Features Continuing Education Education
Essentials of Assessment: Fall 2002

Massage therapists do not belong to a diagnosing profession. But many of us feel that the line between diagnosis and assessment is a rather fuzzy one. Unless we want to rely on other health care professionals to tell us what is wrong with our clients we need to map out the difference between diagnosis and assessment and have a firm understanding of the relationship between assessment, treatment planning and treatment outcomes.  We want to see assessment as something that stands beside diagnosis not as something that stands beneath diagnosis.

Linguistically, diagnosis is a Greek word meaning ‘through knowing,’ while assessment is a Latin word meaning ‘to establish an amount.’ Sadly, these are the two best definitions that I could find. Usually diagnosis refers to finding the cause of a pathology. Assessment usually refers to measuring abilities and impairments. Normally one would see assessment as a necessary step preceding diagnosis.  The diagnosis is the name given to the complete abilities and impairments picture.

The new language of “impairments” and “outcomes” that is being brought into massage therapy to replace the earlier focus on conditions & syndromes, aims of treatment, and prognosis is a very appropriate change¹.

Establishing impairments implies that we have measured or mapped out functions: range of motion, levels of discomfort or pain, etc. But we can do more than this. Some of our “Special Tests” imply that we are establishing causes for the client’s restrictions, dysfunctions, and/or pain. This is the grey area, and it may well mean that as a profession we can argue that we are competent to diagnose some soft tissue injuries or dysfunctions. After all, a diagnosis would really be just adding a name that describes the functions and impairments that we have already mapped out.

Though we do tests for carpal tunnel and the like we need to understand that at present these are done as screening tests to either confirm a diagnosis that a client comes with, or establish a reason for a referral to their physician or other diagnosing professional. 

Even when clients come to us with a diagnosis it isn’t always helpful. Some diagnoses are vague or do not give us the whole picture.

We need to do our own testing to establish the impairments that are specific to our client, and then on that basis we can proceed to establish outcomes that we can present to our client so that they can be informed about the aims of treatment and reasonable treatment goals. A well-structured assessment procedure can provide this.

Too often the cause of the client’s pain or discomfort is never found. The cause of low back pain, for example, is identified in only 10 to 20 per cent of patients². 

If we always need to know the cause of the client’s pain prior to treating the client, we would often find ourselves with nothing to do.

We can assess the client’s impairments and work on the outcomes that are related to those impairments, with or without a diagnosis. Ideally we would love to address the cause, but realistically the cause is not always discernable. We can still hope to address many of the symptoms and help the client. Even if the cause remains elusive our assessment skills can provide us with a list of impairments that we may be able to address across a spectrum of outcomes: resolution of the dysfunction or pain, improvement of function, maintenance of function, slowed progression of chronic symptoms, and management of pain. We aren’t just band-aiding symptoms we are directly addressing impairments.

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. This map in turn allows us to chart, with our client, the course of actions we will take, and so address the outcomes we hope to achieve through our course of treatments.

Many massage therapists feel that they are only treating symptoms if they can not 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. Further, as we deal with impairments like pain and/or restriction of motion then the underlying causes may become more apparent. 

An Assessment Protocol
Many of us feel the client would rather have an hour of massage treatment than 10 minutes of assessment and only 50 minutes on the table. Let’s face it; the client would rather have 50 minutes of planned treatment that really addresses their complaint than 60 minutes of treatment that merely feels good. The following eight steps can take as little as 10 minutes.

1. Client intake: Active Listening is our most important skill here. Giving the client the time to have their say, and repeating back to them what we have heard them say so that there is no misunderstanding. Most health care professionals agree that it is at this stage of assessment that 90 per cent of what we will need to know to help the client happens. We need the patience to let the client describe their symptoms in their own terms.

2. If any physical testing is appropriate, the client needs to be informed about what is to happen. Address client concerns, answer client questions and get consent before proceeding.

3. Observations begin when you greet the client and continue through the intake process. You continue to observe through the treatment and will continue until you see the client out the door. None the less at times we may wish to do a ‘formal’ postural assessment. This should be done before any manual testing which might cause discomfort or pain. We may wish to palpate the area of complaint, but should do so in a cursory manner and not probe for the lesion site, other wise we may cause pain or apprehension that will interfere with our manual testing.

4. Rule-Outs: Although we are told in school about how other structures above and below the effected area may be referring pain to the area of the client’s chief complaint, we are often not told how they can be ruled out. Hence pain felt at the elbow may in fact be caused by dysfunction from the shoulder, or from the wrist3. The basic rule of thumb for ruling out the joint above or below the area you are going to investigate is to have the client do active free movements of those joints. When a movement is pain free, then apply overpressure. If these ‘rule-outs’ of the joints above and below recreate the client’s chief complaint then that joint and surrounding tissue needs to be investigated more fully, along with the original area of complaint.

Range of Motion: The usual order for assessment is active ROM first, then passive ROM, followed by resisted ROM4. This order is changed, however, if you suspect joint involvement.

If any preceding assessment information lead us to suspect that the joint is involved then we would change the order to active, resisted and then passive. Follow the rule of doing the most painful test last whenever possible.

At this point we should have mapped out the ranges of movement that are impaired and noted and inquired about pain or discomfort etc. (Weakness without pain signals a ‘red flag’ for neurological involvement5. Also at this point we should have some idea about ‘what is going on.’

We may be ready to provide our assessment to the client at this point (see point #8). Or if we are suspicious of specific structures for which there are special or differential manual tests we can proceed to do those as “special tests.”

6. Special Tests: Here is where we can, when appropriate or called for, do differential muscle testing. We can do tests that test specific soft tissue (e.g. like McMurry’s meniscus test for the menisci of the knee) and perform appropriate neurological tests or scans.

7. Once all range of motion testing and special tests are completed then we may choose to palpate the lesion site proper. We should again begin with a light palpation to re-test for any changes to temperature that testing may have caused and for changes in edema. Then we can proceed, with the client’s permission, to palpate deeper to note the texture of the subcutaneous tissue, and possibly to palpate the lesion site itself if this is possible.

8. Assessment and Treatment Plan: Again, many of the orthopaedic special tests will result in referring a client out to get a “confirming diagnosis” for our “suspicions” of causes or pathologies that our testing implies. But we may proceed to work with the impairments found if no contraindications for treatment are apparent. If we remain within the impairment-model we can then proceed to establish outcomes that seem reasonable to achieve in light of our assessment and its findings. Having presented these outcomes or options to the client we can then arrive at a mutually agreed upon plan of treatment.

The above represents to me an outline or protocol to follow when conducting an assessment, though we don’t need to do it all in one visit.  When a client presents with an injury or dysfunction we always need to explore this by “taking a case history” specific to their complaint, and do at least some brief observations, a little “inspection palpation” if called for prior to treatment, some rule-outs, and then map out their range of motion as best as is possible depending on the acuity of their injury or impairment. All of these can take as little as five minutes or so. 

Post-treatment, we can see what we have accomplished (and have the client see as well) by re-testing effected ranges and asking the client “how does it feel now?” It’s important to mention that you might do some more testing next appointment and ask the client to keep a mental note of their progress until then. 

While writing up treatment notes use all of that information that you found during treatment, including the client’s response to treatment to re-evaluate the client’s condition. I often think of a few areas that I would like to explore through questioning or testing the next time I see them. 

Even if no ultimate cause for the client’s condition is found, addressing specific impairments and having an impact on those impairments gives the client reassurance that they are moving forward. Re-testing gives the client an opportunity to measure that improvement. A diagnosis may give the client the reassurance of a name to attach to their condition, but a diagnosis may also mean that the client becomes a “disease process” instead of an individual.

A diagnosis cannot really give you the information that you need to provide measurable help to your specific client. An effective assessment can lead to the selection of client-specific techniques that result in positive client outcomes. Assessment really is a way to value the client.

References

1. For an excellent explanation of “impairments,” establishing a client’s impairments and how to arrive at appropriate outcomes for treatment see Outcome-Based Massage by Carla-Krystin Andrade & Paul Clifford.
2. See  Management of Common Muscluloskeletal Disorders 3rd Ed. by Darlene Hertling and Randolph Kessler,  p. 638; see also p. 643
3. I am indebted to Geoff Harrison (C.)A.T., R.M.T. for information about this.  As an Athletic Therapist and  co-instructor  in my first forays into teaching clinical assessment, he lead me to an invaluable source for rule-outs:  See Ann Hartley’s Practical Joint Assessment –Upper Quadrant and Practical Joint Assessment – Lower Quadrant 2nd Ed., 1995.
4. Of course, if the client lacks the ability to move the limb then we may be involved with active assisted etc.  But we will leave that aside for now for brevity.
5. Weakness without pain may imply a rupture of muscle or ligament and that specific structure may be pain-free, but the amount of swelling etc. and compensatory splinting of the area will not be without discomfort, to say the least.

David A. Zulak has been teaching clinical assessment since 1995. Presently, he is the director of massage therapy for an Ontario private vocational school that has several campuses. He is co-ordinator for the Hamilton campus and, of course, teaches assessment.