Easy Assessment for Massage Therapist By Sean Riehl, LMT
Only a small fraction of massage therapists use any assessment testing in their practice. Although most massage training includes some type of kinesiology and assessment tests, therapists quickly forget this information and rely only on their touch. Touch is powerful, and because of this, most therapists don’t find a need for any assessment testing. I believe that adding a few simple assessment tests can dramatically enhance the massage experience.
The problem with assessment
The problem with testing is that there are too many tests. Even after making many DVDs on orthopedic testing, even I can’t remember them all. Also, in a normal massage practice, muscle tension dominates the client’s complaints, and so a therapist with good palpation skills can easily find the areas of complaint and relieve them. Finally, many clients don’t expect to have any testing done. What we really need is a simple set of tests that we can do quickly that will reveal restrictions to both the therapist and client.
What assessment can bring
Due to the complexity of all the orthopedic tests, we need some simple tests that can be done quickly, and are applied to every client every session. Range of motion testing is the perfect answer to these requirements, especially since we are working with muscles, which control the joints. By performing a quick full body range of motion testing sequence, we can see where someone is restricted. This tells the therapist where to work, but just as importantly, alerts the client to an area that needs attention. This can create a goal that the therapist and client can work towards. Tension is the precursor to injury, and restricted range of motion is an indication of tension and dysfunctional movement. By revealing these areas to a client, we can design session that will not just get them out of pain now, but make them healthier in the future.
The Spa Challenge
Many of my students reflect that people who come to spas don’t want any testing. I contend that every human wants to be listened to deeply. We listen to our clients when they tell us where they hurt. We can listen to them with our eyes when we notice one shoulder is higher than the other. We can listen to them with our touch when we flex their wrists, elbows or shoulders and notice restriction. To spend 90 seconds to go through some tests that reveal major holding patterns usually is met with excitement by clients. Therapists that can engage with their clients, and focus on what is needed, are the therapists that are successful. The fact that 99% of therapists don’t do any testing before the session means that there is a huge potential for massage therapists to create even more value for their clients.
Start with the wrists
When someone enters the session, after you have listened to the reason they are there. Ask them is you can run through a quick full body evaluation. I like to start this by touching them, since it puts the clients at ease. Grasp both of their hands, bring them up towards you and flex and extend each wrist. Notice if one side doesn’t move as far as the other. Comparing the sides is an easy way to notice if there is restriction, and is much easier than memorizing the correct number of degrees a joint is supposed to move. When you do all these tests, give a little extra pressure, springing into the end of the range. A hard end-feel reveals that the restriction is in the ligaments. A soft or springy end feel reveals that the restriction is from muscle tension.
Now make sure both elbows are at their sides, and supinate and pronate both wrists and compare each side. Notice if there is any restriction on either side. You will be surprised by how many people have a little restriction in some wrist motion on one side. When you find some restriction, smile and tell you client “look at that, you have a little restriction here in this wrist”. Ask them if they can feel it. Have a playful attitude with no judgement. Don’t say “wow, you’re really restricted!”, or “That’s really bad!”. All of this is done with a light spirit. The idea is to raise your awareness about areas that you can help, and raise the clients awareness about restrictions in their body.
There are hundreds of shoulder evaluations to distinguish joint capsule issues as opposed to muscle issues. We are not going to worry about that too much right now. First we will test general external rotation. With the client’s elbows at their sides, have them externally rotate their shoulder, which will look like them rotating their arms out to their sides as far as they can. Notice if one side goes further than the other.
To test internal rotation, we would do the opposite motion, but if we do that the arms run into the body… so another way to do this is to have the client put one have behind their back and inch their hand up their back as far as they can go. You should mark with your finger where they reach on their upper back. Then the relax and try the other hand up their back. The side that doesn’t go as high up is the restricted side. This tests for the ability to internally rotate and extend the shoulder joint.
It is very difficult to test for the length of the shoulder abductors, so instead we will test for function. Have the client bring their arms overhead. As they do so, watch to see if both sides move equally, and if once raised, both are equally straight up. Pain or hesitation indicates muscle weakness in the abductors, and if one side can’t quite make it all the way vertical, it could be from restriction below the joint, or weakness again in the abductors.
Next have the client relax, arms at their sides. Notice if one hand is more forward over the thigh than the other. This indicates a forward shoulder, because when the shoulder moves forward it brings the hand forward too. Now look at the shoulder that is forward. Is it higher or lower than the other shoulder? If it is higher, it indicates the serratus anterior is tight. If it is lower, it indicates the pectoralis minor is tight. This is a big distinction to make since both these muscles pull the shoulder forward, but only the pectoralis minor pulls it forward and down.
To perform the neck assessment, have your client rotate their head to the right and then the left. Notice if they don’t move as far on one side. Limited neck rotation is very common, and incredibly easy to help. It is one of the most satisfying evaluations that you can do, since the clients will usually experience a big improvement after the session.
Next have your client laterally flex- bring their ear to their shoulder. Have them do this several times, and as they do, notice if the motion is happening in the upper neck(C1-C3), or lower neck. It is very common for the lower neck to be almost immobile, and all the motion happening in the upper neck. Note where there is restriction.
You may be wondering why we don’t perform flexion or extension of the neck. The reason is that most of the muscles that perform these motions also perform rotation, so we can get most of what we need by looking at rotation. Once rotation is restored, any limited flexion or extension usually resolves itself.
Next have the client take a few steps in place without looking down. Then have them stop and stand normally. Look at the position of their feet. Notice if one foot is pointing out, or if one is pointing in. If the feet are pointing out, it indicates tension in the hip external rotators. Feet pointing inward can indicate tension in the internal hip rotators. If we want to address the lower back and hips, we can get confirmation of this initial assessment once the client is on the table.
At this point we have the client sit on the edge of the massage table, cross their hands in front of their chest and rotate to each side. This will tell us about the ability of the thoracic vertebrae to move. Notice if one side is more restricted than the other.
Next we can look at the ability of the lumbar vertebrae to side-bend, which will tell us something about the health of the spine. Still with hands crossed over their chest, have them side bend to each side. Watch their torso and ignore shoulder or neck motion. Really note what type of motion is happening between the bottom of the ribs and the top of the ilium. Restriction bending to the right indicates a strong possibility of a tight quadratus lumborum on the left.
There are so many tests, and this is just a few. We have also skipped a few joints that either don’t need to be assessed every time, or are best assessed with the client on the table. The few that I have shown here give us a great amount of information before the session starts.
Massage is powerful work. We as therapists have a great sensitivity in our hands to feel areas of tension. There is no reason, however, for us not to use our eyes and motion evaluation to really understand our clients. With the simple steps I have outlined here, we can reveal all types of restrictions. Once we bring these restrictions to the attention of our client, we are in a much better position to help them during the session, and for planning future session. I invite the massage community to adopt these simple and powerful techniques, so we can help our clients even more.
Sean Riehl has been teaching massage therapy for over 20 years. He has authored and produced over 40 massage training DVDs and is the president of Real Bodywork. This article is based on his newest work, Structural Massage.
Easy Assessment for Massage Therapist By Sean Riehl, LMT