Key Points

• Expressing a genuine interest in hearing the nature of the client’s complaint is the first step to building trust between you and them. 

• Knowing what information to delve into is partly experience, but having a working knowledge of the most common musculoskeletal issues can help develop your investigation strategy.

The HOPRS framework is a great guideline for performing client assessment. HOPRS stands for history, observation, palpation, range-of-motion and resistance testing, and special tests. Not all these elements are necessary for every situation, and assessment doesn’t need to take long. But each part of HOPRS plays a different role in determining the best course of action for a client. 

In health care, treatment failure can often be due to a lack of investigation by the provider. When critical facets of history influencing a complaint are missed, a client will likely continue to suffer. Additionally, it is far more expensive for the client when a trial-and-error approach is taken versus evaluating more thoroughly. 

There is a reason history is the first component of this framework. A detailed client history is the most crucial part of your evaluation. Taking a thorough history is both an art and a science.

The history is also the beginning of the client-therapist relationship. It is how you develop rapport with your client and gain their trust in your care. Expressing a genuine interest in hearing the nature of the client’s complaint is the first step to this trust. This article will explore several key factors that make for an effective client history.  

History Taking: The Basics

You likely learned the basics of history taking in massage school. These questions should include information about the client’s current symptoms, recent surgeries, and medications or supplements. Always ask your clients about allergies as well, including seasonal, food, skin, and medication side effects. It is critical to ask about reactions to lotions, scents, or other things involved in your treatment. 

Allergies are at an all-time high, likely due to environmental reasons. It is essential not to ignore these concerns. Early in my career, I had a client who was a heavy smoker. The room reeked of cigarette smoke after the client left. I sprayed citrus air freshener to lessen the smell for my next client. Unfortunately, my next client had to cancel her appointment because she was allergic to air freshener chemicals. 

Interactions between medications and massage therapy treatments also warrant precautions. While massage therapy is generally safe, certain medications may affect how the body responds to massage. For example, blood-thinning medications can increase the client’s risk of bruising or internal bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) or prescription pain medications can sometimes mask pain during a massage, making it difficult to gauge the appropriate pressure. Conditions like diabetes can change how someone perceives sensations in their feet or hands. Also, a client may seek massage for side effects from a medication, used for symptoms such as headaches or discomfort, that massage treatment cannot address. 

Uncovering contraindications to massage treatment is another important reason for an effective history. Clients are unlikely to know what these contraindications would be; it is the practitioner’s responsibility to be informed. As a practitioner, you might recognize a potential contraindication only if you explore the nature of the client’s current situation in greater detail. For example, suppose a client came in complaining of pain in their leg. You might think massage is warranted if you only perform a cursory history and minimal physical evaluation. However, a more detailed history might uncover symptoms such as leg swelling, sensations of heat, cramping in the calves, and generalized aching in the leg. These significant symptoms are all common indicators of deep vein thrombosis. 

What Makes a Good History?

For clients with potential injuries or pain complaints, the history should be more than just asking questions about their current symptoms, recent surgeries, or medications. The first place to start is with the chief complaint. Exploring the main complaint is the primary way to delve into relevant factors. For many people, there may be more than one issue, but usually, it’s a primary complaint that has brought them to the clinic. 

Knowing what questions to ask can be intimidating if you are unaccustomed to pursuing detailed histories. However, practice makes you more comfortable and savvier at choosing questions. Four main categories of investigation to pursue are: how, what, when, and why.

• How: At a minimum, a history will include information about how the complaint occurred. Did the pain have an acute or chronic onset? Was there a specific incident that caused the complaint, or was the pain slow to develop, getting worse over time?

• What: What behaviors could have led to the injury event or chronic complaint? Are there other factors that may have been or are present to create or aggravate the condition? What other symptoms might the client be experiencing? Now or in the past?

• When: When did the complaint start? How long has the client been experiencing the issue? Similarly, has this complaint happened before? 

• Why: Learning why the client is suffering and what tissues may be involved are revealed as you investigate other aspects of the assessment. For example, why is there pain with a particular movement? What tissues seem to be involved? 

With any of your questions, listen carefully to what the client says. Good listening skills are paramount. Pursue greater details when you think they are relevant. Knowing what information to delve into is partly experience, but having a working knowledge of the most common musculoskeletal issues can help develop your investigation strategy. When you know more about various problems, you can recognize patterns and pursue that line of inquiry.

Techniques for an Effective History

There are several important factors in good interviewing skills. The following are the most common. 

Active Listening

It may be tempting to continue taking notes while the client is talking, but it’s more effective if you are actively listening. Active listening is a communication technique that is a valuable skill set for a massage therapist. It involves paying attention to the client, reflecting on what they say, asking for clarification, avoiding assumptions, empathizing, exploring further details, and offering an appropriate response. Active listening is a handy skill in all relationships—work or personal. 

Your body language and eye contact are giveaways as to whether a client is being heard. However, eye contact can be substantially different based on culture and community. Whether to maintain eye contact, the level of direct eye contact, and speaking while looking at your partner can be different for different people. If you have a diverse clientele, learn the common communicative practices for your clients. Then, pay attention to your clients’ cues when speaking to them. Do not judge those who have different ways of communicating. And be aware enough to adapt your communication style to fit the client. 

Open-Ended Questions

Sometimes a simple yes or no answer question is appropriate. However, in most cases, open-ended questions are more valuable. Open-ended questions encourage your client to provide detailed information. These questions begin with words such as “what,” “how,” “why,” “tell me about,” or “describe.” You can then explore aspects of the answers more thoroughly to better understand what is happening for your client.

For instance, a closed-ended question would be: “Does your shoulder hurt at night?” An open-ended question would be: “Is there a particular time of day when your shoulder hurts?” The latter refrains from putting pain at night into the client’s head and helps them think about when the pain is worse. The client is more likely to add information in the answer with an open-ended question, such as offering more about the location and quality of the pain.

Probing Questions

Start your interview with several open-ended questions to gather the most general information about the complaint. The answers will lead to more probing questions to draw out other significant details. You can help the client formulate descriptions of pain by asking directed questions. However, be careful about influencing their answers. 

For example, you might start with an open-ended question like, “Describe the pain you are experiencing.” You could then assist by further asking, “Is the pain sharp and stabbing, dull and diffuse, prickly, or a deep throbbing, or how else might you describe it?” The client now has several optional descriptors for the pain but can also think of their own words. With the pain’s nature and location noted, you can ask about other things, such as activities or positions that worsen or lessen the pain. 

Reflective Listening

You’ve likely noticed several of these communication techniques come from other fields. Learning strong communication skills taught in these different fields is good business practice. Another skill we can borrow from communication studies or counseling is reflective listening. Reflective listening in the massage profession would mean asking for verification and confirming what you think the client said. For example, you might clarify by saying, “If I understand you correctly, you are having pain in this right side of your forearm,” (while pointing to the location).

What Not To Do in a History

Taking a quality history is an art developed over time and with practice. However, there are also some important things to avoid when taking a detailed history. These are the most common mistakes made.

Failing to Ask Follow-Up Questions

An open-ended question will only succeed if you pursue information in the answer. Knowing how to follow up can be intimidating. But learn to listen carefully; practice with a friend. There is no convenient list of questions to consult; assessment is an organic process. Learning more about human anatomy and individual conditions will improve your ability to recognize symptom patterns. The key to any assessment is effective pattern recognition.

Making Incorrect Assumptions

When talking with clients about their current experience, it is essential to avoid making assumptions about what condition might be in play. Be diligent in taking in information without immediately relating it to another client’s experience or what you initially think may be happening. Previous experience and knowledge do inform assessments, but it is crucial to approach each client’s situation with an open mind. Conditions may have generalized presentations, but every client experience will be unique. 

Assuming a Given Diagnosis Is Accurate

It is not within the scope of practice for massage therapists to diagnose any medical condition for their clients. And telling the client what you think they “have” is flirting with diagnosis. A massage therapist can, however, explain to the client what tissues seem to be involved and how. The assessment process can bring new information to light. What a massage therapist finds can sometimes differ from what another health-care professional has concluded. Because a client comes in with a particular diagnosis, it should not mean you are free to skip a thorough interview and investigate the complaint. At a minimum, you will need to assess whether massage is appropriate and how it would best be used.

Failing to Refer When Appropriate

Similarly, it is a significant error not to refer somebody to an appropriate health-care professional when the critical information they provide in the history indicates  massage may be inappropriate or harmful.

Assuming the Client Told You Everything

Remember that clients may not recognize when something in their history is important. We have probably all had the experience when in the middle of a massage, the client says, “Oh, I forgot to mention I fell on that shoulder when I was a teenager and had to have surgery to fix it.”

Never Underestimate the History

The importance of taking an effective history cannot be overstated. Massage therapists can formulate the most effective treatment plan by gathering detailed information on a client’s current problem, relevant medical history, and lifestyle factors. A quality history also enhances the professional credibility of the massage therapist, resulting in trust from other health-care professionals. Finally, clients who feel heard and understood are more likely to trust your expertise, become regular clients, and refer others to you.