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Essentials of Assessment: Spring 2005

One of the most common comments and concerns I get from MTs when teaching an impairment assessment protocol, centres around the notion that the patient would not be accepting of having their massage or treatment shortened by the therapist taking up time to do more than one or too specific tests.

September 29, 2009  By David A. Zulak MA RMT

One of the most common comments and concerns I get from MTs when teaching an impairment assessment protocol, centres around the notion that the patient would not be accepting of having their massage or treatment shortened by the therapist taking up time to do more than one or too specific tests.

There is an all too common assumption by MTs that the patient is in a hurry to get on the table and get “their massage.”

This in itself points to the tendency for many schools, and hence their graduates (myself included), to refer to the people that we work with as clients and not patients. 

This is sometimes done purposefully in order to equalize the relationship between the therapist and those they treat; to equalize the power balance that many instructors in the ’70s and ’80s felt was inherent in medical relationships.


eoa1.jpgThis somewhat pop-psychological view has done much good in having therapists empower their patients. It can, however, also lead some therapists to hide or undervalue their training.

No matter what word is used, any medical professional, of any kind, can be arrogant enough to think that they heal their patients. Or, any medical professional can be humble enough, and feel grateful to be present, and to be a facilitator with the patient as the patient heals from within.

I try to use the term patient because it helps me to remember that I am taking on a great responsibility. That my training and skills require me to remember that the trust and confidence patients place in me, to help them with their healing, is a gift.

I do not see us as equal in the treatment setting, as I see myself as a servant. When my patients thank me, at the end of a treatment, I have a habit of replying with “and thank you for letting me be of help.” The word “Client” sounds too commercial for me.

Returning to the point; concerning the source of the assumption that a patient will be upset or ‘difficult’ if they do not get on the table right away. This seems to stem from MT students’ experiences in their educational Public Clinics:

1) Students often start off by giving mostly relaxation based massage and become reluctant to change or alter their routine approach, even as they learn more assessment skills along the way, and 2) Patients of a school’s public clinic also “learn” or come to expect that a full hour on the table will take place after an obligatory and perfunctory case history taking. 

These two expectations also become self-fulfilling by students feeling the “pressure” from the patient “to get on with it.” Though, more often than not this is merely the student’s fear and lack of confidence projected out onto the patient. This pattern is then often carried over into their practices upon graduation.

On the other hand, those therapists who do take their time with patients who suffer from impairments, by taking a thorough case history and doing an exploratory assessment, usually discover that the patient is more than happy to find that there is someone out there in the health care field who is willing to take the time to listen. Not being “listened to” is one of the biggest complaints I hear from patients about their experience with the health care system.

A thorough case history taking that includes the patient’s medical history shows the patient that the therapist is a health care professional in their own right. The skill level along with the knowledge base of the profession is revealed.

Though some in the massage therapy profession do not like the term “medical massage,” for the patient, it would convey that the therapist has undergone in-depth training. In this situation the patient is not surprised by the length of time it takes to become a massage therapist.

When the initial and subsequent assessments are brief (if they happen at all), the patient is usually surprised to learn that the therapist spent 2200+ hours being trained.

Patients are not just appreciative about being listened to: the patient who has an injury or dysfunction is further relieved there is someone willing to take the time to explore (i.e., assess) their problem, and especially when the therapist in turn informs (educates) them of what is found or not found. I can not count the number of times a patient has told me that no one had ever done any actual hands on testing (the usual complaint), or at best, had only the most cursory of examinations.

The time taken to listen to the patient, which includes ‘listening’ to their body, in itself can be a great comfort for the patient. If you skip this step, the patient will inevitably feel that they are not being taken a) seriously, b) are not being seen as an individual, and c) will come to question the effectiveness of the therapy.

The more a massage therapist displays the breadth of their training and skills, the more confidence the patient will have in them.

Without this level of trust and confidence, therapists are only impairing their effectiveness; they are short-changing the patient by leaving the patient ignorant of the therapist’s scope of practice, ignorant of the numerous ways that the therapist can help, and unappreciative of the various levels we can be  affecting, (somatic/physical, physiological, emotional, spiritual).

With respect to educating the patient about their condition; many times patients have thanked me for explaining what was going on. There is nothing more fearful for a person than not knowing and not understanding what is happening to them. Although verbal explanation is very important, I feel that actions speak just as loud. It is imperative to show and explain what and why tests are being performed, as well as their outcome, as the patient communicates what they are feeling.

I converse with them about how what we are finding together makes a coherent picture, or a not-so-coherent picture of what might be happening. If the latter, I always tell them I love a challenge, and that seems to make them feel a little comforted, knowing that I am going to keep looking, and thinking about them and their complaints.

So, if you want compliant patients; patients who will keep their appointments, who will work with you and who will actually try the home care you suggest, then you need informed patients.

By having the patient understand their own impairments –  about what is actually going on, and why is it is that they can not do what they once did – the patient is then already engaged in their own treatment plan. They are already motivated to be a partner in their treatment. With a little more encouragement, they can make the jump to actually carrying out a full, progressive remedial exercise program, especially as they understand why they need to do it. They understand this because of the time taken during their initial and ongoing assessments.

Another benefit, of this time well spent, is that the patients themselves come to know what to look for to see if they are improving and if the treatment is working. They can then give us feedback that allows us to be more responsive and efficient in either modifying or sticking to the original treatment plan.

One benefit that may not be apparent to us as therapists is that the knowledge and understanding we can impart to our patients about their health, and how to be well, not only helps them as massage therapy patients, but also as the patients of all health care professionals. 

It empowers them, with the family doctor, to ask for the help that they may need, to be informed about their choices, and to get the referrals that may help them in their healing of soft tissue dysfunctions.

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