Proper assessment is one of the most important aspects of effective manual therapy. With a simplified screening system called ART, massage therapists can speed up whole-body assessment and more quickly identify root causes of client complaints. The acronym ART stands for asymmetry, restriction of motion, and tissue texture abnormalities. I was introduced to ART while attending osteopathic trainings, and it has been a staple in my private pain management practice and teachings for almost three decades. Many of you, consciously or unconsciously, are using part or all of this assessment protocol already. For those who want to take a deeper dive into ART, I’ll break it down for a better understanding of how to apply ART in your practice.

Asymmetry

Humans are born asymmetrical. The structure and location of the musculoskeletal, digestive, respiratory, neurological, and cardiovascular systems all require us to be asymmetrical to some degree. Regardless of whether we are right- or left-handed, most of us are right-motor dominant, and the resulting weight imbalance is often reflected in asymmetrical postural patterns. For example, research has found most people bear more weight on the right motor dominant leg, causing it to be nearly 5 percent larger in volume.¹ Over time, uneven loading of the dominant leg may result in leg-length discrepancies, pelvic-bowl rotations, and spinal compensations (Image 1).  
Keep an eye out for the asymmetry aspect of ART as soon as a client enters your office. Be on the lookout for posturofunctional deviations, such as loss of cross-patterned gait, upper- and lower-crossed syndromes, and unleveling of the head and tail. The myoskeletal alignment goal is to establish balanced symmetry of the head on the neck and the lumbar spine on the sacrum (head on tail). 

Restriction of Motion

After performing a visual postural analysis, it’s time to evaluate movement restrictions side by side. We’re not as concerned with comparing anatomic landmarks as we are with determining how one side of the body moves compared to the other. For example, in Image 2, I’m assessing my client, Keith, for pelvic-rotation restrictions using the “ilium rocking” test. By alternately depressing each of his anterior superior iliac spines, I can determine which way the pelvis moves easiest and which side may be restricted. 
In this demonstration, Keith tested with a right-sided restriction that resisted posterior glide during depression. This indicated his right ilium was fixated anteriorly/inferiorly in relation to his left, causing his pelvic bowl to rotate left around a vertical axis (Image 3). Left untreated, this can lead to lumbar compensations in the form of a functional scoliosis. While these postural adaptations do upregulate the central nervous system, they may or may not become symptomatic. In Images 4–6, I’m evaluating Keith’s glenohumeral joint for internal/external rotation and abduction restrictions and comparing side by side. While performing these tests, I’m also assessing for tissue texture abnormalities, such as altered joint end-feel and tenderness.

Tissue Texture Abnormalities 

Massage therapists are exceptionally good at evaluating spastic or fibrotic tissues, joint-end ranges of motion, and hypermobility issues. By motion-testing the neck, back, and extremities for tension, tenderness, and trick movements, we’re better able to structure an efficient treatment plan.  
When assessing for tenderness, I typically begin by performing digital pain-provocation tests of suspected muscles, tendons, ligaments, joint capsules, bursa, and joints. These tests may tell us the tissue is under load, but the pain may result from compensations, meaning it is not the “main event.” In fact, the real culprit triggering the compensations could go undetected if we continue to get distracted by end effects and symptoms and fail to gain the perspective of the whole first. This is where ART comes in handy. 
By standing back and observing, palpating, and motion-testing the whole person, we can more accurately trace the effects back to the originating cause. This will offer insight and help us gain context as to how and why they are under load in the first place. Once the art of listening to the tissues is mastered, asymmetry, tissue texture, and motion quality become reliable indicators of the true treatable dysfunction.  

Summary 

The human body is a resilient yet extraordinarily asymmetrical piece of organic machinery. Studying different methodologies over the years has allowed me to formulate a deeper understanding of how strain patterns develop and how to address them. ART has aided me significantly in identifying the imbalances that unravel the mystery of the client’s symptoms. Successful treatment of the “key lesion” not only restores balance to the primary perpetrator, but also helps resolve stress, tension, and tenderness in the muscles and connective tissues that are forced to overwork to compensate for the symptom-provoking lesion. By using ART to improve symmetry, function, and texture, we can better help our clients find lasting relief. 

Note

1. J. P. Chapman, L. J. Chapman, and J. J. Allen, “The Measurement of Foot Preference,” Neuropsychologia 25, no. 3 (1987): 579–84.

Erik Dalton, PhD, is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfing, he has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit erikdalton.com.