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A standard approach to the treatment of soft tissue conditions or injury has been presented within Canadian Massage Therapy programs. This area is known as “Treatments” or “Clinical Approach.”


September 22, 2009
By Jill Rogers RMT & David Zulak MA RMT

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A standard approach to the treatment of soft tissue conditions or injury has been presented within Canadian Massage Therapy programs. This area is known as “Treatments” or “Clinical Approach.”

Prior to the initiation of “Treatments” students traditionally study massage theory, techniques, pathophysiology, anatomy and assessments skills.

Students are presented with a list of conditions or injuries to be covered, along with the written approach that will best suit that condition.

Assessment, massage, hydrotherapy, remedial exercise and other specific modalities are applied to each condition in a recipe-like fashion.

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There is a potential for students to become dependent upon this pre-made approach. There is also a built-in risk of retention loss soon after the examination process. All educators and students alike understand the toll that ingesting large volumes of information takes on the human system. 

The “clear and present danger”  with the “suggested treatment approach” method is, that once regurgitated, students lose the memorized material at a most alarming rate. As years of clinical practise pass, MTs would have to ask themselves, if they are clear in their treatment approach with their clients.

The “problem-based approach to treatment” model promotes self-discovered treatment planning rather than the retention of pre-determined treatment approaches.

The following are the levels and categories of thinking, or cognitive operation, delineated in Bloom’s taxonomy AND what type of ability is associated with each.

Level I – Simple, or basic:

Expected level of operation upon the completion of
high school.

  • Knowledge: aggregate of facts pertaining to an area of study which one is able to repeat.
  • Understanding: ability to explain the meaning of a fact, or body of knowledge; being conversant in a given area of knowledge, and using the information to solve simple problems.
  • Application: ability to take what is known in one area and use it in another context; ability to use learned skills in a new context.

Level II – Complex or advanced:
Intelligent level of functioning requiring multi-faceted operations; typical expectation in post-secondary
education.

  • Analysis: process of separating an entity (concrete or abstract) into constituent elements (categorizing); used as a method for studying an entity (e.g. case study); its parts, and their relation to one another; required for complex problem solving.
  • Evaluation: act of appraising, assessing, diagnosing, judging a situation / entity, and forming conclusions about it.
  • Synthesis: the process of creating something new from known components; opposite of analysis.

It is this advanced level of cognition that is required throughout the problem-based model of treatment approach and subsequently accompanies the therapist into the practicing profession.

One group of students at Career Canada College, Hamilton Ontario campus, have completed a full module of “Problem-based treatments”. Instructor Jill Rogers and program developer / coordinator David Zulak set in motion this new approach to treatment protocol learning.

“Outcome based massage,” a text written by Paul Clifford RMT was a useful tool in the creation of
language and intent for this new module.

The Concept

Students are presented with a list of medical conditions or client presentations. By the end of the course these students have created, as a group, their very own manual of approach to treatments. As well, students have developed a method of critical thinking that will serve them throughout their career as massage therapists.

When faced with difficult client conditions I continually found myself reverting back to the most fundamental concepts of massage:

  1. What tissue is impaired
  2. What outcome does this tissue require
  3. What technique/modality will accomplish that outcome.

This thought process may sound so basic it borders on insulting, however, it is this way of thinking that maintains focus, causes one to re-assess, and reveals whether massage therapy, in fact, is the indicated modality required.

 A Look Back
I graduated from my MT program in 1988. At that time there was limited
resources as to treatment approach. In fact, until the works of Fiona
Rattray (An Approach to Treatments) was published, treatment protocol
was a collaboration of instructors notes and experience.

As thorough as they might have been, I felt ongoing client care
involved both trial and error and research on my part. It was this
self-motivation that gave me confidence in treatment when presented
with
conditions unfamiliar to me or possibly newly
discovered following my schooling. For example; Fibromyalgia and Chronic Fatigue Syndrome. 

Remember, “Do no harm.” It is our responsibility to ascertain whether an underlying pathological process exists that may be out of the MT’s scope of practise.

This basic conceptual thinking and decision-making process trains students to think for themselves, and confidently treat beyond a pre-programmed protocol.

As stated in David Zulak’s article, Essentials of Assessment, which appeared in the Fall 2002 issue of Massage Therapy Canada magazine:

– We can say that an orderly assessment procedure allows us to establish the impairment(s) a client suffers from, whether that is loss of movement, loss of strength, the experience of pain or discomfort etc. Some conditions we can interpret as “impairments”: after all what is tendonitis but a descriptive term? Such descriptive terms only serve to imply a collection of signs and symptoms. Our own assessment lets us do the measurements that allow us to draw up a map of what ails our client, course of actions we will take, and so address the outcome we hope to achieve through our course of treatments.

Many therapists feel that they are only treating symptoms if they cannot find a cause for their client’s complaint. But if we look at each symptom as an” impairment” that we can address, then we will be taking a more positive approach to our work.

Furthermore, as we deal with impairments like pain and/or restriction of motion, then the underlying causes may become more apparent.

The Creation of the Student Treatment Manual
Areas studied do not vary from the traditional treatment class. What does differ is the method by which the student processes these areas. In review these are: Case history taking; Consent to assess; Assessment; Treatment plan development; Consent to treat; Treatment; Homecare

In the introductory phase of the module, students are
presented with tissue manifestations (which double as impairments) to create treatment plans for. i.e. bruising,
or swelling. This allows students to initially work through the concept easily. Students are arranged (by the instructor) into groups of, ideally, four. Groups are rotated every few weeks to ensure maximum benefit to each student.

Students organize themselves and divide the areas, of the report to be completed, among the group members.

Group members must work on different areas the next time a report is started. For the introductory classes, students present their reports to the rest of the class for discussion and benefit of all.

It is required that reports are completed and typed to be handed in for the next class. Instructors photocopy reports for all students in and out of that group.

Each group is given the same condition or injury; however, they will create their treatment approach report based on varying stages (acute, sub-acute or chronic) and severity (mild, moderate and severe) of the condition. This will ensure (once shared with other groups) that many considerations to treatment are covered for that condition.

Throughout the treatment class schedule, instructors provide practical time in which to carry out the treatment plans. It is imperative that students work from the reports of other groups as well as their own. This ensures greater experience, report legibility and thoroughness. 

Steps include:
1. Research condition or impairments
Students are required to use massage-related pathology and physiology notes and texts as well as medical texts and the internet to create a clear and commonly agreed upon description. Included in the description is: common groups affected; common pre-disposing factors or causes; as well as common associated conditions (compensatory tissues and systems).

2. Case History Creation
Students create a supportive client description and case history form. Those responsible for the case history creation must include a minimum of 10 crucial questions with answers (pertaining to the condition) that a therapist should pose in the information gathering stage.

3. Listed Impairments
A list of the impairments expected with the assigned condition. For example; swelling, pain, decreased range of motion or strength etc …

4. Documentation of Supporting Assessment

Students list range of motion (active and passive) resisted muscle testing, differential muscle testing, neurological and special orthopedic tests that support the assigned condition. Expected positive findings are only listed. This stage re-inforces potential expected assessment results.

5. Treatment Goals / Outcomes, Plan and Methods
Assigned group members list short and long-term goals with associated specific modalities to be applied in order to achieve the goals. Regional breakdown, time per area (effected and compensatory) is included within this section. The following is an example.

Short-term goal        Modality
Reduce swelling        lymphatic drainage and cool    
                               hydrotherapy application

Long term goal          Modality
Eliminate swelling
lymphatic drainage – active
                               exercise and stretch           
                             – vascular flush

6. Expected Re-Assessment

Students identify and list tests performed prior to treatment that would best indicate, if repeated, improvement or worsening of the chief complaint (an impairment), as a result of the treatment just performed. For example; Increase in active left knee flexion by approximately 10 per cent following treatment.

7. Home Care Program Creation
Assigned students within the group develop a short and long – term remedial exercise, hydrotherapy and client activity adaptation program. This should be best suited to involve their specific client in their road to recovery.

8. Treatment Frequency Plan
Listed in this section is short- and long-term treatment frequency, with and without client participation. This area should also include a reassessment schedule.

The old adage “education is a life-long journey” is very true, particularly with regards to ensuring safe and effective health care. Whether you are a recent graduate, or therapist of many years, the treatment approach concept described in this article may serve to give you direction for continuing education self-study, confirmation of skills presently employed, or a fresh method of enhancing your hands-on health care.


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