Client Assessment – Intro to Client Assessment and Treatment Planning
Intro to Client Assessment and Treatment Planning
Introduction
The client assessment and treatment planning content area of the MBLEx Course covers the following topics in this section of the MBLEx:
- Organization of a massage or bodywork session
- Client consultation and evaluation. This includes written data collection, verbal intake and the use of a health history form
- Visual assessment, including general and postural assessment
- Palpation assessment
- Range of motion assessment
- Clinical reasoning for the massage therapist, including: ruling out contraindications, establishing treatment goals, evaluating a client’s response to treatment, and developing a treatment strategy
The lessons here focus on what an entry level massage therapist needs to know to start offering massage safely to the public. This is the same depth of knowledge that you will need for the MBLEx. You will also find some additional tips that will help you as you begin working as a professional massage therapist.
Purpose of the Client Assessment
A client assessment must be useful. It must serve a purpose. These purposes include:
- To understand the client’s current condition.
- To identify indications for massage, and determine if it is reasonable to assume that massage will benefit this client.
- To gather the information needed to guide client treatments and to establish treatment goals.
- To ensure that massage is safe for this client by ruling out contraindications.
*A client assessment is NOT to diagnose an illness or pathology.
Assessment is an ongoing process. It starts at a client’s initial visit, and continues as long as they are your client. It is important for the massage therapist to recognize abnormalities or changes in the client’s:
- Skin and underlying soft tissue
- Movement and posture
- Affect
Components of a Client Assessment
A client assessment is an evaluation of a client to determine if and how massage therapy can help this person. The components of a client assessment could include: discussion of the client’s current condition, movement analysis (ROM, gait, etc.), strength assessment, posture analysis, special tests, palpation assessment, or vital signs. Client assessment can be as quick as a few minutes, or over 15 minutes, depending on what assessments are needed. For example, a client that just wants a relaxation massage is not likely to need the same level of assessment detail as a client with a complex case who is seeking medical massage. In other words, the assessment should be practical.
A treatment plan is what outlines the interventions to be delivered during this massage session or over a series of sessions. This plan includes the treatment goals, or what the therapist and client hope to accomplish with this massage or bodywork intervention.
Components of a massage therapy assessment can include:
- Posture assessment is an observation and analysis of a person’s standing or sitting posture. The purpose is to identify musculoskeletal abnormalities that may be contributing to the client’s problem (pain, movement dysfunction, etc.). Understanding posture deficits can help the therapist to develop a treatment plan.
- Gait assessment is observing and analyzing the way a person walks or runs in order to discover abnormal or inefficient movement. The purpose is the same as why we would perform a posture assessment, which is to better understand the client’s current condition and to identify problems that can be addressed in the treatment plan.
- Visual assessment is a method of gathering data during a client assessment. It involves observation of the client’s posture, movement, symmetry, skin condition, and body language.
- Palpation assessment is a physical examination that involves gathering assessment data through touch. A palpation assessment can provide information about the client’s soft tissue tone, pliability, temperature, texture, restrictions and elasticity. The therapist uses his or her hands to assess these soft tissue qualities.
- ROM assessment is an examination of the client’s range of motion. The purpose is to identify any restrictions that need to be addressed in the treatment plan.
- Special tests are physical tests that help to rule in or rule out specific musculoskeletal conditions. They help in determining which structures may be contributing to the client’s problem. For example, the Thomas test can indicate restriction in the hip flexors.
Signs can be observed by other people, such as the therapist performing an assessment (with or without a tool such as a blood pressure cuff or thermometer). *Signs are objective data. Examples of signs are decreased ROM, muscle atrophy, elevated blood pressure, or abnormal posture.
Symptoms are felt by the patient/client only. *Symptoms are subjective data. Examples include pain, fatigue, anxiety, depression, nausea, and dizziness.
*A client assessment should occur in the following order:
- Client interview
- Visual assessment
- Palpation assessment
The reason palpation is last is because you may discover something during the client interview or the visual assessment that informs you that you should not proceed with a palpation assessment. For example, you may learn that the client has a contagious skin condition or other contraindication. It is also a natural and customary order to talk with someone first, before palpating them.
Types of Assessment Data
Subjective data is information that is reported by the client. This is often a feeling, opinion or interpretation of something. Symptoms and reported client history types of subjective data. An example is if a client says, “I feel cold” or “It’s cold”.
Objective information can be detected by someone else and is verifiable. An example is “It is 62 degrees in this room”.
Written data is useful and relevant information that is written down (on paper or electronically). Written data is important for the massage therapist because it serves as a reference to measure progress towards a treatment goal.
Visual data is data that has been visually observed. Posture and gait assessment produce visual data.
Palpation is a method of gathering tactile information through touch. Palpation can reveal information about the client’s body that is not visually apparent. For example, palpation can provide information about skin texture, muscle tone, fascial restrictions, identification of trigger points, pitting edema, etc.
Auditory simply means receiving information through listening. The information that the client tells you regarding their needs, the onset and progression of any current symptoms, and their expectations for massage therapy is valuable information and should be considered when forming a treatment plan.
Smell (olfactory) is a less common but potentially useful method of client assessment data collection. Nurses are trained to stay observant for certain odors that can alert them to potential problems. For example, the clinician might notice that the client smells of alcohol, or that an infection if present.