ADVANCED MASSAGE DEPENDS ON ASSESSMENT NOT METHODS

CLINICAL REASONING

 

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.

HISTORY-

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

Mood

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.

Back

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

Observe for:

•     Scoliosis

•     Kyphosis

•     Asymmetry

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

Next:

•     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.

Palpation

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.

 

FINIAL IMPORTANT NOTE:

EFFECTIVE HISTORY ASSESSMENT REQUIRES COMMUNICATION SKILLS

EFFECTIVE PHYICAL ASSESSMENT REQUIRES THAT YOU KNOW YOUR ANATOMY AND PHYSIOLOGY INSIDE OUT.

BIGGESTPROBLEMS I SEE IN ASSESSMENT PROCEEDURES IS ---GUESS WHAT?

COMMUNICATION SKILLS, ANATOMY AND PHYIOLOGY KNOWEDGE AND CLINICAL REASONING ABILITY.

 

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.

Mechanical Forces

 

 

 

 

Application of mechanical forces during massage.  A, Compression. B, Tension. C, Bending. D, Shear. E, Torsion. F, Combined loading: compression + tension. G, Combined loading: tension + bend + torsion. H, Combined loading: compression + bend + torsion.

From Fritz: Clinical Massage in the Healthcare

 

In this second post in the series  about Advanced Massage we will explore what massage methods do to the body tissues.  At the foundational base massage introduces mechanical forces into the tissues and then the body needs to figure out how to respond to the force .  All massage methods regardless of name can be described by the mechanical forces introduced and how the application is modified by when it is applied, how long, what speed, what direction, the depth of pressure, etc.  I suggest you get some modeling clay and observe what occurs when you apply the mechanical forces.  Does the clay get warmer,  colder, stretchy, longer, shorter, etc.

Actions that involve pushing, pulling, friction, or sudden loading (e.g., a direct blow) are examples of mechanical force. Mechanical forces can act on the body in a variety of ways. The different types of mechanical force and the ways they are applied therapeutically are important aspects of massage.

The five kinds of force that can affect body tissues are compression, tension, bending, shear, and torsion. Not all tissue is affected the same way by each type of force. We will look at each of the five types of force, the different ways they can cause tissue injuries, and the ways they produce important therapeutic benefits when applied by a skilled massage practitioner.

 

Compression

Compressive forces occur when two structures are pressed together. Compressive force is a component of massage application and is described as depth of pressure. This kind of force may be sudden and strong, as with a direct blow (percussion), or it may be slow and gradual, as with gliding strokes. The magnitude and duration of the force are important in determining the outcome of the application of compression .

Some tissues are quite resilient to compressive forces, and others are more susceptible. Nerve tissue is an interesting example. Nerve tissue can withstand a moderately strong compressive force if the force does not last long (e.g., a sudden blow to the back of your elbow that hits your “funny bone”). However, even slight force applied for a long time, as occurs with carpal tunnel syndrome, can cause severe nerve damage. The practitioner must take this into account when determining the duration of a massage application that involves compression over nerves. Compressive force should not be maintained on a specific area for extended periods during massage. Generally, a compressive force need not be sustained for longer than 15 seconds to achieve results.

 

Ligaments and tendons are quite sturdy and resistant to strong compressive loads. Muscle tissue, on the other hand, with its extensive vascular structure, is not as resistant to compressive forces. Excess compressive force can rupture or tear muscle tissue, causing bruising and connective tissue damage. This is a concern when pressure is applied to deeper layers of tissue. To prevent tissue damage, the practitioner must distribute the compressive force of massage over a broad contact area on the body; the more compressive force used, the broader the base of contact with the tissue.

Compressive force is used therapeutically to affect circulation, sensory and autonomic nerve stimulation, nerve chemicals, and connective tissue pliability.

 

 Tension

Tension forces (also called tensile forces) occur when two ends of a structure are pulled in opposite directions. This is different from muscle tension. Muscle tension is created by excess muscular contraction, which results from an increase in motor tone or an increase in tissue density caused by fluid accumulation and connective tissue changes (muscle tone). Muscles that are long as a result of being pulled apart are affected by tensile force. Certain tissues, such as bone, are highly resistant to tensile forces. An extreme amount of force is required to break or damage a bone by pulling its two ends apart. Soft tissues, on the other hand, are very susceptible to tension injuries. In fact, tensile stress injuries are the most common soft tissue injuries. Such injuries include muscle strains, ligament sprains, tendinitis, fascial pulling or tearing, and nerve traction injuries (i.e., sudden stretching of nerves, such as occurs in whiplash).

Tension force is used during massage with applications that drag, glide, lengthen, and stretch tissue to elongate connective tissues and lengthen short muscles .

 

Bending

Bending forces are a combination of compression and tension. One side of a structure is exposed to compressive forces as the other side is exposed to tensile forces. Bending occurs during many massage applications. Force is applied across the fiber or across the direction of the muscles, tendons or ligaments, and fascial sheaths. Bending forces rarely damage soft tissues; however, they are a common cause of bone fractures. Bending force is very effective in increasing connective tissue pliability and affecting proprioceptors in the tendons and belly of muscles.

 Shear

Shear is a sliding force, and significant friction often is created between the structures that slide against each other. The massage method of friction uses shear forces to generate physiologic change by increasing connective tissue pliability and creating therapeutic inflammation. However, excess friction (shearing force) may produce an inflammatory irritation that causes many soft tissue problems .

 

Torsion

 

Torsion forces are best understood as twisting forces. Massage methods that use kneading introduce torsion forces and target connective tissue changes and fluid movement.

Application of torsion force to a single soft tissue structure is not very common and is rarely the cause of significant tissue injury. Torsion force applied to a group of structures (e.g., a joint) is much more likely to be the cause of significant injury. For example, when the foot is on the floor and the individual turns the body, the knee as a whole is exposed to significant torsion force .

 

Massage Manipulations and Techniques (Mode of Application)

The methods of massage introduce one or a combination of the five types of mechanical force into the body to achieve a therapeutic benefit .  As mentioned, this process is influenced by the quality of touch, depth of pressure, drag, duration, speed, rhythm, and frequency. Appropriate use of mechanical force is necessary. If insufficient force or the wrong type of mechanical force is used, the application will not be effective; conversely, excessive or inappropriate use of force can damage tissues.

 

The variety of massage and bodywork modalities in the profession  can be clarified by describing what is done during the application, using qualities of touch, mechanical forces, and mode of application. For example, the method called active release is compression applied by the massage therapist and tension force that occurs as the client moves the area.  

A trained massage therapist should be able to modify the massage application from surface to deep, fast to slow, and long to short, as appropriate, based on the client's individual needs. The intention and outcome of the massage application appropriately influence fluid movement, nervous system function, musculoskeletal function, and connective tissue pliability in both acute and chronic conditions. Our attention to the client is based on an intent to serve our clients in a focused and compassionate manner.

Advanced massage is skillful use of the basics.  

 

Simply Advanced

Fundamentals of Therapeutic Massage 5^th ed by Sandy Fritz

I am going to begin a series of blogs about how to simplify the concept of ADVANCED massage application.  There is so much confusion about  methods considered advanced i.e.  orthopedic or deep tissue or myofascial, or neuromuscular or lymphatic  etc, etc. etc.   There are a trillion ( well maybe not that many) names out there being marketed as advanced massage and under the umbrella of continuing education . This is confusing because if a massage method is going to work then it must be tied to anatomy and physiology or location and function.  Naming of methods adds to confusion and I suggest that any naming should describe how the method interacts with the location and function.

My definition of advanced massage application: Skilled, experienced use of the fundamentals  to  achieve desired outcomes.  

A foundational problem occurs when the fundamentals of massage are lacking and unfortunately I believe this is a common problem in education especially at entry level—but that is another topic.  Another major problem is experience.  Most entry level massage programs will provide a clinic of some type and student may due 50 massage sessions and then they graduate and are expected to perform at a professional level that the general public is going to pay for?  I think this is ludicrous.   If  believe a person needs to do 1000 massage sessions before they even grasp the concept of therapeutic massage within and entry level framework..  If I ran the world a person would be required to complete this level of experience before being allowed licensure and certainly before beginning any sort of advance training.

We also have to consider the validity of the  advanced methods.  This begins with the correct anatomy and physiology of the methods target. For example: lymphatic drainage or myofascial release.   There should also be a research search to determine the level of evidence for the support of the benefit of the method or does the method do what it says it does.   There are many types of valid evidence from high level met analysis of research studies to expert opinion.  Right now the amount of high level evidence for just about all massage methods is scant so beware of unrealistic claims made by those teaching “advanced “ massage methods.  Any of us that teach need to be honest about the claims for benefit we make. It is ok to say that there is no research evidence or to indicate that expected benefits are antidotal.  It is not ok to make claims that are inaccurate.

 I typically consolidate benefits that cluster around relaxation and pleasure based benefit,  stress/mood management, pain management,  mobility management.

Relaxation and pleasure benefit is likely the most important benefit of massage. I can get frustrated when this type of massage outcome is seen as insignificant when I think it is the most significant outcome of all and massage application should have this approach as a primary focus.  The massage approach is what Dr. Leon Chaitow calls –constitution- meaning general and non specific.  The massage approach typically is what is thought of as the Classical / Swedish style.  Unfortunately this type of massage is often taught and applied in a routine and in a mindless “paint by number or follow the dots” approach when it should be the foundation for massage therapy.   The massage application is rhythmic, full body, nonspecific,  broad based medium  pressure, non-painful, involves rhythmic but passive joint movement and  provided by a caring, nurturing and empathetic massage professional in a safe environment, .  The primary physiology targeted is the autonomic nervous system.  In my mind the biggest application mistake for this approach is too light or too deep of a pressure.  If we visualize the anatomy as a sandwich- with the bone as one slice of bread and the skin/superficial fascia as the other piece of bread with the muscle based soft tissue as the filling, then the depth of pressure is through the top layer of bread and just into the filling.  

I strongly believe that this type of massage application is lost in all the “fancy stuff” when true advanced massage application is based on this foundation.  This massage application is the main avenue for palpation and joint assessment.  As the soft tissues are moved in a variety of directions and each joint is also moved, the areas of tissue changes and altered range of motion are identified.   It is also my belief that this is the massage application skill set that must be perfected in entry level massage training.

The next topic in the subject will be assessment since “advanced work” is often considered application to address dysfunction.  You cannot understand dysfunction until you understand function.  I am speaking of a solid, functional understanding of anatomy and physiology normal function.   I think initially in education we focus too much of pathology without cultivating a strong knowledge of normal body function.  Our anatomy and physiology is marvelous and a cornerstone of professional practice in massage. 

More to come.  I welcome your comments.