picture of a Christmas Bird that my granddaughter made.  She is 5 years old.  How can we question the hope for our future when these little ones bring blessings.

Thursday, December 13, 2012

I been around a long time and-----

I been around a long time and-----

The massage profession still does not have a definition of massage

Why is this so difficult?  When I provide massage I use my body to apply a mechanical force to the client’s body. The intent is the help and not harm. I adapt the type and intensity and location of the mechanical force to best influence the physiology I am attempting to influence.  What physiology can I influence? Well we really don’t know all this for sure however there is certainly stimulus from the massage application to the sensory aspect of the nervous system.  There appears to be indirect affect to the autonomic nervous system-i.e. sympathetic /parasympathetic which would then influence the neuroendocrine physiology.  Maybe massage can influence fluid movement-blood and lymph both directly and indirectly – maybe …..So in this situation the massage application should mimic the body’s own fluid movement physiology. Massage appears to help people relax especially when it is provided in a general full body rhythmic manner with sufficient non painful pressure.  Somehow a really good massage helps most people move better with less stiffness-Fascia pliability? Nerve stimulation? Both?

Why do we need to complicate the issue so much?


I been around a long time and----------

The massage organizations just can’t seem to work together to present a unified position.  I truly get so frustrated with this. Why can’t each organization do it’s job and support the other organizations to do their jobs.  Why can’t the AMTA be a really excellent nonprofit member organization?  Why can’t the Federation of State Massage Boards be about licensing and that’s it? Why can’t the National Certification Board for Therapeutic Massage and Bodywork focus on real quality and meaningful certification and professional development including continuing education?  Why can’t the ABMP- a for profit organization- be and excellent support for massage therapists and offer products –like insurance, practice building materials and so forth to help the profession and why can’t all the organizations support the Massage Therapy Foundation, COMTA and the Alliance for Massage Therapy Education. And finally---WHY CAN’T ALL THESE ORGANIZATION WORK TOGETHER TO HAVE ONE COMBINED MEETING AT AN AFFORDABLE LOCATION SO MORE PEOPLE CAN ATTEND????????


 I been around a long time and----------

When will there be an agreed upon entry level curriculum recommendation  provided as a guide to schools so that the educators can teach a quality program and graduates are able to perform a quality massage –not a fancy massage with lots of gimmicks- a really good massage and be able to do enough massage sessions a week to make a living without hurting themselves.  Of course this would require a for real BIOMECHANICS AND ERGONOMICS studies.

I been around a long time and-----------


Saturday, November 24, 2012


Might as well smile.

UGH—If you think having to pass multiple choice exam to graduation from massage school and become licensed and then finally certified is a pain you should try writing them.  I write textbooks for massage education and each book has a huge test bank.   I also write a review guide for the tests used for licensing.  I am in process of writing 10 practice tests 150 questions each and my brain is exhausted.  I have five of them completed and five to go.  I write really good multiple choice question. I see every question as a little problem to be solved and a little lesson to be learned. I wish I could tell you that I approve of  multiple choice questions as a method for evaluation but I don’t (even though I write really good multiple choice questions).  Doesn’t matter if I approve or not- the licensing exams are based on multiple choice exams.  Multiple-choice questions can be used to measure knowledge outcomes and various types of learning outcomes.  They are most widely used for measuring knowledge, comprehension, and application outcomes.

 I think the biggest reason multiple choice questions are used because scores are more reliable than subjectively scored items (e.g., essays),  scoring is easy, objective, and reliable and they can cover a lot of material very efficiently (about one item per minute of testing time).

 Constructing good questions is time consuming and it is difficult to find plausible wrong answers. My biggest concern is that real world problem solving differs – a different process is involved in a real critical thinking and clinical reasoning processes.    If a multiple choice exam is used that the questions should be well written.

Multiple-Choice Item Writing Guidelines

Multiple-choice questions typically have 3 parts: a stem, the correct answer – called the key, and

several wrong answers, called distractors.

Procedural Rules:

• Use either the best answer or the correct answer format.

• Best answer format refers to a list of options that can all be correct in the sense that each

has an advantage, but one of them is the best.

• Correct answer format refers to one and only one right answer.

• Use good grammar, punctuation, and spelling consistently.

• Minimize the time required to read each item.

• Avoid trick items.

• Use the active voice.

• The ideal question will be answered correctly by 60-65% of the tested population.

• Have your questions peer-reviewed.

• Avoid giving unintended cues – such as making the correct answer longer in length than the


Content-related Rules:

• Base each item on an educational or instructional objective of the course, not trivial


• Test for important or significant information.

• Focus on a single problem or idea for each test item.

• Keep the vocabulary consistent with the examinees’ level of understanding.

• Avoid overly specific knowledge when developing items.

• Avoid textbook, verbatim phrasing when developing the items.

• Avoid items based on opinions.

• Use multiple-choice to measure higher level thinking.

• Be sensitive to cultural and gender issues.

• Use case-based questions that use a common text to which a set of questions refers.

Stem Construction Rules:

• State the stem in either question form or completion form.

• When using a completion form, don’t leave a blank for completion in the beginning or

middle of the stem.

• Ensure that the directions in the stem are clear, and that wording lets the examinee know

exactly what is being asked.

• Avoid window dressing (excessive verbiage) in the stem.

• Word the stem positively; avoid negative phrasing such as “not” or “except.” If this cannot

be avoided, the negative words should always be highlighted by underlining or capitalization:

Which of the following is NOT an example ……

• Include the central idea and most of the phrasing in the stem.

• Keep the length of options fairly consistent.

• Avoid, or use sparingly, the phrase all of the above.

• Avoid, or use sparingly, the phrase none of the above.

• Avoid the use of the phrase I don’t know.

• Phrase options positively, not negatively.

• Avoid specific determinates, such as never and always.

• Make sure that there is one and only one correct option.

Distractor (incorrect options) Development Rules:

• Use plausible distractors.

• Incorporate common errors of students in distractors.

• Use familiar yet incorrect phrases as distractors.

• Use true statements that do not correctly answer the item.

• Avoid the use of humor when developing options.

• Distractors that are not chosen by any examinees should be replaced.

Suggestions for Writing Good Multiple Choice Items:

• Present practical or real-world situations to the students.

• Present the student with a diagram of equipment  or procedure and ask for application, analysis or


• Use pictorial materials that require students to apply principles and concepts.

• Use charts, tables or figures that require interpretation.

For all my whining and complaining the multiple choice question is here to stay until a better way evolves and right now I do not have a better way for the licensing exam process.  When I write practice exams I will include a few questions that break the rules provided above just so the reader will have experience with it.   By the time anyone trudges though 10 practice exams they should be able understand  how to approach the multiple choice exam format and since licensing exams are multiple choice exams so if you are going to be licensed as a massage therapist you have to pass a multiple choice exam whether I like it or not.

 I do however have a better way for the classroom- Rubrics.

A rubric is an explicit set of criteria used for assessing a particular type of work or performance. A rubric usually also includes levels of potential achievement for each criterion, and sometimes also includes work or performance samples that typify each of those levels.  Levels of achievement are often given numerical scores.  A summary score for the work being assessed may be produced by adding the scores for each criterion.

Here is a general example


Based on a draft from Elaina Bleifield and the Paulus CT Group



4—The work consistently demonstrates clear, accurate, detailed and comprehensive understanding of the relevant facts /data / theories/ terms as well as the ability to organize the information for application, presentation, documentation, and/orfurther examination.

3--The work demonstrates an adequate understanding of the relevant facts / data / theories/ terms as well as the ability to organize the information for application, presentation, documentation, and/or further examination

2-- The work demonstrates an uneven and shaky understanding of the relevant facts / data / theories/ terms as well as a limited ability to organize the information for application, presentation, documentation, and/or further examination.

1-- The work demonstrates an inadequate understanding of the relevant facts / data / theories/ terms as well as a limited ability to organize the information for application, presentation, documentation, and/or further examination.


4—The work demonstrates confident ability to work with the key concepts / information / process / theory -- applying or extending them to a wide variety of new problems or contexts, making predictions, recognizing hidden meanings, drawing inferences, analyzing patterns and component parts, communicating insightful contrasts and comparisons.

3--The work demonstrates adequate ability to work with the key concepts / information / process / theory -- applying or extending them to a variety of new problems or contexts, making predictions, recognizing hidden meanings, drawing inferences, analyzing patterns and component parts, communicating insightful contrasts and comparisons.

2-- The work demonstrates uneven and shaky ability to work with the key concepts / information / process / theory --applying or extending them with mixed success to new problems or contexts, making predictions, recognizing hidden meanings, drawing inferences, analyzing patterns and component parts, communicating insightful contrasts and comparisons.

1-- The work demonstrates extremely limited ability to work with the key concepts / information / process / theory --applying or extending them with very limited success to new problems or contexts, making predictions, recognizing hidden meanings, drawing inferences, analyzing patterns and component parts, communicating insightful contrasts and comparisons.


4—The work demonstrates surprising/insightful ability to take ideas / theories / processes / principles further into new territory, broader generalizations, hidden meanings and implications as well – as well as to assess discriminatively the value, credibility and power of these ideas (etc) in order to decide on well-considered choices and opinions.

3-- The work demonstrates adequate ability to take ideas / theories / processes / principles further into new territory, broader generalizations, hidden meanings and implications as well – as well as to assess discriminatively the value, credibility and power of these ideas (etc) in order to decide on well-considered choices and opinions.

2-- The work demonstrates uneven and superficial ability to take ideas / theories / processes / principles further into new territory, broader generalizations, hidden meanings and implications as well – as well as a limited ability to assess discriminatively the value, credibility and power of these ideas (etc) in order to decide on well-considered choices and opinions.

1-- The work demonstrates little ability to take ideas / theories / processes / principles further into new territory, broader generalizations, hidden meanings and implications as well – as well as a limited and superficial ability to assess discriminatively the value, credibility and power of these ideas (etc) in order to decide on well-considered choices and opinions.


Here are some more examples





Well now that I have vented I need to get back to writing multiple questions. UGH

Saturday, November 17, 2012


Yes that is a dog on the massage table.  To be an advanced massage therapist you also need to be flexible. 
Advanced massage begins with a goal for the outcome of the massage.  I have been observing myself while giving massage (being my own teacher) though the lens of "advanced massage" and identified that I pay attention. That may seem simplistic but I think this is very important.  Regardless of the goal for the massage (or series of massage sessions) my focus remains pretty solid.  Yes my mind will wander -whose doesn't? However because I know what I am trying to accomplish I stay on track.  I have a massage routine that I tend to follow-not stuck on it but the sequence allows me to be systematic about the assessment process.  The general full body massage that will lead to a state of relaxation ( primary goal) but is also the main assessment for the secondary goals of the session.  For example, I may be working on scar tissue limitations during knee movement. I feel strongly that spot work is limited in effectiveness and almost always provide a full body massage that moves the various tissue layers and moves all the joints. Again to me this is assessment  but to the client it feels like an excellent general massage.  During the massage if indicated I may perform some additional assessments such as a muscle strength test or an orthopedic test.  I do "clean up " minor tissue , postural and movement issues I find along my journey through the massage even if they may not be directly related to the identified goals because often -guess what- they are or involved in some aspect of compensation that no longer is desirable.  You know--might as well pick up the clothes on the floor while on my way to do the dishes-as an example. I don't loose my focus though. If the client goal is less back aching then my massage stays on that path.  I won't go off path in another direction to work on something- only address issues I find along the way.  You can't do everything in one massage for goodness sake! Advanced massage is about know when to quit as well as when to do something.

 I do not use a bunch of " methods".  For example - I don't think in terms of lymph drain, myofascial release, trigger point, energy work, deep tissue and the hundreds of other approaches out there.  I think in terms of how can applying mechanical forces to the body support a more normal function. I have to really understand anatomy and physiology and pathology to function this way.  For example, if something is swollen I want to know why.  Swelling can be a really good thing ya know.  If something hurts I want to know why.  Pain can also be a really good thing, If however, there is too much of a good thing that is now a bad thing. I wonder what massage can do to tip the physiology back toward homeostasis. So, if an area is excessively swollen and if I understand the reason why it is swollen, I may attempt to mimic the normal action of the lymphatic system with a rhythmic pumping action. If tissue is dense and lacking pliability and it is causing problems I might attempt to soften it by kneading and rolling it.  You get the idea I hope.  While doing this I position the client's body so I can most easily get to the area I am working on and apply the forces (ie tension force, compression force, shear force) as easily and efficiently as possible. I am really efficient and seldom need more than 60 minutes to be effective.  Rarely is there a need for the 90 minute massage.

Occasionally the client will endure an uncomfortable sensation such as a burning pulling sensation as I pull on bound down scar tissue or a localized tender point that I might focus on with some inhibitory pressure but it isolated, focused directly on the goal, feels right and is familiar. It makes sense to the client.  Sometimes the client may be a little sore to the touch  in an isolated spot but it is important that the massage does not make the client sore to movement or painful and stiff in large areas.

 I do not use a lot of stretching during the massage.   My research indicates that there is often more potential for harm than benefit. Besides most problems that people stretch for are related to hyper mobile  joint function.  The limits in movement are the body's attempt to stabilize the joint.  I may use localized direct tissue stretching but I am not supportive a aggressive stretching methods.  Passive and active joint movement to asses ROM.- yes. Movement of a joint beyond physiological limits and to anatomical barriers--NO! I use simple muscle energy methods, usually contract relax antagonist contract, and then gently stretch only those areas with hypo-mobility and only look for an increase is 5 to 10 degrees. I mess with increasing the range over a series of sessions and remember the GOAL is the GOAL!  Functional flexibility- good but too loose in the joints- REALLY BAD.

Goals for massage outcomes can be clustered into four categories   Relaxation/pleasure--( really really important), stress management , functional mobility, and pain management.  Often there is overlap but the good news is that a really good general massage with moderate pressure will address relaxation, stress and pain issues.  Mobility goals require the little bit of specific work. Not gobs- just some.

Finally-to be advanced you need to really understand the body as a functioning whole- all the anatomy and physiology together- not just individual muscles. Relaxation, stress and pain goals are related to the nervous system and endocrine system for goodness sake.  To be advanced as a massage therapist you need to put in your time and be your own teacher while doing hundreds of massage sessions. It is important to learn from experienced massage therapists who do not rely on gimmicks and complicated stuff  and want to sell you stuff and most important have practiced massage for years and years.  And to be advanced you have to care about your clients.

I hope this series has been  helpful.

Thursday, October 25, 2012




 I have been posting these blogs about my feelings about the concept of ‘ADVANCED MASSAGE” an hope that they have made those reading evaluate how they work with clients as they gain experience from the actual  DOING OF MASSAGE.  I do massage and each massage teaches me.  There are however some factors that advance the teaching from just doing. When you are your own teacher then you are your student as well.  This is interesting.  I was teaching an entry level group of students that just started school and we introduce how to research for information with the main source being MedlinePlus and how to find and use research with the main source being Pubmed.  I don’t see research ability as an advanced skill but a basic skill.  They also had to fool around with a few case studies where the clients were complex yet they then figured out that the massage focused on general nonspecific massage with individual adaptations (previous post).   They did really well showing ability to critically think as well as problem solving skills that I believe are fundamental- not advanced.  I taught them how to look up reliable data and then apply that to each client.  We were discussing medications. There are thousands of them and if I can’t remember all that data how can anyone else.  I taught them to sit with the client – using MedlinePlus and look up there medications. Learn what the medication is for and what are possible side effects.  Then they had to problem solve about what might happen when various massage applications are introduced to the client’s body when the physiological effects of massage and the medication combine.  This is always an exercise in the educated guess.  Then we looked up a condition one of the students actually had experienced- breast cancer and using the information on MedlinePlus learned about the condition and treatments along with side effects.  Then we went to Pubmed to see what research existed to guide massage application.  Finally we came up with a treatment plan using the experiences of the student who had been treated for breast cancer. Some of the ideas we had developed she thought would work well for her and others she did not agree with.  Yup that’s what happens- come up with a great plan and then modify to serve the individual client. 


The students need to learn this process and do it over and over because ultimately then need to be their own teacher.  Maybe –just maybe- massage schools should be teaching students from the very beginning how to do this.  We become more “ADVANCED” or skilled with the increase in experience expecially if we learn about the situation for each client we serve. I am skilled working with athletes because I have worked with hundreds of them.  I am skilled with chronic pain conditions in all the various forms because I have worked with-and therefor learned from many clients with variety of chronic pain issues.  Each time I look stuff up.  Check for new research and continue to learn.  So now I have to research a condition so I am skilled as I work with my next client.

Wednesday, October 10, 2012


Figure this one out!


Popular in the world of advanced massage is the concept of targeted populations. This approach comes in the form of geriatric massage, prenatal massage, infant massage, oncology massage, sports massage, massage for fibromyalgia, massage for anxiety, and the list goes on and on.   I think this approach is more logical than method systems such as  the myriad of connective tissue methods or the huge variety of trigger point methods however in this day of massage confusion both fall short.

Previous posts in this series describe the fundamentals of massage therapy.   Massage is the skilled application of methods that introduce 5 basic mechanical forces into the soft tissue.  The effect of the mechanical forces is modified by direction, drag, location which includes where on the body and what tissue layer or depth and duration. 

Adaptation then involves choices and changes in the type and combination of mechanical forces introduced and the modification i.e. What direction, how much drag, where or where not to apply massage and so forth.  Adaptation also involve positioning of the client, where the client is located (hospital, home, office), alteration of the environment such as barrier free access, massage table, mat or chair etc.

Now we all know that every client is unique therefor a recipe approach to massage will not work.  For example geriatric massage: yes there is a commonality to the physiology of the aging process but each person ages in their own unique way.   There is great variety in those individuals with a cancer diagnosis, however there is commonality in the treatment.   There is commonality in joint replacement procedures however there is huge variety in those receiving a joint replacement.  There is actually a great deal of commonality in all forms of acute care but a huge variation in how to approach chronic conditions.

When an “advanced” massage therapist begins to work with any individual the history and assessment process determines, among other things, the process of adapting the massage to best achieve the determined outcomes in a safe way.

There are in the massage profession excellent educators who are teaching adaptive approaches to various populations- again examples include oncology, infant, sport and so forth.  What you get when you take their courses or read the books is the cumulative adaptive experience which in turn shortens your trial and error learning.  This is a good thing.  You can to some extent increase your individual level of experience by incorporating the cumulative experience of others.  However, even the very best teachers can only offer what they have learned and it will never be enough. 


So how do we do that?  I know a lot about a lot of different adaptive changes during massage.  Most I learned in the trial and error method.  That is what happens when you do many, many massage sessions over many years.  

I learned best when a client challenged me with a problem to solve.   I have learned a huge amount about knee injury for example because I have had many clients with knee injuries.  I have learned a lot about pain in all its many forms because I have had many clients that deal with pain.  And let’s not forget our own personal experiences and how they influence our learning.  A year ago I blew out my left knee-torn ACL, MCL, meniscus, quad. Ugh it was bad.  So I had an idea about what had occurred but still needed the doctors to perform the necessary tests to provide an accurate diagnosis.  I needed a brace and needed to going through the healing process.  I really get knee injury now in my gut as well as in my head.   I also had open heart surgery 6 years ago and that entire process was an invaluable learning experience as you can imagine.

When encountering a client needing adaption during the massage-(AND GUESS WHAT ALL CLIENTS NEED ADAPTATION)- they are your first and most important source of information and your greatest teacher.   Then you need to research. You need to learn about the anatomy, physiology pathology, and treatments including adverse effects of treatment.  You need to determine how the individual is manifesting the condition or responding to the circumstance.  You have to look up all the treatments and learn about them including surgery, medication, herbs, counseling, physical therapy and so forth.  You need to gather information about how massage has been used in the circumstance through research studies such as found on PubMed and those with extensive clinical experience.   YOU HAVE TO DO THIS.  You can take all the classes offered and read all the books and this is a good start but to be “ADVANCED” you have to do the work because your client is unique. 

You also have to adapt based on the limits of your own skills including body mechanics.  There are many different ways to apply a mechanical force to a specific location.   Begin with what you intent to accomplish and then experiment with how you can best perform the method for your most efficiency and clients comfort and benefit.   You can start by doing something the way the teacher does but you will have to modify how you do it somewhat because your body is different.


Massage is actually very basic and fundamental.  The ability to adapt is the mark of excellence.

Friday, September 21, 2012


 Two questions come to mind when I think about “advance massage”.


What is the goal of the massage?

Why is the body functioning the way it is?


One of my teacher’s years ago said.” Every behavior, physiology shift and anatomical change is an attempt at a solution.”

I consider this every time I approach a massage client. 

So for a simple example: A client has a grade one medial collateral ligament sprain in the sub-acute healing stage. 

Now if you do not know what this means you need to look it up.  It is impossible to do so called “advanced massage” if you do not have a handle on anatomy, physiology and pathology.   I think the best way to do this is to always look up any condition a client may have even if you think you know what it is. 

The client is complaining about her calf aching.   So my next thought is ,”What purpose does an aching calf have related to a knee sprain?”

Well, a sprain is a tear-which makes a hole-which has to knit together to heal.  A grade one is a little hole and sub-acute means the connective tissue repair is occurring but is a little fragile.  An aching calf would restrict movement so that the healing edges of the tear do not separate. Maybe the aching calf is a good solution right now.    Think I will leave it alone.   However, the change in how she is walking is making her hip sore.  Maybe massage could help to normalize the soft tissue changes occurring secondary to the primary injury and local protective response (aching calf).  Let’s check and see if there are some changes in the tissues around the hips and because of the gait reflexes that link hip movement with arm movement I think to also assess the shoulders.   Yup it is tender to moderate palpation in both places.  I ask if her neck been a little stiff since the IT band on the injured leg will also be involved in knee stabilization and that structure weaves into the glut soft tissue which weaves into the lumbar dorsal fascia and affects the resting length of the latissimus dorsi especially on the opposite side which alters position of the arm at the shoulder joint which then influences scapular movement resulting in trapezius and associated soft tissue shortening and since the upper trap attaches into the skull and scalp it would seem logical that she might have neck stiffness and even a headache.

In this case I think I will give her a really good full body massage, target areas that are logically part of compensation, gently mobilize soft tissue around the injured knee. Carefully massage the calf just to calm it down and manage some of the aching but not really change the muscle tone and then reevaluate the progression next session.   

So advanced massage is a way of thinking—not advanced methods.


What do you think?

Thursday, August 30, 2012



Assessment is a learned skill that collects and interprets information provided by the client, the client's consent advocates (parent or guardian), and the referring medical professionals, in addition to information gathered by the massage practitioner.* In reality, the assessment and the application of massage t are almost the same thing. Often massage manipulations and techniques are used during a massage first to evaluate the tissue; then, altered slightly in intensity, to support tissue-appropriate change; and finally to reassess for tissue changes.

Keep in mind that:

·         Assessment does not change a condition; rather, it is an attempt to understand it.

·         Interventions (e.g., massage applications) address the abnormal findings revealed by the assessment

Components of the Assessment

For the massage practitioner, the information gathered during a pre-massage assessment has four purposes:

           To determine whether the client should be referred to a medical professional

           To discover any cautions that would modify the massage application

           To obtain input from the client that is used to help develop the massage care/treatment plan

           To design the best massage for the client; specifically, the types of methods used and the mechanical forces generated by those methods, in addition to the proper application of depth of pressure, drag, direction, speed, rhythm, frequency, and duration of each method, to achieve the desired physiologic outcome.

Compensation Patterns

Compensation patterns are the result of the body's adjustment to some sort of dysfunction. Assessment identifies what is functioning normally, what is abnormal, and whether the abnormal condition is problematic (maladaptive), requiring attention, or is a resourceful and successful adaptive compensation. Patterns of resourceful compensation develop when the body has been required to adapt to some sort of trauma or repetitive use pattern. Permanent resourceful adaptive changes, although not as efficient as optimum functioning, are the best pattern the body can develop in response to an irreversible change in the system. Resourceful compensation must be supported, not eliminated, because determining whether the changes in the body are helpful or harmful can be difficult.

The history interview provides subjective information pertaining to the client’s health history, the reasons for massage, a history of the current condition, a history of past illness and health, and a history of any family illnesses that may be pertinent. It also contains an account of the client’s current health practices.  Information you need from the history includes but not limited to:

Surgery or medical procedures

Medications and supplements

Therapeutic exercise activities

Sleep patterns

Breathing patterns


Previous massage experience

Use of alternative therapies (essential oils, magnets)

What was the nature of the condition to be addressed? Some questions to ask include:

How much does it hurt?

Where does it hurt?

What is the nature of the pain——hot, pokey, sharp?

Does it hurt to the touch?

Does it hurt when you move?

What are the details of onset?

Did the condition arise suddenly or gradually?

Was there a specific injury?

Where is the location of the area? Show me.

What were the prior treatments——medication, surgery?

What was the outcome?

What diagnostic studies have been performed——radiography, magnetic resonance imaging?

What were the results?

What is the nature of the progress?
 Abbreviated Physical Assessment Protocol

Begin by viewing the client from three standing positions: front, back, and side. Note any areas of asymmetry. Then proceed according to the following outline.


Instruct the client to reach (they do not have to touch the toes) for the toes, keeping the knees straight.

Observe for:




Instruct the client to side-bend by sliding the hand down the side of the leg; compare the two sides.

Instruct the client to twist the torso left and right; compare the two sides.

Cervical Spine Range of Motion

Instruct the client to do the following:

     Look at ceiling (extension)

     Look at floor (flexion)

     Look over each shoulder (rotation)

     Bend the ear to each shoulder (abduction/lateral flexion)

Shoulder Range of Motion

Instruct the client to do the following:

     Scratch the back with each hand from over the shoulder (external rotation and abduction)

     Scratch the back with each hand from under the shoulder (internal rotation and adduction)

Muscle Tests—Instruct the client to do the following:

     Shrug the shoulders

     Flex the shoulders to 90 degrees

     Abduct the shoulders to 90 degrees

     Rotate each shoulder internally and externally

Upper Extremity Range of Motion

Instruct the client to do the following:

     Flex and extend the elbows

     Pronate and supinate the wrists with the arms at the sides and the elbows flexed to 90 degrees

     Spread the fingers

     Make a fist

Muscle Tests—Instruct the client to do the following:

     Flex and extend the elbows

     Pronate and supinate the wrists with the arms at the sides and the elbows flexed to 90 degrees

     Spread the fingers

     Make a fist

Lower Extremity—Hip Motion

Instruct the client to bend forward at the hip joints to touch the toes.

     Observe for hamstring shortening at the hip and the knee.

Instruct the client to do the following:

     Contract and relax the quadriceps; observe for symmetry

     Contract and relax the quadriceps; observe for patellar tracking


     Observe for knee effusion

     Observe for ankle effusion

Instruct the client to do the following:

     Rise up on toes; observe for calf strength

     Rise up on heels; observe for leg strength

Instruct the client to perform the one leg standing balance test:

     Have the client stand first on one foot and then on the other; compare the two sides and observe for balance and coordination

Instruct the client to perform the squat test:

     Have the client raise the arms over the head and then squat by pretending to sit down in a chair; observe for symmetry and reduced or excessive movement, core strength, hip, knee ankle flexion, hip adduction, shoulder abduction, and latissimus shortening

When performing the following assessments, remember that pain is the indication of a pathologic condition—do not cause an increase in pain; only locate the source of the pain.


1       Perform palpation on the uninvolved side first. The uninvolved area is “normal.”

2       Palpate all bony landmarks.

3       Palpate all ligament and tendon attachments.

4       Palpate all muscles that act on the area.

5       Palpate for edema and effusion.

Range of Motion

1       Perform active joint movement assessments to evaluate for changes in range of motion.

2       Perform a passive joint movement assessment and compare the range of motion to that seen with active movement assessment.

Manual Muscle Testing

1       Perform strength testing on the normal side.

2       Perform strength testing on the affected area. Do not cause additional pain or strain the injured area.

Intervention Guidelines

If the practitioner notes no pain, stiffness, mobility issues, or other concerns during the assessment, the joint can be considered normal. General massage for the jointed area is indicated to support normal function.

If the practitioner notes pain with movement or on palpation, discoloration, indications of inflammation, unusual stiffness, exaggerated hypermobility or hypomobility, weakness caution is indicated. If no logical cause exists for the finding (e.g., recent unusual activity or a fall) or if the client does not have pertinent information or is being treated by a physician, referral may be necessary to determine the cause. Once the cause has been identified, massage treatment plans can be developed.








Fritz. Mosby's Fundamentals of Therapeutic Massage, 5th Edition. Mosby,

*Although the massage professional observes, interprets, and makes decisions based on information gathered during assessment procedures, it is important to remember that the massage professional is not equipped to diagnose any specific medical condition or to treat one except under the direct supervision of a licensed medical professional.