Ep 421 - Assessment for Treatment Success with Whitney Lowe

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0:01:55.3 Whitney Lowe: Hi everyone, I'm Whitney Lowe, and today I'm honored to be your guest host as you are listening to the ABMP podcast, a podcast that speaks to the massage and bodywork community. Currently, I'm the director of the Academy of Clinical Massage and I wanna thank you for sharing some time in your earbuds with me today. And I'm here to speak to you about a topic that's very critical to your practice and that is assessment. Assessment is a topic you probably learned some things about in school, but what I found is a lot of people have a tendency to drop off focusing a good bit of attention on this once they get into practice. And I really want to remind you that I think this is a critically important part of being successful in your massage practice. Now, there's all kinds of different assessment that you might go into.

0:02:38.9 WL: I'm gonna speak mostly in the direction of, if you're working with people who have some type of complaint that they would like for you to address. And that really is gonna be most of the people who come to see you. They've got, maybe their shoulders hurt, their neck hurts, or they've had an injury or an accident or something like that. But that doesn't mean that you don't do assessment, if somebody wants to just come and get a general relaxation massage from you as well. This is one of the things that we'll talk about in terms of, you know, how do you do this and what, how much of this is really necessary in some of these different environments. Now, briefly, let's just go over the topic of assessment and make sure we're all on the same page here. So, the first place I wanna start is talking about kind of the definition of assessment.

0:03:18.9 WL: So in essence, assessment is a systematic process for gathering information that you're going to use to make informed decisions about treatment. And that's a very important distinction because one of the most common misunderstandings that people have is assuming that assessment is the same thing as diagnosis. When you talk about maybe you go through assessment and you say, oh, well my client has carpal tunnel syndrome. Well, assessment is the process that you go through to make a determination of how you're gonna proceed or maybe what the nature of that problem is. But as then everybody knows diagnosis, which is really the naming of that condition and giving a specific label to that group of signs and symptoms, that's outside the scope of practice of a massage therapist. But that doesn't mean that assessment is outside your scope of practice, because assessment is really essential. And you can't do any type of massage without doing assessment, because as soon as you put your hands on somebody and make a determination or think a thought about what you feel underneath your fingertips, you've done assessment, you are assessing the nature of those tissues and you cannot help but your brain making decisions about how am I going to work with whatever I feel underneath my hands? 

0:04:32.1 WL: Maybe this tissue feels tighter, this feels like something I need to work on a little bit more. Or your client says, Hey, I'd like you to work on this area a little bit more. These things all involve some degree of assessment. And what I wanna focus on is like, how much should you do? How do you go about doing it? What is really entailed in assessment? So, let's take a look at some of those different things.

0:04:51.4 WL: Now, as I said before, the nature of assessment can vary significantly. And some people do lots of different models and strategies of assessment. There is visual assessment that's very common, and this is commonly taught in a lot of our massage programs, where you look at somebody's posture and make some determinations about maybe which muscles you think are tighter, which areas might need to be addressed. If somebody's got a forward head posture and their shoulders are kind of rounded, there's a upper thoracic kyphosis and you think, oh wow, that person really probably has a lot of muscle tightness and restriction from those muscles that are overused in their upper back. And that's a visual assessment, making a determination about how you're gonna proceed with your treatment. One of the areas where we excel as massage therapists is in palpatory assessment, what you feel underneath your fingertips. So, as you're working on somebody, you are constantly assessing the whole time that you're working because you're feeling things in those tissues that you're working on, and making determinations about, does this feel like the way that I want it to? 

0:05:48.5 WL: If it was tight going into this? Does it feel like it's loosening up? What's happening? What's changing underneath my fingers and hands as I'm working? These are all gonna be critical things that are a big part of your assessment. Now, another place where we focus a great deal of attention in the idea of assessment is on the physical examination procedures, such as range of motion testing. And there's different types of range of motion testing, like active motion testing, passive motion testing, or looking at manual resistance testing. These are all different methods of testing, does a person have full functional capability in an area or is there some type of impairment maybe that's causing a pain problem for them? Those are various important parts of the physical examination process. And a lot of people get tripped up by thinking assessment is way too complex, because they look at these big orthopedic textbooks with hundreds of these special orthopedic tests in them and they start thinking like, oh man, there's no way I'm gonna remember all this stuff.

0:06:41.5 WL: Like, how do I remember all this? And my encouragement to you is, don't go down that road of feeling that sense of overwhelm about it, because assessment can be relatively simple and easy, and incredibly effective if you focus some attention on the key pieces of information that you really need to pick up from somebody. One of the things that I think gets overlooked a great deal when we talk about assessment is the critical importance of history. A person, you can gather so much information about the nature of what's going on with somebody, maybe about, you know, what's the, what's behind their current existing pain complaint. If you take a detailed history and focus in on a lot of the key things that they're letting you know about that led to this, the positions that make it worse, the positions that make it better, what do they do at home that helps it or hurts it or makes it more aggravated? 

0:07:26.4 WL: Those things are a key part of the process of gathering information that you're going to use in your informed decision process. So, one of the things that we always wanna think about is that no part of the assessment process exists in a vacuum. It's all part of a comprehensive, bigger picture and the assessment is going to drive your treatment. You're going to make treatment determinations based on what you find out during the assessment. So those are crucial parts of putting together a comprehensive and entire picture. Now, some people who don't put a lot of emphasis on assessment in their treatment practice might say, well, you know, I don't really need to learn this stuff. I don't really do much of that kind of work, so this is not really that important to me. But one of the things that I want to emphasize is I don't care where you work, whether it's in a spa, a cruise ship, a health club, a medical office, a physical therapy clinic, orthopedic clinic, whatever it is that you do, and wherever it is you work, you're going to go through some degree of assessment with your clients.

0:08:18.4 WL: And here's the other thing, people may come in with things and not know that they're problematic and not know that this is something that they should be telling you about. And maybe somebody comes in with a group of signs and symptoms and they think like, what's this kind of odd, how much of this do I really need to tell my massage therapist? There might be things going on that you would not or you'll know that there are problems that might need to be referred to another healthcare professional and they might not even realize or know that. So, a crucial part of the assessment process for you is even at the very beginning, just determining, is this something that I really should be working on? So that's one of the biggest factors that's a crucial necessity for assessment, determining, should I be doing this at all? 

0:08:58.3 WL: And if you shouldn't be doing it, then who should be the, who should I be referring this to? Who's the best person for me to be sending this client to, to really get them the care that they need? Now, if you determine this is something that you're going to be working with because you think you can help this person, assessment is gonna help tell you what kind of things that you can do with them and how you're gonna measure their progress and know whether or not it's working and making significant benefits for them. Now, another crucial, important part of assessment and why it's so valuable in your practice is that it really can help sort of define for you what you're gonna be doing with some of these different clients, and whether or not their current situation falls within two different categories. One of these categories we call scope of practice.

0:09:38.0 WL: And this means is this something that falls within the realm of what we should be doing with massage? That's pretty obvious. Most people are familiar with what their scope of practice is, but a lot of people get sort of a bit more confused when we start talking about the other category. And that's your scope of expertise. So, something can fall within your scope of practice, but fall outside of your scope of expertise. For example, when I started, first started practicing, there were a lot of things that would fall within my scope of practice of something that massage could be used for, but they would be outside my scope of expertise because I wasn't experienced enough to really know what I should be doing with these people, what kind of things I should be doing. There's a lot of other things that when we're in massage school, sometimes this is kind of taught to us as like a real black and white decision process.

0:10:26.7 WL: This is in your scope of practice, this is not. Or this is something that you can do with massage or this is something that you can't. But anybody who spent any time in the treatment room knows that once you get in there, that black and white line goes away and it becomes a lot of gray area. I was taught a lot of things in massage school with these sort of rules and absolutes, you know, you don't do this and you don't do that. And then years later, I went to work in an orthopedic clinic and I was violating those rules all the time, because the physical therapists and the orthopedists were sending all kinds of people in to me saying like, Hey, see if you could do something with this person. I'm like, well, we were told to massage school, you don't do this. And the reality is, well, maybe you don't do certain types of things, but there are a lot of other things that you could do with this person that could still be really helpful for them.

0:11:10.0 WL: How do you know what you should be doing? Part of that becomes decisions that you make after you go through assessment to determine, what is really the nature of that problem and what's gonna be a beneficial strategy for addressing it. So one of the things that we see most often happening in the clinical environment with massage is and I certainly found this to be true. When I got out of school, I started taking all kinds of continuing education workshops because I was looking for that magic technique. What was that thing that was gonna help all these people get better when they come to see me? So I could say like, Hey, come see me 'cause I do this thing and this is gonna help you get out of pain. And I was taking a bunch of classes and a lot of the people that I was taking classes with were sort of convincing me through their marketing materials that they had the secret of what was gonna help everybody get better.

0:11:54.3 WL: And a lot of times it was, Hey, help these people get better in just two magical treatments or whatever it was. And I bought into that a lot, a lot into that. And really became sort of thinking like, oh, I want to go, I gotta get this. This is something I've gotta get. You know, I have a big FOMO of fear of missing out. I was like, oh, I gotta get this thing. I don't wanna miss out on it. But the more time went on, the more I recognized there was a lot of times when that didn't work. It was a lot of times when this particular approach didn't work or maybe it was effective with this person, but it wasn't effective with somebody else. And they seemed to have kind of similar problems, like, why did it work with one person and not with another? 

0:12:27.6 WL: And it wasn't until I first started recognizing the necessity for looking at assessment and really figuring out what's going on, not only in a broad scale in terms of a determination by maybe the tissues and how they're behaving, but what's going on for this particular individual and this particular person. And I realized that we have to take each one of these clients that comes to us as an individual and somebody who's got a unique presentation of things going on. And it's up to us to be comprehensive in our evaluation and assessment processes, to determine what kind of work are we gonna be doing and is this gonna be appropriate for them? And a lot of times as you go through that assessment process, you might find, well, this is a condition that's well within the scope of practice of massage. It's well within the scope of, my scope of expertise, but you know what, I don't think this is the right person for me.

0:13:16.0 WL: I mean, I remember a client in particular I had who came in one time as a young girl who had been injured in a car accident and her mother brought her in for treatment. And I was going through the assessment evaluation process with her, and it was clear to me that she felt uneasy and uncomfortable with some of the things that we were doing in the evaluation process. And with the, I think with the whole idea of being treated with massage and it may have been because also because I was a man and she felt uncomfortable with that even though her mom was there with her in the treatment room. So, after going through this comprehensive assessment with her, I said, you know, I think there's a lot of things in here that could be beneficial with massage and I'm not sure I'm the right person for you to do this.

0:13:53.5 WL: And I gave her a referral for somebody who I thought could be more effective with her and potentially resonate with her more on that level. So a lot of times, the assessment is so valuable in telling us, how do we work with this particular individual and this particular person, and their unique set of signs and symptoms to determine how we can be most effective with them. And again, it's a comprehensive picture. There's no one piece of it. And well, no one particular model. There's a lot of different models that you can be using, but this will really help you get a good idea of how this might guide your most effective treatments.

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0:15:12.4 WL: So, I wanna circle back around to something I was saying earlier about how assessment drives our treatment decisions. And this is so valuable and so important. It gets into the idea too, of documentation, which I hear from a lot of massage therapists. Ah, yeah, I don't really keep treatment notes and I just want to encourage you and emphasize that, that really is important for you to do that because, when people come in to see you multiple times, especially if they have some kind of complaint that they're looking to have you help address, it's gonna be hard to remember everything that goes on in that session. And your treatment notes are an effective way to remember the nature of what's happening with that person. How they were last time, how did they respond to these different evaluation procedures, and then how are they responding today to those evaluation procedures? 

0:15:50.9 WL: And that gives you a marker that you can use to show them, Hey, you're making progress here and this is really valuable. That's also really effective as getting those markers to determine, how is their success improving between the beginning of the session and the end of the session to show them, Hey, look, we've got this degree of increased range of motion here. Or when I pressed here earlier, you were saying that was really painful. And now that level of pain has really decreased. That again, is assessment and a determination of how you're measuring treatment progress. And that's gonna be very effective for them as well.

0:16:20.5 WL: Now, when I hear people talk about assessment and the things that they're learning, you know, there's all kinds of different ways that they will look at it. Again, I want to emphasize that assessment is much more than just a bunch of tests or it's a lot more than just looking at somebody's posture and making a determination about what you think is happening with them, or just making some basic determinations about something from maybe one or two special orthopedic test procedures that you went through there.

0:16:44.4 WL: It's a comprehensive system and I really encourage people to find a model that works effectively for them. Years ago I learned about this model called the HOPRS model, which is an acronym, HOPRS, where essentially standing for history, observation, palpation, range-of-motion and resistance testing and special orthopedic tests. And I've found that model to be a really good way to organize all of the information that comes in during the assessment process. And as a result of the information that I take in, then I'm making the most effective treatment decisions. But find a model that works good for you. I mean, there's lots of different strategies out there and lots of different models of doing that. But the important thing is make sure you cover all those bases. Be very thorough and comprehensive in your history, and look at the various different factors that you're getting out of that, other aspects of the physical examination process, 'cause those are gonna be crucial as well.

0:17:34.2 WL: Now, one of the things that I hear from a lot of practitioners, and I've had this very experience myself too, is like, I don't have time to do this in my treatment session 'cause you know, client's paying for an hour and they wanna come in, they wanna get their 58 minutes of hands-on therapy or whatever it is. Or in particular, this is really true in more pressured time environments where somebody works, let's say in a, you know, another type of setting where they've got clients every hour and they've gotta do the changeover in the sheets and the interview and all this kind of stuff in there, and they say, I just don't have time to do any kind of comprehensive assessment. And I get it. I've worked in those kinds of environments as well.

0:18:06.4 WL: And I really found how to get very efficient in what you were doing in a lot of these different situations, various different ways. And one of, in particular I'd mentioned earlier, I spent a number of years working in a physical therapy clinic that was it was actually an orthopedic clinic in the working in conjunction with the physical therapist and orthopedist. But I was seeing patients every half hour and that meant, you know, interview, talk to them, do some assessment, do some treatment, get them off the table, get them dressed, and the next person comes in a half hour later. So, you know, that was a quick turnaround and obviously there's a lot of things that we didn't get to in terms of being effective with massage treatments, but I still felt it was critically important to do some types of assessment evaluation because to be honest, some of these people came in and they were coming directly from the orthopedist.

0:18:52.8 WL: They were coming in with a diagnosis of something that just did not seem to make sense at all to me. And a lot of that was because the physicians oftentimes who are working with minor musculoskeletal pain conditions, this isn't their area of specialization in looking at soft tissue disorders like this. And without that level of time spent focusing on palpatory examination and some of the other things that we do in our comprehensive assessment evaluation process, there's different things that might get missed. It might be called something different than what they really are. And so that's again why assessment is so critical and important. But again, the assessment doesn't have to be things that you're doing as a separate entity before you start doing your massage. You can do all kinds of assessment in the midst of your massage.

0:19:35.7 WL: While somebody's on the table, you can be doing range-of-motion activities. You can offer resistance to particular movements and see what's happening with active motion and passive motion and resistant movements through there. You can, you know, as we said earlier, you're doing your palpatory examination throughout the entire time that you're working. So, there's all kinds of things that you can do while that person is on the treatment table to gather extensive information about the nature of what's going on with them and how you can most effectively help them. Now one of the things that's really challenging is, you know, people ask me all the time, well, how do I get better at assessment and how do I learn this? It's not like something where you can go to a book and memorize a bunch of information because the challenge with assessment is we're talking about clinical reasoning processes, and how do you get better at thinking through a thought process? 

0:20:20.2 WL: How do you get better at a reasoning process? And that is indeed challenging. So, one of the things that I would encourage you to do is spend some more time learning about pathological conditions, because in doing that, you learn about signs and symptoms from those conditions. And a lot of the research articles, for example, that will talk to you about various different conditions, will talk to you about what kinds of things cause more pain or discomfort, what are the things that somebody's likely to report in their history if they have this particular type of condition? All those things will be gradually added into your wealth of knowledge about the nature of some different soft tissue pain problems. And that is gonna greatly help you in your critical thinking and clinical reasoning process. So, by going through and learning about those types of things, that's what's gonna help you the most in terms of improving your assessment skills.

0:21:08.8 WL: And take some time to really do this. A lot of times people are fretting about the time that they might spend with their clients going through assessment process thinking, oh, well my client wants to get on the table and start doing their, you know, getting their massage right away. But again, if your goal, if your main goal in working with a client is to help them relieve some type of discomfort or pain problem that they're experiencing, I would assume they really wanna know how can you best help them with that? And what I've found is that when I, if I got somebody who I'm working with to address a particular type of pain complaint, I'll let them know at the very outset. We're gonna take some time at the very beginning to go through some assessment and evaluation procedures, because that's gonna help me figure out how to do the most effective, most efficient and best work with you.

0:21:51.3 WL: So, that's gonna be a real benefit for you. And what I've found is, over and over again, people have not complained about the time that was spent doing that when I established that with them upfront. But what I did find over and over again, people asking me, how come nobody ever did this with me before? They've been to see doctors, PTs, chiropractors, whoever else, nobody ever did this with them before. And this is one of the things that's illustrated a lot with a big problem in our healthcare system, which is so many of the people who others are going to see for musculoskeletal pain and injury complaints have very short office visits. They don't have a lot of time that they spend with each individual person. And consequently, if you don't spend that time with them, you don't have the time to pick up and identify a lot of these types of things.

0:22:36.1 WL: And that's one of the most beneficial and beautiful things that we do in the massage therapy world, is spending more comprehensive time with our clients and evaluating what's going on with them. You've got the possibility and the potential to find all kinds of things that other people won't, because you're gonna spend a lot more time with your client, you're gonna delve a lot more into depth about what's going on with the nature of their complaint. And you're going to by that means give them a whole lot more efficient and beneficial care as a result. So that's today's quick take on assessment and why I think it's so important. Again, I really encourage you to make this an integral part of your treatment process. And again, when it comes to trying to get an idea of how to be more efficient and effective with this, I've got a free resource for you that can help you consolidate your assessment process in the clinic and make it far more efficient.

0:23:20.8 WL: So grab a copy of our assessment cheat sheet. You can find that over on our website at academyofclinicalmassage.com/cheatsheet. Again, that website, academyofclinicalmassage.com/cheatsheet. And this will help you get some a good jumpstart on interpreting and identifying a lot of the things that are happening when you're going through some of your evaluation processes with your clients. So, thanks so much for sharing some time with me today, and please feel free to let me know what you would like to learn more about in relation to assessment. And I always wanna find out what do people really wanna learn more about. You can contact me directly through my email; whitney@academyofclinicalmassage.com. And again, thanks so much for joining me today on the ABMP Podcast.

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